ENTUK Guidelines for changes in ENT during COVID-19 Pandemic

20 March 2020

Guidance based on experience in New Territories Eastern Cluster NTEC = New Territories hospital cluster, Hong Kong.

Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis. 2020.  Long et al.  J Evid Based Med. 2020;1–9.

Definitions of Vulnerable people, long term conditions and High risk individuals from https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults accessed 19 March 2020

 

Abbreviations

• AED = Accident and Emergency Dept
• AIIR = Air-borne Infection Isolation Room
• N95 = face mask that filters out a minimum of 95% efficiencies for filtering facepiece respirators (National Institute of Occupational Safety).
• FFP3 = Class P3 face mask that requires 99% efficiencies for filtering facepiece respirators
   

---

Priorities

1. Fit test for N95, FFP2 & FFP3 face mask for all staff

2. Re-educate staff on

• Putting on Personal Protective Equipment
• Hand hygiene
• Correct technique for Aerosol-generating procedures (AGPs)
  • Aerosols generated by medical procedures are one route for the transmission of the COVID-19 virus
  • The following procedures are considered to be potentially infectious AGPs (relevant to ENT).
    • Tracheotomy/tracheostomy procedures;
    • Intubation, extubation and related procedures;
    • Open suctioning
    • Bronchoscopy
    • Surgery in which high-speed devices are used
    • Manual ventilation
    • Non-invasive ventilation (NIV) e.g. Bi-level Positive Airway Pressure (BiPAP) and Continuous Positive Airway Pressure ventilation (CPAP);
    • High-frequency oscillating ventilation (HFOV)
    • High-flow Nasal Oxygen (HFNO)
    • Induction of sputum
       
  • (COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.0.)
    
    For patients with suspected/confirmed COVID-19, any of these potentially infectious AGPs should only be carried out when essential.
     
• Where possible, these procedures should be carried out in a single room with the doors shut.

• Only those healthcare staff who are needed to undertake the procedure should be present.

• A disposable, fluid repellant surgical gown, gloves, eye protection and a FFP3 respirator should be worn by those undertaking the procedure and those in the room.
  
  (COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.0.)
  
  Certain other procedures/equipment may generate an aerosol from material other than patient secretions but are not considered to represent a significant infectious risk. Procedures in this category include:
   

• administration of pressurised humidified oxygen;

• administration of medication via nebulisation.
  
  Note: During nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol.

  Staff should use appropriate hand hygiene when helping patients to remove nebulisers and oxygen masks.
  
  (COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.0.)

3. Stop all non-urgent Elective Surgery and Outpatients

• Continue emergency cases
• Continue cancer cases
• Prioritise other urgent cases based on whether the clinical deterioration outweighs the risk of catching COVID19 and experiencing morbidity or mortality
  • Vulnerable people (Household isolation for coronavirus PHE)
    • Pregnant
    • Aged 70 or older
    • Under 70 with long term conditions
      • Respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis
      • Chronic heart disease, such as heart failure

      • Chronic kidney disease

      • Chronic liver disease, such as hepatitis

      • Chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy

      • Diabetes

      • Problems with your spleen –for example, sickle cell disease or if you have had your spleen removed

      • A weakened immune system as the result of conditions such as HIV and AIDS, or medicines such a steroid tablets or chemotherapy

      • Being seriously overweight (a BMI of 40 or above)

    • Clinical conditions with an even higher risk of severe illness from COVID-19 should rigorously follow Social Distancing Measures

      • ​​​​​​​People who have received an organ transplant and remain on ongoing immunosuppression medicationPeople with cancer who are undergoing active chemotherapy or radiotherapy

      • People with cancers of the blood or bone marrow such as leukaemia who are at any stage of treatment

      • People with severe chest conditions such as cystic fibrosis or severe asthma (requiring hospital admissions or courses of steroid tablets)

      • People with severe diseases of body systems, such as severe kidney disease (dialysis)
         

4. Decrease patient contact

• in ward
• in outpatients
• reserve manpower,
• reserve resources
   

5. Educate staff to practice social distancing

• Especially at meal times and meetings.
• Aim to keep 2metres (3 steps away)
   

6. Establish the tracheostomy protocol for confirmed case within department (see full ENTUK guidance for more details)

• Avoid if possible e.g keep intubation especially if there is a reversible cause for airway obstruction
• Avoid use of high flow oxygen/AIRVO
• Full PPE according to the hospital guideline
• Arrange senior staff to do in day time e.g senior head & neck surgeon
   

7. Recommended PPE in different settings for ALL patients (not just suspected or confirmed COVID19 patients)

	AIIR for suspected/ confirmed COVID-19	Triage station/ fever room	Surveillance ward/ cubicle/ side room	Aerosol generating procedures (AGP)	Other wards	Other patient areas (outpatients/ radiology etc)	Other areas with no direct patient contact
Hand hygiene	Yes	Yes	Yes	Yes	Yes		Yes
Type of mask	FFP3	FFP3	FFP3	FFP3	FFP2		FFP2
					Standard precautions +/- transmission based precautions		N
Isolation gown	AAMI level 1 or AAMI level 3 if splashing anticipated. Or AAMI Level 1 + waterproof apron						N
Disposable gloves	Yes	Risk assessment	Risk assessment	Yes			N
Eye protection	Goggles/ face shield	Eye visor/ goggles/ face shield	Eye visor/ goggles/ face shield	Goggles/ face shield			N
Hair cover	optional	optional	optional	optional			N

*Shoe covers not recommended

 

8. Recommended PPE during different procedures in ENT for ALL patients (not just suspected or confirmed COVID19 patients)

• Make sure endoscopy is absolutely necessary for management of the patient. Endoscopy should be carried out by video monitoring if possible, rather than direct viewing through eyepiece.
• Consider / avoid use of local anaesthetic to reduce chance of droplet spread from sneezing or coughing. If use is deemed necessary use soaked pledgets rather than spray.
   

 

	History taking	Procedures/ examination
		Flexible laryngoscopy/ nasendoscopy Oral, nasal & ear open suction Change of tracheostomy tube	Endoscopic guided insertion of feeding tube Change of tracheoesophageal prosthesis Deep throat examinations  (e.g. checking of tonsil mass, ulcer at retromolar trigone region)
Hand hygiene	Yes
Type of mask/ respirator	FFP2	FFP3
Isolation gown	No	AAMI level 1
Disposable gloves	Yes.  Use separate pair of gloves for each patient. The same applies to accompanying nurse. Gloves have to be appropriate to allow palpation, use of switches and fine controls (some of the polythene gloves are not suitable).
Eye protection The eye is an important point of entry for viral infection.	Visor / Face shield*	Face shield
Hair cover	Optional

 

Miss May Yaneza, Consultant ENT Surgeon