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Infection Prevention Adjustments for the Anesthesia Provider with APSF · The SHEA Podcast

• 0:10
  SPEAKER_02: Welcome to the podcast series.
• 0:12
  SPEAKER_02: We're all in this together, COVID-19 Allies in Infection Prevention, as part of the Society for Healthcare Epidemiology of America, SHAY's Rapid Response Program.
• 0:22
  SPEAKER_02: I'm Josh Shapson, Director of Infection Prevention and Control at Cincinnati Children's Hospital Medical Center, and I will serve as your SHA moderator and speaker.
• 0:30
  SPEAKER_02: I'm also very happy to welcome Dr.
• 0:31
  SPEAKER_02: Richard Prelip, Professor of Anesthesiology at the University of Minnesota, who will serve as your anesthesia patient safety foundation, or APSF speaker for today's podcast.
• 0:42
  SPEAKER_02: Richard, thanks so much for joining us.
• 0:44
  SPEAKER_00: Thank you, Josh.
• 0:44
  SPEAKER_00: A pleasure to be here with you today.
• 0:46
  SPEAKER_02: Discussion on the podcast does not reflect Shay's or APSF's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:58
  SPEAKER_02: Today's episode will focus on collaboration and how we as a team can work together to address the most important questions surrounding the COVID-19 outbreak.
• 1:06
  SPEAKER_02: So let's dive in.
• 1:07
  SPEAKER_02: When we talk about anesthesia, and Richard and I work together on the guidance document, so we've talked quite a bit about infection control and anesthesia, there are a lot of areas to address.
• 1:18
  SPEAKER_02: But what we'd like to focus on today is on direct airway manipulation.
• 1:23
  SPEAKER_02: And specifically intubation and extubation in OR and other settings, and then exit and entry of non-anesthesia personnel during airway management and aerosol generating procedures or AGPs.
• 1:35
  SPEAKER_02: If there's time, we will try to touch on transport of patients within facilities and the use of anesthesia machines as ventilators in intensive care units that has been proposed to respond to shortages.
• 1:48
  SPEAKER_02: Richard, let's start with airway manipulation.
• 1:51
  SPEAKER_02: Talk a little bit about what considerations we have, especially in the light of COVID.
• 1:56
  SPEAKER_00: As a preamble, I think people need to recognize prior to the SARS-CoV-10, anesthesia professionals rarely were required to adopt precautions against transmissible respiratory organisms.
• 2:11
  SPEAKER_00: Occasionally we deal with a tuberculosis or an active influenza patient.
• 2:16
  SPEAKER_00: But literally, these were five or ten patient interactions per year for an average practice.
• 2:22
  SPEAKER_00: And of course, today we find ourselves faced in a scenario where the risk of aerosolizing COVID infection to yourself and to others in the OR is a daily, if not an hourly, concern.
• 2:38
  SPEAKER_00: One of the guideposts that we learned starting in mid-March was that we were taking our standard operating procedure book and essentially shredding it because we had to start pulver in how we addressed patients coming to the operating room, whether they were known COVID positive or patients under investigation.
• 2:59
  SPEAKER_00: To begin with, patients normally, of course, have a stopover in a pre-anesthesia holding room to confirm process and procedures prior to going to the OR, but that has been bypassed in the COVID era.
• 3:15
  SPEAKER_00: So patients will go directly from either a care unit or perhaps the emergency room directly into an operating theater in order to ensure the safety of as many personnel as possible.
• 3:29
  SPEAKER_00: Only the two anesthesia providers present at the head of the table are initially present with the patient into the operating room until their airway is secured with an endotracheal tube and the cuff and circuit have all been closed down.
• 3:46
  SPEAKER_00: So this means surgery personnel and nursing personnel are out of the operating room during this key process of patient entry and induction of anesthesia.
• 3:59
  SPEAKER_00: This has been a real transition point.
• 4:02
  SPEAKER_00: Moreover, the two anesthesia professionals managing the patient at this juncture are going to be experienced certified people, and as with many teaching hospitals, students and even graduate residents are not permitted in this setting to participate in these patient care procedures.
• 4:24
  SPEAKER_00: Only the most experienced personnel are in the operating room during this intubation and induction process.
