POLICY & PROCEDURE

MANUAL:

NO.

PAGE 1 OF 8

DATE:

REV. DATE

INFECTION CONTROL
SECTION:

VI - Significant Organisms

APPROVED BY:

POLICY

PROCEDURE

June 2003

GUIDELINES FOR HIGH RISK PROCEDURES WHEN

DEALING WITH HIGH RISK PATIENTS
PREAMBLE:
During certain high-risk procedures that generate droplets and aerosols, health
care workers may be exposed to a very high burden of respiratory secretions. Highrisk procedures include, but are not limited to the following:
- administration of aerosolized/nebulized therapy
- Intubation/extubation
- Bag-valve mask ventilation
- Tracheostomy
- Chest tube insertion
- Cardio/pulmonary arrest (may include any of the above procedures)
- bronchoscopy
- non-invasive ventilation (CPAP, BiPAP)
- needle thoracotomy/open thoracotomy thoracostomy
High risk procedures should be avoided whenever possible. However, in situations
where they become necessary (e.g. intubation of a patient in respiratory distress),
staff must follow the additional level of precautions outlined in this policy and
procedure.
Areas where high-risk procedures on high-risk patients may be performed include:
a) Emergency Department
b) ICU
c) Rooms in which patients are placed on Droplet and/or Airborne Precautions
d) OR
High-Risk patients include:
Patients - with an infectious respiratory disease (e.g. TB, probable or suspect
SARS, or patient under investigation for SARS)
- who develop new onset of symptoms (unexplained cough, unexplained
high fever, hypoxia, shortness of breath or difficulty breathing)
- with Congestive Heart Failure with/without concurrent pneumonia
- with Exacerbation of COPD

- with Exacerbation of Asthma

- with pulmonary infiltrates and presumptive diagnosis
(not SARS)
Patients transferred - from a (SARS) Level 2 hospital
- from a (SARS) Level 3 hospital

POLICY & PROCEDURE

MANUAL:
SECTION:

INFECTION CONTROL
VI - Significant Organisms

APPROVED BY:

POLICY

NO.

PAGE 2 OF 8

DATE:

REV. DATE

PROCEDURE

June 2003

GUIDELINES FOR HIGH RISK PROCEDURES WHEN

DEALING WITH HIGH RISK PATIENTS
1.0

POLICY:
1.1

High risk procedures will be performed:

i)
in a private room with negative pressure, whenever possible
(negative pressure rooms currently located in - ER Rm. 8, ICU
Rm. 124, Medical Unit Rm. 165, Surgical Unit Rm. 264)
ii)
by the most experienced staff (whenever possible)
iii)
with a minimum number of staff present in the room (but
adequate for the situation)
iv)
with strict adherence to infection control precautions and hand
disinfection (see Procedure)

DISTRIBUTION:
Administration (Master)
Nursing
Infection Control
Cardiorespiratory
Food & Nutrition Service
Pharmacy
Environmental Service
DI
Laboratory
LUK:aa

POLICY & PROCEDURE

MANUAL:

NO.

PAGE 3 OF 8

DATE:

REV. DATE

INFECTION CONTROL
SECTION:

VI - Significant Organisms

APPROVED BY:

POLICY

PROCEDURE

June 2003

GUIDELINES FOR HIGH RISK PROCEDURES WHEN

DEALING WITH HIGH RISK PATIENTS
2.0

PROCEDURE:
2.1

FOR ALL NON-SARS PATIENTS:

Personal Protective Equipment
i)

For emergency endotracheal intubation of patients, each patient

unit will have:
-

a manual resuscitation bag with bacterial/viral filter

in-line suction catheters
intubation equipment, and
full protective apparel (see ii below) for the individual
performing the intubation, and for all other individuals in
the room.

ii)

All individuals involved in performing high risk procedures

(intubation, cardiopulmonary resuscitation interventions
bronchoscopy etc.) will wear full protective apparel.
This includes an N95 mask, a gown, gloves, eye protection
(goggles), and full-face/head protection (full face
Shield).

iii)

Protective apparel will be removed carefully at the

end of the procedure to reduce the risk of contamination
and reaerosolization of droplets (see Appendix IV).

