If lacking PPE supplies, should providers and nursing staff be wearing face masks with all patients and re-use them? When should N95 masks, face shields, goggles, gowns, etc. be used?
Gowns, goggles, gloves, and regular masks are recommended when caring for patients with suspected or confirmed COVID-19. N95s are only required for aerosol generating procedures. However, if you have N95s available, you can use them in place of a surgical mask.
We realize that many offices do not have the quantity of PPE to support this. One possible solution is to provide clinical staff with two masks per day, one for the morning and one for the afternoon. Additional masks could be provided only if masks become soiled or moist. When gloves and mask are worn, the risk of infection transmission to the health care provider is low.
How should I manage a suspect or confirmed COVID-19 patient?
If patients are calling ahead and have what you consider to be mild symptoms that do not need medical attention, ask that they stay home and self-quarantine.
If patients need to be seen in your office, recommend using alternate entrances for sick patients, waiting in their car until you can room them, and then place them in a room with the door shut. If you have masks and the child will keep it on, use it. For the most recent CDC recommendations regarding PPE, visit the CDC website.
Do not allow sick patients to wait in lobbies or waiting rooms. Patients with cough or shortness of breath with or without fever (not due to another cause such as allergies or asthma) should be immediately placed in an exam room with the door shut. If no aerosol generating procedures are performed (e.g. nebulized treatment), the room can be cleaned per routine upon patient discharge.
What isolation procedures should we use if we don't have negative pressure rooms?
Negative pressure rooms are ONLY needed for aerosol generating procedures. This would typically be a nebulizer in the community practice setting. Try to use MDIs where available instead. Consider asking patients with MDIs to bring them to their visit.
How is Children’s Mercy managing its PPEs?
We are constantly evaluating our PPE supply to ensure appropriate use in caring for our patients. Children’s Mercy currently has enough supplies but are not able to share with community physicians and providers at this time. However, we continue to look for solutions that could help provide valuable PPE supplies to the community.
Should I wear mask and gloves when examining a child or infant to protect them from anything that I myself may have been exposed to inadvertently?
Providers who are healthy should use good hand hygiene and do not need to wear gloves or other PPE for situations in which they would not normally wear it. If providers are seeing a patient with respiratory symptoms consistent with COVID-19, they should wear contact, droplet PPE with eye shield.
Our current policy at Children's Mercy is that health care workers who have been exposed do not have to wear PPE but they are only able to care for patients who are not immunocompromised. Community physicians and provider should do monitor for temperature, signs and symptoms of COVID-19.
Can I work after an exposure during care of a COVID-19 patient when I did not wear PPE?
If exposed but asymptomatic, you should self-monitor twice daily (once prior to starting work) for temperature and respiratory symptoms for 14 days after the exposure event. If symptoms develop within 14 days, you should follow CDC guidelines for COVID-19 testing.
Is Children’s Mercy accepting donations for cloth PPE masks or other PPE?
We have received many generous offers for donations from community members who are working to procure additional PPE for our CM locations. This generosity is much appreciated and a testament to how the KC community comes together in times of need. We are evaluating each offer that comes in through our logistics team to ensure that these donations meet regulatory standards for use in hospitals. As an organization, we must continue to use PPE that meets national regulatory standards.
What recommendations are there for donated PPE?
N95 respirators should be approved by the National Institute for Occupational Safety and Health (NIOSH) and surgical masks should be of medical grade.
Are procedures to test for flu, strep or bronchiolitis considered aerosolizing procedures?
No. We don't even consider a nasopharyngeal swab for COVID-19 testing and flu testing to be an aerosol-generating procedure. A mid-terminate swab, which is typically done in clinics and what we’re currently doing at Children’s Mercy, will suffice.
If clinics don't have the ability to separate well from sick patients, what should we do?
Clinics have done various things, including separating patient visits by time if they are not able to separate by location within the clinic. It also depends on a clinic's physical layout and patient flow.
For example, some clinics are seeing well visits only in the morning followed by non-respiratory sick visits. Others are seeing all respiratory visits in the afternoon.
Some practices have implemented having patients stay in their car until they are ready for the patient to come in and register. The patient then goes back to their car and stays there until a room is ready. If the patient has respiratory symptoms, a mask can be put on them if available, and an alternate entrance could be considered instead of the routine entrance.
What is your guidance on proper N95 mask prolonged use, storage, reuse and disposal?
In a non-COVID-19 world, after you saw a patient, you would dispose of a surgical mask each and every time. Now, we are facing PPE shortages and must conserve as much as possible. Some clinics, even hospitals, are so short on surgical masks, they can no longer follow the previously recommended guidelines. In those cases some health care providers are leaving surgical masks on through their shift and only replacing it if it gets wet or soiled. Some institutions have given health care workers two surgical masks per day - one to wear in the morning and one for the afternoon. For those working longer shifts, up to 12 hours, they may receive three or four masks. But it's important to keep a surplus in case masks get wet or moist.
