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Original Articles

Isolation Requirements and Personal Protective Equipment in the COVID-19 Pandemic

Rabold, Erica MD; Rovnan, Helene DO, MPAS; DuMont, Tiffany DO

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doi: 10.1097/CNQ.0000000000000326
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Abstract

SARS-CoV-2 is an RNA virus that has only recently been found to infect humans. Its name was given after the severe acute respiratory syndrome (SARS) virus, named SARS-CoV, when genome sequencing showed great likeness between the 2 pathogens. The similarities are also beneficial in predicting how this pathogen behaves and spreads and in developing strategies to minimize the incidence.1 The disease that is caused by SARS-CoV-2 is referred to as COVID 19, which stands for coronavirus disease 2019. In this article, we explore isolation requirements for patient with COVID-19 in the health care settings, the appropriate use of personal protective equipment (PPE), safe handling of patient-shared supplies and equipment, and the current challenges faced with PPE shortages.

ISOLATION INDICATIONS AND REQUIREMENTS FOR PATIENTS WITH COVID-19

Minimal studies have been done to date on the modes of transmission of SARS-CoV-2. A recently published correspondence evaluated the stability of both SARS-CoV-1 and -2 in aerosolized forms and in the form of droplet on various surfaces and found that SARS-CoV-2 remains viable in aerosols for at least 3 hours and for 72 hours on surfaces such as plastic. The findings were similar for both CoV-1 and -2 viruses.2 Based on these findings, the viruses' numerous similarities in genetics and symptoms, it is reasonable to postulate that for infectious purposes they are likely to behave similarly. Similar infection prevention measures used for SARS should be implemented in hopes to mitigate the spread of COVID-19. Like for SARS, patients diagnosed with COVID-19 should be placed on standard isolation precautions plus droplet or airborne according to the clinical setting.

STANDARD AND CONTACT PRECAUTIONS

Health care workers (HCWs) should always observe the principle that all secretions, body fluids, blood, excretions, skin, and mucous membranes may contain infectious agents. As such, even in patients with no known active infection, a minimum of hand hygiene and/or use of gloves and safe injection practices should always be implemented. Use of gowns, masks, and eye protection should also be considered depending on the anticipated exposure.

Unfortunately, it is recognized that for some pathogens, the routes of transmission may not be interrupted by using standard precautions alone and this applies for COVID-19.

Contact precautions are used when pathogens are recognized to spread by direct or indirect contact with patients and their environment. They also apply when the circumstance suggest increased risk of infection, that is, patient with suspected Clostridium difficile infection and diarrhea. Patients should be placed in single rooms, and HCWs entering the rooms should don gowns and glove upon entering the room and doffing before exiting to contain pathogens.3 HCWs should also wash their hands before leaving the room with soap and water in cases of C difficile infection.

Droplet precautions

Droplets are particles of greater than 5 μm in size that are naturally generated by sneezing, coughing, or talking. If an individual is infected, his or her droplets can carry viral particles and infect others if they come in contact with mucosal surfaces. Respiratory droplets can also be generated by procedures such as open suctioning, intubation, cardiopulmonary resuscitation, and sputum inductions. Past investigations, including during the SARS outbreak in 2003, demonstrated that droplets are able to travel up to 3 ft from their source but do not remain infectious over long distances.4

Based on the aforementioned facts, recommendations are to keep patients in single rooms and to use spatial separation of at least 3 ft if a multibed scenario is needed. HCWs are instructed to don a mask upon entering the room of an infected patient. No special air handling or ventilation is required to prevent droplet transmission. Eye protection should be worn as well.

Airborne precautions

Airborne transmission occurs via spread of airborne droplet nuclei or small particles containing infectious agents that remain infective over time and distance.10 Organisms that are carried this way can be disseminated over long distances by air and be inhaled by susceptible individuals.

SARS-CoV-2 can be classified as a virus with opportunistic aerosolized transmission, that is, under certain circumstances it may be transmitted via fine aerosol particles.5 Such circumstances have been identified thus far as intubation, bronchoscopy, sputum inductions, use of noninvasive positive pressure ventilation devices (ie, continuous posi-tive airway and bilevel positive airway pressure devices), cardiopulmonary resuscitation, use of high-flow oxygen devices, and use of nebulizer treatments based on studies done on SARS-CoV-1.4,6–11

Patients in airborne isolation should ideally be in airborne infection isolation rooms: a single patient room with air handling and ventilation that meets the American Institute of Architects/Facility Guidelines Institute standards. The requirements are as follows:

  • Monitored negative pressure relative to the surrounding area.
  • Twelve air exchanges per hour if new construction or renovation or 6 air exchanges per hour for existing facilities.
  • Air exhausted directly outside or recirculated through HEPA filter prior to return.

