GI Procedural Algorithm for COVID-19 Case booked* COVID-19 status Is it safe to wait for COVID-19 test results?** Is the test positive? Known Test for COVID-19 Yes Proceed with new standard GI PPE*** Suspected No Proceed to workflow for suspected/positive COVID-19* Is patient already intubated? Follow workflow/SOP for Intubated patient *Front desk staff must make direct phone contact with patient care team to verify screen status before putting patient on call **Consult Highly Infectous Disease P# 33860. A confirmatory test may be required after 24h of first negative test. *** Follow new PPE recommendations for aerosolizing procedures like upper and lower endoscopies GI procedural workflow_V4.0. Updated: 03/28/2020 No Follow workflow/SOP for UnINTubated patient Not Suspected Requires transfer to Stoneman4? No Bedside ICU procedure Yes No Yes Yes
Transcript
GI Procedural Algorithm for COVID-19
Case booked* COVID-19 status
Is it safe to wait for COVID-19
test results?**Is the test positive?
Known
Test for COVID-19Yes
Proceed with new standard GI PPE***
Suspected
NoProceed to workflow for
suspected/positive COVID-19*
Is patient already intubated?
Follow workflow/SOP for Intubated patient
*Front desk staff must make direct phone contact with patient care team to verify screen status before putting patient on call **Consult Highly Infectous Disease P# 33860. A confirmatory test may be required after 24h of first negative test. *** Follow new PPE recommendations for aerosolizing procedures like upper and lower endoscopies
GI procedural workflow_V4.0. Updated: 03/28/2020
No
Follow workflow/SOP for UnINTubated patient
Not Suspected
Requires transfer to
Stoneman4?
No
Bedside ICU procedure
Yes
No
Yes
Yes
Transfer into the Procedure Roomq Directly transfer patient into the procedure roomq Do NOT bring patient to holding/PACU areas
q Confirm that the patient is wearing a surgical maskIf transporting from ICU:
q Pre-transfer huddle inside patient room with transfer teamq Direct transfer into procedure roomq Call GI desk to confirm patient is en-routeq Continue current infusions, per clinical indicationq Transport monitor – use monitoring brick from patient roomq Transfer members verify patient and staff PPE is per codeIf arriving from Med-Surg Floor:
q GI desk calls for patient when procedural staff is ready
GI HARD STOP
q Team members present with appropriate PPE & lead (if applicable)q Anesthesia providerq GI attending / fellowq Interventional technicianq RNq Airway Team member (as required)
q GI Safety checklist initiated by RNq Ensure HEPA filer is turned ON
Anesthesia Induction If MAC
q All procedural team members present per usualIf GA/Intubation
q Follow SOP for intubation of COVID+/PUI patientq Maximum 3 staff in attendance in room with patient:
q Primary anesthesia providerq Assisting anesthesia provider q RN (not present if RT is in room) q All other staff briefly exit the room– doffing not necessary
q Use anesthesia machine as per usual, adjust settings through plastic covering
Transfer patient to procedural table
q If supine, avoid disconnecting ETT from circuit q If prone position required, follow below steps in sequence :
q Place bite-block PRIOR to proning
q Preoxygenate for 3 minutes with 100% O2, turn OFF ventilator, clamp the ETT, prone, reconnect ventilator after appropriate positioning, remove clamp, RESTART ventilator
q In room team strips linens off bed & pushes bed into hallwayq GI technicians decontaminate patient bed immediately in
hallway
End of CaseTeam leader confirms the return pathway , choosing one of the
options below
q Confirm members and roles for subsequent careq End of case sign out, as usualq Call scope room ST4 7-5568, ST3 7-5484 to inform technician
to prepare for incoming used scopeAt case end, if planning to extubate
q Page PACU nurse to be ready for post-op careq PACU nurse to identify 1 additional inside aide and 1
additional outside runner to assist with careIf planning to transfer to ICU
q Call ICU to notify of case finish
Option 1 (Extubate & recover in procedure room)
q Staff not involved with extubation may doff PPE & exitq Primary anesthesiologist performs extubation, per COVID-19
airway management SOP, assisted by 2 other staff members in the room (GI fellow, RN)
q Discard airway supplies and seal equipmentq PACU nurse dons PPE and enters room q GI fellow & RN doff PPE and leave roomq Certain logistical situations may necessitate transfer of the
