ACEP COVID-19 Field Guide

Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic

Establish a process to identify and manage individuals with suspected or confirmed SARS-CoV-2 infection

• Ensure everyone is aware of recommended IPC practices in the facility.
• Post visual alerts (eg, signs, posters) at the entrance and in strategic places (eg, waiting areas, elevators, cafeterias) with instructions about current IPC recommendations (eg, when to use source control and perform hand hygiene). 
• Dating these alerts can help ensure people know that they reflect current recommendations.
• Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed.
• Options can include, but are not limited to, individual screening on arrival at the facility or implementation of an electronic monitoring system in which individuals can self-report any of the above before entering the facility.
• Health care personnel (HCP), even if fully vaccinated, should report any of these three criteria to occupational health or another point of contact designated by the facility: (1) a positive viral test for SARS-CoV-2; (2) symptoms of COVID-19; or (3) those who meet criteria for quarantine or exclusion from work. 
• Additional information can be found at the CDC's "Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2."
• Generally, visitors meeting any of these three criteria should be restricted from entering the facility until they have met criteria to end isolation or quarantine, respectively. 
• Unvaccinated HCP, patients, and visitors should be offered resources and counseled about the importance of receiving the COVID-19 vaccine.

Implement source control measures

Source control options for HCP include a:

• NIOSH-approved N95 or equivalent or higher-level respirator;
• Respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators (Note: these should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated); or
• Well-fitting facemask.

Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a health care setting and is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have:

• Not been fully vaccinated; 
• Suspected or confirmed SARS-CoV-2 infection or another respiratory infection (eg, those with runny nose, cough, sneezing); 
• Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection for 14 days after their exposure, including those residing or working in areas of a health care facility experiencing SARS-CoV-2 transmission (ie, outbreak); 
• Moderate to severe immunocompromise; or
• Otherwise had source control and physical distancing recommended by public health authorities.

Fully vaccinated HCP

• Consistent with guidance for the community, HCP can choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (eg, staff meeting rooms, kitchen).
• They should wear source control when they are in areas of the health care facility where they could encounter patients (eg, hospital cafeteria, common hallways and corridors).

Patient visitation

• Indoor visitation (in single-person rooms; in multi-person rooms, when roommates are absent; or in designated visitation areas when others are absent): The safest practice is for patients and visitors to wear source control and physically distance, particularly if either of them are at risk for severe disease or are unvaccinated.
  • If the patient and all their visitors are fully vaccinated, they can choose not to wear source control and to have physical contact.
  • Visitors should wear source control when around other residents or HCP, regardless of vaccination status.
• Outdoor visitation: Patients and their visitors should follow the source control and physical distancing recommendations for outdoor settings described in the Interim Public Health Recommendations for Fully Vaccinated People.

Fully vaccinated residents in nursing homes in areas of low to moderate transmission

• Consideration could be given to allow fully vaccinated residents to not use source control when in communal areas of the facility; however, residents at increased risk of severe disease should still consider practicing physical distancing and using source control.

Implement universal use of PPE for HCP

If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below:

• NIOSH-approved N95 or equivalent or higher-level respirators should be used for:
• All aerosol-generating procedures; and
• All surgical procedures that might pose higher risk of transmission if the patient has COVID-19.
• Facilities could consider use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP working in other situations where multiple risk factors for transmission are present. 
• Eye protection (ie, goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters.

Encourage physical distancing

• In situations when unvaccinated patients could be in the same space (eg, waiting rooms, cafeterias, dialysis treatment room), arrange seating so that patients can sit at least 6 feet apart, especially in counties with substantial or high transmission. This might require scheduling appointments to limit the number of patients in waiting rooms, treatment areas, or participating in group activities.

