As COVID-19 developments change day-to-day, nurses and healthcare professionals need to be informed on developing guidance and recommendations for protective measures to be taken. This blog post will outline precautionary and protective elements, the new Center for Disease Control (“CDC”) guidance as of March 10, 2020, and National Nurses United’s recommendations (“NNU”). NNU has published an infographic that can be located here which further details old CDC guidance, updated CDC guidance in response to COVID-19, Cal/OSHA ATD standards and guidance, and NNU recommendations.
- Transmission Route of Virus
- New CDC Guidance: person to person, close contact, respiratory droplets primarily
- NNU Recommendation: person to person, follow precautionary principle and implement highest level of protection
- Increased Patient Injuries and Reduced Patient Safety
- New CDC Guidance: Increased emphasis on early identification and implementation of source control; Source control procedures for patients with symptoms of respiratory illness; Triage procedures to detect and isolate PUIs before or immediately upon arrival to health care facility
- NNU Recommendation: Implement screening protocols to promptly identify and isolate patients with possible COVID-19 infections at the first point of contact/entry in the health care facility or before arrival at the health care facility; Protocols should be proactive and preventive, based on the precautionary principle, rather than reactive to COVID-19
- Isolation Protocols
- New CDC Guidance: Ensure that patients with symptoms wait in separate waiting area and are separated by six feet from other patients; Isolate patient in exam room with door closed; Place any patient with unexplained fever or respiratory symptoms on appropriate Transmission Based Precautions and evaluate; Passively screen visitors for symptoms.
- NNU recommendation: Immediately place patients with known or suspected COVID-19 in AIIR isolation until COVID-19 has been ruled out or has patient recovered and been discharged; Prepare separate waiting areas for potential COVID-19 cases or patients and visitors and respiratory symptoms to prevent exposures
- Negative Pressure Rooms
- New CDC Guidance: AIIR should be at negative pressure with minimum of 6 air changes per hour, 12 air changes per hour recommended for new construction or renovation; Air from AIIR should be exhausted directly outside or through HEPA filter before recirculation; Room doors should be kept closed except when entering or leaving the room; Should monitor proper negative-pressure function of these rooms
- NNU Recommendation: AIIR rooms must be maintained at negative pressure and checked regularly
- If Negative Pressure Rooms Not Available
- New CDC Guidance: Guidance recommends that patients with known or suspected COVID-19 should be cared for in single-person room. AIIR should be reserved for aerosol-generating procedures.
- NNU Recommendation: Patients who require hospitalization should be transferred as soon as possible to facility where AIIR available; If no AIIR available, patients should be placed in private room with surgical mask on, closed door and HEPA filter with required PPE for HCW, until AIIR room becomes available
- Engineering Controls in Addition to Negative Pressure Room
- New CDC Guidance: Recommends designing and installing engineering controls to reduce or eliminate exposures.
- NNU Recommendation: Implement additional engineering controls to prevent exposure to workers or other patients; Consider separate screening areas, plans to deal with significant numbers of patients, and ensure staff are aware of surge plans before implementation
- Transport of Patients Throughout Facility
- New CDC Guidance: Only for medically essential purposes; Patients should wear face mask during transport.
- NNU Recommendation: Must implement protocols to protect patients and staff from exposure if patient must leave room; There should be a dedicated transport route and routes of entry involving source control for patient, PPE for workers, and environmental cleaning.
- Contact Precautions
- New CDC Guidance: Contact precautions not specifically named. Recommended every entry to patient room or care area:
- Use a respirator or face mask.
- Isolation gown.
- Gloves.
- Eye protection
- NNU Recommendation: Every time HCW enters room of patient with known or suspected COVID-19.
- New CDC Guidance: Contact precautions not specifically named. Recommended every entry to patient room or care area:
- Airborne Precautions
- New CDC Guidance: Airborne precautions not specifically named; Patients with known/ suspected COVID-19 should be cared for in single-person room with door closed; AIIRs reserved for aerosol generating procedures; Respiratory or face mask; N95 or higher for aerosol generating procedures; When supply chain is restored, return to use of respirators for facilities with respiratory protection.
- NNU Recommendation: Every time HCW cares for suspected COVID-19 patient, probable, or confirmed case; Highest level of respiratory protection should be provided- PAPR (or CAPR); While employers are taking action to get PAPRs, if they are not available, minimum respiratory protection must be N95.
- Respirators
- New CDC Guidance: Respirator or face mask okay.
- NNU Recommendation: Highest level of respiratory protection should be provided- PAPR (or CAPR); While employers are taking action to get PAPRs, if they are not available, minimum respiratory protection must be N95.
- Aerosol-Generating Procedures
- New CDC Guidance: Perform cautiously, avoid if possible; Should ideally take place in AIIR and personnel should use respiratory protection N95 or higher, eye protection, gloves, and gown; Limit number of health care workers present during procedure, only those necessary for patient care/ procedural support.
- NNU Recommendation: Procedures should take place in AIIR; Health care workers should wear PAPR/CAPR; Limit number potentially exposed HCW present during procedure
- Training on PPE
- New CDC Guidance: Health care workers must receive training on and demonstrate an understanding of when to use PPE, how to use it safely, and other content
- NNU Recommendation: In-person, hands-on training and education for all nurses regarding PPE and safe donning and doffing practice, maintenance, disinfection and at minimum, annual fit-testing for HCW; In-person, hands on training on all protocols and plans implemented by employer for COVID-19.