patient after extubation to a designated COVID room for
further recovery
q Patient PPE must be maintained for the transferq Place an O2 mask over the surgical mask
Option 2 (patient remains intubated; transfer to ICU)
q Patient is moved to ICU, with transfer teamq Follow transfer protocol for intubated patientq Ventilation during transfer: Ambu bag + HME filterq Staff members not on transfer may doff PPE and exit
procedure room
Post-procedure Careq Anesthesia staff to remain with PACU nurse until RN is
comfortable with patient statusq When appropriate, anesthesia staff doffs and leaves roomq PACU nurse manages care until patient is ready for transfer
back to non-ICU bedq When appropriate, patient is moved to hospital room or
dischargedq Contact EVS (Pg: 92746 East, 92745 West) to inform end of
recovery care
End of Case – DecontaminationRefer to Room Turnover for suspected or confirmed COVID-19
GI - Workflow for a COVID-19 case – UnINTubated PATIENTPre-procedure Huddle & Room PreparationTeam members designated to be in the procedure room should huddle ASAP after the case is booked (in person or virtually): q Designated Team leader q Anesthesia provider assigned for caseq Anesthesia runnerq GI attending and Fellowq RNq Interventional tech & anesthesia techq Outside door runnerq GI resource nurse & PACU nurseq Designated safety officer to prevent any entry without PPEq Designated anesthesia Airway team member (optional)
q Print and display signage outside all doors to the designated procedure room (STOP and PPE posters)
Anesthesia prep:
q Confirm anesthesia plan (GA/MAC)q Confirm if OR/Procedure Room is readyq Cover anesthesia machine and Omnicellq Ensure additional HMEF on expiratory limb of anesthesia circuitq Prepare required airway equipment onto a designated cart,
including an HME filter, Ambu bag & Kelly clamp in case of disconnection, extubation or ventilatory failure
q Prepare required drugs onto a second cart inside the ORq Confirm which supplies/drugs may be required outside the OR
Procedure prep:
q Procedure staff physically verify & confirm the setup for caseq Confirm supplies required inside the roomq Confirm supplies that may be required outside the room
Preoperative Consent, H&P
q Confirm pre-procedure phone consents and H&P are completedq RN completes pre-operative intake formsq GI front desk contacts patient care team for ETA if applicable
Prepare for intubation (if required): q Schedule designated Airway Team Member if needed*
Prepare for transfer into the Procedure Room:q Identify transfer team members based on patient locationq Confirm route & ensure it is clear of all moveable obstacles
Contact ICP (Pg: 94277) to clarify start & stop time for HEPA filterContact EVS (Pg: 92746 East, 92745 West) to inform case start
Ensure correct PPE is worn by all members**
Workflow v12_4/12/2020
Inadvertent Extubation
q Oxygenation: HME filter must be present between facemask & anesthesia circuit/Ambu bag
q Runner calls CODE BLUE, verifies PPE available for Code teamq If patient is in prone position: runner pushes stretcher into
procedure room and procedure team repositions patientq Early re-intubation or insertion of i-gel with gentle mask
ventilation
**PPE for staff involved with careIn the procedure roomAll staff entering room
N95 respirator + eye protection + gown + head covers + double gloves +/- leg covers
Out of the procedure roomAnesthesia and nurse runner
Surgical mask + eye protection + gloves
On transfer to/from ICUTeam leader Surgical mask + eye protection + glovesAll transfer staff except team leader
N95 respirator + eye protection + gown + head covers + double gloves +/- leg covers
Patient Surgical facemask
Location of Donning In clean area near or in procedure suite
Doffingq Ensure a buddy is present to observe doffing
Endoscopic Procedureq Procedural time-out, as usualq Designated safety officer and runner stay outside during caseCommunication during case:
q In room team uses hospital phone/intercom to contact outside support
q GI proceduralist to alert staff BEFORE scope extractionHanding in supplies or drugs
q Place onto designated cart immediately outside procedure room
q Inside RN opens procedure room door & collects supplies or drugs
Transferq Pre-transfer huddle inside patient room with transfer teamq Direct transfer into procedure roomq Call procedural room to confirm patient is en-route & to ensure HEPA filer is
