The current outbreak of the novel respiratory pathogen Coronavirus is an opportunity to remind ourselves of how to properly and adequately prepare for an emergency outbreak in our EDs. Although the mortality rate in patients with Coronavirus in this outbreak is less than 1% (which pales in comparison to Ebola or SARS), historically these types of outbreaks have been occurring every 5-6 years (SARS 2003, HINI 2009, Ebola 2014, Coronavirus 2020), so they are somewhat predictable and we should know how to prepare for them in our EDs. In this special edition EM Cases podcast Dr. Megan Landes, a Global Health expert, researcher and EM educator runs us through how you can best prepare for an outbreak like Coronavirus, including screening, PPE and the protected code…

Podcast production by Anton Helman

Written by Megan Landes, edited by Anton Helman, February 2020

Preparation for a novel respiratory pathogen outbreak in your ED

Recently, the World Health Organization has declared a public health emergency of international concern for the outbreak of a novel Coronavirus in China.  As a frontline provider, what do you need to think about in the ED?  We all need to be experts in screening, proper personal protective equipment (PPE) and performing protected critical care procedures.

 

1. Screening for an emergency infectious outbreak in your ED

Screening procedures need to be both reinforced and constantly reassessed as right now it is based on both symptoms and epidemiology.  Both may change over time, so  follow your institutions directives on countries of concern or case definitions.

Patients meeting the screening definition at triage, should immediately be given a surgical mask and placed in a designated isolation room, ideally with negative pressure.  You could consider information gathering through a window at this point via a whiteboard and or calling the patients cel phone to collect triage and registration data.

 

2. Personal Protective Equipment (PPE) in preparation for emergency infectious outbreak in your ED

Make sure to protect yourself and your team with appropriate PPE.  While the guidelines for PPE may evolve, currently the recommendations are DROPLET/CONTACT, with some ERs adding airborne precautions for aerosol generating procedures. Your PPE should include a gown, gloves, mask, and eye protection (which is not your regular glasses but instead goggles, or a visor).

 

CDC PPE donning and doffing sequence pdf

 

 

Donning should be straightforward but have instructions posted by the PPE and isolation rooms.  A few more tips:

  • Make sure your gloves cover your sleeves.
  • If you are using an N95 mask, make sure you are fitted for it.
  • Figure out what eye protection works for you before you see your first patient. Most will fog somehow and you don’t want to have to adjust it and contaminate yourself.

 

Doffing technique is extremely important and this where you are at most risk of contamination. A few key tips:

  • Go slowly and pay attention. Be careful and conscious of how you take everything off.
  • Consider a buddy – one person that can observe your doffing and help you follow the checklist for safe removal.
  • Practice taking off your gloves properly, your eye protection and facemask from behind.
  • What do you do if you have been contaminated? Do not rush or panic.  Take a pause, clean or sanitize the area.  Call IPAC.

“What about PAPRs?” Or a power air-purifying respirator?  PAPRs are much more comfortable over long durations of exposure, but you must be trained on them or you are actually far more likely to contaminate yourself in doffing.  Currently in Canada, our needs for PPE for suspected cases is much more episodic and short-term during a shift, so it makes the current recommendations for PPE more appropriate.

 

3. Practice a protected code

It is so important to think through this in advance.  Here is a quick review:

  1. Remember that many of the tools we usually use can aerosolize the virus. Do not use nebulizers, humidified O2 or OPTIFLO, BIPAP or BVM. You can use nasal prongs or facemasks and consider placing a droplet mask on the patient if they can tolerate it.
  2. Take control of the situation early. Make an early decision to involve ICU, transfer to an ICU bed or intubate early in the ED.  Current recommendations are to consider intubation if the Fi02 reaches 50%.
  3. IF you need to intubate, take the time to prep yourself and your team, ensure you have on your PPE and gather everything you need before you enter the room.
  4. Who should go into the room? Only three people: the most experience MD for the airway, an RN and an RT. Have one RN fully dressed in PPE to assist on the outside or anteroom and one RN for charting through the window.
  5. Think about sedating and paralysing the patient early to control the situation and reduce coughing/virus spread.
  6. Choose your safest and best intubating technique and have your backup ready.
  7. Finally, I would highly encourage everyone to practice this. At our site, we have an amazing group of in situ simulation leaders who have been running simulated protected codes in our department with not only MDs but everyone who would be involved. They do it with gold dust that the patient coughs up and black light at the end of the session shows where everyone is contaminated.

The bottom line on preparation for an emergency infectious outbreak in your ED

Practicing during an evolving outbreak can be a very anxiety provoking but we can all practice the techniques that we know will protect us (and our patients).  This current outbreak is a reminder that new pathogens come along at regular intervals, and we should prepare as best we can.