PANDEMIC: Coronavirus (COVID-19)Nursing Knowledge and Protection During a Pandemic

Effective March 13, 2020 - March 12, 2021

MICHIGAN NURSES ASSOCIATION IS ACCREDITED AS A PROVIDER OF NURSING CONTINUING PROFESSIONAL DEVELOPMENT BY THE AMERICAN NURSES CREDENTIALING CENTER’S COMMISSION ON ACCREDITATION.

• SUCCESSFUL COMPLETION:

To receive contact hours, participants must complete the evaluation form and post-test. Participants who are not a registered nurse in the state of Michigan will receive a certificate of completion. Submission instructions and links to the post-test and evaluation are on the last page of this self study.• This CE is free for MNA members and $20 for non-members.

• Participants who achieve a minimum passing score of 80% will receive a certificate awarding 1.0 contact hour.

• Participants who do not achieve a passing score will have the option to retake the test at no additional cost.

• MNA members will have the title of the CE and a copy of the certificate posted in MemberLink under “My Profile.”

• CONFLICTS OF INTEREST:

All activity planners for this educational activity have reported no relevant financial relationships with commercial interests.

Presenter(s) for this educational activity have reported no relevant conflict of interest.

• COMMERCIAL SUPPORT:

No commercial support was received for this presentation.

• NON-ENDORSEMENT OF PRODUCTS:

The presence of commercial exhibits during the presentation does not imply endorsement by MNA, the Michigan State Board of Nursing, or the American Nurses Credentialing Center’s Commission on Accreditation.

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NOTEInformation about COVID-19 is changing every day. We have updated our original CE module to include PPE instructions and other information that is current. This continuing education module is designed to give healthcare professionals basic information regarding the coronavirus with full realization that information can and will change as the disease progresses globally. It is recommended that healthcare professionals visit the following websites regularly:

World Health Organization

Centers for Disease Control and Prevention

Michigan Department of Health and Human Service

Minurses.org/covid-19

Michigan.gov/coronavirus

Health care professionals are also encouraged to read reports in the media carefully. In an effort to deliver the news, some media sources have increased the “fear factor” regarding the coronavirus. It is important that health care professionals weigh the information they hear and see, then assess the clinical applications in the United States.

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Learning Outcomes

Nurses and healthcare workers after taking this course will be able to:

● Understand basic information about the coronavirus (COVID-19) and its current world status

● Define issues facing healthcare workers in regard to COVID-19

● Determine the nurse/healthcare worker’s role in addressing patients infected with COVID-19

WHAT IS CORONAVIRUS?• The coronavirus is part of an extensive category of viruses.

• These viruses can cause illnesses ranging from the common cold to more serious diseases such as severeacute respiratory syndrome (SARS).

• This particular coronavirus is new. Scientists are working hard to define the virus.

• As of February 11, 2020, the World Health Organization (WHO) announced official names for the outbreak:

• The novel coronavirus is designated “Severe Acute Respiratory Syndrome” or SARS-CoV-2.

• The disease it causes has been designated as COVID-19.

• There is currently no vaccine for COVID-19. 5Gorbalenya, 2020

A History of SARS

● COVID-19 is genetically similar to previous SARS outbreaks● The 2002/03 SARS outbreak killed 774 out of a total

8,096 infected● The 2012 MERS outbreak (Middle East respiratory syndrome)

killed 858 people out of 2,494 infected● COVID-19 is the “Same species, but [a] different member of

the species” - Benjamin Neuman, Virologist, Texas A&M University

Achenbach, 20206

Anatomy Of An Outbreak

• Discovered in Wuhan City, Hubei Province, China in December 2019• Some models suggest the coronavirus outbreak actually began in

November, with officials in China suppressing the news.• Dr. Li Wenliang, a Wuhan City ophthalmologist, posted his concerns about

several “bursts” of pneumonia that resembled SARS on social media in late December 2019. He was then suppressed by the Chinese government. Wenliang would later become infected with COVID-19 and die on

• February 7, 2020. • Incubation period on average is 14 days and can be as long as 24 days.• COVID-19 has already surpassed the number of people infected and the

number of people who died during a SARS-type outbreak.

