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Hello, my name is Maureen Carroll. I'm Assets Online Learning and Development Manager. It gives me great pleasure to introduce the two presenters for today's presentation on infection prevention 2020. The first is Anna Bonner who joined Asset as the director of publications in 2014 and serves as managing editor of the neurodiagnostic journal. Anna holds degrees in biology, biopsychology and neurodiagnostic Technology and is registered in EEG and polysomnography. The next presenter will be Petra Davidson. Petra is currently the clinical coordinator at Intra Neve Neurosciences. She has volunteered with Asset for many years including time as an asset board of trustee member and working with the Skin Safety Task Force and Standards and Practice committee. She has been well trained in literature reviews and has published several articles in the neurodiagnostic journal. Petra loves to teach and as and as will be evident from her presentation, she's a curious individual with passion for Neurodiagnostics. She also has an insatiable thirst for disorders related to seizures that can be prevented. It's my pleasure to welcome both Petra and Anna. Anna. You can take your first slide. Hippocratic oath, do no harm applies. Not only to the physician but to every health care, professional healthcare associated infections are infections that people get while they're receiving health care for another condition. These infections can happen in any healthcare facility and are caused by bacteria, viruses and other less common pathogens. Um AIS are a significant cause of illness and death affecting as many as 10% of hospitalized patients worldwide. It's estimated thatis affect over a million patients in the United States alone inflating the cost of healthcare delivery by over 40 billion annually and mortality costing as many as 90,000 lives each year. Now, you may think that our work is less risky than other allied health care professions in its contribution to the spread of infection. But you'd be wrong. A study published by Steve Bild who is a neurodiagnostic technologist and it was conducted at Rush Presbyterian back in 1997 confirmed the presence of occult blood on reusable eeg electrodes which were routinely used in EEG labs at the time is a study followed on the heels of a class action lawsuit that was filed in 1996 in Toronto, Canada which involved an outbreak of Hepatitis B. This outbreak was attributed to six outpatient eeg and sleep clinics all owned and operated by the same physician and chief technologist. It was the largest outbreak of Hepatitis B in history and it was due to the use of both subdermal and gold disk electrodes that were not properly disinfected or sterilized between patients. A total of 75 patients were confirmed to have contracted hepatitis B, but there were over 18,000 patients that were exposed and this was all due to improper infection control practices. These two reports from the 19 nineties necessitated the need for all neurodiagnostic labs to develop and enforce a more stringent cleaning and reprocessing protocol. However, it appears that as a profession, we may still have a ways to go just in um as recently as 2018 and 2019. Uh there was a series of papers that were published about the contamination of reusable eg electrodes and the variability in cleaning practices among clinics within the same hospital system. Um These were papers published by Nancy Albert and she found that over on um about 25% of their reusable electrodes uh uh was still found with bacteria and this is even after cleaning and reprocessing. Um While there was no evidence of blood, there were um seven of eight bacterial species that were found on clean electrodes um which were cata categorized as posing risk. Furthermore, the group also found great variability among cleaning and repro practices of reusable electrodes even within the same hospital system. This emphasizes the need for standardization and cleaning processing. Um So how do we render items safe for patient use through proper cleaning, disinfecting and sterilization? What you don't know may hurt you and just as important, may hurt your patients and your loved ones. There are infection prevention topics and procedures specific to neurodiagnostic technology. And in this presentation, we strive to educate you on this very important topic. In this presentation, we're gonna uh go over some policy resources in governing organizations responsible for health care standards on infection prevention. We're going to go through some sources of exposure and transmission. Um Of course, there'll be discussion of hand hygiene and use of uh personal protective equipment or PPE, we'll review the disinfection levels necessary for neurodiagnostic equipment and methods to achieve proper disinfection. And also uh we will discuss performing neurodiagnostic procedures on patients who are positive or under investigation for COVID-19 or other highly inves infectious diseases. So how do I protect my patients, myself and my family know about infection prevention and know where to find the information you need to protect yourself. Neuro diagnostic department should have infection control policies and procedures that not only reflect individual needs in clinical situations but are also in compliance with federal state and local regulations. Note infection control is an active process requiring the incorporation of new information as it becomes available. So it's important that you review governing agencies for updates so that you can ensure your labs um policies and procedures are current. So who are those governing agencies? So uh the CDC OS A EPA, you're all familiar with these organizations um per the CD C's guideline for disinfection, sterilization in health care facilities, health