- Duration of Precautions for PUIs and Confirmed COVID-19 Patients
- New CDC Guidance: Reference to more detailed guidance: https://www.cdc.gov/coronavirus/2019-ncov/
- NNU Recommendation: All precautions should be maintained for patients with suspected COVID-19 infections until COVID-19 is confidently ruled out or patient is discharged; A negative test should not be, by itself, grounds for removing precautions if the patient has signs and symptoms matching COVID19.
- Covering of Health Care Workers’ Clothing/Skin/Bodies
- New CDC Guidance: Isolation gowns; if shortage of gowns, they should be prioritized for aerosol-generating procedures.
- NNU Recommendation: Highest protection should be provided based on precautionary principle – coveralls that meet ASTM standards for viral impenetrability; Employers should provide temporary scrubs to nurses caring for patients with suspected or confirmed COVID-19
- Hand Hygiene
- New CDC Guidance: Recommended before and after all patient contact, before putting on and upon removal of PPE, including gloves; Recommends using alcohol-based hand sanitizer for hand hygiene and using soap and water
- NNU Recommendation: Hand hygiene with soap and water after removal of gloves or other PPE, after contact with potentially infectious materials, before and after and patient contact; Inappropriate to recommend hand sanitizer as primary hand hygiene method
- Occupational Exposure Surveillance
- New CDC Guidance: No longer specifically addressed
- NNU Recommendation: Employers shall clearly communicate with all RNs, including notifying RNs when there is a possible or confirmed COVID-19 case; Employers shall conduct a thorough investigation after a VODI patient is identified to ensure all staff and individuals who were exposed are identified and notified.
- Quarantine and Testing for Exposed Health Care Workers
- New CDC Guidance:
- High-risk exposures: health care workers with prolonged close contact with patients with COVID-19 not wearing a face mask while health care worker nose and mouth were exposed.
- Medium-risk exposures: health care workers who had prolonged close contact with patients with COVID-19 who were wearing a face mask while health care worker nose and mouth were exposed.
- Low-risk exposures: brief interactions with patients with COVID-19 or prolonged close contact with patients who were wearing a face mask for source control while health care worker was wearing face mask or respirator.
- Health care providers with confirmed or suspected COVID-19 should be excluded from work until their fever has resolved without medication and their respiratory symptoms have improved and either two consecutive tests come back negative OR at least seven days have passed since symptoms first appeared
- NNU Recommendation: Any nurse/health care worker who is exposed to COVID-19 should be placed on precautionary leave for at least 14 days and should maintain pay and other benefits during the full length of that leave
- New CDC Guidance:
- Staffing
- New CDC Guidance: Determine how staffing needs will be met as the number of patients with known/suspected COVID-19 increases and HCW become ill and are excluded from work.
- NNU Recommendation: Minimum 1:1 RN to patient assignment to prevent possible exposure to other patients via contaminated objects or surfaces; Additional staffing must be placed to ensure safety, including a buddy or observer system to ensure safe donning and doffing of PPE; Additional staffing must be placed to ensure that nurse assigned to patient has rest breaks and relief as needed.
- Training
- New CDC Guidance: Provide health care workers with job- or task-specific education and training on preventing transmission of
- infectious agents; Ensure that health care
providers are educated, trained, and have practiced appropriate use of PPE prior to caring for a patient.NNU Recommendation: In-person, hands-on training and education for all nurses and other health care workers regarding PPE and safe donning and doffing practices including, at minimum, annual fit-testing for HCW; Communicate clearly with nurses and other staff regarding COVID-19 preparation, protocols, and any confirmed or suspected cases in the facility; Ensure that nurses and other health care workers receive effective training and education regarding facility plans, protocols, preparations, and response to COVID-19; Training and education should be implemented proactively, in preparation for a possible COVID-19 case
- Communication
- New CDC Guidance: Recommends to implement mechanisms and policies that promptly alert key facility staff including frontline staff and other positions; Recommends to communicate and collaborate with public health authorities.
- NNU Recommendation: Communicate clearly with nurses and other staff regarding COVID-19 preparation, protocols, and any confirmed or suspected cases in the facility.
- Visitor Policies
- New CDC Guidance: Recommends establishing procedures for monitoring, managing, and training visitors; Visitors to most vulnerable patients should be limited; Limit visitors to patients with known or suspected COVID19. Encourage use of alternate mechanisms of interaction with patient; Facilities should evaluate health risk of visitor; Additional considerations during community transmission include actively assessing all visitors for fever and respiratory symptoms upon entry to facility, policies around restricting entry, others.
- NNU Recommendation: Employers should implement protocols and plans based on the precautionary principle to limit exposure and transmission of COVID-19. This should include policies to limit and screen visitors.
- Surge Preparation
- New CDC Guidance: Not specifically addressed
- NNU Recommendation: Employers should plan for surge of patients with possible or confirmed COVID-19, including plans to isolate, cohort, and to provide safe staffing; All protections must be implemented in a proactive, preventive manner.
For more information and the most up to date information regarding changes guidelines and requirements, refer to the CDC and CDPH.