This document is intended for patients in NSW emergency departments with possible or confirmed COVID-19 infection .1 Airway interventions during basic and advanced life support may result in aerosol generation. Aerosol generating procedures (AGPs) must not be performed on patients with high probability of COVID-19 infection until all healthcare workers within the treatment space are wearing PPE for contact, droplet and airborne precautions.
Goals of treatment and resuscitation plans should be clearly escalated, communicated and documented as soon as possible after presentation to hospital.
Assess safety for self and others
First responder to do PPE for contact and droplet precautions.
Assess patient response by talk and touch
Signs of life (e.g. chest and limb movement) can be visually assessed from a distance until PPE is available.
Send for help
IMPORTANT - Additional responders to don PPE for contact, droplet and airborne precautions now.
Opening the airway is not an AGP and can be performed by first responder using contact and droplet precautions.
WARNING - Intubation is an AGP and should only be performed by an experienced operator trained in use of PPE for airway management. Airborne precautions are required.
WARNING - Insertion of a laryngeal mask airway (LMA) is an AGP and is a temporary alternative to intubation. Airborne precautions are required.
Look, but do not listen or feel for breathing.
WARNING - Bag-valve-mask ventilation is an AGP. Airborne precautions are required.
WARNING - Chest compressions are potential AGP. Airborne precautions are required.
IMPORTANT - Defibrillation is not an AGP. Do not delay. Defibrillation can precede compressions using contact and droplet precautions.
Prevalence of COVID-19 infection varies across NSW. When local prevalence is low, clinicians should undertake a risk assessment for each patient regarding the probability of COVID-19 infection. When local prevalence is high, staff may be directed by the ED director/nurse manager to manage all patients in the emergency department as if they have high probability of COVID-19 infection.
Clinical decision making points
Individual goals of care should be discussed for all patients, clearly escalated, communicated and documented by multidisciplinary health teams. This includes consideration of ‘not for resuscitation’ (NFR) orders, end-of-life wishes and/or advance care directives.
Senior members of the resuscitation team must also consider the most likely outcome of any resuscitation attempt to determine if commencing or continuing CPR will result in overall benefit for the patient. These decisions need to be made in real-time and are best done in consultation with other specialist teams.
Healthcare worker and patient safety
One responder using contact and droplet precautions should commence resuscitation immediately. All basic life support (BLS) interventions that are not aerosol generating procedures (AGP) should be performed without delay. Early defibrillation of shockable rhythms is extremely important.
Additional responders should wear PPE for contact, droplet and airborne precautions so that all resuscitation interventions (including AGP) can proceed as quickly as possible. PPE should be worn for the duration of the resuscitation event and doffed when exiting the treatment space.
AGP PPE includes contact, droplet and airborne PPE such as, P2/N95 respirator mask, eye protection, goggles or face shield, fluid resistant long-sleeved gown and disposable non-sterile gloves.
The use of hair and shoe coverings should be considered per local health facility policy.
PPE kits for AGP should be available in resuscitation bags and trolleys.
Avoid exposure to infectious aerosol
Limit the number of healthcare workers in the treatment space at all times. Signs of life can be visually assessed from a distance until PPE is available.
Wherever possible, care should be delivered in a negative pressure or single room, and preference given to use of disposable or dedicated equipment.
Evacuate the area of all other patients, visitors and non-responding staff. Only transport a patient to another location if the risk of contamination during transportion can be mitigated. Post resuscitation, the treatment space should be cleaned per infection control guidelines.
Oxygen therapy and masks
Oxygen therapy using a Hudson mask (6L/min) or non-rebreather mask (10L/min) is not an AGP and should be used as indicated. Surgical masks contain the spread of droplets and aerosol that may be generated during BLS. If first responders are concerned about aerosol generation, they may leave an existing surgical mask in place with an oxygen mask applied over the top until additional responders in airborne PPE arrive. Alternatively consideration may be given to covering an oxygen mask as additional protection (e.g. with a surgical mask).
Despite limited evidence, consensus suggests that:
- LMA gastric port should be occluded to prevent aerosol spread
- oxygen should be turned off at the wall when delivering a shock
- use of bag-valve-mask ventilation should be minimised.
Known or potential AGP that occur commonly during resuscitation and induction include:
- manual ventilation using a bag-valve-mask (BVM)
- open airway suctioning
- chest compressions (potential AGP)
- intubation/insertion of LMA
- high flow O2 therapy
- nebuliser therapy.
- When COVID-19 risk status is “Red” alert, this may be all patients. When COVID-19 risk status is “Amber”, staff may be directed by the ED director/nurse manager to manage all patients in the emergency department as if they have high probability of COVID-19 infection. When COVID-19 risk status is at “Green” alert, clinicians should undertake a risk assessment for each patient regarding the proNbability of COVID-19 infection.
Refer to CEC Infection Prevention and Control Guidelines Infection Prevention and Control Guidelines for Management of COVID-19 in Healthcare Settings
Refer to COVID-19 Infection Prevention and Control Response and Escalation Framework
Refer to National COVID-19 Clinical Evidence Taskforce
Emergency Department Community of Practice (EDCOP) chaired by Dr Clare Skinner and Natalie Wright in collaboration with the Emergency Care Institute (ECI), Agency for Clinical Innovation (ACI) and multiple COVID19 pandemic preparedness COPs and relevant NSW Health services.
Dr David Gattas on behalf of ICU COP, EDCOP ECI, multiple other NSW Communities of Practice representatives and leads including Cardiac, Respiratory, Anaesthetic Paediatric COP, Adult and Paediatric ICU and the Clinical Excellence Commission (CEC).
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning
For use by
To assist ED clinicians with safe practice of ALS and CPR in ED during COVID-19 pandemic.