This is an early version of this document and it is likely to be updated over time as more information
about COVID-19 comes to hand. This document refers to the critically ill adult patient and is intended to be a Clinical Advisory document – for extra operational guidance, please refer to the HSE Acute Operations document as referenced above.
Although there every effort should be made to identify patients likely to have COVID-19 disease as quickly as possible, it is important to accept that there remains some possibility that a patient could present with atypical features or with gaps in clinical history. Therefore, an important part of preparation is to reinforce adherence to Standard Precautions for all patients all of the time. The most important elements of protection against transmission of any respiratory virus are likely to be scrupulous adherence to hand hygiene, cough etiquette and respiratory hygiene. Refresher training on hand hygiene and other key elements of Standard Precautions should be provided to and availed of by healthcare workers (HCW) working in ICU at this time.
There is no proven specific treatment or vaccine for COVID-19. Therefore, all clinical care is supportive in nature at this time.
These guidelines are not designed to be all-encompassing but to give a practical guide to clinicians in ICU tasked with the care of the critically unwell COVID-19 patient. The guidelines cannot substitute for local preparation, planning and infection prevention and control training, including hand hygiene, standard precautions and training in the appropriate use of PPE.
It is important that those aspects are considered carefully by all individual institutions. It is also vitally important that individual ICU/HDU beds are not utilized for isolation purposes alone and that they are reserved exclusively for clinical reasons. Again, this viewpoint needs to be established on a local institutional basis.
Early information suggests that the main critical illness manifestation of COVID-19 is severe acute respiratory infection (SARI) leading to respiratory failure. Reports of primary cardiac and renal failure are more likely to be secondary events to the SARI.
ARDS may develop secondary to the pneumonitis and can be categorized as mild, moderate or severe, as per the Berlin Classification. Sepsis and septic shock are also described as part of a Multi-Organ Failure syndrome (MOF). The China CDC publication of Feb 11th 2020 suggests a pattern of disease of: 80.9% Mild, 13.8% Mild and 4.7% Severe.
Immediate Implementation of Infection Prevention and Control (IPC) Measures*
• Critically ill patients who are likely to require procedures that generate aerosols should be cared for in a room with appropriately-controlled ventilation (negative pressure or neutral pressure room NOT positive pressure). However, where such a room is unavailable, a single room without controlled ventilation may be used – the door of which should remain closed.
• Aerosol generating procedures (AGPs) include;
• Isolation signage should be placed at the entrance to the room to restrict entry and indicate precautions required.
• A record of all HCW in contact with a patient must be maintained - the number of HCW in contact with the patient should be kept to the minimum
• Where possible, use single use/disposable equipment or dedicate patient care medical
devices to single patient use (e.g., stethoscopes). To minimize risk of disturbance of concentration and risk of contamination of the item, staff should not bring mobile telephones or pagers into the patient’s room.
• Patient chart/records should not be taken into the room. For Electronic Health Records a designated workstation should remain in the room with the patient.
• All waste in the isolation room should be disposed as Category B waste – healthcare risk waste (otherwise known as clinical/infectious waste)
• Refer to HSE-HPSC IPC guidance for information on cleaning/decontamination of equipment and the environment.
*Refer to most recent version of HSE-HPSC Interim IPC precautions for Possible or Confirmed 2019 novel Coronavirus, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and Avian Influenza A in Healthcare Settings
• To be worn by ALL staff and visitors entering the room where a suspected, or confirmed case is being cared for
• An adequate supply of alcohol-based hand rub must be available outside and inside the patient’s room
• PPE should be available outside the patient's room for donning prior to room entry
• A buddy system to observe donning and doffing of PPE is recommended
• In addition to standard precautions, the following PPE for contact and droplet precautions should be used by all HCW involved in patient care:
• For aerosol generating procedures put on a minimum of a FFP2 respirator instead of surgical
mask and fit check.
**Given that an accidental disconnection or extubation (AGPs) can occur at any time in ICU it can be argued that a FFP2/3 should be worn at all times.
Please note the extra bacterial/viral filters that can be placed on both the inspiratory limb (upper left) and expiratory limb (left lower) of this ventilator (Hamilton portable ventilator).The other filter at the patient end (pink) is also a bacterial/viral filter, but differs as it also operates as a HME.
Removing PPE In Patient’s room
Removing PPE In ante room or directly outside patient’s room Ensure door is closed
Considerations for the pregnant patient.
Health Library Ireland, Health Service Executive. Dr. Steevens' Hospital, Dublin 8. Tel: 01-6352555/8. Email: firstname.lastname@example.org