COVID BLOCK

Introduction: COVID BLOCK

Most COVID-19 patients will stay at home for their illness. Some will require in person visits by health care staff. The goal of this project is to make it safe for healthcare workers to perform essential functions including checking blood pressure, pulse oximeter, listening to the chest, chest ultrasound and collecting nasal and pharyngeal swabs on patients who are able to walk to their door and sit in a chair.

The idea is to use tension spring rods to hold up the clear shower liner in the doorway. A second tension rod should be used about halfway down to secure it, and a third at the bottom. These will not get contaminated since they are on the health care workers side of the door. The tension rods that I choose adjust from 28 to 48 inches. Average door widths are 30-36 inches.

If a patient will require multiple visits, it is best to put the rings in the shower liner holes and string the curtain up on a tension rod, I recommend a sturdy one at the top. This way the residents can just slide the curtain out of the way when they want to enter or exit. The healthcare worker's side of the curtain would have to be sprayed down with bleach prior to use, which will take about 5 minutes. This works well if the patient has a storm/screen door and a regular door. This allows the shield to be protected from weather.

One or more 5 inch holes are cut into the curtain, or you can simply cut an X and leave the flaps. The patient should be sitting so that the lateral side of their body is up close next to the curtain. This will allow access to their arm, and easy access to their anterior and posterior chest. The hole position is marked, the center of the hole is at the level of the patient's humeral head. The patient should then move at least 6 feet away from the curtain so the hole can be cut. A second hole should be cut if chest ultrasound or any procedures requiring two hands will be performed.

The inner ring of the embroidery hoop is inserted about 2 inches into the bovine OB glove. The open end of the glove is inserted into the six inch diameter circle that is made of the 12 gauge wire. The open end of the glove is then folded over the wire and secured with tape. The wire is then pressed into an oval and inserted through the hole in the curtain, leaving the embroidery hoop on the opposite side. The wire is then reformed back into a circle. The embroidery hoop is pushed as close as possible to the curtain and secured with the outer loop.

When the visit is over, the patient moves at least 6 feet from the door. The worker removes the two bottom most tension rods. Then, the top tension rod is removed while holding the curtain on the "safe" side. It is then laid on a sheet on the ground with the contaminated side facing up. All surfaces are then sprayed with bleach, then wiped, and folded for the next patient. If the curtain is to remain on the door, it can be slid to the side and secured with a clip so that the health care worker's gloves are not exposed. On subsequent visits, the worker can double glove with the long gloves or carefully clean the glove's interior surface.

The curtain will protect the healthcare worker's ppe, but failure of the system is possible. Make sure the patient's dog is locked up! The healthcare worker should wear a surgical mask, gloves and an apron or gown to protect the front of their body. The gloves should be disposed of and hand hygiene performed before and after every patient encounter. The apron or gown should be removed using standard doffing procedure if any contamination occurred or is suspected.

Supplies

1. Clear shower liner. PEVA or vinyl. Shower curtain rings if the shield is going to be left hanging in the doorway. These range from $3-$10.

2. Tension rods- AIZESI 6PCS Tension Rods Spring Rod 28 to 48 inch Tier Valance Curtains Rod for Kitchen Window Bathroom(White) for $22 from Amazon. I expect most brands will work okay. Tension rods for shower curtains are about $4 each, make sure you get the 24-40 inch size. They are stronger but harder to hang. You need three tension rods per shield. You could use wooden dowels or tape to secure the curtain, but the tension rods are quick and easy. The rod at the top should be a good one. There will be a gap at the bottom, it is unlikely virus could travel below the curtain and then get carried aloft. You could cover this with a section of cardboard or hang a section of plastic sheeting to cover the gap.

3. Bovine OB gloves, clear (not pink) that extend to the axilla. The ones I bought were $17 for 100 from Amazon. I also found them at Rural King, you can probably find them at feed stores that cater to cows and horses. Your local large animal vet or farmer might spare you a few. The gloves are surprisingly durable.

4. Embroidery hoops, 6 inch diameter - plastic are a little sturdier, but the bamboo ones work fine too.

5. 12 gauge craft wire, which is about 2 mm in diameter. The wire should be fairly easy to bend, but hold it's shape. Thicker or thinner wire would work. You could use a wire coat hanger too. They sell it on Amazon in pretty colors.

