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Id Subject Object Predicate Lexical cue
T1 0-72 Sentence denotes COVID-19 Personal Protective Equipment (PPE) for the emergency physician
T2 74-89 Sentence denotes 1 Introduction
T3 90-184 Sentence denotes In December 2019, a novel corona virus infection was detected in Wuhan, China, Hubei province.
T4 185-269 Sentence denotes Initial cases all had a common link to an large seafood and live animal marketplace.
T5 270-435 Sentence denotes Corona viruses are a broad class of viruses that are responsible for most of the common colds, as well as several viral illnesses transmitted from animals to humans.
T6 436-589 Sentence denotes They are so-named due to their similar appearance under electron microscopy to the sun's corona during a total solar eclipse (see Fig. 1, Fig. 2 1 , 2 ).
T7 590-990 Sentence denotes The virus responsible for the current outbreak was originally called novel corona virus, now renamed SARS-CoV-2, since it is related to the SARS virus that caused an epidemic in China in 2002-2003 (postulated at that time to have originated in civet cats and then jumped to humans , and the MERS corona virus-related to transmission from camels https://www.cdc.gov/coronavirus/2019-nCoV/summary.html.
T8 991-1205 Sentence denotes The infection is now called COVID-19, and within a few weeks, it became clear that COVID-19 infection was easily spread from person to person, as there was an exponential rise in newly-reported cases seen in China.
T9 1206-1360 Sentence denotes Travelers from China then spread the COVID-19 to other countries, causing the WHO to declare the epidemic a Global Health Emergency on January 30, 20203 .
T10 1361-1732 Sentence denotes Simple recommendations of respiratory protection and glove use early on in the official guidance from health agencies contrasted sharply with wide coverage in the 24-hour news media, showing graphic pictures of civilian authorities and health care personnel in Asian countries wearing extensive protective gear reminiscent of that used for Ebola or even hazmat incidents.
T11 1733-2252 Sentence denotes While initially it was felt that droplet transmission was most the likely mode, recommendations have been upgraded to airborne and contact transmission, since the natural course of this infection is still not completely understood, infectivity or contagiousness seems higher than SARS, and people seem to be able to transmit infection before they ever become symptomatic, and for some days after seemingly full recovery (https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html) (Figs. 3 4 , 3a 5 , 6 , 4a 7 ).
T12 2253-2277 Sentence denotes Fig. 1 Coronavirus- CDC.
T13 2278-2290 Sentence denotes Fig. 2 NASA:
T14 2291-2341 Sentence denotes Sun's Corona during Solar Eclipse August 21, 2017.
T15 2342-2387 Sentence denotes Fig. 3 CDC- airborne particles from a sneeze.
T16 2388-2472 Sentence denotes Fig. 3a NIOSH- Approved N95 mask (above) and N95 duck bill and other styles (below).
T17 2473-2565 Sentence denotes Fig. 4a fit testing N95 mask with qualitative solutions (isoamyl acetate, saccharine, etc.).
T18 2567-2610 Sentence denotes 2 Types of transmission and precautions8,9
T19 2611-2889 Sentence denotes Emergency providers of patient care to persons with suspected COVID-19 infections or who will be in the same room or compartment with such patients should follow Standard, Contact, and Airborne Precautions, including the use of eye protection, as recommended by the CDC and WHO.
T20 2890-2948 Sentence denotes Care should be in single isolated negative-pressure rooms.
T21 2949-3006 Sentence denotes The following sections further explain these precautions.
T22 3008-3033 Sentence denotes 3 Standard precautions10
T23 3034-3225 Sentence denotes The CDC defines standard precautions as common sense utilization of practices and PPE to protect healthcare workers from infections and to prevent spread of infection from patient to patient.
T24 3226-3443 Sentence denotes This includes respiratory hygiene and cough etiquette, proper patient placement/isolation, handling and cleaning of patient care equipment, devices, laundry, clothing, and environment; and sharps and procedure safety.
T25 3445-3470 Sentence denotes 4 Contact transmission11
T26 3471-3706 Sentence denotes Transmission of infection by skin-to-skin contact with an infected person, or by touching contaminated items from a person's room (fomites: patient care equipment, telephones, TV remote controls, countertops, as well as bedding, etc.).
T27 3707-3828 Sentence denotes Wound drainage, as well as secretions or bodily fluids (vomitus, diarrhea, etc.) increase risks for contact transmission.