• 4:33
  SPEAKER_00: As you know, Josh, all of the manipulations of the oral mucosa and the trachea are considered aerosolizing generating procedures.
• 4:44
  SPEAKER_00: And as such, this requires full PPE by the anesthesia personnel, which implies that they will have all the standard precautions.
• 4:54
  SPEAKER_00: In addition, they'll be using N ninety five respirator mass or equivalent, such as a PAPE device, as well as a full face shield.
• 5:06
  SPEAKER_00: During the intubation process, further adjustments have been put into place, including such things as double gloving during the procedures so that any contaminated outer gloves are immediately removed after successful intubation and secured in an appropriate fashion to minimize the contamination.
• 5:27
  SPEAKER_00: Moreover, since this was an aerosolizing procedure, surgery and nursing personnel are not allowed back into the operating theaters for a period of time to allow any droplets or aerosol to be cleared from the operating room air.
• 5:44
  SPEAKER_00: Depending on your specific institution, this can take anywhere from 14 to 18 minutes, and that is a function of the room air exchanges, which is part of the standard operating room airflows, which are set by various health and state department regulations.
• 6:03
  SPEAKER_00: So room exchanges actually occur somewhere between every three to four minutes, and in order to get to a ninety-nine percent clearance, that requires somewhere between 14 to 18 minutes to clean the room, any remaining aerosolized particles that may have been generated during the intubation procedure.
• 6:26
  SPEAKER_02: I find it really interesting.
• 6:27
  SPEAKER_02: I know that processes for anesthesiologists had to change, but I don't think I appreciated just how much.
• 6:33
  SPEAKER_02: So much of what we do in our day-to-day efforts is about muscle memory and about not so much going into autopilot, but we train ourselves how to do techniques and how to do routines, and that's how we create safety and reliability.
• 6:46
  SPEAKER_02: And to throw such a drastic change into so many providers, especially the most experienced ones, that's really striking.
• 6:53
  SPEAKER_02: It really makes me appreciate my anesthesia colleagues.
• 6:56
  SPEAKER_02: One of the hardest parts about COVID for me is we know that aerosols are generated.
• 7:01
  SPEAKER_02: We know that nuclei, so very small droplets, are generated.
• 7:05
  SPEAKER_02: The thing that we don't know is how exactly those nuclei behave.
• 7:09
  SPEAKER_02: Do they behave like TB or varicella?
• 7:12
  SPEAKER_02: Or they behave more like influenza, which can aerosolize, but doesn't require the high-level protection because those nuclei are thought to coalesce or or just not stay suspended for very long.
• 7:23
  SPEAKER_02: And I think that that is one of the toughest questions that we get when it comes to COVID.
• 7:28
  SPEAKER_02: I don't think it's an all or nothing in terms of airborne or aerosolizing.
• 7:32
  SPEAKER_02: And I think we're trying to still figure out these details like when exactly do we need N95, when do we need airborne isolation outside of the OR and what those waiting periods should be.
• 7:42
  SPEAKER_02: You know, so the ASH ray standard is 20 air changes per hour, or like you said, change every three to four minutes, but there's going to be quite a bit of wiggle room, and you see sort of these recommendations all over the place.
• 7:54
  SPEAKER_00: Just one comment on the aerosolization.
• 7:57
  SPEAKER_00: It is a moving target, and we, I think, are learning a great deal more about this phenomenon.
• 8:03
  SPEAKER_00: In addition, the operating room tends to have a very dry, very processed air atmosphere from a lot of sophisticated airway exchange and filtration processes, which are a routine part of the infection control procedures.
• 8:18
  SPEAKER_00: But that complicates the issue of droplets because even after the droplet is initially coughed or in some way interjected into the atmosphere, it's probably undergoing change as the moisture of that droplet is constantly evaporating, and what may have started out as a three or four micron droplet within seconds become a one micron droplet.
• 8:42
  SPEAKER_00: It definitely is a complex dynamic that we in the operating room are hoping we can get additional insights from our infectious disease experts in order to shed additional light on that topic.
• 8:55
  SPEAKER_02: Yeah, no, that's a great point.
• 8:56
  SPEAKER_02: And on the flip side, it could desiccate enough that it inactivates the virus.