Note:
Suctioning may be performed in the normal fashion in small
children.
Procedures

i)

Nebulized therapies should be avoided. Respiratory medications

will be delivered using the metered dose inhaler and
aerochamber, when possible.
ii)
The need for chest physiotherapy must be carefully assessed;
recognizing that cough-inducing procedures may increase the
risk of transmission.
GUIDELINES FOR HIGH RISK PROCEDURES WHEN
PAGE 4 OF 8
DEALING WITH PATIENTS IN CRITICAL CARE AREAS
Procedures (con't)
iii)
Oxygen will be delivered DRY avoiding nebulized humidity.
Maximum flow rate for nasal prongs will be 6 litres per minute.
iv)
If a patient requires up to 50% oxygen by mask, use a ventimask.
v)
If a patient required more than 50% oxygen, then the respiratory
therapist (RT) must be notified. The nebulizer system will be
emptied of the water from the prefilled water bottle. The water
bottle will remain DRY. The RT will monitor and wean the
patient to nasal prongs as soon as the patient can tolerate this.
vi)
Patients will receive frequent mouth care.
vii)
Patients with tracheostomies will be provided with humidity.
viii) Patients who require oxygen greater than 50% must be referred
to RT for set up and ongoing monitoring.
ix)
Non-invasive ventilation (CPAP/BiPAP) should be avoided. If
ventilation is essential for the patient, the patient will be
screened in consultation with the physician and infection control
to ensure that a diagnosis of SARS has been ruled out. The
procedure will be performed in a private room, when at all
possible (Note: in ER, BiPAP will continue to be done in the
trauma room with curtains closed, for patients diagnosed with
Congestive Heart Failure )
Note:
Children may receive nebulized therapy if MDI is not deemed to be
appropriated. Full protective apparel must be worn by all persons
in the room.
For children, oxygen should be humidified as usual.
2.2

FOR SARS PATIENTS:

See Appendix III for Protected Code Blue (sudden cardiorespiratory
arrest in SARS patients)

1.

Aerosol-generating and/or cough inducing procedures may be

performed on patients who may have SARS only when deemed
absolutely necessary by the attending physician and documented by
him/her in the patient's chart.

2.

The following procedures should not be performed on a routine basis

on known, suspected or R/O SARS patients.
a. Bronchoscopy
b. Sputum induction
c. Aerosol theapy (includes O2 aerosol and medicated aerosol)
d. Non-invasive CPAP or BiPAP

GUIDELINES FOR HIGH RISK PROCEDURES WHEN

DEALING WITH PATIENTS IN CRITICAL CARE AREAS

PAGE 5 OF 8

FOR SARS PATIENTS IN ALL CRITICAL CARE AREAS (Con't)

3.

Equipment
On all units that have designated SARS rooms (ER, ICU, Medical unit,
Surgical unit and SARS unit) the following equipment must be
included in the arrest (crash) cart:
- manual resuscitation bag with bacterial/viral filter
- in-line suction catheters
- Personal protection system (PPS) or Positive Airway Pressure
Respirator (PAPR) for 4 individuals
- personal protective equipment (This includes gowns and/or front
zip coveralls, gloves, full- face/head protection (face shields,
goggles, beard hoods, caps and N95 masks) for Unit responders

4.

Intubation and Bronchoscopy:

Personal Protective Equipment:
i)

Those performing or assisting with the intubation will wear full

personal protective equipment that provides full head, face and
neck protection (see Appendix I and Appendix II).

Personnel:

i)
ii)

The most experienced staff members available will perform

intubations and brochoscopies.
The number of persons in the room will be kept to a maximum
of 2-4 persons.

