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INFECTION CONTROL: COVID-19 AND EMERGING POLICIES IN HEALTHCARE

NOAH CARPENTER, MD

Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon. He completed his Bachelor of Science in chemistry and medical school and training at the University of Manitoba. Dr. Carpenter completed surgical residency and fellowship at the University of Edmonton and Affiliated Hospitals in Edmonton, Alberta, and an additional Adult Cardiovascular and Thoracic Surgery fellowship at the University of Edinburgh, Scotland. He has specialized in microsurgical techniques, vascular endoscopy, laser and laparoscopic surgery in Brandon, Manitoba and Vancouver, British Columbia, Canada and in Colorado, Texas, and California. Dr. Carpenter has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of the Indigenous Physicians Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education.

DANA BARTLETT, RN, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 27 years as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, textbook chapters, and more than 100 online CE articles, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology and was a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center. He lives in Wappingers Falls, NY.

ABSTRACT

Cases of COVID-19 have increased around healthcare professionals. This calls for a review and revision of measures to prevent the spread of disease within a healthcare setting. SARS-CoV-2 spread may be faster and consideration of infection control practices should take into account spread that can occur as a result of droplet, aerosol, and other body fluid contact. As a drug or vaccine is being investigated for SARS-CoV-2, healthcare professionals are solely reliant on infection control and prevention measures for safety and to help reduce transmission of infection.

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Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. Continuing Education Credit Designation This educational activity is credited for 2 hours at completion of the activity. Statement of Learning Need As scientists and public health agencies attempt to learn about the novel coronavirus, there are many areas of investigation related to how the virus acts in the wild, within specific geographic regions and populations. Healthcare workers need to understand the various modes of virus transmission and the effective infection control and prevention measures needed to prevent disease while new immunization and treatment are studied by medical scientists. Course Purpose To inform health professionals of the facts about COVID19 disease statistics and the evolving knowledge of viral transmission, disease symptoms, and of current infection control guidelines that impact health teams working near people who have been potentially exposed and/or diagnosed with COVID19. Target Audience Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members. Disclosures Noah Carpenter, MD, Dana Bartlett, RN, BSN, MSN, MA, CSPI, William Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures. There is no commercial support.

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Self-Assessment of Knowledge Pre-Test: 1. In humans, coronaviruses typically appear as

a. an influenza A virus. b. as a form of tuberculosis. c. pneumonia. d. a common cold.

2. The most recent CDC position on how COVID-19 is spread states

that it is transmitted through person-to-person contact primarily

a. from shaking hands. b. via respiratory droplets. c. through sharing objects. d. from contact with surfaces.

3. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is

distinctive from MERS-CoV, SARS-CoV-1 or the influenza virus because it

a. appears to be more contagious. b. attacks only the upper respiratory system. c. can lead to pneumonia. d. can be transmitted from person to person.

4. A symptomatic healthcare worker with suspected or laboratory-

confirmed COVID-19 can return to work using a symptom-based strategy if

a. at least 3 days (72 hours) have passed since recovery. b. 14 days have passed without symptoms. c. the worker is able to remain 6 feet apart from others. d. at least 14 days have passed since the symptoms first appeared.

5. Airborne transmission of SARS-CoV-2 from one person to another

over long distances

a. has been documented. b. is unlikely. c. is one of the major concerns of healthcare workers. d. is more likely than not.

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Introduction

The worldwide outbreak of the coronavirus disease (COVID-19) has led to extreme challenges within the healthcare industry. Healthcare workers must perform their critical role while taking precautions to protect patients, family, co-workers and themselves from contracting COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes COVID-19. Understanding SARS-CoV-2 and how it is transmitted has been vital to the development and implementation of healthcare facility precautions and procedures. This has been difficult because information about SARS-CoV-2 has not been static, and it has even been conflicting at times. In this challenging environment, infection control precautions and procedures have been developed to help reduce the risk of healthcare workers contracting the virus and to reduce the rate of virus transmission and nosocomial infection. If a healthcare worker is exposed or suspects exposure to SARS-CoV-2, additional actions and precautions must be taken related to infection control and isolation until the virus and/or symptoms are cleared.

Emergence and Prevalence of COVID-19

In humans, coronaviruses typically appear as a common cold. The common cold usually causes an upper-respiratory tract infection that leads to mild or moderate symptoms in healthy individuals.1 However, in the past 20 years, three coronaviruses have emerged in humans that have attacked the lower-respiratory tract, leading to more serious illnesses such as pneumonia or bronchitis.2 These emergent coronaviruses included the Middle East respiratory syndrome coronavirus (MERS-CoV) and the severe acute respiratory coronavirus-1 (SARS-CoV-1). The MERS-CoV and SARS-CoV-1 serious outbreaks that led to hospitalization and death, especially among individuals who have weakened immune systems and comorbidities.2

In the latter part of 2019, cases of COVID-19 appeared in Wuhan China.3

Like MERS-CoV and SARS-CoV-1, the SARS-CoV-2 may cause lower-respiratory tract infection generally referred to as COVID-19.3 Some patients

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with COVID-19 may be asymptomatic but others may sustain acute respiratory distress syndrome, which may be fatal.3

Severe acute respiratory syndrome coronavirus 2 is distinct from MERS-

CoV, SARS-CoV-1 or the influenza virus because it appears to be more contagious than these other viruses.2 Also, individuals who carry SARS-CoV-2 may be asymptomatic. A report published by Wu and McGoogan (2020) found that 1% of patients with SARS-CoV-2 infections were asymptomatic;4 however, more recent reports suggest that a substantial proportion of SARS-VoV-2 infections are asymptomatic.4 The CDC follows this view.4

