Practice Example

Recommendations, tips and best practice examples during the Coronavirus pandemic: Hygiene experts report on their daily work in health facilities.

  • COVID-19 risk stratification in the emergency department
    Practise examples
    16.12.2020

    COVID-19 risk stratification in the emergency department

    Emergency departments are facing enormous challenges during the coronavirus pandemic. A new triage model at the Göttingen-Weende Hospital ensures early detection of COVID-19 as well as patient isolation. This efficient risk stratification also succeeds in protecting vulnerable groups in all areas of the hospital.

    How can an emergency department (ED) with around 30,000 emergencies per year operate efficiently in the context of SARS-CoV-2 while ensuring protection against nosocomial spread of the pathogen? Marc Wieckenberg, Head Physician of the ED at the Evangelisches Krankenhaus Göttingen-Weende, and his colleagues answered this question with a model for risk stratification of suspected SARS-CoV-2 and COVID-19 cases [1]. Based on the epidemiological criteria of the Robert Koch Institute and internal case definitions, the emergency physicians defined five risk categories.

    COVID-19 risk categories I-V:
    RK I = Confirmed SARS-CoV-2 infection
    RK II= COVID-19 Reasonable Suspicion
    RK III=COVID-19 Differential diagnosis
    RK IV= COVID-19 19 Low probability
    RK V = COVID-19 No suspicion

    Aim: Comprehensive protection against infection

    A standardized treatment procedure for emergency diagnostics and therapy has been established for all emergency patients on the basis of the system of risk categories I-IV. This procedure is used to strictly separate COVID-19/non-COVID-19 emergencies, thereby protecting staff and patients against nosocomial infection. The focus is on particularly vulnerable groups, such as patients with risk factors including advanced age, immunodeficiency, lung, heart and kidney diseases and malignancies.

    In order to establish risk stratification, considerable structural changes within the hospital building were necessary, for example to enable CT and conventional X-ray diagnostics for accident victims with an increased risk of COVID-19. The changes were implemented by measures such as

    • Installing a walk-through tent to protect waiting patients from the weather
    • Expanding the available space by means of movable partitions
    • Integrating the trauma room CT into the isolation area
    • Separating the isolation ED from the routine ED by means of a rolling grille and airlock system
    • Relocating the main entrance and closure of all side entrances
    • A Plexiglas-protected space for patient interviews and administration

    Standardized procedure for all emergency patients

    Risk stratification becomes the central means of controlling patient flows in the ED by linking the respective risk category to criteria such as

    • Symptoms and/or occupational group
    • Specific hygiene protection measures
    • Specific treatment room within the ED
    • Specifying the room used for further inpatient care

    Treatment Procedure in the ED

    Download infographic [PDF]

    Treatment Procedure in the Emergency Department

    1. Initial coronavirus screening by the doctor in charge and the ED nurse according to the dual-control principle.
    2. Determining the COVID-19 risk status. 
    3. Triage using the Manchester Triage System (MTS) to determine the urgency of treatment.
    4. Allocation of the primary, appropriately labeled treatment and isolation site in the ED.
    5. Determining hygiene protection measures according to risk category.
    6. Emergency diagnostics (vital signs, laboratory diagnostics, nasopharyngeal swab/gargle test, thoracic ultrasound, low-dose CT in cases of reasonable suspicion).
    7. Re-evaluation of the COVID-19 risk status if the patient is to be hospitalized.
    8. Selection of the appropriate ward according to risk category:

    RC I = COVID-19 ward NC/IMC/ICU
    RC II and RC III = suspected COVID-19 ward NC/IMC/ICU
    RC IV and RC V = Pre-isolation NC/IMC/ICU
    (Barrier measures; no further functional diagnostics until test result)

    Source:

    Wieckenberg M, Meier V, Pfeiffer S, Blaschke S. Risikostratifizierung von Notfällen während der COVID-19-Pandemie in der Zentralen Notaufnahme. Med Klin Intensivmed Notfmed, Springer, https://doi.org/10.1007/s00063-020-00748-2. Eingegangen: 4. Juni 2020. Überarbeitet: 21. August 2020. Angenommen: 12. September 2020.

