October 1, 2020

The 'what' isn't changing. It's the 'when' and 'who.'

WIPEOUT In a world where a dangerous aerosolized virus has brought society to its knees, robust surface disinfection protocols are a must.

The COVID-19 pandemic has had major impacts on elective surgeries. The most obvious was the devastating shutdown that took place in the spring. The other is that changes to existing practices need to be, and have been, implemented quickly. That's a sea change from the usual management process at surgical facilities, which often involves months or years of research, education and cultural modification.

It's not perfect, of course, but that's just how things are in 2020. Patient and staff safety have gone from being very important to being hyper-important. It's in this new world that surface disinfection has taken on new urgency. As Donna Nucci, RN, MS, CIC, infection preventionist at Yale New Haven (Conn.) Hospital and owner of her own consulting business, told Outpatient Surgery, the new normal of surface disinfection will center on how well and how often you clean high-touch areas in your ORs and common areas.

"The science is most likely not going to change, but implementation will," says Ms. Nucci. "This is a wakeup call for outpatient facilities to make sure their cleaning protocols align with CDC guidance, including the use of EPA-approved cleaning products and a clear process for performing surface disinfection."

Another angle on the surface disinfection situation: the possibility of new regulations. "Regulatory agencies and patient advocacy groups may require facilities to have a structured environmental cleaning program in place," says Ms. Nucci. "I think we're going to see many more checks and balances."

At Yale New Haven, the cleaning procedures, as well as the chemicals staff use to disinfect, haven't changed at all. What has changed is the frequency. For example, staff are disinfecting the bathrooms nine to 10 times per shift.

"There's a heightened awareness of cleanliness and disinfection right now," says Dean A. Caruso, MBA, executive director of support services and sustainability at Yale New Haven. "Everyone understands that just because something looks clean, it could still make them sick."

Patients are also on edge about the virus and many are frightened about going to surgical facilities because of COVID-19. Ms. Nucci says patients are asking questions such as, "How often are you cleaning?" and "What are you cleaning with?" and "Am I safe?" Simply seeing staff frequently wipe surfaces sends a strong message that will make many patients feel more confident and less anxious about your center's safety. If your surface disinfection protocols haven't yet been updated and explicitly codified, now is absolutely the time to do it.

Video laryngoscopes shine as surgical facilities try to keep both patients and providers safe.

VIEW FROM AFAR Video laryngoscopes allow anesthesia providers to intubate patients at a safer distance than the traditional direct approach.

Intubating patients has never been easy, but the presence of a dangerous aerosolized virus has changed the calculus of this delicate and dangerous procedure. After all, anesthesia providers work inches from patient airways to insert laryngoscopes, putting them in the direct path of the airborne coronavirus particles of an infected patient. In addition to the other potential complications of this procedure, there's an added focus on protecting clinicians from patients who might have the virus during intubations.

"COVID-19 has complicated airway management," says Michael Aziz, MD, a professor of anesthesiology and medicine at Oregon Health & Science University in Portland. "Providers must protect themselves with several layers of PPE, which makes the job more physically demanding. Communication is hampered and visualization is more difficult."

Roxanne McMurray, DNP, APRN, CRNA, a clinical assistant professor at the University of Minnesota School of Nursing in Minneapolis, characterizes the pandemic as a reset for anesthesia. "Providers must be more vigilant when securing the airway," she says. "The current challenges will force us to up our game, and that's a good thing."

Rudimentary boxes and shields have been fashioned to protect anesthesia providers during the pandemic, but it's the usage of video laryngoscopes that might prove to be the lasting difference. Previously viewed by many providers as a luxury or an emergency-use tool for difficult airways, video laryngoscopes now are increasingly becoming standard tools. "The devices were gaining a stronger foothold because clinical evidence shows higher rates of first pass intubation success," says Dr. Aziz. "Some providers had already been using them universally. Many who weren't are now discovering the benefits they provide."

Video laryngoscopes remove the need for the anesthesia provider to put their face directly over the patient to visualize the airway. The provider enjoys a direct view of the glottis from a safer distance to make intubation much easier. These products have been around for about a decade, and they have become more ergonomic and portable over the years, adding high-definition video along the way. They can also accommodate various laryngoscope blade designs.