As a result of the virus’ contagious effects, absence of symptoms, and

global spread, COVID-19 has been called the most serious public health threat from a respiratory virus since the 1918 H1N1 influenza pandemic.2,3 The extent of this threat has been seen in its global impact. More than five million confirmed cases of COVID-19 worldwide have been reported.5 Following the initial cases reported in late 2019 from Wuhan, China, more cases of COVID-19 have been reported in all continents, excluding Antarctica.5

Healthcare workers have been at the forefront of the fight to control the spread of COVID-19 and to treat individuals who have contracted the disease. This means that healthcare workers have been, and continue to be, at higher risk of developing COVID-19 in the workplace.6 A review from Italy surveyed healthcare workers caring for COVID-19 patients across the country. Most of the respondents were physicians. The survey showed that up to 18% of the responding healthcare workers tested positive for COVID-19, and that 33% were asymptomatic.7 In the United States, the Centers for Disease Control and Prevention (CDC) reported that the majority of healthcare workers who were diagnosed with COVID-19 (6,760, 90%) had not been hospitalized.7 There were reports, however, of severe outcomes: “27 deaths, occurred across all age groups; deaths most frequently occurred in HCP [health care personnel] aged ≥65 years.”7 Whether the healthcare worker acquires COVID-19 during work or in the community, healthcare workers are at risk of health consequences.7

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The high risk of contracting COVID-19 among healthcare workers has led to the development of CDC infection control recommendations and guidelines.8-10 These recommendations and guidelines reference that they were based on the information available at that time.8-10 This is important because of the uncertainty surrounding the transmission of COVID-19.

Transmission of COVID-19

All aspects of how COVID-19 spreads is not currently known. The CDC has stated in an early, mandated fact sheet: “Common human coronaviruses usually spread from an infected person to others through the air by coughing and sneezing; close personal contact, like touching or shaking hands; and from touching an object or surface with the virus on it, then touching your mouth, nose, or eyes before washing your hands.”1 The World Health Organization agreed with this early position.11

By spring 2020, the CDC revised its policy for healthcare workers by clarifying that investigations into how COVID-19 spreads were ongoing and that theories of its spread were principally based on what was known of other coronaviruses.10 The CDC reported on two ways COVID-19 could spread: person to person from people in close contact with each other (6 feet or less) and from respiratory droplets produced when an infected person coughs or sneezes; and, it may spread when a person comes in contact with an infected surface or object, and then touches the mouth, nose, or eyes.10

The most recent CDC position on how COVID-19 is spread stated that it

is transmitted through person-to-person contact, “primarily via respiratory droplets produced when the infected person speaks, coughs, or sneezes. Droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs of those within close proximity.”12 The CDC has also stated that the “contribution of small respirable particles, sometimes called aerosols or droplet nuclei, to close proximity transmission is currently uncertain. However, airborne transmission from person-to-person over long distances is unlikely.”8

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The CDC’s current position is consistent with a number of studies suggesting that COVID-19 is primarily spread from human to human through respiratory droplets.13 Virus-infected droplets are expelled from the upper respiratory tract when someone coughs, sneezes, or talks, and the virus is transmitted when the infected droplets contact the mucous membranes of the eyes, mouth, and nose.14 Airborne/droplet infection “is caused by infected agents in the air around a person.”15 Airborne transmission of pathogens are “aerosols, re-aerosols, microbe-carrying particles, huge amounts of bacteria-carrying airborne skin cells, dust, droplets and droplet nuclei.”15 Contact transmission from contaminated environment, equipment, textiles and waste is also a coinciding possibility, because small droplets (<5 µm) can be spread to surfaces when a person coughs, sneezes, shouts, sings and speaks distinctly.15 Droplets can remain for many hours in the air and may be carried long distances outside a patient’s room by normal air currents; therefore, droplet isolation and droplet precaution is included in the airborne isolation regime.15

Unanswered questions about COVID-19 transmission of significance include: 1) How long an infected person can transmit the disease? 2) Is transmission of COVID-19 by contact with an infected surface significant? 3) Is airborne transmission of COVID-19 possible and has it occurred? 4) Are there non-respiratory routes of transmission? 5) What is the nature of droplet transmission of COVID-19? Person-to-Person Transmission

The incubation period of COVID-19 is thought to be within 14 days of exposure. The reported range is 2-14 days.6 The median time from exposure to the development of symptoms is thought to be 4-5 days. Lauer, et al. (2020) found that 97.5% of infected patients developed symptoms within 11.5 days.16

The risk of transmission depends on the duration of contact with an

infected person, the type of contact, whether personal protective equipment had been used, and the amount of virus in the respiratory secretions.17 The

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period during which an infected person can transmit the disease remains unknown.17 People who are in the incubation period and asymptomatic may have a viral load as high or higher than symptomatic patients.18

Transmission of COVID-19 can be from an asymptomatic person.17,18

Also, there is evidence suggesting that people who have a COVID-19 infection but never develop symptoms can infect others.19-22 Viral RNA shedding can continue for some time after symptoms have resolved, but the presence of viral RNA does not necessarily mean that infectious viral particles are present.17

Fomite Transmission

A fomite is an object that is not itself harmful but can be contaminated by a pathogen and become a source of pathogen transmission.23 There are reports of contamination of surfaces in the rooms of COVID-19 patients.24

COVID-19 contamination of bed rails, clothing, doorknobs, PPE, shoes,

sinks, toilet bowls, and many other personal objects and environmental surfaces has been documented.25-29 In these cases, viral viability was not established. Importantly, environmental contamination does not necessarily mean that viable, transmittable amounts of COVID-19 are present. It is also not known how long COVID-19 virus can survive and remain infectious in the environment. Other coronaviruses have been reported to remain viable on surfaces for up to 9 days.24 Yung et al., found that despite “close physical contact with the infant during feeding, we did not detect any evidence of SARS-CoV-2 on the gown of the HCW.”24