    Emergency departments are facing enormous challenges during the coronavirus pandemic. A new triage model at the Göttingen-Weende Hospital ensures early detection of COVID-19 as well as patient isolation. This efficient risk stratification also succeeds in protecting vulnerable groups in all areas of the hospital.

    Emergency departments are facing enormous challenges during the coronavirus pandemic. A new triage model at the Göttingen-Weende Hospital ensures early detection of COVID-19 as well [...]

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    01.04.2020
    Practice Example // Health
    01.04.2020

    Effective breathing technique for reducing stress

    When it comes to caring for COVID-19 patients, a lot revolves around breathing: Breathing while wearing an FFP mask can be strenuous and this is very stressful for patients experiencing shortness of breath. Targeted breathing technique that can help to reduce stress.

    The Covid-19 pandemic puts healthcare workers in what is probably an unprecedented situation. Many of the staff face the problem of balancing scarce resources and their own safety needs with their demands for good patient care. This is on top of practical stresses such as working with protective masks and visors and the risk of contamination, e.g. when Discarding protective equipment.

    If you begin to feel overwhelmed, it helps to take care of yourself and just take a deep breath. The breathing technique we are going to show you is easy to do while sitting in a quiet corner of the lounge or on a bench outside. Just taking a few minutes out is enough to make you feel calmer and more energetic.

    Simple breathing techniques for reducing stress

    Sit on a chair with your spine in an upright position. Make sure your shoulders are relaxed, your hands rest loosely on your thighs and your feet are on the ground.

    1. Close your eyes and focus on the point between your eyebrows.
    2. Breathe in deeply for three breaths and then breathe out completely.
    3. Now you can start with the breathing technique:
      • Breathing in: Divide inhalation into eight equal segments (short “sniffing” breaths).
      • Breathing out: Divide exhalation into eight equal segments as well. Focus entirely on your breathing.

        Inhalation and exhalation take place at “intervals”: The air is completely exhaled on the 8th breath out.

        Duration of breathing: Start with 3 minutes and increase to 11 minutes.
    4. Final step: Inhale deeply, hold your breath for a few seconds and then exhale fully.

    When it comes to caring for COVID-19 patients, a lot revolves around breathing: Breathing while wearing an FFP mask can be strenuous and this is very stressful for patients experiencing shortness of breath. Targeted breathing technique that can help to reduce stress.

    When it comes to caring for COVID-19 patients, a lot revolves around breathing: Breathing while wearing an FFP mask can be strenuous and this is very stressful for patients experiencing s [...]

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    03.05.2020
    Practice Example // Reprocessing
    03.05.2020

    Use without personalization

    Together with experts in medical technology and hygiene, Helios Kliniken GmbH has developed a safe procedure for reprocessing FFP2 and FFP3 masks. According to their own statements, the processing method exceeds the security level specified by the Robert Koch Institute (RKI) and allows masks to be reused without personalization.

    Clinics and other healthcare facilities are still complaining about bottlenecks in personal protective equipment for their employees – there is a lack of high-quality FFP2 masks and FFP3 masks in particular. The methods of reprocessing that are currently being discussed are either considered to be not safe enough or require masks to be personalized before they are used again – a requirement that cannot be met by most healthcare facilities, either technically or logistically.

    Now Helios Kliniken, together with experts in medical technology and hygiene, have developed a reprocessing procedure that allows healthcare workers to reuse masks without personalization and yet guarantees a high safety standard. The procedure was shared online in order to help other healthcare facilities to reprocess respiratory masks in a safe and at the same time practicable way.

    There are several steps to the procedure:

    • Drying the masks according to the recommendations from the RKI for 35 minutes at 70 degrees in washer-disinfectors
    • Processing in recirculated air convectors at 70–75 degrees for a total of nine hours

    Both procedures together achieve a processing value which corresponds to the value A0 of 3000. Such a high A0 value also includes the safe inactivation of thermostable viruses. For comparison, the procedure described by the RKI only achieves an A0 value of 60.

