Electronic supplement
Expanding ICU facilities in an epidemic: recommendations based on experience from the SARS epidemic in Hong Kong and Singapore.
CD Gomersall1, DYH Tai2, S Loo2, JL Derrick1, MS Goh3, TA Buckley4, C Chua2, KM Ho5, GP Raghavan2, OM Ho5, LB Lee6, GM Joynt1
1. Dept of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Hong Kong.
2. Intensive Care Units, Tan Tock Seng Hospital, Singapore
3. Facilities Engineering Department, Tan Tock Seng Hospital, Singapore
4. Intensive Care Unit, Princess Margaret Hospital, Hong Kong
5. Adult Intensive Care Unit, Prince of Wales Hospital, Hong Kong
6. Dept of Care and Counselling (Medical Social Work), Tan Tock Seng Hospital, Singapore
Contents
Infection control 2
Setting-up the environment 2
Standard personal protective equipment 4
Specific respiratory precautions 6
Potentially high risk procedures/activities 6
Hand hygiene 7
Waste management 8
Guidelines for handling medical records in contaminated area 8
Prevention of staff-staff transmission 8
Role of infection control patrol staff 8
Environmental control 10
Rationale for recommended respiratory PPE 12
Visiting 16
General information to relatives 16
Transport of patients 18
Intra-hospital transport of patients from ICU 18
Intra-hospital transport of patients to ICU 18
Inter-hospital transfer of patients with suspected/confirmed disease 18
Regional organization of ICU services 19
Anticipating ICU bed requirements 19
References 20
Acknowledgements 21
Infection control
Setting-up the environment
Basic points to note:
1) Prominent warning sign on the outside of the isolation area indicating ‘high risk area’
2) Separate entry and exit points
3) Separate gowning-up and gowning-down areas of adequate size to avoid cross contamination
a) Use different colors to indicate gowning-up and gowning-down areas (figure1)
i). ‘green’ – gown-up area
ii). ‘red’ – gown-down area
4) Separate undressing and de-masking zones (figure 1)
Figure 1. Plan shows the modification made to the entrance of the Prince of Wales Hospital ICU to create separate areas for donning PPE, removing gowns and removing masks. If an emergency exit can be utilized as an exit or entrance this may be preferable as it allows complete separation.
5) Prominent instruction signs on
a) Gowning up and gowning down steps
b) Restricting number of staff in both the gown-up/ gown-down areas at any one time
6) Adequate facilities for hand-hygiene both in the ‘gown-up’ zone and in the ‘gown-down’ zone
Gown-up rooma) Hand-hygiene facilities
i). Handwash
- Handwash basin
- hand-antiseptic
ii). Hand-rub
- Alcohol-based handrub
iii). Paper hand towels
b) PPE (Personal protective equipment) – adequate amount
i). Disposable particulate respirator
- N95, N100, P100 mask
ii). Protective eyewear
- Visor
- Goggles
iii). Full-face shield
iv). Disposable cap
v). Disposable long-sleeved protective gown
- Water repellent
- Waterproof
vi). Latex gloves
vii). Disposable shoe cover
viii). Disposable hood that covers both the head and neck
c) Rubbish bins lined with ‘non-clinical waste’ bag
d) Transparent plastic bags for holding stationary and pager (hung outside the isolation gown)
e) Mirror
f) Clear instructions on correct sequence of putting on PPEs
Gown-down area – separate undressing and de-masking zones
a) Hand-hygiene facilities
i). Handwash
- Handwash basin
- Hand antiseptic
ii). Hand-rub
- Alcohol-based handrub
iii). Paper hand towels
b) Rubbish bins
ii). Foot operated lid
iii). Lined with designated ‘clinical waste’ bags
c) Paper bags for temporary storage of disposable particulate respirators, protective eyewear and full-face shields (if inadequate supply necessitates re-use)
d) 70% alcohol and gauze packs for wiping used protective eyewear and full-face shield before putting in paper bag
e) Bucket for holding used goggles
f) Surgical masks, for use outside unit
g) Mirror
h) Prominent instructions on correct sequence of gowning-down
Specimens and documents
a) Separate documents and specimens that are sent into and to be sent out of the unit
b) Keep documents and specimens in different trays or receptacles
Reception
c) Intercommunication device, video-phone.