The CDC has suggested that the virus may be spread from contact with

a contaminated surface but this method of transmission “is not thought to be the main way the virus spreads” and the CDC is still learning about the virus.12 The World Health Organization takes a more definitive approach to surface contamination. It states that “droplets can land on objects and surfaces around the person such as tables, doorknobs and handrails. People can

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become infected by touching these objects or surfaces, then touching their eyes, nose or mouth.”30

Airborne Transmission

Currently, airborne transmission of the COVID-19 virus has not been documented.31 However, commonly performed procedures where the virus can potentially spread may include bronchoscopy, nebulizer treatments, positive pressure ventilation, and endotracheal intubation, which can generate airborne aerosols.29 There may be evidence that COVID-19 can become airborne, staying suspended in the air for a significant amount of time and travel a significant distance.31-35 Although the presence of COVID-19 in the air is not the same as airborne transmission of the virus, Finberg (2020) stated that “... available research supports the possibility that SARS-CoV-2 could be spread via bioaerosols generated directly by patients’ exhalation.”33 Non-Respiratory Routes of Transmission

COVID-19 virus has been detected in blood, feces, ocular secretions, saliva, semen, and in the gastrointestinal (GI) tract.32,36-38 It is not known as yet whether the virus can be transmitted by contact with these body fluids.17 There are no documented cases of COVID-19 being transmitted from domesticated animals like cats and dogs to people or from people to domesticated animals.17

Infection Control Techniques in Healthcare

Infection control techniques in healthcare facilities are vitally important for preventing transmission of infection in a healthcare setting. Standard precautions provide infection prevention guidelines and practices that apply generally to patient care.39 In addition to following standard precaution guidelines, healthcare workers coming in contact with patients with COVID-19 or suspected of being infected should follow additional recommendations adopted by their facility under recommendations from the CDC, WHO or other applicable agency or association.

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Infection Control in Healthcare: Source Control

Source control decreases the risk that healthcare workers and patients will be exposed to COVID-19 from the community by controlling visitor access to healthcare facilities and by ensuring that while in the facility, visitors use infection control techniques that prevent virus transmission. Source control also protects healthcare workers and patients by evaluating patients when they arrive either by emergency medicine services (EMS) transport or as walk-ins to an emergency room. The CDC provides recommendations, which are reviewed next.

Visitors

All visitors to a health facility should be instructed to use hand hygiene, cough etiquette, and respiratory hygiene techniques. They should understand when to use such precautions to avoid spread of infection.18 Visitors should also observe social distancing, described as always maintaining six feet of distance from other people.

Droplet transmission is defined, in part, by the distance an infectious respiratory particle can travel through the air. If the particle goes no more than six feet (two meters), this is considered droplet transmission. If the particle goes farther than six feet, then airborne transmission could be possible. There is evidence that suggests that the COVID-19 virus could travel farther than six feet.31,32 As previously mentioned, airborne transmission of the COVID-19 virus has currently not been documented and the CDC recommends six feet of separation as the proper, safe social distance.18

Visitors to a healthcare facility should wear a face cover, either a surgical

mask or an approved cloth mask, and if the visitor does not have either type of mask, then one should be provided by the health facility.18 The face cover should be put on before entering the facility, and it should not be removed until the visitor has left.18 The American Academy of Pediatrics recommends that children < two years of age should not wear a face covering.40 For this particular pediatric population, social distancing is advised. Face covers or

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masks should not be placed on anyone who is unconscious or cannot remove the mask if needed.18

Visitors should be instructed on the proper use of face covers. Face covers can become saturated with respiratory secretions, and they should be changed if they become damp or soiled.18 Once the face cover is in place, it should not be touched, and if the face cover is touched, visitors should be encouraged to wash their hands, or to use an alcohol-based hand sanitizer as soon as possible.18

The CDC also recommends that in a public setting, everyone should wear a cloth face cover.41 In some state regions, wearing a face cover when in public is mandatory. A cloth face cover is not a surgical mask or an N95 respirator; those are commercially produced personal protective equipment (PPE).41

There are no clinical trials that have proven that community use of

home-made face coverings can stop or reduce the transmission of COVID-19 or other respiratory viruses.42 However, research has shown that home-made face covers do provide a meaningful level of protection against exposure to particles, they can prevent exposure to airborne transmission of viruses, and they can significantly reduce the number of microorganisms transmitted.41 Also, computer modeling has shown that even a relatively ineffective face cover could significantly reduce the rate of community transmission of COVID-19.42

Eikenberry, et al. (2020) has stated that “broad adoption of even

relatively ineffective face masks may meaningfully reduce community transmission of COVID-19 and decrease peak hospitalizations and deaths, and masks could synergize with other non-pharmaceutical measures. Hypothetical mask adoption scenarios, for Washington and New York state, suggest that immediate near-universal (80%) adoption of moderately (50%) effective masks could prevent an estimated 17% - 45% of projected deaths over two months in New York. Even very weak masks can still be useful (20% effective) if the underlying transmission rate is relatively low or decreasing.”42

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The CDC recommendations state that measuring body temperature and checking for symptoms are relatively ineffective at identifying individuals who are infected with COVID-19.18 There are multiple reasons why this is the case: 1) Asymptomatic infections are well documented and relatively common; 2) Not all symptomatic patients have a fever; 3) Transmission of the virus from asymptomatic patients has been documented; 4) Screening procedures can be done incorrectly; and, 5) Previous experience with these types of screening have shown that it is not effective for preventing the spread of a viral disease.43-45 Many U.S., healthcare facilities do ask visitors about COVID-19 risk factors and symptoms and measure their body temperature before allowing them access to the facility. Given that this process is quick and harmless, visitors are expected to comply with requirements of the health facility. Health Staff

Health clinicians working in an acute care or community care setting are generally familiar with Standard Precautions, infection control techniques related to cough etiquette and hand hygiene, and the use of personal protective equipment (PPE). The CDC provides a helpful resource for healthcare administrators and staff to ensure proper education and training:18

● Provide job- or task-specific education and training on preventing

transmission of infectious agents, and provide education updates; ● Provide both education and training of healthcare staff for the appropriate

use of personal protective equipment (PPE) prior to providing patient care, including the correct use of PPE, prevention of contamination of clothing, of skin, and of the environment while removing such equipment.

