Personal Protective Equipment: Current Best Practices for Orthopaedic Teams
Identifieur interne : 000708 ( Pmc/Corpus ); précédent : 000707; suivant : 000709Personal Protective Equipment: Current Best Practices for Orthopaedic Teams
Auteurs : Yale A. Fillingham ; Matthew J. Grosso ; Adolph J. Yates ; Matthew S. AustinSource :
- The Journal of Arthroplasty [ 0883-5403 ] ; 2020.
Abstract
The COVID-19 pandemic caused by the SARS-CoV-2 virus is challenging healthcare providers across the world. Current best practices for personal protective equipment (PPE) during this time are rapidly evolving and fluid due to the novel and acute nature of the pandemic and the dearth of high-level evidence. Routine infection control practices augmented by airborne precautions are paramount when treating the COVID-19 positive patient. Best practices for PPE use in patients who have unknown COVID-19 status are a highly charged and emotional issue. The variables to be considered include protection of patients and healthcare providers, accuracy and availability of testing, and responsible use of PPE resources. This article also explores the concerns of surgeons regarding possible transmission to their own family members as a result of caring for COVID-19 patients.
Url:
DOI: 10.1016/j.arth.2020.04.046
PubMed: NONE
PubMed Central: 7169903
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Personal Protective Equipment: Current Best Practices for Orthopaedic Teams</title><author><name sortKey="Fillingham, Yale A" sort="Fillingham, Yale A" uniqKey="Fillingham Y" first="Yale A." last="Fillingham">Yale A. Fillingham</name><affiliation><nlm:aff id="aff1">Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH</nlm:aff></affiliation></author><author><name sortKey="Grosso, Matthew J" sort="Grosso, Matthew J" uniqKey="Grosso M" first="Matthew J." last="Grosso">Matthew J. Grosso</name><affiliation><nlm:aff id="aff2">Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA</nlm:aff></affiliation></author><author><name sortKey="Yates, Adolph J" sort="Yates, Adolph J" uniqKey="Yates A" first="Adolph J." last="Yates">Adolph J. Yates</name><affiliation><nlm:aff id="aff3">Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA</nlm:aff></affiliation></author><author><name sortKey="Austin, Matthew S" sort="Austin, Matthew S" uniqKey="Austin M" first="Matthew S." last="Austin">Matthew S. Austin</name><affiliation><nlm:aff id="aff2">Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmc">7169903</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7169903</idno><idno type="RBID">PMC:7169903</idno><idno type="doi">10.1016/j.arth.2020.04.046</idno><idno type="pmid">NONE</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000708</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000708</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Personal Protective Equipment: Current Best Practices for Orthopaedic Teams</title><author><name sortKey="Fillingham, Yale A" sort="Fillingham, Yale A" uniqKey="Fillingham Y" first="Yale A." last="Fillingham">Yale A. Fillingham</name><affiliation><nlm:aff id="aff1">Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH</nlm:aff></affiliation></author><author><name sortKey="Grosso, Matthew J" sort="Grosso, Matthew J" uniqKey="Grosso M" first="Matthew J." last="Grosso">Matthew J. Grosso</name><affiliation><nlm:aff id="aff2">Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA</nlm:aff></affiliation></author><author><name sortKey="Yates, Adolph J" sort="Yates, Adolph J" uniqKey="Yates A" first="Adolph J." last="Yates">Adolph J. Yates</name><affiliation><nlm:aff id="aff3">Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA</nlm:aff></affiliation></author><author><name sortKey="Austin, Matthew S" sort="Austin, Matthew S" uniqKey="Austin M" first="Matthew S." last="Austin">Matthew S. Austin</name><affiliation><nlm:aff id="aff2">Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA</nlm:aff></affiliation></author></analytic><series><title level="j">The Journal of Arthroplasty</title><idno type="ISSN">0883-5403</idno><idno type="eISSN">1532-8406</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>The COVID-19 pandemic caused by the SARS-CoV-2 virus is challenging healthcare providers across the world. Current best practices for personal protective equipment (PPE) during this time are rapidly evolving and fluid due to the novel and acute nature of the pandemic and the dearth of high-level evidence. Routine infection control practices augmented by airborne precautions are paramount when treating the COVID-19 positive patient. Best practices for PPE use in patients who have unknown COVID-19 status are a highly charged and emotional issue. The variables to be considered include protection of patients and healthcare providers, accuracy and availability of testing, and responsible use of PPE resources. This article also explores the concerns of surgeons regarding possible transmission to their own family members as a result of caring for COVID-19 patients.