The first case of COVID-19 in the UK was diagnosed on 31 January 2020 (Tang et al, 2020) and, since then, this viral infection has dominated healthcare, the country and the world at large. Several studies have been published about the disease and how to manage patients infected with it, but the vast majority of them are about hospital and in-patient care. However, the majority of patients with COVID-19 are not admitted to hospital (UK Government, 2020a). This article looks at the risk of cross-infection of COVID-19 in patients' own homes, especially from aerosol-generating procedures, and what can be done to reduce this risk.
COVID-19 and how it spreads
COVID-19 is a novel, or new, coronavirus (World Health Organization (WHO), 2020). Coronaviruses are named after the crown-like spikes that cover their surface (Centers for Disease Control, 2019), and the group includes the Middle East respiratory syndrome (MERS) virus, severe acute respiratory syndrome (SARS) virus and the influenza virus that causes the common cold (CDC, 2019). Similar to other coronaviruses, SARS-CoV-2, the causative agent of COVID-19, is a respiratory virus that is spread via respiratory droplets, from coughing and sneezing, and being in close proximity (within 2 meters) presents the greatest risk of transmission (Master and Gerrard, 2020).
Healthcare workers, by the nature of their work, have to come in close proximity to patients, including those with confirmed or suspected COVID-19. The use of fluid-resistant (type IIR) surgical masks has proved very effective in managing this risk (Cook, 2020). These masks have been showed to reduce COVID-19 transmission in healthcare environments by 80% (Lianga et al, 2020). Evidence has also shown that wearing non-type IIR masks by members of the public, in non-home environments, can reduce cross-infection by 56% (Lianga et al, 2020).
Nonetheless, there are clinical procedures that can increase the risk of COVID-19 transmission, even when type IIR masks are correctly worn, such as aerosol-generating procedures (AGPs) (Public Health England (PHE), 2020a).
Aerosol-generating procedures
AGPs are clinical or medical procedures where high-spread or high-pressure air is passed over the respiratory mucosa and epithelium and causes the fluid or mucus to be aerosolised and expelled into the environment (WHO, 2014). Because COVID-19 is spread through respiratory particles, AGPs pose a higher risk of its spread (WHO, 2014).
PHE has produced a list of AGPs that pose a risk of transmitting COVID-19 (Box 1). For community nurses, the main AGPs to be concerned with, the ones that are practiced in the home setting, are:
- Manual ventilation
- Tracheotomy or tracheostomy procedures (insertion or removal)
- Non-invasive ventilation (NIV); bi-level positive airway pressure ventilation (BiPAP) and continuous positive airway pressure ventilation (CPAP)
- Respiratory tract suctioning.
Box 1.Common aerosol-generating procedures
- Tracheal intubation and extubation
- Manual ventilation
- Tracheotomy or tracheostomy procedures (insertion or removal)
- Bronchoscopy
- Dental procedures (using high speed devices, for example ultrasonic scalers/high speed drills
- Non-invasive ventilation (NIV); bi-level positive airway pressure ventilation (BiPAP) and continuous positive airway pressure ventilation (CPAP)
- High-flow nasal oxygen (HFNO)
- High-frequency oscillatory ventilation (HFOV)
- Induction of sputum using nebulised saline
- Respiratory tract suctioning
- Upper ENT airway procedures that involve respiratory suctioning
- Upper gastro-intestinal endoscopy where open suction of the upper respiratory tract occurs
- High-speed cutting in surgery/post-mortem procedures if respiratory tract/paranasal sinuses involved
Public Health England, 2020a
Cough and sneezing, although they do generate aerosols of respiratory fluids, are not considered AGPs because they are not medical procedures (Public Health Scotland, 2020). Unfortunately, they can still spread COVID-19, so special care should be taken with patients when they cough or sneeze.
Nebulisation is not an AGP either (PHE, 2020a). The vapour from a nebuliser is not from respiratory fluids but from the fluid or medication in the nebuliser's chamber. When the vapour comes into contact with a mucus membrane, it is no longer aerosolised (PHE, 2020a). Nebulisers do make patients cough, but this can be contained within the nebuliser mask, so patients should be encouraged not to remove the mask, even when coughing. Hands should always be cleaned after any contact with a nebuliser because of the risk of contamination from respiratory fluids.
There is debate on whether or not chest compressions, during cardiopulmonary resuscitation (CPR), can be considered AGPs. PHE does not list chest compressions or defibrillation in its list of AGPs (PHE, 2020b). The Resuscitation Council UK (RCUK) has questioned this, stating that the clinical realities of CPR could cause respiratory secretions to be aerosolised (RCUK, 2020). However, manual ventilation is on the PHE list of AGPs. Therefore, care should always be taken to protect against COVID-19 transmission during CPR, and nurses must always follow their trust's guidelines when it is being performed.