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CURRENT WORLDWIDE STATUS

• Cases of confirmed COVID-19 have been found across the world, including Michigan

• As of March 12, 2020, there are 118,322 confirmed cases globally with 4,292 deaths

• As of March 12, 2020, the United States has 1,215 cases with 36 deaths (this figure is changing on a daily basis)

8Richards, 2020

9CDC, 2020

LOCATION OF COVID-19 (as of 3/11/20)

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LOCATION OF COVID-19 in the United States (as of 3/19/20)

Status In China

Hawkins, 2020; Winsor and Schumaker, 2020; Post, 2020; WHO (2020)11

February 3, 2020 February 19, 2020 March 12 ,2020

20,438 confirmed cases 74, 280 confirmed cases 80, 955 confirmed cases

425 deaths 2,006 deaths 3,162 deaths

Status In The World

As of March 1, 2020

118,322 confirmed cases

4,292 deaths

113 countries/territories affected

WHO, 202012

Status Among Healthcare Workers in China

As of March 4, 2020

3,400 confirmed cases

13 deaths

Estimate that nearly ⅓ of the infections in China are healthcare workers

Secon, 202013

What Does COVID-19 Do To The Body?

McKeever, 2020 14

• Attacks the lungs in three phases:• viral replication• immune hyper-reactivity• pulmonary destruction

• Kills cilia cells

• Lung damage continues to build

• Patients die from respiratory failure (bilateral interstitial pneumonia)

• Some patients are left with permanent lung damage - according to WHO, the virus leaves holes in the lungs, creating a “honeycomb-like appearance”

• Elevated liver enzymes, lower white blood cell and platelet count

• Possible “cytokine storms” that create inflammation

• Liver damage and failure

• Complete organ shutdown

SymptomsClinical Features & Epidemiologic Risk

Fever orsigns/symptoms of lower respiratory illness

(e.g. cough or shortness of breath)

AND Any person, including health care workers, who has had close contact

with alaboratory-confirmed 2019-nCoV

patient within 14 days of symptom onset

Fever andsigns/symptoms of a lower respiratory

illness(e.g., cough or shortness of breath)

AND A history of travel from Hubei Province, China within 14 days of symptom onset

Fever and signs/symptoms of a lower respiratory

illness (e.g., cough or shortness of breath) requiring hospitalization

AND A history of travel from mainland Chinawithin 14 days of symptom onset

15CDC, 2020

Other Symptoms

• A significant portion of coronavirus patients experience diarrhea, nausea, vomiting, and/or abdominal discomfort before the onset of respiratory symptoms

• Viral RNA is detectable in fecal samples from suspected cases, indicating that the virus sheds into the stool

• Viral gastrointestinal infection and potential fecal-oral transmission can last even after viral clearance from the respiratory tract

Medpage, 2020

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17CDC, 2020

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TRUE OR FALSE• It’s safe to receive a letter or package from China (True)

• If you are quarantined, you should separate yourself from your pets. (True)

• Pneumonia vaccines such as pneumococcal vaccine and Haemophilus type (Hib) do not protect against COVID-19 (True)

• Regularly gargling mouthwash or rinsing your nose with saline will not protect against COVID-19 (True)

• COVID-19 only infects older people. (False. Any age can be infected but older people and those with medical conditions such as asthma, diabetes, heart disease, etc. are prone to becoming severely ill.)

• Sesame oil will block COVID-19. (False)

• Eating garlic will prevent COVID-19. (False)

WHO, 2020; Grimm, 2020 19

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Transmission● Respiratory droplets from sneezing and coughing● Animals, such as pangolins, civet cats and bats● Urine, saliva, and fecal-oral transmission● Close contact (planes, cruises, etc.)● Under review:

○ Sewer pipes ■ Two apartments 10 floors apart in the same building had coronavirus

cases and led to 100 people in 34 apartments being evacuated■ In 2003, 300 people in the same building were infected with SARS and

42 died after a defective bathroom pipe was discovered○ Surfaces

Achenbach, 2020; Swift, 2020

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Super-SpreadersA super-spreader is an infected person who transmits more infections than other people.

One in five persons is a super-spreader.

It is not known how a person becomes a super-spreader. There is some evidence the person has a higher dose of the virus or is infected with more than one pathogen.

There is no test to determine who is a super-spreader.

Example: a British man contracted the virus at a conference in Singapore, then flew to a family vacation in France, returning home to England. At least 11 people in three countries were infected by one man.Boseley, 2020

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Screening For Coronavirus

Almost all passengers coming to the United States from China are being quarantined.

Detroit Metro is one of the airports cooperating with this program.

The Michigan Department of Health and Human Services has activated the Community Health Emergency Coordination Center to assist with the response and prevention of coronavirus in Michigan.