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Hall, C B" uniqKey="Hall C">C.B. Hall</name></author><author><name sortKey="Douglas, R G" uniqKey="Douglas R">R.G. Douglas</name></author><author><name sortKey="Schnabel, K C" uniqKey="Schnabel K">K.C. Schnabel</name></author><author><name sortKey="Geiman, J M" uniqKey="Geiman J">J.M. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Arthroplasty</journal-id><journal-id journal-id-type="iso-abbrev">J Arthroplasty</journal-id><journal-title-group><journal-title>The Journal of Arthroplasty</journal-title></journal-title-group><issn pub-type="ppub">0883-5403</issn><issn pub-type="epub">1532-8406</issn><publisher><publisher-name>Elsevier Inc.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmc">7169903</article-id><article-id pub-id-type="publisher-id">S0883-5403(20)30433-2</article-id><article-id pub-id-type="doi">10.1016/j.arth.2020.04.046</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Personal Protective Equipment: Current Best Practices for Orthopaedic Teams</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Fillingham</surname><given-names>Yale A.</given-names></name><degrees>MD</degrees><email>yale.fillingham@gmail.com</email><xref rid="aff1" ref-type="aff">1</xref><xref rid="cor1" ref-type="corresp">∗</xref></contrib><contrib contrib-type="author" id="au2"><name><surname>Grosso</surname><given-names>Matthew J.</given-names></name><degrees>MD</degrees><xref rid="aff2" ref-type="aff">2</xref></contrib><contrib contrib-type="author" id="au3"><name><surname>Yates</surname><given-names>Adolph J.</given-names></name><degrees>MD</degrees><xref rid="aff3" ref-type="aff">3</xref></contrib><contrib contrib-type="author" id="au4"><name><surname>Austin</surname><given-names>Matthew S.</given-names></name><degrees>MD</degrees><xref rid="aff2" ref-type="aff">2</xref></contrib></contrib-group><aff id="aff1"><label>1</label>Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH</aff><aff id="aff2"><label>2</label>Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA</aff><aff id="aff3"><label>3</label>Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA</aff><author-notes><corresp id="cor1"><label>∗</label>Corresponding author: Yale A. Fillingham, MD, Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756 USA Phone: 603-650-5133 Fax: 603-650-2097 <email>yale.fillingham@gmail.com</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>20</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>20</day><month>4</month><year>2020</year></pub-date><history><date date-type="received"><day>15</day><month>4</month><year>2020</year></date><date date-type="rev-recd"><day>16</day><month>4</month><year>2020</year></date><date date-type="accepted"><day>16</day><month>4</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 Elsevier Inc. All rights reserved.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder></copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0010"><p>The COVID-19 pandemic caused by the SARS-CoV-2 virus is challenging healthcare providers across the world. Current best practices for personal protective equipment (PPE) during this time are rapidly evolving and fluid due to the novel and acute nature of the pandemic and the dearth of high-level evidence. Routine infection control practices augmented by airborne precautions are paramount when treating the COVID-19 positive patient. Best practices for PPE use in patients who have unknown COVID-19 status are a highly charged and emotional issue. The variables to be considered include protection of patients and healthcare providers, accuracy and availability of testing, and responsible use of PPE resources. This article also explores the concerns of surgeons regarding possible transmission to their own family members as a result of caring for COVID-19 patients.