key: cord-0867987-n2newik0
authors: Ren, Jie; Yang, Xilin; Xu, Zhen; Lei, Weiwei; Yang, Kun; Kong, Yonggang; Qu, Jining; Liao, Hua; He, Yi; Chen, Huidong; Wang, Yan; Zeng, Feng; Hua, Qingquan
title: Prevention of nosocomial COVID-19 infections in Otorhinolaryngology-Head and Neck Surgery
date: 2020-07-03
journal: World J Otorhinolaryngol Head Neck Surg
DOI: 10.1016/j.wjorl.2020.06.003
sha: c0ca4d95ca2ec8b6fdbfe5b89c383c3b7ab7c667
doc_id: 867987
cord_uid: n2newik0

Coronavirus disease 2019 (COVID-19) has rapidly evolved into a pandemic, causing a global public health crisis. Many frontline healthcare workers providing ear, nose and throat services have been reported to contract COVID-19 at work. Early during the COVID-19 outbreak, several medical professionals in Otolaryngology-Head and Neck Surgery were infected in Wuhan, China. A series of measures were then taken immediately, which successfully halted the spread of the disease. Here we would like to share the lessons we have learned, and our experience to protect our health care workers during the COVID-19 pandemic.

Since COVID-19 infection was first described in Wuhan China in December 2019, it has rapidly spread worldwide, and become a pandemic and global crisis. The cumulative total number of COVID-19 cases worldwide is increasing exponentially. As of April 3, 2020, there were nearly one million of confirmed COVID-19 cases worldwide, including 80000 in China. COVID-19, caused by SARS-CoV 2, is a highly infectious respiratory disease, transmitted mainly through droplets and direct contact [1] [2] . The frontline healthcare workers are thus at high risk of contracting the virus [3] , especially in otolaryngology, pulmonary medicine, infectious diseases, and those working in COVID-19 isolation wards. Early during the outbreak, a number of healthcare workers were successively diagnosed with COVID-19 infection in the Department of Otolaryngology-Head and Neck Surgery at one hospital in Wuhan. Most of them were all involved in the care of one ENT patient who was later diagnosed with COVID-19. The Department then took a series of preventive measures immediately. Since then, no more COVID-19 nosocomial infection was observed.

A 63 year old male with laryngeal carcinoma was admitted on December 31. Preoperative workup including chest CT did not show changes consistent with COVID-19 infection. A total laryngectomy was performed on January 6th. He started to have productive cough on Jan 15 th , and was found to have pharyngo-cutaneous fistula. Wound care was then delivered daily. Since then his respiratory symptoms kept worsening. A chest CT was repeated on the 20th and showed patchy opacification involving bilateral lower lobes. Lab workup included normal total WBC counts with increased neutrophil but decreased lymphocyte counts (20 th and 23 rd ) , elevated C-reactive protein (CRP, 23 rd ) , elevated procalcitonin (23 rd ), and negative PCR for COVID-19 (26 th ). He was on antibiotics which improved his symptoms including cough and sputum. On the 28th, the patient started to have a fever (37.9 ℃). A repeated chest CT showed worsened bilateral patchy opacification, especially the lower lobes. The patient was immediately placed in isolation. Sputum PCR for COVID-19 was performed which was positive.

Summary: The suspected index patient started to have cough and sputum with bilateral lower lobe opacification, and was diagnosed with pharyngo-cutaneous fistula on postoperative day 9. His first PCR for COVID-19 was negative. However, we could have been a bit more overcautious and suspected possible COVID-19 infection earlier because of the following reasons:1) the confirmed COVID-19 epidemic in Wuhan at that time; 2) the symptoms of COVID-19 are non-specific; 3) PCR sensitivity was unknown. As such, although the patient's symptoms, lab results and CT results could be due to common postoperative complications, COVID-19 should otherwise be suspected and early isolation and precaution should be executed until it was excluded during the epidemic.

(2) Infections of healthcare workers involving the care of suspected index patient 1. Doctor A: a 36 year old male presented with productive cough (20 th ) and fever (38.6 ℃, 21 st ).A chest CT was then obtained, consistent with viral pneumonia. Lab test included elevated neutrophil but normal lymphocyte counts. A COVID-19 pneumonia was later confirmed by positive PCR. He was given oseltamivir, levofloxacin and antipyretic treatment. He is still in isolation as repeated PCR remains positive.

Summary: he rounded on the patient daily and performed wound care for the pharyngocutanenous fistula since Jan 15th. He did not wear a surgical mask and bouffant before Jan 20 th except during wound care.

