The novel Coronavirus SARS-CoV-2, the agent responsible for coronavirus disease 2019 (COVID-19), is producing a growing public health emergency worldwide. The coronavirus family can infect several animal species–including cats, camels, cattle, and bats–and then can spread to people. The most likely person-to-person transmission route is through close contact (within 6 feet) via respiratory droplets. Airborne transmission is unlikely except when aerosol-producing procedures (e.g., bronchoscopy, intubation) are performed. Transmission is highest when patients are overtly symptomatic. Transmission from asymptomatic carriers has been reported, but its extent is unclear. The goal of this activity is to provide healthcare professionals with updated recommendations on how to prevent transmission of SARS-CoV-2 in healthcare settings.
Updated - Shortage of Personal Protective Equipment (PPE)
There is currently a shortage of PPE across the US. Given the current status, the Centers for Disease Control and Prevention (CDC) recommend consideration of these options for hospitals facing a respirator shortage:
- Consider the use of alternatives to N95 respirators including other classes of filtering facepiece respirators (FFR), elastomeric half-mask and full facepiece air-purifying respirators, and powered air-purifying respirators (PAPRs)
- Respirators should be reserved for situations where respiratory protection is most important, such as the performance of aerosol-generating procedures on suspected or confirmed COVID-19 patients or the provision of care to patients with other infections for which respiratory protection is strongly indicated (e.g., tuberculosis, varicella or measles), or for aerosol-generating procedures on suspected or confirmed COVID-19 patients.
For potential impending shortage (contingency strategies), hospitals are allowed to:
- Use N95 respirators beyond the manufacturer-designated shelf life for training and fit testing
- Extend use of N95 respirators (up to 8 hours of continuous use)
- Employ limited re-use of N95 respirators for tuberculosis (up to 5 times/ day)
For critical shortage, hospitals are allowed to:
- Use respirators beyond the manufacturer-designated shelf life for healthcare delivery
- Use respirators approved under standards used in other countries that are similar to NIOSH-approved N95 respirators
- Limited re-use of N95 respirators for COVID-19 patients
- Use additional respirators beyond the manufacturer-designated shelf life for healthcare delivery
- Prioritize the use of N95 respirators and facemasks by activity type
Recommendations for Healthcare Personnel
When scheduling general appointments, instruct patients to call ahead and discuss the need to reschedule if they develop fever or respiratory symptoms on the day of the appointment. If patients are requesting an appointment for fever or respiratory symptoms, a nurse should call the patient to determine if an appointment is necessary.
Facilities should have policies in place to limit exposure to COVID-19. Points of entry to the facility should be limited. Signs and posters regarding respiratory hygiene and cough etiquette should be posted in healthcare facilities for patients and healthcare personnel. Alcohol-based hand rub with 60-95% alcohol, tissues, and no-touch receptacles for disposal should be provided at entrances, waiting rooms, and patient check-in sites. Physical barriers (glass or plastic windows) at reception and/or outside triage stations are encouraged. Triage of patients with respiratory symptoms should be prioritized. A supply of face masks and tissues should be available at triage and provided immediately to patients with respiratory symptoms.
All patients should be asked about the presence of fever and symptoms of respiratory infection, history of travel to high-risk areas, and contact with patients known to have COVID-19 disease. If the patient has fever or respiratory symptoms, isolate the patient in a private room with the door closed. If a private room not available, the patient should not wait among others to seek care. Options, in this case, include a well-ventilated waiting room with patients separated by more than 6 feet or asking the patient to wait in their personal vehicle, or outside the facility where they can be contacted by mobile phone.
Standard and Transmission-Based Precautions (Standard, Contact, Eye Protection with Respirator or Face Mask)
Healthcare workers should perform hand hygiene before and after patient contact, after contact with infectious materials and before donning (putting on) and after doffing (removing) PPE. Hand hygiene should be performed using an alcohol-based hand rub with 60-95% alcohol or thorough washing hands with soap and water for at least twenty seconds.
A patient should be placed in a private room with healthcare providers using contact precautions, e.g., gown and gloves, eye protection (face shield or goggles), and a respirator (a face mask is a reasonable alternative to a respirator given the current shortage).
Stable patients without the need to be hospitalized should be sent home. Hospitalized patients can be placed in a private room with the door closed. A negative pressure is required for aerosol-generating procedures (see below). Hospitals could consider dedicated units for COVID-19 patients. Patient transport should be limited to medically necessary procedures. During transport, patients should wear a face mask when outside the room to cover their mouth and nose (not a respirator). If possible, perform procedures in the patient’s rooms. After patient discharge, environmental services should refrain from cleaning the room until sufficient time has elapsed based on air-exchanges per hour.
