Abstract
At present, China is in the stage of the COVID-19 epidemic where regular prevention and control measures are required to contain the spread of disease. Reports of new sporadic cases are still widespread across China and medical personnel remain at high risk of exposure to infection. This is especially the case for medical staff working within emergency departments. Most gynecological emergency cases are complex and a high proportion require emergency surgical treatment. By referring to national regulations and requirements on COVID-19 prevention and control, and by summarizing our experiences in the battle against COVID-19 within Wuhan, this consensus report provides recommendations on the triage, reception, consultation, admission and surgical management of gynecological emergency patients. We also make suggestions for the environmental layout and disinfection and the medical waste management. This consensus aims to optimize the diagnosis and treatment process of gynecological emergency patients and reduce the exposure risk of medical staff within the current context of routine COVID-19 prevention and control.
1 Introduction
Following the outbreak of the 2019 novel coronavirus disease in December 2019,1 its causative pathogen has spread rapidly into 192 countries, causing over 100 million known infected cases and over 2.2 million deaths to date. The World Health Organization (WHO) announced the official name for the epidemic disease: Corona virus disease 2019 (COVID-19) on 11 February 2020; the International Committee on Taxonomy of Viruses renamed the pathogen of COVID-19 as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).2 Through joint national efforts in 2020, China survived the most difficult period of the COVID-19 epidemic; however, we remain in a period where regular prevention and control of COVID-19 is required to contain the spread of this infectious disease. New sporadic cases are still being reported across many places in China. Medical personnel therefore remain at high risk of exposure to COVID-19, and this is especially the case for healthcare staff working within emergency departments (includes emergency gynecology clinics). In response to the continued risk, the National Health Commission issued the "Notice on Standardizing the Diagnosis and Treatment Process of Medical Institutions under the Regular Prevention and Control of the Epidemic”.3 Medical institutions across the country should adhere to the requirements of this notice, standardizing the diagnosis and treatment process with strict implementation of prevention and control measures. These guidelines aim to optimize both the medical treatment of patients and the safety of medical personnel.
Abdominal pain and vaginal bleeding are the chief complaints amongst gynecological emergency patients. Most of these emergency cases are complex and can involve a wide variety of diseases. In the context of the ongoing COVID-19 epidemic, medical staff are at a greater risk of infection and face greater difficulties in clinical practice than in the past. This raises a number of questions surrounding the management of gynecological emergencies. Therefore, in order to improve the diagnosis and treatment of gynecological emergencies during the COVID-19 pandemic, we carefully summarize our experiences with prevention and control measures within the hospitals of Wuhan and Hubei, discussing the characteristics of emergency gynecological diseases and exposure risk of relevant healthcare personnel during clinical work. In addition, we make recommendations for standardizing emergency pre-examination, admissions, gynecological surgery strategies, environment layout and disinfection management, alongside other medical procedures for gynecological emergency patients.
3 Emergency Inquiries at triage station
Prior to reception on site, when imaging results and SARS-CoV-2 nucleic acid or antibody test cannot be obtained to determine COVID-19 status of the patient, careful assessment of patient history and preliminary analysis of clinical manifestation of disease should be made.4,9
The triage station should first assess whether the patient’s vital signs are stable. For critically ill patients, emergency treatment should be performed under secondary protection. For non-critically ill patients with stable vital signs, the triage station should evaluate whether the patient is of medium- or high-risk. Care should be taken to determine whether the patient has travelled from a high-risk COVID-19 region within the last 14 days. Assessment of the patient for history of close contact with a confirmed/suspected COVID-19 case or demonstration of respiratory infection symptoms such as fever (axillary temperature≥37.3 °C), cough, etc., should also be made.10 SARS-CoV-2 nucleic acid and antibody examination should be performed in a timely fashion. In the absence of fever, respiratory symptoms or epidemiological history of potential COVID-19 exposure, medical staff can quickly receive patients for examination and treatment under first-level protection.
5 Related examinations for gynecological emergency patients
During the current climate of regular COVID-19 epidemic prevention and control, optimization of the clinical laboratory workflow is of great importance. When collecting, testing and transporting specimens from emergency patients, personnel should refer to the "Manual for New Coronavirus Nucleic Acid detection in Medical Institutions (Trial)15". The collection and transportation of specimens from suspected COVID-19 patients must be performed by professionally trained medical staff.16
Results of SARS-CoV-2 nucleic acid testing for emergency patients should be reported within 4–6 h, in line with requirements of the "Notice of the General Office of the National Health Commission on the Prevention and Control of Covid-19 Epidemics in Autumn and Winter in Maternal and Child Health Institutions17". Patients with a positive nucleic acid test should be reported online within 2 h via the Chinese Disease Control and Prevention Information System.
In addition to SARS-CoV-2 nucleic acid and antibody tests, lung CT, routine blood tests, coagulation function, liver and kidney functions, electrolytes, HCG tests, pre-transfusion tests, blood group tests, and gynecological B-ultrasound tests are often required for gynecological emergency patients. Gynecological B-ultrasound is useful when evaluating the patient for potential intraperitoneal hemorrhaging, pelvic mass and ectopic pregnancy, among other applications. It is recommended that the ultrasound and CT/DR examination rooms are set up within the emergency department, where possible. The department should establish a dedicated examination channel separate from the normal channel for staff and patients; where possible, all of these routes should operate a one-way system. Thorough disinfection of the ultrasonic probe and CT/DR inspection table should be performed. Equipment, surfaces, floors and air should be disinfected, and protective equipment should be placed in a designated location.