d) Record of visitors
Staff toilet
e) Instruction sign on the door of the toilet indicating steps to follow before and after using toilet
f) Foot-operated lidded rubbish bins lined with waterproof ‘Clinical Waste’ bags for used PPE
g) Hand-hygiene facilities
h) PPEs
Staff dining area
i) Signs reminding staff of precautions
i). Sit at least 3 feet apart
ii). Use own eating and drinking utensils
iii). Do not talk and cough when not wearing a mask
Staff changing room and bathroom
Adequate shower facilities
Standard personal protective equipment
Ø N 95 mask
– Ensure correct size and model (fit test), and
check for leakage (user seal check) every time when putting on the mask
Ø Powered air purifying respirators for those staff who cannot be fitted with a N95 mask
Ø Protective eyewear
Ø Long-sleeved protective gown
– Water repellent/ waterproof
– Waterproof gown for activities/ procedures that are likely to generate aerosols or splashes
Ø Full-face shield
Ø Cap
Ø Gloves. If latex gloves are used an alternative should be available for staff with latex-sensitivity.
Ø Footwear precautions: working shoes
* Don respiratory protection, gown, gloves, eye protection, full face shield and cap before entering the isolation room or designated isolation area.
* When removing PPE, use great care to avoid contamination to mucous membranes, skin and clothing.
* Removal of respiratory protection must be done outside of the isolation area and not inside the isolation area
* Do not gown down while in close proximity to others
Important points to note about PPEs
If there is sufficient stock, disposable PPE should be used once only. In an epidemic it may be necessary to re-use disposable equipment. All users must receive adequate training in the purpose and use of PPE.
1) N95/100 mask
Ø If it is to be reused
– Protect it with an overlying surgical mask/ full face shield
– The outer surface of a used mask is potentially contaminated. When it has been removed but is to be re-used later, store in a single-use paper bag, so as to avoid contamination of other objects or surfaces.
– Wash hands thoroughly after putting on used disposable particulate respirator
– Dispose of mask at end of shift or after high risk procedure (eg intubation)
2) Disposable protective gown
Ø Water repellent/waterproof
– Use waterproof gown for high risk procedures
3) Disposable full-face shield
Ø If re-used, discard at the end of the shift. For short break, wipe with gauze soaked with 70% alcohol and keep in single-use paper bag
Ø Discard after high risk procedures
4) Goggles
Ø Send to central sterilization unit for disinfection
Ø For short break, wipe with gauze soaked with 70% alcohol and keep in single-use paper bag
5) Gloves
Ø Change gloves and practice hand antisepsis after patient contact, after procedures and between patients.
Ø Remove gloves before touching common touch items such as phones, keyboards and intercoms and patients’ notes.
Ø Do not wash gloves for continual use
Ø Double-gloving is not recommended
6) Mask/ respirator with an exhalation valve
Ø Should not be used by suspected/confirmed infectious patients, and around clean/sterile field. When wearing this kind of mask under these circumstances, add a surgical mask on top.
7) Powered air purifying respirators (PAPR)
Ø Users must receive training
Ø Proper maintenance is essential ( e.g. charging of batteries, replacement of disposable parts )
Ø Clean and disinfect thoroughly after use
Ø A member of staff, wearing standard PPE, should be available to help staff remove PAPR
Ø PAPR incorporating a hood are preferable to those which consist only of a head cover
8) Change or remove PPE, whichever is appropriate, when moving from a zone of higher risk to a zone of lower risk
9) Change gown/ clothes immediately when soiled
10) Change into new protective clothing after performing high-risk procedures
11) Wash as soon as possible after
Ø Very high risk procedures
Ø Extensive soiling
Ø Lapse in infection control
12) All persons inside the hospital compound must wear a mask
Specific respiratory precautions
1) Avoid splashing of respiratory secretions
2) Avoid open suctioning of airway secretions
3) Use closed-suction system for patients with an endotracheal/ tracheostomy tube in place. Keep the suction tubing attached to the closed-suction catheter.
4) Minimize disconnecting the ventilator circuit.
5) Use disposable ventilator tubings. No need to routinely change ventilator tubings.
6) Attach a high quality bacterial/ viral HMEF to endotracheal tube/ tracheostomy tube
7) Scavenge expired gas from the exhaust port of the ventilator
8) Attach a high quality bacterial/ viral filter to the expiratory port of ventilator and portable ventilator
9) Bag-valve-mask unit – attach a high quality bacterial/ viral filter to the expiratory port and another filter between the mask and valve of the bag.
10) Bag-valve-mask ventilation, when required, should be minimized as much as possible. When using the bag-valve-filter-mask unit, one staff uses both hands to hold the mask tightly against the patient’s face, while another staff uses one hand to squeeze the bag gently and observe chest expansion. Ensure a tight seal between the mask and the face to avoid dispersion of exhaled air and droplets.
