Practice Guidelines for Canadian Neurophysiology Laboratories During the COVID-19 Pandemic.

The COVID-19 pandemic has had a major impact on clinical practice. Safe standards of practice are essential to protect health care workers while still allowing them to provide good care. The Canadian Society of Clinical Neurophysiologists, the Canadian Association of Electroneurophysiology Technologists, the Association of Electromyography Technologists of Canada, the Board of Registration of Electromyography Technologists of Canada, and the Canadian Board of Registration of Electroencephalograph Technologists have combined to review current published literature about safe practices for neurophysiology laboratories. Herein, we present the results of our review and provide our expert opinion regarding the safe practice of neurophysiology during the COVID-19 pandemic in Canada.

Safe and Efficient Practice of Bronchoscopic Sampling from Mechanically Ventilated Patients: A Structured Evaluation of the Ambu Bronchosampler-Ascope 4 Integrated System.

BACKGROUND: Bronchoscopic sampling of bronchoalveolar fluid (BAL) should be safe and effective. Current sampling practice risks loss of sample to the attached negative flow, aerosolisation, or spillage, due to repeated circuit breaks, when replacing sample containers. Such concerns were highlighted during the recent coronavirus pandemic. OBJECTIVES: Evaluation of an alternative integrated sampling solution, with the Ambu Bronchosampler with aScope 4, by an experienced bronchoscopist in ICU. METHODS: An observational study of 20 sequential bronchoscopic diagnostic sampling procedures was performed on mechanically ventilated patients with suspected ventilator-associated pneumonia. Mixed methods assessment was done. The predefined outcome measures were (1) ease of set up, (2) ease of specimen collection, (3) ease of protecting specimen from loss or spillage, and (4) overall workflow. The duration of the procedure and the % volume of sample retrieved were recorded. RESULTS: The mean (±standard deviation [SD]) time for collecting 1 sample was 2.5 ± 0.8 min. The mean (±SD) specimen yield for instilled miniBAL was 54.2 ± 17.9%. Compared with standard sampling, the set-up was much easier in 18 (90%), or easier in 2 (10%) of procedures, reducing the connection steps. It was much more intuitive to use in 14 (70%), more intuitive in 4 (20%), and no more intuitive to use in 2 (10%). The overall set-up and workflow was much easier in 69% of the 13 intraprocedural connections and easier or as easy in the remaining 31% procedures. All procedures where pre connection was established were much easier (7, 100%). The Ambu Bronchosampler remained upright in all procedures with no loss or spillage of sample. Obtaining a sample was much easier in 60%, easier in 10%, no different in 20%, and worse in 10%. The ability to protect a sample from start to finish compared to standard procedures was much easier in 80%, easier in 15%, and no different in 5% of procedures. Overall workflow was much easier in 14 (70%), easier in 4 (20%), and no different in 2 (10%) of procedures. CONCLUSIONS: The Ambu Bronchosampler unit was a reliable, effective, and possibly safer technique for diagnostic sampling in ICU. It may improve safety standards during the coronavirus pandemic. A randomized control trial against the standard sampling technique is warranted.

Gynecological laparoscopic surgery in the shade of COVID-19 pandemic

A global public health problem with a high rate spread and transmission, Coronavirus outbreak has become the most talked-about matter throughout the world. We are severely affected by the nations with vast numbers of deaths; it was hard to predict such a colossal pandemic with terrifying consequences. Elective surgeries are limited, but situations requiring an urgent gynaecological or obstetric surgical approach must still be performed during the COVID-19 pandemic. Concerns regarding surgical safety and the risk of viral transmission during surgery are of great importance. In this review, we aimed to summarize the concepts related to laparoscopic gynecological surgery during COVID-19 pandemic in the light of current literature.

US State Public Health Departments Special Pathogen Planning.