turned ONq Transport monitor – use monitoring brick from patient roomq Continue current infusions, per clinical indicationq Emergency and intubation drugs, per clinical indicationq Optimize sedation to prevent awarenessq Deep muscle relaxation recommendedq Move to transport ventilation (performed planned circuit disconnection)
q Turn OFF ICU ventilator (RT to perform this step)q Clamp ETT using Kelly clampq Disconnect ETT from ICU circuitq Connect Ambu bag + HME filter + PEEP valve onto ETTq Remove clamp q Confirm ventilation as per usual
Start of the CaseGI HARD STOP
q Team members present with appropriate PPE & lead (if applicable)q Anesthesia providerq GI attending / fellowq Interventional technicianq RN
q GI Safety checklist initiated by RNTransfer patient to procedural table
q Avoid disconnecting ETT from circuit (unless prone position required)If prone position required, follow below steps in sequence :
q Place bite-block PRIOR to proning
q Preoxygenate for 3 minutes with 100% O2, turn OFF ventilator, clamp the ETT, prone, reconnect ventilator after appropriate positioning, remove clamp, RESTART ventilator
q In room team strips linens off bed & pushes bed into hallwayq GI technicians decontaminate patient bed immediately in hallwayStabilize patient in ORq Connect patient to anesthesia ventilator (planned circuit disconnect as above)q Maintain anesthesia using a volatile agent to conserve supplies of total
intravenous anesthesia
Endoscopic Procedureq Procedural time-out, as usualq Designated safety officer and runner stay outside during caseCommunication during case:
q In room team uses hospital phone/intercom to contact outside supportq GI proceduralist to alert staff BEFORE scope extractionHanding in supplies or drugs
q Place onto designated cart immediately outside procedure roomq Inside RN opens procedure room door & collects supplies or drugs
GI - Workflow for a COVID-19 case – INTUBATED PATIENTPre-procedure Huddle & Room PreparationTeam members designated to be in the procedure room should huddle ASAP after the case is booked (in person or virtually): q Designated Team leader q Anesthesia provider assigned for caseq Anesthesia runnerq GI attending and Fellowq RNq Interventional tech & anesthesia techq Outside door runnerq GI resource nurseq Designated safety officer to prevent any entry without PPEq Designated anesthesia Airway team member (optional)
q Print and display signage outside all doors to the designated procedure room (STOP and PPE posters)
Anesthesia prep:
q Report ICU attending discussion and ventilation management plan q Confirm Procedure Room is readyq Cover anesthesia machine and omnicellq Prepare required airway equipment onto a designated cartq Prepare required drugs onto a second cart inside the ORq Confirm which supplies/drugs may be required outside the ORProcedure prep:
q Procedure staff physically verify & confirm the setup for caseq Confirm supplies required inside the roomq Confirm supplies that may be required outside the room
Preoperative Consent, H&P
q Confirm pre-procedure phone consents and H&P are completedq RN completes pre-operative intake formsq GI front desk contacts patient care team for ETA if applicable
Prepare for transfer:q Prepare routine transport equipment, including
q HME filter, Ambu bag with PEEP valve & Kelly clampq Confirm transfer team members and roles mandatory/optional:
q Team leader (will call/hold elevators/wipe down)q Anesthesiologist (head of bed)q GI attending or fellow (end of bed)q Extra member (ICU nurse or circulating nurse, depending extra equipment
and staffing levels)q Airway Team Member – optionalq If RT required, please see addendum
q Confirm route & ensure it is clear of all moveable obstacles
Contact ICP (Pg: 94277) to clarify start & stop time for HEPA filterContact EVS (Pg: 92746 East, 92745 West) to inform case start
Ensure correct PPE is worn by all members**Workflow v12_4/12/2020
End of CaseTeam leader coordinates the return back to ICU
q Confirm members and roles for subsequent careq End of case sign out, as usualq Call scope room ST4 7-5568, ST3 7-5484 to inform technician to prepare for incoming used
scopeq Move patient from procedure table onto ICU bedq Patient is moved to ICU, with transfer teamq Staff not on transfer may doff PPE and exit procedure roomq Contact EVS (Pg: 92746 East, 92745 West) to inform end of case
End of Case – DecontaminationRefer to Room Turnover for suspected or confirmed COVID-19
