Guest: Moderated by Mounica Soma Susie Damman, RN Panelists: Dr. - - PowerPoint PPT Presentation

Presented in collaboration with Nebraska ICAP, Nebraska DHHS HAI Team, Nebraska Medicine, and The University of Nebraska Medical Center Prepared by Margaret Drake Presented by Kate Tyner Moderated by Mounica Soma

Panelists:

• Dr. Salman Ashraf, MBBS

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

Guest: Susie Damman, RN

Guidance and responses were provided based on information known on 4/28/2020 and may become out of date. Guidance is being updated rapidly, so users should look to CDC and jurisdictional guidance for updates.

Questions and Answer Session

Use the QA box in the webinar platform to type a question. Questions will be read aloud by the moderator If your question is not answered during the webinar, please either e-mail it to NE ICAP or call during our

• ffice hours to speak with one of our IPs

A transcript of the discussion will be made available on the ICAP website Panelists today are:

• Dr. Salman Ashraf, MBBS

salman.ashraf@unmc.edu

• Dr. Maureen Tierney, MD, MSc Maureen.Tierney@Nebraska.gov

Kate Tyner, RN, BSN, CIC ltyner@nebraskamed.com Margaret Drake, MT(ASCP),CIC Margaret.Drake@Nebraska.gov Teri Fitzgerald RN, BSN, CIC tfitzgerald@nebraskamed.com Angie Vasa, RN, BSN avasa@nebraskamed.com Susie Damman, RN

susie.damman@mhcs.us

https://icap.nebraskamed.com/coronavirus/ https://icap.nebraskamed.com/covid-19-webinars/

COVID in Critical Access

Susie Damman, RN Infection Prevention and Control Seward Hospital (NE)

• Central team for planning and policy implementation
• meets at least 3 times per week
• Family Medical clinic and Hospital
• The meetings are led by our CEO.
• Huddle team responds to testing concerns and clinical situations
• Administrative policy changes daily involving:
• hospital visitors and screening
• Masking
• Testing
• PPE,
• staff screening & temperature monitoring.
• Telehealth and virtual visits.
• Changing the flow of clinic visits to well visits in the am and URI visits in the pm.

• Education
• PPE
• patient care
• Housekeeping
• Dietary
• Child care
• COVID testing.
• Frustrations initially on the limited testing. We now have a little

more testing available. Also limitations in receiving supplies such as PPE, testing supplies and cleaning products.

Reopening Facilities to Provide Non-emergent Non-COVID-19 Healthcare- Phase I

Reopening Facilities to Provide Non-emergent Non-COVID-19 Healthcare- Phase I

• As states and localities begin to stabilize it is important to restart care
• Procedural care-surgeries and procedures
• Chronic disease care
• Preventive care
• If states have or regions have passed the Gating Criteria (symptoms,

cases and hospitals) announced on April 16, 2020 they may proceed to phase I

Resources

• https://www.aorn.org/guidelines/aorn-support/roadmap-for-

resuming-elective-surgery-after-covid-19

• https://www.whitehouse.gov/openingamerica/#criteria
• https://www.cms.gov/files/document/covid-flexibility-reopen-

essential-non-covid-services.pdf

SYMPTOMS Downward trajectory of influenza- like illnesses (ILI) reported within a 14-day period AND Downward trajectory of covid-like syndromic cases reported within a 14-day period CASES Downward trajectory of documented cases within a 14-day period OR Downward trajectory of positive tests as a percent of total tests within a 14-day period (flat or increasing volume of tests) HOSPITALS Treat all patients without crisis care AND Robust testing program in place for at-risk healthcare workers, including emerging antibody testing

Gating Criteria

https://www.whitehouse.gov/openingamerica/#criteria

https://nebraska.maps.arcgis.com/apps/opsdashboard/index.html#/4213f719a45647bc873ffb58783ffef3

General Considerations

• Maximum use of all telehealth modalities
• Care that cannot be accomplished virtually may use the following

recommendations to guide as they consider resuming in-person care

• f non-COVID-19 patients should be consistent public health

information and with state public health authorities

• Must have:
• Adequate facilities, workforce, testing, and supplies
• Adequate workforce across phases of care (such as availability of clinicians, nurses,

anesthesia, pharmacy, imaging, pathology support, and post-acute care)

https://www.npr.org/2020/04/26/845224105/nebraska-governor-on-decision-to-partially-reopen-state-in-may https://nebraska.maps.arcgis.com/apps/opsdashboard/index.html#/4213f719a45647bc873ffb58783ffef3

General Considerations

• In coordination with State and local public health officials, evaluate the incidence and

trends forCOVID-19 in the area where re-starting in-person care is being considered.

