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New AAP interim guidance covers use of PPE in ambulatory settings :

August 13, 2020

Editor’s note: This guidance was updated March 8, 2021. For the latest guidance, visit https://bit.ly/36kjk51.AAP interim guidance is based on current evidence and best data at the time of publication. Updates are provided to reflect changes in knowledge about the impact of the disease on children and adolescents.  For the latest news on COVID-19, visit https://www.aappublications.org/news/2020/01/28/coronavirus.

The Academy has released interim guidance on the use of personal protective equipment (PPE) by health care personnel, patients and families in ambulatory care settings.

“Guidance on the Use of Personal Protective Equipment (PPE) for Pediatric Care in Ambulatory Care Settings During the SARS Co-V-2 Pandemic” applies to offices, urgent care centers, school-based or -linked clinics and homes in both urban and rural settings. It addresses PPE supply, risk and mitigation strategies, and precautions related to aerosol-generating procedures (AGPs).

The virus that causes COVID-19 spreads during close contact mainly through respiratory droplets produced by coughing, sneezing or talking. Aerosols, also a source of transmission, may be produced by certain procedures or patients; secondary spread can occur when droplets land and persist on surfaces. As SARS CoV-2 can be transmitted by those without symptoms, standard precautions are warranted to protect health care personnel, patients and families (see AAP policy Infection Prevention and Control in Pediatric Ambulatory Settings).

Recommendations

To mitigate the risk of infection, the interim guidance recommends these precautions:

  • Establish guiding principles for appropriate PPE, hand hygiene, disinfection of equipment and facilities, and physical distancing, while considering the clinical interactions and procedures taking place. Consider practice protocols, staffing and local/regional epidemiology.
  • Use personal judgment and creative solutions when determining the best infection prevention and control (IPC) and PPE protocols to mitigate risk in particular settings.
  • Prepare written protocols specific to the setting, patient population, procedures and PPE availability. These must, at a minimum, align with federal, state and/or local public health guidelines and, when applicable, health care system IPC policy.
  • Offer the most protective PPE available and possibly additional mitigation options for staff who are at increased risk for severe illness manifestations related to COVID-19 (or have household members in this category).
  • Require staff, patients and families to practice hand hygiene.
  • Train staff on use of PPE in various case scenarios taking public health mandates into account. This includes face coverings, standard procedure masks, protective eye wear (goggles, face shields), gloves and gowns. Fit test N95 masks to ensure protection. Review and practice donning and doffing procedures.
  • Ensure the following measures for patients and their families: Provide hand sanitizer to be used when they enter the office. Require patients 2 years and older to wear a clean mask or face covering (with or without face shield) and practice physical distancing when possible (see AAP News article on cloth face coverings).

Risk-mitigation strategies

  • Supply: Address the extended use, reuse, sanitizing and disposal of PPE in the facility’s protocol. Note that certain cloth face coverings may provide similar protection as surgical masks. The public can use face coverings and social distancing to improve protection. When PPE is in short supply, reserve surgical masks and N95 respirators for health care personnel.
  • Reuse: Certain PPE may be reused if cleaned or sanitized between patients; this includes face shields, goggles and glasses. Masks, eye protection and gowns may be used all day if they are not soiled or contaminated and can be sanitized at the end of day and reused. Change gloves with each patient. Consider decontamination/sterilization of noncellulose-based N95 respirator masks if supplies are limited or for stockpiling purposes.

Risk mitigation: Also important in IPC protocols are disinfection of equipment and facilities, engineering controls including physical barriers (sneeze and cough guards), defined routes for patient flow, increased ventilation and rate of air circulation, and use of high-efficiency air filters (see information from the Occupational Safety and Health Administration).

More on AGPs

  • Aerosol-generating procedures (AGPs) and PPE: Higher levels of PPE are necessary to protect clinicians treating patients who are more likely to aerosolize respiratory secretions and/or when performing an AGP. Such procedures are those that produce smaller respiratory droplets at higher concentrations, which increases risk of transmission to individuals near the patient.
  • High-risk AGPs and patients: These include procedures in which instruments are used in the larynx or trachea and those that assist ventilation and continuous positive airway pressure. Use of a nebulizer for medication administration and spirometry also may be considered high risk. Patients with a tracheostomy are high risk for aerosolization of secretions. Other AGPs are sputum induction/cough assist procedures.
  • Other considerations: Consider increasing level of PPE during procedures that could produce spit, tears, a gag or a cough.
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