Public Health Scotland has identified a list of clinical activities that are not considered AGPs but have been confused for them. Box 2 is an adaption of this list, and includes the ones that are performed in the home environment, excluding the ones that are solely performed in the hospital environment.
Box 2.Clinical activities that are not AGPs but have been confused for them
- Induction of sputum (associated with nebulisation of hypertonic saline)
- Tracheotomy removal
- High flow nasal oxygen therapy
- Administration of nebulised saline, medication or drugs
- Chest compressions
- Chest physiotherapy
- Defibrillation
- Administration of oxygen therapy
- Chest drains with activate air leak (pneumothorax or following cardiothoracic surgery)
- Nasogastric tube insertion
- Nose and throat swabbing
- Peak flow device meter use
- Swallowing assessments (SALT)
- Tracheostomy care and management without suctioning procedures, with and without connection to mechanical ventilator
- VAC dressing application
Adapted from Public Health Scotland, 2020
How to reduce the risk
When a patient requires tracheotomy care, non-invasive ventilation and/or respiratory tract suctioning, it should first be considered whether can they perform it themselves. Patients will not infect themselves with their own respiratory fluids. They will also be able to perform it whenever they require and not have to wait until a nurse is available. If the patient is unable to perform it, then it should be taught to a person in the patient's household bubble, their spouse or close relative living in their household. Again, the cross-infection risk is much reduced in this case, because all those involved are in the same household and the carer can perform the procedure when required.
The National Institute for Health and Care Excellence (NICE) advises that, if patients are performing AGPs in their own home, they should:
- Continue to perform them as required, and not to stop them because of the COVID-19 pandemic
- Perform AGPs in a well-ventilated room; this should also involve opening windows and letting in fresh air, which helps change the air in an environment
- Perform AGPs away from other family members if possible (although another family member may need to assist them or need to perform the AGP; if so, then it should be the same family member each time)
- Clean the equipment used and the room it is performed in regularly (NICE, 2020a). Assessing the patient's risk is very important here, including:
- Does the patient need the AGP? Is there an alternative?
- Can the patient or their spouse/close relative (a member of their household bubble) be taught to perform the AGP?
- Do nurses need to perform the AGP?
If nurses do need to perform AGPs in a patient's home, including CPR, then the appropriate precautions should be taken. PHE recommends that an FFP3 mask (respirator mask) or hood, eye or face protection (including full-face visors), single-use gloves and full body gowns or fluid-repellent coveralls are worn for all AGPs (PHE, 2020a), but local trust policies should always be followed. Since AGPs are a high risk for COVID-19 transmission, full precautions are not excessive or over the top.
Although there is debate about the risks from performing chest compressions during CPR, there will always be the potential need for community nurses to perform CPR in a patient's home, and manual ventilation has been identified as a risk (PHE, 2020a). The RCUK has issued advice on reducing the risk of COVID-19 transmission while performing CPR (RCUK, 2020b). It advises:
- Do not place your ear or check to the patient's mouth to check for breathing
- Do not start CPR without appropriate personal protective equipment (PPE)
- If a defibrillator is available, connect it to the patient who has collapsed (PPE is not required to do this). This could negate the need for chest compressions and will also allow time for others or yourself to don appropriate PPE.
Managing the risk of COVID-19 in patients' homes
Early in 2020, the Government contacted all people who were identified as being at risk from COVID-19, advising them to shield at home (Bostock, 2020). Box 3 lists all the clinical reasons identified for shielding. This list also identifies patients on a district nurse team caseload who could be at high risk if they develop a COVID-19 infection.
Box 3.Individuals identified by NHS England to be at increased risk from COVID-19
- Aged 70 years or older (regardless of medical conditions)
- Any long-term condition that requires an adult to be instructed to get a flu vaccination as an adult each year on medical grounds), including:
- Chronic (long-term) 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 the spleen—for example, sickle cell disease or if the spleen has been removed
- A weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroids or chemotherapy
- Being seriously overweight (a BMI of 40 or above)
- Those who are pregnant
Robinson, 2020
As is well known now, the symptoms of COVID-19 are:
- Recent onset of a new continuous cough (beware that it is a new/different and continuous cough with patients with chronic obstructive pulmonary disorder (COPD))
- A high temperature
- A loss of, or change to, normal sense of taste or smell (anosmia) (UK Government, 2020b).
If a patient develops any of these symptoms, then a COVID-19 swab should be arranged for them as soon as possible. A trust's policies should always be followed for COVID-19 tests. Tests can also be arranged through this website: https://tinyurl.com/y5wh77qz, and these tests can be delivered directly to a patient's home.
