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GUIDELINES FOR THE USE OF PERSONAL PROTECTIVE EQUIPMENT WHILE CARING FOR PATIENTS IN HOSPITALS AND CLINICS FACILITIES DURING COVID-19 PANDEMIC

Revised August 19, 2020 The following guidelines meet or exceed local, state, and federal guidelines for use of Personal Protective Equipment (PPE) during the COVID-19 pandemic and reflect the collective input from experts across our health care system. Our priority is the safety of all of our healthcare workers (HCWs) and patients. These guidelines will be updated as needed to reflect new data or recommendations.

These Guidelines apply to HCWs when interacting with and caring for patients. Please see the current version of the Universal Masking Guidelines for use of surgical masks and other masks and items when not interacting with or caring for patients. For EVS personnel, please refer to EVS Guidelines for PUI or Confirmed Positive COVID-19 patients.

Definitions: For purposes of this policy, “eye protection” means face shield, goggles, or hospital approved safety glasses (e.g., trauma glasses) that have extensions to cover the side of the eyes and do not have any gaps between glasses and the face. Do not use safety glasses in situations likely to result in spray or splash of body fluid or chemical. General Surgical Mask Usage:

• Surgical masks can be used by the same HCW for multiple patients (as long as none of the patients seen by the HCW are on droplet or COVID-19 precautions) for the length of their shift. If the mask becomes moist, contaminated or torn, please discard.

• We STRONGLY RECOMMEND minimizing frequent removal of the mask during the shift as this can cause contamination and self-inoculation.

• Surgical mask should be discarded if exposed to a patient with a droplet borne infection such as influenza. Discard the mask upon exiting the room.

• Follow current version of Universal Masking Guidelines for use of surgical masks and other masks and items when not caring for patients.

Patients with Influenza Like Illness (ILI) symptoms: • Droplet precautions are deemed appropriate for ILI evaluation. • In the ambulatory setting, most ILI patients should be able to be managed via

telemedicine. If the patient needs to be scheduled for an in-person encounter, the patient should be screened and should wear a surgical mask per our guidelines.

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Homemade masks or construction masks with an exhalation valve, or other non-approved masks, are not allowed in clinical care areas.

• All staff should use gloves, a surgical mask and eye protection when evaluating a patient with ILI symptoms. Discard gloves and mask after evaluating patient with ILI symptoms. Reusable eye protection should be cleaned with hospital approved disinfectant wipe before storing.

• In situations with a surge or large volume of ILI patients in Emergency Department, Express Care and Urgent Care, the ILI fast-track system in the surge tents or other identified locations may be used. In these settings, the following guidelines apply:

o Maintain 6 feet of separation between ILI patients o Maintain physical barriers (curtains) between patients when available to

minimize transmission. o Enhanced PPE for HCWs including a gown, gloves, N95, and eye protection

should be used. o HCWs should keep the PPE gear on for the entire shift to the extent possible,

except to clean the equipment, and to change gloves. o Repeated doffing of the N95 is discouraged. The reusable eye protection

should be cleaned in between patients as needed. Gloves should be changed in between patients.

o Discard PPE at the end of the shift except for reusable eye protection, which can be cleaned and reused.

Eye Protection and N95 Usage for PUI or COVID-19 Positive Patients: Use N95s, eye protection, gown, and gloves when caring for PUI or COVID-19 positive patients as indicated below. N95s offer a higher level of respiratory protection than a surgical mask and must be fit tested by Employee Health prior to use.

Non-Cohorted Unit:

• All staff should reuse N95s for the same patient until the N95 is visibly soiled, wet, or doesn’t fit properly.

• All staff should reuse the eye protection for multiple shifts until it loses visibility or doesn’t fit properly. The eye protection will need to be cleaned after removal and prior to reuse with a hospital-approved disinfectant wipe.

• Save your N95 in a clean clamshell box, paper bag or approved alternative container, with name written on the container, in the ante room, isolation cart or designated area until such time as it is visibly soiled, wet, or does not fit property.

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• Reusable eye protection should be cleaned with hospital approved disinfectant before storage and can be reused across multiple patients until visibility or fit is impaired. Save your cleaned eye protection in clean paper bag or approved alternative container, with name written on the container, in the ante room, isolation cart or designated area.

Cohorted Unit

• In a cohorted COVID positive/PUI unit, the same N95 and eye protection can be used across multiple patients. In this situation, repeated removal (doffing) of N95 is discouraged. The eye protection should be cleaned with a hospital approved disinfectant wipe in between patients as needed.

