How is your hospital handling PPE with GA's?

[MP RN, RN]

Hey everyone,

Hope everyone is doing well and keeping safe.

Just wanted to compare/contrast what everyone's OR's are doing through the COVID pandemic?

My hospital is relatively small, with 4 OR theaters. We do a decent variety of cases normally- OB/gyne, general, eyes, endoscopy and a few others. We have currently suspended all our elective cases, with the exception of limited/select time-sensitive cases- ie, known bowel Ca's which can't wait long, known breast Ca's.

Currently every Pt in the hospital is being treated as droplet precautions. We have some Covid in our community- ppl isolating @ home and the like, but the storm hasn't hit us yet. Every day more and more Diagnoses though, so it's coming.

Here, any GA is being intubated across the hall in an ICU negative pressure room. They are then brought to the OR for their surgery. Once the case is finished, we bring them tubed, back to the negative pressure ICU room- with Anaesthetist and 1 PACU RN, both in full Covid PPE (boots, gown, N95, gloves, goggles, hood, faceshield). There Pt gets extubated. 30 minutes after extubation, the staff can doff/remove the full PPE and go back to regular droplet precs (gown/gloves, surgical mask with eye protection).

I feel bad for anyone in/around the epicenters. Just wondering what everyone elses OR practices have been during this trying time?? Are you intubating in the OR's? What precautions/changes have been implemented?

Trying to stay ahead of the curve in terms of prevention and safe practice.

Stay safe everyone, and support each other.

[Rose_Queen, BSN, MSN, RN]

3 hours ago, MP RN said:

Currently every Pt in the hospital is being treated as droplet precautions.

Seems like an absurd waste of PPE resources.

Our CRNAs are wearing N95s routinely as intubation is considered an aerosol generating procedure. No one else in the room is, and we are not using another room for intubation unless there is a reason to suspect COVID (another waste of resources if you ask me). There is discussion that all staff with the exception of the intubating CRNA will leave the room for induction until the tube placement is confirmed and secured.

On COVID+ or PUI, we are not operating unless absolutely necessary. If it is necessary, all staff in room are in N95s or PAPRs.

For AGPs, (ENT surgeries primarily, which we only had 1 that couldn't be delayed), all staff in room are in N95s or PAPRs.

[Silver_Rik, ASN, RN]

On 4/2/2020 at 4:20 PM, Rose_Queen said:

Seems like an absurd waste of PPE resources.

Our CRNAs are wearing N95s routinely as intubation is considered an aerosol generating procedure. No one else in the room is, and we are not using another room for intubation unless there is a reason to suspect COVID (another waste of resources if you ask me). There is discussion that all staff with the exception of the intubating CRNA will leave the room for induction until the tube placement is confirmed and secured.

From a new (< 2 months in the OR) circulating nurse, isn't it going to be a handful for the CRNA to have to intubate solo?

[Rose_Queen, BSN, MSN, RN]

16 minutes ago, Silver_Rik said:

From a new (< 2 months in the OR) circulating nurse, isn't it going to be a handful for the CRNA to have to intubate solo?

They do it solo in the ICU or ER when called for a stat intubation. At least in the OR it's much more controlled. Yes, it will be a handful, but I would think a manageable handful.

[Silver_Rik, ASN, RN]

We have 36 rooms in major OR, usually keep 32 running each day plus reserved trauma rooms. Also an ambulatory surgery clinic that is currently closed due to Covid-19, and C-Section rooms on Maternity. Right now we have 10 rooms closed and 2 rooms set up for surgery on Covid-19 patients.

Everyone is fit tested and issued an N95 we are supposed to keep and re-use until soiled or damaged, plus we get a surgical mask at the start of each shift to wear over the N95. This is supposed to last the shift, again unless soiled or damaged. Surgical masks are available with or without face shield. We are supposed to wear a mask our entire shift except when eating / drinking on break. Everyone working in the hospital is given a disposable procedure mask for this purpose and supposed to make it last for a week, but again replace if necessary. Since we have access to surgical masks we can wear those instead.

We briefly stopped RN circulators from assisting with intubations and had a 2nd CRNA or a doc come in and assist; but now that we have N95s and face shields I think circulating nurses will start doing this again. GA induction and intubation is still being done in the OR.

Another change is our EVS people are being pulled to clean rooms on other floors (maybe only Covid-19 rooms?) so now the OR aides, anesthesia techs, and periop nurse interns (like me) have been trained on doing post-case and terminal cleans on the ORs. Well, ATs already were cleaning anesthesia equipment but now are expected to help clean everything.

[MP RN, RN]

On 4/2/2020 at 4:20 PM, Rose_Queen said:

Seems like an absurd waste of PPE resources.

Our CRNAs are wearing N95s routinely as intubation is considered an aerosol generating procedure. No one else in the room is, and we are not using another room for intubation unless there is a reason to suspect COVID (another waste of resources if you ask me). There is discussion that all staff with the exception of the intubating CRNA will leave the room for induction until the tube placement is confirmed and secured.

On COVID+ or PUI, we are not operating unless absolutely necessary. If it is necessary, all staff in room are in N95s or PAPRs.

