With so many questions circulating among the general public, our nurses, and even ourselves, we wanted to speak with true experts to answer some of the most-asked questions. We spoke with Dr. Beam and Thao Tran to get some answers.
Thao Tran (TT) is a nurse specialist for the United States Department of Health and Human Services, specifically under the Assistant Secretary for Preparedness and Response. She collaborated with American Nurses Association\California on a webinar project sponsored by CDC on reprocessing and sterilization of medical devices. Prior to that, she was a federal civil service infection control nurse trained by US Public Health Service nurse officers.
Dr. Elizabeth Beam (EB) is an Assistant Professor at the University of Nebraska Medical Center College of Nursing in Omaha, Nebraska. Beth is a member of the Nebraska Biocontainment Unit Leadership team in the area of research. She has written several manuscripts related to PPE use in healthcare workers and recently has investigated reflective practice interventions in N95 respirator use.
Here are the commonly asked COVID-19 questions from nurses themselves:
EB: I always have people search for the Centers for Disease Control and COVID. This link includes great information for both the community and healthcare professionals. The CDC is always updating their site and ensuring that their information is current.
TT: The White House and CDC have put together a page to provide specific guidance to certain groups such as travelers, health departments, pregnant women, small business owners, laboratory professionals, and those who are already infected with COVID-19. There is also a resource on what you need to do to plan and prepare while at home.
Every state is a sovereign entity. Based on the needs of each state, each state is permitted to create, enact, and enforce its own laws during this pandemic. Follow your local county public health department and state public health department for current and reliable information about COVID-19. The CDC provides guidance but it is up to each local and state public health department to determine whether they want to follow national guidance on COVID-19. You can find state and territorial health department websites here.
EB: There are safe ways to reuse personal protective equipment (PPE). There is guidance on how to do this safely as well as what the current research indicates. Please take some time to review this link and learn more.
TT: It is okay for the hospital to reuse PPE. Because of the global shortage of PPE, the WHO and CDC have released recommendations that it is acceptable to reuse PPE. It is important to note that PPE and manufacturers have made a disclaimer that PPEs do not guarantee you protection against a specific disease. The FDA does not do studies on performance evaluation of each PPE against viruses such as COVID-19 or flu.
If a PPE does provide protection against a specific disease, the PPE label will make that claim. The purpose of having the PPE is to serve as a “non-disease specific barrier” to body fluids, solids, airborne particles, or other substances (FDA, 2020). This claim was made directly on the FDA website.
NIOSH does research on N95 filtering face-piece respirators. You can learn more about the National Personal Protective Laboratory here.
Nurses are at the frontline of this pandemic, but as a nurse, it is important to not overreact. Nurses will need to be mindful of which procedures (i.e., intubation, extubation, open suctioning, manual ventilation before intubation, turning patients to the prone position, disconnecting the patient from the ventilator) could generate aerosols.
Note airborne transmission of COVID-19 during these procedures is a possibility. If you are near a clinician doing a particular procedure such as intubating or extubating a COVID-19 patient or you interact with a patient that is infected with TB, then it is recommended the nurse or clinician should use a fitted N-95 respirator. Keep in mind that we do not know what is the exact transmission of COVID-19 when these procedures are performed.
During these times when PPE shortages are apparent, clinicians should exercise caution. There will be vendors that will sell gowns, face masks, N95 respirators, and PPEs that are not FDA-approved. To check if your PPE is FDA-approved, you can visit this site.
The purpose of the FDA site below is to “demonstrate that the device to be marketed is as safe and effective, that is, substantially equivalent, to a legally marketed device.” I have provided an example using FXX to find all the FDA-approved surgical masks that nurses and providers should be using. If you don’t know the specific code of the PPE, you can use the specific codes below:
Here are screenshots of how to look for an FDA-approved PPE such as surgical masks:
EB: The CDC has provided some information on using expired respirators. More information can be found here.
