restarting your lab a pathway to resuming...
TRANSCRIPT
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RESTARTING YOUR LABA PATHWAY TO RESUMING
DIAGNOSTIC TESTING DURING COVID-19
Matt O’Brien MS RRT RPFT FAARC
May 5, 2020
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BACKGROUND / DISCLOSURES
o I manage the pulmonary labs at the University of Wisconsin Hospital and Clinics in Madison Wisconsin
o We have approximately 12 staff that cover 4 separate testing sites in the Madison area.
o We have been doing “essential” testing and are in the process of restarting our lab.
o We use a variety of vendor equipment for clinical and research related applications.
o References will be made to a variety of equipment types and are for example only.
o
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CONSEQUENCES…COVID-19
Global pandemic
Economic pandemic
Hospital pandemic
Sickness,
Death
Job losses
Business failures
Loss of revenue,
Staff layoffs and pay cuts
Preparedness
phase
Patient surge
phase
De-escalation or
reopening phase
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WHY THIS TALK? o This is a historic event for everyone and especially for
respiratory care.
o There are many unknowns about the SARS-CoV-2, (COVID-19) virus, its transmission, and how to safely proceed with pulmonary testing.
o Cardiopulmonary labs, clinics and research facilities all need guidance to restart services.
o To avoid further transmission, we need to proceed with caution and focus on safety.
o When is it likely safe to resume testing?
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ANSWERING WHEN…IS NOT SIMPLE
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OBJECTIVES: RESTARTING PULMONARY DIAGNOSTICS-DURING COVID-19
o Review of ATS initial, expected and ERS guidance.
o Consider your location: Is the prevalence high or low?
o Explore strategies to help you safely restart diagnostic testing.
o How does the CDC define an aerosol generating procedure?
o Discuss when it is wise to obtain a negative COVID-19 test prior to seeing at patient?
o What infection control practices make sense for pulmonary diagnostics and COVID-19.
o Equipment and testing considerations.
o What role can remote monitoring / telemedicine play?
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INITIAL GUIDANCE ATS
7
March 2020
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KEY POINTS OF INITIAL RECOMMENDATION o PFT testing could represent an avenue for transmission,
because of congregation of patients, coughing and droplet formation surrounding PFT procedures.
o Risk may be significant based on the prevalence, age, severity of lung disease and presence of immunosuppression.
o Limit testing to essential for immediate treatment decisions
o Limit type of testing to essential.
o Implement measures to protect patients and staff.
o Use appropriate PPE
o Enhanced cleaning of testing spaces
o Balance potential risk against need for assessment of lung function to make Rx decisions.
o Risk benefit ratio will change over time8
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OUR EXPERIENCE
o We limited testing to “essential” or urgent testing needed for immediate treatment decisions.
o Over the last 2 months we performed testing on 143 patients / 303 procedures using minimal staff
o We implemented full PPE during all testing (N95, face shield, gown, gloves, and changed the pneumotach out between each patient.
o We ran a HEPA filter in the PFT testing rooms.
o Patients were not required to have a nasal swab test for COVID-19.
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DEVELOPING YOUR PLAN TO SAFELY OPEN YOUR PULMONARY OR CPX LAB
o Prevalence: In the local community/surrounding areas.
o Patients: Prescreen using current recommendations.
o Equipment: Implement additional safety measures to minimize the potential for cross contamination.
o Testing environment: Find solutions to reduce aerosol contamination (patient, nebulizers)
o Time: Allow extra time between patients for disinfection practices and reduce PPE fatigue.
o Review / update your plan as conditions change.
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SHOULD PATIENTS SCHEDULED FOR A “PFT” BE REQUIRED TO HAVE A NEGATIVE
COVID TEST PRIOR TO THE VISIT?
o It depends…
o What specific PFT test is ordered?
o Is the procedure considered “aerosol generating” by CDC?
o Is the patient symptomatic?
o What is the local prevalence of COVID-19?
o Does prescreening suggest a high or low risk patient or community for infection?
o What is your infection control department guidance?11
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THE LOCAL PREVALENCE OF COVID-19
o What is going on in your area?
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WHAT IS AN AEROSOL GENERATING PROCEDURE?
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AEROSOL GENERATING PROCEDURES (AGP)
CDC.gov
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AEROSOL GENERATING PROCEDURES PER THE CDC
CDC.gov
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ARE ALL AEROSOLS INFECTIOUS?