The CDC recommends that hospital infection control include standard

precautions dedicated to the disinfection of medical equipment used to care for patients suspected to have or diagnosed with COVID-19. Non-disposable medical equipment with manufacturer’s instructions should be followed, including health facility policies established to prevent cross-contamination, such as use of hospital-grade disinfectants for equipment surfaces appropriate

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for SARS-CoV-2 in healthcare settings.18 This should also be the case for patient-care areas involving aerosol generating procedures.

The U.S., Environmental Protection Agency (EPA) provides information online that lists EPA-registered disinfectants that are recommended for emerging viral pathogens, including SARS-CoV-2.46 Medical waste, hospital laundry and food service utensils should be carried forward according to CDC recommendations for healthcare agencies and hospital policy aimed at standard procedures to prevent infection transmission between healthcare workers, patients and visitors. Recommended practices for PPE and cleaning procedures may be found at the CDC website at: Healthcare Infection Prevention and Control FAQs for COVID-19.47

Appointments and Elective Procedures

Non-urgent appointments should be done by teleconference, if possible. A patient should not keep an appointment or arrive for an elective procedure with a fever and/or signs and symptoms of COVID-19 infection.18 Patients should put a cloth face cover before arrival for an appointment or an elective procedure, even if afebrile and asymptomatic, and wear it until they are outside.18 During the appointment or procedure, patients should use cough etiquette, hand hygiene, and respiratory hygiene.18 Social distancing should be observed.18

Triaging New Patients and Quarantine Procedures

Triage areas should be set up in hospital care and other healthcare

agencies so that patients will be no closer to one another than six feet. Triage personnel should wear an N95 respirator, gloves, and eye protection, and use other PPE as needed.18 If an N95 respirator is not available, a face mask can be used.18 Standard Precautions, cough etiquette, respiratory hygiene, and contact precautions must be followed.18

Patients should be provided with a face covering or a surgical mask. Temperature measurement is usually done as part of triage, and patients

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should be asked if they have had a fever or any signs or symptoms of COVID-19 infection.18 An abbreviated form of the CDC recommendations for triaging and patient placement is in Table 1.48 The full recommendations can be viewed at the CDC website.49

TABLE 1: CDC COVID-19 TRIAGE GUIDELINES

1. In the past 14 days before the onset of symptoms has the patient traveled to China

or had close contact — six feet or less — with someone who has a COVID-19 infection? 2. Does the patient have a fever or signs and symptoms of a lower respiratory infection? 3. If yes to either question, put a mask on the patient and isolate him/her in a private

room and close the door, or place the patient in a separate area so that there will be no close contact with anyone else.

4. The local health department should be notified about the case and a decision should be made to test or not test the patient.

The CDC guidelines for testing individuals for COVID-19 state that high priority should be given to anyone who has symptoms and who is a hospitalized patient, a healthcare worker, a first responder, and a worker in a congregate living setting.50 The CDC also has guidelines for collecting, handling, and testing clinical specimens for COVID-19.51

Priority guidelines are further explained by the CDC for people with symptoms of potential COVID-19 infection, including fever, cough, shortness of breath, chills, muscle pain, new loss of taste or smell, vomiting or diarrhea, and/or sore throat.51 For people without symptoms who are prioritized by health departments or clinicians, for any reason, public health monitoring may incorporate sentinel surveillance, or screening of other asymptomatic individuals according to state and local plans.51 Emergency Medical Services

Emergency Medical Services (EMSs) that respond to a call will need to determine whether the patient has been exposed to or diagnosed with COVID-19. For COVID-19 cases, on-site triage should be done from at least six feet

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away, if possible until the patient has been given a mask.52 During transport, EMS personnel should use Standard Precautions, contact precautions, and droplet precautions, and wear PPE.52-54 Basic PPE for EMS personnel includes use of a respirator, gloves, a gown, and goggles or a face shield.52 A facemask is acceptable if a respirator is not available (CDC, 2020).52

Aerosol-generating procedures should be avoided, and if possible, the medical command should be consulted before performing an aerosol-generating procedure.52 The number of personnel in the patient compartment should be limited.52-54 Family members should not ride in the patient compartment.52 The receiving facility should be notified that a possible COVID-19 case is arriving and on arrival, the patient should be taken immediately to a private room.52 In-Patient Infection Control

Patients who have a confirmed or suspected COVID-19 infection should be assigned to a private room with a private bathroom and the door should always be closed.18 Whenever possible, procedures and tests should be done at the bedside in the patient’s room.18 If the patient must be transferred to another part of the facility, the patient should wear a mask.18

Personal Protective Equipment

This section covers specific CDC recommendations for the use of personal protective equipment related to confirmed cases of COVID-19. Gloves, an isolation gown, a face shield or goggles, and an N95 type respirator should be worn by anyone who has direct patient contact.18 If an N95 respirator is not available, a face mask can be used, but a respirator is preferable.36 A cloth face covering is not acceptable as PPE.18