• Save your N95 in a clean clamshell box, paper bag or approved alternative container, with name written on the container, in ante room, isolation cart or designated area until such time as it is visibly soiled, wet, or does not fit properly.

• Reusable eye protection should be cleaned with hospital approved disinfectant before storage and can be reused across multiple patients until visibility or fit is impaired. Save your cleaned eye protection in clean paper bag or approved alternative container, with name written on the container, in the ante room, isolation cart or designated area until such time as it loses visibility or does not fit properly.

Gowns and Gloves for PUI or COVID-19 POSITIVE patients:

• Gowns and gloves must be discarded after each interaction with the patient. There is no indication in which a gown or glove can be reused except as necessary in an ILI tent/surge situation noted above.

Rooming of PUI or COVID-19 POSITIVE patients: • Negative pressure room is only needed for patients on whom aerosol-generating

procedures (AGPs) are anticipated. More information noted below. • COVID-19 positive and PUI patients may be cared for in a non-negative pressure

room if the patient is placed in a single room with the door closed. • If a patient is in a non-negative pressure room, the physician will place a nursing

communication order that a negative pressure room is not needed. The patient will still need to be on airborne and contact isolation, and staff will still use the appropriate PPE for that room.

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Specimen Collection-Nasal, Nasopharyngeal or Oropharyngeal (NS, NP or OP) • Obtaining a NS, NP or OP swab for Flu/RSV or COVID PCR testing is NOT considered

an aerosol generating procedure. • Patients receiving an NS, NP or OP swab should be instructed to lower their surgical

mask to still cover the mouth during specimen collection. • PPE recommendation for single NS, NP or OP swab test: surgical mask, eye

protection, gown and gloves. • For large volume testing, drive thru testing, and designated testing sites, the

following PPE should be worn: ▪ Gown, gloves, N95, eye protection. ▪ The same PPE gear should be worn for the entire shift to the extent possible,

except to clean the equipment, and to change gloves. ▪ Repeated doffing of the N95 is discouraged. The eye protection should be

cleaned in between patients as needed. Gloves should be changed in between patients.

▪ Discard PPE at the end of the shift except for reusable eye protection. Reusable eye protection should be cleaned with hospital approved disinfectant before storage and can be reused across multiple patients until visibility or fit is impaired.

Aerosol Generating Procedures (AGPs) for a PUI or COVID-19 Positive Patient:

• AGPs are procedures that include, but are not limited to: sputum induction, open suctioning of airways, tracheal intubation, nebulizer treatment in a non-intubated patient, bronchoscopy, manual ventilation, BiPAP/CPAP. Chest physiotherapy should be performed cautiously and avoided if possible. AGP’s should be limited and take place in a negative pressure room when possible.

• Induction of sputum should not be performed on PUI or COVID-19 positive patients. • If an AGP must be performed, the following should occur:

o The number of HCWs present during the procedure should be limited to only those essential for patient care and procedure support. Visitors and non-essential staff or physicians should not be present for the procedure.

o AGPs should take place in an airborne negative pressure room, if possible. o Unless repeated contact with that patient is anticipated (for example in a

cohorted unit), the N95 and eye protection will be discarded along with the gown and gloves. Reusable eye protection should be cleaned with hospital approved disinfectant before storage and can be reused across multiple patients until visibility or fit is impaired.

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PPE recommendations: All HCW in the room should wear gown, gloves, N95 plus eye protection or CAPR (Controlled Air Purifying Respirator) if a CAPR is available. Priority for CAPR use is based on the prioritization matrix see attachment B).

Aerosol Generating Procedures (AGPs) for patients with negative COVID-19 testing within 72 hours:

• If an AGP must be performed, the following should occur: o All HCWs in the room should wear gown, gloves, surgical mask with eye

protection. o Surgical mask should be discarded after each encounter along with gowns

and gloves. Reusable eye protection should be cleaned with hospital approved disinfectant before storage and can be reused across multiple patients until visibility or fit is impaired.

Aerosol Generating Procedures (AGPs) for COVID-19 unknown patients or those with COVID-19 negative test >72 hours:

• If an AGP must be performed, the following should occur: o All HCWs in the room should wear gown, gloves, N95 mask with eye

protection. o N95 mask must be reused across multiple patients unless visibly soiled, wet,

or does not function properly. Reusable eye protection should be cleaned with hospital approved disinfectant before storage and can be reused across multiple patients until visibility or fit is impaired.