care workers should be aware of federal laws and regulations that govern the sale, distribution and use of disinfectants and sterilant. In particular, healthcare workers need to know what requirements pertain to them. And when the they apply to these products, finally, they should also understand the relative roles of the EPA FDA and CDC. So the contact, the context for the guidance uh provided in that document is clear, you can find this uh guideline on the CDC S website and download it for free. Um The CDC also has an app with the latest updates on COVID-19 and uh many other infection prevention uh related topics on the CDC app. You can find news, journal articles and um ah set the news to your own location. This is particularly useful for travelers who might be changing location regularly like a traveling technologist. So healthcare workers are occupationally at risk to a wide array of infectious microorganisms. Even during routine patient care delivery to healthy individuals. The most common routes of infectious disease transmission um to health care workers are contact droplet and airborne and common pathogens uh that we are exposed to um in our daily work setting. Uh include blood borne pathogens such as hepatitis B, hepatitis C and HIV, as well as uh contact droplet and airborne pathogens such as influenza whooping cough and MRSA. Furthermore, a reduction in the risk of infections um associated with medical equipment, devices and supplies. Ranks third among the top five hospital requirements most commonly cited as noncompliant by the joint commission of the hospital survey. During the first half of 2018, almost 75% were cited as noncompliant in the area of infection prevention and control to better understand risks and exposures. It's important to understand the chain of infection from the sources of infection to transmission to the host of an infection transmission pathways allow for the spread and read a positive infectious in organisms. And um infections may be transmitted directly or indirect in indirectly by the means of an inanimate object such as a um a patient care item. There are five main routes of transmission. This is contact, respiratory, airborne, common vehicle and vector borne common sources of exposure specific to neuro diagnostics. Um You know, there are internal and external sources listed here but the most common sources for transmission um particularly in the area of uh neuro diagnostics are contaminated equipment and devices um such as lanyards, ba badges, uh your computer keyboard, um those those devices that nurses use to reach technologist, uh be aware of all of those items that you are in contact on a daily basis. So we go from common sources of exposure to ways that we address all sources of exposure. And because we're unaware of the sources of exposure at any given time, we must use standard precautions every time there are also transmission based precautions for specific exposures which we will cover later. And this is all over the news right now exposures because people didn't know about or um act to properly protect themselves and others in health care. We must assume that everything we touch or come in contact with is a source of exposure to something that we must protect ourselves. And our patients from the CDC recognizes two isolation categories. Um Standard precautions and transmission based precautions. These categories replaced what used to be called universal precautions and body substance isolation. Standard precautions are used for all patients in all healthcare settings and it is assumed that every patient is infectious. You must protect yourself while you provide them with healthcare. Um transmission based precautions are used in conjunction with standard and provide supplemental practices for specific patients or condi conditions where infection is believed to be highly transmissible. Listed. Here are a few examples of infectious agents um that are transmissible through airborne droplet vector and contact transmission. It is particularly important for neurodiagnostic um technologies to be knowledgeable about contact transmission. And why do you think that that is because our profession routinely comes into contact with lice and scabies specifically for technologists who perform eeg it is important to perform a general hair and skin check and recognize lice and scabies. Before you begin preparing the patient for testing, you want to reschedule the patient 24 hours after treatment and all items should be disposed of. Um If using reusable electrodes, use a high level disinfection um which will discuss uh the levels of disinfection a little further into the presentation. Um You also want to bag all linen and if you don't already, you may want to keep an extra set of scrubs in your locker. So you can immediately change clothes in a situation like this. Additionally, it's important for technologists to be knowledgeable about Jacob disease or CJD. It's a prion disease. Um And uh it's also known as spongiform uh encephalopathy due to the characteristic appearance of infected brains as shown here. Um It's rare degenerative and it's fatal in the United States. There are about 350 cases reported annually. There's a characteristic eeg pattern associated with CJD. And um these characteristics include biphasic or triphasic discharges that are initially sporadic and sometimes asymmetric as the de disease advances. Um The pattern becomes more generalized and synchronous myoclonic jerks are often associated with the sharp waveforms, but the relationship is not constant. Often. We don't even know if uh the patient is a se uh suspect for um CJ T uh CJD until after the second or third eeg. And this isn't something that is um confirmed until after death. So it's essential for us as technologists to use precautions. There are