The N95 respirator is as least as effective as a surgical mask at preventing droplet transmission and it is more effective at preventing airborne transmission than a surgical mask.42 Given the recent onset of the COVID-19 pandemic, there is little data that can be used confirm or disprove that an N95

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is superior to a surgical mask at protecting healthcare workers.55 The World Health Organization (WHO) recommends that a surgical mask is a sufficient protection for healthcare workers.56 However, the CDC and WHO recommend that an N95 be worn during an aerosol-generating procedure.18,56

The CDC recommends that healthcare workers wear an N95 when caring

for COVID-19 patients.18 Extended use, re-use, and decontamination of an N95 respirator are not standard, recommended practices, but because of the COVID-19 pandemic and supply problems, the CDC does have guidelines that allow for the extended-use, re-use, and decontamination of N95s.57,58 Healthcare facilities should have protocols for N95 use that cover these topics, and the CDC guidelines are available at the CDC website.57,58

Aerosol-Generating Procedures

Expert sources consistently state that if a patient is infected with COVID-

19, aerosol-generating procedures should be avoided if possible, and if they are necessary, extra caution should be used to avoid infecting healthcare workers. Currently, there is no definitive, all-inclusive list of procedures known as or potentially aerosol-generating.59 Also, the level of risk of transmission of COVID-19, or of any pathogen, during an aerosol-generating procedure is not known.59 The risk would depend on a multitude of factors that may include the patient’s viral load, the duration of the exposure, and the proximity to the patient or procedure.60

Procedures that may generate an infectious aerosol are listed in Table 2.59 Several of these procedures will be discussed, but there is very little published literature on the topic.

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TABLE 2: AEROSOL-GENERATING PROCEDURES

Bronchoscopy

Cardiopulmonary resuscitation (CPR) Endotracheal intubation and extubation

High flow oxygen delivery Manual ventilation

Nebulizer administration Non-invasive ventilation like BiPAP and CPAP

Open airway suctioning Sputum induction

An aerosol is defined as solid or liquid particles suspended in a gas. Aerosols and droplets are expelled from the respiratory tract during coughing, sneezing, and talking, but droplets quickly fall out of the air and do not travel far. An aerosol (and anything that is in the aerosol) can remain in the air longer and can travel farther than droplets.61

A useful, simple way to distinguish between solid and liquid particle

transmission is to imagine a droplet as a liquid and an aerosol as a mist or vapor. The distinction between aerosol transmission and droplet transmission is used as a practical way of determining which infection control techniques are needed, but is not absolute.19 Cardiopulmonary Resuscitation

Cardiopulmonary resuscitation is a very high-risk procedure for the transmission of infection.62 The CDC and WHO have identified CPR as a possible aerosol-generating procedure. Couper, et al. (2020) searched multiple databases and reviewed the published literature, trying to answer three questions about CPR and the generation of aerosols:62 Do chest compressions or defibrillation generate aerosols? Does performing chest compressions or defibrillation transmit infectious disease? Is PPE effective at preventing the transmission of infectious disease during the performance of chest compressions, defibrillation, and other resuscitation activities?

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The authors found that chest compressions may produce aerosols and that CPR has been associated with the transmission of infection. But they also stated that when transmission of infection occurs during CPR “... it is likely there was simultaneous exposure to airway maneuvers such that the isolated effect of either chest compressions or defibrillation could not be reliably identified.”62 Cooper and colleagues concluded that aerosol generation from chest compressions is clinically and physically plausible, although it is unclear how defibrillation could generate an aerosol.63 The authors did not find any direct evidence that chest compressions or defibrillation either did or did not generate aerosols. No direct evidence was found that chest compressions or defibrillation were associated with the transmission of infection.62 They stated that the use of PPE possibly delayed resuscitation and that performing chest compressions may reduce the effectiveness of a face mask.62 There is a limited amount of research and information about infection transmission and CPR. High Flow Oxygen

High flow oxygen via a nasal cannula is a recommended and commonly used treatment for COVID-19 infected patients, but this mode of oxygen therapy can be aerosol-generating.62,63,64 The level of aerosol that is produced and the risk to healthcare workers by using this mode of oxygen therapy is not known.62 Expert sources, professional organizations, and authoritative reviews, however, all recommend that high flow oxygen via nasal cannula is used, the patient should be in an airborne isolation room, the lowest effective flow rate should be used, and full personal protective equipment should be used.63-65 A surgical mask or an N95 placed on the patient during the treatment may help prevent aerosol dispersion.63 Intubation

Intubation and extubation are very high-risk procedures for droplet dispersion and aerosol generation.62,64 Clinical experience with patients infected with SARS coronavirus 1 (SARS-CoV-1) infection showed a significantly increased risk of virus transmission from intubation66 and a study by Feldman, et al. (2020) used mannequins and a fluorescent dye marker to

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represent droplets and they found that despite the use of PPE, intubation resulted in droplet contamination of uncovered hair, skin, and shoes of the participants.67

Intubation of a COVID-19 infected patient should be done in an airborne

isolation room. To decrease complications and delays it should be done by the most experienced person.62 Staff should wear gloves, a gown, an N95 mask, and a face shield, a hair cover, shoe covers, and a neck covering.62

Nebulizer Administration

Nebulizer treatments can produce aerosols.61,68-70 In addition, aerosols from the patient’s respiratory tract and aerosolized medication are involved during nebulizer treatments.70

Nebulizer treatments may increase the generation of droplets.71 If

possible, the use metered-dose inhalers is recommended for patients who have asthma or chronic obstructive pulmonary disease (COPD) instead of nebulizers.64,69 If this is not possible, nebulizer treatments should be administered in an airborne isolation room, the number of staff in the room should be minimized, and the proper PPE should be worn.64

Discontinuing Transmission Precautions

The CDC has guidelines for discontinuing transmission precautions in

the healthcare setting and for patients who are discharged from a healthcare facility.71 Symptomatic Patients

For symptomatic patients, the decision to discontinue transmission precautions can be made by using a symptom-based strategy or a test-based strategy.72

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Symptom-based Strategy ● Transmission precautions can be discontinued if at least 3 days (72 hours)

have passed since recovery, defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath).