Performing intubation/extubation

• During intubation/extubation of a COVID-19 positive patient, PUI, or an undifferentiated ILI, all HCWs should wear gown, gloves, N95 plus eye protection or CAPR if available (priority based on prioritization matrix in Attachment B) . Unless repeated contact with that patient is anticipated, the N95 will be discarded along with the gown and gloves. Reusable eye protection should be cleaned and can be reused.

• For routine intubation/extubation of all other patients, N95 and eye protection is recommended for all staff and physicians present in addition to standard universal precautions.

o Those present during intubation and extubation should be limited to the individual performing the procedure and only essential assistants.

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o In this situation, the N95 should be reused for multiple patients and days until it is visibly soiled, wet or doesn’t fit properly.

o Likewise, the eye protection should be reused for multiple patients and days until it loses visibility or doesn’t fit properly. The eye protection will need to be cleaned after removal and prior to reuse with a hospital-approved disinfectant wipe.

o Both should be stored in clean paper bags or approved alternative container with user’s name and identification written on the container.

Visitors for COVID+ patients

• The current visitor policy applies at all times. • Visitors that fall within the current visitor policy will be discouraged from visiting

COVID+ patients. At the discretion of the treating team, if a visitor is permitted to visit a COVID+ patient (whether symptomatic or asymptomatic), the visitor will only be permitted after the following occurs:

o Visitor will have temperature screening and symptom screening to be performed upon entry into the facility and again at the unit as needed.

o If any part of the temperature and symptom screen is positive, the visitor will be asked to leave and seek medical care.

o If the temperature and symptom screen are negative, the visitor will be asked to don and doff the following PPE with assistance from nursing: surgical mask, gown and gloves for the entire duration of the stay (please see below for birthing partner specific recommendation)

o Visitors will be counseled by the patient’s physician before visiting on the risks of potential exposure from visitation.

o For adult patients, visitation will be limited to the shortest extent possible and shall be consistent with visitor policy. Social distancing will be maintained to the best extent possible.

Birthing partners of COVID+ laboring mothers: • If the mother is asymptomatic, but tests positive for COVID-19, the following shall

apply: o All birthing partners shall be screened for symptoms per our screening

protocol, taking into account any close contacts with the mother. If the screen is positive the birthing partner will be requested to leave and seek medical care. An alternative birthing partner who is not COVID-19 positive can be designated by the patient.

o If the screen is negative, the care team shall obtain patient’s consent to share the COVID+ status with the birthing partner and advise the birthing partner

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of potential risk of exposure during labor if they are not already infected. The birthing partner shall be sent to the Emergency Department to obtain COVID-19 testing if has not done so already. If delivery is imminent, the birthing partner will be allowed to stay

with the laboring mother while waiting for result. If delivery is not imminent, the birthing partner will be allowed to stay

with the laboring mother after a negative RT-PCR test. o Birthing partner that screened negative but refused testing will not be

admitted to the facility. o The birth partner will be required to wear a surgical mask at all times per our

universal masking guidelines. o During the second stage of labor, the birthing partner will be required to don

and doff the proper PPE with the assistance of OB staff: Gown, gloves, surgical mask and eye protection Social distancing will be maintained as best as possible

• If the mother is COVID positive and symptomatic, birth partner is discouraged from being present with laboring mothers due to high risk of COVID exposure. If the birth partner despite warnings insists on being present with the mother, the birth partner shall be told the risks by the patient’s physician or designee and all of the above steps and PPE shall be followed.

Asymptomatic COVID + patients • Asymptomatic patients who test positive for COVID-19 should be placed into a private room

and should wear a surgical mask at all times when another person enters the room. • A negative pressure room can be used, if available, otherwise the patient should remain in

their room with the door closed. • All HCWs should wear N95, gown, gloves and eye protection when entering the room and

caring for the patient as indicated above. Donning, doffing, reuse and extended use should follow standard policies as indicated above.

• Asymptomatic COVID positive patients being transported in the hospital should follow the Infection Prevention Guidelines: Transport, Diagnostic Imaging, Operating Room, and PACU Guidance for Admitted Persons Under Investigation (PUI) and COVID-19 Positive Patients within Santa Clara Valley Medical Center (SCVMC), the same as symptomatic patients.

Recovered COVID+ patients • Recovered COVID + patients who have recovered from COVID 19 infection will be reviewed

by IP. Based on recommendations from the CDC and PHD, IP will remove the COVID 19 banner when the patient has met the required criteria. Patients who have had the banner removed by IP are no longer considered infectious and should be treated as if COVID negative.

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Asymptomatic patients with unknown COVID test results The following applies to patients admitted to the hospital without COVID-19 symptoms as well as to routine ambulatory encounters not involving AGPs.

