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Coronavirus (COVID-19)Infection Prevention and Control The Operating Department

Version 1.2 14th April 2020

What is Coronavirus and COVID-19

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Coronaviruses are a large family of viruses - they cause infections ranging from the common cold to Severe Acute Respiratory Syndrome (SARS)

Coronaviruses circulate between animals and humans; sometimes new variants of the coronavirus emerge - such as COVID-19

COVID-19 has the potential to spread widely as lack of immunity means everyone in the population is susceptible

What are the symptoms of COVID-19? Symptoms start 5 -11 days

after exposure Similar to seasonal flu Majority have fever and dry

cough (rapid onset) Symptoms last 5 - 6 days Severe illness starts day 7 Shortness of breath Lung inflammation Pneumonia

Symptom Proportion of cases

Fever >37.8oC 88%Dry cough 68%Fatigue 38%Sputum 33%Shortness of breath 19%Muscle/joint pain 15%Sore throat 14%Headache 14%

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Severity of COVID-19 illness Most people have no obvious

symptoms (30-40%) Most children get mild disease More severe disease in:

Older people Diabetics Heart disease Chronic respiratory disease Immune compromised

Less than 2% of cases fatal Highest in high risk groups

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Undetected

CriticalRespiratory/muli-

organ failure

SevereShortness of breath; Respiration; O2 sats

MildFever, cough

How is COVID-19 transmitted? Exposure to large respiratory droplets Coughing/sneezing droplets onto mucous membranes

mouth, nose, eyes Need close contact for this to occur (within two meters)

Contact with respiratory secretions Directly or via contaminated surfaces Tissues contaminated with respiratory secretions Transferred by touching mucous membranes

Not transmitted in air except during a procedure involving the respiratory tract that generates aerosols

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Infection Prevention & Control Strategies

1. Cough etiquette

2. Standard precautions

3. Isolation precautions

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Personal hygiene to prevent spread Cough etiquette Cover mouth and nose with a tissue or your sleeve

(not your hands) Dispose of tissues directly into bin Hand hygiene after contact coughing/sneezing

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Ensure patients have hand wipes

or alcohol gel available

Standard Precautions Essential to minimize risk of transmission

between staff and patients Will reduce the risk of transferring the virus from

patients not recognized to have COVID-19

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Hand hygiene Protective clothing for contact with body fluid Safe disposal of waste Clean equipment & environment

Hand Hygiene

Immediately before touching a patient

Before a clean/aseptic procedure

Immediately after touching a patient or their surroundings

After removing gloves

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Alcohol gel is effective against COVID-19Soap and water should be used if hands are soiled

Patient hand hygiene

Encourage patients to clean their hands After coughing/sneezing Before eating After toilet

Make hand wipes or alcohol gel available at bedside for patients to use

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Standard precautions: Gloves For procedures involving DIRECT contact with blood

or body fluid Risk assess procedure if gloves are indicated put on immediately before

commencing procedure Remove and decontaminate hands immediately after

the procedure

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Take gloves off promptly!Virus (and other pathogens) are transferred between patients,

surfaces and your own mucous membranes on your gloved hands

Standard Precautions: Aprons

For procedures where there is a risk that the clothing may become soiled

Risk assess procedure If indicated put on immediately before commencing

procedure Remove if contaminated or on leaving the

patient and decontaminate hands

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Droplet precautions Operating theatres

Patient with possible or confirmed COVID-19 where no Aerosol Generating Procedures (AGP)

Patient transfers Patient with possible or

confirmed COVID-19

Airborne precautions Operating theatres

Surgery involving AGP on patient with possible or confirmed COVID-19

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Transmission-based Precautions

Aerosol Generating Procedures Associated with high

velocity air passing over respiratory mucosa Generates tiny (<5µm)

respiratory particles which remain airborne

Only perform AGP on COVID19 patients if essential

Only essential staff present Airborne precautions required

(FFP3 mask/gown)

Aerosol Generating Procedures (AGP)

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Intubation & extubationManual ventilation/open suctioning Surgery - high speed devices Dental - high speed drilling Tracheostomy Upper GI endoscopy + open

suction of respiratory tract Bronchoscopy & ENT with suction High flow nasal oxygen Non-invasive ventilation (BiPAP,

CPAP) & HFOV Sputum induction

FFP3 Respirator Masks Filters out very small particles Protects from inhalation of fine airborne particles

(droplet nuclei) Filtration effective only if sealed to contour of face

Fit testing required to ensure effective protection Fit check before each use

Required for procedures which generate aerosols of respiratory secretions (AGP)

Not necessary for close contact without AGP Must be worn with long-sleeved waterproof gown

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Droplet Precautionsknown or suspected COVID-19 patients

