Duke Health’s COVID-19 response has been rapidly evolving as needs arise across our health system and in our communities. These seemingly constant changes to our normal practices can feel frustrating to our team members who are working to care for our patients and doing their best to stay informed. We know that the ‘why’ is important to team members, too – not just knowing what changes are made as we learn more about the disease and its management.

We have answered some common questions from our team members-those working in the COVID units and those who are not but are just curious. Also included are the rationale for why certain decisions have been made. Where possible, we have also included a link to the most current document that explains the specific recommendations and guidance. 

Thank you to all our team members for your dedication to our patients and for staying up to date on the latest recommendations to keep yourself, your team members and your patients safe.

Click a question below to expand the answer.

 

CLEANING AND DISINFECTION (ROOM, EQUIPMENT)


The Occupational and Environmental Safety Office and Infection Prevention teams have reviewed the EPA guidelines for determining which disinfectants and cleaning products are effective against SARS CoV-19 type 2 (COVID-19). The products available at Duke Health are effective against COVID-19. It is important that team members follow the instructions for use, allowing for the sufficient contact time to pass before proceeding to use on another patient. 


Information as to how long to wait before staff can safely enter a COVID room without PPE is provided in the link and includes distinguishing between an ICU room (negative pressure or HEPA filter in use) and a general inpatient room (negative pressure or HEPA filter in use).  


Curtains are to be changed or sprayed with soft surface sanitizer at discharge with all Contact isolation rooms per your facility’s policy.  
Ideally the use of ultraviolet light disinfection would follow manual cleaning of the room.
An informational sheet has been created about the handling of linen and trash in a COVID-19 room. 


All patient care equipment should be cleaned using a hospital-approved EPA registered disinfectant that is effective against SARS CoV2.  After use in a COVID room, the equipment will be cleaned using a 2-step method.  Listed below are the steps to clean and disinfect equipment-with and without an anteroom.

  • With anteroom: Clean equipment in the patient’s room, while fully donned in PPE, and move equipment to anteroom once clean. Doff PPE according the established procedures, perform hand hygiene and don clean gloves. Clean equipment again in the anteroom and then hand or roll equipment to observer/buddy to remove into the hallway. 
  • Without anteroom: Perform initial cleaning in the patient room and move equipment to hallway once clean. Doff PPE according to the established procedures and exit the room; after performing hand hygiene and donning clean gloves, clean the equipment again in the hallway.

 

DUHS TEAM MEMBER EXPOSURE


Before universal masking and employee screenings were initiated throughout DUHS, Employee Occupational Health and Wellness (EOHW) and Infection Prevention performed contact tracing and follow-up evaluations of team members who may have been exposed to COVID-19 positive patients.  However, with universal masking and screenings, the incidence and risk level of team member exposures to COVID-19 positive patients have decreased. EOHW remains available to staff to assist them with their concerns regarding potential exposures. 


Team members should notify EOHW in the event of a breach in PPE or an unanticipated exposure. Call EOHW via the COVID Hotline from 8 am to 8 pm (919-385-0429, option 1) or call the BBF Hotline (919-684-8115) after hours.


 

DUHS TEAM MEMBER FACE MASKS


While personal, homemade face masks are great to wear when you are not at work, cloth masks are not considered PPE for healthcare personnel by the CDC because the capability of these masks to protect the HCW is unknown. Therefore, they are not recommended for use by DUHS team members while at work. The PPE that is used at Duke Health undergoes an extensive review and evaluation prior to deployment for team member use.


There are certain times when you and your peers will need to be closer than the 6-foot physical distancing recommendation, such as during shift report and unit quality safety huddles. Whether you are assisting with a procedure or patient care activities, wearing your Duke-issued face mask when in close proximity to other people keeps you and your coworkers safe while you care for patients. 


Do not touch your masks without performing hand hygiene. This practice alone will prevent contamination. To avoid potential contamination, perform hand hygiene, remove mask by touching the elastic ear loops or ties, fold the mask so that the outer layer is folded on itself, and then place it into the brown paper bag. This method decreases any possibility of contamination while the mask is inside the bag.  Once safely stored in the paper bag, perform hand hygiene again.


 

FACE SHIELDS


Leaning forward slightly helps in two ways. First, it helps us to slow down and think about what we are doing which makes for safer doffing.  Second, it allows gravity to assist so that when we remove items, they move down and away from our faces, thereby reducing the chance of coming into contact with our face or clothing. 


If the plastic forehead piece of the face shield irritates your skin, try wrapping the plastic piece that touches the skin to provide cushion with a stockinette. You only need an 8-inch piece. Next, tape the piece of stockinette to the plastic forehead piece of the face shield. Avoid using adhesives directly on the plastic forehead piece because it could impede cleaning and disinfection. You can also apply moleskin or duoderm to your skin where the face shield touches the skin.