• Inpatient setting: o All patients being admitted to the hospital shall be tested for COVID-19.

Asymptomatic patients pending COVID testing are NOT considered PUI. o These patients will be roomed in a private room with door closed if possible,

until test results are available. If private room is not available, the patients’ bed should be 6 feet apart from other patients with curtains drawn around the bed. Patient will maintain masking if able until test results available, except while eating or drinking.

o All HCWs should wear a surgical mask and eye protection for all patient interactions with the masked patient. Surgical masks can be used by the same HCW across multiple patients. Mask should be discarded when moist, contaminated or torn. Reusable eye protection should be cleaned with hospital approved disinfectant before storage and can be reused across multiple patients until visibility or fit is impaired.

o HCWs should follow standard universal precautions when it comes to usage of gloves or gowns.

o Once the COVID-19 test results are available, PPE and rooming recommendations should follow the standard of care for COVID+ or COVID negative patients.

• Outpatient setting: o All patients and visitors presenting to ambulatory appointments must wear a

mask covering their nose and mouth consistent with current Universal Masking Guidelines.

o HCWs should wear a surgical mask and eye protection or safety glasses for all patient interactions with the masked patient. Surgical masks can be used by the same HCW across multiple patients. Mask should be discarded when moist, contaminated or torn. Reusable eye protection should be cleaned with hospital approved disinfectant before storage and can be reused across multiple patients until visibility or fit is impaired.

o HCWs should follow standard universal precautions when it comes to usage of gloves or gowns.

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Thank you for your continued cooperation and effort during this time. We appreciate everything that you all do for our staff and patients. Please continue to follow all of the infection prevention measures that are in place throughout the system, including good hand hygiene practices, symptom monitoring, and social distancing. Rev. 4.21.20; 5.18.20; 7.23.20; 8.19.20 Attachment A: Table Summarizing Guidelines for Use of PPE While Caring for Patients Attachment B: CAPR Prioritization Matrix

Rev. August 19, 2020 ATTACHMENT A

TABLE SUMMARIZING GUIDELINES FOR USE OF PERSONAL PROTECTIVE EQUIPMENT (PPE) WHILE CARING FOR PATIENTS IN

HOSPITALS AND CLINICS DURING COVID-19 PANDEMIC The following table is for reference purposes only. Please refer to the Guidelines for the Use of Personal Protective Equipment While Caring for Patients in Hospitals and Clinics Facilities During COVID-19 Pandemic, for additional information (the “Guidelines”). To the extent this document conflicts with the Guidelines, the Guidelines control. Definitions: For purposes of this policy, “eye protection” means face shield, goggles, or hospital approved safety glasses (e.g., trauma glasses) that have extensions to cover the side of the eyes and do not have any gaps between glasses and the face. Do not use safety glasses in situations likely to result in spray or splash of body fluid or chemical.

Ambulatory, Outpatient, and Inpatient Encounters • Including Emergency Dept, Express Care and Urgent Care

Definition

Patient

Staff

PPE Reuse

• Active COVID+ patient (symptomatic or asymptomatic)

• COVID PUI (person under investigation)

Surgical mask • N95 • Eye protection • Gown • Gloves

• N95 and eye protection may be reused across multiple shifts for the same patient in a non-cohorted unit.

• N95 and eye protection may be used across multiple patients across multiple shifts in a cohorted unit.

• Gown and gloves must be discarded after each encounter except for ILI screening area and in ED, Express Care or Urgent Care surge situations where gowns should

Rev. August 19, 2020 be changed only if soiled. In all circumstances, gloves must be changed in between patients.

• Asymptomatic COVID-19 negative patients within 72 hours prior, including immunocompromised patients

Surgical mask • Surgical mask • Gloves as needed

• Surgical mask may be reused across many patients unless moist, torn, or contaminated.

• Gloves if used must be discarded after each patient

• Asymptomatic COVID-19 negative more than 72 hours out or COVID-19 unknown )

Surgical mask or masking /source control is not possible

• Surgical mask Eye protection Gloves as needed

• Surgical mask may be reused across many patients unless moist, torn, or contaminated.

• Gloves if used must be discarded after each patient

• Reusable eye protection should be wiped down with hospital approved disinfectant before storage and may be used across multiple patients until visibility or fit is impaired.

Procedures

• Aerosol Generating Procedures: o Aerosol Generating Procedures as defined in the Guidelines.

• N95 + eye protection or CAPR if available per CAPR Prioritization Matrix

Definition Patient Staff PPE Reuse

• Active COVID+ patient (symptomatic and asymptomatic)

• COVID PUI

Surgical mask before and after procedure

• N95 + Eye protection

• Gown • Gloves

• N95 and eye protection may be reused for the same patient if repeated contact is anticipated.

