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As of 2/10/20:
Social media and traditional media have been flooded by headlines of the 2019-nCoV Coronavirus. The coronavirus has overtaken SARS in death toll. I thought about how I could make this blog post relevant for occupational therapy – and that is through the of education of using facts and evidence-based research.
As healthcare workers, we are exposed to daily risks – including that of transmittable diseases. The coronavirus has been shown to transmit from human to human. I hope this may never happen, but you may find yourself donning PPE to protect yourself while treating a client or patient with coronavirus.
Dangers of Comparing to the Flu
Let me start by stating that it is very dangerous to compare the coronavirus to flu. The fact remains that the coronavirus spreads easily, is still not completely understood, there is no cure, and people are dying. Occupational therapy plays a role in prevention, and that includes the prevention of contracting this infection instead of having to manage it.
Signs/Symptoms for Patients and Caregivers
OT Education: Know the symptoms and teach your patients and their caregivers about them.
Person-to-person spread has been reported outside China, including in the United States and other countries
- If you are a healthcare provider, be on the look-out for people who recently traveled from China and have fever and respiratory symptoms.
- If you are a healthcare provider caring for a 2019-nCoV patient or a public health responder, please take care of yourself and follow recommended infection control procedures.
Precautions and PPE
Standard Precautions assume that every person is potentially infected or colonized with a pathogen that could be transmitted in the healthcare setting.
Attention should be paid to training on correct use, proper donning (putting on) and doffing (taking off), and disposal of any PPE.
- Patient placement in single-patient rooms at negative pressure (Airborne Infection Isolation Room – AIIRs). If the patient does not require hospitalization they can be discharged to home (in consultation with state or local public health authorities) if deemed medically and socially appropriate. Pending transfer or discharge, place a facemask on the patient and isolate him/her in an examination room with the door closed. Personnel entering the room should use PPE. Facilities should keep a log of all persons who care for or enter the rooms or care area of these patients.
- Perform hand hygiene using ABHS before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves. Hand hygiene in healthcare settings also can be performed by washing with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS.
- Personal Protective Equipment (PPE)
- Respiratory protection: at least as protective as a fit-tested NIOSH-certified disposable N95 filtering facepiece respirator OR a powered air purifying respirator/PAPR.
- Eye protection: e.g., goggles, a disposable face shield that covers the front and sides of the face.
- Use Caution When Performing Aerosol-Generating Procedures
- Manage Visitor Access and Movement Within the Facility
OT Clinical Guidance and Management – The FACTS
The incubation period is estimated at ~5 days (95% confidence interval, 4 to 7 days). Frequently reported signs and symptoms include fever (83–98%), cough (76%–82%), and myalgia or fatigue (11–44%) at illness onset. Sore throat has also been reported in some patients early in the clinical course. Less commonly reported symptoms include sputum production, headache, hemoptysis, and diarrhea. The fever course among patients with 2019-nCoV infection is not fully understood; it may be prolonged and intermittent. Asymptomatic infection has been described in one child with confirmed 2019-nCoV infection and chest computed tomography (CT) abnormalities.
Risk factors for severe illness are not yet clear, although older patients and those with chronic medical conditions may be at higher risk for severe illness. Nearly all reported cases have occurred in adults (median age 59 years). In one study of 425 patients with pneumonia and confirmed 2019-nCoV infection, 57% were male. Approximately one-third to one-half of reported patients had underlying medical comorbidities, including diabetes, hypertension, and cardiovascular disease.
Clinical presentation among reported cases of 2019-nCoV infection varies in severity from asymptomatic infection or mild illness to severe or fatal illness. Some reports suggest the potential for clinical deterioration during the second week of illness. In one report, among patients with confirmed 2019-nCoV infection and pneumonia, just over half of patients developed dyspnea a median of 8 days after illness onset (range: 5–13 days).
Acute respiratory distress syndrome (ARDS) developed in 17–29% of hospitalized patients, and secondary infection developed in 10%. Between 23–32% of hospitalized patients with 2019-nCoV infection required intensive care for respiratory support. Some hospitalized patients have required advanced organ support with invasive mechanical ventilation (4–10%), and a small proportion have also required extracorporeal membrane oxygenation (ECMO, 3–5%). Other reported complications include acute cardiac injury (12%) and acute kidney injury (4–7%). Among hospitalized patients with pneumonia, the case fatality proportion has been reported as high as 11–15%.