T28 3829-4025 Sentence denotes Some notable pathogens transmitted by contact include norovirus, MRSA, C. difficile, VRE (vancomycin resistant enterococcus), CRE (carbepenum-resistant enterococcus), SARS, and MERS, among others.
T29 4027-4054 Sentence denotes 5 Respiratory transmission
T30 4055-4174 Sentence denotes Respiratory transmission of diseases can occur when people with certain infections talk, laugh, cough, sneeze, or sing.
T31 4175-4218 Sentence denotes There are two types: droplet, and airborne.
T32 4220-4232 Sentence denotes 6 Droplet12
T33 4233-4414 Sentence denotes Droplet transmission occurs when a patient coughs, sneezes, or talks, which generates infected droplets that can contact the eyes nose, or mouth of another person causing infection.
T34 4415-4513 Sentence denotes These droplets are fairly large and do not remain airborne for long and settle out fairly quickly.
T35 4514-4613 Sentence denotes Simply placing a disposable mask on the patient will reduce transmissibility to healthcare workers.
T36 4614-4760 Sentence denotes Diseases transmitted by droplets are influenza, meningococcal disease, H. flu (HIB), mycoplasma, whooping cough, rubella, and mumps, among others.
T37 4761-4948 Sentence denotes Droplet particles are larger than those exhibiting airborne transmission (see below), and therefore simply maintaining a distance of at least 6 feet away from the patient may be adequate.
T38 4949-5051 Sentence denotes Negative pressure rooms are not required, but patients are generally isolated in single-patient rooms.
T39 5052-5281 Sentence denotes Disposable surgical masks and procedure masks are protective to healthcare workers for droplet transmission, but many institutions err on the side of caution and recommend N95 masks for prevention of any respiratory transmission.
T40 5282-5660 Sentence denotes A recent study showed simple medical procedure mask use was just as effective as N95 respirator use for influenza prevention in the outpatient healthcare setting.13 While predominant thought is that the coronaviruses are transmitted via droplets (like influenza), the quick spread of this epidemic and contagiousness suggests airborne particles may be more possible (see below).
T41 5662-5675 Sentence denotes 7 Airborne14
T42 5676-5952 Sentence denotes Airborne transmission refers to situations where smaller droplet nuclei or dust particles containing the pathogen can remain suspended in air for long periods of time (2 hours or more), and can travel a much greater distance from the patient, since they stay suspended longer.
T43 5953-6050 Sentence denotes Patients with COVID-19 and other airborne transmissible diseases require negative pressure rooms.
T44 6051-6148 Sentence denotes Other diseases exhibiting airborne transmission include TB, chicken pox (varicella), and measles.
T45 6149-6261 Sentence denotes These diseases are much more transmissible than droplet, and a higher level of respiratory protection is needed.
T46 6262-6389 Sentence denotes NIOSH recommends N95 respirators that have been properly fit-tested for all personnel caring for COVID-19 patients (see below).
T47 6391-6429 Sentence denotes 8 Personal Protective Equipment (PPE)
T48 6431-6447 Sentence denotes 8.1 Respiratory
T49 6448-6550 Sentence denotes N-95 respirators (see Fig 3 & Fig 3a & Fig. 4 15 ) are required for airborne protection from COVID-19.
T50 6551-6747 Sentence denotes Per OSHA regulations, HCW must be properly fit-tested with either a qualitative or quantitative device to ensure the mask makes a proper seal with the wearer's skin and offers adequate protection.
T51 6748-6816 Sentence denotes Users must be clean shaven for mask use as well as for the fit test.
T52 6817-6915 Sentence denotes Numerous brands are available from multiple manufacturers16 (see photos from NIOSH webiste below).
T53 6916-7010 Sentence denotes Users with beards cannot be fit tested with an N95, since an adequate seal is not possible17 .
T54 7011-7209 Sentence denotes HCW with beards can use a powered air-purifying respirator (PAPR) with a hood, since these function without the need for a tight skin seal and therefore also do not require fit testing (see photos).
T55 7210-7261 Sentence denotes Fig. 4 face shield and N95 for airborne protection.
T56 7262-7449 Sentence denotes N95 designation is from NIOSH, meaning it is actually a dust-mist respirator which filters out 95% of small particles, but is not resistant to oil (N= Not; 95= 95% filtration efficiency).
T57 7450-7543 Sentence denotes An R95 has the same filtering capacity but is recommended for oily solvents (R= recommended).
