CME INDIA Presentation by Dr Anand Malani, MD, Sangli (Maharashtra). Interest – Critical care/ Infectious diseases/ Rheumatology.

PREVENTIVE ASPECTS FOR COVID-19 IN NON-COVID HOSPITAL SETTINGS

We are in UNLOCK phase for COVID-19, which has lived upon its name as it has UNLOCKED COVID-19 more than UNLOCKING people and their routines!

Yes, COVID-19 is already in our OPDs, IPDs, Staff and the people next door. We need to be more vigilant and extremely careful for next 6 months at least. It’s also very true that at one time we were getting complacent and less fearful about it. And now after a few incidences, encountering surprises, finding CORONA at our doorsteps and looking at the exploding number of cases, we are in search of facilities and treatment options for our patients and ourselves!

Remember, just one breathe may be sufficient to get COVID-19! AND CHANCE OF GETTING COVID IS MORE IN NON-COVID SETTINGS THAN COVID. Many of the health care workers including doctors who get infected are in NON COVID settings. This article is primarily applicable to NON COVID health care facility.

Just one breathe of air containing virus laden droplets, just one touch of contaminated fingers with your mucosae. And this can happen from an unsuspecting, asymptomatic patient to any of us. And in turn we might remain asymptomatic and become super spreader or develop the most dreaded complication and die a lonely death in a hospital not of our choice, may be in hands of the inexperienced or uncaring consultant, without getting the best of treatment you deserve! This is the truth. Let’s not play with it and try our best to avoid the infection by taking certain precautions.

Most important thing about the transmission is that the portals of entry of the virus for all practical purposes are only three – MOUTH, EYES AND NOSE. In other words, if all these three are protected in a proper airtight manner, the chance of you getting infected is very very low. Of course, hand hygiene, proper donning and doffing techniques for the facial gear are extremely important.

And the EYES are the most ignored ones. I am pretty sure that one of the reasons for high incidence of COVID-19 among health care workers, despite using PPE kits was ignoring eyes. Other important reason being using improper masks or improper techniques, and many other things done unknowingly without our knowledge that those can be dangerous!

We will discuss about preventive aspects in following headings:

1. PRIMARY DEFENCES
2. SECONDARY DEFENCES
3. TERTIARY DEFENCES
4. AN IDEAL ROUTINE
5. PERSONAL CARE
6. HOSPITAL POLICY
7. STAFF TRAINING

1. PRIMARY DEFENCES – MASKS / GOGGLES / FACE SHIELD/ HAND HYEGIENE.

[These are absolutely essential for everyone at all times.]

If properly fitted airtight mask and goggles are worn properly at all times [not even a second of breach during all of the hospital time], and proper hand hygiene is followed, the chance of getting infected should be very very low even if you are working in COVID ICU. These are more important than the full body PPE suits or kits. Mind that I have not mentioned PPE suits in primary defenses.

MASKS

These constitute the most important line of defense. If the health care worker and the patient both wear the appropriate masks in a correct manner, the risk of transmission will be minimum.

A properly fit tested N95 mask is a must for every health care worker, at least for the medicos. If in short, a good quality three ply mask for all other health care workers in non-COVID settings. Cloth masks to be discouraged.