Procedure:
i)

The procedure will be done in a negative pressure room. If one is

unavailable, it must be done in a private room with the door
closed.

ii)

After hand-washing and prior to entering the room, the

individuals involved in the procedure will apply the personal
protection system (PPS) as outlined in printed instructions (see
Appendix V)

iii)

Staff in the room during the intubation must apply the personal
protection system (PPS) (see Appendix V)

iv)

The intubation will be done while the patient is sedated and

paralysed if medical condition permits

GUIDELINES FOR HIGH RISK PROCEDURES WHEN

DEALING WITH PATIENTS IN CRITICAL CARE AREAS

PAGE 6 OF 8

FOR SARS PATIENTS IN ALL CRITICAL CARE AREAS (Con't)

Procedure (con't):
v)

The ventilator and in-line suction device will be in the patient

room to reduce time needed for bag ventilation and
disconnecting bag from the endotracheal tube suctioning.

vi)

Protective apparel must be removed carefully at the end of the

procedure to reduce the risk of contamination and
reaerosolization of droplets (see Appendix V).

vii)

Minimize staff exposure by limiting staff re-entry into the room

for approximately 2 hours post-procedure.

viii)

Other procedures requiring prolonged exposure to the patient

(e.g. central line insertion) must be avoided until the room can
be thoroughly cleaned (i.e. excess medications must be
discarded at the end of any high risk procedure, immediate

clean up of room and equipment must be done in such a way as

to reduce the re-release of aerosols, contaminated equipment
/surfaces must be discarded/disinfected and cleaned before
room is left and potentially contaminated surfaces in the room
must be wiped with a hospital-approved (eg. Enviro 256)
disinfectant).
ix)

Critical care areas will preassemble medication/equipment for

intubations performed in a SARS patient room. The preassemble
kit will be in a disposable or easily cleaned container.

Cleaning:
i)
ii)
iii)

iv)

v)

Excess medication s will be discarded at the end of the

procedure
Immediate clean up of room and equipment must be done slowly
and in such a way as to reduce the re-release of aerosols.
Staff performing the procedure must ensure that contaminated
equipment and surfaces are discarded/disinfected and cleaned
before leaving the room.
Nursing staff are responsible for informing housekeeping
whenever their services are required and for indicating what
supplies/equipment can be discarded and what can be cleaned
disinfected, and or sterilized for reuse.
Potentially contaminated surfaces in the room will be wiped with
hospital-approved disinfectant.

GUIDELINES FOR HIGH RISK PROCEDURES WHEN

DEALING WITH PATIENTS IN CRITICAL CARE AREAS
3.

PAGE 7 OF 8

Management of SARS Patients on Mechanical Ventilation

Note: Infectious respiratory secretions from SARS patients will
contaminate respiratory equipment and be expelled into the
surrounding environment.
Procedure:

i)

Ventilators
A hydrophobic submicron filter will be placed between the
endotracheal tube and the ventilator circuit tubing.

ii)

iii)
iv)

v)
vi)
vii)
viii)

If possible, ventilators with built in bacterial/viral filters in the

expiratory circuit will be used. If this is not possible, such a filter will
be placed in the expiratory circuit of the ventilator
Filters will be changed when fluid build-up impedes ventilation (at
least every 24 hours)
Disposal of filters will be considered a high-risk exposure and staff
must protect themselves using full personal protective equipment
following the maximal precautions
Filters and respiratory circuits for known SARS cases must be single
use and disposed of after use.
Filters are to be bagged, sealed and then placed in a biohazardous bag
for disposal.
Heated wire circuits will be used on both the inspiratory and
expiratory sides of the circuit.
A water trap/filter combination will be placed at the end of the
expiratory circuit

Manual Resuscitation Bags:

i)
ii)

iii)
iv)

v)
vi)

A Bacterial/Viral (B/V) filter will be attached to any manual

resuscitation bagging device prior to its use on a patient
A hydrophobic submicron filter must be placed between the
endotracheal/tracheostomy tube and the bag when bagging an
intubated patient
B/V filters should be changed when fluid buildup impedes ventilation
(at least every 24 hours).
Disposal of filters is considered a high-risk exposure and staff will
protect themselves following maximum precautions using full SARS
protective equipment
B/V filters will be bagged, sealed, and then placed in a biohazardous
bag for disposal
Equipment used for manual bagging will be disposed of after use, not
cleaned.