• No reuse across multiple patients • CAPR may be reused with same patient and across

multiple patients • Gown and gloves must be discarded after each

encounter.

Rev. August 19, 2020 • Asymptomatic patients with

negative COVID-19 test within 72 hours

Surgical mask before and after procedure

• Surgical mask with eye protection

• Gown • Gloves

• Surgical mask should be discarded after each encounter

• Eye protection may be reused across multiple days across multiple patients unless visibly soiled, wet or does not fit properly

• Gown and gloves must be discarded after each encounter

• Asymptomatic patients (not COVID+) with negative COVID-19 more than 72 hours out or COVID-19 unknown

Surgical mask before and after procedure

• N95 mask with eye protection

• Gown • Gloves

• N95 mask and eye protection may be reused across multiple days across multiple patients unless visibly soiled, wet, or does not fit properly.

• Gown and gloves must be discarded after each encounter

• Non-Aerosol Generating Procedures: o All other non-aerosol generating procedures (e.g; routine appendectomy, line insertion). o These recommendations DO NOT apply to the intubation portion of the procedure (if applicable).

Definition Patient Staff PPE Reuse

• Active COVID+ patient (symptomatic or asymptomatic)

• COVID PUI

Surgical mask before and after procedure

• N95 • Eye protection • Gown • Gloves

• N95 and eye protection may be reused across multiple days for the same patient in a non-cohorted unit.

• N95 and eye protection may be used across multiple patients for multiple days in a cohorted unit.

• Gown and gloves must be discarded after each encounter

• Asymptomatic COVID-19 negative patients within 72 hours prior, including immunocompromised patients

Surgical mask before and after procedure

• Surgical mask • Gloves as needed

• Surgical mask may be reused across many patients unless moist, torn, or contaminated.

• Gloves if used must be discarded after each patient

Rev. August 19, 2020 • Asymptomatic COVID-19

negative more than 72 hours out or COVID-19 unknown)

Surgical mask before and after procedure

• Surgical mask • Eye protection • Gloves as needed

• Surgical mask may be reused across many patients unless moist, torn or contaminated.

• Gloves if used must be discarded after each patient • Reusable eye protection should be wiped down with

hospital approved disinfectant before storage and may be used across multiple patients until visibility or fit is impaired.

I

Tier 3

By Procedure Recommended PPE, in addition to Gown

and Gloves, per prioritization matrix CAPR Use: Highest Priority CAPR Use: Highest Priority

CPAP/BiPAP* (≥30 min) Active CPR* (not intubated)

Intubation/extubation Respiratory Interventions with Continuous Provider Exposure * (≥30 min)

Bronchoscopy/BAL

N95 + Faceshield

OR

CAPR only

Tier 2 By Procedure/Duration 15-30 min*

CAPR Use: Low Priority CAPR Use: Low Priority CPAP/BiPAP*

Active CPR* (intubated) Respiratory Interventions with Continuous Provider Exposure*

Any Nasal Canula Therapy ≥5 lpm (patient is NOT in a mask per our masking policy)

N95 + Faceshield

OR

CAPR only

Tier 1 By Procedure

CAPR NOT INDICATED CAPR Use: Not indicated Daily Care

Imaging Procedures Lab Procedures

Healthcare professional Preference Any Nasal Cannula Therapy (patient is masked)

Proning a Patient Medication Administration

AND

*Longer/shorter duration and urgency of procedure should be taken into consideration when selecting PPE. NOTE: Any HCW that has failed N95 fit-testing or is experiencing skin breakdown due to the N95 respirator should utilize a CAPR, if one is available. If one is not available, work with leadership to identify an alternative assignment 05.18.20 Credit to UNMC. Nebraska Medicine

Updated:5/8/2020 Credit to UN

ATTTACHMENT B: CAPR PRIORITIZATION MATRIX (FOR USE DURING SURGE/LARGE PATIENT VOLUME SITUATIONS OR WHEN SUPPLIES ARE LIMITED (I.E. SUPPLY CHAIN DISRUPTION)

COVID-19 POSITIVE/PUI CAPR PRIORITIZATION MATRIX Our Standard PPE for the below procedures includes Gown, Gloves, N95 respirator and Face Shield. This will keep you safe.

Using a CAPR/PAPR is an acceptable alternative when available and is prioritized by the likelihood of aerosol generation. Patient care should NEVER be delayed because a CAPR/PAPR is not available.