ACEP COVID-19 Field Guide

Employers should select appropriate personal protective equipment (PPE) and provide it to health care personnel (HCP) in accordance with the workplace safety guidelines established by the US Department of Labor. HCP must receive training on and demonstrate an understanding of:

• When to use PPE;
• What PPE is necessary;
• How to properly don, use, and doff PPE in a manner to prevent self-contamination;
• How to properly dispose of or disinfect and maintain PPE; and
• The limitations of PPE.

Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE. The PPE recommended when caring for a patient with known or suspected COVID-19 includes (Figure 3.1):

• Respirator or face mask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or other situations where a respirator or face mask is warranted.)
  • Put on a respirator or face mask (if a respirator is unavailable) before entry into the patient’s room or care area.
• N95 respirators or respirators that offer a higher level of protection should be used instead of a face mask when performing or present for an aerosol-generating procedure. Disposable respirators and face masks should be removed and discarded after exiting the patient’s room or care area and closing the door. Perform hand hygiene after discarding the respirator or face mask. 
  • If reusable respirators (eg, powered air purifying respirators [PAPRs]) are used, they must be cleaned and disinfected according to the manufacturer’s reprocessing instructions prior to reuse.
  • Respirators with exhalation valves should not be used in situations where a sterile field must be maintained because the exhalation valve allows unfiltered exhaled air to escape into the sterile field
• Face masks are NOT PPE. Health care facilities should not purchase or offer these masks as substitutes for surgical masks or filtering facepiece respirators (FFRs). When used as source control, face masks, including cloth facial coverings, may help to prevent or slow the spread of COVID-19. Face masks are authorized under this Emergency Use Authorization (EUA) to be worn for source control only, including in the health care setting. For more information on source control, visit the FDA’s “FAQs on the Emergency Use Authorization for Face Masks (Non-Surgical).”
• Face masks should not be used in place of surgical masks or FFRs to provide protections such as:
  • Liquid barrier protection;
  • Antimicrobial or antiviral protection, prevention, or reduction;
  • Respiratory protection;
  • Particulate filtration; or
  • Protection in high-risk, aerosol-generating procedures.
• When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19. Those that do not currently have a respiratory protection program, but care for patients with pathogens for which a respirator is recommended, should implement a respiratory protection program.
• When in public settings CDC recommends community use of masks, specifically non-valved multi-layer cloth masks, to prevent transmission of SARS-CoV-2. Masks are primarily intended to reduce the emission of virus-laden droplets (“source control”), which is especially relevant for asymptomatic or presymptomatic infected wearers, and also help reduce inhalation of these droplets by the wearer (“filtration for personal protection”).
• Eye protection
• Put on eye protection (ie, goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient’s room or care area. Personal eyeglasses and contact lenses are not considered adequate eye protection.
  • HCPs who wear spectacles can find their spectacle lenses misting up on wearing a face mask. A simple method to prevent this is by using the “surfactant effect.” Immediately before wearing a face mask, wash the spectacles with soapy water and shake off the excess. Then, let the spectacles air dry, or gently dry off the lenses with a soft tissue, before putting them back on. Now the spectacle lenses should not mist up when the face mask is worn. (More information can be found here: Malik SS, Malik SS. A simple method to prevent spectacle lenses misting up on wearing a face mask. Ann R Coll Surg Engl. 2011;93(2):168) 
• Remove eye protection before leaving the patient’s room or care area.
• Reusable eye protection (eg, goggles) must be cleaned and disinfected according to the manufacturer’s reprocessing instructions prior to reuse. Disposable eye protection should be discarded after use.
• Gloves
  • Put on clean, nonsterile gloves upon entry into the patient’s room or care area.
    • Change gloves if they become torn or heavily contaminated.
• Remove and discard gloves when leaving the patient’s room or care area, and immediately perform hand hygiene.
• Gowns
  • Put on a clean isolation gown upon entry into the patient’s room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient’s room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use.
  • If there are shortages of gowns, they should be prioritized for:
    • Aerosol-generating procedures;
    • Care activities where splashes and sprays are anticipated; and
    • High-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP.
  • Examples include:
  • Dressing;
  • Bathing or showering;
  • Transferring;
  • Providing hygiene;
  • Changing linens;
  • Changing briefs or assisting with toileting;
  • Device care or use; and
  • Wound care.

