July FY21

[sarahrollison]

This month's journal club is presented by Sarah Rollison. She chose the article "Providing Anesthesia for Emergent Surgery in a Patient with COVID-19" from the AANA Journal. This article discusses best practices for management of COVID patients undergoing emergent surgery. 

Here is a link to the article. 

Please answer the following questions to engage in discussion:
1. What are the recommendations for transport of a COVID positive patient listed in this article? How does this differ from practice at your facility, if at all?
2. The article discusses reuse of N95 masks - what are your thoughts regarding reuse of N95 respirator masks? 

[nanci]

1) What are the recommendations for transport of a COVID positive patient listed in this article? How does this differ from practice at your facility, if at all?

The article states that if the patient is breathing spontaneously during transport, the patient should wear a mask to prevent aerosolized viral particle spread. Current practice at our facility does the same and masks are provided to patients upon hospital arrival if they do not have one or arrive without one.
The article states that for patients already intubated and on ventilators, the patient should be kept on his/her ICU ventilator for transport to the operating room. This would require the assistance of an RT to manage the ventilator during transport. I believe current practice at our facility is that recommended practice only when the patient's ventilator settings are such that the ICU Ventilator must transport with the patient to maintain their specific ventilator settings. There have been times when we transport with am ambu bag and a filter, no ventilator and no RT on the transport.
The article states that the ICU team should intubate the patient in the ICU and then transport to the OR to minimize potential spread of viral particles during transport or during intubation in the positive airflow OR Rooms- I do not believe that happens at our facility.
The article states that the patient ventilator and bed be wiped off and the patient covered with a clean sheet for transport to reduce viral shedding in the hallways- that does not happen at our facility.

2)The article discusses reuse of N95 masks- what are your thought regarding reuse of N95 respirator masks?
I agree with the article that the N95 should be discarded if used for an aerosol-generating procedure, if contaminated with blood, secretions, or body fluids, or if comes into close contact with infected patients. If the integrity of the mask is disrupted or it does not fit as initially tested it should be discarded and a new one obtained. I understand the difficulty in obtaining and adequate PPE supply, I understand that updated CDC recommendations are based on supply chain and manufacturing challenges. I do not agree that recommendations are not based on evidence or knowledge that reflects a greater understanding of disease transmission of COVID. The health and safety of providers (and patients) should not be placed at risk. Quite the leap from not being able to wear your mask around your neck and changing them frequently to now having to reuse the same mask for months on end- not based on science or evidence which puts providers own health at risk.

[Jennifer Hannon]

1) What are the recommendations for transport of a COVID positive patient listed in this article? How does this differ from practice at your facility, if at all?

a)If the patient is breathing spontaneously during transport, the patient should wear a mask to prevent aerosolized viral particle spread. We do this
b)For patients already intubated and on ventilators, the patient should be kept on his/her ICU ventilator for transport to the operating room. Anesthesia has been transporting with am ambu bag and a filter, no ventilator and no RT on the transport.
c) the ICU team should intubate the patient in the ICU and then transport to the OR. Anesthesia has been intubating, I've only known of a handful of times in the ICU room before OR.

2)The article discusses reuse of N95 masks- what are your thought regarding reuse of N95 respirator masks?
It has been challenging to find and keep a good fit when resuing the N95 all week, because they get wet with our breath all day. The drager is ok but no one can hear you when you speak. I'm wearing mine all day for personal medical preference. The duckbill ones fit and provide a good seal, but the red rubber band straps snap so easily. We are able to go to the office for new PPE. I have been eating Ricola to enjoy the air I breathe as well, and remembering to sneeze with my mouth firmed and close.

[Anne McNulty]

I transported 4 intubated covid positive pts to the Or . WBG rm 1. No respiratory therapy accompanied me. We bagged with a Filter. Two or three of the patients were having tracheostomy done. The bed was not kept in the room. Navigation in rm 1 WBG is difficult. We did have a safety officer escort. On 2 occasions the safety officer did not know the way to Wbg. Securing the PAPR required going to Endoscopy to pick it up. That has now changed. I do not recall designated "clean and Dirty staff as discussed by the article. Everyone was in a papr and touched the pt. There were staff outside for donning and doffing monitoring. The or cleaning was as described in the article. If I had worn an n-95 mask , I would have discarded it. That is CDC recommendation. reuse n-95 unless it is contaminated.