HCWs caring for patients in airborne isolation should don gown and gloves as well as N95 or higher-level respirators or masks. HCWs should also wear eye protection.

PPE IN COVID-19

Appropriate donning and doffing of PPE per CDC recommendations12

Before donning PPE ensure that:

  • Scrubs are clean and footwear is washable;
  • Footwear should be closed-toed and closed-heeled with no holes;
  • No personal items such as jewelry, cell phones, ID badges, or pens should be brought into the patient's room;
  • Ensure that nails are short as to not damage equipment;
  • Ensure hair is pulled back off the face, the neck, and the back; and
  • Inspect that equipment is in working condition and of the correct size.

How to don PPE:

  1. Identify and gather the appropriate equ-ipment to don.
    1. Droplet precaution equipment includes a gown, gloves, a surgical mask, eye goggles, or a face shield.
    2. Airborne precautions equipment includes a gown, gloves, an N95 filtering facepiece respirator or higher, eye goggles, or a face shield.
    3. Powered, air-purifying respirator (PAPR) application requires a trained observer to assist and observe that equipment is applied properly and in the correct sequence. Some PAPR models are self-contained, and it is important to follow the manufac-turer's instructions.
  2. Perform hand hygiene and ensure hands are completely dry.
  3. Don the isolation gown and tie all the ties on the gown.
  4. Apply the face mask. The nosepiece should be fitted with both hands and should not be bent, tented, or pinched with one hand. The mask should cover both the nose and the chin. Mask ties and respirator straps should be placed on the crown of the head and the base of the neck, respectively. Masks with loops should be hooked appropriately behind the ears.
  5. Apply eye protection, either face shield or goggles.
  6. Perform hand hygiene again, and don gloves. Gloves should cover the cuff of the gown—pull them up as high up on the arm as possible.

Donning PAPR equipment contains additional steps and occurs as follows:

  • Step 1: Engage a trained observer and inspect equipment to ensure it is working properly.
  • Step 2: Perform hand hygiene and wait for hands to dry completely.
  • Step 3: May consider a donning of an inner layer of gloves.
  • Step 4: Apply the PAPR at the small of the back and fasten the belt around your waist, securing any loose straps. Alternatively, some may place PAPR belt on after gown is in place.
  • Step 5: Put on gown and tie securely, with the tie easily accessible for doffing. The sleeves should cover the gloves to avoid any skin exposure. Tape can be used to close any gaps that may be present between the gown and the gloves. Make sure to leave a tab in order to remove the tape more effectively.
  • Step 8: Put on PAPR hood.
  • Step 7: Don gloves and ensure the cuffs are pulled up over the sleeves of the gown.
  • Step 9: Apply the outer apron if used.

How to doff PPE:

Removal of PPE is dependent on individual facility procedures. It is important to determine which procedure your facility uses for doffing PPE.

Doffing of standard droplet and airborne precautions occurs in the following sequence:

  1. The anterior portion of the gown, sleeves, and gloves are contaminated. The gown and gloves are removed by pulling the front of the gown away from your body until the ties break with gloved hands.
  2. While removing the gown, fold and roll the gown inside-out into a bundle.
  3. Peel off the gloves as you are removing the gown, only touching the inside of the gown and gloves with your bare hands. Place the gown and gloves in a waste container.
  4. The goggle or face shield is removed next by lifting the headband or straps from the back, taking care not to touch the front of the eye protective gear as the front is considered contaminated.
  5. Next, remove the mask or respirator from the back without touching the front and discard if contaminated.
  6. If at any time during the process of doffing your hands become contaminated, they should be disinfected with alcohol-based hand sanitizer immediately. Also, perform hand hygiene immediately after removing all PPE.

How to doff PAPR equipment:

Take your time and be mindful during the doffing process.