    The experts at Helios were able to prove that SARS-Cov-2 and other pathogens can be safely inactivated with the procedure. This meant that FFP2 masks and FFP3 masks no longer had to be reused in a personalized way.

    Process instruction by Helios Clinics Germany

    PDF download info diagramm

    Step 1: Collection

    Collecting masks used for protection against Covid-19, sorting out and disposing of visually damaged or soiled masks. Masks worn in connection with TBC (tuberculosis patients) are destroyed directly*.

    Step 2: Transport to Central Sterile Services Department (ZSVA)/Processing Unit for Medical Devices (AEMP)

    Transporting the masks to the Central Sterile Services Department or to the Processing Unit for Medical Devices in suitable containers (or equipment that is similarly used).

    Step 3: Quality Control

    Inspect the masks again for contamination and damage.

    Step 4: Thermal Processing

    Pre-treating the masks according to the recommendations from the RKI: Drying/heating in washer-disinfectors that are already available to at least 65 degrees with a holding time of 35 minutes. The total process time is just under one hour and takes into account the time required to heat up the machines**.

    Step 5: Packaging

    After another visual inspection is carried out in the Central Sterile Services Department, the masks are then wrapped in a single layer of sterile fleece and packaged in cartons. These cartons are then transferred to another Central Sterile Services Department, where only the next process step 6 is carried out.

    Step 6: Thermal Treatment

    The masks are heat-treated at 70°C for a holding time of 9 hours in recirculating air ovens (A0 value greater than 3000).

    Step 7: Quality Management

    Implementing a comprehensive QM system: Samples are taken from each batch, which are tested microbiologically, structurally and with regard to the filter effect. Only after all of this will the masks be approved.

    Step 8: Storage

    Investigations into the safety of the procedure

    The team of experts at Helios carried out multi-stage comprehensive microbiological and structural investigations on masks from various established manufacturers using X-ray microtomography (micro-CT) methods and downstream tests on particle retention capacity (following the FIT test).

    The process of “thermal disinfection” inactivates all vegetative microorganisms, including SARS-CoV-2 in the masks. The procedure complies with DIN 149, which requires that new masks must retain their material and shape when subjected to a continuous test at 70°C for 24 hours. In this way, the experts see no change in the masks during their thermal processing. According to Helios, endurance tests have already been initiated.

    However, at the moment Helios is assuming that the masks will lose their structure or be damaged after repeated use. This is considered to be a limiting factor for multiple reprocessing. The filter function and the microbiological integrity of the processing, on the other hand, are currently considered to be less problematic.


    Further information:

    Helios-Gesundheit
    https://www.helios-gesundheit.de/unternehmen/aktuelles/pressemitteilungen/


    * Although Helios assumes that the downstream processes also ensure that tuberculosis bacteria is eliminated, microbiological detection in the laboratory requires a cultivation period of approx. six weeks. This period of time to provide evidence was not yet available and it was therefore decided to follow this approach.

    ** For this purpose, special temperature maintenance programs were agreed with the manufacturers of the washer-disinfectors in the air circulation procedure and programmed in the systems.

    Together with experts in medical technology and hygiene, Helios Kliniken GmbH has developed a safe procedure for reprocessing FFP2 and FFP3 masks. According to their own statements, the processing method exceeds the security level specified by the Robert Koch Institute (RKI) and allows masks to be reused without personalization.

    Together with experts in medical technology and hygiene, Helios Kliniken GmbH has developed a safe procedure for reprocessing FFP2 and FFP3 masks. According to their own statements, the p [...]

    Read more

    22.04.2020
    Practice Example // Personal Protection
    22.04.2020

    Recognizing needs – Keeping your head

    Those responsible for hygiene are confronted with exceptionally stressful situations during the coronavirus pandemic. Gerburg Lutter, mediator and certified social pedagogue from Kiel, Germany, talks about how hygiene experts can take care of their mental health in these uncertain and unprecedented times and, in doing so, continue to carry out their important tasks to the best of their ability.

