key: cord-0891224-34wkfhqd
authors: Yukun, Luo; Jianjun, Yuan; Minghui, Liu; Fang, Nie; Jiao, Bai; Xiang, Fei; Yujiao, Deng; Tengfei, Yu; Juan, Mao; Haohui, Zhu; Chuang, Li; Qinghai, Peng; Ming, Zhang; Shi, Zeng; Ganqiong, Xu; Chengcheng, Niu; Tiantian, Dong; Wen, He; Jie, Tang
title: Chinese Expert Consensus on Protection for Ultrasound Healthcare Workers against COVID-19
date: 2020-10-12
journal: Ultrasound Med Biol
DOI: 10.1016/j.ultrasmedbio.2020.10.006
sha: 950a44c5a649c2c6696c879204e30d2a21f43309
doc_id: 891224
cord_uid: 34wkfhqd

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has become worldwide pandemic and posed a serious public health risk. It was proved that lung ultrasound (LUS) can be extremely valuable in the diagnosis and treatment of the disease, which could also minimize number of exposed healthcare workers and equipment. Since in the department of ultrasound, the healthcare workers are close contacted with patients who might be infected or virus carrying, it is extremely important to offer sufficient protection of them. Too aggressive protection should also be avoided because all the hospital might encounter lack of protection equipment. Guidance about the proper protection management should be provided in detailed, for example, how to choose personal protective equipment, or how to disinfect the environment. To address those problems, on behalf of Chinese Ultrasound Doctors Association, Chinese PLA Professional Committee of Ultrasound in Medicine, Beijing Institute of Ultrasound in Medicine, and Chinese Research Hospital Association Ultrasound Professional Committee, the authors summarized the recommendations for effective protection according to the exist hygienic standards, their experience, and available literature. After the recommendations were finished, two online conferences were held on January 31(st) 2020 and February 7(th) 2020 respectively, and the recommendations were discussed in detail part by part. A modified version of the work was circulated and finally approved by all the authors, which was the present Chinese Experts Consensus on Protection for Ultrasound Healthcare Workers against COVID-19.

The work space should be divided into two passages and three sections with the 120 participation of hospital infection control personnel (if the existing layout cannot be 121 changed to two passages and three sections, signs and actual isolation barriers can be 122 used for partition to avoid cross-infection caused by mixing of contaminated areas 123 and clean areas). 124

Two passages: one passage for the access of healthcare workers and the other for 125 patients. 126

Three sections: clean areas, buffer zones and contaminated areas. Healthcare 127 workers go in and out through the clean area, patients and their relatives go in and out 128 through the contaminated area, and both areas are divided by buffer zones. Healthcare 129 workers should cross clean area → buffer zone A → contaminated area in order when 130 they go to work, and cross contaminated area → buffer zone B → clean area in order 131 when off duty, which means they should exit the department through the clean area. 132

The order of cleaning should be clean area → buffer zone → contaminated area. 133

Clean areas are for healthcare workers to rest, eat, change, etc., where irrelevant 134 persons are strictly forbidden to enter. Anything used in the examination room, 135 including gown, masks, hairnets, gloves, shoe covers, etc. are not allowed to be 136 brought into the clean area. 137

Buffer areas are mainly for preparations, donning personal protective equipment 138 (PPE) and hand hygiene before work for healthcare workers. It also prevent 139 contamination of the clean area by avoiding virus spread due to direct returning back 140 to clean area from contaminated area. 141

Buffer zone A is for donning PPE, while Buffer zone B is for doffing PPE. 142 Buffer zone B-1 is for removing goggles or protective face shields, gowns, shoe 143 covers, outer gloves, etc. 144

Buffer zone B-2 is for taking off working coats, isolation gowns, hairnets, inner 145 masks, inner gloves, shoe covers, etc. 146 Dedicated trash cans for different classification of medical wastes should be used 147 to discard used disposable PPE in buffer zone B, (for example, a trash can for 148 protective clothing, and a trash can for gloves and masks). Non-disposable protective 149 items (such as goggles or protective face shields) can be reused after strict 150 disinfection. 151

Contaminated areas include triage and appointment area, waiting hall and 152 ultrasound rooms. A detailed schematic figure of the arrangement of work space and a 153

proposed flow were showed in Figure 1 . 154

This triage area should have clear signs and be relative separated. The ground 156 and surfaces of objects in this area should be disinfected with chlorine-containing 157 disinfectant (1000 mg/L) or diluted 84 disinfectant at a ratio of 1:50, etc., 1-2 times 158 per day or any time once it is contaminated. 159

