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Inpatient Practice Intensive Care Unit

Reducing Hospital Employee Exposures To COVID-19 Patients

Having patients with COVID-19 in the hospital can be disturbing to the doctors, nurses, and respiratory therapists who take care of them. The good news is that isolation procedures work and proper use of personal protective equipment can dramatically reduce the chance of getting healthcare workers infected. Even though that risk is low, there are certain simple steps you can take that will reduce the risk even further. By taking these steps, you not only reduce healthcare worker exposures but you can also conserve personal protective equipment (masks, gowns, gloves). Here are a few:

  1. Use the right personal protective equipment (PPE) and be sure that it is used correctly.
  2. Minimize blood draws. If you don’t need daily labs, don’t send the nurses in to draw them. When you do get labs, try to cluster all of the lab tests that you need in a single phlebotomy.
  3. To anticoagulant a patient, use oral apixaban, oral rivaroxaban, or subcutaneous enoxaparin instead of a heparin drip. The problem with heparin drips is that you have to do frequent PTT blood tests. Other anticoagulants do not require testing.
  4. Use a sliding scale of subcutaneous insulin rather than an insulin drip. Insulin drips require the nurse to check the patient’s blood glucose every 1-2 hours whereas the SQ insulin sliding scale may only need to be done every 6 hours.
  5. Synchronize medications. Ordering a Q6 hour medication plus a Q8 hour medication means that a nurse has to go into a patient room 7 times a day. If that Q6 hour medication can be stretched out to be given Q8 hours, then a nurse only has to enter a patient’s room 3 times a day. Even better, use medications that only have to be given once a day whenever possible. This is particularly true of empiric antibiotics where there may be multiple equally appropriate antibiotic choices – some that have to be given 3 or 4 times a day and some that only have to be administered once a day.
  6. Use meter dose inhalers instead of nebulizer treatments. Nebulizers can result in aerolsolization of viral particles, at least in theory. Meter dose inhalers for bronchodilator treatments reduce the amount of time that a respiratory therapist has to be in a room to deliver a bronchodilator treatment.
  7. Have patients self-administer meter dose inhalers (or nebulizer treatments). The respiratory therapist can often observe the patient from a door window or a video monitor to ensure that the patient uses proper technique.
  8. Minimize the rounding team. If bedside rounds normally consist of the attending physician, a nurse, a resident, and a physician assistant, then reduce that to just the attending physician and just once a day.
  9. Don’t use physical and occupational therapy if you don’t need it. Frequently, admission order sets will include PT and OT for nearly every admission. Only order it if you really need it.
  10. Don’t order tests that you don’t need. “Routine” daily chest x-rays are usually unnecessary.
  11. Don’t order tests that can be done later. If a chest x-ray shows a suspicious pulmonary nodule and a chest CT is recommended for confirmation, that CT can wait a few weeks.
  12. Empiric treatment is OK. If a patient has epigastric pain, rather than ordering an endoscopy right away, give the patient some empiric omeprazole to minimize procedures.
  13. Utilize inpatient telemedicine for consults. There are two ways to do this, by a regular telemedicine visit or by an eVisit.
    1. CPT 99451 is for an eVisit and reimburses at 1.04 RVUs. There has to be an order for the consult and the consultant has to put a note in the medical record. The consultant must document his/her time and it must be > 5 minutes. This is a way to get reimbursed for the so-called “curbside consult”. An example would be “What follow up should occur for the incidental 5 mm pulmonary nodule that was seen on my patient’s CT scan?”
    2. CPT G0425 (30 minutes ), G0426 (50 minutes), and G0427 (70 minutes) are for initial inpatient telemedicine consults. For follow up inpatient consult visits, use CPT G0406 (15 minutes ), Go407 (25 minutes), and G0408 (35 minutes). These codes are based on the amount of time communicating with the patient
  14. Can you run your pumps outside of the patient’s door? continuous infusion pumps are forever alarming or needing infusion rates to be frequently adjusted. If the infusion pumps can be placed outside of a door with the tubing running under the door then the pumps can be adjusted without the nurse having to enter the room.
  15. Eliminate visitors. Visitors can bring COVID with them and many visitors have often had close contact with COVID patients before they were admitted, making them especially high risk. By eliminating visitors, there are fewer members of the public in patient care areas who can infect hospital staff. Furthermore, there are fewer times that the patient’s door is opened and no additional personal protective equipment consumed by the visitors.
  16. Be sure that the healthcare personnel are getting enough rest. When a nurse, RT, or physician works too long of a shift or too many shifts, fatigue can set in and with fatigue brings mistakes. Mistakes with isolation procedures can create infection risks.

March 31, 2020

By James Allen, MD

I am a Professor of Internal Medicine at the Ohio State University and the Medical Director of Ohio State University East Hospital