A 30 year old female started to have fever on Jan 30 th . A chest CT showed viral pneumonia; however, the PCR for SARS-CoV-2 was negative using nasopharyneal swab.

Summary: She had close contact with Doctor A around Jan 20 th . All results of repeated PCR are negative. A COVID-19 pneumonia was suspected and later confirmed by strong positive for IgG in antibody test after she was discharged from the hospital.

A 48 year old female presented with a fever (38 ° C) with normal white blood cell count but decreased lymphocyte counts. Her chest CT showed right-middle fibrous foci. The nasopharyngeal swab test for SARS-CoV-2 was positive.

Summary: She had close contact with both the patient and Doctor A. 4.Nurse B: a 33year old female was completely asymptomatic but with positive PCR test for COVID-19 on January 24 th in COVID-19 screening for all healthcare works.

Summary: She has a history of close contact with Nurse A before the 23 rd .

(3) A case of unclear source of infection Nurse C: a 25 year old female presented with cough, hyposmia, headache, and fatigue around Jan13th. Her symptoms disappeared quickly within a few days. She had positive PCR test for COVID-19 on the January 25 th in COVID-19 screening for all healthcare works.

Summary: She had no direct contact with the suspected index patient, or the aforementioned healthcare providers.

After this event, we first asked the following questions. In case of a healthcare worker was suspected or confirmed to have COVID-19 infection, rapid assessment and staff assignment at the departmental level was performed by the EICS. Isolation was immediately implemented to contain the infection. Internal investigation was immediately initiated to trace the contact history of that individual to avoid further nosocomial spread A smartphone App was developed for this purpose. For disease screening, chest CT has the highest sensitivity. A PCR cannot rule out COVID-19 infection. All staff within the Department and the hospital administration was notified. Based on the contact tracing, individuals at risk were screened by chest CT and PCR. Regardless of the results, those who had direct contact with suspected or confirmed COVID-19 case were isolated for at least 14 days [1] . Strict isolation policy was implemented throughout the period of outbreak. Suspected COIVD-19 patients were only managed by a designated healthcare provider team.

Early during the COVID-19 outbreak, the majority of ENT healthcare workers were unfamiliar with respiratory-borne infectious diseases. In China, COVID-19 is classified as class-B infectious diseases. However, it has been managed as class-A infectious diseases due to its high infectivity. In order to keep our medical team updated on rapidly evolving information on COVID-19, a designated team was appointed to obtain updated information including guidelines.

This information was delivered to each individual within the Department on a daily basis. In addition, due to the significant psychological stress among healthcare workers during the COVID-19 pandemic, we delivered several articles including "Guiding Principles of Emergency Psychological Crisis Intervention for COVID-19", "Guidelines and Guidance of Public Psychological Self-Help for COVID-19'' to every individual within the Department. Meanwhile, a designated team was appointed to help frontline workers with psychological evaluation and coping using telephone, smartphone apps, and questionnaire. These measures dramatically helped release psychologic stress among frontline healthcare workers, improved their mental health, and thus enhanced their confidence in the fight against the epidemic.

In terms of medical staff assignment, those assigned to the designated fever clinics, isolation wards and intensive care units outside the department were mainly managed by the hospital administrative team. Within the Department, if there was a shortage of staff because of isolation, the hospital administration was notified and asked for help.

At the beginning of COVID-19 outbreak, our clinic was immediately closed, and thoroughly and air was carried out daily. Biohazard waste, trash, and those from suspected or confirmed COVID-19 cases were strictly managed and disposed separately. After the completion of this setup, we gradually opened the outpatient clinic.

After we reopened our clinic, all patients were subject to strict screening based on the Diagnosis and Treatment of Pneumonia of New Coronavirus Infection (Trial Fifth Edition) [1] . In general, the epidemiologic and clinical history was collected. If any suspicion arose, chest CT was then obtained, following by PCR test for COVIDF-19. In addition, the patient volume was controlled to minimize the risk of cross-infection.

For clinical procedures, the following were implemented to minimize the risk of contracting virus among medical profesisonals, [8] :

① For anterior rhinoscopy and oropharyngeal examination using head mirror, level II or III protection was recommended, which includes disposable bouffant, surgical masks or protective masks, safety goggles, white coat or scrubs, and disposable fluid-resistant or non-fluid resistant gown, disposable examination gloves. ② For epistaxis, traumatic wound debridement including laceration repair, anterior nasal packing, wound care for pharyngoctaneous fistula, tracheostomy care, level III protection was recommended, which includes face shield or PAPR plus level II protection [9] . In addition, after completion of the procedure and correct doffing, we also recommended sinus rinse, mouth rinse, showering, disinfection of the ear canal using 75% alcohol swab [8] .

