document title covid-19 work instruction for rnsh

COVID-19 Work Instruction for RNSH Intensive Care Unit. V1. 27.3.20 1

Document title COVID-19 Work Instruction for RNSH Intensive Care Unit

Applies to RNSH Intensive Care Unit

Contributors

In consultation with

Rachel Grundy ICU CNE, Kerryn Taylor ICU CNE, Dr.

Pierre Janin ICU Medical Specialist, Dr. Joshua Pillemer

ICU Medical Specialist, Dr. Jonathan Gatward ICU Medical

Specialist, Dr. Naomi Diel ICU Medical Specialist, Dr. Oliver

Flower ICU Medical Specialist.

Renae McCarthy Manager Corporate Services RNSH on

behalf of HealthShare, Dr. Benjamin Olesnicky Dept. Head

Anaesthetics RNSH, Dr. Jonathon Brock Dept. Head

Anaesthetics RNSH, Julia Carey CNC3 Infection Prevention

& Control, Gonzalo Hamdan Environmental Services

Manager HealthShare RNSH, Nurcan Ozerim Food

Services Manager HealthShare RNSH, Nathan Emmanuel

Chief Radiographer RNSH & Ryde, Katherine Erdman Section Senior Radiographer RNSH, Aldo Severino

Morturary Services Team leader RNSH, Prof. Anthony Gill

Professor of Surgical Pathology RNSH & University of

Sydney, Brad Ernst Post Mortem Assistant RNSH, Robert

Lindeman Executive Director of Clinical Services RNSH,

Tom Kennedy Local Pathology Director RNSH.


Reviewed by Dr. Lewis Macken, Dept. Head ICU, Dr. Pierre Janin ICU

Medical Specialist, Dr. Sarah Wesley ICU Medical

Specialist, Matthew Tinker ICU CNC, Andrea Dunne ICU

CNE, Michael Grew ICU CNE, Claire Harris Director of Nursing & Midwifery Services RNSH, Dr. Philip Hoyle

Director of Medical Services RNSH, Dr. Michelle Mulligan

Clinical Director -Surgery & Anaesthesia RNSH, Dr. Terry

Finnegan Clinical Director of the Dept. of Medicine RNSH.

Version 1.0

Date created 23.03.20

Authorisation The Department of Intensive Care, RNSH

Review date 23.03.21

Disclaimer The following is a guideline for the care of RNSH ICU patients during the COVID-19 pandemic. This guideline will evolve as knowledge and experience with the disease improves. Any updates to this guideline will be made readily available on the ICU website in the COVID-19 section. Please note: This is a living document and is version controlled.


Table of Contents

COVID-19 1

Work Instruction for RNSH Intensive Care Unit 1

Disclaimer 2

1.0 PRECAUTIONS 5 1.1 Uniform Considerations for all Staff 5 1.2 Food and Staff Belongings 5 1.3 Staff Log Error! Bookmark not defined. 1.4 Visitors 5 1.5 Personal protective equipment for ICU Staff 6 1.6 Aerosol generating procedures (AGPs) include 6 1.7 Routine ICU Nursing cares 6 1.8 PPE Safety Huddle 6 1.9 PPE coach 7

3.0 NEGATIVE PRESSURE ROOM SET UP 10 3.1 Signage 10 3.2 Outside the Room 11 3.3 Anteroom 11

4.0 ROOM SET UP STANDARD ICU ROOM 12

4.1 Signage 12

5.0 REMOVING ITEMS FROM ROOMS 13

6.0 COLLECTING SPECIMEN SAMPLES: 13 6.1 Arterial Blood Gas Management/Activated Clotting Time/Rotem: 14

7.0 ENVIRONMENT 15

8.0 IN ROOM PROCEDURES 16 8.1 The 3 Runner System: 16 8.2 Runner System for NEGATIVE PRESSURE ROOMS: 17 8.3 Runner System for STANDARD ICU ROOMS: 17

9.0 COVID-19 EMERGENCY PACKS: 18 9.1 Intubation: 19 9.2 Ventilation: 20 9.3 Extubation: 22 9.4 HFNP: 22


9.5 NIV: 22 9.6 Bronchoscopy: 22 9.7 Proning a Patient: 22 9.8 ECMO: 23 9.9 iNO: 23 9.10 Nebulised Prostacyclin/FLOLAN: 23 9.11 Cardiac Arrest: 23 9.12 Post Cardiac Arrest: 23 9.13 Shared Medical equipment – Echo/Doppler/EEG/USS/C-Mac and Ambuscope: 24 9.14 Sterile Procedures: 24 9.15 Aseptic Procedures – Dressing and line changes: 25

10.0 ORDERING MEDICAL IMAGING: 25

11.0 ALLIED HEALTH 25

12.0 INTRA-HOSPITAL TRANSPORT: 26 12.1.TRANSPORT PREPARATION 26 12.3 Management of the Deceased: 28

13.0 COVID-19 Resources: 29 Reference List 29


1.0 PRECAUTIONS

1.1 Uniform Considerations for all Staff • Cardigans, vests or jumpers are NOT to be worn when providing direct clinical care. • Sleeves must be rolled up to above the elbow level • Footwear must be safe, take a shine, non-slip, and made of sturdy appropriate material. No

joggers/sneakers/runners are to be worn in the clinical areas. • Hand jewellery must be limited to 1 x plain band on one finger (which is freely moving) to facilitate

hand hygiene. No engagement rings are to be worn in clinical areas • No watches or forearm jewellery are to be worn in clinical areas • No nail polish, acrylic/gel nails are to be worn by staff providing direct patient care • Natural nail must be clean and tips must be less than 0.6 centimetres (1/4 inch) long. • ID badges are to worn on the hip. No lanyards are to be worn • No personal stethoscopes into confirmed or suspected rooms • Staff with long hair must wear their hair up and in a bun

1.2 Food and Staff Belongings • NO personal belonging are to be stored in the pod • Staff to use their lockers • A supply of surgical scrubs is available on all linen trolleys for staff to wear • Please change into these scrubs at commencement of your shift • At the end of your shift, place DIRTY surgical scrubs into the linen trolley in the 6H staff shower room

(outside bed 4) or the linen trolleys within the staff change rooms • No eating AT ALL in the pod • No food or empty plastic bottles for recycling to be kept in pods

1.4 Visitors

• Visitors are currently limited to one visitor per patient • Patients will be asked to nominate a visitor, preferably next-

of-kin, to visit during their stay and other loved ones are encouraged to keep in touch via phone or digital technology

• The nominated visitor should be documented in eRIC. MENU→Patient Demographics→Comments→ ”Nominated visitor”

• Admin staff collect nominated visitors driver’s licence/ID so they can identify who that person is.