CONTEXT: US state public health departments played key roles in planning for and responding to confirmed and suspected cases of Ebola virus disease (EVD) during the 2014-2016 outbreak, including designating select hospitals as high-level isolation units (HLIUs) for EVD treatment in conjunction with the Centers for Disease Control and Prevention. OBJECTIVE: To identify existing guidelines and perspectives of state health departments pertaining to the management and transport of patients with EVD and other highly hazardous communicable diseases (HHCDs). DESIGN: An electronic 8-question survey with subquestions was administered as a fillable PDF. SETTING: The survey was distributed to publicly accessible e-mails of state health department employees. PARTICIPANTS: State epidemiologists, emergency preparedness directors, or chief medical officers from each of the 50 states and the District of Columbia were contacted; a representative from 36 states and the District of Columbia responded (73%). MAIN OUTCOME MEASURES: Descriptive statistics were used to identify the proportion of state health departments with various existing protocols. RESULTS: A majority of states reported that they would prefer patients confirmed with viral hemorrhagic fevers (eg, EVD, Marburg fever) and smallpox be transported to an HLIU for treatment rather than remain at the initial hospital of diagnosis. While most (89%) states had written guidelines for the safe transportation of patients with HHCDs, only 6 (16%) had written protocols for the management of accidents or other travel disruptions that may occur during HHCD transport within the state. Twenty-two state health departments (59%) had operationally exercised transport of a patient to an HLIU. CONCLUSIONS: Nearly half of states in the United States lack an HLIU, yet most prefer to have patients with HHCDs treated in high-level isolation. Recent budget cuts and uncertainty of future funding threaten the abilities of health departments to devote the necessary resources and staff to prepare for and deliver the desired care to HHCD cases. The lack of HLIUs in some states may complicate transport to a geographically proximate HLIU. Moreover, limited guidance on diseases that warrant high-level isolation may cause disagreement in HHCD patient placement between health departments, diagnosing facilities, and HLIUs.

Ebola virus disease: the UK critical care perspective.

The recent outbreak of Ebola virus disease (EVD) has required the treatment of affected patients in the NHS system within the UK. Managing patients with a confirmed viral haemorrhagic fever requires a thorough understanding of treatment options within the confines of an effective biocontainment setting. The Royal Free Hospital High Level Isolation Unit (HLIU) in London, is a purpose built facility that allows healthcare workers to safely treat patients with highly contagious diseases. This HLIU uses Trexler isolator tents to prevent the spread of infection from patients to healthcare workers. Provision of invasive organ support can be provided in this environment, if considered appropriate, and is achievable without posing additional risk to staff. We report our recent experiences of managing patients with EVD, with particular focus on those aspects of care pertinent to anaesthesia and critical care medicine.

Transferring patients with Ebola by land and air: the British military experience.

The Ebola epidemic of 2014/2015 led to a multinational response to control the disease outbreak. Assurance for British aid workers included provision of a robust treatment pathway including repatriation back to the UK. This pathway involved the use of both land and air assets to ensure that patients were transferred quickly, and safely, to a high-level isolation unit in the UK. Following a road move in Sierra Leone, an air transportable isolator (ATI) was used to transport patients for the flight and onward transfer to the Royal Free Hospital. There are several unique factors related to managing a patient with Ebola virus disease during prolonged evacuation, including the provision of care inside an ATI. These points are considered here along with an outline of the evacuation pathway.

Performance of bedside diagnostic ultrasound in an Ebola isolation unit: the Emory University Hospital experience.

OBJECTIVE: Individuals with Ebola virus disease, a contagious and potentially lethal infection, are now being treated in specialized units in the United States. We describe Emory University's initial experience, current operating procedures, and ongoing planning with diagnostic ultrasound in the isolation unit. CONCLUSION: Ultrasound use has been limited to date. Future planning considerations include deciding what types of ultrasound studies will be performed, which personnel will acquire the images, and which ultrasound machine will be used.

[General procedures in response to suspected attacks with highly contagious and pathogenic agents]. / Allgemeines Vorgehen bei Verdacht auf einen Anschlag mit hochkontagiösen, hochpathogenen Agenzien.

The discovery of undefined powders that are content of letters or parcels with or without threats in writing addressed to institutions, groups or persons, often raises the suspicion of an attack involving biological agents such as anthrax. Subsequent investigations and analyses by local authorities often aim at excluding anthrax or anthrax spores. Suspicion and actions are then mistakenly justified by referring to the 2001 anthrax letter attacks in the USA, which now lie more than 10 years in the past. In Germany to date there has never been a terrorist attack involving dangerous biological agents, neither in letters nor in any other possible form. In addition, it cannot be assumed that anthrax bacteria or spores will be used again in a bioterrorist event. In the case of a valid suspicion of a threatening letter, neither analyses to exclude only a certain group of substances (e.g. biological, chemical or radiological) nor analyses to exclude only one biological agent (e.g. anthrax) in particular would provide sufficient information for decision makers to conduct further actions in coping with the given situation. Moreover, a sequence of procedures such as consultation, exclusion, and analyses should be followed in order to systematically exclude all relevant threats. Therefore, and in respect to the current CBRNE threat assessment for Germany, the following article provides recommendations of actions to be taken for coping with a valid suspicion of an intentional release of biological agents utilizing powder letters as an example.

[Ebola virus disease in West Africa and Germany : clinical presentation, management and practical experience with medevacuated patients in Germany]. / Ebolafieber in Westafrika und in Deutschland : Klinik, Management und Erfahrungen mit den bisher in Deutschland behandelten Patienten.

