COVID-19 PPE Protocols

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PPE Policy and Precautions

Universal In-Hospital mask policy: Staff (updated 4/17/20)

All staff will be issued one surgical or KN mask (depending on preference) upon entry to the hospital.  This mask should be worn in all patient care areas and all non-clinical areas where you are in close vicinity to other people.

  • When not wearing the mask, it should be kept securely in a brown paper bag or between two sheets of dry paper towels.
  • While donning and doffing the mask, avoid touching the front panel; use the elastic straps and edges of the mask as much as possible.
  • If at any point the mask becomes visibly soiled or wet, discard and replace with a new mask.

Universal In-Hospital mask policy: Patients

Every hospital visitor and admitted patient will be issued a surgical or procedural face mask for use on a daily basis. This mask should be kept in place whenever the patient is anticipated to have a prolonged encounter with a provider (i.e. meeting for > 15 minutes within a distance of 6 feet) or if the patient leaves the room for any reason.

Patient Guidance FAQ on use of masks

N95 Respirator Conservation Statement and Guidance

N95 respirators represent an element of our PPE that is in critically short supply. As continuous efforts to obtain additional supply are ongoing, it is essential that all staff make every effort to conserve our current supply through careful limited reuse and use of designated recollection bins. Detailed description and guidance on each of these strategies is available below

  • Limited Reuse of N95 Respirators
    • Each staff member working in designated areas (ICUs, ED, COVID care areas) will receive one N95 respirator at beginning of shift (Those wearing 3M S will be asked to collect their N95 from central pick up point in Menino lobby.)
    • Before donning N95 for the first time in a shift, all makeup, lipstick or other skin care products like aftershave should be removed to avoid soiling the N95 and limit reprocessing
    • In between uses, place N95 in Tupperware container for storage with exterior surface face down, as demonstrated on video
    • Avoid handing N95 by exterior surface, handle by elastic and edges of mask as much as possible
    • Perform frequent hand hygiene, particularly before and after handling the mask
    • If rounding sequentially on a group of COVID-positive or COVID-suspect cases, can maintain N95 throughout this time period consistent with extended use. Other elements of PPE should still be doffed and disinfected (if reusable) in between patient encounters.  At the end of sequential rounding, doff N95 into Tupperware and continue with limited reuse strategy.
    • At the end of shift, remove N95 and place in designated recollection bin
  • N95 Recollection and Decontamination
    • Boston Medical Center has partnered with Battelle, which is a company providing decontamination service for N95 respirators to permit reuse up to 20 times. Further information is available on the FAQ sheet and Battel website.
    • Each nursing unit has a designated recollection bin for used N95s. These are often located in the dirty utility room, although other locations are possible depending on local needs.
    • At the end of the shift, N95 should be placed in this recollection bin
    • Visible soiling with food product, skincare products, or body fluids will cause the N95 to fail quality checks and be discarded. As such, BMC asks the following:
      • Recollection bins should be used for N95s only, no other trash
      • Avoid use of makeup, lipstick, or aftershave, as these transfer easily to the N95 and will result in it being discarded

Description and Definitions of Isolation Precautions

  1. Enhanced precautions (contact + droplet + airborne)
    • Conditions: COVID positive or suspect patients likely to require the following aerosol generating procedures :
      • Intubation, extubation and related procedures such as manual ventilation and open suctioning
      • Tracheotomy/tracheostomy procedures (insertion/open suctioning/removal)
      • Bronchoscopy
      • Surgery and post-mortem procedures involving high-speed devices
      • Non-invasive ventilation (NIV) such as bi-level positive airway pressure (BiPAP) and continuous positive airway pressure ventilation (CPAP)
      • High-frequency oscillating ventilation (HFOV)
      • Induction of sputum
      • Medication administration via continuous nebulizer
      • Note that ongoing care of an already intubated and ventilated patient is not a specified condition
    • Environment: negative-pressure room when available
    1. Contact + Droplet Precautions
      • Conditions: COVID positive or suspect patients not likely to require any of the specified conditions for Enhanced precautions
      • Environment: room located in geographically-designated COVID care area
      • Cohorting: confirmed positive patients can be cohorted if space requires.