• Go for very good quality masks. Whenever possible NIOSH approved.
• Identify and avoid fake masks. Many in market.
• 3M, Venus are good brands.
• Masks with expiratory valve to be avoided at all times. If at all needs to be used wear a 3-ply mask above N95. Remember that such masks are one-way masks. All the expired air is directly thrown out through the valve. An asymptomatic healthcare worker or patient using it will be spilling droplets all over. Can imagine the risks! Never ever allow any person with such masks into your premises. Put a notice regarding same. Train your gatekeeper for this. Simple surgical masks can be made available for sale to wear over these with the gatekeeper.
• Learn proper donning and doffing technique.
• Masks with head bands fit properly and have got adjustable straps.
• Masks with ear bands don’t fit well.
• Masks with metal clip at top for adjustment fit well and are better than those with plastic clips.
• Never touch any surface of mask anytime, neither with gloved hand, nor with bare.
• Even while donning and doffing, hold the head bands, not the mask!
• Lower band always first, while putting on and even while removing. During removing if you remove the upper band first the mask may dangle with its outer and contaminated surface touching your neck.
• Proper fitting is most important. A leaky mask will never remain N95. Improperly fitting masks will leak at edges, and allow direct exchange of air without filtering. Air will flow through path of least resistance.
• A simple fit test can be used. The mask should partially collapse or get indrawn towards your face on deep or forceful inspiration. This will indicate that air is not entering from sides. Similarly, when you expire forcefully you can feel the mask ballooning out before leaking out from edges.
• Do not remove your mask even for a second!
• Do not pull your mask over your neck or forehead for any reason. Many doctors do that in between two patients for a sigh, a sip of water, for tea etc. This is very dangerous for two reasons. Firstly, the aerosols in the air remain suspended for a prolonged time and you will be inhaling them directly. Secondly, your neck and forehead are exposed and contaminated surfaces. Pulling mask over them will result in contamination of the inner side of the mask which will be in direct contact with your inhalation apparatus!
• Similarly, do not keep mask hanging in the same room or on your table with the inner side open. It will be ideal not to remove at all.
• The best way for mask sterilization will be use of UV light. Many UV sterilization chambers are now commercially available [Philips and Orient have launched and available online]. The least clumsy and most efficient ways to sanitize. 5 minutes for each surface.
• If UV is unavailable, use one mask for a day, then keep it aside in a dry paper bag and reuse on the 5th day.
• Elastomeric masks – available form 3M in two varieties. Full face piece and half face piece. These are used with compatible P100 filters available along with.
  • These are perfectly fitting masks which pass fit test with 100% marks.
  • Adjustment from 3 sides is possible for a perfect but still comfortable fit.
  • The P-100 filter is more efficient than N95 mask. It filters 99.7% of particles above 3 microns. These are resistant to oily fumes as well. The use of these filters is basically in industrial settings but very well can be used in present scenario.
  • These are NIOSH approved.
  • CDC USA has approved for use in present pandemic.
  • Each filter will last for at least 45 days in a clean environment. Can continue use till breathing becomes difficult.
  • The mask can be used for n number of days with appropriate filter changes and cleaning/ sterilizing procedures. The straps can get worn out but can be replaced.
  • These come with an expiratory valve. Can be used as it is in COVID settings as everyone will be in appropriate PPE and the environment is already contaminated.
  • In non-COVID settings the expiratory valve can be covered from inside by a size appropriate cutting from a surgical mask, so that the expired air is filtered as well. Breathing is not much affected.
  • Daily cleaning and sterilization have to be done very carefully with all precautions. A detailed paper is available on CDC website. Also, a SOP [standard operating procedure] is provided by 3M.
  • Disinfecting by UV is equally effective and very easy. Prolonged exposure does damage the elasticated straps.
  • The FULL FACEPIECE MASK is extremely comfortable and 100% safe when used appropriately. I personally use in COVID ICUs. The DOFFING technique and the CLEANING AND STERILIZATION technique has to be learned and practiced before actual use. Improper technique is certainly hazardous. You should have your own SOP at place of your work and/or at home.

Lastly few words about PPARs – Powered purifying air respirators. Available from 3M and others. These are like air-conditioned transparent helmets. Most convenient and safe. These are expensive and cost about 1.4 lakhs. Details are beyond the scope of this article.

GOGGLES

The eye needs to be protected equally well as your nose and the mouth. Transmission of the virus through eyes has already been proved. There are 2 mechanisms in this. Firstly, the infected droplets can contaminate your conjunctivae, from where they are carried by the tears into your nose via the nasolacrimal duct. Secondly the conjunctival mucosal cells do have ACE receptors through which the virus enters the cell.

• The ideal goggle for this purpose has to be an ENCLOSED AND AIRTIGHT one. Not even a small amount of air should enter inside from any side.
• These are large sized, can be wore your spectacles, and come with a thick adjustable elasticated head band.
• Such Goggles are available from 3M / MARSHALL company.
• Non-airtight goggles will prevent from getting exposed to direct splash, but not from micro sized droplets entering from open sides.
• Another advantage of this goggle is that there is less chance of fogging.

FACESHIELDS

• These are not a substitute to enclosed goggles or masks or both. These are always partially closing, preventing direct splash on your face.
• During inspiration, the contaminated air is sucked in from the open sides of the shield and contaminates your eyes if inadequately protected. Similarly, the inside of the shield gets contaminated. Be careful while removing or cleaning/ sterilizing. Ideally disposable variety to be used.
• Can be used as a second cover over mask and goggles, especially in COVID settings.