three main categories of CJD, hereditary um And uh in which the person may have had a family history of the disease um or tested positive for a genetic mutation um associated with CJD. This accounts for about 10 to 15% of the cases in the United States, then there's acquired CJD where the disease is transmitted by exposure to the brain or the nervous system tissue. Usually through medical procedures, there's no evidence that uh that it's contagious through casual contact. Um But by far the most common type um of CJD is sporadic, uh which accounts for about 85% of all cases in sporadic CJD. The disease appears even though the person has no known risk fact factors. Uh Again, for this reason, we as health care providers need to take precautions. When working with patients, all items used on uh CJD, patients should be disposed of and incinerated and all surface areas including the equipment that you bring into. Um A patient's room should be wiped with a highly a high level uh disinfectant. Um So standard precautions everyday precautions begins with what you're all aware of the importance of good hand hygiene with COVID-19. Now more than ever. So is the general public, which is a good thing. Here are some words of wisdom from the truck yard, you should always uh you should wash your hands even when there isn't a global virus panic. By federal law. Specifically, OSHA guidelines, employers must provide sinks with soap and running water which are readily accessible to healthcare employees. Um If soap and water are not available, an appropriate antiseptic hand cleanser or towels must be provided and must be used. But even when antiseptic solutions are used, hands must still be washed with soap and running water as soon as soap and water are available. Now about that hand sanitizer, um there was a recent study uh by Hiro at all. Um just published in 2019. This is before COVID. Um that showed that hand sanitizer solutions were ineffective at deactivating the influenza a virus unless the solution was used for a full four minutes or more. How many of you uh uh you know, used the solution for four minutes? Probably not many. So while the CDC and the who both officially recommend the use of hand sanitizer that contains at least 60% alcohol um for good hand hygiene. The same authors um Harris at all also demonstrated that hand washing with antibiotic soap was the best method against influenza A virus. It deactivated it within 30 seconds. In addition to good hand hygiene, uh neuro diagnostic lab policies should include policies on protective barriers. Uh The use of standard precautions um and hand hygiene in the context of glove and P pe donning and doffing gloves must be worn to measure mark electrode locations uh during electrode application and removal and other barrier precautions as appropriate for patient care, glove removal must be followed by hand hygiene. Um uh ideally hand washing um and must be removed prior to leaving the work area, including removal of gloves, followed again by hand washing. The same uh policies apply to neurodiagnostic testing whether in an independent diagnostic testing facility, um a hospital clinic or other units within the hospital. Um some of these units uh require additional PPE and infection prevention measures such as uh burn units. NICUs, um uh blood marrow trans plant units, they often require scrubbing um up to the elbows and or uh dining gowns and eeg equipment should always be wiped down with a ca wipe or other high level disinfectant. Before entering these units, we've discussed personal protection and now we will discuss infection control and prevention for equipment and devices we use. But before getting into specifics about disinfecting uh neuro diagnostic equipment and supplies, it's important for us to take a step back and uh to discuss the first and most important part of the uh disinfection process. And that is cleaning any disinfection or sterilization process first requires thorough cleaning because any material or residue that remains on the surfaces of objects or instruments may compromise the effectiveness of the the process. Cleaning requires water. It requires friction and motion and it requires detergents or other enzymatic products. Cleaning removes the inorganic and organic material that microorganisms might find favorable for continued life and growth. Um Remember that cleaning alone doesn't not affect or remove the microorganism. It only removes the uh environment that they find favorable to continue living. There are three categories um that our supplies fall under. There's critical instruments, semi critical and non critical items. Non critical items are items that have contact um with intact skin. They require low level disinfection and include items such as your head box, the cables, um your air gun applicator and measuring tapes. Of note, the joint commission is highly scrutinizing the use of retractable tape measures because there's no way to clean it if you accidentally retract it before cleaning it properly. Therefore, consider purchasing a regular tape measure, not a retractable one. The joint commission is also scrutinizing the reuse of China markers and pens. So, consider again single use disposable options. So what about reusable electrodes? What category do they fall in? OSHA classifies disc electrodes as sem critical and these require high level disinfection. Why are electrodes considered semic critical when they're merely placed on the s uh the scalp or skin? The caveat is intact skin is considered a natural uh barrier. A reusable item contacting non intact skin or mucous membranes such as, you know, nose mouth eyes um is a semic critical item that requires high level disinfection. The CDC defines non intact skin as areas of skin that have been opened with dermatitis, cuts, abrasions, uh chapped