TT: Due to worldwide shortage of PPEs, many healthcare facilities are using expired N95 respirators. The suggested maximum number of reuses for an N95 respirator is no more than five uses based on preliminary data. I have provided information from the National Institute for Occupational Safety and Health (NIOSH) with regards to reuse or extended use. Prior to seeing a patient, nurses must do a N95 respirator seal check to make sure the integrity of the expired N95 is not compromised.
According to NIOSH, these are the recommendations:
Before COVID-19 outbreak, China was producing half of the world’s supplies. According to a New York Times (2020) article written by Mariel Padilla, China increased their production of face masks by 12-fold but hoarded most of its supplies. Without a major supplier like China to continue to manufacture and share supplies for the world, we will continue to face PPE shortages.
Even though we have noticed that healthcare providers should have access to PPEs, what is contributing to the shortage is the public buying N95 face masks and various surgical masks when the odds of getting infected is higher from touching a contaminated surface than from droplets traveling through the air.
EB: We know COVID-19 is a coronavirus, and we know that most coronavirus illnesses (like the common cold) are easy to transmit. We are still not sure of the exact transmission of the disease, but we tend to have a posture of use of respirators with most novel infections in order to best protect our healthcare workers.
When we talk about worker protection, we talk about something called the “Hierarchy of Controls.” PPE is at the very bottom.
We can remove hazards or things that are difficult to clean. We can replace hazards like glass bottles for blood cultures with plastic ones. We can put our patients in Airborne Infection Isolation Rooms (AIIR). We can arrange our cares differently. We can ask a patient to put a mask on when we enter the room to care for them. We need to be mindful of our safety as we work to care for patients with COVID-19. Be especially attentive of actions that might generate aerosols or air movement.
TT: Here is an analogy to help explain the difference between droplet and airborne. When you sneeze, you feel and see visible droplets of fluid. Your droplets can land anywhere. On the other hand, it is difficult to see aerosolized/airborne particles. An example of this is when you use hairspray. Although you are done with using hairspray, you can still smell it because some of the hairspray remains floating in the air.
We don’t fully understand the true transmission of COVID-19. Some suggest the transmission lies between droplet and airborne transmission. The science of transmission is still evolving. We must be patient in giving leading epidemiologists and researchers all over the world time to study the exact transmission of COVID-19. What we do know is COVID-19 is a novel coronavirus, and most coronaviruses are not airborne.
I want to add to Dr. Beam’s statement and reinforce what I posted earlier. In Dr. Beam’s Hierarchy of Controls, PPE is at the bottom. The general public thinks that PPE is the best way to protect from COVID-19. This is not true. As I have stated previously, PPEs do not protect you from a specific disease. The FDA has made a claim that PPEs are supposed to serve as non-disease specific barriers to fluids, solids, and airborne particles. The most effective ways to respond to COVID-19 is to eliminate or substitute hazards or advise people to do social distancing to keep them from being exposed to the hazard.
EB: We won’t fully understand some of these things until we can look back at the outbreak. The challenge with most children getting mild symptoms is that they might spread the illness to other older relatives who are more susceptible to the virus and who might ultimately have a more critical illness.
TT: We know COVID-19 does not spare anyone. Anyone is at risk for infection from COVID-19, with immunocompromised adults and the elderly more at risk than children. We don’t know why adults are more infected than children. Children are likely to have mild symptoms. What we have learned is anyone who is asymptomatic or has mild symptoms can also spread COVID-19 to other people. That’s why we are having people shelter-in-place to reduce the risk of spreading COVID-19 in the community.
EB: This seems to be the most current information.
TT: There is a great deal of misguidance about this. There is no solid evidence that says NSAIDs worsen COVID-19 symptoms. WHO made the statement “Based on currently available information, WHO does not recommend against the use of ibuprofen.”