• Evaluate the necessity of the care based on clinical needs. Providers should prioritize

surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary.

• Consider establishing Non-COVID Care (NCC) zones that would screen all patients for

symptoms of COVID-19, including temperature checks.

• Staff would be routinely screened as would others who will work in the facility

(physicians, nurses, housekeeping, delivery and all people who would enter the area).

• Sufficient resources should be available to the facility across phases of care, including

PPE, healthy workforce, facilities, supplies, testing capacity, and post-acute care, without jeopardizing surge capacity.

• Facilities in the state are safely able to treat all patients requiring hospitalization without

resorting to crisis standards of care.

• Does the facility have appropriate number of ICU and non-ICU beds, PPE, ventilators,

medications, anesthetics and all medical surgical supplies?

PPE Considerations

• Continue with source control- all healthcare workers are masked –

procedure mask or surgical mask- N95 for aerosolizing procedures

• Patients procedure mask or surgical mask; at a minimum cloth mask
• Every effort should be made to conserve personal protective

equipment.

• https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-

strategy/index.html

Workforce Considerations

• Staff should be routinely screened for symptoms of COVID -19 and if

symptomatic, they should be tested and quarantined.

• Staff who will be working in these “Non-COVID-19 Care Zones” (NCC)

zones should be limited to working in these areas and not rotate into “COVID-19 Care zones” (e.g., they should not have rounds in the hospital and then come to an NCC facility).

• Staffing levels in the community must remain adequate to cover a

potential surge in COVID-19 cases.

“PPE FATIGUE”

• Healthcare workers have been operating in an enhanced PPE and IPC

posture for extended periods of time

• Maintaining stringent adherence to these practices in the absence of

COVID-19 cases can begin to create complacency

• Reinforcement of SOPs with rationales is critical to sustain

preparedness and response efforts

• Universal masking as a source control method
• Extended use practices to conserve PPE and maintain staff safety
• Reuse of PPE items as a crisis strategy

Facility Considerations

• In a region with a current low incidence rate, when a facility makes the

determination to provide in-person, non-emergent care, the facility should create areas of NCC which have in place steps to reduce risk of COVID-19 exposure and transmission; these areas should be separate from other facilities to the degrees possible (i.e., separate building, or designated rooms or floor with a separate entrance and minimal crossover with COVID-19 areas).

• Within the facility, administrative and engineering controls should be

established to facilitate social distancing, such as minimizing time in waiting areas, spacing chairs at least 6 feet apart, and maintaining low patient volumes.

• Visitors should be prohibited but if they are necessary for an aspect of

patient care, they should be pre-screened in the same way as patients.

Other Considerations

• Ensure that there is an established plan for thorough cleaning and

disinfection prior to using spaces or facilities for patients with non-COVID- 19 care needs.

• Ensure that equipment such as anesthesia machines used for COVID-19 (+)

patients are thoroughly decontaminated, following CDC guidelines.

• Adequate supplies of equipment, medication and supplies must be

ensured, and not detract for the community ability to respond to a potential surge.

• When adequate testing capability is established, patients should be

screened by laboratory testing before care, and staff working in these facilities should be regularly screened by laboratory test as well.

• How a facility will respond to COVID-19 positive worker, COVID-19 positive

patient (identified preoperative, identified postoperative), “person under investigation” (PUI) worker, PUI patient.

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

Call 402-552-2881

IP Office Hours

Final Considerations

• All facilities should continually evaluate whether their region remains

a low risk of incidence

And

• Should be prepared to cease non-essential procedures if there is a

surge.

• By following the above recommendations, flexibility can allow for

safely extending in-person non-emergent care in select communities and facilities.