CDC.gov
ATS: The use of MDIs should be used when at all possible to minimize
the risk of excess aerosol that maybe infectious
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PATIENT & COMMUNITY RISK
Low
o No new symptoms
o History of self monitoring.
o No known contact with someone who was ill.
o Symptoms of cough or sputum production are consistent with the known or underlying chronic disease process.
o Local ID and Public Health report local prevalence is reduced
High
o New or multiple symptoms
o Family member is / was ill.
o Temp was 100 or greater recently or on arrival.
o Nursing home or long term care worker or resident.
o Food processing plant
o “Essential” worker
o Multi family household?
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TWO APPROACHES: TO DECIDE WHETHER TO SCHEDULE A COVID TEST PRIOR TO PFT VISIT
o Consider all cardiopulmonary testing to be aerosol generating procedures:
o Require a negative COVID test prior to pulmonary testing.
o Assess each patient and visit carefully for risks and probability.
o Aerosol generating procedure: Obtain test for COVID prior.
o Higher probability: Obtain test for COVID prior.
o Low probability: Pre-screen and use appropriate PPE
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#1 #2
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TESTS WE PERFORM
o Spirometry pre/post
o Lung volumes (Pleth & Dilutional)
o Diffusion
o ABG
o 6MWT
o RMF
o LCI
o Shunt / HAST
o Breath hydrogen testing
o Sputum induction
o Pentamidine administration
o Bronchoprovocation
o Methacholine challenge
o Exercise
o EIB w/cold air
o Mannitol
o Cardiopulmonary exercise (VO2)
o Metabolic testing (REE)
19Text in red are procedures I feel fall into the category of known or potential aerosol
generating procedures because of high ventilation and risk of significant coughing
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PRESCREENINGTHE PATIENT
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SYMPTOM PRE-SCREENINGPATIENTS AND STAFF
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Be on the alert for any new and unexplained symptoms
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PRE-SCREENING PATIENTS PRIOR
TO PFTS
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• Form is completed for each
patient
• EMR
• Phone screening
• Is testing requested
appropriate or needed?
• Consult ordering
provider if patient has
high risk factors
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SHOULD WE PERFORM PULMONARY FUNCTION TESTING ON PATIENTS SUSPECTED
OR + FOR COVID-19?
NO… Wait until after they
recover and have a negative test.
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SHOULD WE PERFORM PULMONARY FUNCTION TESTING ON PATIENTS WHO
HAVE FLU LIKE SYMPTOMS?
NO… Wait until after they recover and have a negative test.
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SCREENING WHEN THE PATIENT ENTERS THE CLINIC OR HOSPITAL
o Self monitoring?
o New symptoms?
o Temperature?
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ENABLE SPACE FOR SOCIAL DISTANCING WHEN CHECKING IN AND IN SEATING AREAS
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THE PATIENT WAITING AREAS
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Rearrange furniture or tape off areas in patient waiting areas
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STAFF WORKSTATIONS SHOULD ALSO BE SEPARATED
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HAND HYGIENE
o Patients and staff should perform wash hands or gel prior to and at end of testing.
o Gel in / Gel out!
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PERSONAL PROTECTIVE EQUIPMENT
o High risk patients and communities require full PPE: N95 mask, face shield, gown and gloves.
o Low risk patients / communities require a surgical mask
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FILTERS SHOULD BE USED
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o Exceptions include:
o disposable ultrasonic mouthpiece / flow sensors.
o During a CPX test
o Dosimeters
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SOCIAL DISTANCING DURING SPIROMETRY IS
POSSIBLE
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• Consider cable length
• Most vendors offer ample cable
length.
MGC CPF/D: 10 feet with USB cable
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PRACTICE SAFE SPIROMETRY
o Maximize distance when possible
o Use a filter
o Instruct patient to wear mask between breathing maneuvers
o Cough etiquette
o Have tissues ready or dispense ahead of time
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SOCIAL DISTANCINGBODYPLETHYSMOGRAPHY
o Bodyplethysmography…depends on your system
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CARDIOPULMONARY EXERCISE TESTING
o Social distancing is more challenging.
o Umbilical length is approximately 8 feet long.
o Increased risk of droplet contamination because of high ventilatory rates.
o No filter during CPX testing
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6MWTSOCIAL DISTANCING IS POSSIBLE
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o The blue tooth communication to a device/tablet will enable distancing for some patients.
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WIRELESS SPIROMETRYANOTHER TOOL TO AID IN DISTANCING
o There are several devices on the market that communicate via blue tooth.
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FENO
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• Controversies exist regarding filter efficiency
• Some devices include inspiratory and expiratory efforts,
others are expiratory only.