Some N95 mask manufacturers have an extended use protocol that allows health care workers to leave the mask on from patient to patient for a certain time period. Workers would still need to ensure proper changing of gown and gloves and hand hygiene between patients. For N95 masks that are not labeled for extended use by the manufacturer, CDC guidelines allow N-95 masks to be worn on and off up to five times before you need to discard it.
At Children’s Mercy, our policy is that when the N95 is off, we put it in a paper bag so that any contamination is contained within the bag. Good hand hygiene is required before and after handling the bag.
There are no recommendations for putting chemical disinfectants on N95s prior to reuse. However, doing this would make the mask wet and decrease its integrity.
Should physicians, providers and all staff who interact with patients wear PPE for all patients, even well-child visits/hours? Or only with sick visits where COVID-19 exposure is suspected?
If you are a healthcare provider who is sick, you should not be at work.
As long as those present in the visit, including the child, the parent or whoever brought them to the visit, are asymptomatic, health care workers do not need to wear PPE to care for patients. If the parent has respiratory systems, PPE should be worn by the health care provider.
Health care providers caring for sick patients should wear appropriate PPE.
Should N95 masks be worn to obtain strep and flu tests?
If you believe secretions from the patient (cough) could land on your face, we recommend health care workers wear PPE.
What are recommendations on using cloth masks if we run out of PPE? Is there any data showing they are less effective?
Companies are offering free supplies to those who would like to make masks for health care workers. There is evidence showing cloth masks are effective. They do not have the sort of thread count needed to prevent the entry of viruses and bacteria and wearing a cloth mask as opposed to a surgical mask increases your risk of getting infection by up to 13 times. Cloth masks should be considered the last resort. Read more here.
Can we use cloth masks over top of N95 masks for health care workers who are trying to conserve their masks? Are cloth masks better than nothing?
Homemade masks appear to allow in almost 100% of respiratory droplets, based on the study published in BMJ Open. While we don’t have data on putting a cloth mask over an N95, it does not seem like this would be helpful to keep the N95 functioning longer, and could possibly be harmful if the cloth mask gets wet and the N95 get wets due to laying on top of the cloth mask.
It is hard to say if cloth masks are better than nothing. In general, people wearing masks touch their face more than they already do (23 times and hour) and thus could increase their risk if they are not using good hand hygiene practices before and after every patient or wiping down equipment that is being used (e.g., otoscopes, tablet computers).
Is suctioning for babies with bronchiolitis considered an aerosol generating procedure?
Nasal suction is not considered aerosol generating, but deep suction is.
Should clinics consider telehealth for check-ups and then if a follow-up exam is needed have patients seen on the well side? For virtual visits, how should we capture weight and blood pressure?
Seeing patients on site for visits that require vaccines is still important. However, many visits like ADHD follow up or other follow up issues could be seen via telehealth. The only way to get a weight would be from a patient’s home scale. You will likely need to forgo obtaining blood pressure unless the patient has a home cuff and knows how to use it.
Our clinic requires use of an elevator to get there. Should we stop seeing all patients with respiratory symptoms?
COVID-19 is not airborne. We recommend routinely cleaning the elevator buttons to minimize transmission risk from someone who is coughing into their hand and then touches the buttons.
Should healthcare providers be concerned about exposing our families to COVID-19, especially if their family members are immunocompromised?
If you are performing good hand hygiene and infection prevention measures in your office, your risk to transmit at home is low. It is also a good idea to take off your work clothes when you get home before interacting with your family.
Does PPE need to be worn when caring for patients with upper respiratory infection without a fever? If a clinic doesn't have enough PPE masks or gowns, can they still see sick patients? What is a good substitute?
It is okay to see any patient with respiratory symptoms if your practice feels comfortable doing so. Gloves and a mask, along with good hand hygiene, and cleaning rooms and equipment are the most important. If you don’t have those, an eye shield that covers your face is a reasonable alternative.
Should PPE be worn when cleaning clinic rooms where a suspected COVID-19 patient was seen? If not, how long should we wait to clean?
Unless an aerosol generating procedure occurred in the room (e.g. nebulizer treatment), you can clean immediately after the patient leaves. Wear gloves to clean the room and equipment. If an aerosol generating procedure was performed, shut down the room for 1 hour prior to cleaning.
Should we use paper instead of a laptop to document visits with suspected COVID-19 patients?
Using paper is a good idea, as paper is not considered a good fomite of transmission. Or you could wipe down your laptop after every visit.