HAND HYEGIENE

• Just to reemphasize, it is an equally important preventive tool.
• Soap water or Alcohol based sanitizer are both equally effective.
• Be aware of spurious sanitizers in market.
• Hand hygiene after anything is the key. Between each patient, after touching any surface with bare or gloved hand, after handling of fomites etc.
• Practice hand hygiene in such a manner that you should satisfy DSM IV criteria to be diagnosed as OBSESSIVE COMPULSIVE BEHAVIOUR DISORDER. Nothing more to say!

2. SECONDARY DEFENCES – COVERALLS / PPE KITS/ GLOVES

[These are desired/ essential but not compulsory in Non-COVID settings]

You will be surprised that I am calling PPE kits as secondary defenses! They are! The purpose of all of the above is to prevent direct contamination of your clothes/ exposed body parts to the aerosols. The virus doesn’t get transmitted trans dermally. Our hands come in contact with contaminated surfaces i.e. our clothes/ exposed body parts, which in turn come in contact with our nose/mouth unknowingly and causes transmission of virus laden droplets.

A person wearing a proper eye and face protective gear as discussed above, without wearing a full PPE should also be able to visit a COVID unit without getting infected provided he doffs his facial gear properly and decontaminates himself immediately. This is a theoretical possibility and not recommended for COVID units. Just quoted to reemphasize the importance of proper facial and eye gear!

PPE kits are for COVID units only. Not recommended in OPD. Should be used in OT when operating upon suspects or confirmed cases.

PPE kits should be considered in procedures or surgeries where high aerosol generation is expected, especially procedures under GA with patient intubated. A HME filter should be attached to the ET tube or supraglottic device. Similar precautions may be taken in a medical ICU where patients will be on NIV or IMV.

Please remember that many patients are asymptomatic but still transmitting infection. We still don’t have the luxury of testing everyone, and even if we have, we will still miss 30% of them due to false negatives. So, it is better to consider them as positive and proceed with due care.

Coveralls or coats up to midthigh should be used in OPD along with hood or a head cap in addition to primary gear. Either disposable or washable/ autoclavable.

The gloves don’t serve any other purpose if you are practicing hand hygiene meticulously, but it does serve the purpose of refraining you from touching your face. We are less likely to touch our face with a gloved hand even unknowingly.

3. TERTIARY DEFENCES

These are additional security measures. Wherever and whenever possible should be implemented.

• Negative pressure room OPDs with AHU – will be too much, but increase safety by a big margin. Highly desirable in OTs.
• High capacity exhaust fans can be easily installed in OPDs. Noise can be an issue.
• Air Purifiers- Many available in market. Combination of HEPA filters and Plasma cluster technology is most beneficial.
• Ultraviolet boxes for sterilization of masks, mobiles, currency, any other objects of day to day use.
• UV light in room – to be used when room is unoccupied and locked.

4. AN IDEAL ROUTINE

[From entering hospital premises till exiting hospital and entering your home in the safest possible way]