**PPE for staff involved with careIn the procedure roomAll staff entering room N95 respirator + eye protection + gown + head covers + double gloves
+/- leg covers
Out of the procedure roomAnesthesia and nurse runner Surgical mask + eye protection + gloves
On transfer to/from ICUTeam leader Surgical mask + eye protection + gloves
All transfer staff except team leader
N95 respirator + eye protection + gown + head covers + double gloves +/- leg covers
Patient Surgical facemask
Location of Donning In clean area near or in procedure suite
Doffingq Ensure a buddy is present to observe doffing
Inadvertent Extubationq Oxygenation: HME filter must be present between facemask & anesthesia circuit/Ambu bagq Runner calls CODE BLUE, verifies PPE available for Code teamq If patient is in prone position: runner pushes stretcher into procedure room and procedure
team repositions patientq Early re-intubation or insertion of i-gel with gentle mask ventilation
ICU ventilation & Respiratory therapistIf ICU ventilation is required for the caseq RT will assist with:
q Any planned circuit disconnectionsq Transfers while on the ICU ventq Intubation onto the ICU ventq Stabilizing patient inside the OR/procedureq Confirming ventilation settings and ensuring
anesthesiologist has clear instructions on how to modify vent setting
q RT should be donned in the appropriate PPEq Maintenance of anesthesia:
q Avoid the use of the anesthesia machine in OR/procedure room
q Maintain anesthesia with total intravenous anesthesia
Addendum
Workflow v12_4/12/2020
Anesthesia InductionPrepareq Apply standard ASA monitorsq Check for working IV accessq Ensure HME filter is between facemask & circuit/Ambu bag
Preoxygenateq Optimize positionq 5min or until target EtO2 reached (as defined by airway team)
Perform RSIq Rapid administration of induction drugs and flushq If difficulty intubating, follow difficult airway plan belowq Connect ETT to anesthesia circuitq Inflate cuff BEFORE applying PPVq Confirm intubation via EtCO2 (avoid auscultation)q Secure ETT
If bag-mask ventilation is required, use small volumes
In the event of an anesthesia stat callq The outside staff member (circulator/runner) must prevent any
entry without appropriate PPE
Checklist for Intubation & Extubation - COVID19+ Patient
Preparation
Designate team leader and confirm:q Patient IDq Allergiesq Weightq Can the patient be optimized any further?
q Fluids/vasopressorsq NGT aspiration
Prepare for an unanticipated difficult airway*q Is there a clinical indication/need for fibreoptic intubation?
q Call for disposable Ambu fiberoptic scopeq Discuss need for additional expertise
q Confirm primary & backup plan for difficult airway
Reduce exposureq Limit staff member in room during intubation (max 3)q 1st intubator (Anesthesiologist or Airway Team Member)q 2nd intubator (if required)q RNq Runner (outside the room)
Anesthesia prep:q Check equipment:
q Facemask + Ambu bag + HME filterq Oropharyngeal airwayq Yankauer Suctionq VL: McGrathq Bougieq ETT x 2q EtCO2 confirmatory method
q Prepare required drugs which will be brought inside the roomq Induction agentsq Emergency (hemodynamic support)q Maintenance (sedation, hemodynamic support)
q Confirm which supplies & drugs will remain outside the roomq Prepare how you will dispose of used items (2x bags: clean and dirty
contaminated bags)Apply PPE**q Remove personal items (pens, mobile phones, ID badges)q Buddy/mirror checkq Confirm plan with all membersq How will we call for help, if needed?
q Consider using a blue chuck or towel to cover the patient’s mouth during extubation (as a barrier for aerosolization)
q Retain HMEF on ETT during extubationq Deflate ETT and extubate along with the towel/chuck
q Dispose of used disposable supplies (ETT, temp probe, bite block, OPA, NG/OG tube, suction) using the dirty contaminated bag
q Do NOT throw away laryngoscopes, keep in sealed specimen bag in OR for anesthesia technician collection
**PPE for staff involved with careIn the OR/ICU room1st intubator PAPR or N95 + eye protection + gown + head cover + double
gloves +/- shoe/leg covers2nd intubator or Anesthesia stat responder
PAPR or N95 + eye protection + gown + head covers + double gloves +/- shoe/leg covers
Nursing N95 + eye protection + gown + head covers + double gloves +/- leg covers
Out of the OR/ICU roomRunners (Nursing, Anesthesia) Surgical facemask + eye protection + gown + double gloves
Doffingq Ensure a buddy is present to observe doffing!