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:

• Dr. Salman Ashraf, MBBS
• Angie Vasa, RN, BSN
• Kate Tyner, RN, BSN, CIC
• Margaret Drake, MT(ASCP),CIC
• Teri Fitzgerald RN, BSN, CIC

Special Guest:

• Susie Damman, RN

Moderated by Mounica Soma, MHA

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

Responses were provided based on information known on 4/28/2020 and may become out of date. Guidance is being updated rapidly, so users should look to CDC and NE DHHS guidance for updates. NETEC – NICS/Nebraska DHHS HAI-AR/Nebraska ICAP Small and Critical Access Hospitals-Outpatient Region VII Webinar on COVID-19 4/28/2020

• 1. Do you have any recommendations for an asthmatic CNA that is wearing the surgical mask

while at work, but is having increased difficulty with her asthma do to the masks? That is an opportunity to contact employee health. This person deserves a complete workup by a physician to determine their ability to breathe is when they wear a mask (if it is safe to do that) and also if they have some underlying condition such as shortness of breath related to

• COVID. This person should definitely be assessed before coming further in to the work pool.

This could also affect a person on droplet precautions, on beyond COVID.

• 2. One of our CRNAs is requesting all patients be tested prior to surgery even if asymptomatic.

What is your response to this? There are surgeries that may have aerosol-generating procedures associated with that (maybe require intubation, or head and neck procedures), so facilities need to be prepared with full PPE if they don’t know the COVID status of the patient. Some facilities are doing the COVID testing 48-72 hours before the procedure. If the test result is negative, they do know the situation. If you have the capacity to screen those surgical procedures that may be aerosol-generating. With possible expansion of surgeries, sites need to consider if they have the testing capacity to test pre-op so they can open more slots for surgeries if they can screen for COVID in advance. Nebraska Medicine has some guidance in the case of COVID positive or COVID unknown status and it is an ENT cases, etc., intubation needed under anesthesia, initially we will try to do the intubation in negative pressure of PreOp/PACU area before transporting to the OR. We are having anesthesia providers wear an N95 and face shield or a PAPRs as available. For higher risk procedures where positives are patients or emergent and status unknown, we use full

• protection. ICAP has links on their website to the Nebraska Medicine website where guidance

can be found on this and other issues. It is important to link this to context, but elective surgery is separate from emergent issues. When we are expanding these surgeries, everyone coming in with or without symptoms will be considered as possibly positive. Your testing capability has to be available to answer these questions.

• 3. Is there guidance for testing staff? How often? Who needs to be tested (should we do COVID

PCR testing or antibody testing on staff)? It matters whether it is asymptomatic staff, symptomatic staff or staff coming out of isolation. No staff should be tested who is not symptomatic. Exposed staff needs to be quarantined. If they are symptomatic they should be tested and quarantined. That is where screening is different than testing (all should be screened, only symptomatic should be tested – temperature, etc.). Screening should happen every time they come to work.

• 4. We have concerns in regards to amount of individuals who have recovered as there is no

accurate measurement and treatment options that are suggested – what is Nebraska doing?

If this question refers to discontinuation of isolation precautions in individuals who are convalescing from COVID. CDC does have good recommendations for criteria on this for returning to work for personnel. One is test-based strategy, where the healthcare worker is excluded from work until fever is resolved without fever-reducing medicine; and the symptoms are resolved (cough, shortness of breath) and have had two negative tests more than 24 hours apart before they can return (test basis strategy). A non-test basis strategy is available if testing not possible – 3 days without fever and 7 days since symptoms first appeared. Other sites are more strict they require 10 days since symptoms started and five days since there was a fever. Here is the CDC link on this subject: https://www.cdc.gov/coronavirus/2019-ncov/hcp/return- to-work.html

• 5. When our N95 is sterilized, can that mask be used by anyone else?

The standard now is that after UV or disinfection, the mask returns to the original wearer, not because we question the disinfection is adequate to move from person to person, but more about the longevity and reshaping of the mask to different faces for a good seal. We advocate that it returns to the same person who wore it before. Labeling those clearly with names, unit locations and a designated storage procedure is the best way to do that.