skin, et cetera. By this definition, skin preparation with any abrasive to lower impedance levels creates non intact skin. If you were using an electro cap, um that requires skin preparation prior to placement, then this item will also require high level disinfection. Uh Curiously, the, the cap that is shown in this uh slide um The manufacturer only um recommends cleaning with ivory dish soap, but this needs to be looked at more closely. Um It needs a higher level disinfection because the skin was prepped. Um before placement of the cap additionally, uh nasal and oral thermos and even CPAP masks and tubing are considered semi critical as they come into contact with mucous membranes. There was a time when our profession used needle electrodes and other invasive types of electrodes that were reusable. Remember earlier in the talk when I spoke about the largest outbreak of Hepatitis B, these items are unlikely to still be in use. We were not able to find a vendor who still sells them. But if you work in a lab that uses these types of reusable electrodes, you'll need to make sure that they are cleaned properly and sterilized between patients. Um of these uh uh types of invasive reusable electrodes including those used in the or such as stimulation. Uh probes are no longer uh recommended for use. We recommend disposable invasive electrodes. Only the level of disinfection required is based on the amount of contact with the patient. Low level um are for non critical items that have contact with intact skin. High level are sem critical uh items that are exposed to non intact skin, blood or other body, bodily fluids such as mucous membranes. Um Think about this when you ask your patient uh to spin a wheel for um hyperventilation by by blowing how well do you clean that wheel between patient use? So what about items that we use in neurodiagnostic processes that fall under low level disinfection. What do they include? These are your non critical items? Um Again, tape measures, um uh head box cables. Um these have contact with intact skin, high level disinfection. Um What about those items? These are your semi critical items, items that are exposed to non intact skin or blood and body fluids, including reusable surface electrodes and then sterilization to recap. We don't recommend using items that require sterilization um for neuro diagnostic procedures as uh the equipment is readily available as disposable. Now, however, if your facility uses any types of invasive reusable electrodes, including those used in the or such as stimulation probes, you will need to ensure these items are properly cleaned um between patient use to render them safe for use instruments that go through sterilization processes should always be thoroughly inspected before each use and after a cleaning cycle for broken worn or damaged instruments, clean or brush off all visible uh all material that's visible to the eye and clean surfaces, even if no material is visible using hot water and uh regular detergent rinse thoroughly. We also recommend an additional step um following regular cleaning of soaking in an enzymatic cleaner cleaner for one to up to 20 minutes depending on the manufacturer's recommendations. If they rinse in warm water and complete drying before packaging Uh for sterilization is also recommended. And now I'll pass the presentation to Petra. We will need to remind you that while we're talking about cleaning, you always need to wear the proper P pe. So gloves, mask and eye protection. When cleaning, you simply do not start cleaning without the proper P pe first cleaning. Our disc electrodes is absolutely crucial prior to any disinfectant product or disinfection process. Thorough cleaning is required before highlevel disinfection or sterilization because any material or residue that remains on the surface of objects or instruments may compromise the effectiveness of these processes. Risks exist with use of skin preparation agents and abrasion from syringe tips resulting in potential exposure to blood and other bodily fluids, take care when cleaning your supplies and you need to make sure to clean thoroughly. Presence of any organic matter will affect the highlevel disinfectants ability to do its job. Now, we're going to talk about cleaning electrodes for routine electrode cleaning. The first step is cleaning before we disinfect. Just as we had discussed before for cleaning before sterilization, we're going to do our P pe first, which includes eye protection. We're going to clean off all material that's visible to the eye and clean all surfaces even if no material is visible. This includes the hub of the electrode which we will get into a little bit later and the entire lead of the electrode for routine reusable electrodes. We recommend an additional step of soaking in an enzymatic cleaner for a minimum of a minute, up to 20 minutes depending on the manufacturer and then a thorough rinse in warm water. We do have a correction to make um, on an article that was published in the journal based on the ratio of bleach to water. Make sure to pay attention to this correction. The bleach dilution recipe in the table below has been updated. The original table listed a recipe of a quarter cup or four ounces of bleach to four cups or a quart of water for a 0.16% dilution. The correct recipe which needs to be stated again is a half cup or four ounces of bleach to a full gallon of water. So I'll say that one more time. The correct recipe is a half cup or four ounces of bleach to a full gallon of water for the proper ratio. Rendering all reusable objects safe for patient use requires proper cleaning and disinfection. This means that every surface we touch while interacting with our patients must be properly cleaned and disinfected. This includes things like the doorknobs, handles to our