5. Spray bottle with diluted, non-expired bleach, 2100 ppm, or other approved cleaner. A bleach dilution calculator can be found at https://www.publichealthontario.ca/en/health-topi... Freshly diluted bleach should be made up each day.

6. A five gallon bucket with a lid is handy for storing used, bleach wet curtains. It also can be used to hold open screen doors or as a footrest for the worker so the patient's arm can rest on the worker's knee while checking the blood pressure.

7. The patient will need a chair, preferably with a backrest. This chair will be positioned so the patient's lateral side is closest to the curtain. This should be positioned fairly close to the open door. Make sure the patient has something to use to help them up out of the chair, do not let them grab the curtain. You could carry a sturdy old chair in case a patient does not have one.

Step 1: Hoop Prep - to Be Done Prior to Visit

Form a 21 inch section of 12 gauge craft wire into a loop. Tape the ends so they do not poke out.

Insert the inner ring of the embroidery hoop about 2 inches into the bovine OB glove. The open end of the glove is inserted into the six inch diameter wire loop. The open end of the glove is then folded over the wire and secured with tape. The wire is then gently pressed into an oval so it can fit through the hole in the curtain.

The outer loop of the embroidery hoop is gently secured, using the screw, over the inner loop, with the plastic glove sandwiched between them.

Prepare extra hoops before you head out. If you are going to be hanging a curtain via curtain rings, install them now.

Step 2: When You Get to the Door.

When you arrive at the house, call the patient on the phone and tell them you have arrived. If they have a screen/storm door, ask them to unlock it. Ask them to then move at least 6 feet away. They will want to watch what you are doing. Assume all members of the household are infectious, even if they tell you are they are not sick. Do not allow them to touch your materials.

For doorjambs that have rotten wood, or peeling paint, you may need to use wood or other material shim to protect the frame. Warn the homeowner that you might leave a slight indent or discoloration.

Figure out what length to extend the extension rod to. Doorjambs are frequently not exactly square, you should actually measure the tension rod at where you want to place it.

I used regular shower curtain rings in each of the holes. The curtain in this picture is my testing curtain, so it is a little damaged from my over exuberant use of duct tape.

If you are not planning on leaving the curtain, you can simply use the tension rod to hold up the curtain.

Placement of the top of the curtain should be higher than your head and the patient's head. You may need a step stool to get it high enough. SARS-CoV-2 is transmitted via droplets. There will probably be a gap at the bottom. It is unlikely that the virus would successfully move from the patient, to below the curtain, and then up towards the health care worker. This gap can be covered with a piece of cardboard, or by hanging a sheet of plastic or cloth from one of the tension rods.

To keep the curtain in place, additional tension rods should be placed on the healthcare workers side of the door at various positions. I suggest placing one at the workers upper chest level and one at knee level. It can be helpful to give the curtain extra slack from the sides in the section where the glove is inserted so you can reach the patient. If it is windy, this can take a few minutes to get right.

Step 3: Determine Where to Put the Glove(s), Then Secure the Gloves in Position.

Invite your patient to sit down after the curtain is secure. Locate the patient's humeral head, about 2 inches inferior to the top of the shoulder. Mark the spot. Ask your patient to move 6 feet away. Cut an X into the curtain with the center of the X over the marked spot. Cut the X so that each arm of the X is less than 5.25 inches. You want the diameter of the circle to be smaller than the diameter of the embroidery ring and metal ring.

Ask the patient to wear a patient gown, or a short sleeve t-shirt or other loose fitting clothing.

Insert the metal ring, that is now an oval, through the hole in the curtain. Once it is on the patient's side of the curtain, reform it to a circle. Remove the outer embroidery loop by unscrewing the screw. Slide the inner ring up close to the curtain, then secure it with the outer loop. Tighten the screw.

If you plan on doing two handed procedures, or if you need to do an ultrasound, insert a second glove about 12 inches from and at about the same level as the first glove.

If you have not yet put on your PPE, do it now. At a minimum, a homemade cloth or paper mask, or a surgical mask should be worn. If you need to enter the home, and a nebulizer, CPAP or BIPAP macin was used that day, wear an N-95. Eye protection is essential. An apron or patient gown should be worn to protect the front of your body. You can wear a pair of the long arm gloves for your double glove, or regular short cuff gloves.