● At least 10 days have passed since symptoms first appeared. Test-based Strategy ● Transmission precautions can be discontinued if there is a resolution of

fever without the use of fever-reducing medications. ● Improvement in respiratory symptoms (e.g., cough, shortness of breath). ● Negative results of an FDA Emergency Use Authorized COVID-19

molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥ 24 hours apart (total of two negative specimens).

Laboratory-Confirmed COVID-19: Asymptomatic Patients

For asymptomatic patients with laboratory-confirmed COVID-19, the decision to discontinue transmission precautions can be made by using a time-based strategy or a test-based strategy.71 Time-based Strategy

Transmission precautions can be discontinued if 10 days have passed since the date of the first positive COVID-19 diagnostic test, assuming the patient has not subsequently developed symptoms since the positive test. Symptoms cannot be used to gauge where these individuals are in the course of their illness, so it is possible that viral shedding could be longer or shorter than 10 days after the first positive test.

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Test-based Strategy

Transmission precautions can be discontinued if there are negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for the detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥ 24 hours apart (total of two negative specimens). Because of the absence of symptoms, it is not possible to gauge where these individuals are in the course of their illness. There have been reports of prolonged detection of RNA without a direct correlation to viral culture. Empiric Transmission Precautions

Empiric transmission precautions that were put in place for a patient suspected to have a COVID-19 infection can be discontinued if the patient has a negative result from at least one FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA.71 If the clinician has a high level of suspicion that a COVID-19 infection is present, a second test can be done. If the patient was never tested, the decision to discontinue transmission precautions can be made based upon using the symptom-based strategy.71

Clinical judgment and suspicion of SARS-CoV-2 infection should be the determiners for whether to continue or discontinue empiric transmission precautions.71 Home, Nursing Home, or Long-Term Care Facility Discharges

Isolation should be continued if the patient is discharged to home before transmission precautions are discontinued. The decision to send the patient home should be made in consultation with the patient’s clinical care team and local or state public health departments.71

Patients discharged to a nursing home or a long-term care facility and transmission precautions are still required to undergo isolation.71 Patients should go to a facility that can follow the infection prevention and control recommendations for the care of COVID-19 patients. Preferably, the patient would be placed in a location designated to care for COVID-19 residents.71

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Patients who are discharged to a nursing home or a long-term care facility who had their transmission precautions previously discontinued, should be assessed for symptoms. If any patient has persistent symptoms from COVID-19, the patient should be placed in a single room, be restricted to the assigned room as much as possible, and wear a facemask during care activities until all symptoms are completely resolved or at baseline.73 For patients who have been discharged to a nursing home or a long-term care facility with discontinued transmission precautions, if patient symptoms have resolved, no further restrictions are required, based upon their history of COVID-19.71

Both the symptom-based and test-based strategies have limits. The symptom-based strategy depends on the idea that the transmission of the virus occurs early in the infection and in some cases (such as in a situation where a patient is immunocompromised) this may not be true. The test-based strategy may unnecessarily extend the use of precautions because prolonged viral shedding — which may not be a risk of virus transmission — can occur.72

Post-Mortem Care

Cadavers are not infectious, and there is no evidence that exposure to the body of someone who had COVID-19 puts someone at risk for getting the disease.73 Handling the body of someone who had a COVID-19 infection does not require special care or precautions; standard precautions and PPE are used as needed.73

Healthcare Workers and COVID-19 Exposure

The CDC guidelines for healthcare workers who have been diagnosed with or possibly exposed to the COVID-19 virus, or who have signs and symptoms of a COVID-19 infection, are summarized below.74

● Any healthcare worker who had prolonged, close contact with a patient,

visitor or another healthcare worker who had a confirmed COVID-19

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infection and did not use PPE as required should not work for 14 days after the last exposure.

● Exposure can also be contact with a patient being investigated for COVID-19.

● Prolonged is defined as ≥ 15 minutes. ● The healthcare worker should monitor herself/himself for fever and/or

signs and symptoms of COVID-19 infection. If these occur, he/she should notify their point of contact at the healthcare facility.

● Any healthcare worker who develops a fever or signs and symptoms of a COVID-19 infection should immediately self-isolate and notify the appropriate in-house department or contact.

The CDC guidelines for healthcare workers to return to work if they had

a confirmed or suspected COVID-19 infection are summarized below. Symptomatic, suspected or confirmed COVID-19

For a symptomatic healthcare worker with suspected or laboratory- confirmed COVID-19, a symptom-based strategy or a test-based strategy can be used to determine when the healthcare worker can return to work.74 Symptom-based strategy: Exclude from work until - ● At least 3 days (72 hours) have passed since recovery, defined as

resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath) and,

● At least 10 days have passed since the symptoms first appeared. Test-based strategy: Exclude from work until - ● Resolution of fever without the use of fever-reducing medications and, ● Improvement in respiratory symptoms (e.g., cough, shortness of breath) ● There are negative results of an FDA Emergency Use Authorized COVID-

19 molecular assay for the detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens).