Ebolaviruses are the causative pathogens of a severe form of viral haemorrhagic fever with cytokine induced shock and multi-organ failure and a high case fatality rate in humans (50-90 %, more than 70 % in the beginning of the current outbreak), designated Ebola haemorrhagic fever or Ebola virus disease (EVD). Ebola is endemic in regions of Central and West Africa. Ebolavirus Zaire (EBOV) is the most aggressive Ebola virus species and is causing the current epidemic. Currently, beginning in late 2013, an unprecedented epidemic with several thousand cases and deaths (as per WHO report 24.12.2014: 19,497 documented cases, 7588 death, 2352 cases in past 3 weeks) is unfolding in Guinea, Liberia and Sierra Leone, and spreading to other countries in Africa, Europe and the USA, where isolated cases have occurred. Ebola transmission occurs exclusively through direct contact with body fluids through mucosal surfaces, skin abrasions, or by parenteral introduction-an aerolised transmission has not been reported so far. Infections in healthcare personnel have not only occurred after needle stick injuries but also after unsafe doffing procedures of personal protection equipment (PPE). The protection of healthcare personnel caring for Ebola patients, therefore, requires that high standards in the use of PPE are mandatory. In high-income countries the management and treatment of EVD patients in specialized centres is recommended. Using negative pressure rooms and positive pressure suits may provide additional safety. Due to the high degree of training and monitoring needed to prevent occupational risks, treatment of EVD patients in non-specialized hospitals should not take place.

[Exercise scenario of a highly contagious, life-threatening disease in intercontinental aviation : a case report in the context of the International Health Regulations (IHR)]. / Übungsszenario für eine hochkontagiöse, lebensbedrohliche Erkrankung in der interkontinentalen Personenluftfahrt : Eine Kasuistik vor dem Hintergrund der internationalen Gesundheitsvorschriften (IGV).

BACKGROUND: The International Health Regulations (IHR) 2005 were conformed to German law on July 20, 2007 and described in detail by the Implementing Act (IHR DG). According to these legal bases, "designated airports" must maintain special capacities for protection against health threats, and are also responsible for performing regular IHR exercises. OBJECTIVES: Representation of the optimization of established operational concepts of various professions to manage infectious biological threats without obstruction of international travel, and mediation of experience to IHR professionals. MATERIALS AND METHODS: An exercise based on the case scenario of a travel-related febrile illness was performed at Munich International Airport on November 11, 2013. Preparations took 6 months and the exercise itself lasted nearly 12 h. The follow-up lasted an additional 9 months. A qualitative and quantitative evaluation of the exercise was completed. RESULTS: From an Individual Medicine and Public Health perspective, modular work structures and risk communication functioned adequately. The medical examination of passengers was also well managed. Areas requiring further optimization included arrival/departure times of external actors, transport of the index patient to hospital and protective measures for individual participants. Overall, a defined biological threat scenario representing a double infection with two highly pathogenic germs was handled satisfactorily without affecting international air travel. CONCLUSIONS: Modular supply components are an effective and forward-looking means in protection against threats occurring at airports. Key success factors include sufficient staff mobility, immediate self-protection of actors involved, effective risk communication and a strong overall coordination and monitoring of the situation.

Study on infection risk in a negative pressure ward under different fresh airflow patterns based on a radiation air conditioning system.

COVID-19 and other respiratory infectious viruses are highly contagious, and patients need to be treated in negative pressure wards. At present, many negative pressure wards use independent air conditioning equipment, but independent air conditioning equipment has problems such as indoor air circulation flow, condensate water accumulation, and improper filter maintenance, which increase the risk of infection for healthcare workers and patients. The radiation air conditioning system relies on the radiation ceiling to control the indoor temperature and uses new air to control the indoor humidity and air quality. The problems caused by the use of independent air conditioning equipment should be avoided. This paper studies the thermal comfort, contaminant distribution characteristics, contaminant removal efficiency, and accessibility of supply air in a negative pressure ward with a radiation air conditioning system under three airflow patterns. In addition, the negative pressure ward was divided into 12 areas, and the infection probability of healthcare workers in different areas was analyzed. The results show that the application of radiation air conditioning systems in negative pressure wards can ensure the thermal comfort of patients. Stratum ventilation and ceiling-attached jets have similar effects in protecting healthcare workers; both can effectively reduce the contaminant concentrations and the risk of infection of healthcare workers. Ceiling-attached jets decreases the contaminant concentrations by 10.73%, increases the contaminant removal efficiency by 12.50%, and decreases the infection probability of healthcare workers staying indoors for 10 min by 23.18%, compared with downward ventilation.

Aerosol Concentrations During Otolaryngology Procedures in a Negative Pressure Isolation Room.