No. This does not mean that there is something wrong with your N95 respirator.  Always perform a seal check when donning an N95 respirator to ensure you have a good seal prior to donning your face shield.  The disposable face shields with the foam forehead piece lay close to the respirator.  As we breathe in and out through the front filter media of the respirator, our warm breath hits the face shield, mixes with the cooler room temperature causing the face shield to fog up and produce condensation. 


Face shields are permitted to be worn by care providers who come within 6 feet of patients who are on Droplet precautions (including Droplet/Contact precautions) for a duration longer than 10 minutes. During this time when all of us are wearing a face mask all day long, wearing a face shield over your mask helps protect your mask from contamination while taking care of a patient on Droplet precautions.  Remember to perform hand hygiene prior to touching your mask and to clean and disinfect the face shield upon leaving the patient’s room.


 

GOWNS


While it may appear that our gowns used while caring for patients with suspected or confirmed COVID-19 infection are changing frequently, be assured that Duke Health ensures that each different type of gown is safe and meets the OESO requirements for safety. Some gowns are disposable, and some are reusable; please pay close attention to the instructions provided as to which are reusable and which are disposable. Note, “reusable” refers to the gown being laundered by a contracted company for reuse. Reusable gowns are only intended for one patient care episode and should be placed in the designated “gown-only” linen bag and hamper after a single use. They should not be placed in the blue linen bag with other hospital linens. 


No. While the CDC recommends the use of gowns for the care of patients with suspected or confirmed COVID-19 infection, there is no recommendations from the CDC that states that the back must be completely covered. It is more important, the CDC stresses, to have the gown worn securely before entering a COVID + or COVID rule out room so that the front of the body remains protected. The front of the gown is where most contamination occurs, while the likelihood of contamination on someone’s back is quite low. Other reasons the back is open on many isolation gowns is for ventilation and comfort for your body. It also allows for easy air flow to and around PAPR units if one is worn. 


 

N95s


Yes. Duke Health’s N95 respirator decontamination process uses vaporized hydrogen peroxide that safely decontaminates our N95 respirators for reuse. This process has been thoroughly evaluated and validated by Duke OESO as well as other healthcare facilities, and it is a safe and effective measure that prolongs the use of our N95 respirators and helps keep our supply of N95s in good standing. In fact, Duke Health received FDA authorization for the use of this process, and the CDC considers the decontamination process that we use to be among the top 3. 

  • Watch this video for more information about the N95 decontamination process. 

No. DUHS team members must use only NIOSH-approved N95 respirators approved by OESO and Infection Prevention while caring for patients on Airborne and Special Airborne Contact Precautions. The N95 decontamination process is safe and effective.  


No. The risk of infection without proper PPE has to do with close contact of the infected patient via inhaling droplets. Close contact is considered being within 6 feet of an infected person when they are coughing or sneezing, or if you are performing an aerosol-generating procedure. The other route of infectivity would be caused by inoculation into the eye, nose or mouth, either directly from droplets or by self-inoculation by touching your eyes, nose or mouth with unclean hands. With this in mind, the observer at the door is not at risk of infection from droplets due to the distance nor the short period of time that the door would be open to help the person providing direct patient care inside the room with unsnapping or untying a gown, handing in supplies, etc. Cleaning shared equipment and hand hygiene is essential to your safety and the safety of those around you. 


No. Being able to smell scents does not indicate a leak in the mask. These are healthcare N95 respirators which allow smells to come through while filtering out airborne germs.  


According to OESO, staff should follow these steps so that the N95 can be evaluated: Individually place and seal the N95 of concern in a Ziploc bag with these 4 pieces of information written on the outside of the bag with a permanent marker:

  1. Name and Duke ID of the person reporting it
  2. Unit where this PPE use was attempted
  3. What was the user’s original fit tested model and size of N95
  4. Short description of the issue.

Then place the bag in the reprocessing bin with other used N95s.


 

OTHER QUESTIONS


No. There is a small amount of aerosolization that occurs when flushing the toilet; however, there is no evidence that waste from a patient with suspected or confirmed COVID-19 infection is more infectious than waste from a patient who is not infected by COVID-19. 


While this is not solely an Infection Prevention decision, Infection Prevention and Infectious Disease teams have worked with physician teams to establish guidance on removing patients from isolation. 


While this might not be specifically stated on each document provided to staff on the COVID-19 website, DUHS team members are provided with the rationale for why we don and doff our PPE in this manner during their initial training as well as via training videos that are created by CEPD.  Key point to remember is to slow down. When we slow down, we are less likely to make mistakes.