• 9:00
  SPEAKER_02: Obviously, to say that there's a lot more to learn about COVID-19 is kind of stating the obvious, but it's just amazing just how many details will make a difference in our lives.
• 9:09
  SPEAKER_02: Let me ask you about COVID testing.
• 9:11
  SPEAKER_02: In your institution, are you routinely testing everybody pre-op or a certain population?
• 9:17
  SPEAKER_02: And how does the results of those testing influence what you do in terms of PPE?
• 9:22
  SPEAKER_00: Great question.
• 9:22
  SPEAKER_00: I would ask that people recognize the impact of the March shutdown on hospitals has been obviously profound across the spectrum.
• 9:32
  SPEAKER_00: One of the biggest impacts for us was the virtual overnight cessation of elective and semi-elective surgery.
• 9:41
  SPEAKER_00: This has included procedures, you know, as routine as colonoscopies and others, routine health screenings.
• 9:48
  SPEAKER_00: Just to give you an idea, the magnitude is estimated there are some 28 million procedures worldwide which have been delayed or postponed that are now queued up into the system to try and deal with this backlog.
• 10:02
  SPEAKER_00: One of the ways the health department here and in many locations has tried to deal with reopening of the operating rooms is to do mandatory testing on all elective patients coming into the hospital, whether for surgery or any other procedures.
• 10:21
  SPEAKER_00: So we require a PCR COVID test to have been completed no further than 72 hours prior to admission to the hospital.
• 10:31
  SPEAKER_00: And that has been virtually a hundred percent requirement, with just a few exceptions of true emergency surgery, life-threatening type surgery, and in some cases with very small infants just because of the logistic difficulties in getting that completed in a very feisty toddler.
• 10:50
  SPEAKER_00: But at any rate, this does have an important impact on our type of PPE, which will be utilized in that healthy patients, patients who come into the elective surgery arena who are screen negative, in other words, their health screening is all negative for any symptoms, as well as a COVID-negative PCR test within 72 hours, are managed with routine universal precautions in our operating room, which means people will be using standard surgical masks.
• 11:24
  SPEAKER_00: And while the OR personnel, surgery, and nursing are out of the room during the intubation itself, if these are known COVID-negative test patients, immediately following securing the airway, the patients or the surgery, nursing and physician staff will return to the operating room and they no longer have to wait the 14 to 18 minute delay.
• 11:51
  SPEAKER_00: That's exactly correct.
• 11:53
  SPEAKER_02: You talked a little bit about peppers.
• 11:55
  SPEAKER_02: My understanding is that they are not FDA approved for use in sterile cases.
• 11:59
  SPEAKER_02: Are you trying to limit the use of peppers?
• 12:01
  SPEAKER_02: Do you try to target it to specific groups?
• 12:04
  SPEAKER_00: We have limited the use of PAPERS.
• 12:07
  SPEAKER_00: The first recommended option is a N95 respirator mask or equivalent, which of course has some logistic challenges with fit testing requirements.
• 12:17
  SPEAKER_00: And obviously, some healthcare providers won't find a good fit despite multiple attempts.
• 12:24
  SPEAKER_00: For men with facial hair or those unique individuals who can't find a properly fitted mask, we do allow and require PAPER devices, including in the operating room, and those are utilized as an N95 equivalent.
• 12:40
  SPEAKER_00: The issue of utilization in a quote sterile environment, we navigate with the justification of the rapid air exchanges occurring in the operating room, and that the PAPE exhaust air is not felt to be a compromise to the sterility of the surgical field.
• 13:00
  SPEAKER_00: In fact, Josh, it's very fortunate that just this week, the joint statement by organizations AORN, operating room nurses, the ASA, American Society of Anesthesiologists, and the APSF have issued a statement which allows individual institutions much greater flexibility in assessing the proper use of the PAPER map within their operating room.
• 13:56
  SPEAKER_02: I think that it'll be very interesting.
• 13:57
  SPEAKER_02: I imagine there I hope there will be more data during this time because I do think that Pappers are a good option, and especially some of the newer models, they're very light, they're very quiet, they exhaust away from the sterile field, and they really I doubt they disrupt the laminar flow all that much.
• 14:13
  SPEAKER_02: And if providers prefer them are able to stay in the OR longer, perform more challenging procedures, then it seems like a good option.