If the patient wants to take NSAID such as ibuprofen to bring down her fever, then taking an NSAID is acceptable. Keep in mind that many people have fever phobia. Having a fever is good to allow your body to naturally fight the infection. If you bring down the fever too quickly by taking ibuprofen, you are not giving your body time to naturally fight the infection.
The concern about ibuprofen worsening COVID-19 is an example of how rumors, biases, and misinformation brings fear to the community about COVID-19. After the French Health Minister, Olivier Veran, made that inaccurate statement based on a speculative letter. The French Health Minister advised everyone to use paracetamol, a generic for acetaminophen. Although he provided the recommendation for paracetamol, there was no research to support his claim that paracetamol is better than using ibuprofen. The science community intervened and corrected the misinformation. There is no solid clinical evidence about NSAIDs exacerbating COVID-19 symptoms. Unfortunately, the French Health Minister’s misinformed statement about ibuprofen and its link to COVID-19 fueled a global panic about NSAIDs.
In the midst of panic and constant search for definitive answers about COVID-19, people tend to want quick fixes to a problem. As a clinician, it is acceptable to provide ibuprofen or acetaminophen to symptomatic patients. Providers need to know the risk factors for each patient and determine whether ibuprofen or acetaminophen is appropriate. For example, if a patient has liver complications, it’s best to give the patient ibuprofen provided that the patient does not have any GI problems.
EB: I think the answer to this depends on the severity of illness. For mild illness, I would not expect long term effects. I anticipate that after we weather through the COVID-19 storm, we will have a more comprehensive understanding of the long-term effects of COVID. I do expect that there will be profound long term health system effects of this COVID-19 pandemic.
TT: We are still learning about the long-term effects of COVID-19. Because it is a novel coronavirus that hasn’t been studied in great depth, our understanding of how this virus works is evolving. I have been reading a great deal about the work of world’s leading epidemiologist, Gabriel Leung, MD, MPH. He has made good predictions about the global impact of COVID-19. Here is a link to some of his research articles.
EB: This question is out of my personal scope of knowledge related to virology in general. The word “evolving” is used often to explain how the outbreak is moving. We certainly see the number of confirmed cases increasing. Johns Hopkins has a great resource to watch the evolution of the outbreak.
TT: I cannot answer that question. I have to leave it to WHO Director, Tedros Ghebreyesus; President Trump and his team of experts; and, the CDC to answer the question, “Is the virus getting worse?” I do agree with Dr. Gabriel Leung, the world’s leading epidemiologist and an expert on SARS and infectious disease, that we will see notable disparities in care. If the country has PPEs, ICUs, and ventilators, then we could save more lives. If we wait to respond to the outbreak, more lives will be lost.
To respond to COVID-19, you have to prepare and act right away. We saw that with South Korea. The minute the South Koreans heard about COVID-19 cases in China, they immediately mobilized their resources (PPEs, labs, healthcare workforce, ICUs, and ventilators) to prepare for this global pandemic.
Our lack of preparation for COVID-19 is not a surprise. The Ebola outbreak was a warning to all governments to prepare the healthcare system to handle a global pandemic. In 2015, Bill Gates warned the need to avoid a global failure by preparing now. No one listened to his prediction and recommendations. His famous TEDx video can be found here.
EB: No confirmed studies have settled this question at this time. I think it is reasonable to consider COVID-19 like other coronaviruses. This may mean that over time your immune system will forget the virus and the potential for reinfection exists.
TT: We don’t have enough information to say whether someone can get COVID-19 twice. The research on COVID-19 is emerging. While the global community is working quickly to conduct and disseminate research, there is also a great deal of misinformation.
EB: Work with your administrators to identify a low risk area to work in. There are several key response activities that would limit exposure to aerosol generating procedures. Beyond this, a lighter load is safer for both the mom and baby. As delivery becomes imminent, it may be important to isolate the mother from risk to ensure she is not ill when the baby arrives.