• Visitors must be well and free from any respiratory symptoms to be permitted entry to pod • All visitors must wear full PPE when entering the room. Repeated entry and exit is to be avoided • All visitors who have travelled overseas MUST self-isolate for 14 days, during this time they are NOT

permitted to visit RNSH ICU • Visitors with recent close contact with a COVID-19 patient (without wearing PPE) should not attend

RNSH ICU and be in self-isolation for 14 days at home • Visitors who are requesting further information or who are disputing our visitation policy are to be

referred to your pod NUM or AHNUM.


1.5 Personal protective equipment for ICU Staff • Contact Droplet Airborne Precautions in addition to Standard Precautions should be used when

caring for all suspected or confirmed COVID-19 patients in ICU. This means N-95 masks should be worn for all patient interactions.

• Hair nets and face shields are to be worn ONLY during an aerosol generating procedure (AGP) • If an AGP occurs, ideally the door should not be opened for at least 30 minutes post procedure in a

standard ICU room • People who wear glasses can wear a face shield if they cannot source goggles that fit well over their

glasses • An adequate seal on an N95/P2 mask cannot be guaranteed between a Health Care Worker’s (HCW)

face and the mask if they have facial hair (including a ≤2 day beard growth). • HCW’s who are unable to achieve an adequate seal with a P2/N95 mask will need to be re-deployed

to care for alternative patients, where use of a P2/N95 mask is not required

1.6 Aerosol generating procedures (AGPs) include:

• Coughing/sneezing • NIV • HFNP • Delivery of nebulised/atomised medications via simple face mask • Cardiopulmonary resuscitation • Tracheal suction (without a closed system) • Tracheal extubation • Laryngoscopy • Tracheal intubation • Bronchoscopy/Gastroscopy • Front-of-neck airway (FONA) procedures (including tracheostomy, cricothyroidotomy) • Ventilator disconnection • Taking a COVID-19 swab • Placing a ventilated patient in a prone position

1.7 Routine ICU Nursing cares

• Routine cares should remain as close to usual practice as possible • Performing ETT tapes should be done with gloves remaining on at all times • When removing urine and/or faeces from a standard ICU room, cover with bluey, hand the pan or

bottle to a 2nd person who is wearing gloves and a gown, who walks directly to the sluice to discard it and then DOFF PPE.

• Nurses need to cluster cares as much as possible, to minimise entry into the room • Perform a “shopping list” by writing the items you need re-stocked within your room on the whiteboard

so that you can see the list from outside the room • Gather all equipment before entering room for all cares you intend to do • Nurses are to work closely with the RN next to them. Ensure that when someone enters a COVID-19

patient room that another nurse is outside in case the primary nurse needs assistance or a PPE coach

• Take care when using steri7 wipes to use one wipe and not to grab a handful to conserve resources • If patient is coming from another clinical area within RNSH, print off patient ID stickers to pre-label

specimens in preparation for patient arrival • CONFIRMED COVID-19 patients with beards or moustaches need to be nursed with brown ETT

tapes for airway security. • ETAD’s/Anchorfast devices and white tapes are not recommended


• White tapes will be done post intubation, then at a time convenient to the RNs and when ETT position is confirmed brown tapes can be exchanged

• To facilitate brown tapes, this will require the need to shave the patient’s facial hair, this removes the risk of facial hair acting as a reservoir for viral droplets

• Prior to shaving, a phone call to the patient’s “person responsible” needs to occur to inform them of the need to shave the patient’s facial hair. Permission does not need to be obtained but it is a courtesy to the relative. If the person responsible is adamantly against this, we need to enquire as to why and then if this is for religious reasons we need to refer to the ICU Medical Specialist

• Special consideration may need to be given to certain religions.

1.8 PPE Safety Huddle • A member of ICU staff is responsible for providing a safety briefing to any visitors or health care

workers entering or exiting the patient’s room. This briefing should include clear instructions on the required PPE, and the DONNING and DOFFING sequence.

• Health care workers entering the room should be kept to a minimum and for visiting teams the need to enter the room should be considered in conjunction with the ICU medical team

• Staff who should not routinely enter suspected or confirmed COVID-19 patient rooms are: Ø Defence personnel Ø Super-numerary staff Ø Non-essential members of any medical or allied health team, limiting entry to one member of

that team only

1.9 PPE coach

• The purpose of this role is to stand outside the room and actively observe and guide the PPE DONNING & DOFFING sequence of staff caring for suspected or confirmed COVID-19 patients during high risk procedures

• Staff who intend to leave a patient room are encouraged to summon a PPE coach by pressing the green patient call bell

• Every time a patient call alert is heard, staff in the pod must ensure someone responds as a matter of priority

• If a breach in DOFFING sequence is observed. The staff member should be notified of the breach, prompted to STOP and immediately perform hand hygiene with ABHR

• If any uncorrected breach in PPE sequence occurs, please perform an ims+ • The PPE coach is equivalent to the “buddy check” role that is mentioned in other guidelines

disseminated in NSW/Australia (SAS Consensus Statement) • If multiple staff are leaving a room, ONLY one person should DOFF at a time. This is to minimise risk

of error and inadvertent contamination


COVID-19 DONNING and DOFFING PPE sequence for AGP’s:


DOFFING should occur in the red taped zone – the DIRTY area

NSLHD IPAC COVID-19 PPE Sequence for use when

no AGP is in use:


NEGATIVE PRESSURE ROOMS • There are 6 Negative pressure rooms located within the general pods in RNSH ICU • 6H beds 4, 5 & 9 • 6G beds 8, 11 & 16 • Suspected or confirmed COVID-19 patients should be placed in these rooms within the general units

if one is available. • Once the negative pressure rooms in the general pods are all occupied, standard ICU rooms will be

used. • The sliding door on a standard ICU room MUST be closed at ALL times • Positive pressure rooms should be avoided until we have absolutely NO choice but to use them

3.0 NEGATIVE PRESSURE ROOM SET UP

3.1 Signage • Signage is kept in the COVID-19 resource folder located in each pod

Obtain: • PPE sequence sheets • Please Do Not Enter” sign • Room entry visitor log sheet


3.2 Outside the Room • 1 x Fully stocked PPE stand placed on the marked green X • A PPE sequence sheet should be placed next to the PPE stand • 1 x recycling waste bin should be placed on the marked red X • Place “Please do not enter sign” on Anteroom door • Place room entry visitor log sheet on exterior door

3.3 Anteroom • Floors should be marked with a DIRTY/CLEAN area with tape • CLEAN and DIRTY bench spaces should be marked with tape • A PPE sequence sheet should be placed on the interior door of the Anteroom • 1 x packet of Steri7 wipes should be on the DIRTY bench at all times • Gloves sized S, M and L in racks • 1 x recycling waste bin should be placed within the DIRTY area on the space

marked by a Red X • The Anteroom is NOT to be used as a storage for any equipment/supplies, it is a DOFFING and

cleaning equipment zone

Inside the patient room: • 1 X packet of Steri7 wipes • All regular items in silver trolley and pendant drawers • INSIDE SLUICE ROOM – plastic bag lined linen skips • 1 x foot pedal operated clinical waste bin and 1 x general waste bin • Gloves • Dedicated room stethoscope • Calf compressors and pump • Adequate supply of ECG dots • Bring in agilia pumps and syringe drivers as required • White board marker • 2 small clinical waste bags