• 14:21
  SPEAKER_00: Just a follow-up on that.
• 14:23
  SPEAKER_00: As I'm sure you're aware, anybody who's tried to wear an N95 mask for a prolonged period inevitably find it uncomfortable.
• 14:33
  SPEAKER_00: And it becomes uncomfortable for both the pressure on the face as well as the respiratory effort.
• 14:40
  SPEAKER_00: And people tend to find this to be rather confining, constricting, and progressively less comfortable after an hour or certainly two hours.
• 14:50
  SPEAKER_00: So as you suggest, in a complex operation spanning five, six or seven hours, standard N95 mass becomes very problematic from the user acceptance side.
• 15:02
  SPEAKER_02: From a pretesting point of view, when we were still limited in our testing, we focused our testing on cardiothoracic cases that tend to be very long and very complex when you talk about congenital heart disease and repairs.
• 15:14
  SPEAKER_02: For that very reason.
• 15:15
  SPEAKER_02: The surgeons felt their technique could be compromised by either taking break or by wearing the N95s.
• 15:22
  SPEAKER_02: Another method, it sounds like your current method is two anesthesiology professionals in the room doing the intubation and then either waiting for adequate time for clearance or having the rest of the group come in.
• 15:32
  SPEAKER_02: Are you familiar with intubation teams?
• 15:35
  SPEAKER_02: I know some facilities have done that, and actually at Cincinnati Children's, we've taken to that, but I wonder what your take on that is.
• 15:41
  SPEAKER_00: We have identified a group of particularly experienced providers, usually a physician, intensivist, and nurse anesthetist who constitute an intubation team, which is available to go to obviously emergency airway issues throughout the hospital facility, and particularly are focused on managing airways in the intensive care unit.
• 16:06
  SPEAKER_00: And as you're aware, there's been a wide recognition that once COVID patients start to manifest the shortness of breath, dyspia, and uh hypoxemia, they tend to deteriorate fairly quickly at that juncture.
• 16:22
  SPEAKER_00: And there's been efforts to actually intubate these patients earlier rather than later.
• 16:27
  SPEAKER_00: And the intubation teams have become quite experienced at making those assessments and providing the intervention as appropriate.
• 16:35
  SPEAKER_02: That's fantastic.
• 16:36
  SPEAKER_02: What we've been doing at Cincinnati Children's, I was referring more actually in the OR.
• 16:40
  SPEAKER_02: So to try to minimize exposure.
• 16:42
  SPEAKER_02: So the concepts here are minimize aerosols, maximize use of PPE, and then minimize risk or exposure.
• 16:49
  SPEAKER_02: And one of the ways that we've been doing the third is that we basically have a procedure room and there's an intubation team.
• 16:55
  SPEAKER_02: They will intubate every patient that comes through.
• 16:58
  SPEAKER_02: That patient, once airway is secure, will be transported to an operating room where the procedure can proceed.
• 17:03
  SPEAKER_02: So for a certain amount of time, there are only two people performing all of the intubations that are happening on operative patients at that time.
• 17:10
  SPEAKER_00: I have heard of that strategy and approach, and that's not one that that we have adopted, at least during the the peak of the COVID intensity and a large part of the lockdown phase.
• 17:23
  SPEAKER_00: We did alter our staffing model such that the staff essentially took their clinical rotations for five or seven-day periods in a row and then allowed a period of five or seven days out of the hospital setting.
• 17:38
  SPEAKER_00: It was a somewhat altered approach to trying to concentrate the exposure into the minimal amount of people at any given time.
• 17:47
  SPEAKER_02: And I think that a lot of places have done that.
• 17:49
  SPEAKER_02: I think that's been a standard recommendation across the board, rotating teams in and out.
• 17:54
  SPEAKER_02: Let me ask you about aerosols from devices themselves.
• 17:57
  SPEAKER_02: Many ventilator circuits, you can make them into closed circuits so that really there's no aerosol or no air that the patient is exhaling is getting out into the environment.
• 18:07
  SPEAKER_02: But there are other devices with open circuits, there's high flow nasal cannula, there's bipap, CPAP.
• 18:12
  SPEAKER_02: What are your thoughts on risk of aerosol from those machines and how it compares to vents?