Infection is transmitted by respiratory droplets and contact with respiratory secretions therefore: Place patient at end of list Admit directly to operating theatre Anaesthetise & recover in operating theatre Protective clothing for contact (within 2 metres)

Fluid resistant surgical mask, eye protection, gloves, plastic apron Theatre ventilation must be left on Dedicated patient equipment where possible Clean surfaces as for infected patients

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Surgical masks protect mucous membrane from contamination by large respiratory droplets (and are as effective as FFP3 for this)

Protective clothing Known or suspected COVID-19

(no aerosol generating procedures)Direct care (in operating room) Fluid Resistant Surgical mask (Type IIR) Eye protection Gloves

MUST be changed after each task (as per 5MHH) to protect patient from infection

Apron (or sterile gown if scrubbed) change if soiled

Inform Promote SustainRemember to avoid touching your mouth, nose and eyes

Discard all protective clothing and clean hands on leaving room and when patient discharged

Airborne PrecautionsAGP on known/suspected COVID-19 patient Ventilation (ultraclean air or conventional) MUST

be on during the AGP procedure Rapid dilution of aerosols will protect theatre staff

Only staff required to perform procedure to be present

Staff to wear: FFP3 respirator mask Eye protection (visor) Long-sleeved waterproof gown Gloves

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Public Health England

Removal of protective clothing(Doffing)

Discard mask when moist or damaged Remove PPE in this order:

1. Gloves (then decontaminate hands)2. Apron/gown (avoid touching contaminated front surface)3. Mask/eye protection

Decontaminate hands after all PPE has been removed

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Remember!Don’t touch your mouth, nose or

eyes.

Decontaminate your hands

thoroughly on leaving the area/room.

Summary of precautions for known/suspected COVID-19 patients

In-patient areas Operating Department

PPE Patient contact(within 2m)

AGP (in room)& high risk

areas

No AGP AGP

Plastic apron Surgical mask - fluid-resistant (IIR/EN14683)

Long sleeved disposable gown Risk assess

FFP3 respirator Eye protection Risk assess Disposable gloves

Inform Promote SustainAGP = aerosol generating procedures

Additional precautions may be applied in in-patient areas where there is sustained transmission of COVID-19

Environmental contamination Surfaces may become contaminated with respiratory

secretions Directly from coughing/sneezing Indirectly by touching with contaminated hands Contamination greatest where AGP performed

COVID-19 unlikely to survive in significant numbers on surfaces for longer than a few days Studies often recover virus RNA but many do not test if viable

and able to cause infection

Easily removed by cleaning Detergent & water followed by disinfectant Chlorine at 1000ppm effective

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Medical EquipmentFor known/suspected COVID-19 patient Protect ventilators with high efficiency filter Use closed system suction Use single-use equipment where possible Laryngoscope –disposable or processed by sterile services Video laryngoscope –decontaminate handle as per

manufacturers instructions

Near-patient medical equipment Decontaminate after the patient has left the operating theatre Use detergent & water followed by disinfectant

Select disinfectant using protocol for infected cases or manufacturers instructions

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Surgical Instruments Used on known/suspected COVID-19 patient

Apply standard infection control precautions to handle instruments after the procedure Wrap surgical instruments and tray in the usual way Return wrapped trays directly to sterile services Clean trolleys using detergent & water followed by

disinfectant (chlorine 1000ppm)

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Cleaning after procedure on known/suspected COVID-19 patient

Aerosols will be rapidly removed by air changes airborne contamination will eliminated after five mins

Clean surfaces according to infected patient protocol Commence after patient has left operating theatre Use detergent followed by chlorine 1000ppm Decontaminate cleaning equipment immediately after use

Waste - treat as clinical waste Linen - place directly into water-soluble bag

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Staff with COVID-19

If you develop symptoms of a flu-like illness then DO NOT come into work: Acute onset fever >37.8oC and new persistent cough

Inform your manager Self-isolate at home for seven days from onset of

symptoms If your symptoms worsen contact NHS 111

Staff at high risk of complications from COVID-19 risk-assessment to manage their deployment

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Useful resourcesPublic Health England Campaign Resourceshttps://campaignresources.phe.gov.uk/resources/campaigns/101-coronavirus-

Public Health England Coronavirus (COVID-19) infection control guidance https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control

NHS Englandhttps://www.england.nhs.uk/ourwork/eprr/coronavirus/

NHS websitehttps://www.nhs.uk/conditions/coronavirus-covid-19/

Healthcare Infection Societyhttps://his.org.uk/resources-guidelines/novel-coronavirus-resources/

World Health Organizationhttps://www.who.int/emergencies/diseases/novel-coronavirus-2019

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