Precautions for Aerosol-Generating Procedures and Respiratory Samples Collection
Procedures that induce coughing such as sputum induction and open suctioning of airways should be limited. These procedures should be ideally performed in a negative pressure room. A respirator, rather than a face mask, should be used in addition to eye protection and contact precautions (gown/gloves). Only essential healthcare workers should be allowed.
Manage Visitor Access and Movement
Hospitals should develop procedures to monitor, manage, and train visitors on proper hand hygiene, respiratory hygiene, cough etiquette precautions, and appropriate PPE use. Visitors should be either screened for fever and respiratory symptoms, either passively (sign at the entrance) or actively (direct questioning). They should be limited from accessing transplant and oncology units. Hospitals may consider limiting points of entry to the facility.
Visitors to patients with suspected or known COVID-19 should be limited. Alternative methods, such as cellphones or tablets, are encouraged. Exceptions can be made in selected cases (e.g., comfort care). In these cases, visitors should be trained on hand hygiene practices and how to don/doff personal protective equipment. The hospital should have a log of all visitors who enter the room. Visitors should be instructed to call their healthcare provider if they develop a fever or respiratory symptoms within 14 days of their last contact with the patient.
Hospitals should utilize several strategies to protect healthcare personnel from hazardous conditions through engineering control. Engineering control includes physical barriers or curtains in triage/shared areas, a closed suctioning system for intubated patients, and an appropriate air-handling system.
If healthcare personnel are exposed to COVID-19, they should consult with the occupational health team at their facility and with the local/state health department. Hospitals should implement non-punitive sick leave policies according to the occupational health recommendations of the CDC.
Healthcare Personnel Education and Training
All healthcare personnel should receive training on preventing transmission of infectious agents. and donning and doffing the PPE to avoid contamination and potential exposure.
Only dedicated or disposable equipment should be utilized while taking care of patients with suspected or conformed COVID-19. If non-dedicated, non-disposable equipment is used, that equipment should be cleaned and disinfected according to the manufacturer’s instructions. Hospitals should ensure that correct environmental care procedures are followed. Disinfection procedures include precleaning with cleaners and water and applying disinfectants registered with the Environmental Protection Agency (EPA) for sufficient contact times according to the product’s label. Products that have EPA-approved claims of effectiveness against SARS-CoV-2 should be used. Routine procedures are sufficient for managing laundry, food services, and medical waste.
Reporting and Communication
Hospitals should establish policies to promote awareness among hospital staff, including infection prevention/epidemiology, occupational health, laboratory, radiology, and frontline staff regarding any patient with suspected or confirmed COVID-19. In addition, hospitals should communicate and collaborate with public health authorities.
For more information on the topic of Recommendations for Healthcare Personnel please see the CDC website.
The novel Coronavirus SARS-CoV-2, which causes COVID-19 disease, is an emerging pathogen with serious public health concerns. There are key measures that hospitals can take to prepare for handling suspected or confirmed cases and reduce exposure of healthcare personnel. Standard precautions, contact precautions, eye protection with either a respirator or face mask should be applied for all suspected or confirmed cases.
- Centers for Disease Control and Prevention. How 2019-nCoV Spreads. https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html. Accessed: Jan 31, 2020.
- Centers for Disease Control and Prevention. Strategies for Optimizing the Supply of N95 Respirators. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html. Accessed: Feb 29, 2020.
- Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html. Accessed: March 10, 2020.
- Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Patients with Known or Patients Under Investigation for 2019 Novel Coronavirus (2019-nCoV) in a Healthcare Setting. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html. Accessed: Jan 28, 2020.
- Centers for Disease Control and Prevention. Evaluating and Reporting Patients Under Investigation (PUI). https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html. Accessed: March 4, 2020.
- Centers for Disease Control and Prevention. Infection Control in Healthcare Personnel. https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html. Accessed: October 28, 2019.
- Occupational Safety and Health Administration. 2019 Novel Coronavirus. https://www.osha.gov/SLTC/covid-19/. Accessed: February 3, 2020.
- United States Environmental Protection Agency. Guidance to Registrants: Process for Making Claims Against Emerging Viral Pathogens not on EPA-Registered Disinfectant Labels. https://www.epa.gov/pesticide-registration/guidance-registrants-process-making-claims-against-emerging-viral-pathogens. Accessed: February 3, 2020.