Presented in collaboration with Nebraska ICAP, Nebraska DHHS HAI - - PowerPoint PPT Presentation
Presented in collaboration with Nebraska ICAP, Nebraska DHHS HAI Team, Nebraska Medicine, and The University of Nebraska Medical Center Presented by Margaret Drake Moderated by Mounica Soma Panelists Dr. Salman Ashraf, MBBS Dr. Maureen
Presented in collaboration with Nebraska ICAP, Nebraska DHHS HAI Team, Nebraska Medicine, and The University of Nebraska Medical Center Presented by Margaret Drake Moderated by Mounica Soma
Kate Tyner, RN, BSN, CIC Ishrat Kamal-Ahmed, M.Sc., Ph.D Margaret Drake, MT(ASCP),CIC Teri Fitzgerald RN, BSN, CIC
Panelists
Nebraska Acute Care Call every M,W, F at noon previous calls can be found Nebraska Hospital Association https://www.nebraskahospitals.org/coronavirus-covid-19-information.html Nebraska ICAP Long Term Care Webinars every Thursday at noon previous webinars and questions and answers found on ICAP website https://icap.nebraskamed.com/ Nebraska ICAP Outpatient Webinars every Thursday at 9 AM previous webinars and questions and answers found on ICAP website https://icap.nebraskamed.com/
Prevent flow of non-essential personnel between your clinic, hospital, and long term care areas Especially important if they are all in one building Designate staff to work in only one area if previously they floated between clinic, acute care, and long term care Establish where staff are to enter their work area and do active screening temperature signs and symptoms hand out new mask
now
health
procedures (dietary, housekeepers, etc.)
Prepare the Clinic
Communicate with patients.
Prepare the waiting area and patient rooms.
clean them regularly.
When Patients Arrive Place staff at the entrance to ask patients about their symptoms.
Separate sick patients with symptoms.
After Patients are Assessed Provide at-home care instructions to patients with respiratory symptoms. Consider telehealth options for follow up. Notify your health department of patients with COVID-19 symptoms. After patients leave, clean frequently touched surfaces using EPA-registered disinfectants—counters, beds, seating. Find signs for your clinic and infection prevention guidelines: www.cdc.gov/COVID19 Content source: National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinic-preparedness.html
Updated guidance to recommend that nursing homes: Restrict all visitation except for certain compassionate care situations, such as end of life situations Restrict all volunteers and non-essential healthcare personnel (HCP), including non-essential healthcare personnel (e.g., barbers) Cancel all group activities and communal dining Implement active screening of residents and HCP for fever and respiratory symptoms COVID-19 is being increasingly reported in communities across the United States. It is likely that SARS-CoV-2 will be identified in more communities, including areas where cases have not yet been reported. As such, nursing homes should assume it could already be in their community and move to restrict all visitors and unnecessary HCP from the facility; cancel group activities and communal dining; and implement active screening of residents and HCP for fever and respiratory symptoms.
https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html https://www.cdc.gov/coronavirus/2019-ncov/downloads/novel-coronavirus-2019-Nursing-Homes- Preparedness-Checklist_3_13.pdf https://icap.nebraskamed.com/
Plan where you will be caring for a COVID-19 positive patient
air is not flowing from COVID area into area where medical/OB patients are housed
Do you have enough staff to have a dedicated COVID nurse? Best if possible If not – work on plan for removal of PPE and bundling of cares for COVID patient before moving to non COVID patients IMPORTANT Same PPE cannot be worn between caring for COVID and non- COVID patients So if same personnel are care for both types of patients they will need at least 2 sets of PPE if you are doing reuse or extended use PPE Do you do infusions in the hospital?- Separate COVID area away form infusion area- if more than one person receiving an infusion can you do in separate rooms and not one large area
If haven’t already start talking to surrounding other critical access hospitals in your area Could one hospital care for COVID patients only Could one hospital care for medical and OB patients only Caution- your PPS hospital in your area may not be able to take all your COVID patients Have you discussed with your PPS hospital when and who will transfer COVID patients needing a higher level of care? If you care for influenza patients you probably can care for most COVID patients What is your ventilator situation? Do you have ventilators and the staff trained to operate ventilators? If no this is a reason to transfer patient.
Does your CAH have an outpatient Dialysis unit? https://www.cdc.gov/coronavirus/2019-ncov/hcp/dialysis.html American Society of Nephrology https://www.asn-online.org/ COVID-19 patients will still need to come to all their dialysis appointments Both CDC and ASN have good resources on doing dialysis with a COVID-19 patient Screen before appointment Screen when they come again Separate room to do dialysis- best if last station- as far away as possible from all stations- 6 feet Patient wears a mask – staff wear isolation PPE for patient – and remove before moving to another patient.