For more information, review the CDC’s “Interim Infection Prevention and Control Recommendations for Patients With Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.”

The National Academies of Sciences, Engineering, and Medicine also published “Rapid Expert Consultation on the Effectiveness of Fabric Masks for the COVID-19 Pandemic” on April 8, 2020.

Chu DK, Akl EA, Duda S, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. Published:June 01, 2020. doi10.1016/S0140-6736(20)31142-9

Figure 3.1 COVID-19 personal protective equipment for health care personnel. Credit: CDC.

Donning and Doffing PPE

Putting On (Donning) PPE Gear

More than one donning method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of donning.

1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training).
2. Perform hand hygiene using hand sanitizer.
3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel.
4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients.*
• Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator.
• Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears.
5. Put on face shield or goggles. When wearing an N95 respirator or half facepiece elastomeric respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common.
6. Put on gloves. Gloves should cover the cuff (wrist) of gown.
7. Healthcare personnel may now enter patient room.

Taking Off (Doffing) PPE Gear

More than one doffing method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of doffing.

1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak).
2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle.*
3. Healthcare personnel may now exit patient room.
4. Perform hand hygiene.
5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles.
6. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask.*
• Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
• Facemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front.
7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is practicing reuse.*

* Facilities implementing reuse or extended use of PPE will need to adjust their donning and doffing procedures to accommodate those practices.

For more information, review CDC’s Guidance on Using Personal Protective Equipment (PPE)

Utilization of PPE

The CDC acknowledged that the supply and availability of NIOSH-approved respirators has increased significantly over the last several months. Each facility is responsible for determining if they are in conventional, contingency or crisis supply mode.

The April 9, 2021 updates include -

For conventional capacity strategies, used when there is adequate supply and anticipated supply;

• NIOSH-approved masks with an exhalation valve provide reasonable protection and are as good as a surgical/cloth mask.
• Extended use of N95 respirators as source control is an option and they can be used as source control (as opposed to personal protection) until they are soiled/ damaged.
• Extended use of N95s for personal protection is not a recommendation when supplies are available.
• It should be noted that NIOSH-approved N95s (non-medical) do not have moisture barriers and when there is concern for splash, they should be covered by a surgical mask or a face shield should be used.

For contingency capacity strategies, used when supplies are short:

• Respirators should be prioritized for health care professionals who are using them as PPE rather than those health care professionals who are using them only for source control.
• For N95 respirators used as PPE, N95 respirators should be discarded immediately after being removed. For example, if they are removed for a meal/drink, they should be discarded and a new one applied.

For crisis capacity strategies, used when there are severe shortages of N95s:

• Non-NIOSH approved respirators developed by manufacturers who are not NIOSH-approval holders should not be used.
• Re-uses should be limited to no more than five uses (five donnings) per device by the same health care professional to ensure an adequate respirator performance.
• Decontamination of respirators is no longer recommended.
• Standard surgical or cloth facemasks should only be used as a last resort (when supplies are severely limited) while caring for a patient with suspected or confirmed SARS-CoV-2 infection.

