In Response.

We thank Mahajan et al[1] for their thoughtful comments on our article.[2] The issue of cardiopulmonary resuscitation (CPR)in a health care worker (HCW) that has collapsed is an important consideration during the coronavirus disease (COVID) pandemic. There are potentially 2scenarios which put HCWs at risk in such a case: one being the danger of contaminating the collapsed worker in the haste to doff his/her personal protective equipment (PPE) and the other being if the collapsed HCW is himself/herself COVID positive thereby putting responders at risk of infection.

In the midst of caring for suspected or confirmed COVID patients, the entire room and the PPE of the HCWs are considered to be contaminated with infectious viral particles. A common goal is to minimize personnel in the infectious zone. In the COVID patient’s room, the collapsed HCW is in a high-risk area for the code team to enter, in addition to subjecting the collapsed HCW to additional exposure when removing his/her PPE. Besides Mahajan et al’s[1] thoughtful doffing sequence, one may consider performing an additional rapid decontamination procedure similar to other emergency surgical practices (eg, cesarean sections and sternotomies) with a splash of povidone-iodine to sterilize the skin. Since povidone-iodine can inactivate the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and is safe for human mucosal membranes,[3] dousing the collapsed HCW with povidone-iodine in the most likely contaminated areas (head and chest) before attempts to doff the PPE may give an extra margin of error to protect the collapsed HCW.

Indeed, resuscitation in the room will introduce 2potential infectious sources (the original COVID-positive patient and the unknown status of the collapsed HCW) and cross-contamination. Therefore, we recommend moving the collapsed HCW out of the room before resuscitation if the collapsed HCW’s condition is stable. However, we concur with Mahajan et al’s[1] assertion that a pulseless, collapsed HCW may need resuscitation in the COVID-contaminated room. The responding HCWs need to proceed with proper PPE based on institutional guidelines, community prevalence of the disease, and the individuals’ own decision of how to balance the level of PPE based on the situation when different PPE options exist (eg, powered air-purifying respirator versus N95 respirators). For initial resuscitation, high-risk procedures such as chest compressions and airway interventions should be initiated by an available HCWs who already haveon proper PPE, while the rest of the room staff recheck to ensure that they have donned appropriate PPE. The team should be mindful to move the collapsed HCW to a safe area as soon as she/he is stable and transfer care to the code team with proper PPE.

In locations where SARS-CoV-2 testing is not readily accessible, many have commented that all patients should be considered a person under investigation (PUI) until proven otherwise. The PUI designation can be presumed for HCWs in need of CPR, as discussed by Mahajan et al.[1] In fact, given the emergent nature of collapse or code blues, there is insufficient time to locate a HCW’s SARS-CoV-2 testing results. At our institution, we are fortunate to have many of our HCWs tested for SARS-CoV-2, but testing of asymptomatic staff is not currently mandatory. Furthermore, the infectious status is dynamic. The results capture the HCW or patient’s status only during the time of the test. Repeat testing is not performed unless symptoms arise. Asymptomatic positive COVID patients have also been diagnosed at our health system, usually before a surgical or procedural intervention. As a result, HCW don appropriate PPE for all potentially aerosol-generating procedures (AGP), including intubation and CPR. Our institutional guidelines are also germane to the current circumstances given reports that COVID-19 patients may be at higher risk for cardiac arrest.[2]

When considering guidelines for the code response for PUI, it was recognized that limited evidence exists regarding the risk of infection during CPR.[4] Although there was some evidence that chest compressions may generate aerosols with possible viral transmission to rescuers, these circumstances also had simultaneous exposure to airway manipulation. The question of weighing the uncertain infection risk to rescuers against the known risk to the patient from treatment delays by donning PPE is a core ethical concern. This delicate and challenging balance highlights the need for further investigation into the quantification of aerosol generation with chest compressions and defibrillations. Another key consideration is the prevalence of COVID-19 in the surrounding local community of the health system; those hospitals in “hot spots” will have a higher incidence of PUI, necessitating more thoughtful caution about the risk of transmission during CPR.

