Facilities 4.2.2020 Dr. Salman Ashraf, MBBS and Kate Tyner, RN, - - PowerPoint PPT Presentation

COVID-19 Guidance for Outpatient Facilities 4.2.2020

• Dr. Salman Ashraf, MBBS and Kate Tyner, RN, BSN, CIC

Nebraska ICAP

• Dr. Maureen Tierney, MD,MSc

NE DHHS HAI-AR

Guidance and responses were provided based on information known on 4/2/2020 and may become out of date. Guidance is being updated rapidly, so users should look to CDC and NE DHHS guidance for updates.

Prioritize Urgent and Emergency Visits

https://www.cdc.gov/coronavirus/2019-ncov/healthcare- facilities/index.html

Use strategies to separate the well from the sick

• Scheduling well visits in the morning and sick visits

in the afternoon

• Separating patients spatially, such as by placing

patients with sick visits in different areas of the clinic or another location from patients with well visits.

• Collaborating with providers in the community to

identify separate locations for holding well visits for children.

https://www.cdc.gov/coronavirus/2019-ncov/healthcare- facilities/index.html

American Academy of Pediatrics

• If a practice can provide only limited well child visits,

healthcare providers are encouraged to prioritize newborn care and vaccination of infants and young children (through 24 months of age) when possible.

• Dedicate specific rooms for sick visits and well visits; or for

those with multiple practice sites to consider using one office location to see all well visits

• If available, utilize “drive through” dedicated COVID-19

testing sites

https://services.aap.org/en/pages/covid-19-clinical- guidance-q-a/

Voluntary Universal Masking

• Healthcare workers wear a mask during clinical care
• Achieves source control and decreases risk of spreading

infection: protects patients and other healthcare workers if the healthcare worker have pre-symptomatic or asymptomatic COVID-19

• Implemented by facilities on a voluntary basis when the

jurisdiction is experiencing community spread

• Requires very strict adherence to
• Extended use/reuse
• Meticulous hand hygiene
• Proper use and hygiene of the mask

https://www.nebraskamed.com/sites/default/files/documents/c

• vid-19/surgical-mask-policy-and-faq-nebraska-med.pdf

https://med.emory.edu/departments/medicine/divisions/infectious-diseases/serious-communicable-diseases- program/covid-19-resources/conserving-ppe.html

Clean and Disinfect

If surfaces are dirty, they should be cleaned using a detergent or soap and water prior to disinfection. For disinfection, most common EPA-registered household disinfectants should be effective. – A list of products that are EPA-approved for use against the virus that causes COVID-19 is available here. Follow manufacturer’s instructions for all cleaning and disinfection products for (concentration, application method and contact time, etc.). – Additionally, diluted household bleach solutions (at least 1000ppm sodium hypochlorite) can be used if appropriate for the surface. Follow manufacturer’s instructions for application, ensuring a contact time of at least 1 minute, and allowing proper ventilation during and after application. Check to ensure the product is not past its expiration date. Never mix household bleach with ammonia or any

• ther cleanser. Unexpired household bleach will be effective against

coronaviruses when properly diluted. Prepare a bleach solution by mixing: – 5 tablespoons (1/3rd cup) bleach per gallon of water or – 4 teaspoons bleach per quart of water

https://www.cdc.gov/coronavirus/2019- ncov/prepare/disinfecting-building-facility.html

Community Spread: After options to improve staffing have been exhausted

In consultation with their occupational health program- Facilities could consider allowing asymptomatic HCP who have had an exposure to a COVID-19 patient to continue to work:

• These HCP should still report temperature and absence of

symptoms each day prior to starting work.

• Facilities could have exposed HCP wear a facemask while at

work for the 14 days after the exposure event if there is a sufficient supply of facemasks.

• If HCP develop even mild symptoms consistent with COVID-

19, they must cease patient care activities, don a facemask (if not already wearing), and notify their supervisor or

• ccupational health services prior to leaving work

http://dhhs.ne.gov/han%20Documents/ADVISORY%2003232020.pdf

Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance)

Guidance as of March 23, 2020

• Patients with COVID-19 can be discharged from a

healthcare facility whenever clinically indicated.

• Discontinuation of empiric transmission-based

precautions for patients suspected of having COVID- 19.