acquisition stations, chairs, beds, power cords outlets, anything that you touch must be cleaned and disinfected in between patients. Do you see anything in the image that we might have missed? Think about your head boxes, your leads, your electrodes, your EKG S uh containers that you keep supplies in all need to be cleaned. We're going to take another closer look at this photo, paying close attention to the parts that aren't being soaked in the soap. In a publication by Donna Brown in the Critical Care and nursing journal, there was a discussion about cross contamination by resistant bacteria. Inspo EKG leads, not the eeg leads but can be also applied to our ee leads. The cleaning agents must come into physical contact with the bacteria and must either carry the bacteria away or kill it unless you sterilize your reusable electrodes. It is highly unlikely. The the electrode hubs are bacteria free. The Albert and colleagues studied, we mentioned at the beginning of the presentation, the microbiologist swabbed eeg electrodes from multiple wires ensuring that the eeg cup in the lower third of the electrode lead wire were targeted. Please note that that did not include the hub or the upper two thirds of the lead wire which are touched frequently during hookups and disconnects. How frequently do you grasp the hub or the lead while setting up your patient, fix an electrode already on the head and go back to grab the next tub without changing gloves while you're doing your tap test, you're touching the electrodes realize maybe that you need to switch them in the jack Boxx and you switch them in the jack Boxx without thinking about it. The number of small grooves in that hub and the irregular texture of the material or plastic lead provide additional places of contamination recommendation is to move to disposable electrodes as recommended by Brown and colleagues in 2011 is, is a, is a of the of the, of the, the, the the the to dis to the electrodes is highly recommended. In addition to the common hookup tools used measuring tapes, pencils, adhesives, conductive tape, cotton balls, gauze leads and breakout boxes. There's also your keyboard, video and mouse components, power cords, the E eeg acquisition components that we use continuously throughout a routine recording and we handle often throughout the course of an eeg. These same materials are used in every area of Neurodiagnostics. Frequent and thorough cleaning and disinfecting processes are crucial to all supplies. It's especially important when you consider highly infectious diseases such as COVID-19, which can be carried by people who show no symptoms. A report out of Solano County, California in February of 2020 by Hein Serling and colleagues was published by the CDC in April. In this report, among 121 healthcare personnel became exposed to a patient with unrecognized COVID-19. 43 became symptomatic and were tested for SARS COVID. Two of those three had positive test results. All three had unprotected patient contact. The CDC is reporting over 9000 healthcare workers contracted COVID between February and April early recognition and isolation of patients with possible infection and recommended PPE use can help minimize unprotected high risk healthcare professional exposures and protect the healthcare workforce. Here's what we do know and what we don t know, we do know that it is thought to be spread mainly from person to person. But we don't entirely know if it spreads by common vehicle transmission per the CDC COVID-19 is thought to spread mainly through close contact from one person to the next. Some people without symptoms may be able to spread the virus. And we're still learning about how that virus spreads and the severity of the illness that it causes patient is is is the as patients may expose us to infections, we too may expose them. Patients who are already vulnerable are even more at risk. As reported by the Guardian England's new National Health Services found that up to 1/5 of hospital patients with COVID-19 caught it at a hospital. The data reveals that as much as 20% of infections were passed on by hospital staff who were unaware that they had the virus. So here's what we can do. We can take proper precautions. There is currently no vaccine to prevent COVID-19. Healthcare personnel should adhere to standard and transmission based precautions. When caring for patients with SARS COV two infections per the CDC. The best way to prevent illness is to avoid being exposed to the virus. The virus is thought to be spread mainly from person to person. If you have to conduct a test on a COVID-19, positive patient reduce your contact time. Here is the recommended procedures per asset the AC Ns and R. Hanes Kokomo and colleagues 2020 published article in the June journal. A key consideration, not the only consideration, mind you, but an important key consideration is the duration and proximity of staff exposure. When we're talking about neurodiagnostic procedures, it is important to consider the following findings from the Haynes Kokomo study. A reduced array of disposable electrodes. A minimum of eight. The A applied with tape and head wrap with any abbreviations well documented will help reduce your time in the room. You should avoid using an air hose for collodion as that can constitute an airless line. An a aerosolizing procedure, verbal and tactile stimulation and activation procedures. You only do as medically necessary because HV is a risk as it also aerosolizes the patient's breath which can contaminate and spread COVID photic because you have to get the equipment close to the patient. The technologist must leave the room for continuous eeg to reduce exposure time. Our electrode maintenance may not be performed daily depending on the quality of the recording, the supply of PPE and the clinical