</p></abstract></article-meta></front><body><sec id="sec1"><title>Introduction</title><p id="p0010">Humanity is faced with managing the pandemic of the coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome (SARS-CoV-2) virus. Orthopaedic surgeons are being confronted with the challenges of treating patients who have an extremely contagious disease. In 1735, Benjamin Franklin concisely said, “An ounce of prevention is worth a pound of cure.” It is paramount that orthopaedic surgeons understand the rapidly evolving recommendations to achieve viral infection control. This article reviews infection control precautions, use of personal protective equipment (PPE), methods to help optimize PPE supplies during the pandemic, and approaches to limit transmission to the family members of healthcare workers. One must understand that the existing evidence is not high level and the recommendations are fluid secondary to the novel and acute nature of this viral pandemic.</p><sec id="sec1.1"><title>Types of infection control precautions</title><p id="p0015">The United States Healthcare Infection Control Practices Advisory Committee (HICPAC) and Centers for Disease Control and Prevention (CDC) provide the guidelines that hospitals implement across the country to prevent infectious transmission between patients and healthcare workers.[<xref rid="bib1" ref-type="bibr">1</xref>] The HICPAC/CDC guidelines are centered on the mode of transmission of each disease. The transmission-based precautions include contact, droplet, and airborne precautions.[<xref rid="bib2" ref-type="bibr">2</xref>] In theory, SARS-CoV-2 could be transmitted via a bloodborne pathway but additional precautions are not necessary secondary to universal precautions against bloodborne pathogens that have been standard-of-care in the healthcare setting. The CDC has provided guidance on standard precautions that should be utilized for all patient care and in diseases where additional transmission-based precautions are necessary.[<xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib3" ref-type="bibr">3</xref>]</p></sec><sec id="sec1.2"><title>Standard precautions</title><p id="p0020">Standard precautions are common sense measures intended to be used when the healthcare worker could be exposed to bodily fluids, non-intact skin, and/or mucous membranes.[<xref rid="bib3" ref-type="bibr">3</xref>] Historically, standard precautions included hand hygiene, correct use of PPE, proper handling of injections and sharp objects, appropriate cleaning of equipment, and disposal of used equipment.[<xref rid="bib3" ref-type="bibr">[3]</xref>, <xref rid="bib4" ref-type="bibr">[4]</xref>, <xref rid="bib5" ref-type="bibr">[5]</xref>] After the Severe Acute Respiratory Syndrome (SARS) epidemic, infectious disease experts observed that the lack of source (i.e. infected subject) control added to disease transmission.[<xref rid="bib1" ref-type="bibr">1</xref>] As a result, the concept of “Respiratory Hygiene/Cough Etiquette” was added to the standard precautions.[<xref rid="bib1" ref-type="bibr">1</xref>] Respiratory hygiene/cough etiquette is meant to apply to all individuals in a healthcare setting including patients and visitors.</p></sec><sec id="sec1.3"><title>Contact precautions</title><p id="p0025">The most common mode of transmission is contact, which has been divided into direct and indirect contact.[<xref rid="bib1" ref-type="bibr">1</xref>] Direct contact transmission is the transfer of the disease through contact with the patient. Indirect contact transmission is the transfer of the disease through contact with a vector such as contaminated equipment or a person. Contact precautions limit both modes of disease transmission through placement of the patient in a single room, use of gloves and gown during contact with the patient or the patient’s environment, limited transportation of the patient with adherence to precautions when necessary, use of disposable or dedicated patient equipment with appropriate disposal, and decontamination of the equipment and room.[<xref rid="bib1" ref-type="bibr">1</xref>, <xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>] In the event that the patient cannot be placed in a single patient room, the patient beds must have at least 3 feet between the beds with systems implemented to prevent inadvertent sharing of equipment or other items.[<xref rid="bib1" ref-type="bibr">1</xref>]</p></sec><sec id="sec1.4"><title>Droplet precautions</title><p id="p0030">Droplet transmission occurs through direct or indirect contact with contaminated 30 to 50um respiratory droplets that enter through the nasal mucosa, conjunctiva, and/or mouth.[<xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib6" ref-type="bibr">6</xref>] In the healthcare setting, respiratory droplets are most commonly produced via coughing, sneezing, talking, suctioning, endotracheal intubation, and cardiopulmonary resuscitation. Droplet precautions limit the transmission of respiratory droplets through placement of the patient in single room, use of a mask during direct patient contact, limited transportation of the patient, and adherence to precautions during necessary transport.