T58 7544-7666 Sentence denotes Higher designations such as P100 mean they filter out 99.99% of particles (P= particles; 100=essentially 100% efficiency).
T59 7667-7876 Sentence denotes Higher levels of protection (i.e., R95, P100) are acceptable if a situation calls for N95 and an N95 is not available, but lower levels of protection (i.e., simple procedure or surgical mask) are not (Fig. 9).
T60 7877-7919 Sentence denotes Some of the styles of N95 masks available:
T61 7920-7974 Sentence denotes Photos courtesy of 3M, Kimberly-Clark, and Moldex 18 .
T62 7975-8107 Sentence denotes Since OSHA declares N95 masks for HCW as respirators, their use is governed by the OSHA Respiratory Protection Standard 1910.13419 .
T63 8108-8216 Sentence denotes Employers must have a program in place with the following components:• Written worksite specific procedures;
T64 8217-8238 Sentence denotes • Program evaluation;
T65 8239-8297 Sentence denotes • Selection of an appropriate respirator approved by NIOSH
T66 8298-8308 Sentence denotes • Training
T67 8309-8322 Sentence denotes • Fit testing
T68 8323-8437 Sentence denotes • Inspection, cleaning, maintenance, and storage (for loose-fitting hoods- N/A to disposable single-use N95 masks)
T69 8438-8459 Sentence denotes • Medical evaluations
T70 8460-8813 Sentence denotes Paragraph 1910.134(e)(2)(i) of the standard explains that the medical evaluations are to be performed by a physician or other licensed health care professional (PLHCP) identified by the employer to perform medical evaluations using a medical questionnaire or an initial medical examination that obtains the same information as the medical questionnaire.
T71 8814-9112 Sentence denotes The employer shall ensure that a follow-up medical examination is provided for an employee who gives a positive response to any question among questions 1 through 8 in Section 2, Part A of Appendix C 20 or whose initial medical examination demonstrates the need for a follow-up medical examination.
T72 9113-9237 Sentence denotes Questions 10-15 and all of part B regarding full-face respirators do not apply to HCW using N95 or loose fitting PAPR hoods.
T73 9238-9516 Sentence denotes Since the N95 respirator is a negative pressure respirator, if the PLHCP finds a medical condition that may place the employee's health at increased risk if the respirator is used, the employer shall provide a PAPR (such as the hood described above and pictured in Fig. 5, Figs.
T74 9517-9530 Sentence denotes 5 and 6 21 ).
T75 9531-9539 Sentence denotes Fig. 5 .
T76 9540-9545 Sentence denotes Figs.
T77 9546-9646 Sentence denotes 5 and 6 PAPR loose fitting hood with HEPA filters (no fit test required; suitable for bearded HCWs).
T78 9647-9910 Sentence denotes Fit testing for the N95 respirators is required, but can be performed qualitatively using isoamyl acetate (banana oi), saccharin solution, or Bitrex© Fig. 4a (see Fig. 4a), or quantitative using an approved device, such as Port-a-Count® (see Fig. 7, Fig. 8 ) 22 .
T79 9911-10028 Sentence denotes The fit test must be performed with exact make, model, and size of respirator the HCW with be using in the workplace.
T80 10029-10227 Sentence denotes Qualitative testing does not compromise the mask integrity and therefore after the test the employee can take the N95 with them for future single use (important consideration in time sof shortages).
T81 10228-10397 Sentence denotes Quantitative fit tests require insertion of a probe through the mask, compromising mask integrity, and therefore the N95 must be discarded after a quantitative fit test.
T82 10398-10685 Sentence denotes Fit testing is not required for loose-fitting PAPR hoods (which are used primarily by HCW with facial hair that does not allow a proper seal), because the breathing zone environment is under positive pressure and therefore a tight seal is not required for proper function and protection.
T83 10686-10731 Sentence denotes Fig. 7 Fit testing N95 mask with PortaCount®.
T84 10732-10780 Sentence denotes Fig. 8 Portacount® quantitative fit test device.
T85 10781-10851 Sentence denotes Fig. 9 Simple procedure mask with integrated face shield (not an N95).
T86 10852-10875 Sentence denotes Used by general public.
T87 10876-10928 Sentence denotes This could be worn on top of N95 for eye protection.
T88 10930-10942 Sentence denotes 9 Contact23
T89 10943-11019 Sentence denotes Contact PPE includes a single pair of disposable patient examination gloves.
T90 11020-11078 Sentence denotes Change gloves if they become torn or heavily contaminated.
