The prevention and control of COVID-19 in healthcare settings
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4/04/2020
The prevention and control of
COVID-19 in healthcare settings
Ruth Barratt RN, BSc, MAdvPrac (Hons)
Infection Prevention and Control and Quality Advisor, Vector Consulting
Clinical Nurse Consultant, Infection Prevention & Control for Biopreparedness NSW
Pandemic Limerick
• There was an infectious disease
• Which brought the whole world to its knees
• When they sneezed and they coughed
• We donned and we doffed
• And survived with barely a sneeze
1
4/04/2020
NZ Ministry of Health - COVID-19 (novel
coronavirus)
• https://www.health.govt.nz/our-
work/diseases-and-
conditions/covid-19-novel-
coronavirus
Personal Protective Equipment
(PPE)
What's important for you to know
about PPE for essential workers
PPE posters and guidance
2
4/04/2020
What is the goal of infection prevention and control?
Break the Chain of Infection
Interrupt transmission
Breaking the Chain for COVID-19
❌ No definitive treatment
❌ No vaccine or ✔️ Soc️ial distancing
prophylactic therapy ✔️ Respiratory hygiene
✔️ Hand hygiene
- People ✔️ Environmental cleaning
- Environment
✔️ Respiratory hygiene
✔️ Hand hygiene
✔️ Surgical mask
- Mucous - Respiratory droplets
membranes - Hands
✔️ Safe IPC practices
✔️ PPE ✔️ Standard and Transmission-based precautions
✔️ Hand hygiene ✔️ Isolation
- Droplet / Contact /
✔️ Air handling engineering control
Airborne
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4/04/2020
Transmission routes
• Still not fully understood!
• Originally live animals to humans ➔ person-to-person
• Respiratory droplets, resembling the spread of influenza
• Virus in respiratory secretions when infected person coughs, sneezes
or talks
• Infection occurs with direct contact with the mucous membranes
• Indirect contact via touching contaminated surfaces and then
touching eyes, nose, or mouth
• Airborne during aerosol-generating procedures
WHO Scientific Brief – 27 March
Modes of transmission of virus causing COVID-19: implications for IPC
precaution recommendations
“According to current evidence, COVID-19 virus is transmitted between
people through respiratory droplets and contact routes.”
“In an analysis of 75,465 COVID-19 cases in China, airborne transmission
was not reported.”
“In the context of COVID-19, airborne transmission may be possible in
specific circumstances and settings in which procedures or support
treatments that generate aerosols are performed”
“There have been no reports of faecal−oral transmission of the COVID-19
virus to date”
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4/04/2020
Transmission (continued)
• Rates of transmission are varied – 1-5 secondary cases
• Transmission may be higher in early stages of illness – viral RNA levels
appear to be higher soon after symptom onset but more data needed
• Transmission from asymptomatic individuals (or individuals within the
incubation period) also occurs but extent is unknown without large-
scale serologic screening
• SARS-CoV-2 RNA has been detected in blood and stool specimens but
WHO-China advises that faecal-oral transmission not significant factor
Droplet transmission
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4/04/2020
Airborne transmission
- aerosol-generating procedures (AGPs)
• bronchoscopy
• tracheal intubation
• non-invasive ventilation (for example, BiPAP or CPAP)
• high flow nasal oxygen therapy
• manual ventilation before intubation
• intubation
• cardiopulmonary resuscitation
• sputum induction
• Suctioning
• turning the patient to the prone position
• disconnecting the patient from the ventilator
Nebuliser use should be discouraged and alternative administration devices (for
example, spacers) should be used.
Hand hygiene and cough / sneeze etiquette
• Soap and water
• Alcohol based hand sanitiser
• 60-95% isopropyl alcohol, ethanol
(ethyl alcohol) or n-propanol
• Kills most germs
• Alcohol-free hand sanitisers
• quaternary ammonium
compounds (e.g. benzalkonium
chloride)
• can reduce microbes but are less
effective than alcohol
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4/04/2020
COVID-19 in the
environment
Toby Morris - The Side Eye: Viruses vs Everyone
Environmental cleaning products
• TGA statement 27 March - all COVID-19 claims expediated
• Hard surface disinfectants vs medical device cleaners and disinfectants
• Claims that a product kills, or is active against, viruses, spores, tuberculosis,
mycobacteria or fungi are "specific claims". Disinfectants that make these
claims require listing on the ARTG prior to supply in Australia
• Surrogate viruses for use in disinfectant efficacy tests to justify claims
against COVID-19:
• Human coronavirus 229E
• Murine hepatitis virus
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4/04/2020
Environmental Cleaning
• COVID-19 is an enveloped virus - it has an outer membrane
• The outer layer is easily damaged by most environmental
disinfectants
• Must be used in accordance with label instructions
• TGA approved (registered or listed) hospital-grade disinfectant,
suitable for use:
• Detergent and/or disinfectant-impregnated wipes with appropriate claims for
activity against coronavirus can be used for small items of patient care
equipment
• ≥ 70% alcohol,
• quaternary ammonium
• diluted household bleach sodium hypochlorite at 1,000 ppm available
chlorine
Environmental Cleaning
• General cleanliness, declutter
• Detergent to lift dirt and soil
• Disinfectant to kill the virus
• Environmental surfaces should be cleaned on
a regular basis
• at least once daily
• following aerosol- generating procedures or
other activities that might contaminate the
environment
• on patient discharge
• frequently touched surfaces such as handles and
door knobs should be cleaned more often.
