Endotracheal intubation has risen to the top of the list of challenges facing emergency providers on the front lines of COVID-19. Exposure to a wide variety of aerosol-generating procedures (AGPs) has been shown to increase SARS-CoV-2 acquisition risk more than six-fold overall, and across a range of studies, tracheal intubation is most consistently associated with infection transmission and acquisition.
New research, published in the Journal of the American Medical Association (JAMA), further highlights the risk. Researchers used a fluorescent marker to visualize the spread of droplets exhaled during simulated coughing episodes. They discovered the presence of airborne droplets on:
- Exposed skin (seven out of eight participants)
- Neck (six out of eight participants)
- Ears (one out of eight participants)
Additionally, all team members had fluorescent markers on their hair, and four had markers on their shoes. While limitations included small participant numbers, simulation and surrogate exposure measures, the findings suggest that current PPE recommendations from the CDC and other organizations might not fully prevent exposure during emergency room procedures. Accordingly, some experts have concluded PPE use is important, but may not be the ‘end all to be all’ in emergency department settings.
Mitigating risk beyond PPE
Although COVID-19 case numbers among providers are unknown, limited data published by the CDC in mid-April suggests a minimum of 9,000 cases in HCPs, more than half of which were acquired in healthcare settings. Adequate aggregation and desegregation of data will likely reveal thousands more.
Although researchers have not yet determined how long SARS-CoV-2 droplets remain viable on clothing or hair, clinicians and health institutions are devising novel approaches to prevent contact transmission.
- Providers at NYU Langone Health are performing early tracheostomies with a new procedure that allows a bronchoscope to be placed in the patient’s airway, just above the endotracheal tube. This helps ‘prevent patient’s secretions from blowing into the air and exposing healthcare workers to infectious discharges.’
- Clinicians in Taiwan are using a transparent Aerosol Box; designed by an anesthesiologist, the box creates a clear protective shield that allows full range of movement while simultaneously preventing infectious droplets from reaching HCPs performing risky intubations.
What can providers do?
While there is no evidence that the virus can initiate infections on the vulnerable areas identified in the JAMA study, self-inoculation is also possible. HCPs should consider the following important steps:
- Per the Occupational Safety and Health Administration, consider wearing portable, controlled air-purifying respirators (CAPR) that offer eye and facial protection and cover the hair and neck.
- To address supply limitations, use CAPRs on a case-by-case basis, especially when N95 masks are in short supply or improperly fitted.
- Scrupulously adhere to hand hygiene following PPE removal.
- Remove contaminated clothing as promptly as possible and wash the skin and hair.
- Avoid leaving the hospital wearing soiled clothing.
Until more data becomes available, any AGP procedure can be considered high-risk for virus transmission, regardless of COVID-19 patient status. Appropriate steps to avoid infection transmission and acquisition are essential.
- Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, Centers for Disease Control and Prevention.
- Assigned Protection Factors for the Revised Respiratory Protection Standard, Occupational Safety and Health Administration.
- NYU Langone Health Develops Novel Tracheostomy Approach to Improve Patient Care & Reduce Risk of ‘Super-Spreading’ Procedures, NYU NewsHub.
- Taiwan doctor’s easy-to-make aid for health workers welcomed in Japan, Kyodo News.