T91 11079-11247 Sentence denotes A more conservative approach would include double gloving and frequent changing of outer gloves when soiled or torn, with full removal when at risk tasks are completed.
T92 11248-11301 Sentence denotes In addition, a disposable isolation gown is required.
T93 11302-11625 Sentence denotes Many facilities are using clothing that has a hood integrated into a zip-up gown or full jumpsuit-type clothing, with a face shield worn along with an N95; a procedure or surgical mask that has a built-in face shield could be worn over an N95 for the eye protection if goggles or face shields aren't available (see photos).
T94 11626-11697 Sentence denotes All personnel must be mindful of not touching their face while working.
T95 11698-11919 Sentence denotes Upon completion of patient care activities in the negative pressure respiratory isolation room, clinicians should remove gown first, then mask and face shield, and discard PPE; then remove gloves and perform hand hygiene.
T96 11920-11987 Sentence denotes Used PPE should be discarded in accordance with routine procedures.
T97 11988-12130 Sentence denotes Ancillary personnel (ambulance drivers, medics, and techs/aids who help move patients onto stretchers), should wear all above-recommended PPE.
T98 12131-12321 Sentence denotes After completing patient care/transport duties, and before entering clean areas, personnel should remove and dispose of their PPE and perform hand hygiene to avoid contaminating clean areas.
T99 12322-12739 Sentence denotes In addition to the PPE described above, EMS clinicians should exercise caution if an aerosol-generating procedure, such as bag valve mask (BVM) ventilation, oropharyngeal suctioning, endotracheal intubation, nebulizer treatment, continuous positive airway pressure (CPAP), bi-phasic positive airway pressure (biPAP), or resuscitation involving emergency intubation or cardiopulmonary resuscitation (CPR) is necessary.
T100 12740-12841 Sentence denotes BVMs, and other ventilatory equipment, should be equipped with HEPA filtration to filter expired air.
T101 12843-12898 Sentence denotes 1 https://www.cdc.gov/coronavirus/2019-ncov/index.html
T102 12899-12944 Sentence denotes 2 https://spaceplace.nasa.gov/sun-corona/en/
T103 12945-13070 Sentence denotes 3 https://www.npr.org/sections/goatsandsoda/2020/01/30/798894428/who-declares-coronavirus-outbreak-a-global-health-emergency
T104 13071-13141 Sentence denotes 4 https://blogs.cdc.gov/niosh-science-blog/2013/01/15/catchingtheflu/
T105 13142-13199 Sentence denotes 5 https://www.osha.gov/SLTC/mers/control_prevention.html
T106 13200-13290 Sentence denotes 6 https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3healthcare.html
T107 13291-13337 Sentence denotes 7 https://www.facebook.com/RespiratorFITtest/
T108 13338-13420 Sentence denotes 8 https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html
T109 13421-13517 Sentence denotes 9 https://www.who.int/docs/default-source/coronaviruse/getting-workplace-ready-for-covid-19.pdf
T110 13518-13591 Sentence denotes 10 https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html
T111 13592-13675 Sentence denotes 11 https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html
T112 13676-13759 Sentence denotes 12 https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html
T113 13760-13826 Sentence denotes 13 Radonovich LJ Jr, Simberkoff MS, et al; ResPECT investigators.
T114 13827-13913 Sentence denotes N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel:
T115 13914-13942 Sentence denotes A Randomized Clinical Trial.
T116 13943-13948 Sentence denotes JAMA.
T117 13949-14020 Sentence denotes 2019 Sep 3;322(9):824-833. https://www.ncbi.nlm.nih.gov/pubmed/31479137
T118 14021-14104 Sentence denotes 14 https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html
T119 14105-14253 Sentence denotes 15 http://www.sickkids.ca/Nursing/Education-and-learning/Nursing-Student-Orientation/module-one-safety/infection-control-at-sickkids/ppe/index.html
T120 14254-14332 Sentence denotes 16 https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/n95list1.html
T121 14333-14402 Sentence denotes 17 https://www.osha.gov/laws-regs/standardinterpretations/2016-05-09
T122 14403-14494 Sentence denotes 18 https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3healthcare.html
T123 14495-14570 Sentence denotes 19 https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134
T124 14571-14650 Sentence denotes 20 https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134AppC
T125 14651-14730 Sentence denotes 21 https://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respsars.html
T126 14731-14810 Sentence denotes 22 https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134AppA
T127 14811-14882 Sentence denotes 23 https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html