    From having to deal with seriously ill patients to reassuring deeply insecure colleagues and coping with a lack of PPE as well as more difficult conditions for safe protection against infection in general – hygiene specialists are currently under great pressure: What should they pay attention to in order to take care of themselves so that they are in a stable condition to help others?

    In crisis situations such as the current Coronavirus pandemic, it’s essential that you take the time to listen to what your body and mind are telling you. Ask yourself: How do I feel and what needs do I have?

    Why is it so important to recognize your feelings and needs right now?

    This is particularly important now as there is a connection between our feelings, our needs and our ability to act. Being able to act and act according to our abilities is essential for our mental and physical health (especially in an uncertain time such as during the coronavirus pandemic). If basic needs, such as the need for rest and breaks, are not met in the long term, this can lead to burnout and manifest itself psychosomatically, such as in the form of back pain.

    What is the connection between feelings, needs and ability to act?

    Due to the stressful situations caused by the pandemic, unpleasant feelings of distress, anxiety or anger and fear are increasingly common. These difficult feelings indicate to us that an important need is not being fulfilled. In addition to food, drink and sufficient sleep, basic needs in professional life can also be the need for recognition, holidays and security of action. This means that if a feeling of fear, for example, shows us that an important need has not been met, such as for security, then this is a signal for us to adjust our behavior so that the need is satisfied or at least partially satisfied.

    Can you give us a specific example from your everyday work?

    Let’s say, for example, as the person responsible for hygiene in a clinic, I’m not sure that there will be sufficient protective clothing available for the employees in the future, this triggers a deep feeling of concern in me. This feeling, in turn, indicates that my basic need for security has not been met. In order to provide me with more security, one option that could be taken would be to inform me of where I can get protective clothing and how I can use the existing equipment in a way that conserves resources. This would make me feel that there was practical action I could take instead of simply feeling at the mercy of the situation. Instead, I realize that I can have a certain degree of control over the situation through my behavior.

    Do you have any tips on how we can better recognize and understand our needs?

    First of all, it is crucial that you do not ignore or suppress unpleasant feelings. Instead, we should try to identify the feeling. So, to break it down for you: Is it anger, distress or fear, for example? Lists that describe the feelings in detail can help here. Once I’ve recognized the feeling, I ask myself what situation triggered the feeling and what was the important need that was not fulfilled. You can have a good think about this after work, during your break, at the weekend or when out for a walk. All things considered, this is a relatively easy and effective method that anyone can use at any time. This can be very helpful as a basic tool, especially now during the Coronavirus crisis.

    Ms. Lutter, thanks for speaking with us.

    Those responsible for hygiene are confronted with exceptionally stressful situations during the coronavirus pandemic. Gerburg Lutter, mediator and certified social pedagogue from Kiel, Germany, talks about how hygiene experts can take care of their mental health in these uncertain and unprecedented times and, in doing so, continue to carry out their important tasks to the best of their ability.

    Those responsible for hygiene are confronted with exceptionally stressful situations during the coronavirus pandemic. Gerburg Lutter, mediator and certified social pedagogue from Kiel, Ge [...]

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    20.05.2020
    Practice Example // Personal Protection
    20.05.2020

    Conflict: There are always two versions of the truth

    There’s no question about it, the coronavirus pandemic has been a stressful situation for many people. This is evident, for example, from conflicts in the workplace. These conflicts usually have basic causes. Gerburg Lutter, mediator and certified social pedagogue from Kiel, Germany, talks about how to recognize what’s behind the conflicts and how to deal with these situations in a better way.

    Is there anything we need to know in order to be better prepared for conflict situations at work?

    Interpersonal conflicts are first of all characterized by contrasting thoughts, desires and feelings between two people or groups. That being said, it’s not the differences themselves that create the conflict, but the following two aspects: Do the people involved accept that these differences exist and is there a general willingness to face these differences in an open and constructive way?