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Asymptomatic, laboratory-confirmed COVID-19 infection

For an asymptomatic healthcare worker with a laboratory-confirmed COVID-19, a time-based strategy or a test-based strategy can be used to determine when that person can be allowed to work again.75 Time-based strategy: Exclude from work until - ● 10 days have passed since the date of the first positive COVID-19

diagnostic test assuming the patient did not subsequently develop symptoms since the positive test.

● If symptoms develop then the symptom-based or test-based strategy should be used.

● Note: Symptoms cannot be used to gauge where these individuals are in the course of their illness, and the duration of viral shedding could be longer or shorter than 10 days after their first positive test.

Test-based strategy: Exclude from work until - ● Negative results of an FDA Emergency Use Authorized COVID-19

molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens).

● Note: Because of the absence of symptoms, it is not possible to gauge where these individuals are in the course of their illness. There have been reports of prolonged detection of RNA without a direct correlation to viral culture.

There are no cures and no vaccines for COVID-19.76 Decreasing the

number of infections and deaths must, therefore, depend on control and prevention using one of two strategies, mitigation or suppression.77 Mitigation is intended to protect the most vulnerable populations by isolating and quarantining them and the disease can spread, and less vulnerable populations will develop immunity, herd immunity. This approach would hopefully reduce the demand for healthcare resources, protect the people most likely to suffer, and (hopefully) reduce the long-term impact of the virus but like any strategy it has risks. With this approach, the risk is assuming that

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the number of cases and deaths and the stress on healthcare systems will be acceptable and manageable.76,77

Suppression is intended to reduce the number of COVID-19 cases to a manageable number by using aggressive measures to reduce the spread of the disease and prevent transmission of COVID-19, e.g., social distancing and the widespread use of basic infection control techniques like handwashing.77 This approach may be effective at reducing the demands on the healthcare system, and it may reduce the number of infections to a point at which the basic reproduction number — the number of expected cases of an infectious disease directly spread by one person — is low enough that very few new cases will occur, but it does not allow for herd immunity.77 Also, although social distancing is thought to be very useful for preventing the spread of COVID-19, it must be in place for many months to be effective.78 Some form of social distancing would need to be maintained until a vaccine is available.79

The social and economic effects of social distancing are significant. It is

beyond the scope of this section to compare mitigation and suppression but infection control techniques like handwashing, social isolation, and the use of face covers, which are an integral part of suppression strategy, are very effective at preventing virus transmission.79-82 Coronavirus disease is highly contagious.81-83 The nosocomial infection with the COVID-19 virus is a significant risk for healthcare workers and patients. Until a vaccine is available and or herd immunity occurs — and neither is likely to occur very soon — infection control is the most effective weapon against COVID-19.

Case Study: Confirmed Case of COVID-19

The following case study was obtained from a PubMed search where the authors discuss the case of a 65-year-old man who was hospitalized with symptoms of an infection, fever (38.6 °C) and dry cough, after returning home to Beijing, China from a visit at Wuhan, 8 days earlier.84

The authors reported on this case to highlight the clinical manifestation

and lung histological alteration in a patient diagnosed with SARS-CoV-2 viral

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pneumonia. The patient was evaluated to have a fever and dry cough for 4 days after a potential coronavirus exposure. His health history revealed there was no prior history of any chronic diseases. His tobacco use history was negative.84

The diagnosis of COVID-19 in this patient was confirmed. Laboratory

testing through nasal swabs and quantitative polymerase chain reaction (PCR) analysis for SARS-CoV-2 RNA. A chest computed tomography (CT) scan revealed diffuse shadows in the bilateral lungs.84

The patient rapidly progressed to respiratory failure (PO2=47.6 mmHg

and PCO2=24.8 mmHg) and required treatment with methylprednisolone 40 mg every 12 hours and antibiotic (biapenem) treatment. His temperature climbed to 39.2 °C, and the chest CT revealed enlarged pulmonary lesions. In a matter of days, the patient’s condition of respiratory failure worsened (PO2=56 mmHg and PCO2=49.4 mmHg). Multiple shadows could be visualized in both lungs, right side > left side. He developed pulmonary edema, and the dose of methylprednisolone was increased to 80 mg every 12 hours.84

Unfortunately, pneumonia worsened in this patient and he rapidly

progressed to septic shock over a matter of days. He developed severe metabolic acidosis and respiratory acidosis and died within approximately two weeks after being diagnosed. There were four subsequent tests of nasopharyngeal swabs, but the authors pointed out that each were SARS-CoV-2 RNA negative. They discussed the use of the RNA test for SARS infection.84

The Duplex Real-Time PCR Diagnostic Kit for rapid detection of SARS-

CoV-2 RNA ORF1ab/N gene was discussed in this case. The authors stated that the kit was approved with 97.6% specificity and 97.1% sensitivity (unpublished data).”84 Further testing included a lung biopsy and specimen examination. The patient’s family consented to a post mortem percutaneous biopsy of both lungs and protocol established by a laboratory site in Beijing was followed. Lung tissues without pulmonary infection were used as the

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negative control, and three biopsied lung tissue specimens were obtained. The authors stated that there was diffuse alveolar damage, intra-alveolar edema, reactive type II pneumocyte hyperplasia, and focal intra-alveolar fibrosis.84 Purulent discharge was observed in most alveolar spaces, and there was extensive areas of acute alveolitis with numerous intra-alveolar neutrophils and some lymphoid cells and alveolar macrophages. Inflammatory cells were present, and alveoli had collapsed and fused along the alveolar septum. Pulmonary capillaries were found to be dilated by microthrombi, and staining of lung cells showed type II pneumocytes that were increased in nuclear size, hyperchromasia, and multinucleated giant cell.84 There was no secondary lung disease seen, such as fungi or cytomegalovirus (CMV) infection.84