11) CPR- when only 2 persons are available for CPR, the one who performs chest compression will also be responsible for squeezing the bag
12) Discard the filter attached to the BVM unit after use and dispose of as clinical waste
13) Intercostal drainage system – attach a high quality bacterial/ viral filter to the outlet of the underwater seal
14) Put the ventilator on ‘Standby’ mode first when the ventilator needs to be disconnected
15) Ensure that the cuff of endotracheal/ tracheostomy tube is adequately inflated
16) When sampling endotracheal aspirate for investigation, change the closed-suction catheter to a new one and attach a sputum trap to the distal end of the new closed-suction catheter before obtaining the endotracheal aspirate.
17) Put a surgical mask on spontaneously breathing patients
18) No venturi-mask – use nasal prongs, simple face mask or non-rebreathing bag.
19) Avoid nebulizer – use metered-dose inhaler
20) No non-invasive positive pressure ventilation unless it is deemed medically necessary and additional airborne precautions are taken
21) No spirometery/ peak flow measurements
22) Endotracheal intubation – Preparation of drugs and equipment ( including the end-tidal CO2 monitor ) and setting of ventilator parameters should be done in advance. Before connecting the endotracheal tube to the ventilator, ensure that the cuff of the endotracheal tube is adequately inflated and the ventilator is on ‘Standby’ mode.
23) Endotracheal intubation/ bronchoscopy – adequate sedation and muscle relaxant should be given to patients to minimize cough/ resistance and spillage
Potentially high risk procedures/activities
Ø Aerosol generating procedures
Ø Insertion or change of catheter, blood taking
Ø Extensive nursing care activities on dependent patients, confused and uncooperative patients
Ø Caring for patients with vomiting and diarrhoea
Ø Cleaning and disinfection activities
Ø Handling of clinical waste, including changing filters of portable air cleaning device or HEPA filtration unit
Ø Manipulation of the air-conditioning/ ventilation system
Important points to note:
1) Consider additional safety measures as appropriate to the task
– e.g. Tight-fitting goggles, impermeable hood that covers both the head and neck areas, PAPR, and additional airborne precautions (e.g. portable HEPA- filtration unit ).
2) Avoid splashing of blood, body fluids, secretions and excreta, and any other contaminated/ potentially contaminated fluids.
3) When emptying body fluids, direct the flow of drainage against the side of the collecting jug or sluice.
4) Ensure adequate instructions to cleaning staff on the types of high-risk activities possibly encountered in the unit, appropriate PPE required and specific precautions to be taken (e.g. avoid splashes when handling excreta ).
5) See ‘Aerosol generating procedures’
Aerosol-generating procedures
Ø e.g. CPR, endotracheal intubation, bronchoscopy, diagnostic sputum induction, open airway suctioning, nebulization
Important rules to follow (as appropriate to the task):
1) Perform only if deemed medically necessary
2) If condition allows, perform the procedure in an airborne isolation room or, less preferably, in a private room.
3) Place an air cleaning device such as the portable HEPA filtration unit in the vicinity.
4) Limit the number of staff involved.
5) Limit the extent of the procedure.
6) Keep room door closed and minimize entry and exit during the procedure.
7) Give adequate sedation and muscle relaxant for endotracheal intubation and bronchoscopy
8) Personal protective equipment should consist of standard PPE modified as follows:
a) fluid resistant gown
b) powered air purifying respirator with hood
or googles with impermeable hood that covers both the head and neck areas
Following aerosol-generating procedures, clean and disinfect the environment and equipment immediately and with standard PPE on.
Hand hygiene
1) Use antiseptic handwash or antiseptic hand-rub.
2) Use antiseptic handwash if hands are visibly soiled.
3) Follow proper steps to ensure a thorough hand-wash / hand-rub.
4) Do not touch the face and the mask, especially the eyes, nose and mouth.
5) Practice hand antisepsis
a) On entering and leaving the isolation area.
b) Between patients, after patient contact, after procedure, and, after contact with blood, body fluids, secretions, excretions, mucous membranes, and contaminated and potentially contaminated items.
c) After removing gloves.
6) Turn off water taps with paper hand towel.
7) Remove gloves and perform hand hygiene before touching frequently touched items, such as phones, keyboards and intercoms, and before touching patients’ notes and writing notes.
Waste management
1) Items to be treated as clinical waste
a) Items listed as clinical waste under the pre-existing hospital guidelines
b) All contaminated / potentially contaminated wastes
c) Disposable PPEs
d) Linens heavily soiled with blood, body secretions, vomitus and excreta.
2) Disposal
a) Handle gently. Do not disperse.