For Dr. Aziz, screen size and location matter most in a video laryngoscope. "Units with smaller, attached screens are priced competitively, but the visualization and magnification capabilities afforded by larger screens allow for improved intubation performance," he says. "Video laryngoscopes with separate monitors that can be positioned next to the patient let providers stand upright while intubating instead of leaning directly over the airway to perform direct laryngoscopy or manipulate a video laryngoscope with an integrated screen."

As a result of COVID-19, the day may soon come when direct intubations are a relic of the past. "I still teach direct laryngoscopy to new nurse anesthetists, but video laryngoscopes are fabulous tools," says Dr. McMurray. "There's no doubt video laryngoscopy is developing into the standard of care."

The current COVID-19 era has made clinicians and surgery teams look for additional steps to reduce the risk of complications and find ways to operate as efficiently as possible.

Credit: 3M Medical Solutions Division, USAC
Patient safety encompasses the entire journey from preparation to surgery to recovery.

Surgery facilities across the nation are resuming surgeries at different levels, depending on their locations, as the COVID-19 pandemic continues. Elective surgeries never fully stopped, but the challenges of resources, safety and a swiftly evolving healthcare crisis created one of the most difficult environments to navigate this year.

Since patient safety is always top of mind for hospitals and surgery centers, delays in scheduling surgeries during the rise of the pandemic caused a backlog of patients and demanded new safety protocols be put in place. The priorities for practicing safely in this new environment, reducing complications, and managing efficiently have all come into sharper focus as healthcare teams work to resume surgeries.

Today's concerns revolve around safety for both patients and staff. Kim Prinsen, RN, MSN and clinical applications specialist for 3M Medical Solutions explains, "It is important to ensure your staff understands their selection of personal protection equipment (PPE) and they should know the proper donning and doffing procedures to protect themselves."

Reducing contaminations is also a major concern as facilities and clinicians work diligently to keep patients safe through infection prevention, including improved hand hygiene, isolation room procedures and single-patient use considerations, based on WHO and CDC recommendations.

The current healthcare environment is unique, say Prinsen, but patient safety and treating patients with the highest level of care are still the most important parts of the patient journey - from patient preparation to surgical intervention to patient recovery. "Being focused on foundational practices is as important as always," she says.

The current COVID-19 era has made clinicians and surgery teams look at the current process even more closely for additional steps that may help reduce the risk of complications, reduce readmissions, and find ways to operate as efficiently as possible. As surgeries resume, protocols may vary and include requiring rooms to remain vacant for a period of time between occupancy to allow time for air exchange and cleaning.

Resources are available to help healthcare professionals navigate the return to surgery with confidence and adjust to the current environment as well as changing circumstance, says Prinsen, including 3M's respiratory protection (https://www.3m.com/3M/en_US/medical-us/coronavirus/ppe-information-and-guidance/), cleaning monitoring (https://www.3m.com/3M/en_US/medical-us/comprehensive-infection-prevention/cross-contamination/) and reducing contaminations (https://www.3m.com/3M/en_US/medical-us/coronavirus/surgical-solutions/) tools.

"Protocols and practices during the COVID-19 pandemic may change, and as we learn more, we adjust," she explains. "The things we have done and the steps we take to protect patients are still best practices."

Finding the best resources and balancing the risks by addressing all of these important factors is how healthcare teams are finding the way to provide the highest level of care for their patients.

Create an atmosphere where people can speak their minds and offer the help they need.

The pandemic has made everyone's lives more difficult and stressful, but healthcare providers have suffered significantly. Some surgical professionals shifted to the COVID-19 frontlines when elective surgeries shut down. Others had their work and personal lives turned upside down. Now, as they return to whatever could be considered "normal," they carry heavy psychological burdens into the OR.

Karen Foli, PhD, RN, FAAN, an associate professor at Purdue University School of Nursing in West Lafayette, Ind., and coauthor of The Influence of Psychological Trauma in Nursing, offers these tips to help you make your facility the safest space possible for your staff.