GUIDELINES FOR HIGH RISK PROCEDURES WHEN

DEALING WITH PATIENTS IN CRITICAL CARE AREAS
2.3

PAGE 8 OF 8

PATIENTS WITH RESPIRATORY SYMPTOMS OR UNEXPLAINED

FEVER AND UNKNOWN SARS RISK

Treat as SARS until another diagnosis is confirmed. Follow all policies

a s described in 2.2 until that time.
2.4

PATIENTS WITH NO RESPIRATORY SYMPTOMS OR WITH

RESPIRATORY SYMPTOMS/FEVER DUE TO A KNOWN CAUSE
OTHER THAN SARS
Treat as non-SARS patients.

ASSESSMENT:
The Infection Control Co-ordinator, Nurse Managers and Department Managers will
monitor activities and review all cases of SARS to ensure 100% compliance.
DISTRIBUTION:
Administration (Master)
Nursing
Infection Control
Cardiorespiratory
Food & Nutrition Service
Pharmacy
Environmental Service
DI
Laboratory
LUK:aa
Reference: SARS Provincial Operations Centre: Directives to All Ontario Acute Care Facilities for
High-Risk Procedures, June 16, 2003.

Appendix I

PERSONAL PROTECTIVE
EQUIPMENT
For All Adult Intubations:

N95 mask
Gown
Gloves that come up over sleeve of gown
Hair/Head cover cap
Goggles
Full face shield
Bacterial viral filter on bag
Use in line suction only

For SARS (and other communicable

airborne/respiratory disease) Intubations:
Full head , face and neck protection required;
Positive Airway Pressure Respirator (PAPR) or
Personal Protective System (PPS)
N95 mask
Double gown (or hooded coverall)

 Double gloves that come up over sleeve of gown

Hair/Head cover cap (not necessary if hooded
coverall worn)
Goggles
Full face shield
Booties
Bacterial viral filter on bag
Use in line suction only

Appendix II

Source:
Ministry of Health and Long Term Care, SARS Provincial Directives, May 13 & June 16,
2003

Appendix III

Protected Code Blue

To prevent the spread of communicable respiratory diseases to Health Care
Workers, SARS precautions are essential and include eye protection (face shield
and goggles), N95 mask, double gown and double gloves. However, in certain
high-risk situations, such as cardiorespiratory failure requiring airway
management, these may not be sufficient and a "Protected Code Blue" will be
called.
The Protected Code Blue (PCB) Team is an in-hospital team which consists of
designated individuals, at least one of whom is highly skilled in intubation and
resuscitation measures:
1. Physician (staff emergologist, Intensivist, Anaesthetist)
2. RT
3. RN from ICU
4. RN from ER
A number of PCB Teams (consisting of 4 individuals in each team) will be
established by the hospital. Members who are physicians will be selected by the
Chiefs of the Emergency, Family Practice and Surgery Departments. Members
who are RNs will be designated by the Nurse Manager of the ICU/ER. All
Respiratory Therapists will be on the PCB Team.
All designated Protected Code Blue Team members will receive special training
(provided by the hospital initially and on an annual basis) and are expected to
consistently adhere to skills and attend opportunities to maintain skills.
A Protected Code Blue Team will be available in hospital 24/7 during times of
serious regional outbreaks such as SARS, or if a patient is admitted with a known
high risk communicable respiratory disease.
During outbreaks with potential for large numbers of patients, the core PCB
Teams will train staff in high risk areas such as emergency, ICU and affected
medical and surgical units and operating room staff to assist in the PCB.
Ideally, such patients should be placed in the hospital rooms with negative
pressure, but may arrive unexpectedly in the emergency department in need of
life saving care after being transported by family or paramedics. Each of these
situations poses significant risk to all involved and has the potential to rapidly
spread the disease.
The following procedures must be adhered to:

1. Equipment
ER, ICU, Medical, Surgical and SARS Unit must have crash carts which
include:
i.
Manual resuscitation bag with bacterial/viral filter
ii.
In-line suction catheters
iii.
Personal Protective System (PPS) or Positive Airway Pressure Respirator
(PAPR)
2. Preparation:
Consider early ICU transfer or preferably transfer to another facility when
deteriorating (50% O2 necessary)
Consider early controlled intubation when patient's respiratory status
deteriorates
Keep all non-essential staff outside room
All team members and unit staff must have completed fit test for N95 mask
All staff involved with intubation procedures will have completed training
for application and removal of PPS or PAPR
All staff involved with a PCB will be familiar with the "Protected Code Blue"
Protocol
3. Personnel (Protected Code Blue Team):

"airway expert" physician ((staff emergologist, Intensivist, Anaesthetist)

Respiratory Therapist
2 Trained ICU/ER RNs
"Coach" Individual who is trained to assist with donning and removal of PPE
and room entry/exit procedures (Unit Manager or designate, Unit staff
member - first responder) This person must use checklist to ensure all steps
are followed.