[jkim54]

1.The article's recommendations for transporting a COVID-19 patient is not much different than our institution's. If the pt is coming from the ICU on a ventilator, it is also acceptable practice for us to use a filter and ambu bag for transport. Otherwise if the pt is spontaneously breathing, an oxygen mask with a face mask over it is also used for transport.

2.Since the CDC states "there is no way of determining the maximum possible safe reuses for an N95 respirator" I personally use one on average every few days, unless it gets visibly soiled. For aerosol-generating procedures, especially if the pt is +COVID-19, I use a PAPR and not my N95 mask. The literature seems to support that using another surgical mask over the N95 and a face shield can possibly extend the life and usage of the N95 mask as well.

[khall]

1. What are the recommendations for transport of a COVID positive patient listed in this article? How does this differ from practice at your facility, if at all?
The only recommendations that we do at our facility is having a spontaneous breathing patient wear a mask. The article recommends using their ICU ventilator and transporting with RT, I have used ambu and filter without RT. I have not had to intubate known positive for a surgery but it is my understanding that we are doing so in the OR not in the ICU as the article recommends.


2. The article discusses reuse of N95 masks - what are your thoughts regarding reuse of N95 respirator masks?
I agree that the N95 does not fit as well with reuse and it has been challenging to find time to get a new ones.

[Katya]

1. What are the recommendations for transport of a COVID positive patient listed in this article? How does this differ from practice at your facility, if at all?
I transported several patients from COVID unit and patient were breathing on their own. We did have safety officer with us but because they don't go with patient to elevator and we had issue in elevator, we had to push buttons and spread the virus (no wipes available). Article recommends to change scrubs after contact with COVID + patients, it was 1st time I heard that.

2. The article discusses reuse of N95 masks - what are your thoughts regarding reuse of N95 respirator masks?
I was very concern about reuse N95 masks for "until soiled" what ever it means, but so far I didn't notice any increase in infection rate. So I began feeling more comfortable to wear it for a week. I try to change it at least once a week.

[Kels]

What are the recommendations for transport of a COVID positive patient listed in this article? How does this differ from practice at your facility, if at all?

It is also my understanding that at our facility spontaneously breathing patients wear a mask during transport . Overall preventing aresolized viral spread is the ultimate goal and when transporting an intubated patient limiting the disconnection from the ventilator is ideal during transport but more times than not at our facility we do disconnect to an ambu bag and use a filter . Personally I have noticed more intuabtions occurring in the operating room.


The article discusses reuse of N95 masks- what are your thought regarding reuse of N95 respirator masks?

Mentally it has been a challenge reusing the N95 masks since back in the day I was told at an N95 fitting that the mask should be discarded every 8 hours. Now it is hard to hear that we should wear the mask basically as long as we possible can . Changing information about using personal protective gear longer than recommended or longer than we ever have in the past makes one feel a little uneasy at times .

[Vania Milnes]

1. What are the recommendations for transport of a COVID positive patient listed in this article? How does this differ from practice at your facility, if at all?
Our spontaneously breathing patients do wear a mask, but most of the time we do not place regular facemasks over the green O2 masks... I have not transported anyone on a ventilator, only with a filter and ambu. I definitely have not seen anyone wiping beds or covering with clean sheets, and while there are times that I've seen attempts to keep the number of staff exposed to any one patient, I think there is room for improvement there, but it's so hard in a huge place like this! I also believe most patients are not intubated prior to arrival to the OR.

2. The article discusses reuse of N95 masks - what are your thoughts regarding reuse of N95 respirator masks?
I agree with everyone as far as the N95 situation. How was it not ok to let a mask dangle between cases and now we're expected to wear the same one until... when? No one really knows... It's not like we can "fit test" our masks daily to make sure they're still providing full protection, but that would be nice if we could! It's a risk we are all taking out of sheer necessity, which is unfortunate. None of our options are ideal.

