LAC+USC EM – LAC+USC Emergency Medicine



Dear LAC+USC Providers?DHS has released new guidelines on N95 usage.? They are attached and posted below.? The primary difference with the new guidance is that it says N95s may be used when caring for patients in ICU-levels of care, generally, and that N95s may be used when caring for COVID-+ patients generally, even if they are in droplet (not in a negative pressure room).? As well, PPE will be distributed from a central, visually observable location on each ward, but they will distributed?without asking the requesters questions.? It is important to remember that these changes, which were made at the request of multiple staff across the system, will result in an increase of PPE utilization.? We trust our staff to be judicious in their use, in order to preserve our supplies in the face of national shortages.Updated: 3/31/20?Purpose?This document is intended to provide further guidance on the use of N95 for Health Care Workers (HCW) in DHS hospitals and clinics1in the context of ongoing community spread of COVID-19.1?This document does not apply to Juvenile or Correctional Health units as they have different needs and risk. Guidance to address these additional areas is being developed.Definition?Health Care Worker (HCW) – worker engaged in direct patient care that may put them at risk for acquisition of SARS-CoV-2 virus (virus causing COVID-19 disease).Fit-Testing Requirements???HCWs must be fit-tested on the same make, model, style and size of N95 respirator that they will be using.??Annual fit-testing requirements are currently waived.??HCWs should?NOT?use N95 respirators for which they have not been fit-tested as the respirator places the HCW at risk of harm.??If you are unsure of which models you have been fit-tested for, look under My Persinda; see details in Appendix.?Indications for N95 Respirator Use1.?Aerosol-generating procedures:?Consistent with prior DHS guidance, and recommendations from the World Health Organization, the Centers for Disease Control, and the California Department of Public Health, HCW should continue to use N95 respirator or equivalent (CAPR/PAPR), in addition to other Personal Protective Equipment (PPE) in the care of PUIs or COVID-19 positive patients, for any aerosol-generating procedures as listed below:??Intubation procedures??Bronchoscopy??High-flow oxygen nasal canula (airflow delivered at 40-60LPM)??BiPAP/CPAP??Sputum Induction??Nebulized treatment??CPR?In addition to other PPE normally used, N95 respirator is also recommended for use in the following situations:2. Intensive Care Units:?All HCWs should wear an N95 respirator or equivalent while providing care to ICU patients.?Reasoning???HCWs providing care in the ICU are at some increased risk of exposure due to unexpected events such as ventilator disconnections or as a result of procedures including nebulized treatments and/or at risk for sudden declines in patient respiratory status. As such, an N95 respirator should be used when caring for these patients out of abundance of caution.??Environmental Services (EVS) staff entering an ICU rooms of PUI/COVID positive patients should consider using N95 respirators if they have been fit-tested as above. If not fit-tested, then EVS staff should discuss with their supervisor.3. Intubations:?All HCWs involved in intubation of a patient, whether elective or urgent/emergent, should wear an N95 respirator or equivalent.??Location of patient does not matter??If feasible, use negative pressure rooms for these procedures??Only the minimal number of staff required to safely perform the procedures should be present??This include PUIs, COVID-19 (+) patients, and any other intubation?Reasoning???HCWs participating in intubations may be at small but increased risk of COVID-19 acquisition as the airway is manipulated. As an added measure of protection, we recommend N95 respirator or equivalent.?4.?Certain other procedures:?All HCWs involved in performing procedures manipulating the patient’s airway (including endoscopies) or thoracic surgery that generate aerosols should wear an N95 respirator or equivalent.??Team should limit number of providers to those necessary for procedure.Reasoning???Above procedures may generate localized aerosols. Given small but increased risk that an asymptomatic or early symptomatic patient may be COVID-positive, as an added measure of protection, we recommend N95 respirator or equivalent.?In addition, if any fit-tested HCW feels that it is essential for them to wear an N95 respirator while caring for a PUI or COVID-19 positive patient, they may do so, subject to continued availability of N95 supply.?Reasoning???While data shows that surgical masks along with other PPE are equivalent protection to N95s in the general care of PUI or COVID-19 positive patients, we understand some providers may have some lingering concerns. While the current state of data does not support the need for N95 respirator for SARS-CoV-2 virus outside of the above clinical circumstances, we understand some providers may feel that it is necessary to use N95 respirator while caring for PUI or COVID-19 positive patients.In addition to the above, HCW will continue to:??Don an N95 mask while providing care for any patients in Airborne Precaution for other indications such as tuberculosis, measles, etc.??Discard N95 respirators after caring for patients whom are PUIs or known COVID-19 positive patients, or in contact precautions.??Continue the reuse policy as documented in COVID-19 Respiratory Protections document2?as summarized here for non COVID-19 positive or PUI patients. When N95 are reused, the HCP must:?o?Follow the manufacturer’s user instructions, including conducting a user seal check prior to every use.o?Redonning up to five times in a single shift, then must discard in trash.o?Inspect N95 for damage and integrity, do not use if impaired.o?Store used N95 in a breathable bag or container to be used by a single wearer.??Continue proper hand hygiene, i.e., before and after entering the patient care environment.??Continue following other appropriate PPE as identified in policies and procedures.??DHS workforce members performing their job duties in a clinical care area must wear a DHS provided mask when a mask is required.2? will NOT:??Should not place a surgical mask over N95 respirator, as this may damage the mask or break the seal leading to increased risk for the HCW wearing N95?respirator.?ImplementationN95s will be distributed from the nursing stations located in areas where they are used. Each site will be adequately supplied. The supplies will be kept in a manner that will allow direct observation (e.g. behind the desk) to monitor use of N95s. Staff (clerks when available/able) at the nursing stations will distribute N95s when one is requested. The staff will not ask requesters questions or require requesters to sign a log. Identified excessive (>1 per patient encounter) or inappropriate use will be shared with department supervisor/manager.The A.C.N. and Correctional Health3?will have separate N95 distribution processes3?This guidance is adopted and subject to change based on supply availability, anticipated surge needs and the efficient use of respirators. DHS teams are reassessing the situation daily. We appreciate your understanding as we adapt to guidelines, usage, and accepted standards which are likely to continue to change during the COVID-19 outbreak. ................
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