The document discusses how to avoid getting infected during cardiac rehabilitation in the setting of COVID-19. It outlines the chain of infection and various control measures that can be implemented, including environmental disinfection, social distancing, proper use of personal protective equipment (PPE), and staff screening and testing protocols to allow for a safe return to work. Control measures like administrative controls and PPE use appropriately tailored to the task can help break the chain of COVID-19 infection during the delivery of cardiac rehabilitation services.

1. How to Avoid Getting Infected
During Cardiac Rehab
in the Setting of
Marion Aurellado Kwek, MD, FPCP, FPSMID
June 13, 2020
@Mars_IDS

2. Disclosure
• None

3. Objectives
• To give a background on the current COVID-19 crisis and its
effect on the delivery of cardiac rehabilitation services
• To discuss infection control measures that should be
observed
• To orient regarding the proper use of PPEs during care
delivery
• To discuss the role of mass testing in returning to work

4. Worldwide
•7,237,565 confirmed cases
•409,617 deaths
Philippines
•22,992 cases
•1,017 deaths
Data as of June 9, 2020

5. The emergency room department of Papa Giovanni XXIII hospital where suspected COVID-19 patients are
under observation in Bergamo, Italy, on March 21. Image Credit: Fabio Bucciarelli, The New York Times

6. Effects of COVID on Cardiac Rehab
- Reallocation of staff
- Reduction of outpatient
operations
- Lockdown measures
making access to care &
medications difficult
- Fear of accessing
care/possible
exposure
Vigorito, et al., Monaldi Archives of Chest Diseases
Khera et. al., AJPC 100009

7. Effects of COVID on Cardiac Rehab
- Increased social isolation
due to social distancing
- Depression
- Altered physical activity
- More sedentary
- Change in nutrition
patterns
Vigorito, et al., Monaldi Archives of Chest Diseases
Khera et. al., AJPC 100009

8. Infectious
Agent
Reservoir
Portal of Exit
Mode of
Transmission
Portal of
Entry
Susceptible
Host
CHAIN OF
INFECTION
Principles of Epidemiology in Public Health Practice, Centers for Disease Control & Prevention
SARS-CoV 2
Where the agent lives &
reproduces
Respiratory tract, GIT
Droplet, Contact
(direct/indirect)
Respiratory tract,
Mucosa (including eyes)
Young/old;
Immunocompromised

9. Infectious
Agent
Reservoir
Portal of Exit
Mode of
Transmission
Portal of
Entry
Susceptible
Host
CHAIN OF
INFECTION
Principles of Epidemiology in Public Health Practice, Centers for Disease Control & Prevention
SARS-CoV 2
Where the agent lives &
reproduces
Respiratory tract, GIT
Droplet, Contact
(direct/indirect)
Respiratory tract,
Mucosa (including eyes)
Young/old;
Immunocompromised
IPC Policies
Environmental Disinfection
Pest control
Diagnosis and Treatment
Hand Hygiene & Respiratory etiquette
Control of aerosols and splatter
PPE
Waste Disposal
Hand Hygiene & Respiratory etiquette
Cleaning and disinfection,
sterilization
Isolation
Hand Hygiene
Avoid touching your face
Personal Hygiene
PPE
Immunization – not
available YET
Treat underlying disease
Patient Education
Health Insurance

10. Hierarchy of Controls in Risk Management
Most
effective
Least
effective
Physically remove the hazard
NIOSH, Hierarchy of Controls
Cornell University, Environment, Health and Safety
Replacing the hazard with a non-
hazardous object, device or
substance
Isolating the person from the hazard
through physical or mechanical means
Changes made to the way people
work
Worn by the person to protect
themselves from real or potential
hazards

11. Elimination
Disclaimer: Not an endorsement
Home-Based Cardiac Rehab

12. Engineering Controls
Barriers/Sneeze guards
Partitions and space to
promote social distancing
HVAC

13. Engineering Controls
Hands-free Waste
Receptacles
EPA-Registered
Disinfectants (List N)
Hand Hygiene Facilities: Sinks,
soap, handrubs, towels

14. Administrative Controls
Triage or Screening Universal MaskingAppointment Only

15. Administrative Controls
Visual Cues for Social Distancing/Hand and Respiratory Hygiene

16. Administrative Control
Staffing & Work PoliciesSpecific Disinfection Protocols & Schedules

17. Personal Protective Equipment (PPE)
Should be appropriate for the type of activity
Must adhere to proper donning and doffing standards
Highest risk of exposure occurs during removal of PPE

18. Personal Protective Equipment: Must Have
Face mask Eye protection: Face shield or goggles
PSMID-PHICS IPC Guidelines for Outpatient Clinic Resumption in the Context of COVID-19, May 17, 2020

20. Personal Protective Equipment: If w/ AGP
Filtering Facepiece Respirator (ex. N95) Elastomeric Half Facepiece Respirator
PSMID-PHICS IPC Guidelines for Outpatient Clinic Resumption in the Context of COVID-19, May 17, 2020

21. Personal Protective Equipment
Gown Gloves
PSMID-PHICS IPC Guidelines for Outpatient Clinic Resumption in the Context of COVID-19, May 17, 2020

22. Personal Protective Equipment: Not
Required in Outpatient/Clinic Settings
Coveralls, hair covers, booties
PSMID-PHICS IPC Guidelines for Outpatient Clinic Resumption in the Context of COVID-19, May 17, 2020

23. Proper Donning
Gloves
Hand
Hygiene
Face
shield or
goggles
Mask/FFPGown
Hand
Hygiene
CDC Coronavirus Disease Using Personal Protective Equipment

24. Proper Doffing
Hand
Hygiene
Gloves Gown
Exit the
Room
Hand
Hygiene
Face
shield or
goggles
Mask/FFP
Hand
Hygiene
CDC Coronavirus Disease Using Personal Protective Equipment

25. Return to Work
• Testing of all returning workers is not a requirement
precedent to his/her return
• Screening shall be based on symptoms and/or exposure
• Testing asymptomatic returning employees is an option in a
representative sample and have high risk, considering
limitations on the reliability and validity of tests
DOH Circular 2020-0206, May 18, 2020
DOH Circular 2020, 0220, May 11, 2020
https://www.psmid.org/unified-covid-19-algorithms-4/

26. DOH Circular 2020-0206, May 18, 2020
https://www.psmid.org/unified-covid-19-algorithms-4/

27. Patel R, et al. 2020. https://doi.org/10.1128/mBio.00722-20.

28. RT-PCR
DOH Circular 2020-0206, May 18, 2020
DOH Circular 2020, 0220, May 11, 2020
https://www.psmid.org/unified-covid-19-algorithms-4/
Isolate & manage accordingly
Isolate and test close contacts
Continue working

29. Rapid Antibody Test
IgM IgG Action
(-) (+) Not actively infected. Continue
working following usual
precautions
(-) (-)
(+) (+)
(+) (-) Isolate
Repeat test on Day 14
Confirm through PCR*
DOH Circular 2020, 0220, May 11, 2020
*DOH Circular 2020-0180, April 16, 2020

30. Discontinuing Isolation
• If symptomatic: 10 days AFTER symptom onset, plus at least
3 days without symptoms (without fever and respiratory
symptoms).
• For asymptomatic: 10 days after testing positive
WHO Interim Guidance Clinical Management of COVID-19, May 27, 2020

31. Summary
Cardiac rehab delivery has been
changed by COVID-19
Different control measures can break
the chain of COVID-19 infection

32. Summary
The use of PPE should be
appropriate for the task
Proper screening, clear HR policies,
targeted testing allow for safe return
to work