(G)lovers in a Dangerous Time

Since there has been only one topic of conversation for approximately the last 349 years, it seems germane to approach the subject from a healthcare perspective. Specifically, how do we as healthcare workers avoid contracting the SARS-CoV-2 novel coronavirus ourselves, and avoid passing it on to our patients and loved ones?

Well, I'm glad ya asked. According to the CDC, infection prevention and control (IPC) practices begin before patients and staff even enter the building. The simplest way to minimize infection is to keep people from entering your clinic unnecessarily by conducting telehealth PT sessions instead of in-person ones whenever possible. If telehealth is not feasible (for example, the patient's insurance won't cover it, or the patient cannot safely stretch or exercise alone due to poor balance, etc.), then IPC practices should include 1) limiting and monitoring the entrances that staff and patients can use, 2) sanitizing doorknobs and keypads after each use, 3) taking the temperatures of visitors and staff every time they enter the clinic, and 4) providing hand sanitizer (60-95% alcohol) at every entrance/exit and throughout the clinic.

Once inside the clinic, patients should be seated at least 6 feet (~2m) apart from each other, and required to wear a cloth mask over both their mouth and nose at all times during PT (unless there is a medical reason why that is unsafe for them). If possible, patients should remain in their examination room with the door closed from the time they arrive until their appointment is concluded. Visitors should wear their own masks as well, and staff should wear masks as well, even in bathrooms and break rooms, to minimize the amount of moisture droplets in the air. 

Staff should take special precautions with their own masks and PPE, as their risk of vectoring the novel coronavirus is elevated due to their daily close contact with patients. Surgical masks are preferred to cloth masks, because they offer greater protection against splashes and sprays, but the ideal face covering is "an N95 or equivalent or higher-level respirator". To reiterate, "[c]loth masks are NOT PPE and should not be worn for the care of patients with suspected or confirmed COVID-19 or other situations where use of a respirator or facemask is recommended)" [italics in original]. Healthcare workers should also follow the usual Standard Precautions and Transmission-Based Precautions when treating patients who may have other transmissible illnesses such as influenza, HIV, etc.

If anyone at your clinic confirms that they have symptoms of the novel coronavirus, "[c]ontact tracing should be carried out in a way that protects the confidentiality of affected individuals and is consistent with applicable laws and regulations". In other words, HIPAA doesn't go away just because you need to do contact tracing, so continue to respect your patients' right to confidentiality.

As always, healthcare workers "should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves." It is particularly important to wash your hands after removing gloves and before touching anything else, because the heat and moisture present inside nonporous gloves creates a miniature greenhouse effect, encouraging the growth of a wide variety of harmful bacteria and viruses. 

No problem. Everything is fine.

Speaking of gloves and other PPE, the CDC also reminds us that more than one method of donning and doffing PPE may be acceptable; there is not one universal protocol that must be followed exactly in all circumstances. However, the CDC does recommend performing hand hygeine before and after donning or doffing PPE, wearing a face shield or goggles whenever possible, and to avoid touching the front of one's mask at all times. The foregoing link includes videos and illustrated step-by-step instructions on various methods for donning and doffing PPE.

*whew* That's a lot to remember, and I haven't even gone into how to clean reusable PPE, how to deal with Aerosol Generating Procedures (AGPs), or how to approach isolation rooms, respirators, or facemasks! Of course, this paltry article of mine only scratches the surface of IPC practices. To make matters more complicated, other organizations (like OSHA, f'rinstance) have their own guidelines which generally overlap with the CDC's recommendations, but don't always. Ultimately, each of us will encounter situations that aren't in the handbook, or gray areas that don't really fall into one category or the other. In those situations, it will be our job as clinicians to employ our judgement and expertise, trust in our training, act quickly and decisively, and hope for the best. Our fight against the novel coronavirus will be a long hard slog through treacherous landscapes and sleepless nights, but as the Barenaked Ladies once said, "Nothing worth having comes without some kind of fight/ Gotta kick at the darkness 'til it bleeds daylight".

Stay safe out there.