    What are the general signs of a conflict?

    Zwischenmenschliche Konflikte sind zunächst einmal durch Unterschiede im Denken, Wollen und Fühlen zwischen zwei Menschen oder Gruppen gekennzeichnet. Doch nicht die Unterschiede an sich machen den Konflikt, sondern folgende zwei Aspekte: Gibt es für die bestehenden Unterschiede eine Akzeptanz und gibt es eine generelle Bereitschaft, diesen Unterschieden offen und konstruktiv zu begegnen?

    How do the factors of differences, acceptance and willingness relate to each other and how does this play into conflicts?

    To make this clear, I’ve put this into two simple formulas with plus and minus signs. Difference is always a factor in these:

    Difference + acceptance + willingness = absence of conflict is possible.

    Difference – acceptance – willingness = there is a risk of conflict.

    This clearly shows that difference is the main characteristic, but does not necessarily always lead to conflict breaking out. It is rather a question of how people choose to deal with this difference.

    Can there also be physical reactions to conflict?

    Yes, we all already know three of the reactions to conflict: Fight, flight or shock. Simply put, the brain can switch to “danger mode” during conflicts. Then we react automatically from the limbic system, one of the most primitive areas of the brain. The brain switches to survival mode and controls the supply to the muscle and cardiovascular system. The body reacts instinctively as “thinking” is left in the background.

    Fight: Aggression and threatening gestures in volume and posture.

    Flight: Run out of the room and slam the door behind you.

    Shock: You feel as if you are stuck, unable to move and think.

    This also explains why it’s only afterwards that we often realize what we should have said or how we might have acted differently.

    So, the differences and physical reactions apply to all conflicts. What else is typical for professional conflicts?

    In the professional context we act out of our professional role. The issue of role is so important because many professional conflicts arise from unresolved roles. As a hygiene specialist, for example, I have an understanding of how to act in this role. In addition to this concept of oneself, there are also the expectations that my superiors and colleagues have of my role. Sometimes your own understanding of roles and responsibilities on the one hand and the expectations your superiors have on the other hand clash – this is often not discussed at all and then leads to conflicts.

    How can we avoid these conflicts around understanding our roles?

    It all comes down to taking the time to clearly coordinate tasks and expectations as this is important. So it’s helpful to clearly clarify with your superiors what you’re responsible for and what your tasks are. You need to know what to do and what not to do in your role. Clarifying expectations is crucial when it comes to avoiding role conflicts. In situations of crisis and pressure, the time factor is a scarce commodity. However, it’s precisely in these kinds of situations that clarifying roles in advance can effectively save time, as energy losses which are caused by misunderstandings do not occur.

    Are there any personal conflict strategies that prove helpful in these situations?

    You should consider the following points when looking to resolve conflict: There are always two versions of the truth. The truth is never simple or one-sided. There are different points of view and there is at least always a second, third or fourth truth. So if you have a point of view that you can support with good arguments, you can still be open to the perhaps opposite point of view advocated by your counterpart. If you want to solve a conflict constructively, being willing to listen to and understand your counterpart helps. It’s important to remember that you can understand the other person without having to agree with them.

    But how do you arrive at a solution when you have two different points of view?

    If both people accept that the other has a different point of view, you can then move on and find common ground in spite of your differences. And people can often find ways of doing this without having to harmonize positions. Points of view then become starting points for something new. This constructiveness often results in something that didn’t exist before the conflict. And often this is more than just the lazy compromise, but really leads to something great.

    Ms. Lutter, thanks for speaking with us.

    There’s no question about it, the coronavirus pandemic has been a stressful situation for many people. This is evident, for example, from conflicts in the workplace. These conflicts usually have basic causes. Gerburg Lutter, mediator and certified social pedagogue from Kiel, Germany, talks about how to recognize what’s behind the conflicts and how to deal with these situations in a better way.

    There’s no question about it, the coronavirus pandemic has been a stressful situation for many people. This is evident, for example, from conflicts in the workplace. These conflicts [...]

    Read more

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