TT: There haven’t been any studies done on the impact of COVID-19 on pregnant nurses. Research protocols do not allow research studies to be done on vulnerable populations such as women, children, prisoners, individuals with mental disabilities, and those who are economically and/or educationally disadvantaged.
For pregnant nurses, it is best to keep them away from the floor that houses predominantly COVID-19 patients or any airborne patients. Having COVID-19 is stressful but putting a pregnant nurse on an infectious floor will give her added stress. The pregnant nurse can work in low-risk areas such as telehealth, L&D, NICU, or postpartum.
EB: Unfortunately, the symptoms of COVID-19 can be vague. Following the CDC’s guidance on when to test is important. Fever is probably the best indicator of active infection, but know its presence could indicate a number of illnesses. Work with your employee health office to monitor your symptoms and determine if testing is warranted.
TT: Signs and symptoms of COVID-19 are dry cough, tiredness, fever, muscle aches, and shortness of breath. These have been reported as the most common symptoms. Symptoms may appear 2 to 14 days after the exposure to the infected patient. Four emergency signs are troubled breathing, pressure or pain on the chest, new confusion, inability to arouse, or blue lips or face. Do not wait for mild symptoms to progress to these emergency warning signs. If you have mild symptoms, discuss with the primary care provider prior to checking into the hospital.
My advice is if you have mild symptoms, stay home and use supportive therapy to manage COVID-19. The hospital is flooded with many sick patients. Unless your symptoms are severe resulting in any of the emergency warning signs, this is not a good time to check into the hospital for mild symptoms. Let the primary care provider (physician, nurse practitioner, or physician assistant) decide on whether to recommend you to self-quarantine or check into the hospital.
EB: If your symptoms are mild and could be caused by something like allergies or sinusitis, wearing a mask would protect your patients from any harm. If the symptoms persist or get worse, work with your managers or employee health to be evaluated further.
TT: What we do know is COVID-19 could spread while the individual is asymptomatic or has mild symptoms. If you have symptoms that may or may not be specific to COVID-19, check with your primary care doctor to determine what you have and whether you are allowed to work.
EB: The supplies of PPE are part of a national response but are controlled at a local level. Working with your local public health and healthcare coalitions to get your supply information to them will help the Federal government get the supplies to areas of greatest need. This is most important for hospital administrators.
TT: Although PPEs are being resupplied, supplies are depleting fast. China produces half of the world’s supply of face masks. During the COVID-19 outbreak, China had to stop export of its face masks to the world. Production of face masks was twelve-fold after the COVID-19 outbreak in Wuhan, China. Now that COVID-19 incidences have gone down, China is exporting masks to countries that are requesting them.
Unfortunately, the US is not one of China’s recipients for face masks. This leads to other domestic companies producing N95 and face masks. However, the problem with domestic companies making N95 respirators and face masks is none of these PPEs have received FDA’s approval for use.
EB: As per the CDC guidance, an AIIR room (negative pressure) is ideal, but if that type of room isn’t available, a private room would be next best.
TT: Most hospitals don’t have many negative pressure rooms, and it is unlikely there will be one available due to the surge of patients infected with COVID-19. Putting the patient in a private room is acceptable.
EB: Your concerns are valid, but there are many things we can do to prevent transmission. All household members should practice social distancing and good hand hygiene. Frequently cleaning and disinfecting high touch surfaces is also important. If you can identify a room and bathroom that only you use, that will help to reduce their exposure to you.
TT: We all know the importance of practicing good hand hygiene (soap and water are preferred and if soap and water are not available, use hand sanitizers with 60% alcohol or higher). For healthcare workers, wear gowns, gloves, face mask, and face shield prior to handling any human body wastes or body fluids. Because of the shortage of PPE, some reports noted healthcare providers are reusing PPE. The CDC notes face masks reuse is acceptable during a time when we are having PPE shortages.