• 18:17
  SPEAKER_02: And then what are some options that we can do to try to help minimize that risk?
• 18:21
  SPEAKER_00: The non-invasive ventilatory devices are certainly very useful in the pre-COVID era for temporizing respiratory derangements and mechanics.
• 18:32
  SPEAKER_00: That really had to be reevaluated in the era of COVID-positive patients and the risk of aerosolization, particularly with devices like high flow nasal oxygenation.
• 18:43
  SPEAKER_00: In various studies, it has clearly shown that nebulization treatments and high flow nasal oxygen do create clouds of aerosolized particles.
• 18:54
  SPEAKER_00: To a large extent, this can be mitigated by minimizing the flow of oxygen in these devices to the minimum required, and particularly by adding a standard surgical mask over the patient's face as they're wearing these devices.
• 19:10
  SPEAKER_00: It certainly doesn't eliminate the aerosolization, but it certainly mitigates it significantly and reduces the distance of travel to a much more narrow scope immediately around the patient's head.
• 19:22
  SPEAKER_00: It certainly reduces, or we believe it reduces, the risk to other healthcare providers in the nearby vicinity.
• 19:29
  SPEAKER_02: Let me ask you specifically just briefly about nebulized medications.
• 19:34
  SPEAKER_02: So we're not going to get into the controversy of what is an AGP and what isn't.
• 19:38
  SPEAKER_02: But I've always been curious about the nebulized meds because the flow is into the patient.
• 19:42
  SPEAKER_02: It's a medication and some saline that is typically generated, nebulized and aerosolized, and then the patient inhales that.
• 19:49
  SPEAKER_02: It's not really coming out of the patient.
• 19:51
  SPEAKER_02: People talk about the cough that the patient might generate, and certainly a mask could mitigate that.
• 19:57
  SPEAKER_02: But that's where I have trouble clearly classifying NEB as an AGP.
• 20:02
  SPEAKER_02: It just feels like a different mechanism to me.
• 20:05
  SPEAKER_00: I think the majority of the gas flow is certainly in a different category.
• 20:10
  SPEAKER_00: Just in my personal observations, as patients start to receive nebulaized medication, the generation of a cough seems to be a very common side effect of that, at least the initial part of the inhalation therapy.
• 20:24
  SPEAKER_00: So it certainly generates a lot of concern on the part of bedside providers in that setting.
• 20:31
  SPEAKER_02: Yeah, and justified concern.
• 20:33
  SPEAKER_02: What's interesting is that we have not seen a high degree of transmission to healthcare workers.
• 20:38
  SPEAKER_02: We certainly have seen transmission worldwide.
• 20:41
  SPEAKER_02: And I wonder how much of that is PPE and how much of these issues are not as dangerous as we're thinking.
• 20:47
  SPEAKER_02: We're not going to take the chance and try it otherwise, but it's just very interesting to me that that hasn't been that common an occurrence.
• 20:53
  SPEAKER_02: In a time that we have left, let's try to touch base on patient transport within facilities.
• 20:58
  SPEAKER_00: Our transport process is obviously focused on minimizing the time and distance between the care site and the operating room itself.
• 21:08
  SPEAKER_00: So we will have a transport team who will be in full aerosol PPE DOND equipment.
• 21:17
  SPEAKER_00: They will attend to the patient through the transport process and again trying to expedite and minimize the time and distance.
• 21:25
  SPEAKER_00: Moreover, the patients themselves will be wearing at least the equivalent of a surgical mask during that transport with whatever sort of respiratory support they may need underneath that.
• 21:36
  SPEAKER_00: Some facilities have actually dedicated an elevator or two specifically for these kinds of exposures and transports.
• 21:45
  SPEAKER_00: And again, depending on your hospital and kind of reserve capacity, that may be an option you want to consider as well.
• 21:53
  SPEAKER_02: I think all of those are terrific, very much what we've been saying here in Cincinnati.
• 21:56
  SPEAKER_02: And really, we've been taking a page from our TB playbook directly.
• 22:00
  SPEAKER_02: route, minimize exposures, just try to cover as much as you can, dedicated team and really moving from point one to point two.
• 22:06
  SPEAKER_02: Oftentimes people ask us, well, what if I was standing in the hall at that time or somebody was standing in the hall?