[<xref rid="bib1" ref-type="bibr">1</xref>, <xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>] When the patient requires transportation within the healthcare facility or placement in a multi-patient room, source control can be achieved through use of a mask on the patient and placement of the beds at least 3 feet apart.[<xref rid="bib1" ref-type="bibr">1</xref>] Special airborne infection isolation rooms (AIIR) are not necessary because the pathogen does not remain infectious over long distances.[<xref rid="bib1" ref-type="bibr">1</xref>]</p></sec><sec id="sec1.5"><title>Airborne precautions</title><p id="p0035">Airborne transmission occurs when contaminated small (≤ 5um in size) respirable particles are aerosolized and become suspended in the airflow.[<xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib7" ref-type="bibr">7</xref>] For reference, coronaviruses are typically 0.125 um in diameter.[<xref rid="bib8" ref-type="bibr">8</xref>] The main difference between infectious diseases spread via droplet versus airborne transmission is that airborne diseases have the ability to disperse over long distances and remain infective for an extended period of time.[<xref rid="bib1" ref-type="bibr">1</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib7" ref-type="bibr">7</xref>] Currently, the CDC is uncertain about the ability of SARS-CoV-2 to be transmitted as small respirable particles and over long distances.[<xref rid="bib4" ref-type="bibr">4</xref>] Although the mode of transmission for COVID-19 is believed to be through respiratory droplets, the recommended PPE for healthcare workers has been for airborne precautions when possible.[<xref rid="bib9" ref-type="bibr">9</xref>, <xref rid="bib10" ref-type="bibr">10</xref>] Airborne precautions are designed to reduce transmission of small respirable particles and prevent dispersion over long distances through placement of the patient in a single patient AIIR, use of an N95 or higher-level respirator during direct patient contact, and limited transportation of the patient with adherence to precautions during necessary transport.[<xref rid="bib1" ref-type="bibr">1</xref>, <xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib7" ref-type="bibr">7</xref>] When transportation is required within the healthcare facility, or placement is needed in a single patient room not equipped as an AIIR, source control can be achieved by the patient wearing a mask.[<xref rid="bib1" ref-type="bibr">1</xref>]</p></sec><sec id="sec1.6"><title>Recommended precautions for orthopaedic teams specific to COVID-19</title><p id="p0040">In response to COVID-19, different healthcare centers have implemented a variety of often evolving policies for healthcare personnel PPE. This is a highly charged and emotional issue for which there is a dearth of high-level evidence. The variables to be considered include protection of patients and healthcare providers, accuracy and availability of testing, and responsible use of PPE resources.</p></sec><sec id="sec1.7"><title>Operating on the confirmed or suspected COVID-19 positive patient</title><p id="p0045">Surgery on COVID-19 patients should only be considered in the urgent or emergent setting and elective cases should be postponed. A study of 1,099 patients with COVID-19 demonstrated that 19% present with shortness of breath, 41% require supplemental oxygen, 5% become critically ill, and 2.3% require invasive mechanical ventilation.[<xref rid="bib11" ref-type="bibr">11</xref>] Additional precautions include, if possible, a designated operating room (OR) with negative pressure for COVID-19 positive patients throughout the duration of the pandemic.[<xref rid="bib12" ref-type="bibr">12</xref>, <xref rid="bib13" ref-type="bibr">13</xref>] Ideally, this operating room should be separate from the main OR complex with minimal traffic flow. Rodrigues-Pinto and colleagues outline a five zone COVID-19 operating room.[<xref rid="bib14" ref-type="bibr">14</xref>] Additional staffing and transportation work-flows can also be implemented.[<xref rid="bib15" ref-type="bibr">15</xref>] The untested, symptomatic, presumed COVID-19 positive patient requiring surgery, in the authors’ opinion, should be treated as if confirmed positive.