Plan lannin ing for r Emplo loyee Abse senteeis ism
if they have symptoms of respiratory infection
through an agency, when there is insufficient staffing due to illness or increased burden of care
develop staff policies to allow and account for potential absenteeism during community-wide
disinfectant of commonly touched environmental surfaces to decrease environmental
recommendations.html
isolation room is not immediately available, we recommend facilities place the individual in a single room
At present CDC is recommending that healthcare facilities use: St Standard Precautio ions, , Con Contact Precautions, s, Airborne Precautions, , (i (if no no N-95 use use sur surgical l face acemask) an and Eye Protectio ion . . This means wearing a gown, gloves, facemask, and goggles or a face shield. If using surgical facemask a face shield is preferable to goggles.
https://www.cdc.gov/handhygiene/index.html
room)
hand washing
available immediately outside of the resident/patient room.
make it easy for employees to discard PPE
clearly describe the type of precautions needed and required PPE
Provide the right supplies to ensure easy and correct use of PPE
settings, that is frequent daily cleaning with an EPA-registered, hospital-grade disinfectant
https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control- recommendations.html
different than waste coming from facilities without COVID-19 patients.
waste should be performed in accordance with routine procedures.
Notify facilities prior to transferring a resident with an acute respiratory illness, including suspected or confirmed COVID-19, to a higher level of care. Transfer form: http://dhhs.ne.gov/HAI%20Documents/Interfacility%20Infection%20Control% 20Transfer%20Form.pdf Report any possible COVID-19 illness in patients and employees to the local health department, including your state HAI/AR coordinator. Listing of the local health departments and contacts: Nebraska: http://dhhs.ne.gov/CHPM%20Documents/contacts.pdf
for patients with confirmed or possible COVID-19
Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19)
Ho How You
Can Protect You
lf when en cari ring for
tients with ith con
ible le COVID-19?
Do NOT attempt to horde or stockpile PPE DO anticipate that orders will take additional time to be filled.
(monitor supplies routinely)
for delay DO eliminate PPE waste
meal tray delivery when a HCW will be in the room providing care)
up additional supplies as situation dictates)
https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html
asymptomatic COVID-19
community spread
https://www.nebraskamed.com/sites/default/files/documents/covid-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
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.
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
CDC is updating guidance frequently and should be considered the best authority for most situations https://www.cdc.gov/coronavirus/2019-ncov/index.html (main)
Kate Tyner, RN, BSN, CIC Ishrat Kamal-Ahmed, M.Sc., Ph.D Margaret Drake, MT(ASCP),CIC Teri Fitzgerald RN, BSN, CIC
Monday – Friday 7:30 AM – 9:30 AM Central Time 2:00 PM -4:00 PM Central Time
Responses were provided based on information known on 4/7/2020 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 Hospital Region VII Webinar on COVID-19 4/7/2020
In Nebraska, for long-term care facilities, we have been recommending that a test should not be done, because a negative result could provide a false sense of security. Instead, that resident should be admitted, and immediately isolated and screened for symptoms at least once a day (or more often than that) for 14 days for pulse oximetry, vital signs, shortness of breath, and
for one point in time, and symptoms could develop later. The staff should also follow good standard precautions (masking, hand hygiene) and staff should be screened for COVID symptoms daily as well. However, if there was a test ordered, done and pending, the results of the test should be received before transfer. Dr. Tierney will check to see if swing beds and considered to be the same as long term care under the current guidance; that information will be added here if answers are received.
whether they are in contact with patients or not? If surgical facemasks are available and staff has contact with patients, they should wear a mask. If they do not have patient contact, that decision is up to the facility. However, the CDC is recommending that everyone who leaves home should be wearing a cloth mask, which would apply to clinic staff who do not contact patients. Surgical masks on healthcare workers protect both healthcare workers and the patients, as there is evidence that you can get pre- symptomatic transmission up to 48 hours before symptoms and asymptomatic transmission. The cloth masks are for us to protect each other outside of the clinical setting, to keep us from spreading the disease even if we feel well.
We are hoping to isolate sick residents in their LTC facility. Is that an acceptable practice? No transfer for DNR/DNI residents. You are correct that some national organizations are recommending moving sick people to alternative facilities, although that isn’t available nation-wide yet. In Nebraska, we have some beds open for similar patients from assisted living and long-term care. With long-term care, it matters whether the COVID positive patient is an isolated case (moving could be advised to keep
are already exposed and it doesn’t make sense to move the positive patients out. To isolate patients inside the nursing home, use a cohorting model, make sure there is plenty of PPE available to protect the workers, dedicate staff to those positive patients, try to keep the traffic down around the area of the isolation room(s) to the other areas of the nursing where there are residents who are not symptomatic.