4.0 ROOM SET UP STANDARD ICU ROOM

4.1 Signage Signage is kept in the COVID-19 resource folder located in each pod

Obtain: • PPE sequence sheets • “Please Do Not Enter” sign • Room entry visitor log sheet

Outside the Room: • 1 x Fully stocked PPE stand placed on the marked green X • A PPE sequence sheet should be placed next to the PPE stand • 1 x recycling waste bin should be placed on the marked red X • Place “Please do not enter sign” on the sliding door • Place 1 x room entry visitor log on exterior door

Inside the patient room: • A DIRTY area should be marked with red tape on the floor • 1 x general waste bin should be placed on a red x mark in the DIRTY area • A PPE sequence sheet should be placed on the glass window immediately next to the DIRTY area • The centre of the patient’s bed should be positioned between a “goal post” marked by 2x pieces of

red tape placed on the wall • Positioning the bed between the “goal post” ensures a safe distance of AT LEAST 2m is

maintained from the DOFFING area and the patient door • A DIRTY/CLEAN bench should positioned over green tape marker on the floor • 1 x packet of Steri7 wipes should be placed on the DIRTY/CLEAN bench • All regular items in silver trolley and pendant drawers • Plastic bag lined linen skips • 1 x foot pedal operated clinical waste bin • Dedicated room stethoscope • Calf compressors and pump • Adequate supply of ECG dots • Bring in agilia pumps and syringe drivers as required • White board marker • 2 small clinical waste bags • Gloves


5.0 REMOVING ITEMS FROM ROOMS DIRTY/ CLEAN bench sequence: • Any items being removed from a patient room (of any layout or pressure) must be cleaned with Steri7

wipes as per the following sequence: 1. Perform first CLEAN with Steri7 wipes in the patient room 2. Take immediately and place on the DIRTY bench/area 3. DOFF PPE as per sequence (except for mask), perform HH with ABHR,

DON new gloves 4. Perform second CLEAN with Steri7 wipes. Transfer to a CLEAN bench/area. 5. DOFF Gloves again, perform HH. 6. Item is now safe to take from the patient’s room/ante-room

GOGGLE CLEANING: • Goggles will be DOFFED onto the DIRTY bench and then left to be cleaned as a batch • There will need to be multiple pairs of goggles per patient so there is a rotation of goggles in use • To clean the goggles for re-use the bedside RN will need to perform 2 x goggle cleans with steri7

wipes by entering the DIRTY area at a convenient time • They can then be removed and re-used

6.0 COLLECTING SPECIMEN SAMPLES: COVID-19 Testing: • Swabbing of ANY patient in ICU is at the discretion of the senior members of the medical team

only • On admission (if not performed in ED/ward) you need to send:

• A swab or sputum sample for COVID-19 performed as per the section below. If feasible a sputum sample is preferred due to the higher sensitivity

• COVID-19 serology (1 x red with yellow top tube) for storage in the laboratory • 24 hours later (if the 1st sample is negative) – a second COVID-19 swab or sputum is to

be sent


• Who to test, is evolving continuously, please refer to NSLHD intranet – COVID-19 – “Who to test” for the latest information https://www.health.nsw.gov.au/Infectious/diseases/Pages/coronavirus-update.aspx

• Clearing a patient of COVID-19 must be done in consultation with microbiology • Pre label all specimens and complete request form before obtaining the

specimen, place an URGENT ICU SPECIMEN sticker on the form • Stand to the side of patient to avoid contamination from sneeze or cough • Place swab directly into 1 x clear pathology bag • All specimens from suspected or confirmed COVID-19 patients should now be sent to pathology

in a SINGLE bag • An “Urgent ICU Specimen” sticker should also be placed on the outside of the pathology bag

once the bag is dry. This is to highlight that the specimen has come from ICU to ensure the specimen is prioritised by pathology staff

• Specimens can go down in pneumatic tube system as per normal routine.

Transferring Specimen collections from room:

PRE-PROCEDURE

• Gather specimen collection device (e.g. swab, blood tube or pot), clear pathology bag and request form, place an URGENT ICU SPECIMEN sticker on form.

• Fill out request form and label specimen collection device PRIOR to entering the patients room

• Place completed request form in the outside pocket of the clear pathology bag as per normal practice

• DON PPE as per sequence and enter room to perform specimen collection.

POST-PROCEDURE

• Place specimen directly into pathology bag and seal • Clean pathology bag as per DIRTY/CLEAN bench sequence • You can now leave the room with the clean pathology bag containing the specimen,

place it down, DOFF mask, perform HH • Take pathology bag to pneumatic tube system, ensure bag is dry, place URGENT ICU

SPECIMEN sticker on red bag and send as normal

Tracking Specimens:

• An ICU nurse will write a log on the whiteboard, the time and date each swab/sputum was sent so we can keep organised with when the next specimen is due.

6.1 Arterial Blood Gas Management/Activated Clotting Time/Rotem:

ABG should only be taken when clinically indicated as per normal ICU routine


PRE-PROCEDURE

• Gather ABG collection bag (available in each pod) • DON PPE as per sequence and enter room to perform ABG collection

POST-PROCEDURE

• Place specimen directly into clear pathology bag and seal • Before being removed from the patient room, the single pathology bag should be cleaned

with steri7 wipes as per DIRTY/CLEAN bench sequence • You can now leave the room with the clean pathology bag containing the ABG, place it down,

DOFF mask, perform HH • Pick up clean pathology bag, walk to ABG machine

AT THE ABG/ACT/ROTEM MACHINE

Processing the ABG requires a second person, the role of second person is to enter the patient’s details, FiO2 and temperature.

