By: Cesar Jara, MD, FACC, FSCAI, Binita Shah, MD, MS, FACC, FSCAI, and Rajesh V. Swaminathan, MD, FACC, FSCAI
Contributors: Jayant Bagai, MD, FSCAI, Faisal Latif, MD, FACC, FSCAI, Kirk N. Garratt, MSc, MD, FACC, MSCAI, and Ehtisham Mahmud, MD, FACC, FSCAI

This Tip of the Month reviews current recommendations about personal protective equipment (PPE) when dealing with a COVID-19-positive or person under investigation (PUI) being taken to the cardiac catheterization laboratory (CCL).^1,2

Donning and Doffing Sequence 

Exemplified with this video link (at the 20:00-minute mark).³ Here are the key points:

• All CCL team members should wear appropriate PPE during all procedures including an N95 mask or powered air-purifying respirator (PAPR) before patient arrival.
• A team “supervisor” should be designated to call out the steps to ensure the correct order of donning and doffing.⁴
• Doffing is a two-step process: once in the CCL procedure room and once again in the designated anteroom. Avoid compacting contaminated clothing in the waste container to prevent aerosolization. Final mask removal takes place in the anteroom to avoid air droplet exposure. Do not touch the front of your face mask when removing it and follow local hospital policies regarding the need for limited reuse or extending the use of face masks.

CCL and Equipment 

• Designate a single procedure room for the care of COVID-19 patients.
• Note that most CCLs use normal ventilation or positive pressure and if well-ventilated, there is a low risk of cross-contamination from airborne infection with adequate PPE for staff.
• Consider using portable high-efficiency particulate air (HEPA) filters as an additional strategy for safe containment and elimination of the virus.
• Remove all nonessential equipment from the procedure room or keep it covered.
• Minimize the number of personnel who enter/exit the procedure room during each case.
• Consider a dedicated COVID-19 equipment cart.

Patient Transportation and Cleaning Protocol

• Ensure coordination to initiate the transport to/from the CCL only when teams are ready.
• Conduct a terminal clean of the CCL following a procedure by staff wearing full PPE. Entry into the room should be delayed until a sufficient time has elapsed for enough air changes to remove potentially infectious particles.⁵
• Perform frequent wipe downs of commonly touched objects in the control rooms (i.e., computer keyboard, mouse, door handles).

Sample steps for donning and doffing PPE for CCL staff².

Donning:

1. Hand hygiene with an alcohol-based hand sanitizer

2. Tall disposable shoe covers

3. Lead apron

4. Lead or prescription glasses

5. First head cover (cover ears)

6. N95 mask

7. Second head cover (cover ears)

8. Surgical mask

9. Eye protection (over the lead or prescription glasses): goggles or face shield

10. Hand hygiene: surgical scrub

11. Nonsterile gown

12. Sterile gloves 1 (over the arms of gown sleeves)

13. Sterile gown (inner ties should not be tied)

14. Sterile gloves 2 (over the arms of gown sleeves)

Doffing:

1. Hand hygiene 1 with an alcohol-based hand sanitizer

2. Removal of the outer surgical gown by breaking neck/back straps and disposal of the outer gown and sterile gloves together at one time

3. Hand hygiene 2 with an alcohol-based hand sanitizer

4. Removal of the eye protection that is over the lead or prescription glasses

5. Removal of the surgical mask in the room

6. Removal of the outer head cover in the room

7. Removal of the inner gown and gloves together at one time in the room

8. Hand hygiene 3 with an alcohol-based hand sanitizer

9. Removal of shoe covers at the doorway in the room and stepping out of the room into the anteroom

10. Hand hygiene 4 with an alcohol-based hand sanitizer

11. Removal of the N95 mask by pulling straps over the head and keeping eyes closed

12. Removal of the inner head cover

13. Hand hygiene 5 with a surgical scrub

14. Removal of lead apron

15. Changing into clean scrubs

References

1. Welt FGP, Shah PB, Aronow HD, et al. Catheterization Laboratory Considerations During the Coronavirus (COVID-19) Pandemic: From ACC’s Interventional Council and SCAI. J Am Coll Cardiol. 2020 Mar 16. pii: S0735-1097(20)34566-6. http://www.onlinejacc.org/content/early/2020/03/16/j.jacc.2020.03.021?_ga=2.37584992.172201753.1584716293-1958736984.1584716293.
2. Szerlip M, Anwaruddin S, Aronow HD, et al. Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates. Catheter Cardiovasc Interv. 2020 Mar 25. Doi: 10.1002/ccd.28887. https://onlinelibrary.wiley.com/doi/10.1002/ccd.28887.
3. Cardiovascular Innovations. “COVID-19.” YouTube. Published March 25, 2020, https://youtu.be/C83AHSjcrvw.
4. Centers for Disease Control and Prevention (CDC). “Using Personal Protective Equipment (PPE).” Last updated April 3, 2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html.
5. Centers for Disease Control and Prevention (CDC). “Healthcare Infection Prevention and Control FAQs for COVID-19. Last updated April 19, 2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html.