April 9, 2020 | By Ken Colaric, MD, FACEP | News

 

In conjunction with Angel Troxell, the Emergency Department Director at our hospital, we developed this process to reduce the viral load in the treatment room and reduce exposure to the healthcare team for Code Blue and intubation of COVID-19 suspect or confirmed patients.

Before you begin, you must have the following materials at hand:

  • (3) universal N95 masks (duck bill)
  • 1 roll of plastic (you can use clear bags donated from a local dry cleaner)
  • Isolation gowns (3 each)
  • Shoe covers (3 pair)
  • Eye protection (3 pair)
  • Head cover (3)
  • Exam gloves (3 pair)

Follow these steps for intubation:

  1. Ensure patient is wearing a surgical face mask (remove before intubation).
  2. Prepare all medications, instruments and equipment
  3. Place intubation supplies on space that will be covered by plastic sheeting,
    i.e., on the bed at the head of the bed, on sides of patient, or on patient’s chest
  4. Medicate patient as appropriate for intubation
  5. Immediately drape patient from mid-chest, being careful to cover head
  6. Avoid bagging patient with BMV until the plastic sheeting is in place. Ensure the entire
    BMV and tubing is under the drape.
  7. When intubating, be careful to maintain the drape over the patient’s head and chest
    to reduce viral load in the room.
  8. When intubation is complete and the patient is attached to the ventilator tubing,
    carefully collect the drape, preferably folding it from the outside in, and dispose of it
    in a red bag.
  9. Wipe down the ETT and tubing with a Sani-wipe. Be careful not to allow the wipe to
    come in contact with the patient’s face.
  10. Wash the patient’s face.
  11. Change the patient’s gown., bottom sheet, and pillowcase.
  12. Doff you PPE in the proper steps to avoid accidental contamination.

PPE-Demonstration

Additional Points to Consider

  • Limit your code team to 1 provider, 1 RT, 2 nurses (one RN in room and one RN at the door to retrieve additional items if needed)
  • Don proper PPE: N95, gown, gloves, eye protection, head cover and shoe cover—DO NOT ENTER ROOM WITHOUT PROPER PPE
  • Consider early intubation during code to reduce aerosolized viral load
  • Cover patient’s face with plastic sheeting when using BMV as outlined in intubation steps
  • Do not bring the crash cart into the room, only bring in the Zoll
  • Compressions should be performed by the Lucas device to reduce manpower in the room
  • Have an individual at the doorway managing the crash cart and medications (outside the room), limit exposure by staying at the doorway, and maintain distance by preparing meds, placing them on the bedside table positioned between the ”clean” and “dirty” area of the room.
  • Keep the door closed when possible and communicate with the “med nurse” via telemedicine when possible. Prepare multiple medications, and supply meds in “bulk” when possible (i.e., 2 epi, 3 bicarb, vasoactive drip to reduce exposure)
  • The recorder must remain outside the room
  • Place a viral filter between mask and bag to reduce viral aerosolization.
  • Video Laryngoscopy is preferred method of ET intubation.

View THIS VIDEO for a live demonstration of this process.