1. Log in to machine 2. RN DONS gloves, opens pathology bag and retrieves the ABG 3. Gloved RN prepares the sample and places it in the inlet, taking care not to touch anything else 4. The second person should enter the patients ID, FiO2 and temp. 5. When prompted, the gloved RN removes the sample and closes inlet. Place sample back into

the pathology bag and seal. 6. Wait for sample result before discarding ABG bag 7. Once result is confirmed, discard ABG bag directly into the clinical waste bin at the ABG

machine 8. DOFF gloves and perform hand hygiene 9. Once result is confirmed, discard ABG bag directly into the clinical waste bin at the ABG

machine 10. DOFF gloves and perform hand hygiene

7.0 ENVIRONMENT Disclaimer: All staff working in the soft services are valued members of our ICU team and will be respected and valued for the important role they play in this pandemic. No SSO or cleaner will ever be asked to enter a patient room without wearing the same PPE as the doctor or nurse they are entering the room with. As such, the safety huddle is vital in maintaining the positive relationships we have between all members of our ICU family. Linen: • Linen skips should be lined with standard clear plastic bags • When linen bags are ¾ full, RNs are to tie off the plastic bag, seal the drawstring of the linen bag • When all other nursing duties in the room are completed, leave the patient room and bring the linen

bag with you. Place directly into a dedicated linen trolley that will sit outside a standard ICU room or inside the ante-room in a negative pressure room

• Notify the SSO there is linen to be collected and they will come to collect the bag from that trolley • SSO will wear a white gown and gloves to collect linen bag • The next time you enter the patients room you will take a new linen bag and plastic bag liners in with

you


• SSOs must participate in a safety huddle with the bedside nurse before entering the room for any pressure area care and will wear the same PPE as the RN, as guided by the RN.

Waste management: • General waste bins should be used inside the patient rooms • PPE is recyclable therefore the bin in the ante-room and the bin outside the patient rooms can be a

recycling waste bin • 1 x foot pedal operated clinical waste bin should be inside patient room for blood and copious

amounts of body fluids • Any non-reusable item that has come in contact with the patient’s airway must be disposed of in the

clinical waste • Cleaners must participate in a safety huddle with the bedside nurse before entering the room • Every day at 10am, 4pm and 10pm there will be a COVID-19 waste collection round performed by a

cleaner plus Ad Hoc if required. • RNs are to tie plastic bin bags in preparation for collection, bins only need to be emptied if they are ¾

full to conserve resources • If a patient is in a standard ICU room, RN opens patient door, cleaner stands back from door and

nurse hands bin bags directly over, then closes door immediately. Cleaners are to leave new bin liners at bedside ready for the next time the RN enters patient room

• If patient is in a negative pressure room, RN places sealed bin bags (including the actual bin) inside ante-room, re-enters patient room and waits for cleaner who is wearing white gown and gloves to enter ante-room. Cleaner exits the ante-room, discards of bin bags into common waste trolley that is immediately outside the door. The cleaner may re-enter the ante-room to place new bin liners into the empty bins. RN can open door into ante-room to retrieve new bins once cleaner is finished.

Room Cleans: • Cleaners must participate in a safety huddle with the bedside nurse before entering the room. The

bedside nurse will advise what PPE is required. • Cleaners to enter the patients room for routine clean ONCE a day • A spot clean may happen in addition to a routine clean as requested • Cleaners are not to take cleaning trolley into the room • The bedside RN should wipe down the patient environment with a Steri7 wipe immediately post

potential contamination E.g. post intubation, post neb, post deep breathing and coughing exercises • Post discharge from ICU, the room clean for COVID-19 patient rooms is called an “infectious clean” • Before cleaning staff arrive, the RN is to discard of all DISPOSABLE items, empty the silver trolley,

clean both the monitoring cables and medical equipment with steri7s • The ante-room must be empty of all equipment so that all surfaces may be appropriately cleaned

Food services: • Food services staff will NOT enter the ante-room or the patient room under ANY circumstances • The bedside RN will take the patient’s tray, cutlery and crockery into the patient’s room • Food trays should not be left anywhere outside of the patient’s room or in common kitchen areas • When kitchen staff round for tray collection, the designated RN will DON PPE and pass the whole

tray to another member of staff either outside the room or ante-room. • Food services staff will wear gloves and a white apron when they receive the food trays from the

bedside nurse

8.0 IN ROOM PROCEDURES

8.1 The 3 Runner System: NB: May be used to safety facilitate transfer of people and equipment into patient rooms during episodes of acute deterioration, intubation or medical emergencies.


• Ensure microphones are adequately turned up to facilitate clear communication

8.2 Runner System for NEGATIVE PRESSURE ROOMS: Three roles should be allocated, as follows:

Role 1: à In-Room Runner • Usually bedside RN. This person stays in patient room • Transfers equipment in and out of the anteroom via the door runner • Knocks to signal to the door runner that they would like the door to the patient room

opened. Waits for response. • The in-room runner is responsible for performing the first CLEAN of reusable

equipment in the patient room and passing it to door runner

Role 2: à Door Runner • This person stays in the anteroom, they are to wear full airborne PPE for an AGP (as

they are exposed to the open door of the patient’s room many times during a likely AGP).

• This person alone controls the opening and closing of all doors. Only one door can be open at a time (Door runner = door controller!)

• The door runner controls entry and exit of people and equipment by responding to knocks of the door by either of the other runners

• If the door runner needs something, they will knock to signal the outside room runner • The door runner performs the second clean of all re-usable equipment as per

DIRTY/CLEAN bench sequence to facilitate the items removal • Post procedure the door runner controls staff leaving the patient room • Staff should leave the patient room 1 at a time • The door runner acts as the PPE coach for each member of the team exiting the room

by supervising the DOFFING sequence up until mask • The door runner is the last person to leave at the end of the procedure

Role 3: à Outside Room Runner • Transfers equipment into the anteroom via the door runner • Knocks to signal to the door runner that they would like the door to the pod opened.

Waits for response. • The outside room runner is responsible for manning the ICU airway and the ICU red

arrest trolley away from the ante-room door • The outside room runner acts as the PPE coach for each member of the team exiting

the anteroom by supervising the DOFFING of their masks • Outside room runner is not wearing any PPE, drops items into the hands of the door

runner

8.3 Runner System for STANDARD ICU ROOMS: Three roles should be allocated, as follows:

Role 1: à In-Room Runner • Usually bedside RN. This person stays in patient room • Transfers equipment in and out of the room via the door runner • Knocks to signal to the door runner that they would like the sliding door open. Waits for

response. • The in-room runner is responsible for performing the first clean of reusable equipment

with steri7 wipes and passes it to the door runner

Role 2: à Door Runner • This staff member is to wear full airborne PPE for an AGP (as they are exposed to the

open door of the patient’s room many times during a likely AGP).


• This person stays situated immediately outside the sliding door • This person alone controls the opening and closing of the sliding door (Door runner =

door controller!) • This person alone controls entry and exit of people, and equipment by responding to

knocks of the door by the in-room runner • The door runner will ensure that the outside room runner is a safe distance from the

sliding door before opening to pass equipment into the room • The door runner can use the microphone (as long as it is cleaned with steri7’s post

event) to facilitate communication • Post procedure the door runner manages staff leaving the patient room • Staff should leave the patient room 1 at a time • The door runner acts as the PPE coach for each member of the team exiting the room

by supervising the DOFFING sequence • The door runner receives reusable equipment from the bedside runner and performs

the second clean with steri7 wipes and passes it to the outside room runner. The item is now clean.