Hospitals, nursing homes, etc. are creating procedures for screening COVID-19 patients or PUI (Presumptive Positive Case)

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Coronavirus Unchecked - What Would That Look Like?

● Professor Gabriel Leung, Chair of Public Health Medicine, Hong Kong University - “Sixty per cent of the world’s population is an awfully big number.”

● Each person infected transmits the virus to 2.5 other people.● Creates an “attack rate” of 60-80%.● Fatality rate of one percent would still create a tremendous

death toll.● Leung’s concerns

○ Have the restrictions put into place by China affected the virus’ spread?○ If not, experts will need to concentrate on reducing the effects.

● WHO Director General Tedros Adhanom Ghebreyesus - “a very grave threat . . . we may only be seeing the tip of the iceberg.”

Boseley, 202024

A Reminder About Influenza as Compared to COVID-19

● 13 million Americans have had the flu since October 2019● 12,000 adults and 78 children have died● There is a vaccine for the flu● In a bad year, influenza kills up to 61,000 Americans

However, a new analysis by the Chinese Center for Disease Control and Prevention found that the fatality rate for COVID-19 was 2.3 percent and rising. As of March 4, 2020, the WHO estimated the mortality rate to be 3.4% The fatality rate for influenza in the United States is approximately 0.1 percent. CNN, 2020

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Care and Prevention

● Wash hands frequently with soap and water.● Keep hands away from face.● Incubation period can be up to 24 days.● Cover coughs with a tissue, throw the tissue away, and

wash hands.● Stay home when ill.● With COVID-19 spreading, avoid places where people are

gathered in confined spaces such as airplanes, social events, etc.

● Be prepared to quarantine if necessary by having dry goods, books, etc. stored in your home.

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PPE (personal protection equipment

• Refer to minurses.org/covid-19 for a fact sheet on PPE

• Nurses need:• PAPR• N95 filtering facepiece• Goggles• Clean, non-sterile gloves• Disposable gown• Apron (if body fluids are involved)• Any aerosol-generating procedures

need respirators and eye protection

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What does self-quarantine look like? • Purpose – take a possibly infected person out of public exposure.

• The incubation period is 14 days.

• Stay away from other people in the home

• Wipe down all surfaces including doorknobs, toilets, phones

• Wash hands frequently

• Anything shared with others must be washed in soap and water before sharing

• If having contact with pet(s), wear a face mask and wash hands before and after.

• Some sources suggest a separate bedroom and bathroom, and to wear a face mask when around other people

• No going out in public, unless to a doctor – and wear a mask

Post, 202028

Masks or No Masks in Public● The CDC does not currently recommend the use of masks

among the general public. ● Disposable gloves when traveling would be more effective.● Washing hands is better and so is keeping the immune system

healthy with Vitamin C found in leafy greens.● If masks are preferred, they should be N-95 masks. The mask

should form a tight seal around the nose and mouth. ● Masks are helpful for people who are already ill or for

medical professionals who will be around ill people.● Supplies are running low so keep that in mind before ordering

masks for “everyday” wear.● Be aware that as of March 11, 2020 the CDC lowered the

standard for face masks due to a shortage of PPE.Japhe, 2020 29

PPE Shortages

● Prestige Ameritech, the primary vendor for surgical masks, is producing 600,000 masks per day and cannot keep up with the demand.

● American companies rely on Chinese suppliers for everything from active ingredients of prescription drugs to masks, gowns and gloves.

● Because China has initiated severe restrictions to clamp down on the epidemic, many companies are shuttered temporarily.

● Mike Bowen, executive vice president for Ameritech, began writing warning letters to the White House in 2007 warning of possible shortages in masks during a major health crisis.

● Up to 95% of all surgical masks are made in China and Mexico.● Demand is 100% higher than normal and prices are up to 20 times higher.● Items are selling on Amazon with inflated prices.

Sun and Siegel, 2020 30

Roundtable: Are We Prepared? Protecting The U.S. From Global Pandemic

● Presented to the Homeland Security and Governmental Affairs Committee on Wednesday, February 12:

● Luciana Borio, former director for medical and biodefense preparedness at the National Security Council - “COVID-19 is sufficiently lethal to stress severely the health-care system . . . we need to brace ourselves for difficult weeks to come . . . [I’m] very concerned about the prospects for long-term containment . . . we simply don’t have the surge capacity.”