Symptoms can develop as soon as 2 days after exposure or in as many as 14 days after exposure. Symptoms can include fever, cough and shortness of breath. If team members have been exposed to someone at work who has COVID-19 and these symptoms develop, call the Duke Health COVID-19 hotline to notify Employee Occupational Health and Wellness and arrange care.


 

OXYGEN


The maximum level of oxygen that a patient can be on prior to intubation should be an individualized decision based on consultation with the patient’s clinical care team. If a patient needs a certain therapy, such as oxygen, then all means should be taken to ensure they are provided the appropriate therapy. Remember: Team members caring for patients with suspected or confirmed COVID-19 infection should wear the appropriate PPE designated for each clinical setting to protect them while inside the patient’s room.


A patient does not require a mask at all times while inside their room on high-flow oxygen. Please review Respiratory Therapy Guidance during COVID-19 for details on this practice.  Having a patient wear a mask while receiving this type of therapy while inside of their rooms can be quite cumbersome and distressing for the patient who is already struggling to breathe.  Staff are protected with all necessary PPE while in the patient room.  A mask would be required for the patient to provide source control while they are outside of their private room such as in the hallway during transport.


 

PAPRs


The manufacturer designs the shrouds such that they be worn on the outside of the gown to work properly.  Based on request from staff to be able to wear the outer layer inside the gown, OESO tested this with different styles of gown:  open back, closed-back, wrap-around, over-the-head, disposable, and reusable.  In every instance, when the outer shroud was tucked inside the gown, the gown inflated.  When OESO then simulated patient care activities such as bending over a bed rail, the air in the gown was forced back up inside the hood.  Because this overcomes the positive pressure of the PAPR and the possibility exists that the air reentering the hood into the user's breathing zone contains some unfiltered air, we cannot ensure the PAPR is adequately protective.


The initial disinfection of a shrouded hood should be done with the gown in place so arms are not exposed.  A subsequent wiping can be done without the shroud touching the wearer's arms, and at that point most of the hood has already been disinfected.

If an observer is present, with any type of PAPR hood or shroud, it is a good idea to have them assist with wiping it off with a disinfectant wipe, particularly areas harder to reach in the back.


 

PATIENT FACE MASKS


Staff are adequately protected from airborne infectious droplets by wearing the appropriate PPE.   For TB, which is truly an airborne disease, we do not put surgical masks over patients on Optiflow or BiPAP. Patients must be allowed to breathe freely in their rooms, especially while they may already be struggling to breathe inside of their own room. Putting a surgical mask on a patient would only be required if the patient was outside of their room in a common area. Common areas are where we need source control, as not everyone may be wearing the necessary PPE for patients who have suspected or confirmed COVID-19 infection.  We have made the practice of masking patients while on Optiflow or BiPAP optional as one additional component of an infection prevention bundle to reduce the overall environmental bioburden of COVID.  Masking patients can only be performed when certain criteria are met including: 

  • The patient agrees to have the mask placed (i.e. it is not causing distress)
  • Masks are only placed on the patients when providers must perform direct patient care activities that require a prolonged amount of time spent within 6 feet of the head of the bed (i.e. not for other room entry to check IV pump, etc.)
  • The mask is only applied while the provider(s) is/are in the room with the patient and is removed before leaving the room.

Yes. Patients and visitors who arrive at Duke are permitted to wear their own homemade face masks, per hospital mandate.


The patient should wear a mask when they are outside of the room in either inpatient or outpatient settings. In the outpatient setting, if the patient can tolerate wearing a mask, the patient can wear a mask in the exam room.


 

PHYSICAL DISTANCING AT WORK


Even though we are practicing universal masking, it is tempting at times to be in close proximity with each other as we are used to doing, such as during huddles, breaks, and lunches. It is important to stay at least 6 feet away from others while at work as much as possible. This is particularly important during breaks and lunches, when there is a chance that your mask could be off while eating/drinking. 

  • See Keeping Yourself and Your Team Members Safe for more information.

Wearing your face mask while in common areas such as the breakroom, workroom, workstations, cafeterias, courtyards and nurses’ stations, helps reduce the potential spread of COVID-19 from team members who could have COVID-19 infection but are asymptomatic. Please wear your mask in common areas at all times when not actively eating, drinking or using the restroom.


 

PPE GENERAL QUESTIONS


The CDC has disseminated guidelines for healthcare institutions about providing PPE for staff who will be providing care to patients with suspected or confirmed COVID-19 infection. These guidelines were determined based on the amount of exposure time and the intensity of patient care administered as both of these factors determine the risk of COVID transmission  The DUHS guidelines for appropriate PPE during the COVID-19 response make a distinction in the PPE worn by inpatient team members and the PPE worn by outpatient team members. Inpatient team members have a more prolonged, intense exposure to patients with suspected or confirmed COVID-19 infection who spend a prolonged amount of time unmasked in their patient rooms, whereas outpatient team members have a more limited, shortened exposure to masked patients. Whatever the location, DUHS Infection Prevention, OESO and Materials Management work diligently to ensure that our team members are adequately protected against COVID-19 while caring for our patients.


