COVID-19 Perioperative Infection Prevention and Safety: 11 FAQs

Over the past few weeks, as perioperative providers nationwide have slowly begun to reopen and resume operations and elective surgical procedures, Infection Control Consulting Services (ICCS), which is providing a variety of COVID-19 services, has received numerous questions concerning proper infection prevention and safety practices from clients.

What follows are 11 of the most common questions from clients along with answers assembled by the ICCS team. Note: Information provided below is current as of July 27, 2020.

Q1: Are N95 masks required as personal protective equipment (PPE) in the decontamination room since manual cleaning of instruments can result in the generation of aerosols?

A: No, N95 masks are not required as personal protective equipment nor are they recommended for the central processing area. The COVID-19 virus is spread through the respiratory route when droplets are inhaled after an infected person expels the virus via the mouth and nose during coughing, sneezing, talking, and even heavy breathing. Once the virus exits the body, it is possible that the virus can be picked up on the hands when touching contaminated hard surfaces (primarily). Hand contamination can directly lead to contamination of the mucus membranes, such as eyes, nose, or mouth. The mechanism of contamination of surfaces is the heavy droplets that may suspend in the air for a certain amount of time and then drop to the ground or a surface below.

COVID-19 is very easily destroyed by various chemical disinfectants on environmental surfaces, equipment, packaging, etc., if used correctly. Transmission of respiratory viruses is not documented from aerosols created by washing instruments manually.

Instruments should always be washed below the level of the water to prevent dispersal of other pathogens, such as bacteria or blood borne pathogens.

Q2: What is the difference between an N95 mask and a KN95 mask that we are obtaining from an international source?

A2: A critical shortage of personal protective equipment, in particular N95 respirator masks approved by the National Institute of Occupational Safety and Health (NIOSH) as well as a shortage of surgical masks used, for example, during non-aerosol generating procedures, led to importation of masks primarily from China. These are known as KN95 masks. They were not generally considered a substitute for N95 respirator masks, but some hospitals were attempting to fit test the KN95s in the event they needed to be used as respirator masks.

However, several facilities identified flaws in the fit of these masks, leading the U.S. Food and Drug Administration (FDA) to recently ban use of masks from 65 manufacturers in China, claiming that NIOSH tests showed inferior results as compared to N95 respirators.

If facilities need to use KN95 masks, they should not be considered greater in protection than a surgical mask and not used in any situation whereby the requirement by the facility is a respirator mask or higher (e.g., a powered air purifying respirator (PAPR)).

Q3: Until the shortage of masks is resolved, how should we best conduct "extended use" of our N95 respirator masks?

A: As the pandemic continues to evolve, so do the choices for reuse of personal protective equipment. One of the most common extended use methods includes providing each identified provider with one N95 mask per day for the week.

N95 respirator masks are also known as filtering facepiece respirators (FFRs). 3M, the largest producer of these masks highlights the following routine for extended use: "The healthcare worker will wear one respirator each day and store it in a breathable paper bag at the end of each shift. The bag should be marked with the name of user, day of the week and possibly the date, to keep account of how often the mask has been worn. Some facilities are suggesting providers wear a surgical mask over the N95 to preserve it. CDC recommends no more than five cycles of use (i.e., five weeks) before discarding. If supplies are even more constrained and five respirators are not available for each worker who needs them, FFR decontamination may be necessary."

Decontamination of masks is performed using vaporized hydrogen peroxide systems (available in certain states and open to hospitals and outpatient centers) or low temperature sterilization in autoclaves available within the facility.

Note: For more information on decontamination of N95 masks, read this ICCS blog.

Q4: We have heard varying reports about the need to air out the operating room after an intubated patient has left the room. How long do we have to wait before wheeling the next case into the room?

A: The easiest and most accurate way to determine airborne contaminant removal times and how long to wait for a room to be turned around and reused is to know how many air changes per hour your operating or procedure rooms undergo. For the most part, operating rooms are environmentally well-controlled, and it should be feasible to calculate the number of air changes per hour.

The issue with intubation/extubation is that aerosols are emitted in a positive pressure environment and upon opening the doors to the operating room, the positive pressure force will push the aerosols into the hallway, creating a potential contamination issue beyond the specific OR. Therefore, waiting for the recommended time as per the CDC's "Guidelines for Environmental Infection Control in Health-Care Facilities" (2003) is best.

Providers should consider recovering extubated patients in the operating room to save time and protect the PACU from possible droplets if the patient is coughing after removal of the endotracheal tube. It is advisable to begin counting the minutes for "airing the room" from the time the patient stops coughing.

Q5: Can we begin to clean the operating room and remove the trash prior to the patient leaving the room, particularly if we're going to recover the patient in the OR?

A: As per AORN guidelines, it is not advisable that room turnover begins before the patient leaves the operating room. Trash should not be emptied, nor should chemicals be used while the patient is present.