</p><p id="p0050">Preoperatively, the patient should be masked and ideally all providers wear N95 respirators. The N95 mask, when consistently and properly worn, is effective against airborne particles. A recent study of orthopaedic surgeons from Wuhan, China reported that not wearing an N95 respirator mask was a significant risk factor for the development of COVID-19 (OR, 5.20[95% confidence interval (CI), 1.09 to 25.00]).[<xref rid="bib16" ref-type="bibr">16</xref>] When there is a shortage of N95 respirators, the CDC recommends prioritizing N95 respirators for aerosol producing procedures.[<xref rid="bib17" ref-type="bibr">17</xref>] It is the authors’ recommendation that if source control is lost because the patient cannot wear a mask, providers should wear an N95 respirator.</p><p id="p0055">Once the patient reaches the operating room, however, the COVID-19 patient will need airway management with removal of any mask leading to contamination of the room for all personnel, not just anesthesia providers. The presence in the operating room of only essential staff during endotracheal intubation is recommended as the risk of aerosolization and droplet transmission is increased.[<xref rid="bib18" ref-type="bibr">18</xref>] All personnel, upon entering the room, should wear N95 masks, eye/face protection, gloves and gowns. PPE should be donned and removed according to established protocols.[<xref rid="bib9" ref-type="bibr">9</xref>]</p><p id="p0060">A special consideration for orthopaedic surgeries is the use of power instruments and pulsatile lavage, which are aerosol generating.[<xref rid="bib19" ref-type="bibr">19</xref>] Orthopaedic procedure transmission of viral disease through aerosols has been an ongoing concern.[<xref rid="bib20" ref-type="bibr">20</xref>, <xref rid="bib21" ref-type="bibr">21</xref>] Transmission of SARS-CoV-2 by this route has not been reported, perhaps because the aerosols are not from the respiratory tree. Another unique consideration for arthroplasty surgeons is the utilization of surgical hoods (i.e. “spacesuits”). Multiple sources, including formal memos from industry, have stated that this equipment alone is not protective against SARS-CoV-2.[<xref rid="bib20" ref-type="bibr">20</xref>, <xref rid="bib22" ref-type="bibr">22</xref>, <xref rid="bib23" ref-type="bibr">23</xref>] These hoods do not filter enough particles in the 0.02 to 1 μm diameter range to meet the standard for protective respirators.[<xref rid="bib20" ref-type="bibr">20</xref>] This class of PPE is primarily utilized for protection against in-motion debris and was never designed as a respiratory protection system.[<xref rid="bib23" ref-type="bibr">23</xref>] Based on current available evidence, surgical hoods can still be used for COVID-19 positive patients, but must be in conjunction with an N95 respirator.[<xref rid="bib20" ref-type="bibr">20</xref>] Importantly, the ideal technique for proper cleaning of the helmets (including the hard to access fans utilized in the ventilation system) remains to be defined.</p></sec><sec id="sec1.8"><title>Operating on patients without confirmed or suspected COVID-19</title><p id="p0065">There are a substantial proportion of asymptomatic infected patients.[<xref rid="bib24" ref-type="bibr">24</xref>] It may be prudent to test all patients preoperatively, if possible. In a study by Lei et al., asymptomatic patients unknown to be in the incubation phase of the infection experienced mortality rates as high as 20% and rates of ICU admission of 44% as their disease became apparent post-operatively.[<xref rid="bib25" ref-type="bibr">25</xref>] One important testing concern is the possibility of false negative results both with the standard swabs and the more recent released rapid test systems.[<xref rid="bib26" ref-type="bibr">26</xref>, <xref rid="bib27" ref-type="bibr">27</xref>] Due to the prevalence of asymptomatic disease and the lack of accurate testing at this time, proactive PPE use for healthcare providers during the pandemic including the use of N95 respirators at all times may be warranted.</p><p id="p0070">At the time of this writing, elective arthroplasty surgery is not commonly being performed in the United States. When elective operations resume, it may be prudent to test all patients prior to surgery during the waning pandemic.[<xref rid="bib15" ref-type="bibr">15</xref>] The aggressive testing of all pre-operative patients, if testing accuracy, availability and timing allow, is one strategy to reduce the risk for all parties as we resume elective arthroplasty surgery.