• Additional evaluation is needed. (Double filter media?)
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EQUIPMENT INFECTION CONTROL
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CDC GUIDANCEDISINFECTION OPTIONS
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CDC.gov
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PULSE OXIMETRY
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High touch surfaces need cleaning after each patient
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FLOW SENSING DEVICES
o Follow the manufacture recommendations for cleaning / use.
o Wipe off any high touch surfaces with a disinfecting wipe.
o Allow adequate contact time
o Several are single patient use.
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THE BREATHING CIRCUIT OR ASSEMBLY
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• Follow the manufacture recommendations for
cleaning.
• If you are testing a high risk patient or are in an area of
high prevalence you could change out between patients.
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SAMPLE LINES
Gas sample lines aspirate gas during rapid gas analysis for:
o PFT
• DLCO
o Gas exchange
• VO2 max
• REE
o Lung clearance index
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• Wipe tip of sampling connection / interface.
• If contaminated with secretions blow out from
reverse side.
• Do not flush with alcohol.
• Avoid saturating naphion with disinfecting
wipes
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INFECTION CONTROL RELATED TO THE TESTING ENVIRONMENT
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Relating to the recommendations used for
performing PFTs given a diagnosis of Cystic
Fibrosis
1. Negative pressure rooms
2. HEPA filtration
3. 30 min wait between patients
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AIRBORNE ISOLATION INFECTION ROOMS(AIIRS)
CDC.gov
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PFT NEGATIVE PRESSURE ROOMS
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True negative pressure rooms should have an indicator just outside of the room.
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WOULD TESTING OF A PATIENT CONSIDERED A HIGH RISK PATIENT OR IS FROM A HIGH RISK COMMUNITY NEED TO BE TESTED IN A ROOM CAPABLE OF
NEGATIVE PRESSURE?
YES*
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*According to the expected ATS recommendation… I suggested, “or in
a room using a hospital grade HEPA filter”.
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HEPA FILTRATION
o Multiple manufactures of hospital grade devices
o Portable
o Variable fan settings
o Cost ~$1,800 each
o Is this required?
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EXTRA MEASURES TO CONSIDER FOR THE TESTING ENVIRONMENT
UVC Light Room Disinfection• Performed by hospital environmental
services department.
• Multiple cycles of light over 15-30 minutes.
• Done once per week
• Cost prohibitive for most.
• Is this essential?
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TELEMEDICINE AND REMOTE MONITORING
o Telemedicine is now a vital tool.
o Home spirometry has evolved significantly
o Costs for home spirometers vary depending on:
o Design
o Accuracy
o Parameter outputs
o Connectivity to a portal
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EXAMPLE: PLAN ON RESTARTING
o Work with your hospital infectious disease and local public health authority to determine prevalence in your area.
o Hospital based labs may need to obtain approval from administration.
o All staff should be trained regarding the approved plan to prevent resurgence.
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ATS EXPECTEDRECOMMENDATIONS –13 SLIDES
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Expected ATS
Recommendations
Four General Recommendations
#1: Understand the prevalence of
COVID-19 in your community and
those from which referrals may be
coming from
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Expected ATS
Recommendations
Community Prevalence
In high prevalence communities testing must
be more restrictive, testing should be done
only if absolutely necessary
A negative COVID-19 test is less reliable in a
high prevalence community because there are
a greater number of false negative subjects in
the community
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Expected ATS
Recommendations
Community Prevalence
In low prevalence communitiesa negative
COVID-19 test is more reliable because there
are fewer false negative subjects in the
community
Under these conditions pulmonary function
testing may be less restrictive
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Expected ATS
Recommendations
Community Prevalence
Community prevalence should be determined
by consultation with local infectious disease
and public health authorities
Under no circumstances should COVID-19 +
patients or those with flu-like symptoms be
tested
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Expected ATS
Recommendations
Four General Recommendations
#2 Weigh the risks/benefits of PFTs
Pathogen Exposure vs. Clinical Importance
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Expected ATS
Recommendations
Weigh the risks/benefits of PFTs
Some Examples of Essential PFTs
• Evaluate transplant or resection candidacy
• Monitor for bronchiolitis obliterans syndrome
in transplant patients
• Preoperative risk stratification
• Diagnosis of idiopathic or complex dyspnea
• Monitor patients at risk for drug-related
pulmonary toxicity
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Expected ATS
Recommendations
Four General Recommendations