• First, how are YOU? To effectively lead, you must be mentally prepared for the task. "Honestly assess your ability to serve as a therapeutic listener and go-to person for your OR team," says Dr. Foli. "How do you feel about the stigma surrounding depression, anxiety and PTSD? Are you prepared to listen to the firsthand, individual stories of your nurses?" If not, become a referral agent by gaining a full appreciation and understanding of what your organization can offer those who are struggling, such as employee assistance programs. Another option: form in-house or social media support groups for employees.
• Empathy is everything. To create a safe psychological space, focus on establishing a strong culture that promotes safety, empowerment and healing. "Mental health is rarely emphasized for healthcare workers who often suffer from burnout and compassion fatigue," says Dr. Foli. "If someone on your staff is struggling, listen with a tone of openness and acceptance instead of blame. Start the conversation with 'What's happened to you?' instead of 'What's wrong with you?'"
• Look for troubling signs. The residual effects of mental trauma operate on their own timelines. "View everything through a trauma-informed lens, and understand that stimuli in the work environment can trigger flashbacks to what staff may have experienced during the outbreak response," says Dr. Foli. If an event occurs, take the staffer aside and ask if you can help. "Recognize what's happening, avoid retraumatizing the staff member and determine what they need to feel safe again," advises Dr. Foli.
• Listen attentively. When staffers express feelings, don't talk over them. "Maintain gentle eye contact, follow social cues and pay close attention to body language, both yours and theirs," says Dr. Foli. "If you have a close enough relationship, perhaps you can gently touch the person's arm as a gesture of comfort." Summarize what the person just said to show you're listening and, if the situation warrants it, provide context. "Reassure them that their reaction is appropriate, and anyone in their position would likely respond the same way," says Dr. Foli.
• Offer security and control. "Simply asking someone who's struggling for their thoughts on what would be most helpful for them is much more effective than telling them they could use more time off, or making suggestions about the help they need," says Dr. Foli.

It's not just the people who directly cared for COVID-19 patients who need a safe space and help. Everyone has been affected in some way by the pandemic. A positive result of this has been an increased recognition of healthcare providers' mental health. "We can create systematic approaches to supporting all surgical team members with the goal of recovery and post-traumatic growth," says Dr. Foli. "We can also create a new culture of support for mental health and compassion toward each other, letting go of past incivilities and giving staff members the right and space to recover from traumatic experiences."

Nasal decolonization protocols take on added importance during the pandemic.

Pre-op nasal decolonization has risen to prominence over the last decade largely due to the risk of the presence of Methicillin-resistant Staphylococcus aureus (MRSA). Now COVID-19 has placed increased focus on treating the nares of every patient before surgery.

Randy Loftus, MD, a professor of anesthesiology at the University of Iowa in Iowa City, views nasal decolonization as a vital component of a multifaceted approach to prevent transmission of COVID-19 in surgical settings. The current reality, he says, is that every patient should be functionally treated as a carrier of COVID-19, both due to the virus' high asymptomatic rate and continuing issues with testing effectiveness. The nares are a transient base for the virus. The viral load is initially higher in the nasal or oral pharynx before moving to the lower respiratory tract after seven days of infection, according to Dr. Loftus, who with colleagues has studied the epidemiology of disease transmission in the perioperative space for 14 years.

"The modeling we've done on disease transmission has been largely about the behavior of clinicians - it relates to compliance with basic preventative measures," he explains. "Nasal decolonization is currently applied to a subset of patients - primarily those undergoing joint replacements - but the evidence for surgical site infection prevention suggests its use should be more widespread."

The good news, of course, is that COVID-19 is an enveloped virus that's inactivated with brief exposure to agents like isopropyl alcohol, chlorhexidine and low concentrations of povidone iodine, which are typically used in prepping the nares and skin for surgery. "Timely use of these agents, based on our knowledge of the epidemiology of transmission of other infectious organisms like S. aureus, creates an evidence-based defense strategy against COVID-19," says Dr. Loftus. He adds that decolonizing the nares isn't just for the protection of OR staff or the patient undergoing surgery. Because of the ease with which the virus can contaminate and transmit within a closed environment, it's also for the good of patients who will subsequently populate ORs.

"COVID-19 should serve as a wake-up call," says Dr. Loftus. "We need to pay attention to limiting transmission by universally applying evidence-based measures, including nasal decolonization. It's through that approach that we'll control the spread of bacteria and viruses, reduce infections and dramatically improve patient outcomes.