● Scott Gottlieb, former commissioner of the Food and Drug Administration -“there are certainly cases we don’t know about . . . we’re capturing 25 percent of cases at best . . . we’re going to see those outbreaks start to emerge in the next two to four weeks.”

Listen to the entire Roundtable discussion at https://www.youtube.com/watch?v=V-Vs9vfluig&feature=youtu.be

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Prognosis in the United StatesThe Society of Critical Care Medicine recommends meeting the following strategic goals:

○ All patients infected with COVID-2019 must be identified immediately and isolated prior to causing unrecognized, unprotected exposure.

○ Transmission of COVID-2019 to other patients, visitors, and healthcare workers must be a never event.○ Critically ill patients infected with COVID-2019 must receive the best possible care without putting

healthcare workers at unacceptable risk. ○ ED and critical care leaders (eg. nurses, clinicians, respiratory care therapists) should not be passive

receivers of planning. ○ They must be active participants to ensure that infection control recommendations marry with clinical

practices and goals. Healthcare facilities must include clinicians in all preparedness planning and must consider any secondary transmission in their facility a major failure.

○ In everyday clinical practice, most clinical decisions are made with attention only to the risks and benefits to a particular patient.

○ However, during an outbreak, additional considerations regarding risk to staff and other patients may include care decisions.

○ As some centers become experienced in caring for patients with COVID-2019, it is imperative that they share basic information, including features that help distinguish COVID-2019 from everyday conditions, organ dysfunction and required support, response to therapy, duration of infectivity, and treatment strategies.

Rubinson, 2020 32

Prognosis in the United States

• Social distancing is necessary (hundreds of games, concerts, meetings, etc. are being called off)

• People who have been exposed to a COVID-19 patient must self-quarantine

• Wash your hands!

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What Can Nurses Do To Prepare?Meet with or join workplace health and safety committees to help ensure policies and procedures are in place for patients who may need to be isolated.

As part of the committee, ensure that there are enough supplies (PPE) and rooms to take care of an influx of infected patients.

Assess nursing education to make sure nurses who would care for these patients are familiar with processes.

Monitor appropriate websites (CDC, WHO) for updated information.

If represented by collective bargaining, negotiate for nurses to be a part of all decisions regarding preparation and care of patients with COVID-19.

Use the facility checklist at minurses.org/covid-19 to make sure you are ready to care for COVID-19 patients. 34

Resources For Health Care Workers

These resources from the World Health Organization answer questions regarding disposal of waste materials, hospitalization, cleaning and more.

Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and management of contacts

Q&A on infection prevention and control for health care workers caring for patients with suspected or confirmed 2019-nCoV

Minurses.org/covid-19

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CDC Reference Websites• Risk assessment guidance

https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html

• Travel Health Alert Notice (THAN)https://www.cdc.gov/coronavirus/2019-ncov/travelers/communication-resources.html

• Interim Infection Protection and Control Recommendationshttps://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html

• 2019 Novel Coronavirus https://www.cdc.gov/coronavirus/2019-ncov/index.html800-CDC-INFO (800-232-4636)|TTY: (888)232-6348

• Michigan 2019-nCoV: www.Michigan.gov/coronavirus

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REFERENCESAchenbach, J. (2020, February 11). Evacuation of Hong Kong building renews SARs-era fears about virus spread through sewage pipes. Washington Post. Retrieved from https://www.washingtonpost.com

Boseley, S. (2020, February 10). Coronavirus ‘could infect 60% of global population if unchecked’. The Guardian. Retrieved from https://www.theguardian.com

Boseley, S. (2020, February 10). What are super-spreaders and how are they transmitting coronavirus? The Guardian. Retrieved from https://www.theguardian.com

Centers for Disease Control and Prevention (CDC). www.cdc.gov

Denyer, S. (2020, February 10). Coronavirus updates: Global death toll passes 1,000 as China records most deaths in a single day. Washington Post. Retrieved from https://www.washingtonpost.com

Duhigg, C. (Host). (2020, February 4). How to protect yourself against the coronavirus. How To! Slate. https://slate.com/podcasts/how-to/2020/02/avoid-the-coronavirus-advice-doctor-who-lived-through-sars

Feur, W. (2020, February 18).US health officials will check patients with flu-like symptoms for coronavirus. CNBC. Retrieved from https://www.cnbc.com

Gorbalenya, A. E. (2020, February 7). Severe acute respiratory syndrome-related coronavirus - the species and its viruses. Coronavirus Study Group. Cold Spring Harbor Laboratory. BioRxiv. https://www.biorxiv.org/content/10.1101/2020.02.07.937862v1