Role 3: à Outside Room Runner • Stays in the pod • The outside room runner is responsible for manning the ICU airway and the ICU red

arrest trolley 2m away from the sliding glass door • The outside room runner gathers equipment or drugs to hand to the door runner then

steps back to stand by the trolleys • Outside room runner is not wearing any PPE, drops items into the hands of the door

runner

9.0 COVID-19 EMERGENCY PACKS: • Located opposite the standard emergency trolleys • 2 complete sets per pod • If used, please notify your NUM, AHNUM or CNE ASAP for replacement


9.1 Intubation: • All intubations should be managed as per the RNSH COVID-19 Emergency Airway Management and

Tracheal Intubation Guideline • Use COVID-19 intubation pack and COVID-19 intubation checklist • Refer to RNSH ICU COVID-19 Intubation video on the ICU wiki • 2 x Intubation packs should live in designated area of each pod marked by the roof sign • Preference for negative pressure room • Obtain portable CMAC Stand from the respiratory storeroom. Remove all surplus items from the

stand, including CSSD form. • Fill out CSSD form before taking equipment into room. Note serial number (SN) on sterile pack. Place

sterilisation plug into pathology bag and then CSSD form into side pocket of bag as per normal practice.

• All equipment should be passed in and out of the room using the 3 runner system • ICU Airway trolley NOT to enter patients room • 4 people in room: Airway Operator, Airway Assistant, Team Leader and In-Room Runner (NB: if

required, Team Leader can performed role of in-room runner as well) • Ventilator circuit should be set up, including system checks outside the room • In this circumstance, a second gas supply check does not need to occur in the room • Do not start ventilation (positive pressure) therapy until the circuit has been connected to the ETT and

to the doctor has instructed you to do so • Airway operator and airway assistant should DOFF gloves after intubation and airway security,

perform HH and DON new gloves – this must be done very carefully due to high risk of contamination • PPE: Airway Operator, Airway Assistant and Team Leader should wear:

• Surgical Gown sz XL • Hair net • Long cuff gloves • N95 mask • Face shield

Post Intubation • If used, the Macintosh Laryngoscope handle and blade are to stay in the patient’s room until the

patient is discharged, then sent to CSSD for sterilisation • Unused equipment from intubation packs is also to stay in the room for any further emergencies • Green trays to be removed and sent to CSSD once the patient is discharged • The CMAC stand should be cleaned with steri7 wipes before being removed from the patient room

using the 3 runner system ASAP, ready for re-use elsewhere.

Send the CMAC Blade and handle to CSSD for sterilisation: • Airway assistant to place CMAC blade into pathology bag and seal (CSSD form is in side of bag

already) • Airway assistant performs first clean of outside of bag with steri7 wipes • Door runner holds open a SECOND pathology bag for in-room runner to place first bag into • Door runner cleans bag and hands to outside room runner • Outside room runner takes the CMAC blade directly to CSSD drop off on level 5 for sterilisation and

return to ICU


9.2 Ventilation: • Circuit disconnections are considered an AGP • If a PLANNED disconnection is required, this is a high risk procedure.

Face shields and hair nets must be worn. • DO NOT use the manual disconnection button under ANY circumstance. • The ventilator must be put into STANDBY • Ventilators should be set up with “Wet circuits” – F&P 950 Adult

Ventilator Dual Heated Circuit Kit (with filter) • The grey PALL filter will be placed in expiratory limb of the ventilator

ONLY • There will be NO filter in the inspiratory limb of the ventilator as per

photo • TO CHANGE PALL (GREY) FILTER:

• This is an AGP, shields and hair nets must be worn • This is a 2 person job • Open new pall filter ready to proceed • Assistant manages the ventilator and holds the clean filter • Assistant places ventilator on STANDBY • Second person disconnects filter from ventilator side of the filter, leaving it on the ventilator

tubing • Hold ventilator tubing at arm’s length pointing it away from yourself into clean clinical waste

bag • Disconnects PALL filter dropping it directly into small clinical waste • Assistant hands the second person the clean filter • Place new PALL filter onto ventilator tubing, reconnect to the ventilator • Check all connections are tight • Assistant, recommences ventilation

• The components of the circuit should be routinely changed are as follows:

• the wet circuit tubing every 7 days unless indicated prior or ICU Medical Specialist advises to leave for longer

• the inline suction every 72 hours • the grey PALL filter on the expiratory limb every 72 hours unless there is signs of

increased airway resistance • The ICU Medical Staff Specialist should review the ventilator daily and monitor for signs of increased

airway resistance • Use of hypertonic saline and atrovent (ipratropium) nebs is NOT recommended • Consultation is required prior to administration of N-acetylcysteine nebs by ICU Medical Staff

Specialist as this leads to more frequent filter changes • If nebulised prostacyclin (FLOLAN) is used, the grey PALL filter will need to be closely monitored and

changed at least once per shift • Tube clamping for PEEP maintenance should not be done routinely, if this is felt to be necessary, this

decision should be made by the ICU Medical Staff Specialist. This is to minimise risk of damage to the tube

• No taping of any connections is permitted, all connections should be checked regularly for tightness • Low Tidal volume strategy is ideal: 4-8mls/kg predicted body weight and limiting PIP to <30cmH20 • Permissive hypercapnia can be tolerated


9.3 Extubation: • Extubation is a high risk AGP. Hair nets and face shields should be worn. • Pulling out of the ETT should be timed with patient exhalation • Do NOT encourage patient to cough • After the ETT has been removed a simple face mask should be applied to the patient IMMEDIATELY • Oral suctioning may be performed, with care taken not to precipitate coughing • Extubation is a two person job, perform as follows:

• Remove ETT tapes • Place Ventilator on STANDBY • Disconnect ventilator tubing from inspiratory and expiratory ports (including

expiratory filter). Patient should now be breathing freely through the intact ventilator tubing (with expiratory filter attached). This is to protect staff from aersolisation into the room

• This should be for as little as time a possible as this will increase patient WOB and potentially cause patient distress

• Cuff down, pull ETT • Place ETT and ventilator circuit directly into clinical waste • Place oxygen mask over patient, turn on oxygen • Wipe down immediate area with steri7 wipes

9.4 HFNP: • HFNP is considered an AGP • Patients should be taught to make adjustments to their nasal cannula independently • HFNP should not be used if the patients trajectory suggests that they will require invasive ventilation,

these patients should be intubated early • Patients must NOT be transported anywhere on HFNP, this includes receiving a patient from ED