Infection prevention and control recommendations regarding PPE use

• HCP should wear a face mask at all times while they are in the health care facility. 
• When available, face masks are generally preferred over cloth face coverings for HCP. 
• If there are anticipated shortages of face masks, face masks should be prioritized for HCP and then for patients with symptoms of COVID-19 (as supplies allow). 
• Cloth face coverings should not be worn instead of a respirator or face mask if more than source control is required. 
• HCP should receive job-specific training on PPE and demonstrate competency with selection and proper use (eg, putting on and removing without self-contamination).
• HCP (eg, nurses, physicians) may wear their cloth face covering for part of the day when not engaged in direct patient care activities, only switching to a respirator or face mask when PPE is required. 
• They should also be instructed that if they must touch or adjust their face mask or cloth face covering, they should perform hand hygiene immediately before and after.
• To avoid risking self-contamination, HCP should consider continuing to wear their respirator or face mask (extended use) instead of intermittently switching back to their cloth face covering. Of note, N95s with an exhaust valve may not provide source control.
• HCP should remove their respirator or face mask and put on their cloth face covering when leaving the facility at the end of their shift.  
  • Because cloth face coverings can become saturated with respiratory secretions, care should be taken to prevent self-contamination. They should be changed if they become soiled, damp, or hard to breathe through; they should be laundered regularly (eg, daily and when soiled); and hand hygiene should be performed immediately before and after any contact with the cloth face covering.

Refer to the CDC’s “Interim Infection Prevention and Control Recommendations for Patients With Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.” 

Do-it-yourself PPE

The NIH 3D Print Exchange provides models in formats that are readily compatible with 3D printers, and offers a unique set of tools to create and share 3D-printable models related to biomedical science. These 3D-printable designs for COVID response are assessed by the VA, and the NIH posts them on its 3D Print Exchange.

Existing data and references include:

• Davies A, Thompson KA, Giri K, Kafatos G, Walker J, Bennett A. Testing the efficacy of homemade masks: would they protect in an influenza pandemic? Disaster Med Public Health Prep. 2013;7(4):413-418. doi:10.1017/dmp.2013.43;
• MacIntyre CR, Seale H, Dung TC, et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open. 2015;5(4):e006577. Published 2015 Apr 22. doi:10.1136/bmjopen-2014-006577; and
• van der Sande M, Teunis P, Sabel R. Professional and home-made face masks reduce exposure to respiratory infections among the general population. PLoS One. 2008;3(7):e2618. Published 2008 Jul 9. doi:10.1371/journal.pone.0002618.

ACEP also offers these resources collated from member suggestions but cannot vouch for their safety and efficacy: 

• A video of a doctor explaining how to make the safest face mask; 
• More directions for making masks; 
• Mask patterns;
• A pattern for a gown; 
• A pattern for a Tyvek nonisolation gown;
• Dimensions for an intubation hood; 
• 3D printable face shields; and
• Prusa face shields.

Reuse of PPE

The CDC has recommended that masks not be reused where there is an adequate supply (see the “Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings”).

The CDC has not approved the routine decontamination and reuse of disposable FFRs as the standard of care. However, FFR decontamination and reuse may need to be considered as a crisis-capacity strategy to ensure continued availability. Based on limited research, ultraviolet germicidal irradiation, vaporous hydrogen peroxide, and moist heat showed the most promise as potential methods to decontaminate FFRs. The CDC provides the following guidance summarizing the research about “Decontamination and Reuse of Filtering Facepiece Respirators.”

On April 12, 2020, the following COVID-19 update was announced: “FDA Issues Emergency Use Authorization to Decontaminate Millions of N95 Respirators.”

Restrictions on Respirator Decontamination and Reuse

In response to public health and safety concerns about the appropriateness of decontaminating certain respirators, the FDA is reissuing certain EUAs to specify which respirators are appropriate for decontamination. Based on the FDA's increased understanding of the performance and design of these respirators, the FDA has decided that certain respirators should not be decontaminated for reuse by health care personnel. 

• For example, the FDA has learned from the CDC's NIOSH testing that authorized respirators manufactured in China may vary in their design and performance. As such, the FDA has determined that the available information does not support the decontamination of these respirators and has accordingly revised the relevant EUAs. 
• In addition, the FDA is also revising relevant EUAs to no longer authorize decontamination or reuse of respirators that have exhalation valves.