For a family member who enters the room of the individual infected with COVID-19, you want to keep your distance as much as possible to minimize respiratory droplets from landing on your clothes, hair, etc. Change clothes if needed. You don’t want to walk around with respiratory droplets on your clothes and infect others. As we found out recently on March 18th, we had the first death among the pediatric population. There is more about COVID-19 that we still do not know.
Clean and disinfect surfaces. Make sure you allow the disinfectant to have contact time with the surface. Each disinfectant has a manufacturer’s recommended disinfectant contact time. For example, if the disinfectant product says disinfectant contact time is 2 minutes, then you should allow the surface to be visibly wet for at least 2 minutes to ensure the disinfectant is given enough time to kill the microorganism. Disinfect regularly using household cleaning wipe or spray. The EPA has a list of recommended disinfectants here.
EB: We live in a world where we are used to having laboratory results quickly and efficiently. With a brand new test, we need to understand that the clinical laboratory takes time to ensure that the test is accurate. We also have to understand that the test is conducted on nasopharyngeal or oropharyngeal swabs. These have to be collected properly to get a good sample.
All of these steps take time, and the test is not a simple gram stain or pregnancy test. It is looking at PCR which is examining very small parts of cells (DNA and RNA).
TT: When this is over, we will be able to back track our steps and figure out what has worked and what we could do to prepare for another public health emergency. We will need to learn best practices from South Korea and other countries that were successful with testing. Our initial response to the pandemic was not timely. The minute we heard about the growing incidence of COVID-19 cases in China, the US should have prepared.
However, we did not do that. We lost valuable time to prepare for the pandemic. Furthermore, despite the recommendations made by Dr. Anthony Fauci that we needed to prepare for the pandemic, government leaders did not fully consider Dr. Fauci’s response; this slowed our response as a nation.
EB: Work with your employer to determine your exposure and your protections. Decisions need to be made on a case-by-case basis.
TT: Due to limited swabs, media, vials, and testing kits, not everyone is getting tested for COVID-19. As of Tuesday, March 24th, there are more than 48,000 COVID-19 results still pending.
The recommendation is against COVID-19 testing if someone has mild febrile respiratory illness. The goal is to limit exposure to other patients and healthcare co-workers and have them manage the symptoms at home.
Testing is tricky because if COVID-19 testing is done too early before the onset of symptoms, then we will have a negative test result. Not everyone who is exposed to COVID-19 will have symptoms. A negative COVID-19 result does not mean you are free from having an infection. It could be that you were exposed but haven’t developed the onset of symptoms yet.
EB: It seems very reasonable to bring your uniform to work and change into it there. Then you can leave your work at work and wear your personal clothes home. Bringing your work clothes home to wash should be fine, but you may want to wash them separately with a warmer setting for wash and drying to ensure a good disinfection. Bleach or disinfectant wiping your shoes is good practice, and if they can be left at work, all the better. This limits exposure to your car, your home, and your community.
TT: Hospital disinfectant wipes are meant to be used only in the hospital or healthcare settings. These wipes are made using very strong chemicals to kill most pathogens. Tips to not bring home COVID-19 would be to change clothes before you go home. Disinfect your shoes before you leave the hospital, or change out of your work shoes into your regular walking shoes. Get in the habit of washing your hands before and after your shift ends. You don’t want to bring any hospital microorganisms home.
EB: Most people only require typical over the counter cold and flu medications. Beyond that, good isolation of the ill, distancing, hand hygiene, and cleaning/disinfection of high touch surfaces… these are our best defenses.
TT: There is no treatment specific for COVID-19. It is treated with supportive therapy at home. Unless you have GI problems, then it is not recommended to overload yourself with ibuprofen. If you have liver problems, it is not recommended that you take acetaminophen. If you are infected with COVID-19, make sure you’re in a room that is only for you. You should not be sharing utensils, bathrooms, or common household items with healthy family members.
Social distancing is key to mitigate the risk of developing COVID-19 infection. Get in the habit of cleaning and disinfecting surfaces and common objects (door knobs, etc.) that we touch.