    PPE Use Policy

    • COVID Care areas
      • Inpatient Med/Surg Floors, ICU, ED
        • N95 and eye protection (goggles or reusable hard face shield/disposable face shield), gown and double gloves
        • All staff wearing N95s should practice limited reuse. One N95 respirator will be issued per shift and in between uses is to be kept in Tupperware container.  At the end of the shift, the N95 should be placed in recollection bin.
        • When N95 not in use between patient encounters, surgical or KN mask should be continuously worn thoughout the shift, as per universal mask in hospital Discard and obtain a new mask if visibly soiled or wet.
        • If sequential rounding is performed for a cohort of suspect and/or confirmed COVID-19 patients, recommend extended use of N95 respirator (i.e. leave on while rounding and after rounding is complete, remove and place N95 in Tupperware for continued limited reuse).
        • All other elements of PPE MUST be disposed of before exiting patient room with the exception of reusable face shields (which should be removed and disinfected per manufacturer protocol).
      • ILI/tent
        • Reusable/disposable face shield, N95 (PAPRs for those with facial hair or those unable to be fit tested), gown and double gloves.
        • PPE can be maintained between patient evaluations for the duration of the healthcare worker’s shift, with the exception of outer layer of gloves, which MUST be replaced between patients. Any visible soiling or contamination of PPE warrants removal and replacement of all PPE prior to the next patient encounter.
        • Following completion of shift, N95 should be placed in recollection bin.
        • All other elements of PPE MUST be disposed of by the end of the healthcare worker’s shift with the exception of reusable face shields (which should be removed and disinfected per manufacturer protocol).
        • Collection area should be separated by at least 6 feet from where patients are waiting; preferable to perform specimen collection in a separate room with the door closed.
    • Non-COVID areas
      • Inpatient non-COVID floors and units
        • Surgical or KN mask and eye protection (goggles or reusable hard face shield/disposable face shield) OR pre-attached surgical mask and face shield, and gloves
        • In addition to the above, gown can be used if splash or gross contamination with body fluids is anticipated
        • Surgical or KN mask should be continuously worn throughout the shift, as per universal mask in hospital Discard and obtain a new mask if visibly soiled or wet.
        • All other elements of PPE MUST be disposed of before exiting patient room with the exception of reusable face shields (which should be removed and disinfected per manufacturer protocol)
      • Ambulatory
        • Surgical or KN mask and eye protection (goggles or face shield) OR pre-attached surgical mask and face shield, and gloves
        • In addition to the above, gown can be used if splash or gross contamination with body fluids is anticipated
        • Surgical or KN mask should be continuously worn thoughout the shift, as per universal mask in hospital Discard and obtain a new mask if visibly soiled or wet.
        • All other elements of PPE MUST be disposed of before exiting patient room with the exception of reusable face shields (which should be removed and disinfected per manufacturer protocol).
        • Do not recommend obtaining NP/OP swabs in clinic; these can be obtained in ILI/tent or ED

    Isolation ordering and removal

    Positive COVID precautions removal decision chart

    Provider guidance on isolation orders and removal

    Fact Sheets for Patients and Caregivers 
    Fact Sheet for Patients and Caregivers-Haitian Creole 
    Fact Sheet for Patients and Caregivers-Portuguese  
    Fact Sheet for Patients and Caregivers-English  
    Fact Sheet For Patients and Caregivers-Spanish

    Labor and Delivery PPE/Isolation Protocols
    Labor and Delivery Triage flow
    COVID Questionnaire for Labor and Delivery

    Relevant Literature 

    Absence of Apparent Transmission of SARS-CoV-2 from Two Stylists After Exposure at a Hair Salon with a Universal Face Covering Policy — Springfield, Missouri, May 2020

    Contact Tracing Assessment of COVID-19 Transmission Dynamics in Taiwan and Risk at Different Exposure Periods Before and After Symptom Onset 

    Viral RNA load as determined by cell culture as a management tool
    for discharge of SARS-CoV-2 patients from infectious disease wards 

    Efficacy of Face Shields Against Cough Aerosol Droplets from a Cough Simulator

    Physical distancing, face masks and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis.

    Universal Masking in Hospitals in the COVID-19 Era: 

    Medical Masks vs N95 Respirators for Preventiong COVID-19 in HCWs: A Systematic Review and Meta-Analysis of RCTs

    Impact of Doffing Errors on HCW Self-Contamination WShen Caring for Patients on Contact Precautions.

    Occurrence and Timing of Subsequent SARS-CoV-2 RT-PCR Positivity Among Initially Negative Patients 

    Herd Immunity

    Presymptomatic transmission of SARS-CoV-2 – Singapore; 

    SARS-CoV-2 is not detectable in the vaginal fluid of women with severe COVID-19 infection: 

    Symptom Screening at Illness Onset of Health Care Personnel With SARS-CoV-2 Infection in King County, Washington. 

    COVID-19 in a Long-Term Care Facility-King County, Washington, February 27-March 9, 2020

    Risk of nosocomial transmission of coronavirus 2019: an experience in a general ward in Hong Kong. 

    Epidemiology of and Risk Factors for Coronavirus Infection in HCWs.  

    Airborne or droplet precautions for HCWs treating COVID-19?

    Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards, Wuhan China.

    Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents.

    Air, Surface Environmental and PPE Contamination by SARS-CoV-2 from a Symptomatic Patient. 

    Anesthesiology: 

    Radiology: