Here in Virchester the number of patients with Covid-19 are ramping up and we are putting the incredible amount of training, simulations, education and more into practice. That time in preparation (we’ve been running daily simulations for over 3 weeks), has paid off at this stage, though we all fear what might come in the next few weeks.
A major aspect of our training has been around the safe use of PPE and how that is affected by the types of patients and procedures we encounter. This has understandably been a source of concern for many, and one which we’ve found a little difficult to explain.
Thomas Bannister is an EM doc in Virchester who conceptulises this as the Covid Bubble. We like this concept and he’s agreed to share it here.
A “bubble” approach to COVID-19
What’s your Mindset?
Your role is to prevent onward transmission of the virus. To do this you must treat the individual patient. There is no ‘one size fits all’ solution.
What’s the context?
Infection results from viral contact with mucous membranes (eyes, nose, mouth). Spread is predominantly by contact with contaminated surfaces, or via respiratory droplets (2 meter radius around the patient). The virus can be aerosolised, but only by certain aerosol generating procedures (AGPs), such as CPR, or non-invasive ventilation.
Think about what you touch. If you touch a contaminated surface, you are contaminated. If you’re contaminated, anything you touch is contaminated. Don’t touch your eyes, nose or mouth. Hand washing is the main contact precaution. Regularly wash your hands with soap and water for at least 20 seconds.
Wear “droplet PPE” – Fluid resistant surgical mask (FRSM), apron, gloves, eye protection.
Only enter a room in which there has been aerosol generation if you absolutely have to. Wear “aerosol PPE” – Filtering Face Piece class 3 (FFP3) mask, long sleeved fluid repellent gown, gloves, eye protection.
The Bubble Principles
1. Create a bubble around the patient
Everything that enters a 2 meter radius (“bubble”) around the patient is considered contaminated. It should be disposed of (PPE) or appropriately cleaned (linen, medical equipment). Anything that can’t be disposed of or cleaned (medical notes) should not enter the bubble. Don’t bring anything unnecessary into the bubble (ID badge, pen, vocera/bleep/phone).
2. Stay outside the bubble
Anything that can be done at a distance from the patient, should be. Most spread will be by droplets (within 2 meters of the patient) or by contact with contaminated surfaces. Assess from the end of the bed. Don’t use a stethoscope in most circumstances – get a chest x-ray instead. Consider telephoning the patient from outside the room to take a history. As few people as possible should enter the bubble, and only when necessary.
3. Enter the bubble consciously
Nobody should enter the bubble without knowing that they are doing so. Anyone who may be exposed to a patient, sample or environment that is potentially contaminated should be notified in advance and should take appropriate precautions. With colleagues: communicate; call ahead; write clearly on requests that the patient is ?Covid-19. Don’t ask the patient to do anything that will bring other people inside their bubble without appropriate PPE; for instance, going to a pharmacy, or getting a taxi.
4. Stop the bubble touching the environment
Everything inside the bubble is considered contaminated. The bubble can move, to x-ray or ITU for instance, but it shouldn’t touch the environment in transit. Staff wearing PPE inside the bubble can push the patient’s trolley. But a “clean buddy” should open doors and ensure that the path is clear ahead. ?Covid-19 patients should not enter non-respiratory areas (such as non-Covid x-ray).
5. Samples leave the bubble in a bubble of their own
Nothing should leave the bubble without a bubble of its own. Create a new bubble around any contaminated objects leaving the patient’s bubble. Double bag samples so the outside layer is clean. Make sure whoever is handling or receiving the sample knows what it is and is able to “enter the bubble consciously”.
6. Aerosols break the bubble
Aerosol generating procedures break the bubble. The entire room should be considered contaminated. Everyone in the room should wear “aerosol PPE”. The air in the room will need to change over several times before the concentration of aerosolised virus drops to a safe level – this takes a minimum of 20 minutes.
Learning and Unlearning in medicine
These principles are designed to allow trainees to conceptualise the bubble and infection control principles and to change the way that we interact with the potentially infectious patient. Some of these skills and behaviors are new and need to be learned (dofing and donning PPE for example), but in many ways we also need ‘unlearn’ techniques and behaviours and that’s arguably harder to do. Reducing or stopping stethoscope use as an example is really hard to enact. Not leaning in, close to a patient’s face, to take a history from a quietly spoken patient is not something that we are used to and yet these are important to prevent health care worker infections.
Times are tough and we are surrounded by change. We must look after ourselves and our colleagues. Remember that we are all in the process of flattening the curve of infections, but also remember that the curve that we must really flatten is that of healthcare worker infections. If we all go sick at the same time it will be a disaster. Remember your bubble, stay safe and wash your hands.
Thomas Bannister and Simon Carley