Froedtert Hospital Operating Room and Procedural Areas Process for PPE – udpated 3/31/2020

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Definitions:

AGP: Tracheostomy, Sinus, Upper airway and pharyngeal procedures, Thoracotomy/chest tube placement, EGD, Bronchoscopy, Certain pulmonary function tests, TEE, Nebulizations, BiPAP, CPAP, or high flow oxygen (optiflow), Pulse irrigation, Deep suctioning, Nasogastric tube placement, All laparoscopic and robotic procedures. Intubation and Extubation.

Standard Precautions: Standard precautions include hand hygiene, gloves, eye protection, and mask. Note: Ortho Stryker hoods are not considered appropriate PPE to protect the surgical team members against COVID Positive or PUI

PUI: Person under investigation for COVID-19 (tested, not resulted)

Team Members caring for patients who are NOT COVID-19 Positive and are NOT PUI

1. Pre-Op Staff: Standard precautions

2. Anesthesia Providers:Standard precaution, plus disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and two pairs of nonsterile gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR. The person doing the intubation will wear a new gown during intubation and extubation (i.e. two yellow isolation gowns per case). The supervising attending anesthesiologist will have a gown available, in the OR, which they will donn, in the event that they need to directly intervene with the patient. Anesthesiology providers are eligible for one new N95 mask per day.

3. Surgical Providers: Standard precautions

4. OR RN: Standard precautions, if present for intubation or extubation wear a N95 mask (with surgical mask on top)

5. OR ST: Standard precautions

6. Anesthesia Tech:Standard precautions, if present for intubation or extubation wear a N95 mask (with surgical mask on top) or PAPR/CAPR

7. PACU Staff: Standard precautions

8. Transport Staff: Standard precautions

9. Care for patients in the OR:
   1. Intubation/extubation is considered an AGP- however it is being managed differently in the OR by having all nonessential staff who are not needed to assist with intubation/extubation step outside the room and wait 3 minutes post intubation/extubation before entering the room. Rationale for this is to let viral particles settle. The staff anesthesiologist should use their judgement, as they may need to leave the room prior to the 3 minutes if attending to other rooms. The air in the OR is exchanged every three minutes.
   2. If staff are present for intubation and extubation they do not need to replace the N95 mask – keep it for reuse and follow the UV light process for cleaning.

10. EVS: Wait 60 minutes before entering the room to clean.

Team Members caring for COVID-19 POSITIVE Patients or PUI:

1. Pre-Op Staff:In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

2. Anesthesia Providers:In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and two pairs of nonsterile gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR. The person doing the intubation will wear a new gown during intubation and extubation (i.e. two yellow isolation gowns per case). The supervising attending anesthesiologist will have a gown available, in the OR, which they will donn, in the event that they need to directly intervene with the patient. Anesthesiology providers are eligible for one new N95 masks per day (One per case when caring for patients who are known COVID19 positive).

3. Surgical Providers:In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

4. OR RN:In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

5. OR ST:In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

6. Anesthesia Tech:In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

7. PACU Staff:In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

8. Transport Staff: Standard Precautions, plus surgical face mask.

9. Care for patients in the OR:
   1. Intubation/extubation is considered an AGP- however it is being managed differently in the OR. All nonessential staff who are not needed to assist with intubation/extubation step outside the room and wait 30 minutes post intubation/extubation before entering the room. Rationale for this 30-minute internal is to provide time for viral particles to settle. The staff anesthesiologist should use their judgement, as they may need to leave the room prior to the 30 minutes if attending to other rooms.
   2. Patients will be brought directly to the designated OR when COVID-19 POSITVE or PUI.
   3. Post-op patient will be transported to isolation bay in PACU or ICU.

10. PPE:
    1. When caring for COVID-19 POSITIVE patient, wear a standard face mask on top of the N95. At the end of the procedure, discard the face mask and conserve the N95. Otherwise, discard the N95 at the end of the procedure. You will receive a new one.
    2. When caring for person under investigation (PUI), wear a standard face mask on top of the N95.
       1. Care for PAPRs:
          • After use of PAPR, please wipe down with wipes in purple-topped container or grey-topped container, follow the instruction on the container for dry times
          • Please return PAPRs to their respective storage locations when finished.

11. EVS: Leave doors closed and wait 60 minutes before entering to clean the OR. Follow EVS standards for cleaning rooms after discharge of COVID-19 POSITIVE/PUI patient.

Team Members caring for patient having an AGP procedure:

1. Pre-Op Staff:Standard precautions, unless patient is COVID then apply positive wear eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

2. Anesthesia Providers: In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and two pairs of nonsterile gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR). The person doing the intubation will wear a new gown during intubation and extubation (.e. two yellow isolation gowns per case). The supervising attending anesthesiologist will have a gown available, in the OR, which they will donn, in the event that they need to directly intervene with the patient. Anesthesiology providers are eligible for one new N95 masks per day (One per case when caring for patients who are known COVID19 positive). During the surgical AGP anesthesia providers must wear eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 (with surgical mask on top) or PAPR/CAPR.
   

3. Surgical Providers:In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

4. OR RN:In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

5. OR ST:In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

6. Anesthesia Tech:In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

7. PACU Staff: In addition to standard precautions, use disposable head cover or surgical beard cover hood, eye protection (goggles or a disposable face shield that covers the front and sides of the face), a gown, and gloves, in addition to airway protection n with an appropriately fitted N95 mask (with surgical mask on top) or PAPR/CAPR

8. Transport Staff: Standard Precautions, plus surgical face mask.
9. Care for patients in the OR: Intubation/extubation is an AGP-however in cases where the surgical procedure is deemed an AGP, if staff have the appropriate PPE-see PPE list above-it is not required that they leave the room during intubation and extubation.

9. EVS: Wait 60 minutes before entering the room to clean.