• 22:10
  SPEAKER_02: The key is that close contact is defined as 10 or more minutes.
• 22:13
  SPEAKER_02: So within six feet, 10 or more minutes, and if you're moving a patient through, even in an elevator, that amount of time is unlikely to take place.
• 22:22
  SPEAKER_00: Classic combination of time and distance and hopefully you can minimize both.
• 22:26
  SPEAKER_02: Yes, and we all remember high school physics and now we're going to move on.
• 22:30
  SPEAKER_02: Let's talk about anesthesia machines as ventilators.
• 22:34
  SPEAKER_02: We talked about it in our pre-meeting and it was something that I hadn't even thought of.
• 22:37
  SPEAKER_02: Can you sort of talk about when that might be and what consideration we should be taking?
• 22:41
  SPEAKER_00: During the government's investigation of trying to make sure they had adequate ventilator capacity for hot spots like New York at that time, it was quickly brought forward that there are tens of thousands of available emergency ventilators sitting in every hospital operating room and that is an integrated part of the standard anesthesia machine.
• 23:04
  SPEAKER_00: The current modern anesthesia machines are fully capable, complex ventilators capable of all kinds of standard ventilatory modes from controlled ventilation, cyst control, pressure support, pressure control with a volume guarantee and just straight pressure support ventilation.
• 23:23
  SPEAKER_00: Moreover, they have reasonably sophisticated monitoring modalities of that so you can monitor things like compliance, static compliance, driving pressure, etc, things which are followed in an ICU setting.
• 23:38
  SPEAKER_00: I should highlight that using an anesthesia machine in this capacity is quote, off label, but the manufacturers such as GE, Daytech, Omita, and North American Draeger have all put out product information sheets to help guide you if you would need to invoke this option.
• 23:57
  SPEAKER_00: Two caveats if you do get into that situation of potential concern is a lot of the plumbing hardware in an anesthesia machine is internal and the anesthesia machine has to be protected from contamination by a COVID positive patient.
• 24:14
  SPEAKER_00: So that should uh mandate the use of HEPA filter at least on the expiratory limb of the circuit and potentially a second HEPA filter or a heat moisture exchange filter at the patient connector to the endotracheal tube.
• 24:31
  SPEAKER_00: Once an anesthesia machine, if it were to get contaminated, the decontaminated process is very involved, complex, and expensive so users must take every precaution to avoid internal contamination of the machine.
• 24:46
  SPEAKER_00: The other caveat from a logistic perspective is most people in the ICU are unlikely to be familiar with the workings of an anesthesia machine and its controls.
• 24:58
  SPEAKER_00: And some anesthesia providers would likely need to be part of the rounding team and the monitoring team to make sure these machines are being utilized in a safe and appropriate fashion.
• 25:10
  SPEAKER_02: Any closing thoughts?
• 25:12
  SPEAKER_02: Any last thoughts?
• 25:13
  SPEAKER_00: Thank you, Josh I I think there's been a great discussion.
• 25:16
  SPEAKER_00: Three points in closing I would encourage everybody across the whole medical spectrum to keep in mind the stresses on various components of the team and all the frontline patient-facing areas within the hospital.
• 25:31
  SPEAKER_00: There's lots of uncertainty we see daily if not weekly changes in our procedures and hopefully your medical center has some sort of psychological support program.
• 25:43
  SPEAKER_00: We have a Battle Buddies program here at the University of Minnesota through a collaboration with our psychiatry department which has been very well received and has provided a lot of support.
• 25:54
  SPEAKER_00: Secondly I want to make people aware there is an interesting registry that you can access through the APSf.org website that you mentioned at the beginning of our discussion.
• 26:07
  SPEAKER_00: And this is a registry of healthcare workers who are part of these intubation teams or who are routinely dealing with tracheal intubations in the operating room.
• 26:18
  SPEAKER_00: This is the run out of headquarters one is in London the other is here at the University of Pennsylvania and the idea is to track and understand exactly what is the risk to our frontline healthcare workers who are dealing with some of these aerosolizing generating procedures.
• 26:36
  SPEAKER_00: The last component is one I want to I think seek your help and that of Shay is to help all of our personnel understand the utility of N95 mass and its proper application and utilization in and around the operating rooms and ICU?