• Wear a N95 mask when you start from home.
• Mark one clean room in your hospital where you will enter first and even exit to home from this room.
• Should be as close as possible to the hospital entry.
  • This should be used in such a manner that it doesn’t get contaminated.
  • Minimum people should use this room.
  • Housekeeping at the beginning of the day by a staff who has not yet entered or worked in hospital, and also wears masks/ gloves etc. and practices hand hygiene properly.
  • Room should be well ventilated but in such a manner that air from hospital side should not enter.
  • Keep all sorts of safety gear – masks, gloves, head caps, sanitized coveralls, goggles, shoe covers, tissue rolls, few PPE kits etc. in adequate quantity here.
  • Foot operated sanitizer dispenser and a closed foot operated dust bin is a must, immediately next to the door.
  • Keep a UV box either in this room or at entrance of home.
  • Drinking water bottle and tea-coffee machine/ some dry snacks can be kept.
  • A working desk, as away as possible from the door.
  • Keep 3 chairs, 2 marked as clean, one near the desk, and one near the door, the third one semi clean, near the door
  • Multiple hangers or hooks, again a clean row and a contaminated row.
  • Should have an attached toilet.
• Once you enter this room, change into hospital clothes. Change your mask. Hang the first one on the clean hanger. Wear coverall, disposable shoe covers, enclosed goggles and then enter the hospital.
• You will need one or two breaks during your working period. Use only this room for the same. At no time, you should remove your mask or goggles during hospital time.
• Once you enter for a break, dispose off shoe covers first with a gloved hand, then remove reusable coverall and either hang it inside out on the contaminated row of the hanger if you are going to reuse it for the remaining part of the day or put it in a laundry bucket with 0.05 hypochlorite solution if using a new reusable one. Dispose of if using disposable ones. Don’t forget hand hygiene at each step. Remove goggles, mask and hang them on the contaminated hanger. If having UV box, put in them and UV for one cycle-usually 4 minutes.
• Take a semi bath or soap water wash for face and hands. Dry with a tissue paper.
• 0.5% Betadine gargles before you eat or drink.
• Can relax, drink, eat and get refreshed.
• Follow the logical sequence again while going back to work, and the same sequence while going back home. Wear the mask you had kept on your arrival while going back home.
• Keep the dustbins and laundry bucket outside while going back.
• Keep room under lock and key.
• If you are carrying your day to day money collection home, then put it in a paper envelope, mention date, UV the envelope and then carry it to home. Do not open for at least 4 days.
• Do not carry any documents/ files / anything else not absolutely necessary to your home from the hospital. This includes gifts/ sweets from MRs/ Patients, if at all you are getting!
• A thorough shower immediately after reaching home without even sitting anywhere.

5. PERSONAL CARE

• Proper diet, hydration, rest and sleep.
• Exercise with stress on Pranayama or breathing exercises and cardio exercises. Increase your lung capacity and cardiac capacity.
• 0.5% Povidone iodine gargles and nasal drops multiple times a day. Has proven to be useful. Keep at your home and in clean room.
• HCQS-Controversial. Should take if not contraindicated and tolerating well.
• Try to sleep prone for few hours each night. Will be useful in the unfortunate event of you catching COVID.
• The use of half facepiece masks also trains you for NIV!

6. HOSPITAL POLICY

• Strict checking of SPO2 at entry gate of all patients and relatives. More important than temperature.
• History taking at gate for cough/ fever etc. Triage and isolation area to examine such patients in a designated area. Such patients should not enter the main hospital premises.
• NO MASK – NO ENTRY.
• STRICT NO TO MASKS WITH EXPIRATORY VALVES.
• No entry to multiple relatives.
• No or minimal visitors in a restricted time span.
• Foot operated sanitizer dispensers at multiple places.
• Hospital disinfection multiple times a day using appropriate method and your own SOPs which includes manual sanitization of surfaces, floor, walls by disinfectant sprays, alcohol-based sprays.
• All patients and relatives have to wear masks at all times.
• Ensure that patient and everyone else in the room wears a mask before staff of doctor enters. Ensure that they don’t pull it down while speaking.
• Hand over a printed mask etiquette and other instruction sheet on admission to each patient/relative. Staff can instruct them and give a short training as well.
• COVID test before each planned surgery can be helpful.
• Immediate quarantine of exposed staff. If required, their testing.
• Provide all the necessary safety gear to your staff as well.

7. STAFF TRAINING

• The most important link between you and COVID!
• The most complacent and the least fearful. They bank on us and are confident that we are there to take care if something happens.
• Explain it to them that you will be unable to handle it. At the least we can get them insured!
• Careless staff attitude will take you very close to COVID. All the above precautions may go in vain.
• Train them, each and every one, to practice Primary Defenses at least if not all. Repeated counselling will be needed to get training converted into useful implementation.
• Staff following all precautionary measures, and then sitting all together very near to each other for meals/ tea/ chitchat is a universal scenario and very dangerous proposition for everyone.
• Their chance of getting infected outside the hospital is also very high. They always ignore this aspect. Reemphasize on repeated basis.

It is indeed difficult to practice each and everything mentioned above on a continuous and prolonged basis, but believe me, it is not that difficult if you decide. Just a matter of few days to get used to!

If all things are followed at all times, I am sure the chance of you getting COVID-19 from your work place will be minimal!

And this shouldn’t make you complacent in non-hospital settings. A casual approach outside the hospital [of you and your staff as well] will again put all the efforts down the drain!

Stay safe – Work safe – Always!!

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