As reported by Wang (J Hosp Inf 2020, see below), by 24th February, the National Health Commission of the People’s Republic of China reported in a press conference of WHO-China Joint Mission on COVID-19 that 3 387 healthcare workers had been confirmed with COVID-19, with 22 (0.6%) deaths. More than 90% of infected HCWs were from Hubei province. The director of National Hospital Infection Management and Quality Control Centre summarized some reasons for such high number of infected HCWs during emergency outbreak. These included inadequate personal protection of HCWs at the beginning of the epidemic; long-time exposure to large-scale of infected patients, which directly increased the risk of infection for HCWs; pressure of treatment, work intensity, and lacking of rest, which indirectly increased the probability of infection for HCWs; shortage of PPE ; and inadequate training to infection prevention and control for front-line HCWs (except infectious disease physicians).
Guidance on infection prevention and control strategies for use when COVID-19 is suspected has been issued by WHO as early as in March 2020 (https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125). This guidance was intended for HCWs, healthcare managers and IPC teams at the facility level but it was also relevant for the national and district/provincial level. More detailed practical recommendations could also be found at : https://www.who.int/teams/risk-communication/health-sector.
Additional recommendations are available at country level, as done for instance in Canada (Wax Can J Anaesth 2020, see below).
Personal protection of health-care workers
Very early in the epidemic, available epidemiological data showed that not only can subclinical patients transmit the virus effectively but patients can also shed high amounts of the virus and infect others even after recovery from the acute illness. Chang (Lancet Resp Med 2020, see below) concluded that these findings warrant aggressive measures (such as N95 masks, goggles, and protective gowns) to ensure the safety of HCWs during the COVID-19 outbreak especially in the initial stages where limited information about the transmission and infective potency of the virus is available. Wang (J Hosp Inf 2020, see below) presented data supporting the efficacy of N95 respirators, disinfection and hand washing to reduce risk of COVID-19 transmission among medical staff at Zhongnan Hospital of Wuhan University.
A systematic review and meta-analysis of randomized trials by Bartoszko (Influenza Other Respir Viruses 2020, see below) compared medical masks to N95 respirators in preventing laboratory confirmed viral infection and respiratory illness including coronavirus. Compared to N95 respirators; the use of medical masks did not increase laboratory confirmed viral (including coronaviruses) respiratory infection (OR 1.06; 95% CI 0.90-1.25; I2 =0%; low certainty in the evidence) or clinical respiratory illness (OR 1.49; 95%CI 0.98-2.28; I2 =78%; very low certainty in the evidence). Only one trial evaluated coronaviruses separately and found no difference between the two groups (p=0.49).
Of note, a limitation to the effectiveness of face masks was first raised when a medical expert, who visited Wuhan to investigate the COVID-19 outbreak, after returning to Beijing, initially exhibited conjunctivitis of the lower left eyelid before the appearance of catarrhal symptoms and fever. The individual tested positive for COVID-19, suggesting the virus tropism to non-respiratory mucosal surfaces (Chang Lancet Resp Med 2020, see below).
Yan (Dermatol Ther 2020, see below) presented a consensus of Chinese experts on protective measures and advice on hand-cleaning- and medical-glove-related hand protection, mask- and goggles-related face protection, UV-related protection, eye protection, nasal and oral mucosa protection, outer ear and hair protection. The authors noted that insufficient and excessive protection will have adverse effects on the skin and mucous membrane barrier and that using moisturizing products is highly recommended to achieve better protection.
Zhao (J Cardiothorac Vasc Anesth 2020, see below) described more specifically the level 3 personal protective measures for healthcare workers to be used for emergency procedures in patients with confirmed or suspected SARS-CoV-2 infection in China. They included hand disinfection, wearing a cap, a medical protective mask, goggles/face screens/eye protective surgical masks, isolation gowns/protective suits, shoe-covers and gloves.
A review by Cook (Anaesthesia 2020, see below) indicated that personal protective equipment is an important component, but only one part, of a system protecting staff and other patients from COVID-19 cross-infection.
Appropriate use significantly reduces risk of viral transmission. Personal protective equipment should logically be matched to the potential mode of viral transmission occurring during patient care - contact, droplet, or airborne.
