Learning from experience: A Critical Care COVID-19 Infection Prevention focus

With increased efforts to save as many COVID-19 patients as possible, critical care has become the main focus of this pandemic. Different healthcare facilities have had to create more critical care beds and built new hospitals like the NHS Nightingale to meet increasing demands. Different healthcare professionals are also being trained to enable them to support an existing pool of critical care staff. So what really is involved in critical care and how best can one minimise the risk acquiring COVID-19 and yet keeping patients safe and applying the best infection prevention principles in this setting?

Critical care patients

Most critical care patients require at least one major organ support and may have many lines that are used for invasive monitoring and administration of life saving medications or fluids. Examples of invasive monitoring include Arterial lines used for continual Blood Pressure (BP) monitoring; Central lines used to administer different life saving medications and fluids etc.; Vascaths used for renal or kidney dialysis that helps to purify blood when kidneys stop working properly. Patients may also have Urinary catheters and Feeding tubes to support their nutritional needs. Since COVID-19 infection causes pneumonia/breathing difficulties in those with severe - critical disease, patients may require invasive or non-invasive ventilation. Patients requiring invasive ventilation are put to sleep (sedated), so a ventilator (breathing machine) can take over their work of breathing. Depending on patients’ condition and level of sedation, ventilator settings can be adjusted accordingly to enable them to also take some breaths so that the lungs ‘don’t become lazy’ thus possibly prolonging recovery. Sedation can sometimes reduce BP, so can sepsis, therefore patients may require medications to keep their BP up. Considering all the above points, critical care patients tend to be connected to complex machines and monitors that help to keep them alive meaning that staff who look after these patients must possess skills that enable them to provide safe care. Additionally, critical care staff must have adequate Personal Protective Equipment (PPE) or ‘Please Protect Everyone’ (as they have been recently termed on Twitter), to keep them safe whilst delivering life-saving treatment to COVID-19 patients.

COVID-19 PPE guidance for staff

Everyone working in critical care units or intensive care units (ICU) during COVID-19 must adhere to designated personal protective equipment (PPE) guidelines from Public Health England (PHE) or own country’s public health authority. PHE PPE and infection prevention and control (IPC) guidance for care homes and community settings is also available. In line with available guidance, staff performing aerosol generating procedures (AGP) must use enhanced respiratory protective equipment and this is applicable to most critical care units. It is acknowledged that some bodies feel full COVID-19 PPE should be used for NG insertions and during Cardiopulmonary Resuscitation (CPR). I think IPC specialists and leads should undertake adequate risk assessments for various clinical scenarios and support implementation of best evidence based recommendations locally, preserving scarce PPE resources whilst putting in place adequate measures aimed at reducing anxiety for various staff groups. Under no circumstances should staff enter COVID-19 wards, isolation rooms/homes/facilities or critical care areas without adequate PPE. Staff should not put themselves at risk and should feel confident to speak up if they are concerned.

My COVID-19 critical care IPC considerations

In line with evidence based COVID-19 guidance, I must don PPE meticulously before entering any COVID-19 areas. I should always have a buddy to check me out and tell me off particularly when I am tired. I aim to use the WHO 5 moments of Hand Hygiene at every opportunity to protect myself and my patients. I must take my time when doffing as this stage carries the greatest risk of me contaminating myself as I am possibly tired and/or emotionally drained from a recent episode or session of care. I have therefore taken my time to prepare my guidance at a glance of important IPC /PPE considerations or things I MUST do to protect myself and my patients, see here.

Other IPC considerations

My behaviour during handover

Also available via this this link.

Invasive devices & other possible sources of infection

Breaking a patient's natural skin barrier increases the risk of healthcare acquired infections (HCAI). Since many critical care patients will have many invasive lines and or devices, these must be monitored closely to reduce the risk of HCAI. Examples of these lines & devices here and also shown below.

Useful Twitter hashtags / sites - #MouthCareMatters #SurgicalSiteInfectionPrevention #GramNegativeBloodStreamInfection #CouldItBeSepsis UK Sepsis Trust #STOPPRESSURE

Recent COVID-19 evidence

(To be interpreted with caution)

I enjoyed reading a very recent British Medical Journal (BMJ) COVID-19 paper. In this article, authors report that they determined the amount of SARS-CoV-2 (COVID-19) ribonucleic acid (RNA) in various respiratory, serum, stool and urine specimens by polymerase chain reaction (PCR) analysis. They discovered that ‘the median duration of the virus in stool is about 22 days [interquartile range (IQR) 17-31 days] which is significantly longer than in respiratory secretions (18 days, IQR 13-19 days) p=0.02…’. The median duration of virus in the respiratory samples of patients with severe disease (21 days, 14-30 days; p=0.04) was significantly longer than in patients with mild disease (14 days, 10-21 days; p=0.04’. Furthermore PHE COVID-19 guidance suggests a peak viral load of 10-12 days after onset of symptoms and that viral shedding can continue for about 3 to 6 weeks in critical care patients. Viral load is also thought to be higher in those with severe than in mild disease. Interestingly, I had a Twitter discussion with Dr Elaine Cloutman-Green just before posting my blog who made this comment 'I think if the virus is non culturally we know that you will have virus detectable for sometime based on other viruses. Therefore in most cases I would judge the clinical risk to be low. We obviously need more data as 1 paper saying non culturable does not necessarily make it so'; and this too urging caution on current decision making around COVID-19 step downs.

Considering the above data, factors and comments, and given that we don't know very much about COVID-19 at present, I'd err on the side of caution and aim to reduce risk of environmental contamination as much as possible. This will not only help with COVID-19 management but also reduces environmental contamination from other possibly resistant gut and respiratory microorganisms. I was therefore inspired to come up with my do's and don'ts of patient re-positioning.

My Dos & Don’ts for patient re-positioning

Critical Care / ICU Handover

To maintain patient safety during a shift, a full patient handover must be obtained, detailing patient safety priorities.

ABCDE approach from the Resuscitation Council. My slightly modified ABCDE approach here and below.

Summary

Optimising critical care/ward/community/residential settings COVID-19 patients’ outcomes is of paramount importance. I must have sufficient knowledge and skills to care for patients in any of these settings safely. Myself and other staff must adhere to evidence based COVID-19 PPE guidance as well as generic patient safety and IPC guidelines for respective settings. As most COVID-19 patients with severe or critical disease and possibly very high viral loads end up in critical care settings, all care must be carefully planned and executed to reduce risk of patients and staff harm whenever possible. A holistic approach that prioritises patients and staff safety during the COVID-19 pandemic and beyond is therefore desirable.

Disclaimer:  Some of the information presented in this blog is derived from learning at Guy's & St Thomas' NHS Foundation Trust (GSTT) critical care units and available Trust patient safety guidelines.

The views presented are my own and do not in any way reflect care delivery at GSTT. 

I would like to thank everyone who has provided a supportive experience which has humbled and also inspired me to learn more about a holistic patient safety approach, not only from an infection control perspective. I now view practical infection prevention and control and patient safety very differently.