Optimize the use of engineering controls and indoor air quality

• Optimize the use of engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals (eg, physical barriers at reception / triage locations and dedicated pathways to guide symptomatic patients through waiting rooms and triage areas).
• Guidance on ensuring that ventilation systems are operating properly are available in the following resources:
• Guidelines for Environmental Infection Control in Health-Care Facilities
• American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) resources for healthcare facilities
• Ventilation in Buildings

Perform SARS-CoV-2 testing

• Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible.
• Asymptomatic HCP with a higher-risk exposure and patients with close contact with someone with SARS-CoV-2 infection, regardless of vaccination status, should have a series of two viral tests for SARS-CoV-2 infection. 
• In these situations, testing is recommended immediately (but not earlier than 2 days after the exposure) and, if negative, again 5–7 days after the exposure. 
• However, testing is not recommended for people who have had SARS-CoV-2 infection in the last 90 days if they remain asymptomatic
• Expanded screening testing of asymptomatic HCP without known exposures is required in nursing homes and could be considered in other settings. It should be conducted as follows:
• Fully vaccinated HCP may be exempt from expanded screening testing.
• Guidance for expanded screening testing for nursing homes is described in the CDC’s Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes.
• Performance of pre-procedure or pre-admission viral testing is at the discretion of the facility. 

Create a process to respond to SARS-CoV-2 exposures among HCP and others

• Health care facilities should have a plan for how SARS-CoV-2 exposures in a health care facility will be investigated and managed and how contact tracing will be performed. Guidance on assessing the risk for exposed patients and HCP is available in the Healthcare Infection Prevention and Control FAQs for COVID-19.
• Health care facilities responding to SARS-CoV-2 transmission within the facility should always notify and follow the recommendations of public health authorities.

Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection

The IPC recommendations described below also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for Transmission-Based Precautions (quarantine) based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. In general, the following patients who are asymptomatic do not require use of Transmission-Based Precautions (quarantine) for SARS-CoV-2 following close contact with someone with SARS-CoV-2 infection:

• Fully vaccinated patients
• Patients who have had SARS-CoV-2 infection in the last 90 days

However, there may be circumstances when Transmission-Based Precautions (quarantine) for these patients might be recommended (eg, patient is moderately to severely immunocompromised, if the initial diagnosis of SARS-CoV-2 infection might have been based on a false positive test result). 

Patient placement

• Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom.
• Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shifts.
• Only patients with the same respiratory pathogen should be housed in the same room.
• Limit transport and movement of the patient outside of the room to medically essential purposes.
• Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (eg, radiology) and to other health care facilities.

PPE

• HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (ie, goggles or a face shield that covers the front and sides of the face).

Aerosol generating procedures (AGPs)

• Procedures that could generate infectious aerosols should be performed cautiously and avoided if appropriate alternatives exist.
• AGPs should take place in an airborne infection isolation room (AIIR), if possible.
• The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure.

Duration of transmission-based precautions

A symptom-based strategy for discontinuing transmission-based precautions is preferred in most clinical situations. The criteria for the symptom-based strategy are:

• Patients with mild to moderate illness who are not moderately to severely immunocompromised:
• At least 10 days have passed since symptoms first appeared and
• At least 24 hours have passed since last fever without the use of fever-reducing medications and
• Symptoms (eg, cough, shortness of breath) have improved
• Patients who were asymptomatic throughout their infection and are not moderately to severely immunocompromised:
• At least 10 days have passed since the date of their first positive viral diagnostic test.
• Patients with severe to critical illness or who are moderately to severely immunocompromised:
• At least 10 days and up to 20 days have passed since symptoms first appeared and
• At least 24 hours have passed since last fever without the use of fever-reducing medications and
• Symptoms (eg, cough, shortness of breath) have improved

A test-based strategy could be considered for some patients (eg, those who are moderately to severely immunocompromised) in consultation with local infectious diseases experts if concerns exist for the patient being infectious for more than 20 days. The criteria for the test-based strategy are:

• Patients who are symptomatic:
• Resolution of fever without the use of fever-reducing medications and
• Symptoms (eg, cough, shortness of breath) have improved, and
• Results are negative from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) tested using an FDA-authorized laboratory-based NAAT to detect SARS-CoV-2 RNA.
• Patients who are not symptomatic:
• Results are negative from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) tested using an FDA-authorized laboratory-based NAAT to detect SARS-CoV-2 RNA. 

Environmental infection control

• Dedicated medical equipment should be used when caring for a patient with suspected or confirmed SARS-CoV-2 infection.
• All non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer’s instructions and facility policies before use on another patient.
• Routine cleaning and disinfection procedures are appropriate for SARS-CoV-2 in health care settings, including those patient-care areas in which aerosol generating procedures are performed.
• Once the patient has been discharged or transferred, HCP, including environmental services personnel, should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles. After this time has elapsed, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use.