[LarSharVeA Bailey]

The recommendations are not much different than our everyday practice; I have not seen a patient transported on a ventilator, however. Fortunately, I have not assumed care of a covid positive surgical patient. The perioperative mortality rate for such patients are reportedly 20%.

For all of our healthcare lives, we have practiced proper PPE application and disposal. While I understand that there has to be some sort of effort to conserve PPE, wearing the same mask for an infinite amount of time is like saying it's ok to reuse a syringe as long as the needle is changed. It goes against everything that we know to be true with no studies supporting that providers are safe in doing so. While intubating and extubating, I wear the draeger mask with a face shield, always.

[jessica switzman]

1. The article recommendations for transporting COVID positive patients are the same as what we are doing at Bayview. When a COVID ventilated patient goes to the OR we employ RT and use the existing ventilator. When transporting a pt from a COVID OR, the CRNA stays in the OR and the Attending or another CRNA meet at the door, the CRNA that was in the rm then changes and meets the patient and other provider in the PACU or ICU.

2. While we try to preserve PPE, mask need to be changed when soiled. I where a regular mask over my N95 to protect it. We have been lucky to the proper PPE here at Bayview and are able to get fresh masks when necessary. Of course, it would be ideal to change masks more often than we are currently doin.

[Jessica Hadley]

1.As has been previously discussed, the article states that a spontaneously breathing COVID+ patient should wear a mask for transport. I have seen this done at JHH. As several others have mentioned for intubated patients, I have not seen RT staff going with patients off the floor with their vent but rather an ambu and filter.

2. I do understand the concept of preserving PPE, however I do not feel that an N95 that has been used multiple times is as effective as one that is new. I have noticed over time my N95 has gotten more comfortable (aka not as tight) with subsequent uses which leads me to wonder, am I fully protected. While working in the COVID ICU I always wore a PAPR for this very reason.

[Wai-Ling Lo]

1. What are the recommendations for transport of a COVID positive patient listed in this article? How does this differ from practice at your facility, if at all?
According to the article, pt who is breathing spontaneously should have a mask on while transporting, same as in Hopkins. For intubated pt, pt should be kept on ICU vent and RT helps with the transport. We transport intubated pt with ambu bag and filter without RT.



2. The article discusses reuse of N95 masks - what are your thoughts regarding reuse of N95 respirator masks?
In order to conserve supplies, CDC and many hospitals recommend the reuse of N95 as long as it maintains its fit and function. Like everyone has noticed, the fit of N95 is not as good after a day or 2 of extended use. Therefore, I don't know how reliable it is. I too wear PAPR for COVID positive pts.

[Soo-Ok Kim]

1. What are the recommendations for transport of a COVID positive patient listed in this article? How does this differ from practice at your facility, if at all?

The recommendation on the article for transporting COVID positive patient is similar to what we do in Hopkins except bringing ICU ventilator to OR when pt is needed surgery.

2. The article discusses reuse of N95 masks - what are your thoughts regarding reuse of N95 respirator masks?

I think single use of N95 is ideal, but in the time of PPE shortage, it is encouraged to be reused with regular surgical mask over it. Some facility autoclave them up to 4 times until we can discard it.
Trying to keep N95 mask clean will be needed to preserve the integrity of the mask.

Soo-Ok Kim

[chris velarde]

1. The transport of COVID patients at Hopkins mirror the article's transport regimen . There is also a safety officer for donning/doffing to make sure everyone remains safe. The patient is directly transported into the room so there is less exposure to other clinicians.
2. The infectious control officer states that we should not where two masks because the moisture between the two masks can make the N95 mask less effective. I think this may be a good practice in general but impractical with the supply of N95 we have here at our disposal. We are currently involved with highly aerosol cases and exposed to potential coughing. The face shield should offer protection however I think the potential for exposure still exists.