Recommendations from international organisations are broadly consistent, but equipment use is not. Only airborne precautions include a fitted high-filtration mask, and this should be reserved for aerosol-generating procedures.
Uncertainty remains around certain details of personal protective equipment including use of hoods, mask type and the potential for re-use of equipment.
Due to the risk of skin damage, it has also been recommended that HCWs are instructed about rational hand-hygiene measures respectful of the skin along with proper use of protective gloves and moisturizers (Cavanagh J Am Acad Dermatol 2020, see below).
Availability of medical supplies
A comment by Wang (Biosci Trends 2020, see below) addressed the importance of medical supplies availability. As the pandemic developed in China, a serious dearth of emergency medical supplies emerged, and especially an extreme shortage of personal protective equipment such as masks and medical protective clothing. This is considered as one of the major factors affecting the progress of epidemic prevention and control.
Facilities
As of February 19th, the Chinese government converted 13 large-scale public places in Wuhan into makeshift hospitals for patients with COVID-19 with mild symptoms. Chen (J Hosp Inf 2020, see below) noted that insufficient ventilation in these makeshift hospitals may increase infection risk of opportunistic airborne transmission.
Patient flow and triage
In February 2020, an innovative approach was developed in the United Kingdom to stop unnecessary ambulance use and hospital visits, whereby people with suspected COVID-19 are being tested in their homes (Mahase BMJ 2020, see below). The community testing scheme started at the end of January at North West London NHS Trust and has now been implemented in other trusts. More than 130 patients have been reported to be tested in two weeks. Mahase (BMJ 2020, see below) subsequently indicated that in Wales, 90% of suspected cases are managed at home. Members of the public who call NHS or 111 and are assessed as a possible case, are evaluated for their suitability for home testing on the basis of their self-reported health status and their ability to self-isolate at home. Public Health Wales’s microbiology team then coordinates with the relevant health board community testing teams to arrange home testing within 12-36 hours.
Safety of procedures
Wong (Can J Anaesth 2020, see below) described the outbreak response measures of the anaesthetic department of 2 hospitals in Singapore. These included engineering controls such as identification and preparation of an isolation operating room, administrative measures such as modification of workflow and processes, introduction of personal protective equipment for staff, and formulation of clinical guidelines for anaesthetic management.
Aerosol-generating procedures, such as non-invasive ventilation (NIV), high-flow nasal cannula (HFNC), bag-mask ventilation, and intubation are of particularly high risk when dealing with COVID-19 patients. Cheung (Lancet Respir Med 2020, see below) described the approach developed by a local intensive care unit in a Hong Kong hospital to managing the risks to health-care staff, while maintaining optimal and high-quality care. They did not recommend using NIV or HFNC until the patient is cleared of COVID-19. Airway devices providing 6 L/min or more of oxygen were considered high-flow and they discouraged their use if an airborne infection isolation room is unavailable. They recommended that endotracheal intubation is done by an expert specialised in the procedure, and early intubation considered in a patient with deteriorating respiratory condition. They recommended avoiding bag mask ventilation for as long as possible; and optimising preoxygenation with non-aerosol-generating means. Methods included the bed-up-head-elevated position, airway manoeuvres, use of a positive end expiratory pressure valve, and airway adjuncts.
Zuo (Chin Med Sci J. 2020, see below) noted that endotracheal intubation may put the anaesthesiologists at high risk of nosocomial infection. In fact, SARS-CoV-2 infection of anaesthesiologists after endotracheal intubation for confirmed COVID-19 patients have been reported in hospitals in Wuhan. The expert panel of airway management in
Chinese Society of Anaesthesiology drafted a recommendation to guide the performance of endotracheal intubation by frontline anaesthesiologists and critical care physicians.
Zhang (Anesthesiology 2020, see below) also reported that the Wuhan Union Hospital’s Department of Anaesthesiology drafted the “Perioperative Care Provider’s Considerations in Managing Patients with COVID-19” and carried out 45 surgical procedures on such patients. An upgraded surgical safety checklist for patients with suspected or confirmed COVID-19 was drawn up and implemented, along with infection-control guidelines for the care of such patients. Task forces dedicated to procedure standardization, infection control, and staff scheduling within anaesthesia were quickly assembled in most hospitals across the country. Monitoring was implemented to ensure that anaesthesia providers wore and removed personal protective equipment before working in the perioperative environment. Drills were held to ensure the optimal management of emergencies, with mandatory multidisciplinary participation across anaesthesia, surgery, critical care, paediatrics, and obstetrics and gynaecology.