Not all infections with these symptoms will be COVID-19 (NICE, 2020b), but other infections can produce similar symptoms, especially during flu season. However, patients with severe COVID-19 can deteriorate rapidly and would need urgent hospital admission. Older patients with comorbidities (Box 3) can be at higher risk of deteriorating with a COVID-19 infection and may require closer monitoring (NICE, 2020b). Therefore, the sooner that COVID-19 is diagnosed, the sooner monitoring measures can be introduced, or the sooner COVID-19 can be eliminated.
It is estimated that 18%–81% of patients with COVID-19 are asymptomatic (Nikolai et al, 2020), but mask usage can reduce transmission by up to 80% (Lianga et al, 2020). Since community nurses work with a range of patients who are very vulnerable to COVID-19, protecting nurses from COVID-19 is very important. Preventing community nurses from catching COVID-19 does not just protect the workforce, but it also protects patients by preventing nurses themselves from being the source of infection.
Protecting patients and staff is best achieved through the use of standard infection prevention control precautions (SIPCP) (PHE, 2020a). These involve:
- Hand hygiene
- Respiratory hygiene/cough etiquette
- PPE-gloves, aprons, gowns or fluid-repellent overalls, eye protection and face masks (local policies should always be followed with the use of PPE, but face mask usage does reduce COVID-19 transition)
- Safe management of the environment (although community nurses do not have control of the home environment, they need to consider were clinical activity takes places: does the surface need cleaning, is the room appropriate, should it take place in another room, etc.)
- Safe management of clinical equipment: keeping equipment clean and undamaged, taking the minimum equipment into a patient's home (wherever possible), using single-patient equipment (wherever possible, having equipment dedicated for one patient's use) and appropriate cleaning of equipment between patients
- Safe disposal of waste and clinical waste, including sharps
- Occupational health
- Maintaining social distancing, where possible (PHE, 2020a).
Occupational health is also important in helping to stop the spread of COVID-19, by ensuring that nurses' health is also protected. With COVID-19 this also involves isolating nurses who are infected with COVID-19 or have been exposed to it, so prompt staff reporting of anyone suspected of having COVID-19 is very important. Many district nurse teams are now being asked to perform regular lateral flow device tests, self-testing for COVID-19, to ensure nurses are not a source of infection, especially with up to 81% of people with COVID-19 are asymptomatic (Nikolai et al, 2020).
Cough etiquette
The CDC (2009) defined coughing etiquette as covering the nose and mouth with a disposable tissue when coughing, disposing of the tissue in a bin straight after coughing and performing hand hygiene as soon as possible after contact with respiratory secretions or objects/materials that have been contaminated with them. When a patient coughs, they should always be asked to use a disposable tissue, especially if the nurse is less than 2 m away, and the nurse should either turn away from the patient or ask them to do so.
The NHS guidance, for coughs and sneezes, is Catch it, Bin It, Kill it (NHS England). Catch it, the use of disposable tissue; Bin it, dispose of used tissue into a bin, Kill it, then wash hands or use hand sanitiser.
Conclusion
COVID-19 has caused a worldwide pandemic, with grim daily mortality rates. It is a very serious infection and preventing transmission is still our best method of fighting it.
COVID-19 is spread via respiratory fluids and AGPs are a very high risk for transmission of it because of the nature of them. Although the number of AGPs performed in patients' own homes is low, it still presents a risk, and this risk needs to be managed. Community nurses, by the nature of the role, are often the best placed healthcare professionals to help patients manage this risk. Although there will always be emergency situations where AGPs cannot be avoided, such as CPR, community nurses must also protect themselves to protect their patients, following local policies and national guidance, and the appropriate use of SIPCPs will help achieve this. Helping to reduce the spread of COVID-19 will help protect the most vulnerable of patients.
KEY POINTS
- SARS-CoV-2, the novel virus that causes COVID-19, is spread via respiratory secretions, and up to 81% of people with COVID-19 are asymptomatic
- Fluid-resistant (type-IIR) surgical masks can reduce the risk of COVID-19 by up to 80%
- Aerosol-generating procedures (AGPs) can cause respiratory secretions to become aerosolised and are, therefore, a high risk for COVID-19 transmission
- AGPs commonly conducted in community settings include manual ventilation, non-invasive ventilation and respiratory tract suctioning
- Enabling patients to perform their own AGPs, whenever possible, is a very effective way to reduce the risk of COVID-19 transmission
CPD REFLECTIVE QUESTIONS
- Which aerosol-generating procedures (AGPs) are the most commonly performed ones in a patient's home?
- Why is nebulising not an AGP?
- What activities, during performing cardiopulmonary resuscitation, should not be carried out to prevent transmission of COVID-19?
- What is coughing etiquette?