Recommendations from other CDC and FDA references include:

• “ASPR TRACIE Technical Assistance Q&A From Optimizing Healthcare Personal Protective Equipment (PPE) and Supplies”;
• “Strategies for Optimizing the Supply of N95 Respirators”;
• “Summary List for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators During the COVID-19 Response”;
• “Respirator Reuse and Extended Use”;
• “Enforcement Policy for Sterilizers, Disinfectant Devices, and Air Purifiers During the COVID-19 Public Health Emergency”; and
• “Respirator Trusted-Source Information” (see Section 3: Ancillary Respirator Information).

ACEP also offers these resources collated from member suggestions but cannot vouch for their safety and efficacy: 

• “Microwave-Generated Steam Decontamination of N95 Respirators Utilizing Universally Accessible Materials” by Katelyn E. Zulauf, Alex B. Green, Alex N. Nguyen Ba, Tanush Jagdish, Dvir Reif, Robert Seeley, Alana Dale, James E. Kirby;
• “Decontamination and Reuse of N95 Respirators with Hydrogen Peroxide Vapor to Address Worldwide Personal Protective Equipment Shortages During the SARS‐CoV‐2 (COVID‐19) Pandemic” by Antony Schwartz, Matthew Stiegel, Nicole Greeson, Andrea Vogel, Wayne Thomann, Monte Brown, Gregory D. Sempowski, Thomas Scott Alderman, James Patrick Condreay, James Burch, Cameron Wolfe, Becky Smith, and Sarah Lewis; 
• “Recommendations for the Use and Cleaning of Non-Medical Respirators in Emergency Medicine During the COVID-19 Pandemic” by Howard Mell, MD, MPH, FACEP; Christopher Guyer, MD, FACEP; and Mary-J Thompson, CSP, CHMM;
• “Information and FAQs on the Performance, Protection, and Sterilization of Face Mask Materials” by Dr. Peter P. Tsai; 
• Facebook post 1 and post 2 on reusing an N95 mask or making one by Jennifer Lopez; and
• “Disinfection of Filtering Facepiece Respirators” by 3M. 

Intubation and aerosolized procedures

Author: Sandra Schneider, MD, FACEP, Associate Executive Director for Clinical Affairs, American College of Emergency Physicians

Aerosol-generating procedures (AGPs) have been described as “…procedures performed on patients [that] are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing.”¹ Although there is no widely accepted, comprehensive list of AGPs performed during clinical care, examples include open suctioning of airways, sputum induction, manual ventilation, endotracheal intubation and extubation, noninvasive ventilation, bronchoscopy, and tracheotomy.²

If AGPs are performed, according to the CDC, the following precautions should be taken: 

• HCP in the room should wear an N95 or higher-level respirator, eye protection, gloves, and a gown.
• The number of HCP present during the procedure should be limited only to those essential for patient care and procedure support. Visitors should not be present for the procedure.
• AGPs should ideally take place in Airborne Infection Isolation Rooms. 
• Procedure room surfaces should be cleaned and disinfected promptly, as described in Section 10 on environmental infection control in the CDC’s “Interim Infection Prevention and Control Recommendations for Patients With Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.”

Among the AGPs, performing endotracheal intubation is especially hazardous, as during intubation and suctioning, such droplets are common, potentially infecting personnel who perform these procedures. Given that high viral loads of SARS-CoV-2 are found in sputum and upper respiratory secretions of patients with COVID-19, endotracheal intubation should also be viewed as a high-risk procedure for exposure to and transmission of SARS-CoV-2.³ 

As the emergency department provides care to an undifferentiated population, the patient’s COVID-19 status may not always be known at the time emergency procedures are required. While PPE provides a level of protection, the placement of a transparent barrier between the patient and the physician provides an additional layer of protection from contamination. The CDC has stated that the best protection from droplets is the use of barriers, and they have suggested the use of plexiglass barriers for clerical workers and in triage.⁴

