"COVID-19 Considerations in a Non-ICU Inpatient Setting During
Emergency Response and CPR" by Maeve Giangregorio, on behalf of the
8 East EPQI* Team
Objectives.
Review PPE required during resuscitation events, regardless of patient's COVID-19 status.
Discuss COVID-19 precaution zones during
emergency events. Demonstrate how to prevent
cross-contamination across COVID-19 precaution zones.
Demonstrate communication pathways across COVID-19 precaution zones.
Discuss new emergency response roles as a result of COVID-19 precautions.
Emergency response including cpr events in pediatric patients with confirmed or
suspected COVID-19 presents unfamiliar challenges to
in-hospital staff. Harmonizing the urgent needs of a
patient with the safety of staff is a constant and unique concern. Interim
guidance to support these challenges has been provided by the American Heart
Association. COVID-19 is highly transmittable during
resuscitation events. Optimizing patient outcomes and
protecting staff from COVID-19 exposure are the utmost importance. Guiding
principles to reducing staff exposure: consistent, proper donning of necessary
PPE. Limiting staff in the room when possible
and establishing clear zone boundaries when
not in an airborne room. When called to, or responding to a
situation where there is potential for the patient's condition to deteriorate,
and AGPs to take place, staff should enter the room wearing full
PPE. The AHA recommends donning full PPE before engaging in CPR or other AGPs
to reduce staff exposure to COVID-19. Donning full PPE is done before entering
either the Hot or Warm Zones, and includes a gown, gloves,
N95 or PAPR, and eye protection. Consideration for the location of a
patient resuscitation is important. Negative pressure rooms
provide clear Warm Zone boundaries, standard rooms do not. Establishing clear
Warm Zone boundaries when there is no anteroom is important.
Following guidelines for PPE in the Warm Zone is essential to minimize staff
exposure.
Teams and zones.
Three teams form.
The in-room emergency response team, the anteroom team
when using a negative pressure airborne precaution room, and the outside team.
The responding teams are divided into three zones.
The patient's room is considered the Hot Zone. The anteroom and designated area
outside of the patient's room, which is particularly important to establish
during events in a non-negative pressure room,
are the Warm Zones. And the remainder of the hallway
outside of the patient's room is the Cold Zone.
Whenever possible, staff not in full PPE should prioritize donning all the
necessary PPE recommended during a resuscitation as
soon as they are able to do so. Staff in full PPE entering a clinical
emergency should recognize and encourage those not
in full PPE to don the necessary items. Acknowledging
and considering the safety of all staff, especially when in a patient care
situation that requires more PPE than currently in place,
is an important and ongoing consideration.
The patient's condition has deteriorated. The response team is activated
while CPR is initiated.
Staff entering Warm Zones must don PPE
appropriate for aerosol generating procedures, including gown,
gloves, face shield, and N95 respirator or PAPR
prior to entering these zones. With full PPE in place,
staff in the Warm Zone are prepared to enter the room rapidly if needed.
If members of the anteroom team must enter the Hot Zone,
backup team members from the Cold Zone should replace anteroom staff.
It is important to have an anteroom team. Typically two nurses are positioned
in the anteroom or designated Warm Zone. One nurse monitors safe entry and exit
into patient's room by ensuring the integrity of the doors
while the other nurse relays information, medications, and supplies
between the inside and outside teams. Prior to staff being positioned in the
anteroom, it is important to establish visual contact with staff
inside the room and whiteboards for communication as needed.
This schematic highlights the key roles in the Warm Zone.
The team inside the room is limited to only those necessary for patient care.
That includes the airway manager, the nursing event manager,
who is most often the charge or resource nurse,
the patient's nurse, recorder, and respiratory therapist.
Additional nurses will be present as necessary for compressions
and defibrillation, vascular access, and medication administration.
If an icu or code team provider arrives for additional support,
the provider already in the room should remain.
Establishing key roles for the outside team is important
As staff respond to the event, donning PPE should be done away from the code
cart and room entrance to prevent disruption of supplies,
medications, and communication between teams.
An outside team provider dons preliminary PPE
in case they are needed in the room, and also assists with order entry and
relaying communication to the inside room provider.
The hallway nursing event manager, usually an experienced nurse, such as a
charge nurse or resource nurse, organizes the outside team by
assigning roles, receiving and sharing communication with
the inside team, and providing important information to
arriving code response staff. The code cart team positions the code
cart in the Cold Zone outside the patient's room to prepare
medications and airway supplies. The PPE enforcer acts as a gatekeeper
to supervise and ensure proper PPE donning before staff
enter the room. The biocontainment site manager
may take this rollover, or assist with proper PPE donning once they arrive.
A staff member is designated to the communication role.
This team member establishes communication between the inside room
team and outside hallway team by setting up
Zoom connections on multiple devices.
This schematic also demonstrates key personnel.
Communication has distinct challenges. In addition to usual team huddles and
assigning roles, establishing a plan for communication
between the inside and outside team is essential. Zoom ID numbers and login
information should be posted inside each patient
room, and outside the patient's door whenever possible.
Consideration for both audio, such as smartphones,
and visual, such as writing on whiteboards, is recommended.
Headsets may be used if available. Only key personnel,
such as the providers and nurse event managers, should remain unmuted for
communication. All other devices should be muted to
reduce feedback. The code cart team positions the code
cart in the Cold Zone outside the patient's room to prepare
medications and airway supplies. The code cart team ensures integrity of
doors before passing medications and supplies
into the anteroom. The emergency airway kit
(EAK) with intubation medications is brought to the code cart from the PYXIS,
if not on the code cart, to conserve medications.
Weight-based doses are calculated and labels created in anticipation of a
rapid sequence intubation. However, the medications are
not prepared until they're needed necessary equipment such as the
defibrillator and ambu-bag with HEPA filter are gathered and
relayed into the room. In addition to requesting medications
and supplies, it is important for the inside team to broadcast
key milestones and updates to the outside team.
Keeping the entire team informed of the patient status
is essential. Whiteboards can be used to assist communication between
teams. Having whiteboards readily available
is recommended. As additional code team members arrive,
the hallway provider and nursing event manager provide essential information to
the arriving code team. the biocontainment team is part of code
activations and response. a biocontainment site
manager will support a range of duties including ensuring appropriate donning
and doffing, establishing Zoom connections,
and overseeing safe transfer to a higher level of care.
In-room participants that do not need to be in direct contact with the patient
should maintain a distance of six feet from the airway whenever possible
to reduce exposure. This patient has successfully been defibrillated with
return of circulation. Preparations may begin to transfer the
patient to a higher level of care. The inside team communicates to the
outside team when the patient needs to be transferred to a higher level of care.
Cold Zone staff, including the hallway nursing event manager and biocontainment
site manager, help to prepare for the patient transfer
by clearing the hallway for patient transport. Once ready, the
inside team initiates transport of the patient.
The inside team confirms with the outside team prior to leaving the room.
Only the minimum necessary staff should accompany the patient
on transfer. Once the hallway is cleared, staff from the inside room transfer the
patient to a higher level of care, being mindful of keeping away from other
people and equipment. When possible, the biocontainment site
manager will oversee transport of the patient. The
biocontainment site manager is available to supervise doffing of all
staff who participated in the event. The staff remaining in the patient's
room should enter the anteroom two at a time
to doff safely. At the end of doffing, all gowns are placed in the dirty linen cart
inside the patient's room.
Thank you.
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