7 Environmental layout and disinfection management
Strictly implement the "Management specification of air cleaning technique in hospitals20" and "Regulation of disinfection technique in healthcare settings21". Formulate disinfection measures, dividing each area into routine disinfection areas, enhanced disinfection areas, key disinfection areas and special disinfection areas.
The emergency gynecology clinic is a routine disinfection area: i. For object surfaces and floors, wipe with 500mg/L chlorine-containing disinfectant every 3h, then wipe with clean water 30min later; ii. For air disinfection, open the air disinfection machine every 4h for 1h. When no patients are present, turn on ultraviolet light for 1h every night. Open the window for ventilation once every 12h: the ventilation time should be ≥30min.
The temperature measurement room and emergency triage table used by fever patients in the non-epidemic area are enhanced disinfection areas: i. For object surfaces and floors, wipe with 1000mg/L chlorine disinfectant every 2h, and wipe with clean water after 30min; ii. For air disinfection, turn on the air disinfector for 1h every 3h. When no patients are present, turn on the ultraviolet light for 1h every night. Open the window for ventilation once every 8h: the ventilation time should be ≥30min.
The temperature measurement room and the medical waste disposal room of fever patients in medium- or high-risk areas are the key disinfection areas: i. For object surfaces and floors, spray 1000mg/L chlorine disinfectant every 2h, wipe with clean water after 30min. ii. For air disinfection, turn on the air sterilizer for 1h every 2h. When no patients are present, turn on the ultraviolet light for 1h every night. Open the window for ventilation once every 6h: the ventilation time should be ≥30min.
The isolation and rescue room is a special disinfection area: after the patient leaves, the air, the surface of the items and the floor should be immediately disinfected using the methods described above for the key disinfection areas.
8 Management of healthcare workers exposed to COVID-19
The population is generally susceptible to SARS-CoV-2. The principal source of transmission is thought to be COVID-19 patients; asymptomatic infections are recognized as a source of transmission. Known SARS-CoV-2 transmission routes include respiratory droplets, contact transmission, aerosol and digestive tract, etc.22 Gynecologists, - being in close contact with respiratory droplets or body fluids when they receive emergency patients, performing gynecological examinations or performing operations such as posterior fornix or abdominal puncture, - have a high risk of exposure. Management procedures for exposure should be formulated according to the exposure risk.23–25
8.1 Management after exposure of respiratory tract
Leave the exposure site as soon as possible following respiratory exposure.
Report exposure to the hospital infection-control department as soon as possible. Wear qualified masks.
After receiving the report, the hospital infection-control department should immediately evaluate the exposure risk. If the exposure source is a COVID-19 patient or the environment at the time of exposure is an isolation ward, fever clinic, or isolation observation room, the risk of infection is high.
Exposed individuals should be isolated in a single room at the designated medical observation site. High-risk exposed individuals should be isolated for 14 days in a single room. If there is no abnormality, the isolation can be terminated after 14 days.
8.2 Management after exposure to blood and body fluids
When exposed by direct blood or bodily fluid contamination of the skin, the individual should immediately go to the buffer room for cleaning: wipe the site with 75% ethanol or iodophor and then clean with water.
When goggles or protective clothing and masks are contaminated, individuals should immediately discard and replace the items within the buffer room.
When eyes are contaminated, individuals must immediately go to the buffer room and thoroughly wash the affected eye(s) with clean water.
When a needle stick or sharp injury occurs during inspection or surgery, remove gloves nearly and squeeze blood from the injured area, rinse with running water and disinfect the wound with 75% ethanol or iodophor. Gloves must be discarded and replaced. Carry out emergency measures according to the workflow of blood and bodily fluid exposure.
9 Principles of health care waste management
In the current climate of regular epidemic prevention and control of COVID-19, medical staff still need to follow the requirements of the "Regulations for Medical Waste Management26" and the "Measures for the medical waste management in medical and health institutions27". Medical waste from suspected or confirmed COVID-19 patients must be treated as infectious waste.28 Use double-layer yellow medical disposal bags for transportation. Sharp objects must be placed in a designated plastic box and sealed. Disposal bags and sharps boxes should be sprayed with 1000mg/L chlorine disinfectant prior to collection and transfer by a trained cleaner. Waste should be transferred to a temporary storage point for medical waste along a specified route at a fixed time. Only authorized personnel should have access to the medical waste storage area. Infectious waste must be collected and disposed by a medical waste disposal vehicle within 48h; the date and quantity of medical waste should be recorded and signed for upon collection. Non-infectious waste generated by non-COVID-19 patients should be treated as general medical waste and should be stored and treated separately to infectious waste.
Conclusion
This consensus is based on currently available literature, regulations and expert opinions. Its purpose is to optimize the timely diagnosis and treatment of gynecological emergency patients and reduce the exposure risk of medical personnel working within the COVID-19 epidemic. However, this consensus cannot be used as a legal basis for any medical disputes and litigation. This consensus captures the contemporary concerns surrounding the topic but cannot address emerging and future issues; the changing landscape of the COVID-19 pandemic will necessitate further discussion and updated consensus.
Financial support
This work was supported by the National Natural Science Foundation of China (grant number 81701423).
Declaration of competing interest
The authors declare that there is no conflict of interest.