Step 4: Exam Time.

Invite your patient to return to their seat. Explain the exam.

Guide your patient's hand into the glove. Apply the pulse ox, try to smooth the glove over the anterior and posterior aspects of the chosen finger. If the sun is out, try shading the sides of the pulse ox.

A blood pressure can be obtained if the patient is able to fully insert their arm. I'm not a fan of the forearm devices, but they could be used if the patient is unable to fully insert their arm. If the patient's arm is too large for the glove, a clear, 5 gallon plastic garbage bag could be used instead of the glove with a 10 inch diameter embroidery hoop.

After the pulse ox and BP are obtained, the patient extracts their arm. The healthcare worker then inserts their arm into the same glove, but in the opposite, clean side side. A stethoscope can be inserted into the glove with a hand and be used for auscultation. This is a bit awkward. Perform hand hygiene prior to touching your stethoscope.

A chest ultrasound can be done. You will need to have a gel packet on the patient's side of the curtain in addition to applying a generous glob on the probe. You can then hold the probe in one of the gloves with your gloved hand such that a smooth gelled surface is achieved. This takes some practice as the fingers have to be out of the way. A rubber band on the patient's side that is holding the probe cover in place may make this easier. You might need to bring a dark sheet or towel to cover up the machine and your head if the ambient light is too bright.

A cardiac ultrasound will be a bigger challenge since the patient will not be supine or in the lateral decubitus position. A subxiphoid window might be possible. There are reports that some patients with COVID-19 have myocarditis.

If swabs are to be obtained, label the tubes prior to placing them on the patient's side of the curtain.

A thermometer could be inserted into one of the fingers of the gloves and placed in the patient's axilla. I did not test thermometers, and would not suggest obtaining an oral temp through the glove on account of it being a choking hazard.

Step 5: Clean Up

A spray bottle with diluted, non-expired bleach, at 2100 ppm, should be made up fresh each day. If multiple patients are to be seen, a pump style 2 gallon garden sprayer will be more convenient.

The lower tension bars are removed. The top tension bar is carefully extracted from the doorway with the contaminated surface kept away from the healthcare worker. The curtain is laid on a clean sheet that is on the driveway with the contaminated side facing up. Using a fine mist, it is sprayed with bleach solution until the entire surface is covered. A picker upper tool can be used to hold the contaminated gloves up so they can be sprayed. The bleach solution should remain on the curtain for at least 1 minute. Excess fluid can then be mopped up.

If the curtain is going to be processed at the end of the day, it can be carefully folded with the contaminated surface folded inside and stored in a garbage bag or the 5 gallon bucket. It should be sprayed with bleach prior to folding.

If the curtain will be used on the next patient, the used glove can be removed by unscrewing the embroidery hoop, and squeezing the metal ring into an oval so it can fit through the hole. This glove can then be discarded. The embroidery hoop can be reused after soaking it in a 2100 ppm bleach solution for at least one minute. The metal screw should be rinsed with fresh water to delay corrosion.

If the patient will be getting regular visits, the curtain can be left up, especially if it is behind a screen/storm door. The glove/hoop unit should be removed. Slide the curtain out of the way and tie it off. At the next visit, the healthcare workers side of the curtain should disinfected with bleach spray and then wiped down, then clean gloves/hoops are reinserted.

At the conclusion of the visit, the health care worker should perform hand hygiene. If a breach occurred, the PPE should be doffed according to protocol.

Thanks for reading! Stay safe, remember, there are no emergencies in COVID-19. Your safety is your top priority. Patients may be put off by the curtain at first, but might appreciate a healer's touch and attention. A back or side door will provide more privacy. Watch out for crazy stoops. Ask that the dog, cat, house rabbit, house rat and free flying birds get locked up before your visit, even if you love critters. If your visit will be inside the house, be mindful of infection control. A clean 5 gallon bucket for your uncontaminated items and a second, clearly labeled bucket for your contaminated items will be helpful. Do not use a stethoscope if there is any chance of contamination. If a nebulizer or CPAP or BIPAP machine has been used that day, do not enter the house without an N-95. Tell the family to put a fan in the patient's room window that sucks air out of the patient's room.

Please write in the comments if you make improvements! This has been a continuous work in progress.

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