Post-intubation
q Place laryngoscope (handle & blade) into biohazard bag and seal
q Place facemask into biohazard bag and sealq Ensure HME filter is between ETT and circuitq Clamp ETT if disconnection of circuit is required
SPECIAL FLU DROPLET + CONTACT PRECAUTIONS REQUIRED
Do NOT enter unless necessary
Refer to the PPE checklists BEFORE & AFTER entering the OR
RESTRICTED ENTRY
STOP!!
Stop signage_v2. 3/19/2020
1. RESPIRATORY AND EYE PROTECTION
Routine care: Mask with Eye Protection
Aerosol-generating procedures: N95 Respirator with Eye Protection • Secure elastic bands at middle of head and at neck• Fit flexible band to nose bridge• Fit snug to face and below chin• Ensure respirator fit -OR-PAPR
2. GOWN (Blue Gowns)• Fully cover torso from neck to knees and arms to wrists• Wrap around the back• Fasten in back of neck and waist
3. HAND HYGIENE
4. GLOVES• Extend to cover wrist of isolation gown• Double glove
Use Safe Work Practices to Protect Yourself and Limit the Spread of Contamination• Keep hands away from face
• Limit surfaces touched
• Change gloves once torn or heavily contaminated
• Perform hand hygiene
Sequence for Putting On
The type of PPE used will vary based on the level of precautions required, such as standard and contact, droplet or airborne infection isolation precautions. The procedure for putting on and removing PPE should be tailored to the specific type of PPE.
Adapted from CDC Poster: Revised ICHE 2020.03.19, Flu and Norovirus\management\2019-20\PPE
Personal Protective Equipment (PPE) for Patients on Special Flu Droplet and Contact Precautions
SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE) FOR PATIENTS ON SPECIAL FLU DROPLET AND CONTACT PRECAUTIONS
The type of PPE used will vary based on the level of precautions required, such as standard and contact, droplet or airborne infection isolation precautions. The procedure for putting on and removing PPE should be tailored to the specific type of PPE.
1. Respiratory and Eye Protection a. Routine care:
i. MASK with EYE PROTECTION b. Aerosol‐generating procedures:
i. N95 RESPIRATOR with Eye Protection
x Secure elastic bands at middle of head and at neck
x Fit flexible band to nose bridge x Fit snug to face and below chin x Ensure respirator fit
OR ii. PAPR
2. GOWN (Blue Gowns for All Staff) x Fully cover torso from neck to knees, arms
to wrists, and wrap around the back x Fasten in back of neck and waist
3. HAND HYGIENE
4. GLOVES x Extend to cover wrist of isolation gown x Double Glove
USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION
x Keep hands away from face x Limit surfaces touched x Change gloves when torn or heavily contaminated x Perform hand hygiene