Of note, another report noted that during pandemics the number of intensive care unit beds for mechanical ventilation through tracheal intubation could rapidly become insufficient. Therefore, non-invasive ventilation could be required outside the intensive care unit. To increase safety during NIV, use of a helmet has been suggested by Cabrini (Lancet 2020, see below).
In order to limit the risk of nosocomial transmission, Chen, Tian et al. (Lancet Inf Dis 2020, see below) reported the use of an innovative infection-control system in a Guangdong hospital, called the "observing system", whereby cameras cover the negative pressure isolation ward and infection control observers monitor medical staff and provide assistance in real time via computer monitors. The main responsibilities of these infection control observers are to maintain the normal operation of the negative pressure isolation wards, supervise the implementation of disinfection, ensure a sufficient supply of protective materials, arrange specimens for inspection, and relieve anxiety of the medical personnel while treating patients.
A role for telehealth and telemedicine
The COVID-19 pandemic has had unprecedented global effects, yet the rapid emergence of telehealth across the globe has allowed healthcare professionals to connect virtually with patients and families while following safe social distancing guidelines (reviewed by Cohen Curr Opin Cardiol 2020, see below). For instance, Zhai (manuscript on MedRXiv : https://www.medrxiv.org/content/10.1101/2020.02.20.20025957v1) described the Emergency Telemedicine Consultation System (ETCS), a telemedicine-enabled outbreak alert and response network, established by the National Telemedicine Center of China in Zhengzhou. ETCS was built upon a doctor-to-doctor (D2D) approach, in which health services can be accessed remotely through terminals across hospitals. The system architecture of ETCS comprises three major architectural layers: (1) telemedicine service platform layer, (2) telemedicine cloud layer, and (3) telemedicine service application layer. The ETCS has demonstrated substantial benefits in terms of the effectiveness of consultations and remote patient monitoring, multidisciplinary care, and prevention education and training.
Hollander (NEJM 2020, see below) presented the benefits that can be expected from telemedicine. Direct-to-consumer (or on-demand) telemedicine allows patients to be efficiently screened. It is both patient-centered and conducive to self-quarantine, and it protects patients, clinicians, and the community from exposure. It can allow physicians and patients to communicate 24/7, using smartphones or webcam-enabled computers. Health care providers can easily obtain detailed travel and exposure histories. Automated screening algorithms can be built into the intake process, and local epidemiologic information can be used to standardize screening and practice patterns across providers. Interestingly, more than 50 U.S. health systems already have such programs, and systems lacking such programs can outsource similar services. However, the authors also identified the numerous challenges to be faced (incl. reimbursement) before such approach can be used in the management of COVID-19 in the U.S.
Greenhalgh (BMJ 2020, see below) reported that video could be useful for people with heightened anxiety (for whom a video consultation may be more reassuring than a phone call), those with mild symptoms suggestive of coronavirus (for which visual cues may be useful), and those with more severe symptoms (when a video consultation may reduce the need to visit a potentially contagious patient). Well patients seeking general advice could be directed to a website or recorded phone message. Moreover, there may be a trade-off between staying at home and coming to clinic for a full examination—for example, in frail older patients or immunosuppressed patients.
A study by Khairat (JMIR Public Health Surveill 2020, see below) assessed the potential of a system call Virtual Care.
The study included 733 total virtual visits, including 257 (35%) with COVID-19-like symptoms. Of the COVID-19 like visits, the number of females was 178 (70%). People in the 30-39 years of age (26%) and 40-49 years (25%) were 50%
of the total patients. Virtual Care was shown to provide efficient triaging. The authors concluded that Virtual Care is capable to reduce emergency room visits, conserve healthcare resources, and avoid the spread of COVID-19 by treating patient remotely.
It is well recognized that telehealth visits will not supplant all patient-physician interactions, but is a very acceptable first step in the majority of cases and can often steer the patient to subsequently undergo more selective and streamlined care.