All staff in vicinity of the patient's room must wear full SARS protective apparel.
4. Procedure:
a) First Responder (First person to recognize non-responsiveness or
cardiorespiratory arrest)
i.
Likely Wearing Full Personal Protective Equipment but no PPS
ii.
Must not perform high risk procedures (e.g. bag valve mask
ventilation/intubation) or be present in the room when these take place
if not wearing fPPS
iii.
Call "Protected Code Blue"
iv.
Puts N95 mask on patient
v.
Attaches cardiac monitor, if available; defibrillates if indicated (if trained)
vi.
If no pulse, performs chest compressions

vii.
viii.
ix.
x.

Must leave room when PCB Team arrives

Gives report on leaving room
Assists dressing team in appropriate PPS as required
Prepares any drugs or equipment requested

b) PCB
i.
ii.
iii.
iv.

Team Member - #1
Wears PPS
Takes report and assumes responsibility
Attaches cardiac monitor if not already done; defibrillates, if indicated
Continues compressions, if indicated

c) PCB
i.
ii.
iii.
iv.
v.

Team Member - #2
Wears PPS
Prepares BVM with exhalation filter and intubation equipment
If airway expert is not present, initiates BVM ventilation
Prepares for intubation
Assists with intubation

d) PCB
i.
ii.
iii.
iv.

Team Member - #3
Wears PPS
Prepares appropriate drugs
Administers appropriate drugs
Records events

e) PCB Team Member - #4

i.
Wears PPS
ii.
Performs intubation
iii.
Provides ACLS assistance as directed by Team Leader

5. Termination:

If resuscitation is successful, a member of the PCB Team must remain with

the patient until transfer to another area of the hospital or to another hospital
if possible. If there is a prolonged delay in moving the patient, this Team
member must have back-up. Precautions for patient movement such as plastic
tent over stretcher, etc. will be at the discretion of the PCB Team.
Consideration should be given to termination of resuscitative attempts at the
time survival is deemed to be futile (e.g. unwitnessed arrest, asystole) as
outcome of resuscitation is inversely proportional to the length of time of
resuscitation, and the risk to the providers increases.

Reference: SARS Provincial Operations Centre: Directives to All Ontario Acute Care Facilities. May
13 & May 16, 2003.

Protected Code Blue

There are numerous infection control concerns that arise during acute
resuscitation of patients, especially those under SARS precautions. Resuscitation
requires performance of high-risk procedures (airway management - intubation,
chest tube insertion etc) Time needed to put on additional personal protective
equipment may introduce delays in response. The need to provide best care for
the patient must be integrated with the need to protect health care workers.
To prevent the spread of communicable respiratory diseases to Health Care
Workers, additional personal protective equipment is required to be worn while
performing high-risk procedures on high risk patients. SARS precautions are
essential and include eye protection (face shield and goggles), N95 mask, double
gown and double gloves. However, in certain high risk situations, such as
cardiorespiratory failure requiring airway management, these may not be
sufficient and a Protected Code Blue Team will be called.