situation. A study published in our June journal. This same Kokomo study showed that they could reduce the time in the room by almost 50% by following those steps that were on the last slide. It is important that you reduce your time in the room to reduce your exposure to COVID-19 when performing procedures on patients with highly infectious diseases. It is absolutely crucial that you follow these steps. This is an overview of procedural steps focused on infection prevention per the A CNS. These are based on the University of Maryland's P PE and equipment disinfection procedures for patients on respiratory isolation precautions. It is important that you consider keeping the machine outside the patient's room via long wiring to minimize equipment contamination and the amount of time that the EEG tech needs to stay in the room. These are the CDC S recommendations for PPE dawning and doffing the PPE including respirators and face masks for patients positive or suspected of COVID-19 or any other highly infectious disease is described in detail on the CDC website. They also provide a how two video, a downloadable fact sheet and a full poster. Implementing the universal use of personal protective equipment. Healthcare professionals working in facilities that are located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS CO2 infection. If SARS COV two infection is not suspected in a patient presenting for care based on their symptoms and exposure history. Healthcare professionals should follow standard precautions. If it is a suspected diagnosis, they must also follow the transmission braced precautions. These healthcare professionals should wear eye protection in addition to their face mask to ensure that the eyes, nose and mouth are all protected from exposure to respiratory secretions during patient care encounters. You should wear an N95 or equivalent or higher level respirator instead of a face mask for aerosol gene procedures to know which those are, you should check on the CDC website surgical procedures that might pose higher risk for transmission if the patient has COVID-19 also require the full face mask. Respirators with exhalation, valves are not recommended for source control and should not be used during surgical procedures. As unfiltered exhaled breath would compromise the sterile field for healthcare professionals working in areas with minimal to no community transmission. They should adhere to the standard and transmission based precautions as well including the use of eye protection and or N95 or equivalent respirators based on anticipated exposures and suspected or confirmed diagnoses. Universal use of a face mask for source control is highly recommended for healthcare professionals. As far as face shields and goggles go, you should check with your facility, infection prevention department to verify whether face shields or goggles are necessary for your specific job role, modality of practice and your particular areas. Risk of contamination based on limited research that's currently available as of April of 2020 ultraviolet germicidal irradiation, vaporous hydrogen peroxide and moist heat have shown the most promise as potential methods to decontaminate FRS which were unable to do between patients. It may be necessary to reuse N95 respirators when caring for patients with varicella or measles. Although contract transmission poses a risk to healthcare professionals who implement this practice. Ideally, in 95 respirators should not be reused by healthcare professionals who care for patients with COVID-19 and then care for other patients with varicella measles and tuberculosis and vice versa. The CDC recommends extended use versus reuse because it reduces contact and risk for transmission, not reused after aerosol generating procedures, contamination with blood or other bodily fluids and they need to be discarded following close contact with or exit from the care area of any patient with an infectious disease. Following contact precautions. If using wear your face shield over the respirator, clean and store between use and the person should be assigned to. The device should be clearly identified on the device. The storage container must be disposed of and or cleaned regularly and labeled as well. If the inside of the respirator is touched, it must be discarded. You should perform hand hygiene before and after touching or any adjusting of the respirator, the mask and the face shiel or goggles to use an N95 respirator in caring for patients with varicella or measles. Although contact transmission poses a risk to healthcare professionals who implement this practice. Ideally N95 respirators should not be re reused by healthcare professionals who care for the COVID patients and then for other patients with transmission based precautions. The CDC C, the extended use over the reuse, this takes care of the rest of the procedure. So we talked about going into the room and following the procedure properly with donning your proper P pe cleaning and preparing to go into the room. These are the proper steps for doffing your P pe getting your equipment out of the room, redrawing new P pe to clean things and leaving the patient area. When we're disinfecting equipment, we need to make sure we're doing it twice. We cannot stress that enough. You need to allow for appropriate dwell time or dry time. As per the manufacturer's recommendations, you will visit the Environmental Protection Agency's criteria for use against SARS COV two and to check for the COVID-19 approved fighting products announced by the American Chemistry Council and the Center for biocide Chemistries. The CDC recommends cleaning surfaces with soap and water and wearing disposable gloves, high touch surfaces that require attention include tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, sinks, et