When drafting a policy for code response for PUI patients at our health system, we used an Situation, Background, Assessment, and Recommendation (SBAR) format to communicate the guidelines to the staff. The summary of these recommendations is listed in theTable. Our health system’s policy follows the guidelines from several societies regarding the CPR and code responses in patients with unknown COVID status.[5] Most notably, the overarching approaches of limiting the number of personnel exposed to an unresponsive patient, appropriate donning of PPE before rescue, and considering resuscitation appropriateness and the survival status of the patient post-CPR were all consistent themes in the various society guidelines. In elucidating these recommendations and changes to code and airway algorithms, several have commented on the ethical guiding principles during these circumstances.[6] General agreement in the ethics community has been that HCW safety should take precedence with proper donning of PPE before attempts at resuscitation.

The decision tree for a collapsed HCW since the COVID pandemic needs to take into consideration ethical concerns during crisis standards of care. These concerns must strike a balance between resource allocation, protecting rescuers and HCW safety, and upholding our professional duties to our patients. Thoughtful recommendations and policies such as those described here can provide guidance during these unprecedented times.

ACKNOWLEDGMENT

The authors acknowledge the Stanford COVID taskforces, staff, and health care workers, from Stanford Health Care for their contribution.

Table 1.

Frequently Asked Critical and Practical Questions in Caring for PUI and COVID Patients

Code Responsefor CardiacArrest
Questions	Answers (Represented Authors’Opinionsand Preferencesand for InformationOnly)a
What would happen with the activation of an emergency response system?	When the emergency response system is activated, the hospital page operator will ask staff, “Is the patient being ruled out for COVID or have they tested positive for COVID?” All patients are considered PUI until proven otherwise.
How is the status of the patient communicated to the emergency response team?	For all PUI and COVID-positive patients, “COVID” will appear as part of the emergency text message.
What is the approach of the emergency response team?	Each member responsible for code responses will respond according to the ACLS and PALS algorithms for PUI and confirmed COVID-19 patients.[3]
	The goal is to minimize the number of people at the immediate resuscitation location or in the room:
	• CAPR to be used by key code team members which include
	○ Respiratory therapist
	○ MICU/codeteamleader
	○ COVID airwayphysician
	○ Critical careresponsenurse
	Outside the room or more than 6 feet away:
	• N95 and eye shield are utilized by all supporting staff
	• Supporting staff (pharmacy, additional nursing staff, primary team) remain outside the room or more than 6 feet away from resuscitation.
Where should we resuscitate the collapsed HCW while caring for suspected or COVID-positive patients?	When caring for suspected or COVID-positive patients, it is paramount that HCW wear proper PPE at all times.
	• If the collapsed HCW is stable, the HCW would be best cared for outside of the room or at least 6feet away from the patient. Consideration should also be given to air circulation, with the ideal location being a negative pressure isolation room.
	• However, if the collapsed HCW is pulseless, chest compressions may commence immediately in the room with the responding HCW already wearing proper PPE while the rest of the HCW confirms that their PPE is appropriate for their role (eg, whether or not they will be involved in aerosol-generating procedures). One may consider performing an additional rapid decontaminate procedure similar to other emergency surgical practices with a splash of povidone-iodine to sterilize the collapsed HCW’s skin and PPE.
	• The collapsed patient should be moved to a safe area as soon as possible for transferring the care to the code team with proper PPE.
Does the COVID status of collapsed HCW matter?	All asymptomatic patients or HCWs are considered PUI until proven otherwise.
What should the bystander or HCW without PPE do in these circumstances?	This is a challenging ethical issue. The general agreement has been that HCW safety should take precedence with proper donning of PPE before attempts at resuscitation, including compressions and airway instrumentation.

Abbreviations: ACS, advanced cardiac life support; CAPR, controlled air-purifying respirator; COVID, coronavirus disease; HCW, health care worker; MICU, medical intensive care unit; PALS, pediatric cardiac arrest life style; PPE, personal protective equipment; PUI, patient under investigation.

aDisclaimer: The questions and answers were adapted in response to Mahajan et al[1] comments based on the authors’ preferences and may not apply to your institutional practice.