Coronavirus disease 2019 (COVID-19) has tested the resilience of health care systems on a global scale. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the infectious agent of COVID-19, was first identified in Wuhan, China on December 31st, 2019. In only a few months, the virus resulted in a pandemic that was declared by the World Health Organization on March 11th, 2020.1 As of October 21st, 2020, it has infected nearly 41 million people with over 1.12 million deaths worldwide.2 The United States leads all countries in COVID-19 cases with the state of Texas trailing only California.3 Moreover, the greater Houston area ranks fourth in the nation in confirmed cases.4
The detrimental effects of COVID-19 are more commonly observed in adult patients, though children can also display symptoms. While uncommon, pediatric patients infected with SARS-CoV-2 can develop severe sequelae such as multisystem inflammatory syndrome in children and adolescents.5 Because of COVID-19’s ubiquitous impact, hospital systems have followed strict personal protective equipment (PPE) guidelines to minimize viral transmission within the hospital for both health care staff and patients.6–8
Texas Children’s Hospital (TCH), the largest pediatric hospital in the nation, resides within the Texas Medical Center (TMC) in the city of Houston. With a staggering number of patients having presented with SARS-CoV-2 infection within the TMC, health care professionals are being challenged to maintain quality patient care while following appropriate safety measures. Medical providers are at higher risk of contracting SARS-CoV-2 while managing COVID-19 patients given the prevalence of both nosocomial and asymptomatic infections.8–13 It has also been reported that SARS-CoV-2 can remain aerosolized for up to 3 h and remain on surfaces such as stainless steel and plastic for 72 h if not properly cleaned.14 More stringent regulations regarding use of PPE have contributed to an appreciable reduction in cases associated with hospital staff.15 However, while it has been shown that PPE can minimize transmission of the virus, the extent to which PPE should be utilized to safely protect health care providers and patients is a topic of debate in the literature.8
TCH has been at the forefront of the COVID-19 pandemic, which has provided us a unique experience managing surgical patients with PPE. The process of designing and implementing PPE protocols, however, has not come without its own set of difficulties. In accordance with the Centers for Disease Control and Prevention (CDC) guidance, governmental regulations, and our internal infrastructural recommendations, we have undergone numerous modifications to provide a safe environment for all members within our institution. Consequently, in this report we will discuss the evolution of our surgical PPE protocols, describe their distribution within our institution, and delineate the major lessons learned from this experience.
PERSONAL PROTECTIVE EQUIPMENT
On April 2nd, 2020, our institution put forth its first protocols that were initially created to handle an Ebola crisis. The basic PPE requirements included donning double gloves, a gown, an N95 mask, and eye protection. In addition to these measures, surgical staff were instructed to don shoe covers and a surgical mask over the N95 respirator. If an individual who had failed fit testing was required to be in the procedure, a controlled-air-purifying respirator was worn prior to entering the operating room (Figure 1). The surgical team was also originally monitored through the donning and doffing process by a designated observer who was also obligated to wear full PPE. During the doffing process, the observer was responsible for dispensing hand sanitizer on the gloves before removing them to prevent contamination. Upon completion of the surgical procedure, a protective drape was placed on the floor within the operating room for all surgical personnel to dispose of their PPE. All waste was then placed in a biohazard bag following any surgical procedure. Lastly, it was mandated that the surgical team members shower after completion of each operation.
At the beginning of the pandemic, our institution enforced a “runner” system in which we designated an individual to help provide any additional PPE and surgical equipment that were requested by the surgical team. During the months of March and April, this runner, who had no direct patient contact, remained outside of the operating room and maintained full PPE coverage to minimize any potential risk of exposure. With new and adapted information distributed almost daily from the CDC, staff members felt compelled to follow strict PPE rules regardless of direct exposure to patients and their preoperative screening results.
While it was imperative to develop and implement PPE protocols to protect our health care workers and patients, we aimed to design a more efficient system without compromising on safety. As we looked within our internal infrastructure combined with changing guidelines from the CDC, we continued to modify our initial approach to create a more robust and efficient system while still maintaining proper precautions. Specific changes to our protocols included eliminating the mandated use of shoe covers and an additional surgical mask over an N95. It was also not required for the observer to wear full PPE, and the dispensing of hand sanitizer was no longer necessary prior to doffing gloves. Furthermore, the team did not have to discard their PPE on a protective drape nor did they have to place the disposable items within a biohazard bag at the end of the surgical procedure. Perioperative personnel were also not mandated to shower following each case. Lastly, the runner was only required to don a surgical mask and goggles. Many of these modifications have led to our current donning and doffing protocol for perioperative care designed and utilized by our providers.
Donning and doffing
The anesthesiology department at TCH has devised a performance checklist for all providers to follow to ensure proper safety precautions in donning and doffing PPE. When this checklist was originally implemented, the observer was required to examine the donning and doffing process of all members caring for this patient population including surgeons, anesthesiologists, nurses, and surgical technicians. However, as the providers became more familiar with the requirements, a collective team approach has been adopted in which members observe each other don and doff PPE.
The sequential order in which this protocol is executed is crucial to reduce the risk of intraoperative transmission (Table 1). To begin, all jewelry and personal items must be removed prior to entering the operating room. Team members then don gloves after they perform hand hygiene. Afterwards, isolation gowns are worn and tied in the back. Importantly, the gloves are placed under the sleeve of the gown. Health care providers then don an N95 mask, followed by goggles or a face shield for eye protection. To complete the donning process, a second set of gloves are placed over the sleeve of the gown. It should be noted that double gloving is standard in the operating room when at risk of contact with blood or other bodily fluids.