Grimm, David. (2020, March 12). Quarantine the cat? Disinfect the dog? The latest advice about the coronavirus and your pets.Science Magazine. Retrieved from https://www.sciencemag.org/news/2020/03/quarantine-cat-disinfect-dog-latest-advice-about-coronavirus-and-your-pets

Hawkins, D. (2020, February 3). First patient diagnosed with coronavirus in U.S. leaves hospital. Washington Post. Retrieved from https://www.washingtonpost.com

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REFERENCESHomeland Security and Governmental Affairs Senate Committee Hearing. (2020, February 12). Retrieved from https://www.hsgac.senate.gov/templates/watch.cfm?id=DEA06455-5056-A066-60C1-6F7A737B7323.

Japhe, B. (2020. February 3). What travelers should know about face masks amid growing coronavirus concerns. Washington Post. Retrieved from https://www.washingtonpost.com

McKeever, A. (2020, February 16). Here’s What Coronavirus Does to the Body. National Geographic. Retrieved from https://www.nationalgeographic.com.

Makanda, F. (2020, February 7). Model built by U of T Researchers suggests coronavirus outbreak began in November, has yet to be controlled University of Toronto News. Retrieved from https://www.utoronto.ca/news/model-built-u-t-researchers-suggests-coronavirus-outbreak-began-november-has-yet-be-controlled

Oates, M. (2020, February 12)Balancing flu risks and deaths while everyone’s talking about coronavirus. Purdue News Service. Retrieved from https://www.purdue.edu

Rauhala, E. (2020, February 8). Chinese officials note serious problems in coronavirus response. World Health Organization keeps praising them. Washington Post. Retrieved from https://www.washingtonpost.com

Robinson, L. (2020, January 31). Preparing for Critically Ill Patients with Novel Coronavirus. Society of Critical Care Medicine.Retrieved from https://www.sccm.org/Blog/January-2020/Caring-for-Critically-Ill-Patients-with-Novel-Coro

Secon, H. (2020, February 14). More than 1,700 Chinese healthcare workers have gotten the coronavirus, and 7 have died. A study found that 29% of infections were in medical staff. Business Insider. Retrieved from https://www.businessinsider.com

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REFERENCESSenthilingam, M. (2020, February 4). WHO says Wuhan coronavirus outbreak is not yet a pandemic. CNN. Retrieved from https://edition.cnn.com.

Sun, L. H. and Siegel, R. (2020, February 15). As demand spikes for medical equipment, this Texas manufacturer is caught in coronavirus’s supply chain panic. The Washington Post. Retrieved from https://www.washingtonpost.com.

Swift, D. (2020, March 9). Study: COVID-19 is also spread by fecal-oral route. MedPage. Retrived from https://www.medpagetoday.com/infectiousdisease/covid19/85315

Szabo, L. (2020, January 24). Coronavirus terrifies us, but another virus has already killed 6,000. Kaiser Health News. Retrieved from https://www.jacksonville.com

Update and Interim Risk Assessment and Management Guidance for Potential Travel or Community Setting 2019-nCoV Exposure. (2020, February 4). Michigan Health Alert Network. https://courts.michigan.gov/Administration/SCAO/Documents/CoronavirusMemo02132020.pdf

Winsor, M. and Schumaker, E. (2020, February 11) Coronavirus Infects Residents’ Floors Apartment Building Raising Fears. ABC News. Retrieved from https://abcnews.go.com

Wired.com. (2020, February 8). Coronavirus is Bad. Comparing it to the Flu Is Worse. Wired. Retrieved from https://www.wired.com.

World Health Organization (WHO).

Yang, L., Denyer,S. (2020, February 11). China’s migrant workers head back to cities as country slowly gets back to work. The Washington Post. Retrieved from https://www.washingtonpost.com

PANDEMIC: Coronavirus (COVID-19)Nursing Knowledge and Protection in a Global Health Emergency

POST-TEST DIRECTIONS

Complete the evaluation and post-test response form online and make your payment by clicking here.

AWARDING OF CE

This CE is FREE for MNA members and $20 for non-members.

Michigan RNs who achieve a minimum passing score of 80% will receive a certificate awarding 1.0 contact hours. Non-Michigan RNs and non-RNs who achieve a minimum passing score of 80% will receive a certificate of completion. A contact hour will not be awarded.

Participants who do not achieve a passing score will have the option to retake the test at no additional cost.

Michigan Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

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