EB: These decisions will be based on supplies available to you, and I know that in California there are some difficult situations. Wearing masks all the time often results in more facial touching because they are uncomfortable. That being said, something is better than nothing. Remember that covering the source is a critical component, so if we can get a mask on the symptomatic patient or person, that helps to limit spread.
TT: I do question the efficacy of these makeshift masks. At the beginning of this document, I posted an FDA link. These PPEs have been tested for efficacy and approved by FDA. While psychologically, a makeshift mask will make the nurse feel better thinking that she has some protection from breathing droplets or airborne particles in the hospital, she is not actually protecting herself. The safest way to protect from airborne particles is the N95 respirator and a makeshift mask does not receive any approval that it is as effective as an N95 mask.
EB: Negative airflow is desirable. If a unit can be identified which is separated from typical patients, I do think that is wise.
TT: It is ideal to put the COVID-19 patients in a negative pressure room. Every hospital has at least one negative pressure room. The negative pressure room is expensive to build and maintain. Given the design of the U.S. hospital and in response to the surge of COVID-19 cases, administrators could identify a floor for COVID-19 patients separate from non-COVID patients.
EB: There is not a serology test available yet from CDC. The PCR test is not quantitative.
TT: At this time, a serology test for COVID-19 does not exist. Testing for COVID-19 is done through use of a nasopharyngeal or oropharyngeal swab.
EB: Quite a while. They were originally designed for very dusty environments, and the healthcare setting is typically very clean. Moisture is probably the biggest issue that would impact the filtration or contamination of internal aspects of the respirator… if you are reusing them.
TT: N95 respirators are quite sturdy and meant to last until the N95 respirator becomes deformed or damaged. The exact duration of how long N95 respirator lasts depends on how it is used during the shift. If you expose the N95 respirator to too much moisture or it gets damaged or soiled during the shift, it is a good idea to replace it. Ideally, N95 respirators that are cleared by FDA are designed for single use.
EB: The best indicator is when you no longer have symptoms. I know this can be difficult to determine, but a good rule of thumb might be at least 24-48 hours after any medications for symptoms are needed… similar to what we do everyday for day care settings. Even after feeling well, keeping up your social distancing is important. You may still shed some virus after the illness has improved.
EB: Low (but not zero), if we are careful and work together as a team to keep each other safe. A culture of safety is really important. This is not a time to keep quiet about something a colleague might be doing that is unsafe. A nurse has to be willing to tell a doctor that they are doing something incorrectly. Create a level playing field for all health professionals.
The likelihood of nurses getting sick at work is low as long as infection prevention measures are taken. For instance, after you take care of a COVID-19 patient, do not wear your PPE into the hospital cafeteria or walk out into the parking garage. If you are not well, stay home. You don’t want to get your co-workers sick.
Be mindful about mitigating the risk of infection at work. Protect your co-workers. If you see your co-workers not washing their hands before, between, and after patient care, kindly tell them to wash their hands and get in the habit of good hand hygiene. In a good sense, the COVID-19 is a reminder to all the healthcare workers to always practice good infection prevention and control.
EB: This depends on how ill the person gets. It may be limited to a week or 10 days, or as long as several weeks.
TT: It varies according to each person’s immune system. If you have a good immune system, you will be able to recover from COVID-19 more quickly. If you have engaged in unhealthy habits that reduce your immune system, your immune system will have to work harder to fight the infection. Remember, most people will recover from COVID-19.
And a final word about mental health. I do want to add that worrying about COVID-19 will not do you any good. Worrying brings psychological distress as well as weakens your immune system. COVID-19 is an infectious virus but not as fatal as Ebola. To avoid bringing down your immune system due to stress, limit watching the news about COVID-19 because over exposure to good and bad information may create fear, anxiety, or panic. Maintaining your mental health is important.
The CDC has a good site to help all of us cope during a pandemic.
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