#3 Only perform tests that are essential
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Expected ATS
RecommendationsOnly perform tests that are essential
• Spirometry with or without DLCO
• If post BD testing is necessary, MDIs are preferred over nebulizers
• Lung volumes less frequently affect clinical decision-making
• Bronchoprovocation and exercise tests should be post-postponed if possible due to the higher risk of aerosol production from high minute ventilation and coughing
• Consider home spirometry for patients requiring on-going surveillance
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Expected ATS
Recommendations
Four General Recommendations
#4 Appropriate precautions and disinfection
procedures must be followed
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Expected ATS
RecommendationsAppropriate precautions and disinfection
• Video-based language interpreters are recommended
• Patients and staff must clean their hands before and after testing
• Filters must be used
• Instruct the patient in cough etiquette and provide tissues before testing begins
• Patients should wear surgical masks when not performing a testing maneuver
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Expected ATS
Recommendations
Appropriate precautions and disinfection
High Risk Patients/High Risk Communities
• Testing should be done in a negative
pressure room
• Staff should wear full PPE including N95
mask, gown, gloves, and face shield
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Expected ATS
Recommendations
Appropriate precautions and disinfection
Low Risk Patients/Low Risk Communities
• Staff should wear a surgical mask during
testing to avoid exposure to aerosols
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Expected ATS
Recommendations
Appropriate precautions and disinfection
• Equipment should be disinfected according
to the manufacturer’s instructions
• Local policy should dictate cleaning
procedures between patients, and time
allotted between patients to allow adequate
room ventilation
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KEY POINTS OF THE ERS RECOMMENDATIONS
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Pandemic phase (Postpone all routine testing)
Limit testing to Spiro and DLCO
Telemedicine for remote testing with video coaching
High community prevalence
Level 1 safety recommendations(Full PPE)
Test in a neg pressure room
Eye protection: goggles or face shieldGloves Hand hygiene protocols for patient and staff.
HEPA filters are NOT recommended (viral colonization)
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KEY POINTS OF THE ERS RECOMMENDATIONS
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Post Peak phase(All testing can be reintroduced with extra precautions including: Exercise testing, nebulization, Bronchoprovocation.)
Low community prevalence
Level 2 safety recommendationsFull PPE and mask guided by locate policy
• Use filters to minimize escape of aerosol from exhalation ports when
using nebulizers.
• Filters for CPX testing suggested but not recommended (Full PPE)
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KEY POINTS OF THE ERS RECOMMENDATIONS
o Screening patient referrals and prioritize patients. Use triage questionnaire.
o Reorganize waiting areas, testing rooms, staff spaces to minimize transmission of the virus. (IP / OP space)
o Ventilate room (min 15 min)
o Recalibrate equipment after decontamination.
o HEPA Filters not recommended because of possible viral colonization.
o Spiro devices without filters should be adapted to accommodate a filter.
o Post Pandemic Phase –Level 3 safety (return to normal) 70
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ERS TRIAGE QUESTIONNAIRE
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HOW WILL COVID-19 CHANGE PULMONARY DIAGNOSTICS?
o The volume of testing and FTE may decrease.
o Ordering frequency and scope of testing
o Additional time for:• Prescreening patients
• Appropriate PPE
• Room and equipment cleaning
o The ease of equipment cleaning related to infection control - will be more important.
o Negative pressure rooms for all hospital PFT rooms will be the norm.
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REVIEW
o Know the prevalence of the virus in your area and the surrounding areas.
o Develop a method to prescreen patients in advance of testing.
o Considering your testing environment; are you allowing enough time for appropriate disinfection?
o Considering your PFT or CPX equipment: what additional steps can be implemented to enhance patient safety?
o Perform only essential testing when in an area of high prevalence.
o Keep up to date regarding additional recommendations from the CDC, ATS and ERS.
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THANK YOU
oMGC DIAGNOSTICS
o Jeff Haynes for expected ATS recommendations
o EVERYONE IN ATTENDANCE
Matthew J. O’Brien MS RRT RPFT FAARC
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Common Cannister Method Bronchodilator Administration
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SAFE HANDLING OF LAUNDRY FROM WORK
o Transport clothes in a plastic bag if removed prior to exiting the healthcare environment.
o Perform hand hygiene after handling dirty laundry
o Wash and dry laundry at the highest temp the fabric can stand to kill germs
o When providing direct care to COVID-19 or persons of interest patients; remove scrubs/work attire either at the end of a shift or immediately after arriving home. Place clothes in plastic bag for 48 hours before laundering. Throw away plastic bag-do not reuse.
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