Emergency medical services

Considerations for vehicle configuration when transporting a patient with suspected or confirmed SARS-CoV-2 infection

• Isolate the ambulance driver from the patient compartment and keep pass-through doors and windows tightly shut.
• When possible, use vehicles that have isolated driver and patient compartments that can provide separate ventilation to each area.
• Before entering the isolated driver’s compartment, the driver (if they were involved in direct patient care) should remove and dispose of PPE and perform hand hygiene to avoid soiling the compartment.
• Close the door/window between these compartments before bringing the patient on board.
• During transport, vehicle ventilation in both compartments should be on non-recirculated mode to maximize air changes that reduce potentially infectious particles in the vehicle.
• If the vehicle has a rear exhaust fan, use it to draw air away from the cab, toward the patient-care area, and out the back end of the vehicle.
• Some vehicles are equipped with a supplemental recirculating ventilation unit that passes air through high-efficiency particulate air (HEPA) filters before returning it to the vehicle.
• After patient unloading, allowing a few minutes with ambulance module doors open will rapidly dilute airborne viral particles.
• If a vehicle without an isolated driver compartment must be used, open the outside air vents in the driver area and turn on the rear exhaust ventilation fans to the highest setting to create a pressure gradient toward the patient area.
• Before entering the driver’s compartment, the driver (if they were involved in direct patient care) should remove their gown, gloves and eye protection and perform hand hygiene to avoid soiling the compartment. They should continue to wear their NIOSH-approved N95 or equivalent or higher-level respirator.

Additional considerations when performing AGPs on patients with suspected or confirms SARS-CoV-2 infection:

• If possible, consult with medical control before performing AGPs for specific guidance.
• Bag valve masks (BVMs) and other ventilatory equipment should be equipped with HEPA filtration to filter expired air.
• EMS systems should consult their ventilator equipment manufacturer to confirm appropriate filtration capability and the effect of filtration on positive-pressure ventilation.
• If possible, the rear doors of the stationary transport vehicle should be opened and the HVAC system should be activated during AGPs. This should be done away from pedestrian traffic.
• If possible, discontinue AGPs prior to entering the destination facility or communicate with receiving personnel that AGPs are being implemented.

Existing Emergency Department Pandemic Preparation

Authors: ACEP Emergency Department (ED) Redesign Task Force

Recommendations for emergency department (ED) preparation for high-risk infectious diseases (HRID) are provided below. These recommendations are intended as considerations. The ability to implement these suggestions in any given department may depend on the disease involved, the mode of transmission, and pre-existing capacity and ED design. Certain infection prevention strategies are preferred, but when not possible, alternative modalities are suggested.

Note: These HRID preparation considerations are limited to the physical (built) environment and do not include other important risk mitigation strategies, such as the elimination of hall beds and boarding of inpatients in the ED.

Common areas/public

Arrival/entrance  

• Triage for presence of HRID
• Promote pandemic infection concern alert notification by EMS (via established communication methods) prior to patient arrival at ED for patient assignment/placement/logistics/planning.
• Implement temperature screening outdoors, at entry, and/or tele-screening
• Refer asymptomatic/minimally symptomatic patients to remote site for testing after ED medical screening exam
• Flow management
• Implement wayfinding and signage system directing visitors/patients to appropriate entrance

Waiting room and common areas

• Capacity management
• Post capacity limits in any non-clinical space (ie, break rooms) to allow for social distancing
• Utilize remote meetings whenever possible
• Flow management
• If possible, separate entrance and egress
• Triage for presence of HRID
• Screen individuals for signs and symptoms of infection prior to entry to waiting room
• Risk mitigation to reduce transmission
  • Establish separate waiting rooms, or separate locations within same waiting area, for screen positive and screen negative patients
  • Consider outdoor space/tents for screen positive patients
  • If lockers are used for storing personal items, they should either be assigned to one person or disinfected between users
  • If possible, create negative pressure waiting space for PUI/infected patients
  • If this is not possible, discuss with facilities the best available alternative to improve ventilation (eg, HEPA filters). Additional information can be found in the ASHRAE Position Document on Infectious Aerosols.
• Install high-efficiency air filters as supported by your HVAC system.
• Exchange upholstered chairs for seating made of plastic or another easily disinfected material
• Provide face-level clear barriers between face-to-face contact locations at check-in desk, and/or have triage/check-in staff in mask and eye-covering
• Utilize touchless check-in/payment methods, include QR codes and mobile devices etc.
• Institute masking policy including supplying masks at reception, universal masking, and masking/eye-covering for triage/check-in staff
• Remove unnecessary furnishings, decorative items, or other items that are difficult to disinfect, so it is easier to clean surfaces regularly
• Cohort patients with signs and symptoms of infection
• Provide EPA approved cleaning products at each workstation to allow individuals to disinfect between users
• Discourage bringing personal items into the workplace. Any items brought should be left in a single location, such as a desk drawer or locker if possible
• Install high-efficiency air filters as supported by your HVAC system.
• Physical distancing
• Maintain as much space between workstations as possible (ideally six feet between individuals)
• Demarcate distance requirements where queuing may occur
• Rearrange furniture to promote six-foot distance between chairs and remove excess chairs
• Create outdoor break or dining areas
• Protective equipment
• Place hand sanitizer stations in common areas
• Install PPE storage units/stations in patient triage areas 
• Consider placing face-level clear barriers around workstations