OBJECTIVE: To evaluate the role of a negative pressure room with a high-efficiency particulate air (HEPA) filtration system on reducing aerosol exposure in common otolaryngology procedures. STUDY DESIGN: Prospective quantification of aerosol generation. SETTINGS: Tertiary care. METHODS: The particle concentrations were measured at various times during tracheostomy tube changes with tracheostomy suctioning, nasal endoscopy with suctioning, and fiberoptic laryngoscopy (FOL), which included 5 times per procedure in a negative pressure isolation room with a HEPA filter and additional 5 times in a nonpressure-controlled room without a HEPA filter. The particle concentrations were measured from the baseline, during the procedure, and continued until 30 minutes after the procedure ended. The particle concentrations were compared to the baseline concentrations. RESULTS: The particle concentration significantly increased from the baseline during tracheostomy tube changes (mean difference [MD] 0.80 × 106 p/m3 , p = .01), tracheostomy suctioning (MD 0.78 × 106 p/m3 , p = .004), at 2 minutes (MD 1.29 × 106 p/m3 , p = .01), and 3 minutes (MD 1.3 × 106 p/m3 , p = .004) after suctioning. There were no significant differences in the mean particle concentrations among various time points during nasal endoscopy with suctioning and FOL neither in isolation nor nonpressure-controlled rooms. CONCLUSION: A negative pressure isolation room with a HEPA filter was revealed to be safe for medical personnel inside and outside the room. Tracheostomy tube change with tracheostomy suctioning required an isolation room because this procedure generated aerosol, while nasal endoscopy with suctioning and FOL did not. Aerosol generated in an isolation room was diminished to the baseline after 4 minutes.

Association between negative-pressure room utilization and hospital-acquired Aspergillus rates in patients with coronavirus disease 2019 (COVID-19) in two academic hospitals.

Hospital-acquired Aspergillus rates among coronavirus disease 2019 (COVID-19) patients were initially higher at a hospital with high negative-pressure room utilization compared to a similar hospital with low utilization but with otherwise identical infection control policies. After the index hospital decreased negative-pressure utilization, hospital-acquired Aspergillus case rates at the 2 hospitals converged.

Aeromedical evacuation using an aircraft transit isolator of a patient with Lassa fever.

BACKGROUND: Lassa fever is a viral hemorrhagic fever only present in West Africa. The mortality rate is 1% and may reach 15% among hospitalized patients. Transmission between humans is mostly due to direct contact with infected body fluids. Aeromedical evacuation of patients with viral hemorrhagic fevers (such as Lassa fever) demands strict isolation measures. Only a few cases of such evacuations have been reported in the literature during the last 40 yr. The use of an aircraft transit isolator device could be helpful. CASE REPORT: We report the aeromedical evacuation of a confirmed Lassa fever patient from Sierra Leone to Sweden with a dedicated air ambulance using an aircraft transit isolator. The patient was a 30-yr-old physician working for a nonprofit organization. The patient contracted the disease working with infected hospitalized patients. The duration of the mission between activation and arrival at the Swedish hospital was 36 h, which is within the World Health Organization recommendations. DISCUSSION: Evacuation of patients with potentially lethal contagious infections is possible, but only with strict isolation measures. Specific protective equipment and isolator are mandatory. Medical and technical crews performing such evacuations should be trained in proper equipment use and the isolator should first be used with a low-risk patient to create minimal risk transport conditions.

Visualization of the infection risk assessment of SARS-CoV-2 through aerosol and surface transmission in a negative-pressure ward.

Since December 2019, coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a great challenge to the world's public health system. Nosocomial infections have occurred frequently in medical institutions worldwide during this pandemic. Thus, there is an urgent need to construct an effective surveillance and early warning system for pathogen exposure and infection to prevent nosocomial infections in negative-pressure wards. In this study, visualization and construction of an infection risk assessment of SARS-CoV-2 through aerosol and surface transmission in a negative-pressure ward were performed to describe the distribution regularity and infection risk of SARS-CoV-2, the critical factors of infection, the air changes per hour (ACHs) and the viral variation that affect infection risk. The SARS-CoV-2 distribution data from this model were verified by field test data from the Wuhan Huoshenshan Hospital ICU ward. ACHs have a great impact on the infection risk from airborne exposure, while they have little effect on the infection risk from surface exposure. The variant strains demonstrated significantly increased viral loads and risks of infection. The level of protection for nurses and surgeons should be increased when treating patients infected with variant strains, and new disinfection methods, electrostatic adsorption and other air purification methods should be used in all human environments. The results of this study may provide a theoretical reference and technical support for reducing the occurrence of nosocomial infections.