Adapted from CDC Poster Revised BIDMC ICHE 3/2020
SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE)
HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 15IFSF�BSF�B�WBSJFUZ�PG�XBZT�UP�TBGFMZ�SFNPWF�11&�XJUIPVU�DPOUBNJOBUJOH�ZPVS�DMPUIJOH �TLJO �PS�NVDPVT�NFNCSBOFT�XJUI�QPUFOUJBMMZ�JOGFDUJPVT�NBUFSJBMT��)FSF�JT�POF�FYBNQMF��Remove all PPE before exiting the patient room�FYDFQU�B�SFTQJSBUPS �JG�XPSO��3FNPWF�UIF�SFTQJSBUPS�after�MFBWJOH�UIF�QBUJFOU�SPPN�BOE�DMPTJOH�UIF�EPPS��3FNPWF�11&�JO�UIF�GPMMPXJOH�TFRVFODF�
2. GOGGLES OR FACE SHIELDt� 0VUTJEF�PG�HPHHMFT�PS�GBDF�TIJFME�BSF�DPOUBNJOBUFE�t� *G�ZPVS�IBOET�HFU�DPOUBNJOBUFE�EVSJOH�HPHHMF�PS�GBDF�TIJFME�SFNPWBM �
1. GOWN• Grasp the front of the gown with gloved hands• Pull the gown away from the body until attachments
break• While removing gown, roll inside out into a bundle,
touching only the outside of the gown with gloved hands
• Discard the gown into a waste container
2. GLOVES• Using a gloved hand, grasp the palm area of the
other gloved hand and peel off first glove• Hold removed glove in gloved hand• Slide fingers of ungloved hand under remaining
glove at wrist and peel off second glove over first glove
• Discard gloves in a waste container in patient room
3. HAND HYGIENE
4. MASK WITH EYE PROTECTION• Grasp bottom ties/mask elastics, followed by ties/
elastics at the top• Remove without touching the front of the mask• Discard into designated bin if soiled OR
implement reuse protocol
5. N95 RESPIRATOR or PAPR• Grasp either bottom ties/mask elastics, followed by
ties/elastics at the top• Remove without touching front of the mask• Discard into designated bin if soiled OR
implement reuse protocol
6. HAND HYGIENE
Sequence For Safely Removing
Outside surfaces of gloves, gown, sleeves, mask and respirator are contaminated! If your hands become contaminated during PPE removal, immediately wash your hands or use an alcohol-based hand sanitizer.
Adapted from CDC Poster: Revised ICHE 2020.03.19, Flu and Norovirus\management\2019-20\PPE
Personal Protective Equipment (PPE) For Patients On Special Flu Droplet And Contact Precautions
INSI
DE
OPE
RA
TIN
G R
OO
MO
UTS
IDE
OPE
RA
TIN
G R
OO
M
HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 15IFSF�BSF�B�WBSJFUZ�PG�XBZT�UP�TBGFMZ�SFNPWF�11&�XJUIPVU�DPOUBNJOBUJOH�ZPVS�DMPUIJOH �TLJO �PS�NVDPVT�NFNCSBOFT�XJUI�QPUFOUJBMMZ�JOGFDUJPVT�NBUFSJBMT��)FSF�JT�POF�FYBNQMF��Remove all PPE before exiting the patient room�FYDFQU�B�SFTQJSBUPS �JG�XPSO��3FNPWF�UIF�SFTQJSBUPS�after�MFBWJOH�UIF�QBUJFOU�SPPN�BOE�DMPTJOH�UIF�EPPS��3FNPWF�11&�JO�UIF�GPMMPXJOH�TFRVFODF�
2. GOGGLES OR FACE SHIELDt� 0VUTJEF�PG�HPHHMFT�PS�GBDF�TIJFME�BSF�DPOUBNJOBUFE�t� *G�ZPVS�IBOET�HFU�DPOUBNJOBUFE�EVSJOH�HPHHMF�PS�GBDF�TIJFME�SFNPWBM �
ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE
PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE
HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2
)FSF�JT�BOPUIFS�XBZ�UP�TBGFMZ�SFNPWF�11&�XJUIPVU�DPOUBNJOBUJOH�ZPVS�DMPUIJOH �TLJO �PS�NVDPVT�NFNCSBOFT�XJUI�QPUFOUJBMMZ�JOGFDUJPVT�NBUFSJBMT��Remove all PPE before exiting the patient room FYDFQU�B�SFTQJSBUPS �JG�XPSO��3FNPWF�UIF�SFTQJSBUPS after MFBWJOH�UIF�QBUJFOU�SPPN�BOE�DMPTJOH�UIF�EPPS��3FNPWF�11&�JO�UIF�GPMMPXJOH�TFRVFODF�
1. GOWN AND GLOVESt� (PXO�GSPOU�BOE�TMFFWFT�BOE�UIF�PVUTJEF�PG�HMPWFT�BSF�
2. GOGGLES OR FACE SHIELDt� 0VUTJEF�PG�HPHHMFT�PS�GBDF�TIJFME�BSF�DPOUBNJOBUFE�t� *G�ZPVS�IBOET�HFU�DPOUBNJOBUFE�EVSJOH�HPHHMF�PS�GBDF�TIJFME�SFNPWBM �
4. WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE
PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE
HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2
)FSF�JT�BOPUIFS�XBZ�UP�TBGFMZ�SFNPWF�11&�XJUIPVU�DPOUBNJOBUJOH�ZPVS�DMPUIJOH �TLJO �PS�NVDPVT�NFNCSBOFT�XJUI�QPUFOUJBMMZ�JOGFDUJPVT�NBUFSJBMT��Remove all PPE before exiting the patient room FYDFQU�B�SFTQJSBUPS �JG�XPSO��3FNPWF�UIF�SFTQJSBUPS after MFBWJOH�UIF�QBUJFOU�SPPN�BOE�DMPTJOH�UIF�EPPS��3FNPWF�11&�JO�UIF�GPMMPXJOH�TFRVFODF�
1. GOWN AND GLOVESt� (PXO�GSPOU�BOE�TMFFWFT�BOE�UIF�PVUTJEF�PG�HMPWFT�BSF�
2. GOGGLES OR FACE SHIELDt� 0VUTJEF�PG�HPHHMFT�PS�GBDF�TIJFME�BSF�DPOUBNJOBUFE�t� *G�ZPVS�IBOET�HFU�DPOUBNJOBUFE�EVSJOH�HPHHMF�PS�GBDF�TIJFME�SFNPWBM �
4. WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE
PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE
Please page EH&S at pager #33137 with PAPR questions.
HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2
)FSF�JT�BOPUIFS�XBZ�UP�TBGFMZ�SFNPWF�11&�XJUIPVU�DPOUBNJOBUJOH�ZPVS�DMPUIJOH �TLJO �PS�NVDPVT�NFNCSBOFT�XJUI�QPUFOUJBMMZ�JOGFDUJPVT�NBUFSJBMT��Remove all PPE before exiting the patient room FYDFQU�B�SFTQJSBUPS �JG�XPSO��3FNPWF�UIF�SFTQJSBUPS after MFBWJOH�UIF�QBUJFOU�SPPN�BOE�DMPTJOH�UIF�EPPS��3FNPWF�11&�JO�UIF�GPMMPXJOH�TFRVFODF�
1. GOWN AND GLOVESt� (PXO�GSPOU�BOE�TMFFWFT�BOE�UIF�PVUTJEF�PG�HMPWFT�BSF�
2. GOGGLES OR FACE SHIELDt� 0VUTJEF�PG�HPHHMFT�PS�GBDF�TIJFME�BSF�DPOUBNJOBUFE�t� *G�ZPVS�IBOET�HFU�DPOUBNJOBUFE�EVSJOH�HPHHMF�PS�GBDF�TIJFME�SFNPWBM �
4. WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE
PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE
SEQUENCE FOR SAFELY REMOVING PERSONAL PROTECTIVE EQUIPMENT (PPE) FOR PATIENTS ON SPECIAL FLU DROPLET AND CONTACT PRECAUTIONS
Outside surfaces of gloves, gown, sleeves, mask and respirator are contaminated! If your hands becomecontaminated during PPE removal, immediately wash your hands or use an alcohol based hand sanitizer.