(PCB) Team is an in-hospital team which consists of designated individuals, at

least one of whom is highly skilled in intubation and resuscitation measures:
5. Physician (staff emergologist, Intensivist, Anaesthetist)
6. RT
7. RN from ICU
8. RN from ER
A number of PCB Teams (consisting of 4 individuals in each team) will be
established by the hospital. Members who are physicians will be selected by the
Chiefs of the Emergency, Family Practice and Surgery Departments. Members

who are RNs will be designated by the Nurse Manager of the ICU/ER. All
Respiratory Therapists will be on the PCB Team.
All designated Protected Code Blue Team members will receive special training
(provided by the hospital initially and on an annual basis) and are expected to
consistently adhere to skills and attend opportunities to maintain skills.
A Protected Code Blue Team will be available in hospital 24/7 during times of
serious regional outbreaks such as SARS, or if a patient is admitted with a known
high risk communicable respiratory disease.
During outbreaks with potential for large numbers of patients, the core PCB
Teams will train staff in high risk areas such as emergency, ICU and affected
medical and surgical units and operating room staff to assist in the PCB.
Ideally, such patients should be placed in the hospital rooms with negative
pressure, but may arrive unexpectedly in the emergency department in need of
life saving care after being transported by family or paramedics. Each of these
situations poses significant risk to all involved and has the potential to rapidly
spread the disease.
The following procedures must be adhered to:
5. Equipment
ER, ICU, Medical, Surgical and SARS Unit must have crash carts which
include:
iv.
Manual resuscitation bag with bacterial/viral filter
v.
In-line suction catheters
vi.
Personal Protective System (PPS) or Positive Airway Pressure Respirator
(PAPR)
6. Preparation:
Consider early ICU transfer or preferably transfer to another facility when
deteriorating (50% O2 necessary)
Consider early controlled intubation when patient's respiratory status
deteriorates
Keep all non-essential staff outside room
All team members and unit staff must have completed fit test for N95 mask
All staff involved with intubation procedures will have completed training
for application and removal of PPS or PAPR
All staff involved with a PCB will be familiar with the "Protected Code Blue"
Protocol
7. Personnel (Protected Code Blue Team):

"airway expert" physician ((staff emergologist, Intensivist, Anaesthetist)

Respiratory Therapist
2 Trained ICU/ER RNs
"Coach" Individual who is trained to assist with donning and removal of PPE
and room entry/exit procedures (Unit Manager or designate, Unit staff
member - first responder) This person must use checklist to ensure all steps
are followed.

All staff in vicinity of the patient's room must wear full SARS protective apparel.
8. Procedure:
f) First Responder (First person to recognize non-responsiveness or
cardiorespiratory arrest)
xi.
Likely Wearing Full Personal Protective Equipment but no PPS
xii.
Must not perform high risk procedures (e.g. bag valve mask
ventilation/intubation) or be present in the room when these take place
if not wearing fPPS
xiii. Call "Protected Code Blue"
xiv. Puts N95 mask on patient
xv.
Attaches cardiac monitor, if available; defibrillates if indicated (if trained)
xvi. If no pulse, performs chest compressions
xvii. Must leave room when PCB Team arrives
xviii. Gives report on leaving room
xix. Assists dressing team in appropriate PPS as required
xx.
Prepares any drugs or equipment requested
g) PCB
v.
vi.
vii.
viii.

Team Member - #1
Wears PPS
Takes report and assumes responsibility
Attaches cardiac monitor if not already done; defibrillates, if indicated
Continues compressions, if indicated

h) PCB
vi.
vii.
viii.
ix.
x.

Team Member - #2
Wears PPS
Prepares BVM with exhalation filter and intubation equipment
If airway expert is not present, initiates BVM ventilation
Prepares for intubation
Assists with intubation

i) PCB Team Member - #3

v.
Wears PPS

vi.
vii.
viii.

Prepares appropriate drugs

Administers appropriate drugs
Records events

j) PCB Team Member - #4

iv.
Wears PPS
v.
Performs intubation
vi.
Provides ACLS assistance as directed by Team Leader

5. Termination:

If resuscitation is successful, a member of the PCB Team must remain with

the patient until transfer to another area of the hospital or to another hospital
if possible. If there is a prolonged delay in moving the patient, this Team
member must have back-up. Precautions for patient movement such as plastic
tent over stretcher, etc. will be at the discretion of the PCB Team.
Consideration should be given to termination of resuscitative attempts at the
time survival is deemed to be futile (e.g. unwitnessed arrest, asystole) as
outcome of resuscitation is inversely proportional to the length of time of
resuscitation, and the risk to the providers increases.

Reference: SARS Provincial Operations Centre: Directives to All Ontario Acute Care Facilities. May
13 & May 16, 2003.