We advocate that patients who don’t meet the inpatient hospital criteria are not moved into the hospitals where they would use beds that are expected to be needed others during the expected surge of COVID-19 patients who need the higher level of care. It also keeps the residents in an environment where they are most comfortable. There are resources on the ICAP website (https://icap.nebraskamed.com/ ) to help long-term care centers treat these COVID positive patients, if they have the capacity (and if the patients don’t meet the criteria for hospitalization), and these resources are constantly updated as guidance changes. CMS says Long Term Care should admit patients they would normally accept; to keep the patients they would normally keep or accept COVID positive patients; keep these patients if they can have the capacity, and they need to prepare for that capacity now. There are some times where there are overwhelming situations that might require that patients need to be transferred to a site where there is an alternative level of care (not acute care – beds need to be saved there). In those cases DHHS works with the local health department and the facility, ICAP and NETEC to make that determination, but that is not the primary option.
If the housekeeping is going into the patient/resident’s room, they will be considered clinical in terms of what precautions (surgical mask) they need to use. If there is a suspected or definite COVID positive patient, then bundling of care should be considered (slides on this are available
shortages, plan the entrances to the room carefully to conserve PPE and minimize the number
frequently; the clinical staff could do the cleaning of high touch surfaces when they are already in the room. Training is needed for anyone doing cleaning (wet times for killing organisms, etc.) that is available on the ICAP website through videos at this link: https://icap.nebraskamed.com/practice-tools/educational-and-training-videos/draft- environmental-cleaning-in-healthcare/ . Any other deliveries of the meals could be clustered as
available at https://www.youtube.com/watch?v=Md2Qb3cdyeM&feature=youtu.be.
visits even if we have well care hours and sick patient hours and we have no cases yet in our county? DHHS says that almost everyone has a case in each county, known or unknown. The recommendation statewide (directed health measure) is to hold off on elective procedures. Exception might be vaccinations in pediatric to stay on schedule, etc. Annual physicals, etc. should be postponed. In other states the recommendations may be different, and those facilities need to check with their states’ current guidelines. The other reason would be to cut down on any extra usage of PPE when those products are in short supply everywhere.
DHHS does not know of particular guidance on this right now. The University of Florida and UNMC are studying this but haven’t given out any guidance yet on tests on the number of layers, etc. NETEC said the number of layers depends on the thickness of the surgical draping
being used for these masks. UNMC is using the thinner layers and doubling this right now; they are also testing thicker layers, but these may prove too thick to use for long periods of time, such as clinical staff and visitors who couldn’t’ deal with the heat of the masks for that long.
before they will allow a patient to be readmitted? Is there a reference or a directive we can cite? In Nebraska (we don’t know about the other states on this call) we are working with the Nebraska Hospital Association, Leading Age and the Nebraska Healthcare Association to develop an algorithm to address this problem. The algorithm will not mandate a test unless someone is having respiratory symptoms. For an asymptomatic patient who is there for something like a hip fracture, there is no need to ask for a test. That test could give a false reassurance, because it tests a point in time, and they could be in the incubation period and it wouldn’t show up in the
the long-term care should set up a transition zone within the nursing home where the resident can stay for 14 days, working with staff dedicated to that area to make sure the resident does not have COVID before moving into the general population of the facility If the patient has symptoms, the long-term care facility has the right to ask for that test. The DHHS says that if the test has been ordered for COVID-19 in the hospital but test results are pending, the long-term care facility has the right to refuse the transfer until tests results are received. ICAP suggests that friendly communication between the facilities can smooth out any misunderstandings during this process.
If you talk about universal masking, anyone coming into the room of the patients (including housekeeping) should wear a surgical mask. Administrative and IT working in offices not contacting the patients are not a clinical area.
care facility? No, they don’t need to go to acute care facility just for that purpose. If you can switch them to inhalers, that is better, but if you still have to do nebulization and the facility doesn’t have a negative pressure room, close the door, staff going in needs to wear an N95 mask and face shield, gown glove and full PPE on while they are in the room.
patients there. Should these nurses wear a procedure mask during their shift at our hospital also? These nurses may not have contact with patients on some days when we do not have inpatients. Right now, anyone who is coming into contact with anyone, out in public or at work, everyone is recommended to wear at least a cloth mask. Healthcare workers are asked to wear a mask when there are clinical encounters. Those include wearing masks in hallways, etc., although a person working alone in an office would not need a mask. As we work with facilities, in a small community, one positive healthcare worker could infect others and decimate a facility’s staff,
and so prevention and protection is key. Wearing a mask is important for any type of person-to- person encounter.