1. GOWN
x Remove outer pair of gloves x Pull gown away from neck and shoulders,
touching inside of gown only x Turn gown inside out x Fold or roll into a bundle and discard in regular
trash
2. GLOVES x Using a gloved hand, grasp the palm area
of the other gloved hand and peel off first glove��
x Hold removed glove in gloved hand��x Slide fingers of ungloved hand under
remaining glove at wrist and peel off second glove over first glove��
x Discard gloves in a waste container in patient room��
3. HAND HYGIENE
4. MASK with EYE PROTECTION x Grasp either both ear loops or bottom
ties/elastics of the mask, followed by the ones at the top
x Remove without touching the front x Discard if soiled or implement reuse
protocol
5. N95 RESPIRATOR or PAPR x Grasp either bottom ties/elastics of the mask,
followed by the ones at the top x Remove without touching the front x Discard into a waste container if soiled or
implement reuse protocol
If PAPR questions, please page EH&S at pager #33137
6. HAND HYGIENE
Adapted from CDC Poster Revised BIDMC ICHE 3/2020
OUTSIDE OF ROOM
HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2
)FSF�JT�BOPUIFS�XBZ�UP�TBGFMZ�SFNPWF�11&�XJUIPVU�DPOUBNJOBUJOH�ZPVS�DMPUIJOH �TLJO �PS�NVDPVT�NFNCSBOFT�XJUI�QPUFOUJBMMZ�JOGFDUJPVT�NBUFSJBMT��Remove all PPE before exiting the patient room FYDFQU�B�SFTQJSBUPS �JG�XPSO��3FNPWF�UIF�SFTQJSBUPS after MFBWJOH�UIF�QBUJFOU�SPPN�BOE�DMPTJOH�UIF�EPPS��3FNPWF�11&�JO�UIF�GPMMPXJOH�TFRVFODF�
1. GOWN AND GLOVESt� (PXO�GSPOU�BOE�TMFFWFT�BOE�UIF�PVUTJEF�PG�HMPWFT�BSF�
2. GOGGLES OR FACE SHIELDt� 0VUTJEF�PG�HPHHMFT�PS�GBDF�TIJFME�BSF�DPOUBNJOBUFE�t� *G�ZPVS�IBOET�HFU�DPOUBNJOBUFE�EVSJOH�HPHHMF�PS�GBDF�TIJFME�SFNPWBM �
2. (Trash the room) throw away all disposables into trash. Throw away all drapes/covers on machine and from carts in the room from Anesthesia. (Gently remove covers from carts and Anesthesia Machine)
3. Wipe all surfaces including (IV poles, pumps, TOF, SS anesthesia cart and inside drawers of cart, Ranger, Bair Hugger, McGrath, AW Cart all surfaces on the anesthesia machine front, back, tops, and sides. Wipe telephone if mounted to machine.
4. Dispose of trash on instrument cart to be covered by OR Attendants.
5. Dof all PPE and dispose of properly.6. EVS Terminally cleans room.7. Return to room Re-stock and set up room with drapes/covers.
Attachment 2Attendant Cleaning
NOTEThird Person outside of room to provide additional supply needs
PERSON ONEPREPARE• Wash hands; don PPECONTAIN• Trash• Biohazard Trash• Linen• SharpsWIPE DOWN• Wipe down trash and linen receptaclesMANAGE FLUIDS• Remove suction; add solidifier; replace caps
securelyFLOOR CLEANING• Remove suture and string• Remove furniture; mop thoroughly• Dispose of mop head properlyFINISH• Push case cart to decontam• Remove PPE and wash hands• Return equipment to storage area
Two Person TurnoverPERSON TWO
PREPARE• Wash hands; don PPE• Remove blood cooler; wipe down and alert deskCLEAN• Overhead lights• OR bed tables and attachments• Ring stands• Mobile equipment as needed• Boot machines• IV poles• Kick buckets• Sitting stools• Step stools• Computers monitors, keyboards, telephones• Viewing monitorsFINISH• Remove PPE & wash hands• Make bed with trash linen
Attachment 3Terminal Cleaning
1. Perform hand hygiene and don Personal Protective Equipment (PPE)
2. Dust and disinfect X-ray view box
3. Wipe, disinfect suction regular system
4. Wipe, disinfect HVAC vents (exterior)
6. Empty trash containers disinfect (in & out) and replace liners
7. Empty and disinfect kick buckets and rolling stands (in & out)
8. Empty and disinfect linen hampers (replace liners)
9. Wipe and disinfect rolling chairs and rolling stools
10. Wipe and disinfect overhead light and arms
11. Wipe and disinfect step on stool
12. Wipe and disinfect Mayo stands
13. Break down and thoroughly wipe and disinfect OR table (base)
14. Wipe and disinfect IV poles
15. Wipe and disinfect countertop and computer monitor and keyboard at workstation
16. Wipe and disinfect supply cabinet (exterior)
20. Thoroughly wet mop entire floor surface using microfiber mop
21. Remove iodine stains (floor surface)
22. Clean and disinfect sinks and faucets
17. Spot cleaning of walls and ceilings
18. Viewing monitors
19. Light switches, door handles, push plates, and telephones