• 26:53
  SPEAKER_00: We all understand that the mask itself is obviously highly effective and efficient at its filtration and probably is on the order of 10 times more efficient at microfiltrations and is a standard surgical mask.
• 27:09
  SPEAKER_00: But the question still remains does this additional filtration actually translate into a clear reduction in the clinical respiratory infections of healthcare workers?
• 27:22
  SPEAKER_00: And that is obviously a much more difficult as well as relevant question to be asking because as we alluded to earlier people tend to not find their N95 respirators comfortable for prolonged periods.
• 27:37
  SPEAKER_00: They're frequently manipulating them adjusting them sliding them around and one must wonder whether the fit of these masks at the end of the day is anything close to what it was at the beginning of the day.
• 27:50
  SPEAKER_00: If people have insights into those elements we would certainly appreciate understanding.
• 27:56
  SPEAKER_01: Thank you Richard yeah in terms of that third point I would love help on that too but I think your point is extremely well taken.
• 28:02
  SPEAKER_01: I think that one thing that we think about with N95s is it's not just about the filtration.
• 28:07
  SPEAKER_01: It's about the ergonomics and the practical ability for people to use it and truthfully I worry about that and also for universal N95s I worry that it will give a false sense of security because a non-sealed N95, I don't know that it's any better than a surgical mask.
• 28:22
  SPEAKER_01: It may be worse and if wearing a comfortable mask provides adequate protection or the addition of a face shield or the changing of that mask periodically something that can be done more readily if that is more protective then then I think that that makes more sense.
• 28:38
  SPEAKER_01: The other thing that we find uh that we're talking about quite a bit and that has been going around on the Shea discussion boards is airborne isolation is a bundle.
• 28:47
  SPEAKER_01: It's a package deal.
• 28:48
  SPEAKER_01: It involves N95s properly fit tested but it also involves adequate air exchanges either in the OR those are positive pressure 20 air changes per hour or an airborne isolation room which are a minimum of 12 air changes per hour and then that the exhaust is directly to the outside.
• 29:06
  SPEAKER_01: The combination of those things is what's thought to protect healthcare workers and other patients from agents like TB and Vericella and so if we're going to apply the same principles to COVID then we really need to think about applying as much as we can.
• 29:20
  SPEAKER_01: We've had a lot of questions about making rooms quote unquote negative.
• 29:24
  SPEAKER_01: The thing is that's not going to give you airborne isolation.
• 29:27
  SPEAKER_01: Wearing an N ninety five isn't necessarily going to give you airborne isolation either.
• 29:32
  SPEAKER_01: Interestingly a recent systematic review came out showed that masking is better than no masking and suggested that N ninety five's maybe better than regular masking.
• 29:42
  SPEAKER_01: But the hardest part of that was in the studies which took into account SARS and MERS and COVID were the very few of the studies distinguished between aerosol generating procedures and not.
• 29:55
  SPEAKER_01: And so that's really the crux of this is if you're in an aerosol generating procedure, does N95 truly protect you better than surgical?
• 30:04
  SPEAKER_01: And in in general if you're not in one does N ninety five protect you better than surgical and I I agree with you I think those are very timely and important questions.
• 30:13
  SPEAKER_01: I want to thank you very much, Dr.
• 30:15
  SPEAKER_01: Richard Prift for joining us today and sharing your perspectives.
• 30:19
  SPEAKER_01: I've really enjoyed talking with you.
• 30:21
  SPEAKER_01: And a sincere thank you from Shay to all healthcare personnel for all that you're doing to respond to COVID 19 and I will include the APSF which I love that idea of the registry and I really appreciate your proactive efforts to try to help keep people safe.
• 30:38
  SPEAKER_01: This podcast can be accessed on Shay's online education center, Learning CE under the Rapid Response Program.
• 30:45
  SPEAKER_01: You'll also find additional resources such as the recorded webinars Healthcare Facility Outbreak Preparedness and the SHA COVID nineteen town halls as well as the additional podcast series COVID nineteen updates what we know now which is released every Thursday.
• 31:00
  SPEAKER_01: This concludes this episode of the COVID nineteen Allies and infection prevention podcast series.
• 31:05
  SPEAKER_01: Thank you for tuning in