Despite several common, everyday practices being turned upside down due to the pandemic, basic infection prevention must continue to the best of your ability to mitigate risks of healthcare-acquired conditions, including surgical site infections (SSIs).

Q6: Do we need to wear N95 masks and isolation gowns in our surgery center's PACU?

A: Despite asymptomatic carriage and the uncertainty of viral testing results due to length of time between obtaining test results and admission to the surgery center, as well as issues with the tests themselves (rapid tests can yield false negative results as reported at the time of this publication), N95 masks are not recommended per the CDC for general use in a healthcare setting such as the PACU.

As we are still undertaking universal masking, a surgical mask must be worn by all staff members in the surgery center at all times. Disposable or fabric washable gowns should be worn based on standard precautions and the risk of contamination of clothing from secretions/drainage. However, each surgery center should conduct a risk assessment to determine the benefits of universal gowning and inventory availability should be considered.

Q7: How do we disinfect or treat privacy curtains in the pre-op/PACU?

A: This is a common question in general, and COVID-19 has heightened the concern about curtains between patients and the risk of contamination. It is imperative that staff remove contaminated gloves and perform hand hygiene prior to touching the curtains. It is very difficult to disinfect curtains between patients and thus prevent contamination.

Use of traditional disinfectant wipes or liquid products is not advisable unless they have a soft surfaces claim. Hydrogen peroxide products are available for use on curtains and must be used according to manufacturer's instructions for use (MIFU). If you will use a spray, patients should not be in the area and staff should wear the necessary personal protective equipment as per the MIFU. Curtains should also be laundered on a routine basis according to a facility-specific schedule.

Q8: Every patient coming in for elective surgery is being tested for COVID-19. We reschedule those that test positive. Can we assume a negative test clears the patient of the risk of transmission and we can relax any of the precautions?

A: No, you cannot assume a negative test clears the patient. Precautions for prevention of transmission should not be relaxed for anyone. At present, the rapid screening tests for the virus are resulting in several false negative results, thereby possibly missing infected patients, particularly those that are asymptomatic. We may also be missing symptomatic patients that are thought to be negative, despite a clinical suggestion of COVID-19. Performing surgery on a symptomatic patient is highly unlikely as surgery should always be delayed if someone is displaying symptoms of any communicable disease.

In addition, if a patient tests negative, assuming the kit used is accurate, consider how many days prior to the procedure they received a test and whether they are self-isolating until surgery. These uncertainties imply that infection prevention precautions need to remain in place for every patient, regardless of their negative result.

Q9: While we are adhering to universal masks for everyone in the facility including non-patient care staff, how do we organize staff breaks and use of break rooms to adhere to social distancing, particularly as the staff will need to remove masks to eat and drink?

A: It is important to review factors such as the layout of the break room, how many employees are in the facility at one time, and whether can staff eat in their individual offices, if they have one. Breaks can be staggered to avoid too many people in the room at one time and the setup rearranged to allow staff to "mingle" but at a safe distance.

It is very important for the staff to enjoy their well-earned breaks and have some unmasked time with each other. However, maintaining distance is imperative and a well thought out plan is important.

Q10: It took so long for us to grasp the concepts of surface disinfectants, what products to consider, the dwell/wet/kill time for room turnover, and terminal cleaning. We are now wondering whether the disinfectants we are using in the perioperative setting are effective against COVD-19?

A: Yes, the disinfectants and their use have been confusing over time, particularly as many new products have been developed over the past several years. Fortunately, as virulent as COVID-19 is in the body, it is fragile when exposed to disinfectants on surfaces and easy to eradicate. It has been documented that the virus can live the longest on stainless steel and plastic surfaces (up to 72 hours), although the amount of viable virus decreases over that amount of time.

The virus can survive only four hours on copper and up to 24 hours on cardboard. It is critical to thoroughly disinfect surfaces, especially during room turnover and terminal cleaning thereafter. The traditional products used in healthcare settings should appear on the expansive list released by the EPA specific to COVID-19.

However, it is strongly urged that facilities review the list and ensure that their product(s) is listed either under its trade or generic name. The risk of persons touching live virus and then touching other surfaces or a patient (particularly mucus membrane) is realistic and disinfecting is simple, as long as instructions for use are followed properly.

Q11: We are getting pushback from our office staff who have no contact with patients and sit in their own space away from others. Can we allow them to remove their masks if nobody is entering their offices?

A: This should be a facility-based decision and based upon local regulations. Depending on the location of your facility, you may be required to continue masking while at work as the goal is to eliminate as much spread as possible.

However, the risk of spreading the virus from one person to the other from an office occupied by only one person with nobody else entering it would assumed to be lower. If standardized processes are mandated in the facility, the office staff will need to wear masks at all times except when eating or drinking.

Staying Current With COVID-19 Infection Prevention Developments​

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