• When using a testing-based strategy for

discontinuation of transmission-based precautions is preferred.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized- patients.html

Discontinuation from self-isolation:

CDC guidance states that an individual can stop self-isolation if:

• It has been at least 7 days since symptoms first appeared

AND

• No fever for at least 72 hours (fever-free for 3 full days off

fever-reducing medicine) AND

• All other symptoms have improved (e.g., cough has

improved)

www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-whensick.html And http://dhhs.ne.gov/han%20Documents/ADVISORY%2003232020.pdf

Discontinuation from self-monitoring and self- quarantine:

Discontinuation from self-quarantine and self-monitoring may cease if after 14 days there has been NO development of respiratory illness symptoms. Symptoms may include:

• Fever
• Cough
• shortness of breath
• sore throat
• runny nose.

http://dhhs.ne.gov/han%20Documents/ADVISORY%2003232020.pdf

Monday – Friday 7:30 AM – 9:30 AM Central Time 2:00 PM -4:00 PM Central Time

Call 402-552-2881

Infection Prevention and Control Office Hours

Questions and Answer Session

Use the QA box in the webinar platform to type a question. Questions will be read aloud by the moderator, in the order they are received A transcript of the discussion will be made available on the ICAP website Panelists today are:

• Dr. Salman Ashraf, MBBS
• Dr. Maureen Tierney, MD,MSc

Kate Tyner, RN, BSN, CIC Margaret Drake, MT(ASCP),CIC Teri Fitzgerald RN, BSN, CIC

https://icap.nebraskamed.com/resources/

Airborne Contaminant Removal

CDC Environmental Infection Control in Healthcare Facilities (2003)

Air Exchanges per hour Time (in minutes) required for removal 99% efficiency Time (in minutes) required for removal 99.9% efficiency 2 138 207 4 69 104 6 46 69 8 35 52 10 28 41

https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1 Values apply to an empty room with no aerosol-generating source. With a person present and generating aerosol, this table would not apply. Removal times will be longer in rooms or areas with imperfect mixing or air

• stagnation. Caution should be exercised in using this table in such situations.

http://dhhs.ne.gov/Documents/COVID- 19%20Screening%20and%20Testing%20Information.pdf

Nebraska Medicine N95 Decontamination Resources

Extended Use and Reuse of PPE Guidance https://www.nebraskamed.com/sites/default/files/documents/covid- 19/COVID-Extended-Use-Reuse-of-PPE-and-N95.pdf?date03212020 N95 Filtering Facepiece Respirator Ultraviolet Germicidal Irradiation (UVGI) Process for Decontamination and Reuse (updated 3/26/2020) https://www.nebraskamed.com/sites/default/files/documents/covid-19/n- 95-decon-process.pdf?date=03262020 Site source: Nebraska Medicine COVID-19 Resources for Providers https://www.nebraskamed.com/for-providers/covid19

Responses were provided based on information known on 4/2/2020 and may become out of date. Guidance is being updated rapidly, so users should look to CDC and NE DHHS guidance for updates. Nebraska DHHS HAI-AR and Nebraska ICAP Outpatient Care Facility Webinar on COVID-19 4/2/2020

• 1. Drive through facilities was mentioned. Where are these located and where are they sending

testing? There is a listing on the acute care hospital call slides and this will be added to today’s slides. Newer drive through capacities are expected. There is one in Lincoln (call Bryan Hospital to schedule appointment). Two in Omaha, one at Methodist and one is free-standing. At Great Plains Health in North Platte, they have done them in the parking lot. We hope to add this slide to today’s information. Where the tests are sent varies, many go to commercial labs, but also can be sent to NPHL in case of need of quick results, or in case of a healthcare worker who may be exposed/ill. These are listed on the NE DHHS website at http://dhhs.ne.gov/Documents/COVID-19%20Screening%20and%20Testing%20Information.pdf

• 2. We see many employees who are pregnant or high risk who would like to wear an N95, how

are you handling those? It seems like wearing a surgical mask is a better option for those

• people. This is for wearing all day, not with patients who have COVID-19 symptoms.

The pregnant women could be at higher risk, although there is no data yet available. N95 are not the answer; surgical masks will help with that. N95 masks are needed if a healthcare worker is going to be taking care of a suspected COVID 19 patient, especially if a procedure is involved, such as taking a specimen for a COVID test, but that applies to all healthcare workers doing those procedures. For the regular day, a surgical mask should be enough.

• 3. Are these calls recorded? If so, where do we find them? ICAP website -

https://icap.nebraskamed.com/

• 4. Once a patient is discharged from the hospital but needs follow-up with their PCP, should they

be retested to determine if still infectious or tested for immunity? Do we schedule them with

• ur morning "healthy" patients or with our afternoon "sick" patients?

As much as possible, if you can do a phone or video follow up visit it is better. If they have come into a clinic, if you are dividing by who has a respiratory illness and who does not (i.e. follow up for an abscess or a wound and they don’t have respiratory illness, too) I would not have them come at the same time as patients who have respiratory illness. Try to use tele- health as much as possible in all situations now, and if you don’t have that capacity, the Nebraska Medical Association has contracted with a company for members (and contact, even if nonmembers) to use that option to establish tele-health in your facility. Only bring in patients when you have no other choice.