While we have all heard of healthcare institutions that have a limited supply of PPE available for their staff, Duke Health has worked hard to ensure that our team members are protected and have ample amount of supplies to care for our patients. DUHS Procurement, OESO, Materials Management and Infection Prevention are at the forefront of evaluating different types of PPE so that we can have sufficient supplies while keeping our team members safe. While the PPE might look different than what we are used to seeing, it has all gone through a rigorous approval process and meets the level of protection needed for our team members to safely care for our patients.


If you believe you may be allergic to the masks provided, consult with Employee Occupational Health and Wellness for assistance (919-684-3136). Be sure to properly wear and store your mask throughout the day while at work.


According to the CDC, wearing double gloves is not necessary.  You may change your gloves while in a COVID-19 room.  Remember to follow standard practices and perform hand hygiene after glove removal prior to putting on a new pair.  The patient’s care should be planned and bundled so that all of the clean activities are performed first, followed by the soiled activities, such as emptying urinary collection bags and cleaning up stool.  


Team members removing trash from anterooms must don gloves prior to performing the activity. Make sure the trash bag is kept away from clothing. After the trash is disposed of in the appropriate receptacle in the Soiled Utility Room, remove gloves and perform hand hygiene.


 

SHOES AND SCRUBS


DUHS team members have quite a few options on what to do with their work shoes: 1) You can designate a pair of work shoes that are only worn at work and are kept in your locker to use while caring for patients. 2) You can remove your work shoes prior to entering your home to prevent possible contamination inside your home. 3) You can carefully wipe down your shoes and allow them to dry prior to leaving work. Shoe covers are available to accommodate up to a shoe sized 16 for staff who need to don shoe covers for patient care. 


An extra pair of scrubs might come in handy if the scrubs become grossly contaminated with blood or body fluids. However, Duke Health will provide a clean pair of scrubs to wear so that you can complete your shift. If there is a breach in PPE while you are caring for a patient with suspected or confirmed COVID-19 infection, Employee Occupational Health and Wellness can assist you with an exposure evaluation by contacting the Duke Health COVID-19 Hotline.


 

SWAB SQUAD


When a COVID-19 test is warranted and ordered, the patient care nurse can notify the team of DUHS team members (called the Swab Squad) who have been trained and are available to swab the patient to ensure that the sample is obtained correctly.


The Swab Squad typically asks that the nurses on the unit provide the swabs. The Swab Squad may have a few sets of swabs on hand in case a specimen is dropped or contaminated or if the nurse is unable to locate one. This is in an effort to reduce the time it takes to get the specimen collected and sent (reduce turnaround time). 


The patient’s nurse should still do the scanning and send it to the lab. The Swab Squad was put in place to simply standardize the way a specimen is collected. Having a smaller group perform the actual swabbing reduces the potential for errors across DUHS. 


Swabbing can be a droplet producing procedure, though some may disagree. When a patient is swabbed appropriately, the swab must be inserted about 6-8 inches through the nasal passage. This may cause the patient to cough or sneeze while the healthcare worker is in extremely close proximity to the patient’s airway, so PPE would be appropriate for that scenario. 


 

TESTING


Point of Care Testing (POCT) is not a practical way to test every patient for COVID as it requires a significant amount of hands-on time to perform the test (up to 15 minutes per test), requires a machine in close proximity to the patient, and has a very low throughput (one test per run).  Running 100 POCT would take up to 1500 minutes (25 hours) active technologist time versus a laboratory-based platform that can run approximately 100 samples in 8 hours.  Therefore, when trying to perform tests on a large population, it does not make sense to use a POCT platform for all patients.  The microbiology laboratory has a large capacity to perform tests at this time and the overall turnaround time is usually 8 hours or less.  POCT testing decisions went through an application and committee decision process and we continue to evaluate the application of these tests as time goes on and we gain experience. 


There are testing guidelines available that list the type of patients who qualify for administrative and POCT. Administrative tests are typically used for patients who may be preparing for a high-risk procedure or treatment, such as surgery or hematopoietic stem cell transplant. Many skilled nursing facilities or rehabilitation centers also require testing prior to admission or returning to the facility. POCT is often used for expedited results in the Emergency Department. 


When a patient’s provider deems a POCT test is warranted and acceptable based on the above criteria, the provider orders the test in EPIC.


According to the test ordered by the provider and the presence/absence of symptoms, the indications for type of isolation and PPE will be listed.


 

TRANSPORT


The PPE that team members wear when performing unit-to-unit transfers depends upon the role of the team member and care being provided by the team member during transport.