What are the three most important considerations for audiologists when observing COVID-19 precautions?
Audiologists have been expected to practice infection control according to Standard Precautions, which are the minimum precautions applicable to all patients in any type of setting, including the audiology clinic. Given how easily and quickly the virus spreads, the CDC has focused on three things:
- Masks: Providers, staff, and patients are to wear masks during on-site interactions at least for the interim until further notice from the CDC.
- Commitment to Hand Hygiene: As simple as it seems, hand hygiene is one of the most effective ways of minimizing the spread of disease. CDC recommends the use of alcohol-based hand sanitizers with greater than 60% ethanol or 70% isopropanol as the preferred form of hand hygiene in health care settings. Patients should also have access to product to practice hand hygiene in your place of business.
- Re-emphasis on Disinfecting: While the COVID-19 virus spreads from person to person, disinfecting touch surfaces in between patients remains important as a standard of care for all patients in clinical settings. Using EPA-registered, hospital-grade disinfectants on all splash and touch surfaces in between patients is necessary.
What are the best practices regarding surfaces and infection control in the soundproof booth?
Patients and providers entering a booth should wear masks. Equipment inside the booth (e.g., patient response button, headphones) and other touch surfaces (e.g., armrest of chair) must be cleaned and then disinfected between patients using an EPA-registered, hospital-grade disinfectant.
The risk of pathogen spread can be affected by airflow patterns within a space, which is why audiometric-booth manufacturers are recommending leaving booths vacant with the door closed to allow for one full cycle of air exchange to occur, assuming the booth is connected to the building’s HVAC system.1 The amount of time for a full cycle to occur will depend on the booth dimensions and power of the HVAC. For testing booths not connected to the building’s HVAC, the situation is more complicated, requiring more extensive consultation with a qualified hearing and air-conditioning engineer.
There’s been a bit of discussion regarding UV lights. What are your thoughts for audiologists?
There are different categories of UV light, with UVC representing the specific spectrum used for disinfecting. Colleagues are asking two questions: 1) Is UVC effective as a surface disinfectant, and 2) Is UVC effective in disinfecting air? Regarding surface disinfections, “kills germs” may appear on the label, but it doesn’t mean it kills the specific ones that pose problems in the clinical setting. The potential efficacy of these products depends on strength of the bulb and distance of the bulb to the source, and it is limited to line of sight.2 Unless the product comes packaged with documentation from a reputable third-party authority on what germs the bulb kills and specific instruction for how this is achieved, I personally would refrain from relying on this technology as the sole means of disinfecting surfaces.
In terms of disinfecting air, as mentioned above, disinfection is a function of UVC light intensity and time. Since air moves, the efficacy of disinfecting will be dramatically reduced. Given the high cost and unclear return on investment, it’s not clear what this really accomplishes.
Which mask(s) do you recommend for providers when seeing patients?
Within in the context of the audiology clinic, it is important to use an N95 mask that is tight-fitting during aerosol-generating procedures (AGP) including cerumen removal via irrigation or suction, and during vestibular testing as patients may potentially experience emesis.3,4 In addition to a mask, eye protection in the form of googles, safety glasses, or a face shield is also necessary. If N95 masks are not available, KN95 masks are acceptable. In most other situations, the use of a surgical mask or face shield is sufficient. See my recent blog post called Masking Dilemma for more detailed information.3
Not all supplies are readily available. What are your thoughts on alternative products to perform the same tasks (such as hand washing)?
Increased demand of infection-control supplies has resulted in critical supply shortages, creating a lot of anxiety because the product we are used to using isn’t available. The CDC and other agencies have issued some interim flexibility on acceptable alternatives as follows:
When no face masks are available, the use of a face shield that covers the entire front (extending to the chin or below) and sides of the face with no face mask is an option.5
In response to mask shortages during the COVID-19 pandemic, the CDC outlined strategies for optimizing supply, including extended and limited reuse of masks. Both involve the practice of wearing the same mask for multiple encounters with different patients. Extended use involves wearing the same mask without removing the mask between patient encounters, whereas limited reuse involves removing and reusing the same mask between patients.5,6
Supply disruptions in alcohol-based hand sanitizers have resulted in the Food and Drug Administration (FDA) providing flexibility to manufacturers and other designated professionals to increase the supply of sanitizers, but they have not endorsed homemade solutions.7,8 The use of alcohol-based hand sanitizers is the preferred method of hand hygiene in health care settings; if your preferred brand is not available, switch to another brand in stock, even if it means temporarily switching from a gel to a liquid product. If nothing is available, the use of plain soap and water meets infection-control standards and represents an acceptable form of hand hygiene.
For audiologists waiting for delivery of product, keep in mind that qualified disinfectants are available in different forms ranging from individually wrapped single wipes to sprays and gallon solutions. If the canister of disinfectant towelettes typically used in your office is not available, consider switching to a spray disinfectant, even if it means switching to another brand.
The CDC and FDA recently issued statements that food-grade and industrial-grade gloves are viable options when access to medical-grade gloves is limited.5 In addition, since the CDC does not recommend double gloves when providing care to suspected or confirmed COVID-19 patients,2 if your state or local public health authorities require the use of gloves beyond Standard Precautions, double gloving is not necessary.
Finally, any other recommendations that you’d like to include?
- Be sure you know how to contact the health department of your individual state,and stay connected with them along with other state, county, and local authorities to keep informed about COVID-19 in your community, including developing a plan as to how your clinic will respond and adapt in the event of an outbreak in your community.
- Keep informed by following CDC recommendations.
- Keep patients informed by using appointment-reminder calls to remind patients of your current clinic policies so they are up to date and know what to expect and what is expected of them.
- Communicate with staff to make sure they are up to date on what they need to do to minimize the spread of disease, and to keep them informed of status so that everyone stays on top of it as a team.
- American Academy of Audiology (2020). Booth Safety: COVID-19 and Beyond. Available: https://www.audiology.org/news/booth-safety-covid-19-and-beyond
- International Ultraviolet Association. (2020). IUVA Fact Sheet on COVID-19. Available: http://www.iuva.org/resources/IUVA_Fact_Sheet_on_COVID_19.pdf
- Bankaitis, A.U. (2020). Masking Dilemma. Available: http://aubankaitis.com/masking-dilemma/
- AAA (2020). Vestibular Testing Safety: COVID-19 and Beyond. posted May 19, 2020. Available: https://www.audiology.org/news/vestibular-testing-safety-covid-19-and-beyond
- Strategies for Optimizing the Supply of Facemasks. Published online March 17, 2020. Available: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html
- NIOSH (2020). Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Setting. Posted March 27, 2020. Available: https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
- FDA. Guidance for Industry: Temporary Policy for Preparation of Certain Alcohol-Based Hand Sanitizer Products During the Public Health Emergency (COVID-19). Published online March 2020. Available: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/guidance-industry-temporary-policy-preparation-certain-alcohol-based-hand-sanitizer-products-during
- FDA. Policy for Temporary Compounding of Certain Alcohol-Based Hand Sanitizer Products During the Public Health Emergency. Published March 2020. Available: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-temporary-compounding-certain-alcohol-based-hand-sanitizer-products-during-public-health