No specific treatment for 2019-nCoV infection is currently available. Clinical management includes prompt implementation of recommended infection prevention and control measures and supportive management of complications, including advanced organ support if indicated.
Patients with SARS reported fear, loneliness, boredom and anger, and they worried about the effects of quarantine and contagion on family members and friends.
They experienced anxiety about fever and the effects of insomnia. Staff were adversely affected by fear of contagion and of infecting family, friends and colleagues.
Caring for health care workers as patients and colleagues was emotionally difficult. Uncertainty and stigmatization were prominent themes for both staff and patients.
- Follow MD orders for level of activity – bedrest vs. mobilize. Implement early mobilization if appropriate with appropriate isolation precautions. Communicate acute changes immediately to staff.
- Don appropriate PPE (especially home health practitioners visiting homes).
- Monitor vitals including oxygen saturation before, during, and after activity.
- Educate patients and caregivers about the facts vs. myths of coronavirus at an age and cognitively appropriate levels.
- Educate patients and caregivers about when to self-admit to the hospital and when to self-quarantine from others.
- Educate patients and caregivers about signs/symptoms including the (1)route of transmission (airborne, contact; fecal-oral), the (2)incubation period (possibly several days of no symptoms despite infection), and (3) presentation of resolved symptoms to be cleared for discharge (fever, cough, negative images).
- Educate AND observe return-demonstration about proper hand hygiene and infection prevention best-practices (especially in public spaces such as public restrooms).
- Encourage parents to teach their children these techniques too. Avoid contact with your face. Avoid touching public surfaces with your hands (doorknobs, elevator buttons, handlebars). Consider flushing toilets with lid, avoid the use of blower-dry style hand dryers.
- Educate about facts of social susceptibility, stereotypes, and stigma. Currently, race and gender are not believed to be associated with a higher risk or infection rate of the virus.
- Just because someone is wearing a mask does not mean they are contracting the disease.
- Just because someone shows no symptoms does not mean they are disease-free. A younger child who was asymptomatic was positive for coronavirus.
- Educate about the use of medically approved pharmacological interventions and avoid the use of non-approved remedies (there is no current cure or vaccine as of 2/10).
- Educate on energy conservation, self-monitoring of symptoms, and pacing techniques. Patients may want to keep a detailed symptom log for personal insight and to share with medical professionals. A good free App is UpDoc: Health Diary for IOS & Android.
- Encourage daily logging of body temperature (disinfect between if sharing a thermometer) and fatigue at a minimum. Log when a cough or fever starts.
- Educate patients about therapeutic breathing and supplemental oxygen use (and smoking precautions, see below).
- Contain and redirect visitors to appropriate areas. Follow facility protocol for logging who comes in and out hospital & rooms. Ensure that signs are posted in the correct language. You may often see visitors entering isolation rooms because they may not understand the signs that are posted! Coughing persons should don appropriate masks.
- Continue to manage co-morbidities and prevent additional complications (e.g., COPD, bed sores). The perception that younger persons are less susceptible to coronavirus may be true, but younger persons have died due to opportunistic infections (e.g., MRSA).
- In higher acuity patients, e.g. ICU, promote optimal positioning for therapeutic breathing according to treatment & MD protocol (which may possibly be prone instead of supine).
- Prevent physical, cardiac and musculoskeletal deconditioning – maintain ROM and strength.
- Utilize psychosocial techniques to manage anxiety, stress, and depression in patients, caregivers, and staff. Take care of yourself too.
- Promote a healthy diet and exercise both for the patient and caregivers.
- Maintain and return to habits, roles, and routines in patient in all settings.
- Educate on smoking & Vaping Cessation – which may lead to poorer recovery and increased mortality with coronavirus infection.
- Initiate discharge planning as early as possible including identified caregivers, appropriate supplemental oxygen, assistance with ADLs, IADLs (shopping), medication management, emergency response systems (evacuation, calling 911, etc.), and safe entry-exit.
- Consider placement and infection prevention of bedside commodes (which may spread the disease via fecal-oral route).
The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. https://www.ncbi.nlm.nih.gov/pubmed/12743065