Discussion

The authors stated that the patient presented with no pre-existing diseases, yet died of COVID-19 due to severe and diffuse lung damage, which led to adult respiratory distress syndrome and septic shock.84 This highlights the need for healthcare personnel to always be vigilant in following the guidelines and procedures related to patients who may be infected with SARS-CoV-2. SARS-CoV-2 RNA tests confirmed virus positivity on the first two nasal swabs but not for subsequent swabs. SARS-CoV-2 was not detected with biopsy of lung tissue. The authors suggested that SARS-CoV-2 infection could have cleared at least two weeks after presenting to the hospital.84

Disease progress was confirmed by CT scan confirmed bilateral

pneumonia. Respiratory failure, kidney injury, cardiac insufficiency/failure and septic shock ensued, which led to organ failure and death. The authors reviewed the timing of treatment with steroid and antibiotic therapy. Steroid therapy started a day before the antibiotic therapy until death. The patient had suffered from SARS-CoV-2 viral pneumonia at least 4-5 days prior to receiving medication. Although the virus was inhibited and cleared between following treatment, the patient developed significant lung damage and then respiratory failure with deterioration unconnected to SARS-CoV-2 infection at that point. By the time of lung failure, sepsis and multisystem organ failure, the virus was undetectable.84

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The authors stated that patients with severe COVID-19 have been reported to develop superimposed bacterial or fungal infection. The thought that possibly two treatments might have worsened the disease: steroid therapy and a late start of the antibiotic therapy from disease onset. Steroid therapy can inhibit immune responses to pathogen infections, which may have been the case in this patient’s outcome. They believe that the high dosage of methylprednisolone treatment led to deleterious pneumonia. Given the potential for bacterial infection, they concluded that antibiotic treatment was started too late in this patient, leading to sepsis and multiorgan failure.84

Summary The coronavirus disease (COVID-19) has resulted in serious challenges

worldwide in terms of public policy and within the healthcare industry to prevent disease transmission. Understanding SARS-CoV-2 and how this virus is transmitted has been an important massive undertaking of scientists and healthy policymakers to establish effective infection control precautions and standard procedures for public businesses and healthcare facilities. Because knowledge of SARS-CoV-2 is an evolving and changing development, the implication for health organizations and for frontline health clinicians has not been static and has been continuously reviewed for possible improvements to reduce the risk of healthcare workers contracting the virus and to reduce the risk of nosocomial transmission.

The Centers for Disease Control and Prevention and other worldwide

infectious disease control agencies, such as the World Health Organization, have published recommendations for healthcare workers who provide health care for COVID-19 patients and who are at higher risk of contact with the virus. Standard recommended practices and guidelines for the COVID-19 pandemic have been reviewed. Healthcare facilities need to ensure facility protocols to help reduce virus exposure and transmission rates occur, and that CDC guidelines are made known to all who are entering a health facility.

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Self-Assessment of Knowledge Post-Test: Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. 1. In humans, coronaviruses typically appear as

a. an influenza A virus. b. as a form of tuberculosis. c. pneumonia. d. a common cold.

2. The most recent CDC position on how COVID-19 is spread states

that it is transmitted through person-to-person contact primarily

a. from shaking hands. b. via respiratory droplets. c. through sharing objects. d. from contact with surfaces.

3. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is

distinctive from MERS-CoV, SARS-CoV-1 or the influenza virus because it

a. appears to be more contagious. b. attacks only the upper respiratory system. c. can lead to pneumonia. d. can be transmitted from person to person.

4. A symptomatic healthcare worker with suspected or laboratory-

confirmed COVID-19 can return to work using a symptom-based strategy if

a. at least 3 days (72 hours) have passed since recovery. b. 14 days have passed without symptoms. c. the worker is able to remain 6 feet apart from others. d. at least 14 days have passed since the symptoms first appeared.

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5. Airborne transmission of SARS-CoV-2 from one person to another over long distances

a. has been documented. b. is unlikely. c. is one of the major concerns of healthcare workers. d. is more likely than not.

6. When disinfecting medical equipment used to care for patients

suspected to having or who have been diagnosed with COVID-19,

a. the manufacturer’s instructions should be disregarded and replaced with new COVID-19 procedures.

b. standard precautions do not need to be followed so long as appropriate disinfectants are used.

c. the equipment must be tested for SARS-CoV-2 before it can be used again.

d. hospital-grade disinfectants appropriate for SARS-CoV-2 should be used.

7. True or False: The American Academy of Pediatrics recommends

that children of all ages should wear a face covering or face mask to reduce the possible transmission of COVID-19.

a. True b. False

8. For an asymptomatic patient with laboratory-confirmed COVID-

19, transmission precautions may be discontinued if the patient’s tests from respiratory specimens

a. show a decline in SARS-CoV-2 RNA. b. are negative for SARS-CoV-2 RNA, in at least 2 tests out of 3. c. negative or SARS-CoV-2 RNA in 2 consecutive tests ≥ 24 hours apart. d. are negative for SARS-CoV-2 RNA over the 14 day quarantine period.

9. In medical facility triage areas that handle actual or suspected

COVID-19 patients,

a. patients should be kept six feet apart. b. personnel should wear an N95 respirator, gloves, and eye protection. c. personnel may use a face mask if an N95 respirator is not available. d. All of the above

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10. The CDC guidelines provide that any healthcare worker who had “prolonged,” close contact with a person who had a confirmed COVID-19 infection and did not use PPE as required should not work for 14 days after the last exposure. Prolonged is defined as

a. more than a minute. b. 3 minutes or more. c. any meaningful length of time. d. ≥ 15 minutes.

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