Treatment - resuscitation/trauma

• Capacity management
• Limit number of personnel allowed in bay based on minimum needed
• Post "Limited entry to clinically necessary personnel only." 
• Find alternative locations to store items required in the remainder of the ED to limit the necessity of entering the bay for supplies
• Limit visitors allowed in bay
• Consider installing telemedicine capabilities to allow observers to chart without entering bay and allow tele-consults
• Flow management
• Re-route through traffic and transportation of patients so that they do not need to enter bay
• Triage for presence of HRID
• Screen all traumas and other patients entering the bay for s/s of HRID including via EMS in-code
• Consider placing an outdoor screening area for triage prior to entry to bay
• Risk management to reduce transmission
  • If possible, establish separate bays or separate locations within same bay for screen positive and screen negative patients
  • Consider creating negative pressure bays
  • If this is not possible, discuss with facilities the best available alternative to improve ventilation (example: HEPA filters). Additional information can be found in the ASHRAE Position Document on Infectious Aerosols.
  • If patients are cohorted to a PUI/infection + unit, consider assigning one machine, if available, to that unit only
  • Only allow those absolutely necessary in higher risk zones
  • Post PPE requirements for all zones
  • Store supplies in low risk (“green zones”) whenever possible
• Cohort patients with signs and symptoms of infection
• When available, create a separate resuscitation bay for patients with s/s or diagnosis of HRID
• Install high-efficiency air filters as supported by your HVAC system
• Remove all unnecessary items from bay to limit necessity for cleaning/disinfecting large quantities of items between patients
• Procedural equipment (eg, airway) preparation for disposable "to go" packs
• Keep items stored in bay covered either in storage units with doors or plastic covering
• Perform plain films via portable machine
• Designate low, medium, and high-risk zones within the bay (ie, “green”, “yellow”, and “red” zones)
• Physical distancing
  • Utilize sliding doors or tent flaps with zippers, such that these spaces can be closed from common areas during AGPs or other high-risk patient care procedures, depending on the pathogen
• Consider physician workstation/reading modifications (eg, plexiglass dividers)
• Consider physical barriers (ie, clear plastic/glass barriers/movable walls/screens) between/ within treatment areas to create individual care spaces between patients
• Cohorting
• When available, create a separate resuscitation bay for patients with s/s or diagnosis of HRID
• Protective Equipment
• Place PPE storage units at entry to resuscitation bays
• Place hand sanitizer immediately outside and inside all patient care areas

Diagnostic

General radiology  

• Risk management to reduce transmission
• If patients are cohorted to a PUI/infection + unit, consider assigning one machine, if available, to that unit only 
• Position x-ray tube six feet away from patient
• Utilize disposable cartridge cover for each patient use
• Perform cartridge cleaning between each use
• Install high-efficiency air filters if supported by HVAC system

Computed tomography (CT)/magnetic resonance imaging (MRI)

• Risk management to reduce transmission
• Identify scanner(s) available only for PUI/infection + patients
• Implement predetermined down time between patients to allow ventilation of radiology rooms

Point-of-care ultrasound (POCUS)

• Risk management to reduce transmission
• Decontamination of entire system after each use with disinfectant recommended by EPA
• If patients are cohorted to a PUI/infection + unit, consider assigning one machine, if available, to that unit only 
• Use of a handheld ultrasound system may allow for better disinfection between patients

Additional information can also be found on the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.