Staff protection in the triage area: the staff should be provided primary or 160 secondary personal protective equipment (PPE), wearing surgical masks or medical 161 protective respirator (i.e. N95 masks), goggles or protective face shields, latex gloves, 162 disposable hairnets, work coats and isolation gowns, disposable shoe covers. Hand 163 hygiene should be strictly performed during consultation. An infrared thermometer is 164 suggested for keep distance when taking temperature, and electronic instructions are 165 also suggested for guidance for the same reason ( Figure 2) . 166

Appointment for patients should be in different time slots to reduce the number 167 of patients in the waiting hall. A separate waiting zone should be available specialized 168 for pregnant women, children and the elderly, and appropriate priority of treatment 169 may be provided to the special population to shorten their stay in the department. 170

Triage: (i) patients and accompanying persons were reminded to wear disposable 171 medical masks to prevent cross infections, and if they have fever or coughs, the masks 172 should be provided if necessary; (ii) Information about symptoms like fever, dry 173 cough, and shortness of breath, as well as the medical history, like whether they have 174 visited an virus out-break area or had contact with the persons who did; (iii) 175 temperature of the patients and the accompanying persons should be double checked 176 using an infrared thermometer (first measurement performed at hospital entrance); 177 (iv) any case with fever or other suspected symptoms should be reported according 178 hospital infection control process, and diagnoses or treatments might have to be 179 rescheduled; and (v) examination for children with suspected or confirmed 180 COVID-19 who are crying and refused to wear masks can be performed after sedation 181 if necessary. A schematic flow of triage and examination were showed in Figure 3 . Supplies for patient's examination: disinfect the bed sheets, pillowcases, etc., 203 should be changed and disinfected with disinfectants or high-temperature disinfection 204 at least once every half a day or immediately after contamination. It is recommended 205 to use disposable bed sheets to prevent cross infections where applicable for certain 206 healthcare institutions. 207

Disposal of medical supplies: during the prevention of the outbreak, hand 208 hygiene should be performed before and after removing the masks. Medical wastes 209 such as the disused masks and hairnets should be disposed of in the medical trash can 210 (yellow). The trash can should be disinfected twice a day using 75% alcohol or 211 chlorine-containing disinfectant. 212

Room environment: ultrasound examination at the bedside in the isolated area is 214 preferred for a suspected or confirmed patient; an examination room in an isolated 215 area may be built where applicable, or the patient can be provided with appropriate 216 protective equipment in a room specialized for fever patients or in the isolated ward 217 and go to the specialized room for examination accompanied by a special person via 218 the specified route. Air disinfection should be performed strictly using 3% hydrogen 219 peroxide spray or UV lamp irradiation for 60 minutes each time after completion of 220 examination in the specialized room; and a plasma air disinfection machine that can 221 co-exist with human could be put in the room if applicable. The beds for diagnoses, 222 door knobs, objects' surfaces and ground should be wiped for disinfection with 223 chlorine-containing disinfectant (1000 mg/L) any time once contaminated. If the 224 surface of the environmental object or the ground is contaminated with obvious 225 contaminants (such as patient's blood, secretions, vomit, and excrement), 5000 mg/L 226 chlorine-containing disinfectant should be used to carefully remove the contaminants 227 and wipe the contaminated areas for disinfection. 228

Ultrasound system and computers: (i) an exclusively used ultrasound system 229 should be used for examinations of confirmed and suspected patients; (ii) protection 230

of ultrasound system such as protective sleeve for the probes, and a transparent plastic 231 protective cover for the machine which completely covers the monitor and operation 232 panel without affecting the movement of trackball can be used; (iii) for exclusively 233 used ultrasound system, the plastic cover should be changed daily after work, and 234 protective sleeve for probe should be changed for every patient; (iv) wiping 235 disinfection should be performed 1 or 2 times after examination for probes and cable, 236 machine, monitor, operation panel or the surface of its protective cover, the 237 workstation computer (including the monitor and computer case), keyboard, and 238 mouse using 75% alcohol or 3% hydrogen peroxide or disinfecting wipes containing 239 the above ingredients. 240

If exclusive use of the ultrasound system is not feasible, it is recommended that: 241 (i) protective cover for machine, monitor, operation panel and protective sleeve for 242 ultrasound probe should be changed after every examination; (ii), strict wiping 243 disinfection should be performed 1 or 2 times after every examination for probe and 244 cable, display, operation panel, the workstation computer (including the monitor and 245 computer case), keyboard, and mouse, using 75% alcohol or 3% hydrogen peroxide or 246 disinfecting wipes containing the above ingredients. Work attire: employ the secondary PPE, including wearing a medical protective 292 masks (N95 respirator or higher), goggles or face shield, latex gloves, disposable 293 work hairnets, work attire or two-piece surgical gown, isolation gown and disposable 294 shoe covers, and the same protection should be provided for participants such as 295 medical assistants and nurses as that for physicians who stay in the same room . In 296 view of the fact that there are some asymptomatic SARS-CoV2 carriers, the 297 healthcare institutions, where applicable, may prepare protective clothing, boot 298 covers, etc. in addition to basic secondary PPE. There should be two persons to 299 cooperate with and supervise each other when putting on and taking off protective 300 equipment, and provide video instructions if possible. 301