9.5 NIV: • Routine use of NIV is not recommended for COVID-19 patients but may be used in selected cases

after careful consideration

9.6 Bronchoscopy: • Avoid bronchoscopy unless deemed clinically necessary • Single use Ambuscopes must be used • Obtain portable Ambuscope stand from the respiratory storeroom. Remove all surplus items from the

stand • Sampling should be done with Ambu Bronchosamplers • Ambu Bronchosampler collection tubes should be pre-labelled before entering patients room, then

double bagged as per specimen collection guideline

9.7 Proning a Patient: • Prone ventilation is effective in improving hypoxia in COVID-19 patients • Please refer to ICU Proning Policy and watch the RNSH ICU COVID-19 proning video on the ICU wiki • Proning a patient requires 6 staff members to safely facilitate the procedure if patient is under 100kg,

8 staff members if patient is greater than 100kg


• If patient is on CRRT, the blood must be returned and filter placed onto re-circulation mode prior to proning, it can be re-commenced once procedure is complete (only if the patient has a vascath in the neck)

• A bluey must be placed over the top of the pink pad that will be placed under the patients head to catch any oral secretions

9.8 ECMO: • Early VV-ECMO is not recommended • Please refer to ICU ECMO policy • When required, there will be one ACT machine per pod, which will be located next to the ABG

machine, this will allow every nurse caring for a patient on ECMO to perform an ACT as you would for the ABG sequence and avoids the ACT machines being inside the patient’s room

• The Rotem machine will remain located in 6E • ECMO management will be via the Perfusionists as per normal ECMO routine • ECMO circuits are considered clinical waste

9.9 iNO: • iNO circuits are considered clinical waste • This is an AGP if ventilator circuit disconnected or patient was on iNO via NPs or HFNP and not a

closed ventilation circuit

9.10 Nebulised Prostacyclin/FLOLAN: • This is an AGP if circuit disconnected

9.11 Cardiac Arrest: • COVID-19 Cardiac arrest packs will be situated in signed area in the pod • In the event of a cardiac arrest, staff are to bring both the COVID-19 Cardiac arrest pack AND the

standard ICU red arrest trolley to outside of the patient’s bedspace. • ICU standard red arrest trolley is not to enter the patient room or ante- room AT ANY time • COVID-19 Cardiac Arrest Responders should be kept to a minimum • Performing chest compressions is an AGP, hair nets and face shields must be worn • If a patient arrests while you are outside the patients room, call for help, instruct someone to dial 222.

Staff can press the red arrest button in a nearby room to get staff en route, while you DON PPE and enter the room

• RRT team NOT to attend ICU medical emergencies • Transfer the LifePack 20e Defib, the COVID-19 Cardiac arrest pack and all necessary equipment into

the room using the 3 runner system • U2MA to be completed outside of the room. Turn volume up on audio equipment

9.12 Post Cardiac Arrest: • Unused equipment from Cardiac Arrest pack to stay in the room • Green trays to be removed when patient is discharged and sent to CSSD • The Lifepack 20e Defib should be cleaned with steri7 wipes utilising the 3 runner system


9.13 Shared Medical equipment – Echo/Doppler/EEG/USS/C-Mac and Ambuscope:

• Avoid taking shared medical equipment into rooms where possible • All procedures must be logged on eRIC • No ECHO’s on COVID-19 patients for training purposes • Shared medical equipment should be cleaned with steri7 wipes as per DIRTY/CLEAN bench

sequence

9.14 Sterile Procedures: • Sterile procedures in the context of a COVID-19 patient are most likely to include; insertion of central

lines, arterial lines and vascaths • Where possible, consideration should be given to insertion of a pressure injectable central line.

Preference would be given to a 4-lumen line, assessed as per clinical requirement of individual patient

• All equipment should be passed in and out of the room using the 3 runner system • The overall process around sterile procedures will remain as close to usual practice as possible • The bedside nurse will fulfil the role of assistant. The assistant will be required to be in the room for

the duration of the procedure for the various supportive tasks involved (Passing ultrasound probe, adjusting ultrasound settings)

• The beside nurse/assistant, door controller or anteroom runner will DON and DOFF their PPE as outlined previously in this document

• The proceduralist is responsible for the preparation of equipment, including: • Set up of the procedure trolley • Set up of the ultrasound machine • Appropriately positioning the patient

• There are a number of changes in the PPE DONNING and DOFFING processes for the proceduralist. The primary change relates to the transition from the preparation stage (equipment setup, patient positioning, etc.) to the procedure itself, with sterile scrub occurring in between. Crucially the hair protection, eye protection and face mask are recommended to be left on in this transition, so as to decrease contamination risk and reduce PPE consumption

• The location of the sterile scrub and gown/gloving process will depend on whether the patient is in a negative pressure room with ante-room, or in a standard room

• IN A NEGATIVE PRESSURE ROOM: • DOFF initial gloves and gown in the anteroom • Perform sterile scrub and DON the sterile gown and gloves also in the ante-room

• IN A STANDARD ICU ROOM: • DOFF initial gloves and gown and perform sterile scrub in the patient room • DON sterile gown and gloves just outside the room • The Door Runner controls the entry and exit of the proceduralist during the

scrubbing process. The Door runner must closely observe the proceduralist to ensure the DOFFING PPE sequence is safety adhere to (PPE coach role).

A summary of the process is provided below: DONNING PPE for Proceduralist only (for equipment preparation and patient positioning):

NEGATIVE PRESSURE ROOM: STANDARD ICU ROOM: - Hand hygiene - DON thumbs-up gown - DON face mask - DON eye protection - DON hair protection

- Open sterile gown and gloves on a trolley outside patient room

- Hand hygiene - DON thumbs-up gown - DON face mask


- Hand hygiene - DON gloves - Enter ante-room and open sterile gown

and gloves on CLEAN bench

- DON eye protection - DON hair protection - Hand hygiene - DON gloves

- Enter patient room with all relevant equipment for procedure - Prepare equipment and position patient ready for procedure commencement

DOFFING PPE and PERFORMING STERILE SCRUB:

NEGATIVE PRESSURE ROOM STANDARD ICU ROOM - Exit patient room and enter anteroom - DOFF gloves - DOFF gown - Perform 2-minute sterile scrub - DON sterile gown and gloves

- Move to “DIRTY zone” in patient room (marked by red tape on the floor)

- DOFF gloves - DOFF gown - Perform 2-minute sterile scrub - Assistant to open door to allow exit from

patient room - DON sterile gown and gloves

- Assistant to tie gown at back and then open door to allow entry to patient room - Enter room and complete procedure

Following completion of the procedure, DOFFING of PPE should occur as per DOFFING sequence

9.15 Aseptic Procedures – Dressing and line changes: • Enter room with PPE on and procedural equipment at hand • Wipe in-room silver trolley with steri7 and set up dressing pack and sterile gloves. Position patient

and remove dressings • DOFF gloves, perform HH with AHBHR and DON sterile gloves to perform the procedures.