• 5. Can you share a gross estimate of PPE available for the state? Our clinics have been told to

request PPE from our local County Health Department. It is difficult to determine the best use

• f our limited supplies and calculate our need without knowing any information about

county/state supply. Are there 100s of masks, 1000s of masks, millions available in our state? I fear using a surgical mask daily now, and run out in a month. The amounts we have are not known, but Nebraska hopes to get increasing supplies. We think it more than hundreds, less than millions. The amounts we request and then get are not the

• same. As the DHHS gets shipments it distributes to local health departments in accordance

with earlier plans for preparedness and the local health department disseminates based on

• need. This has changed and the need has increased with the changes in requirements for long-

term care workers to all wear masks, using the one mask per day guidelines, plus recent

• utbreaks in long-term care and assisted living. ICAP suggests outpatient facilities takes

inventory and plans for what will be needed (Masks and gowns). NETEC had a great webinar on controlling PPE that is a great resource and is available on their website in a recorded version and with the slides and we recommend going there. (https://netec.org/). It is best to do the math on what you need based on population and number of healthcare workers.

• 6. I've seen on the internet of hospitals making supplemental surgical masks out of new blue

waterproof wraps that are used in surgery. What are your thoughts on that?

• Dr. Ashraf has not seen this particular reference, but in general right now, healthcare workers

should stick to medical grade, surgical grade masks made for those purposes. Do not alternate with non-tested masks for now. AS we go forward things may change, but right now we don’t have a reason to go to a non-tested mask; try the extended use policy to increase life for the masks we are using. There is use for N95s reuse, but this doesn’t apply as often to outpatient care, but data on cloth masks or other regular surgical grade masks, there is no data that shows those are near the efficacy of the regular surgical grade masks.

• 7. Regarding pregnant healthcare workers - for those that work in a hospital but in an ancillary

department where there is interaction with healthcare workers and the public, what would be the recommendation for that type of pregnant worker? For a pregnant healthcare worker who is involved with patient care, the individual facilities recommend masking. In other settings, it depends on how close their patient interaction is. That situation should be discussed with employee or occupational health in that scenario. If they are going to be coming in contact with a patient, they should be wearing a mask, for benefit of the worker and the patient as well.

• 8. A patient called about blood testing for antibodies. Apparently, there is a test that comes out
• n Friday. Is there any data on theses?

No data available on these tests right now. The antibody tests being developed, but they are not for diagnosis but right now just are beneficial for surveillance. Serology in the future may help decide who has been infected in the past, but the time frame of when they are positive is not known. There is some point of care testing that’s out there, rapid testing is a different point

• f care test that is only about 60 percent sensitive, which makes you uncomfortable with

negative results in that setting

• 9. I know you are collecting surgical masks for potential reuse for later. Should we be doing the

same -just in case you develop something? Is there any way to decontaminate them? There is no way to decontaminate surgical masks. Decontamination has been studied for N95 masks only; the surface with folds of surgical masks means they are not using UV masks. Right now Nebraska Medicine is holding aside used masks that aren’t damaged, just in case there becomes a method to decontaminate the surgical masks, but there isn’t anything right now.

• 10. What is the protocol for UV light usage on masks? What percentage of effectiveness of killing

virus? This is an area where the study is ongoing. Nebraska Medicine has developed the UV light protocol and it is available on the Nebraska Medicine website. See links below. It is still being studied how many times an N95 can go through a UV light cycle and still be effective. There are not widespread studies yet on this. This is used on N95 masks only, not surgical/procedural masks right now. Extended Use and Reuse of PPE Guidance https://www.nebraskamed.com/sites/default/files/documents/covid-19/COVID-Extended-Use- Reuse-of-PPE-and-N95.pdf?date03212020 N95 Filtering Facepiece Respirator Ultraviolet Germicidal Irradiation (UVGI) Process for Decontamination and Reuse (updated 3/26/2020) https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon- process.pdf?date=03262020 Site source: Nebraska Medicine COVID-19 Resources for Providers https://www.nebraskamed.com/for-providers/covid19

• 11. In regards to point of care testing, ABBOTT also has a molecular testing for rapid triage. Do

you have any evaluations on that? See #8 above. This has not been reviewed yet but we will study it and complete this in the Q & A answers. Our laboratory colleagues have some concerns about the new test. We’ve heard that the reagents are not yet readily available and that there are concerns about the sensitivity of the

• test. Stay tuned for further national conversation about this new tool.
• 12. Are any facilities having problems with patients answering screening questions no, and then

getting back into clinic and then answering yes to providers once roomed? If so, are you doing anything differently for this? This is new information for us; we can learn from you here. We need to think if a better way of questioning can help, but if someone has figured this out, please share this strategy with us.

• 13. Dr. Ashraf asked for input from others in the group; here are some responses:

 Yes; that is happening here  We are have experienced that. Our providers are staying 6 feet away from them until they can have an honest conversation with them hoping to get those answers before they are right there in their space  Best to start everyone with a tele-med visit first

 We haven't solved it yet ICAP will look at this and study this issue more to see if there are best strategies to share in a later webinar or on our website.