• 6. We are seeing a lot of patients testing positive. We are trying to test household contacts who

have symptoms. This is starting to feel overwhelming. Whom would you recommend we continue to test in order to provide information to both the patient and to their meat packing employers? This question came from a provider; we advise they work closely with the local health department in this case; this is why they have deployed the National Guard in some locations. If providers have a positive patients and there are home contacts for that positive person, if those home contacts have symptoms they can be tested, but the home contacts should be assumed COVID-19 positive and they should all be insolation. Some load sharing can be done with the local health departments.

• 7. How can the rural hospitals in the low-risk areas who do not have Covid 19 testing available

be expected to test patients for COVID 19 before opening up their outpatient clinic at a critical access hospital? This does not seem practical with test results taking up to a week for the rural areas. Testing availability is getting better, but one of the criteria for opening up clinics is having the ability to do this testing. If you don’t have this ability it isn’t time for opening up those facilities. In the case of outpatient clinics, it is not a criterion to see patients, but you do that in an

• utpatient surgery centers. For outpatient clinics routine appointments, you need universal

masking for appointments not related to respiratory pathogens,

• 8. What is the recommendation for re-testing positive COVID inpatients for discharge to long-

term care? Some providers are going every 72 hours; others 7-10 days. Can you please elaborate? Before you discharge a patient to a nursing home, they have to have symptoms resolved and two negative tests 72 hours or more apart. It may take longer for you to get negative results.

The length of time between tests is a case-by-case decision. There have been cases where patients have been positive for 21-28 days after symptoms started.

• 9. Our regional numbers are low; however, we are located within 20 miles of a high COVID

positive county. Do we consider that county in our gating criteria assessment or only our local county data? The slides say you should look at the complete continuum of care in your area. If a patient in a critical access hospital significantly decompensates, you may have large hospitals in “hot” areas may not be able to accept those patients. Contact the local health department in your area to help with these decisions.

• 10. If we are currently using crisis strategies such as re-use and extended use of mask is the

recommendation to postpone re-opening elective procedures? Yes, if you are using crisis level strategies for your PPE, you want to continue to prioritize your PPE for those COVID patients. This could impact your ability to provide safe care for your patients and staff in these cases. Delaying expanding your patient census could be wise with elective surgeries would be wise without a plan to obtain more PPE. In long-term care, we are also recommending against reusing disposable gowns. Gown reuse is a risky strategy. The state is receiving additional PPE daily; we encourage you to use the link on the Nebraska ICAP website to an online form on the DHHS website to request more PPE. Please call ICAP during our office hours (402-552-2881, 7:30-9:30 a.m. CT or 2-4 p.m. CT) to discuss strategies for PPE reuse, etc.

• 11. Can a facility make a decision based on its community and facility or County or do we have to

follow the risk for the entire Health Department? We strongly encourage you to work with your jurisdictional/local health department to help make this decision. Gov. Ricketts is encouraging local decision-making on this item. You want to consider the local health department input on restarting elective procedures, etc.

• 12. Are people utilizing the point of care testing such as Abbott ID Now and if so, what types of

patients do you use these tests on (certain prioritization)? Do you require that if the test is negative to send out a test (to NPHL or Commercial lab) to verify? This is not required to verify. That is still debatable on the sensitivity of the Abbott ID Now testing (some reports show a lower sensitivity, but the company says that if the testing is done correctly, the sensitivity is not that low. Make that decision based on clinical judgement, and if you get a result of negative, you question because of symptoms, you would want to end that test to the NPHL or other avenues as another check. This is true of anyone’s test, if there is high suspicion of COVID, we will ask for a second test.

• 13. Elective colonoscopy procedures and elective minor procedures not requiring general

anesthesia -- should these patients be tested or just screened? In the case of an abscess drained, cellulitis, who don’t show symptoms but if you don’t need an IND in local anesthesia. You should require the patient to wear the mask as well as all providers (this can be a cloth mask for the patients). There may be surgical procedures where there are risks that a procedure may have to be converted to general anesthesia. For those surgeries,

where things can change in surgery and intubation is needed, sites are doing pre-surgical screening.