10.0 ORDERING MEDICAL IMAGING: • Due to the additional workload associated with PPE only clinically relevant imaging should be

requested and MUST be approved by the ICU Medical Specialist • All medical imaging must be ordered as per “eMR Powerchart – Quick Reference Guide Adding a

medical imaging order (COVID-19 suspected)” • Complete the mandatory Current Clinical History tab. The words “SUSPECTED OR CONFIRMED

COVID-19” must be written in the “Current Clinical history” box • Complete the Order Details box. Under “Infection Risk?” Select YES for suspected or confirmed

COVID-19 • These steps ensure that radiology services are able to take appropriate precautions

11.0 ALLIED HEALTH Mobile XRAY: • A safety huddle must occur before any radiology staff enter a patient’s room • COVID-19 patients should be performed at the END of the XR round • Radiology will send a 2 person team to perform mobile chest x-rays on confirmed or suspected

COVID-19 patients


• ONLY the person designated the DIRTY radiographer will enter the patient room. This person will be assisted by the bedside nurse, unless bedside nurse is required to support patients ETT and therefore a second radiographer is required

• The CLEAN radiographer is not to enter the room • The radiology staff will bring their own stock of clear bags to cover the x ray board • The X-Ray equipment will be cleaned by radiology staff • Use of the slide sheet method for the XR board to slide underneath the patient will be directed by

radiology staff and the slide sheet will remain in the patient’s room • DOFFING of PPE should be supervised by a PPE coach

Physio: • A safety huddle must occur before entering patient’s room • No routine chest physio on COVID-19 patients, performing chest physio should be based on clinical

indication – this decision needs to be made in discussion with the treating physio and the ICU Medical Specialist

Dietician: • Please ensure a current height and weight is record in eRIC under NURSING→Weight and

Dimensions • Dieticians will continue to provide consults remotely to suspected or confirmed COVID-19 patients

Social Work: • Social work will continue to provide its usual service to ICU during this time. • If you identify a patient, carer or family member who requires social work intervention, please ensure

a timely referral is done via either pager or eMR. Pager if the referral is urgent. • On call social work will still be available and can be contacted via switch (#9). Support can be offered

either face to face with PPE, over the phone or in the ICU waiting room for families. • Please also remember Louise Sayers is here for staff support Tel: 9463 2605.

Speech Pathology: • Speech pathologists will not routinely be involved in suspected or confirmed COVID-19 patients • During the COVID-19 situation, all FEES procedures will cease across the hospital as per SP

Department in line with global recommendations as this is an AGP • They can be consulted remotely for input and advice

12.0 INTRA-HOSPITAL TRANSPORT: • Transports should be limited to essential movement within other clinical areas ONLY • Ventilated patients are transferred by a 4 person transport team: Dr (ICU/Anaesthetics), Bedside

nurse, SSO and Hallway runner • Non-ventilated patients are transferred by a 3 person transport team: Bedside nurse, SSO and

Hallway runner • The purpose of the hallway runner is to enforce a distance of AT LEAST 2m between the patient and

any other person is maintained at all times • The Hallway runner is not required to wear PPE as long as they maintain a 2m distance at all times

12.1.TRANSPORT PREPARATION • Communicate with receiving destination regarding timing of intervention and the team required • In discussion with the transporting doctor, prepare patient for transport by disconnecting unessential

equipment


• The regular transport bag and drug pack are NOT to be taken on transport • Prepare transport equipment (as below) • EQUIPMENT :

1. Transport Monitor if available 2. Transport Ventilator - Reusable tubing for vent circuits should

be single use only. Any ventilation circuit that is disconnected to facilitate transport should be closed using a red cap. Red safety caps can be sourced from Jo and Rendell.

3. Suction equipment 4. COVID-19 Intubation Kit (protected in separate plastic bag) -

please note this may already be in the patient room and should be restocked for transport

5. COVID-19 Cardiac Arrest Kit (in plastic bag)- please note this may already be in the patient room and should be restocked for transport

6. From the room: Kidney Dish containing the patient’s face mask and guedel, green mapleson bag with viral filter, as well as the rooms packet of Steri-7 wipes

GENERAL TRANPOST PROCEDURE: • A safety huddle over the phone with receiving destination is performed immediately prior to patient

transfer • Transport Team (except hallway runner) enter patient room wearing contact droplet airborne PPE • If the patient is not intubated and on low flow nasal cannula or Hudson mask < 6L/min place a

surgical mask over the patient’s face. Nasal prongs can be placed under the mask whilst the Hudson/accurox mask needs to be placed over the patient’s surgical mask. If the patient is not intubated but not stable on this oxygen then transport is contraindicated and intubation for safe transport should be considered.

• Once the hallway runner has confirmed that the area is clear, the transport team can open main doors to the patient’s room and exit. The doors to the patient room must then be IMMEDIATELY shut.

• Hallway runner continues to be responsible for ensuring clear pathway to destination and that a person clear zone of 2m is maintained around the transport team and patient

• Care must be taken to avoid touching anything other than the patient and their equipment. • The centre lift well (black lifts) should be used and emergency lift access using swipe cards must be

utilised for all suspected and confirmed COVID-19 transports.

RADIOLOGY: • Radiology have agreed to contact ICU 30 minutes before the appointment • ICU to then contact CT 5 minutes before they leave the ward • CT will hold a room open for the patient to go straight into • Radiographers will DON PPE in preparation for the patient • On arrival the patient immediately enters the imaging room and doors are closed • Hallway runner remains in radiology viewing area to assist radiology staff and transport team • Radiology Staff required to enter the room must DON PPE (Staff required to assist in the

performance of the scan should be limited to the radiographer +/- second SSO if deemed necessary to ensure safe manual handling)

• During scanning when the transport team/radiology staff must exit the room the hallway runner continues to watch the patient from the radiology viewing room. The transport team should remain in the corridor immediately adjacent to the scanner in PPE whilst ensuring safe distance around them is maintained

• Patient is then transported back to ICU maintaining same precautions as above • Radiographer (and Radiology SSO) in PPE would then DOFF in designated radiology DOFFING

area.


OPERATING THEATRE/MRI/ANGIOGRAPHY: • These patients should be transported to this destination by the doctor responsible for their care during

these procedures. The anaesthetist, anaesthetic nurse and SSO therefore become the transport team.