</p></sec><sec id="sec1.9"><title>PPE outside of the operating room</title><p id="p0075">PPE utilization for the orthopaedic surgeon outside of the operating room is based on the current CDC recommendations for all personnel in the health-care setting.[<xref rid="bib9" ref-type="bibr">9</xref>] When possible, N95 respirators should be utilized by all healthcare personnel working with or near COVID-19 positive patients. In situations where shortage of N95 respirators precludes the utilization by all personnel, surgical masks can be substituted, with the recognition of their reduced effectiveness for preventing airborne transmission. Bartoszko et al. demonstrated the effectiveness of surgical masks for preventing droplet transmission in most scenarios.[<xref rid="bib28" ref-type="bibr">28</xref>] In a meta-analysis of available literature, Offeddu et al. demonstrated equivalence between standard surgical masks and respirator masks for healthcare workers in preventing infection of viral respiratory illnesses.[<xref rid="bib29" ref-type="bibr">29</xref>] However, these studies were on influenza and do not consider the potential increased transmissibility of SARS-CoV-2.[<xref rid="bib29" ref-type="bibr">29</xref>] In addition to N95 respirators, additional protection typically worn for airborne precautions is required. This includes an isolation gown, face shield or goggles, and gloves.[<xref rid="bib9" ref-type="bibr">9</xref>] There is some evidence that in the setting of COVID-19, the N95 respirator should be worn at all times in the hospital.[<xref rid="bib16" ref-type="bibr">16</xref>]</p></sec></sec><sec id="sec2"><title>Methods for extending N95 respirator supply</title><p id="p0080">There are grave concerns regarding a sudden surge in COVID-19 cases leaving PPE in short supply, as has been seen in New York State. The CDC has provided guidance on strategies to optimize the rate of PPE consumption, allowing for use outside the manufacturer’s instructions and expiration date.[<xref rid="bib30" ref-type="bibr">[30]</xref>, <xref rid="bib31" ref-type="bibr">[31]</xref>, <xref rid="bib32" ref-type="bibr">[32]</xref>, <xref rid="bib33" ref-type="bibr">[33]</xref>] Broadly, the PPE supply strategies are conservation, extension of use, and decontamination with reuse.</p><p id="p0085">The primary method for conservation of PPE supply is the delay of elective and non-urgent surgical procedures.[<xref rid="bib30" ref-type="bibr">[30]</xref>, <xref rid="bib31" ref-type="bibr">[31]</xref>, <xref rid="bib32" ref-type="bibr">[32]</xref>, <xref rid="bib33" ref-type="bibr">[33]</xref>] Other techniques include altering the annual N95 fit testing (i.e. just-in-time training, qualitative testing, or temporarily suspending testing), decreasing hospital length of stay for medically stable COVID-19 patients, limiting face-to-face encounters with COVID-19 patients, and excluding visitors to COVID-19 patients.[<xref rid="bib30" ref-type="bibr">[30]</xref>, <xref rid="bib31" ref-type="bibr">[31]</xref>, <xref rid="bib32" ref-type="bibr">[32]</xref>, <xref rid="bib33" ref-type="bibr">[33]</xref>]</p><p id="p0090">Extended use of an N95 is not recommended under normal circumstances, but the practice of wearing the same N95 respirator during repeated encounters with different patients can help extend the supply of N95 respirators.[<xref rid="bib33" ref-type="bibr">33</xref>] The CDC does not recommend the extended use of the same N95 respirator for more than 8 to 12 hours.[<xref rid="bib33" ref-type="bibr">33</xref>]</p><p id="p0095">The CDC has been working on the development of evidence-based protocols for decontamination of disposable filtering face-piece (DFFP) N95 respirators that maintain filtration and tight-fit capacity.[<xref rid="bib34" ref-type="bibr">34</xref>] An additional resource has been N95DECON, a consortium of scientists, engineers, and clinicians who are working to provide up-to-date evidence-based statements on the decontamination of DFFP N95 respirators.[<xref rid="bib35" ref-type="bibr">35</xref>] The use of vaporous hydrogen peroxide (VHP), ultraviolet germicidal irradiation (UVGI), and moist heat are promising methods for decontamination of DFFP N95 respirators.[<xref rid="bib34" ref-type="bibr">34</xref>, <xref rid="bib35" ref-type="bibr">35</xref>] As of yet, however, none of these promising methods have been evaluated for decontamination of SARS-CoV-2 on DFFP N95 respirators; as such, their ability to decontaminate similar viruses is used as a proxy.[<xref rid="bib35" ref-type="bibr">35</xref>] The VHP cycle takes approximately 6 to 8 hours and whole-room decontamination systems have been described that allows for decontamination of 700 N95 respirators in a 12x12 foot room.