For AGPs, (ENT surgeries primarily, which we only had 1 that couldn't be delayed), all staff in room are in N95s or PAPRs.

What is absurd about it? You didn't support this with anything.

Your CRNA is the only person wearing N95 during aerosolyzing procedure? What has the assistant been wearing during intubation?

And then what- everyone else comes in shortly after?

Aerosolyzed virus is in the air still, it isn't droplet precs immediately after the tube is secured. Sure, there is no NEW aerosolyzed virus since the system is closed once tube is secure and connected. But that room should be considered airborne precautions still. There are studies that show Covid can be airborne for 2 hours after aerosolyzing procedure.

[Rose_Queen, BSN, MSN, RN]

35 minutes ago, MP RN said:

What is absurd about it? You didn't support this with anything. 

You stated your facility is treating all patients as droplet precautions. Why? Are all patients showing respiratory symptoms? If not, what’s the rationale to treat all patients as droplet?

36 minutes ago, MP RN said:

Your CRNA is the only person wearing N95 during aerosolyzing procedure? What has the assistant been wearing during intubation? 

The CRNAs are the only ones wearing N95s for intubation. They are working by themselves or with the assistance of another anesthesia provider who also has an N95. The other staff either step out of the room or ensure they are at least 6 feet away. For aerosolyzing procedures, all staff in the room are to be protected. However, those are being kept to an absolute minimum- trachs are only being done after testing negative and after being vented for 3 weeks (including trauma patients). Per our facility’s protocol, created and approved by both infection control and infectious diseases specialists, remaining masked (surgical, not N95) and 6 feet away is what we are to follow.

[frozenmedic]

On 4/6/2020 at 7:38 AM, Rose_Queen said:

You stated your facility is treating all patients as droplet precautions. Why? Are all patients showing respiratory symptoms? If not, what’s the rationale to treat all patients as droplet?

Data is currently all over the place on the exact numbers, but what we do known are two essential facts:

1-People can shed Coronavirus prior to their symptom onset and unknowingly transmit the disease to others.

2-People can be completely asymptomatic carriers of Coronavirus and unknowingly transmit the disease to others.

How much more rationale could you need? Both these facts also hold true for you, the healthcare provider. If you are in an area of high Coronavirus prevalence it is irresponsible bordering on negligent for you to not wear a mask at all times for the above reasons.

[MP RN, RN]

On 4/6/2020 at 9:38 AM, Rose_Queen said:

You stated your facility is treating all patients as droplet precautions. Why? Are all patients showing respiratory symptoms? If not, what’s the rationale to treat all patients as droplet?

There is Covid in the communities here, and a few long term care facilities have had staff and Pt outbreaks. When you consider the insidiousness of Covid- that many people can carry it with no outward symptoms at all (up to 30% !!) and be shedding virus at the same time.. protecting yourself only against symptomatic individuals is not going to be effective. We are at the point of protecting ourselves from the symptomatic and asymptomatic people.

On 4/6/2020 at 9:38 AM, Rose_Queen said:

The CRNAs are the only ones wearing N95s for intubation. They are working by themselves or with the assistance of another anesthesia provider who also has an N95. The other staff either step out of the room or ensure they are at least 6 feet away. For aerosolyzing procedures, all staff in the room are to be protected. However, those are being kept to an absolute minimum- trachs are only being done after testing negative and after being vented for 3 weeks (including trauma patients). Per our facility’s protocol, created and approved by both infection control and infectious diseases specialists, remaining masked (surgical, not N95) and 6 feet away is what we are to follow.

You didn't follow up about what your facility does after the Pt is intubated in the OR. Does the surgical team come in soon after that? What are they wearing?

[MP RN, RN]

13 hours ago, frozenmedic said:

Data is currently all over the place on the exact numbers, but what we do known are two essential facts:

1-People can shed Coronavirus prior to their symptom onset and unknowingly transmit the disease to others.

2-People can be completely asymptomatic carriers of Coronavirus and unknowingly transmit the disease to others.

How much more rationale could you need? Both these facts also hold true for you, the healthcare provider. If you are in an area of high Coronavirus prevalence it is irresponsible bordering on negligent for you to not wear a mask at all times for the above reasons.

Also, consider that there are studies that suggest the false negative rate on Covid swabs are estimated to be between 20-30%- that lends even more credence to this use of PPE.

[Rose_Queen, BSN, MSN, RN]

40 minutes ago, MP RN said:

You didn't follow up about what your facility does after the Pt is intubated in the OR. Does the surgical team come in soon after that? What are they wearing?

They are to wait the full 3 minutes for an air exchange to occur then are entering the room with standard PPE for a surgical case per our infection control experts.

[MP RN, RN]

44 minutes ago, Rose_Queen said:

They are to wait the full 3 minutes for an air exchange to occur then are entering the room with standard PPE for a surgical case per our infection control experts.

So your OR has the typical 20 air exchanges/hr then.

Guidelines reveal at that rate of air exchange, it would take 14 minutes for the air to be considered 99% "clean" of airborne pathogen such as Covid. 21 minutes for 99.9%.

Curious how your workplace settled on 3 minutes, or a single air exchange. Very little airborne pathogen would theoretically be removed from circulation at that point.