• The ICU nurse will have packed up the patient ready for transport • The ICU medical team will hand over to the Anaesthetist and the ICU nurse will hand over to the

anaesthetic nurse, completing the pre-op checklist that would usually occur at the red line • Following this, the anaesthetic team will DON PPE and enter the patients room • Transport to these destinations should then be carried out using the transport procedure above • The ICU bedside nurse will be the hallway runner, getting the anaesthetic team safely to the black lifts

on level 6, using the priority swipe access, then they will return to ICU. • The anaesthetic team will enter the lift and take the patient to level 4 main theatres, entering the back

doors opposite OT 6 and 7. • When the patient is ready to be returned to ICU, the Anaesthetist will give ICU a 30 minute courtesy

phone call, and then a 5 minute warning phone call so that ICU staff can DON PPE in preparation for the patient’s arrival

Receiving patients from OT/ED/RRT/RETRIEVAL i.e. Heli-pad: • All staff who enter ICU from other clinical departments or from the Heli-pad must exit the patient’s

bedspace DOFFING PPE as per sequence in the appropriate locations to do so. • Attempt communication with retrieval team before their departure at origin to communicate patient

bedspace at RNSH ICU, requesting a phone call prior to their arrival/ETA so staff can be prepared in PPE

• Pre label admissions specimens if you have a RNSH MRN ready for collection in room • Patient is to be wheeled into the bedspace with ICU staff already in room wearing PPE • Door is to be immediately closed once patient is inside • Staff are to receive handover before commencing changing over of equipment and admission

process • Once handover is complete, the transporting team can clean the bed and equipment and prepare for

the doors to be opened for the bed to be removed • A second person outside the doors must be standing ready to receive the bed as it is passed out

through the open doors • The inside staff must DOFF in designated dirty area as per sequence before exiting not outside in the

hallway • If patient is ventilated, patient is to remain on the transport ventilator until they are on the ICU bed and

the transport bed, equipment and staff have left the room. • The patient can then be changed to the ICU ventilator once the transport ventilator is on standby • The ventilator can then be cleaned and removed as per DIRTY/CLEAN bench sequence to be

handed back to transport staff • This process is done to prevent a ventilator disconnection prior to the doors being opened again • If patient is ventilated, ICU staff must be wearing face shield and hair nets due to high risk AGP when

changing ventilators

12.3 Management of the Deceased: • Bodies must be DOUBLE BAGGED • Ensure that the decedent has two ID bracelets attached. Confirm details with 2nd RN • The RN must ensure that the body of a deceased person is not removed from ICU until:

a. the body has been placed and secured in a body bag that prevents the leakage of any body exudate or other substance

b. change gloves, perform HH c. then place patient in first body bag inside a SECOND body bag d. the Name and the MRN of the deceased patient and the words COVID-19 must be clearly

written on BOTH the first AND second body bags in permanent marker


e. place either a sticker OR use permanent marker to write the words “PRESCRIBED INFECTIOUS DISEASE—HANDLE WITH CARE” (In capital letters) on the SECOND body bag

f. each bag is sealed with the zip lock available with the body bag.

• Fill out the usual three Mortuary tags as per normal routine (Secure the first around the decedents neck, place the second in the clear pocket of the second body bag and the third is to be checked to the morgue with the body. Ensure that you tick “Yes” to prescribed disease and write COVID-19 underneath

• To transport the deceased patient to the mortuary you must be wearing your PPE and you must not touch anything on your way down to the mortuary

• A hallway runner must be utilized to ensure we clear the corridors of staff and visitors • Once in mortuary usual process for signing in a deceased patient applies, SSO and RN will transfer

body into walk in fridge with mobile holding trolley. • Staff can then DOFF PPE at the registration desk area where a clinical waste bin will be located,

perform HH.

13.0 COVID-19 Resources: For the latest information regarding this evolving situation please refer to the NSLHD intranet page and the COVID-19 section as below: mailto:http://intranet.nslhd.health.nsw.gov.au/ClinicalNet/cgu/QSP/AS/Pages/COVID-19-Links.aspx

Reference List ANZICS. 2020, The Australian and New Zealand Intensive Care Society (ANZICS) COVID-19 Guidelines Version 1. Australian and New Zealand Intensive Care Society, viewed 18 March 2020, https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf Bradford, C. ICU 2011, Prone positioning Protocol, RNSH ICU Policy, viewed 18 March 2020, http://10.206.164.221/mediawiki/images/0/00/228.pdf Brewster, D., Chrimes, N., Do, T., Fraser, K., Groombridge, C., Higgs, A., Humar, M., Leeuwenburg, T., McGloughlin, S., Newman, F., Nickson, C., Rehak, A., Vokes, D. & gatward, J. 2020, ‘Consensus statement: safe airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group’, The Medical Journal of Australia, viewed 18 March 2020, https://www.mja.com.au/journal/2020/212/10/consensus-statement-safe-airway-society-principles-airway-management-and Clinical Excellence Commission. 2020, Coronavirus COVID-19 Infection Prevention and Control, viewed 18 March 2020, http://cec.health.nsw.gov.au/keep-patients-safe/infection-prevention-and-control/Coronavirus-COVID-19 Clinical Excellence Commission. 2020, Infection Prevention and Control Novel Coronavirus 2019 (2019-nCoV)- Hospital Setting, NSW Government, viewed 18 March 2020, http://cec.health.nsw.gov.au/__data/assets/pdf_file/0006/567987/Infection-control-nCoV-2019-Hospital-Setting-V2-.pdf Griffin, J., Johnson, P., Tinker, M. 2013, Nitric Oxide Therapy Administration Guide, RNSH ICU Policy, viewed 18 March 2020, http://10.206.164.221/mediawiki/images/2/20/262.pdf Harris, R. 2019, Nebulised Prostacyclin/Epoprostenol (Flolan) for Hypoxic Respiratory Failure, RNSH ICU Policy, viewed 18 March 2020, http://10.206.164.221/mediawiki/images/5/50/205_V2.1.pdf


NSLHD SARS-CoV-2/COVID-19: Who to test? Version 1, 16th March 2020. http://intranet.nslhd.health.nsw.gov.au/ClinicalNet/cgu/QSP/AS/Documents/COVID-19%20FILES/Who%20to%20test2.PNG Nursing and Midwifery, Allied health. 2013, Uniform and dress Code for Clinical Staff-NSLHD, NSLHD, viewed 18 March 2020, http://intranet.nslhd.health.nsw.gov.au/AreaGov/NSGovSys/AreaPPGLibrary/Nursing%20and%20Midwifery/PO2013_001.pdf#search=uniform%20and%20dress%20code%20for%20clinical%20staff NSLHD, SARS-CoV-2 / COVID-19: Who to test?, Version 1.5, Accessed 25/3/20. https://www.health.nsw.gov.au/Infectious/diseases/Pages/coronavirus-update.aspx NSW Public health Regulation, 2012 https://legislation.nsw.gov.au/#/view/regulation/2012/311/part8/div3 Stedman, W., Janin, P., Williams. E. & Tinker, M. 2019, Extra-Corporeal Membrane Oxygenation management guideline for intensive care Patients, RNSH ICU Policy, viewed 18 March 2020, http://10.206.164.221/mediawiki/images/2/29/324.pdf Wastell, D. & Tinker, M. 2011, High Flow Nasal Oxygen, RNSH ICU Policy, viewed 18 March 2020, http://10.206.164.221/mediawiki/images/7/7b/242.pdf