One such barrier is an intubation PPE "box." This is a barrier created from transparent material that can be quickly disinfected and formed into a box without a bottom. The PPE box, with cutouts for the neck, is placed over the head of an unconscious patient. The PPE box has two holes on one side to provide access for the intubation or suctioning. The PPE box therefore provides a barrier for this very high-risk procedure without reducing the ability to observe the patient or perform the task. One simulation showed that with the use of PPE only, the laryngoscopist’s gown, gloves, face mask, eye shield, hair, neck, ears, and shoes were all contaminated.⁸ However, when the simulation was repeated with the aerosol/intubation box, the simulated cough resulted in contamination of only the inner surface of the box and the laryngoscopist’s gloves and gowned forearms.^5,8

Though there are efforts being made across the globe to develop new and creative strategies and methods to protect health care workers from infection during the COVID-19 pandemic, it is critical that these be tested rigorously before they are put into use. It is important to note that there have been concerns regarding the effectiveness and “usability” of these “boxes.”^6,7,9 Therefore, it is critical to test the safety and effectiveness of the device prior to using it.  

These protective barrier enclosures have been authorized for use during the COVID-19 pandemic per this Emergency Use Authorization issued by the FDA issued on May 1, 2020. Additional information can also be found in the Fact Sheet for Health Care Providers on the Emergency Use of a Protective Barrier Enclosure During the COVID-19 Pandemic (Issued May 1, 2020)

Figure 3.2. Prototype and Demonstration of Intubation Box

Photos provided by Dr. Hsien Yung Lai

References

1. US Centers for Disease Control and Prevention. COVID-19 infection prevention and control in healthcare settings: questions and answers. Accessed April 11, 2020. 
2. Public Health England. Guidance: COVID-19 personal protective equipment (PPE). Accessed April 10, 2020.
3. Cook TM, El-Boghdadly K, McGuire B, et al. Consensus guidelines for managing the airway in patients with COVID-19. Anaesthesia. Published online March 27, 2020. 
4. US Centers for Disease Control and Prevention. COVID-19 Infection Control Guidance. Accessed May 4, 2020. 
5. Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier enclosure during endotracheal intubation. N Engl J Med. DOI: 10.1056/NEJMc2007589 
6. Turer D, Chang J, Banmay H. Intubation boxes: an extra layer of safety or a false sense of security? Stat News. Published May 5, 2020. 
7. Chan A. Should we use an “aerosol box” for intubation? LITFL. April 24, 2020. 
8. Weech DC, Ashurst J. How to Intubate Suspected COVID-19 Patients With a Protective Box. ACEP Now. May 19, 2020
9. Simpson JP, Wong DN, Verco L, et al. Measurement of airborne particle exposure during simulated tracheal intubation using various proposed aerosol containment devices during the COVID-19 pandemic [published online ahead of print, 2020 Jun 19]. Anaesthesia. 2020;10.1111/anae.15188. DOIi:10.1111/anae.15188

ACEP also offers these resources collated from member suggestions but cannot vouch for their safety and efficacy: 

• Aerosol Box Design
• COVID Box - Make your own box

Donning and doffing

The following resources cover proper donning and doffing of PPE:

• CDC’s sequence for putting on PPE;
• A training video from Main Line Health on the donning and doffing of PPE; 
• A video from the University of Nebraska Medical Center on biological PPE for Ebola virus disease and high-level donning; and
• A video from the University of Nebraska Medical Center on biological PPE for Ebola virus disease and high-level doffing.

Collection and distribution of PPE

With the demand for desperately needed PPE overwhelming the global supply, numerous organizations, which are new to the health care supply chain, have come forward, promising to bring more PPE to the market. Unfortunately, unscrupulous companies are engaging in price gouging, failing to provide product after receiving deposits, and fraudulently providing unsafe products that do not meet the promised standards. Even legitimate companies coming into the market can redirect limited resources and further disrupt the normal health care supply chain. Due to the extreme difficulty in vetting these organizations, ACEP has partnered with Get Us PPE to coordinate donations of PPE and suggests buyers and sellers of PPE connect through Project N95. These organizations were developed specifically to address the PPE shortage by matching donor to recipient and seller to buyer. GetUsPPE was formed and is led by physicians. ACEP members are encouraged to ensure their hospitals consider these organizations when looking for PPE.