cetera for equipment used in rooms with COVID-19 patients. Both those suspected and confirmed. The University of Maryland cleaning procedures have been recommended for all of these equipment processes. These procedures include cleaning and disinfecting the eeg equipment twice when disinfecting electrodes, disposable electrodes are recommended for use if at all possible with disposal of all single use items such as measuring tapes, marking, pencils, et cetera, sterilizing the reusable electrodes between use or following the manufacturer's instructions for cleaning and then disinfecting using approved highlevel disinfectants such as a diluted sodium hypochlorite solution for up to 60 minutes. With regards to measuring tapes, it cannot be stressed enough that single use are the preferred or non retractable measuring tapes are acceptable. If using a retractable measuring tape, it is vital to ensure that the tape is properly cleaned and disinfected prior to retraction. Remember that wiping and cleaning equipment between patients is vital regardless of diagnosis or status, we must follow standard precautions. The best practices are to wipe equipment fully upon exiting the patient's room using the approved disinfectant and cleaning processes following the manufacturer's recommendation time for dwell or dry time as well. When disinfecting supplies, we do that twice when we're disinfecting electrodes for all disposable electrodes is the recommendation. When that's not possible, we're going to sterilize reusable electrodes between use or follow manufacturer's instructions for cleaning and then disinfecting with the highlevel disinfectants for up to 60 minutes. If possible, we need to disinfect our measuring tapes. It is preferable as said before to use single use or non retractable measuring tapes. If you're using a retractable measuring tape, you absolutely must clean it and disinfect it and allow it to dry completely before retracting, wiping and cleaning your supplies twice is absolutely vital to your health and your patient's health. Best practices are to wipe supplies twice upon exiting the room wearing clean gloves and using a pro approved disinfectants. You will follow this link to get the EPA S recommendations on approved disinfectants and you can follow the second link to the American Chemistry website to look for additional products that have been approved for fighting COVID-19. As far as waste management goes, there are currently no recommendations specific to COVID-19 with regards to waste management. It is important to check with your particular waste management. Depart department to determine the best procedure. We've had several questions posed to the interest section forums on the asset page and to many Facebook pages regarding ee text. Some of those most important questions are, how do COVID-19 precautions change activation procedures for ee should patients perform hyperventilation? And what about photic stimulation and proximity to the equipment to the patient's face as far as activation procedures are concerned? This is what we believe should happen. We know that COVID-19 is transmitted between people who are in close contact with one another through respiratory droplets that are produced when an infected person coughs sneezes or talks. These droplets can land in the mouth or noses of people who are nearby or be inhaled into the lungs. Some recent studies have suggested that COVID-19 may be spread by people who are asymptomatic contact transmission between healthcare workers was at a high risk. This leads the A CNS and asset to recommend that hyperventilation should be avoided for COVID-19 patients or patients who are under investigation for COVID-19 patients must be fever and symptom free. You must use your mask, face shield or goggles as the healthcare worker hyperventilation needs to be medically necessary. In order to do that if you're using a pinwheel to get someone to do hyperventilation it should be disposed of. After the hyperventilation is completed, you should clean all surrounding surfaces in between patients because the photic stimulator must be close to the patient. In order to work appropriately, the patient must wear their mask and you must clean and disinfect the photic stim light, the holder and the cables in between patients. You should maintain safe distance as much as possible as you can tell in the image behind the words, those respiratory droplets spread very far and are difficult for us to see. So we don't know all the surfaces they're landing on. It is very crucial that you're cleaning all surfaces in between patients. Additional questions, how do COVID-19 precautions change test processes for PSG nerve conductions and autonomic? Many labs use reusable ground electrodes. What about reusable stimulators? And how do we ensure proper cleaning in between patients? It is recommended that we use disposable equipment as much as possible and this goes for any modality of ee of Neurodiagnostics. When you cannot use disposable equipment, we keep the equipment as far from the patient as possible and we clean thoroughly and disinfect twice between every patient. Switch all equipment and devices that touch the patient to single use disposable, including your stimulators grounds and recording electrodes. If using disposable is not an option, we're going to clean and disinfect twice as you can note by the red arrow that electrode hub is not plugged all the way into the jack Boxx. In order to fix this and make your impedances come down, you will need to touch that. After touching all the other electrodes. This is one example of the reason it's so important to go back and clean and disinfect twice. How do COVID-19 precautions change test processes for autonomic. Is there a change with patient screening and medical