③ For nasal or laryngopharyngeal endoscopy, because of the high chances of generating aerosols, we strictly avoided unnecessary endoscopic examination. In addition, these procedures must be performed with appropriate PPEs with adequate topical anesthesia to minimize sneezing or nausea.

In addition, the procedure should be completed quickly. The patient should wear a surgical mask. If the patient had frequent sneezing, coughing, nausea or vomiting, the room was disinfected using ultraviolet ray for 15 minutes immediately before next patient. In addition, one medical provider was allowed in the room to perform the entire procedure. For emergency cases under general anesthesia which have unknown COVID-19 status or have not been tested but have high-risk factors such as symptomatic or contact with COVID-19 positive individuals, we recommend the following: 1) For traumatic wound debridement, incision and drainage, level II protection or above is recommended. In addition, surgical aseptic techniques, safety goggles, N95 mask, double surgical gloves, and disinfection of surgical field with 75% alcohol is recommended.

2) For upper aerodigestive endoscopic procedures, digestive and respiratory tract endoscopic surgery (esophageal foreign body, tracheal foreign body, epistaxis): We recommend level III protection.

3) For tracheotomy, due to its high risk of aerosol generation, we recommended negative pressure laminar flow operation room, level III protection with PAPR. If tracheostomy was performed under general anesthesia, both assisted and spontaneous ventilation was paused right before the trachea was entered. The ventilation was then resumed after cannula was inserted with cuff inflated and circuit being connected. If it was performed under local anesthesia, oxygen can be delivered using a mask which could also cover the nose and mouth. After the tracheal anterior wall was adequately exposed. Hemostasis should be achieved. The patient was then paralysed by anesthesia. The tracheal window was then generated followed by cannula insertion, cuff inflation and circuit connection. Assisted ventilation was then started.During the case is after tracheotomy made, the risk is highest. Cuffed non-fenestrated trach tube should be used to avoid aerosolization. We also can create a tent over the surgical site with a clear see-through plastic to trap particles from being released into the environment. Besides， ， ， ，we should not forget proper hand hygiene,which is also important. We shoule pay even more attention during doffing PPE to prevent contamination. During emergency surgery， ， ， ，only essential personnel should be in the room.

COVID-19 is a highly infectious disease. Because COVID-19 patient can be asymptomatic or have a long incubation, the practice in Otolaryngology-Head and Neck will be very challenging. As such, it is necessary for otolaryngologists to have a better understanding of this diseases, to develop plans to minimize the risk of contract the virus. On February 2, 2020, the Chinese Journal of OHNS published the guidelines to protect Otolaryngologists during COVID-19 pandemic [11] .

Since Wuhan was the epicenter of COVID-19 oubreak, we like to share our experience in this regard, and hope it can help our otolaryngology colleagues worldwide to better protect themselves, their family and their patients.

Office of state administration of traditional Chinese medicine. Notice on the issuance of a programme for the diagnosis and treatment of novel coronavirus (2019-nCoV) infected pneumonia

First travel-related case of 2019 Novel Coronavirus detected in United States

Early Transmission dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia

Disease control of 2019 novel coronavirus infection in hospital：West China urgent recommendation

A Novel Coronavirus from patients with pneumonia in China

Strategy and technology to prevent hospital-acquired infections: Lessons from SARS, Ebola, and MERS in Asia and West Africa

Protection suggestions and operation process of rhinolaryngoscopy during epidemic

Head and Neck Surgery Society of Chinese Medical DoctorAssociation. Occupation prevention and control novel coronavirus infection among medical staff in otolaryngology head and neck surgery

National Health and Family Planning Commission of the people's Republic of China. Prevention and control of nosocomial infection by air borne diseases

Chinese society of Anesthesiology. Novel coronavirus infection and suspected operation room diagnosis and operation of operation room

Suggestions for prevention of 2019 novel coronavirus infection in otolaryngology head and neck surgery medical staff

Epub ahead of print

Jie Ren：Organize, summarize, write and edit, participate in the formulation of diagnosis and treatment plan during the epidemic

Xilin Yang：Participate in the formulation of the diagnosis and treatment plan of the Department during the epidemic, and draw the flow chart

Weiwei Lei：Make the plan of ward reform and arrange the nursing work

Outpatient reconstruction

Making ward management strategy and emergency treatment Jining Qu: Make ward management plan Liao Hua: Make ward management plan Yi He: Make the plan of ward reform Huidong Chen: Consulting literature Yan Wang: Consulting literature Feng Zeng: Consulting literature Qingquan Hua: Formulate ward management strategy and emergency treatment，Review and Editing