Choosing Appropriate PPE

Topic Progress:

Pearls for COVID-19 PPE

1. Combine local guidelines and point of care risk when choosing PPE.
2. Doffing contaminated PPE has been found to the biggest risk of contamination.
3. Don appropriate PPE for the job at hand
.

Combine local guidelines with your point of care risk assessment when choosing PPE.

That being said, the following are potential situations where you could find yourself needing to critically think about PPE.

Case 1

A 43 year old woman with confirmed COVID-19 has rhinorrhea, sneezing and coughing is in your care. She is coughing and sneezing frequently. Her room air SPO2 is 90%. The team has consulted critical care to see her. She is in an isolation room.

What type of precautions would you don to perform an assessment?

Our Answer

Airborne.

Studies have found greater symptoms are associated with greater viral load, resulting in a higher risk of viral particles potentially transmitted with symptoms1-5.

Case 2

A 71 year old woman is in ICU with confirmed COVID-19. Her SPO2 is 86% despite being intubated, mechanically ventilated and on 100% oxygen. The plan is to ventilate her in the prone position.

What PPE would you don for prone patient positioning?

Our Answer

Airborne.

Patients who are intubated are at high risk of aerosolizing the virus, thus airborne precautions should be worn9. When proning the patient, there is an even higher risk of the ventilator circuit disconnecting and exposing the staff to the virus6.

Case 3

A 52 year old man with confirmed COVID-19 is admitted for observation. SpO2 96% on 3L O2 by nasal cannula. He is not coughing or sneezing.

What type of PPE do you don to check his vital signs?

Our Answer

Droplet and contact.

This patient is not coughing; therefore, risk of airborne transmission is low therefore droplet and contact precautions should suffice.

WHO, Canadian and ANZICS guidelines recommend droplet and contact precautions for patients with suspected or confirmed COVID-197-9.

The USA CDC recommends airborne precautions for all suspected or confirmed cases of COVID-19; however, for instances where an N95 or equivalent is not available, a surgical mask is an appropriate alternative10.

WHO, Canadian, ANZICS and USA CDC guidelines all recommend airborne precautions for any aerosol-generating procedures. In this case, there is no aerosol-generating procedure.

Case 4

A 54 year old man is on high-flow nasal cannula for refractory hypoxemia due to confirmed COVID-19. He has an intermittent cough.

What type of PPE do you don to perform an assessment?

Our Answer

Airborne.

High flow nasal cannula generates an aerosol. Some hospitals have applied a surgical mask over the high flow nasal cannula to reduce spread of aerosol; however, the patient should be on airborne precautions.

Case 5

A 72 year old woman comes to the hospital for shortness of breath. Her SpO2 97% on room air. COVID-19 swab results are pending. She is not coughing nor sneezing.

What type of PPE do you wear to check their vital signs?

Our Answer

Droplet with contact precautions.

There is low risk for coughing and sneezing; therefore, droplet precautions should suffice according to WHO, Canadian and ANZICS guidelines7-9.

The American CDC recommends airborne precautions; however, a surgical mask should suffice should there be no N95 or equivalent available10.

References

  1. Salim Rezaie, “COVID-19: Screening, Testing, PUI, and Returning to Work”, REBEL EM blog, March 1, 2020. Available at: https://rebelem.com/covid-19-screening-testing-pui-and-returning-to-work
  2. Liu Y et al. Viral Dynamics in Mild and Severe Cases of COVID-19. Lancet Infectious Disease 2020. [Epub Ahead of Print]
  3. Zou L Ruan F Huang M et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med. 2020; (published online Jan 30. DOI:10.1056/NEJMc2001737
  4. Pan Y Zhang D Yang P Poon LLM Wang Q Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020; (published online Feb 24.) https://doi.org/10.1016/S1473-3099(20)30113-4
  5. WHO Laboratory testing for 2019 novel coronavirus (2019-nCoV) in suspected human cases. https://www.who.int/publications-detail/laboratory-testing-for-2019-novel-coronavirus-in-suspected-human-cases-20200117 Date: 2020 Date accessed: April 12, 2020
  6. Resus Tonight Podcast. Episode 21: COVID-19 Experiences from the Frontline. https://resustonight.com/index.php/2020/03/18/podcast-21-covid-19-experiences-from-the-front-line-with-sara-icu-rn/
  7. WHO. (2020). Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125
  8. Government of Canada. (2020). Coronavirus disease (COVID-19): For health professionals. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals.html
  9. ANZICS. COVID-19 Guidelines. https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf
  10. CDC. (2020). Using Personal Protective Equipment (PPE). https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html

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