necessity? Absolutely. You need to make sure that it is absolutely necessary that the test occur when it is going to make a difference in the patient s care. Increased cleaning of surfaces must occur between every patient and increased precautions must be used when exercising the deep breathing exercises. In autonomic, autonomic testing uses many reusable devices such as finger cuffs, respiratory belts, iontophoresis, electrodes and mouthpieces. The mouthpiece for the valsalva maneuver is disposable, but the tubing that attaches to it is not, it is absolutely crucial that you follow the manufacturer's cleaning instructions for the cue sweat system before cleaning, always ensure the unit is powered off and that the power cord is disconnected, never immerse the unit or any components. Never apply cleaning solutions or moisture to the unit directly. Instead apply to the cloth and then use the cloth to clean the requisite components. Always ensure that the unit is clean and dried completely before reconnecting power and resuming testing. Making sure to clean your power cords and any surfaces that you touched in between. For the main unit, we're going to clean with a dry lt, free clean cloth. If the main unit or desiccant housing becomes soiled, they may be cleaned using a damp lent free cloth, enzymatic cleaner or bleach wipes. Isopropyl alcohol may be used as an alternative, but it might strip the ink from the labels and printed materials over time. The parking fixture and the hose connectors may be cleaned with a damp cloth and somatic cleaner or bleach wipes and they may also be cleaned with 70% isopropyl alcohol. Please note that the rubber gasket seals may deteriorate over time but those can be purchased from the manufacturer. Your measurement hoses and capsules can be cleaned on the exterior with a damp cloth, enzymatic cleaner, Isopropyl alcohol or bleach wipes. The hose interiors may acquire a buildup of material over time if visible buildup has occurred and cannot be removed. Replacement hoses should be purchased from your manufacturer. If material buildup in the hoses has reached the host connectors, the hosing unit may be contaminated as well. End users may carefully remove the cover of the main unit visually inspect the housing. If internal hosing is affected, the unit should be sent to the manufacturer for cleaning and repair. It is also important to pay attention to your tilt table belts and arm supports. Ordinary dirt may be removed from vinyl by washing with warm water and soap, apply soapy water to a large area allowing it to soak for a few minutes, brisk rubbing with a cloth should remove most of the soil. Then you should clean it with a soft brush that has been used with soapy water painted components can be cleaned with warm water and mild soap. Any further cleaning needs to be checked with the manufacturer first. Your heart rate variability acquisition has its own cleaning process as well. Before cleaning always make sure it's powered off and that the power cord is disconnected. Don't immerse any components apply. It never apply the cleaning materials directly to the machine but to the cloth first and then using the cloth clean, the requisite components always make sure the unit is clean and dried before reconnecting the power and resuming testing. As with the other components, isopropyl alcohol at 70%. Enzymatic cleaners or bleach wipes may be used to help clean the outside surfaces of the unit. For polysomnography. How do COVID-19 precautions change the test processes for PSG should facilities dispense HS set devices while COVID-19 is spreading should patients with COVID or use CPAP and is soap and water enough to disinfect a CPAP mask. We recommend following manufacture recommendations and using CDC guidelines for cleaning of the CPAP HS A and PSG equipment. While some sleep laboratories are dispensing the home sleep study units through mail delivery to reduce patient contact and others are suspending services for a limited time. Decisions must be made on a case by case basis. Exceptions may be required when there is an intolerable risk of acute adverse outcomes such as unavoidable emergency or safety sensitivity activities such as emergency workers who report drowsiness while driving if it S A is performed. Some labs are waiting for at least three days before handling the equipment. Once it's returned, thorough, manufacturer's cleaning instructions should be followed. As always, standard precautions should be followed by personnel handling, recovering testing equipment. Asymptomatic patients can pass COVID-19. We have to use standard precautions. We must maintain proper use of PPE and cleaning procedures, which means cleaning twice every time. It means donning your proper P PE in order to clean equipment, doffing it when you're done cleaning and making sure to do the process twice. Keeping in mind that our ESLTM units, epilepsies, sleep disorder centers, autonomic labs must thoroughly clean and disinfect keyboards, mice monitors and surfaces, doorknobs, et cetera. Between shifts and between visits to patient rooms. We have to remain vigilant every single day. Even after the COVID crisis is over. Every patient requires standard precautions. Every time every patient needs to be viewed as potentially contaminated. We need to remember that other exposure risks for neurodiagnostic tests can be commonly encountered such as lice and scabies and CJD are all high risks that we can pass on to our colleagues and to the rest of our patients, to all of our health care heroes. We thank you for your time and effort and for the time put in to learning how to properly take care of clean and disinfect your areas for yourself, your family members and your patients. If you have any questions, you can contact both of us at ana at asset dot organn A at a set dot org.