  1. Before exiting the room, inspect equipment for obvious contamination, cuts, or tears. If contamination is appreciated, the area must be cleaned with alcohol-based hand rub or Environmental Protection Agency–designated disinfectant wipe.
  2. Disinfect outer gloves with alcohol-based hand sanitizer or a disinfectant wipe.
  3. Get the attention of a trained observer and an assistant and enter the doffing area only when the trained observer signals for you to do so.
  4. Remove the outer apron if used.
  5. Disinfect the outer gloves again.
  6. If double-glove method is used: Remove and discard the outer gloves without contaminating the inner gloves or snapping the gloves that could result in spraying of contaminants. Start by removing the first glove from the wrist to the fingers until it is a ball in the palm of the other hand. Then slide a finger inside the outer glove of the other side and pull down until it is balled around the first glove.
  7. Inspect the inner gloves and disinfect with disinfectant wipes or alcohol-based hand sanitizer.
  8. If your belt is outside your gown (see steps 8-16): You will now remove the belt-mounted respirator based on the manufacturer's recommendations. Unfasten the belt, place all reusable PAPR components in the designated area for later disinfection, and take off the hood by rolling it toward the shoulders. When the hood is near the ears, bend forward at the waist and pull the hood slowly down and away from your head. Take extreme care not to touch your face once the hood has been removed. Discard or keep PAPR hood for later disinfection based on your institution guidelines.
  9. Disinfect your hands with alcohol-based hand sanitizer.
  10. Remove the gown by pulling down from the shoulders and roll the gown inward. Dispose of it in the waste container.
  11. Disinfect the inner gloves.
  12. Sit down in a clean chair and disinfect your shoes including the soles.
  13. Disinfect inner gloves again.
  14. Remove and discard the inner gloves with the same technique as the outer glove removal.
  15. Perform hand hygiene using alcohol-based hand sanitizer on bare skin.
  16. Perform one last inspection of your clothing and exit the doffing area.
  17. If your belt is outside the gown (see steps 17-27): Remove the gown by pulling down from the shoulders and roll the gown inward. Dispose of it in the waste container.
  18. Disinfect the inner gloves.
  19. Disinfect the outside of your PAPR hood. Take off the hood by rolling it toward the shoulders. When the hood is near the ears, bend forward at the waist and pull the hood slowly down and away from your head. Take extreme care not to touch your face once the hood has been removed. Discard or keep to PAPR hood for later disinfection based on your institution guidelines.
  20. Disinfect the inner gloves.
  21. Sit down in a clean chair and disinfect your shoes including the soles.
  22. Disinfect inner gloves again.
  23. Remove and discard the inner gloves with the same technique as the outer glove removal.
  24. Perform hand hygiene using alcohol-based hand sanitizer on bare skin.
  25. Apply new gloves.
  26. Remove PAPR belt and properly disinfect and store.
  27. Perform hand hygiene using alcohol-based hand sanitizer on bare skin.

STRATEGIES TO PRESERVE PPE

A big challenge during this pandemic has been derived from the fact that this virus is highly contagious, resulting in a large percentage of the population being infected in a short span of time. This causes a shortage of hospital beds, medications, and supplies needed to treat those affected by COVID-19, including a shortage of PPE. This was worsened by the public's desire to protect themselves from infection, leading to mass buying of hospital-grade PPE by the general population. As a result, many institutions have implemented strategies to preserve PPE and we have listed some as follows:

  • Administrative control measures:
  • Reducing the number of essential employees going to patient care areas;
  • Reducing the number of patients going to hospitals;
  • Reducing face-to-face encounters with patients;
  • Limiting the number of visitors allowed in the hospital;
  • Cohorting patients and providers to the same hospital units;
  • Maximizing use of telemedicine;
  • Staff training regarding proper donning and doffing of equipment in order to minimize damage to equipment;
  • Changing from using disposable supplies to reusable supplies such as reusable goggles and washable gowns made of polyester or polyester-cotton fabrics that can be safely laundered and extending use of isolation gowns;
  • Prioritize equipment for essential surgeries and procedures;
  • Cancelling of elective procedures; and
  • Decontamination of reusable filtering face mask respirators.
  • Provider control measures:
  • Consolidate patient care tasks to minimize personnel entry and exit from the room. Attempt to obtain laboratory studies, administer medications, and nursing care during the same trip into the room. Not only will this minimize personnel exposure but it will also conserve PPE.
  • Limit the number of physicians entering the room.
  • Ensure dietary and environmental services to not enter the room.
  • Place intravenous poles outside the room to limit entry.
  • Turn all machines to face toward the outside of the room to be visible to the staff without entering the room.
  • Limit unnecessary testing.

ANCILLARY EQUIPMENT

Attention must be paid to the proper cleaning of equipment that comes into contact with patients with COVID-19 as they have the potential to disseminate infection. As addressed in other articles in this issue, these patients can become quite ill and require multiple tests and supportive therapies such as electrocardiograms, electroencephalograms, renal replacement therapy, ultrasound-guided intravenous access, and radiographs. If the health care facility possesses multiple units of same equipment, it is probably wise to designate one specific piece of equipment to be used in the rooms of patients with COVID-19.

After using any equipment in a COVID-19–positive patient room, the staff member responsible for cleaning must start the process inside the patient's room while wearing appropriate PPE. Hospital-grade cleaning wipes embedded in disinfectant material are used to thoroughly wipe down all exposed surfaces of the equipment, with extra attention paid to areas that come into direct contact with the patient. Once equipment is wiped, it must stay untouched for at least 2 minutes. Subsequently, the machine is taken outside of the room, the staff must don new gloves, and wipe down all surfaces again, letting it sit for another 2 minutes to complete cleaning process.

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Keywords:

airborne isolation; COVID-19; droplet isolation; personal protective equipment

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