Examination process: enter the room in the attire that conforms to the protection 302 requirements; strictly perform hand hygiene during the work; disinfect the ultrasound 303 probe, cable, devices and relevant non-disposable items immediately after the 304 examination. It is recommended to use a bedside ultrasound system which should be 305 disinfected after every patient, and disinfect everywhere in the room after the 306 examination before leaving the room. 307

Work attire: employ the secondary PPE, including wearing a medical protective 309 masks (N95 respirator or higher), goggles or face shield, latex gloves, disposable 310 work hairnets, work attire or two-piece surgical gown, isolation gown and disposable 311 shoe covers, and the same protection should be provided for participants such as 312 medical assistants and nurses as that for physicians who stay in the same room. 313

Considering the existence of non-symptomatic COVID 19 patients, the healthcare 314 institutions should prepare protective clothing, boot covers, etc., in addition to basic 315 secondary PPE. 316

Patient's attire and requirements: patients should wear surgical masks. It is 317 recommended to use bedside ultrasound system; patients should, where applicable, be 318 accompanied by a special person via the specified route to the dedicated room or the 319 isolated ward for bedside examination; and the used wheelchair or patient trolley, if 320 any, should be disinfected with 1000 mg/L chlorine-containing disinfectant on its 321 surface. 322

Examination process: enter the room in the attire that strictly conforms to the 323 protection requirements; hand hygiene should be strictly performed during the work; 324 probes, cable, devices and relevant non-disposable items should be disinfected 325 immediately after the examination; disinfect everywhere in the room and every 326 medical waste before leaving the room, sanitize hands strictly following the rules of 327 hand hygiene and remove the protective equipment conforming to relevant 328 requirements. It is recommended to prevent dedicated bedside ultrasound system from 329 being used for examination in isolated wards. 330

Although not widely applied in China, pocket devices and wireless probes were 331 reported recently, which were proved to be helpful in minimizing the number of 332 health-care workers and medical devices exposed to suspected or confirmed cases of 333 COVID-19 (Buonsenso, et al. 2020a , Buonsenso, et al. 2020b , De Rose, et al. 2020 , 334 Inchingolo, et al. 2020 ). If those portable devices are available, they are highly 335 suggested in use of bedside examination for suspected or confirmed patients under the 336 protection of disposable plastic covers. 337

Besides, previous study also suggested that lung ultrasound examination might 338 guide therapeutic decisions and procedures in patients with COVID-19 in many 339 critical settings (Allinovi, et al. 2020 , Soldati, et al. 2020 , for example, general 340 practitioners' offices, nursing homes, emergency departments, general internal 341 medicine wards, pulmonology wards, hemdialysis units, obstetrics and paediatrics. In 342 those above settings, pocket devices and wireless probes are also highly suggested, 343 and protection of the healthcare worker or disinfection of relative machine should not 344 only follow the above suggestions, but also fulfill the need of the special clinical 345 settings, which might need multi-disciplinary discussion and is beyond the scope of 346 the present study. 347

Work attire: employ the tertiary PPE, including a medical protective masks (N95 350 respirator or higher), full-face respirator or higher-level powered air-purifying 351 respirator (positive pressure headgear), latex gloves, disposable work hairnets, 352 two-piece surgical gown, isolation gown, disposable shoe covers and protective 353 clothing and boot covers. 354

Examination: bedside ultrasound system should be used and attire that strictly 355

conforms to the protection requirements should be worn before entering the room; 356 hand hygiene should be strictly performed during the work; probes, cable, devices and 357 relevant non-disposable items should be disinfected immediately after the 358 examination; disinfect everywhere in the room and every medical waste before 359 leaving the room. Hand hygiene should be strictly performed and PPE should be 360 remove according to relevant requirements. 361

Detailed suggestions for the different protection of healthcare workers were 362 summarized in Table 2  363 364 Summary 365

As is stated above, lung ultrasound examination might be used in many critical 366 settings (Allinovi, et al. 2020 , Soldati, et al. 2020 , and protection of the healthcare 367 worker might need further multi-disciplinary discussion. Besides, in the rapid 368 changing pandemic, all the suggestions might seem to be imperfect or even incorrect 369 in future. However, the above suggestions are the expert consensus based on former 370 

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