[<xref rid="bib35" ref-type="bibr">35</xref>] The respirators appear to maintain filtration and tight-fit for approximately 20 to 50 cycles.[<xref rid="bib35" ref-type="bibr">35</xref>] The UVGI process provides a more rapid cycle of only approximately 30 seconds and maintains filtration and tight-fit for approximately 10 to 20 cycles but does not allow for as many DFFP N95 respirators in a single cycle and “shadowing” can lead to incomplete decontamination.[<xref rid="bib35" ref-type="bibr">35</xref>] The use of moist heat takes approximately 30 minutes depending on the temperature and humidity but it most rapidly degrades the filtration and tight-fit with respirators only withstanding 1 to 5 cycles.[<xref rid="bib35" ref-type="bibr">35</xref>] Although decontamination with VHP, UVGI or moist heat demonstrates promising results not all manufacturers and models of the respirators have been tested under these conditions. Therefore, the CDC and N95DECON provide recommendations for the type of decontamination and number of cycles for specific manufacturers and models of a DFFP N95 respirator.[<xref rid="bib34" ref-type="bibr">34</xref>, <xref rid="bib35" ref-type="bibr">35</xref>]</p><p id="p0100">Autoclave, dry heat, isopropyl alcohol, soap, dry microwave irradiation, bleach, or disinfection wipes are not recommended because they lead to more rapid degradation of the respirator’s filtration capacity.[<xref rid="bib34" ref-type="bibr">34</xref>, <xref rid="bib35" ref-type="bibr">35</xref>] Ethylene oxide is not recommended because it is carcinogenic.[<xref rid="bib34" ref-type="bibr">34</xref>]</p><sec id="sec2.1"><title>Protecting your family from COVID-19</title><p id="p0105">Transmission of COVID-19 to those close to us is a concern all healthcare providers share. In their study of 26 orthopaedic surgeons infected with SARS-CoV-2, Guo and colleagues demonstrated a substantial risk of transmission to others.[<xref rid="bib16" ref-type="bibr">16</xref>] They report confirmed transmission in 25% of cases, including family members (5 [20.8%]), colleagues (1 [4.2%]), patients (1 [4.2%]), and friends (1 [4.2%]). The authors report that this high rate of transmission led to “great stress and depression for these surgeons.” Their recommendation, for orthopaedic surgeons working in hospital settings during the pandemic, was to avoid close contact with family members at home.[<xref rid="bib16" ref-type="bibr">16</xref>] This is obviously a difficult recommendation to follow from both a psychological and pragmatic standpoint. Currently, there is little clinical evidence to guide recommendations. The American College of Surgeons recommends removing and washing clothes immediately upon arrival at home, cleaning cell phones before and after patient care activities, frequent hand washing, and reducing physical contact with family members.[<xref rid="bib18" ref-type="bibr">18</xref>] In addition, they recommend that healthcare institutions and systems allow for hotel accommodations for healthcare works who cannot, or prefer not to, go home following patient care activities.</p></sec></sec><sec id="sec3"><title>Conclusion</title><p id="p0110">The COVID-19 pandemic caused by the SARS-CoV-2 virus has had a devastating human and economic toll. Viral outbreaks may be of concern even after the current pandemic has faded. The challenge of caring for patients in the face of rapidly evolving and often conflicting data is reflected in the fluidity of currently published guidelines by the CDC and other governmental agencies. 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Accessed April 12, 2020.</mixed-citation></ref></ref-list><sec id="appsec1" sec-type="supplementary-material"><label>Appendix A</label><title>Supplementary data</title><p id="p0115"><supplementary-material content-type="local-data" id="mmc1"><caption><title>Fillingham COI</title></caption><media xlink:href="mmc1.pdf"></media></supplementary-material><supplementary-material content-type="local-data" id="mmc2"><caption><title>Grosso COI</title></caption><media xlink:href="mmc2.pdf"></media></supplementary-material><supplementary-material content-type="local-data" id="mmc3"><caption><title>Yates COI</title></caption><media xlink:href="mmc3.pdf"></media></supplementary-material><supplementary-material content-type="local-data" id="mmc4"><caption><title>Austin COI</title></caption><media xlink:href="mmc4.pdf"></media></supplementary-material></p></sec></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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