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4/04/2020
Social Distancing
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4/04/2020
Out of hospital and GP testing for COVID-19
Isolation / Quarantine
104/04/2020
Personal Protective Equipment (PPE)
Using PPE safely
• Familiarity with products
• Training in correct donning and doffing - competency
• Understanding transmission routes
• Safe donning and doffing techniques
• Visual aides - posters / videos / virtual reality
• Quality checks / audits – are staff doing the right thing?
114/04/2020
Which mask?
Surgical masks P2/N95 particulate respirator masks
• Surgical masks protect the • The use of P2 respirators
wearer from droplet prevents the inhalation by
contamination of the nasal or healthcare workers of small
oral mucosa from respiratory particles that may contain
droplets (i.e. large-particle infectious agents transmitted via
droplets >5 microns in size) that the airborne route
are generated by a patient who
is coughing, sneezing or talking
AS/NZS 1715:2009 - Selection, use and
AS 4381:2015 - Single-use face maintenance of respiratory protective
masks for use in health care equipment
What about PAPRs?
124/04/2020
Contact and Droplet Precautions - PPE
Donning PPE with surgical mask
STEP 1. STEP 2. STEP 3.
HAND HYGIENE PUT ON GOWN PUT ON SURGICAL MASK
STEP 5. STEP 6.
PUT ON FACE SHIELD PUT ON GLOVES IPAC v1 17/2/2020
Airborne and Contact COVID-19
Precautions Removing PPE with N95/P2 mask
INSIDE PATIENT ROOM
1 3
2
HAND HYGIENE
REMOVE GLOVES
5
REMOVE GOWN
4 6
HAND HYGIENE HAND HYGIENE
REMOVE FACE SHIELD
OUTSIDE PATIENT ROOM
8
7 9
HAND HYGIENE HAND HYGIENE
IPAC Westmead Hospital v2 22 Feb 2020
134/04/2020
Fit checking a seal on P2/N95 mask
Always refer to the manufacturer’s instructions for fit checking of individual brands and
types of P2/N95 respirators.
People with beards should shave before using a P2 mask as a good seal between the mask
and the wearer’s face cannot be guaranteed if they have facial hair.
• Place the respirator on your face.
• Place the headband or ties over your head and at the base of your neck.
• Compress the respirator to ensure a seal across your face, cheeks and the bridge of your
nose.
• Check the positive pressure seal of the respirator by gently exhaling. If air escapes, the
respirator needs to be adjusted.
• Check the negative pressure seal of the respirator by gently inhaling. If the respirator is
not drawn in towards your face, or air leaks around the face seal, readjust the respirator
and repeat process, or check for defects in the respirator.
144/04/2020
Conserving PPE
• Control supply
• One point of distribution
• Lock up masks – e.g. medication room
• Hand out masks to patients – do not make readily available
• Reduce use
• Always available for staff when required
• Do not use unnecessarily
• Use other products e.g. reusable eyewear, aprons instead of
gowns, reusable splash-resistant gowns
Extended use of PPE
• Wearing the same PPE for repeated patient interactions without
removing and replacing the PPE
• Use physical barriers or use intercom systems or phones to
communicate with patients in isolation
• Use where COVID-19 patients are cohorted together in the same
ward or waiting area
• Use is most appropriate for masks or eye protection – they do not
come into contact with patient
154/04/2020
Extended use of masks
• Masks must be:
• discarded if contaminated with blood or bodily fluids
• not worn outside of the patient care area (i.e. to a ward reception
area or break room or between wards or bathroom)
• removed before proceeding to care for patients other than those
who are isolated for COVID-19
• removed when it becomes wet or damp (surgical mask)
• replaced if it becomes hard to breathe through or no longer holds
its shape or no longer conforms to the wearers face (P2 mask)
• must be discarded after an aerosol generating procedure (P2
mask)
Extended use of eye
protection
• Eye protection should:
• be reprocessed or discarded
if visibly contaminated with
blood or body fluids
• not worn outside the patient
care area
• removed before proceeding
to care for patients other
than those who are isolated
for COVID-19
164/04/2020
Reprocessing masks – mixed messages
• Delft University of Technology
• Sterilization of disposable face masks by means of dry and steam sterilization
processes
• Hydrogen peroxide or low steam sterilizer
• 30/3/2020 -the FDA approved a decontamination process for N95 face masks
• Sterrad - cellulose components of mask filtration material, and
compatibility with the low temp plasma
• “Based on currently available data, 3M does not recommend or support
attempts to sanitize, disinfect, or sterilize 3M FFRs
• … may impact the filtration performance and/or the respirator materials in such a
way that may reduce the respirator’s ability to seal to the wearer’s face and provide
the expected protection for this type of respirator.”
Taking swabs – not an AGP
174/04/2020
Other IPC measures
• Waste
• Dispose of waste as per transmission-based precautions in the medical waste
stream
• No requirements for double bagging
• Linen
• Used linen should be bagged inside the room and managed as for patients on
transmission-based precautions. A linen chute should not be used as this may
create aerosols
• Normal crockery and dishwashing procedures
Resources
• MOH COVID-19 https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-
coronavirus
• Queensland Health – conserving PPE https://www.health.qld.gov.au/clinical-practice/guidelines-
procedures/novel-coronavirus-qld-clinicians/personal-protective-equipment-ppe
• 3M Technical Bulletin 20th March 2020 - Disinfection of Filtering Facepiece Respirators
• TGA https://www.tga.gov.au/regulation-cleaners-and-disinfectants-information-sponsors-and-
manufacturers
• Australian Government https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-
ncov-health-alert/coronavirus-covid-19-advice-for-the-health-and-aged-care-sector
• ANZICS COVID Guidelines https://www.anzics.com.au/coronavirus-guidelines/
• AMA COVID-19 Transmission and Personal Protective Equipment (PPE)
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