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

Dr. Salman Ashraf, MBBSDr. Maureen Tierney, MD,MScKate Tyner, RN, BSN, CICIshrat Kamal-Ahmed, M.Sc., Ph.DMargaret Drake, MT(ASCP),CICTeri Fitzgerald RN, BSN, CIC

Panelists

Unique situation in Critical Access Hospitals

Clinic

Long Term Care

Hospital

Dialysis

Things we will cover in this webinar

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/

Links to Nebraska webinars

Prevent the introduction of respiratory germs INTO your facility

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

Lock Down Access between Clinical Areas

Use the experience you have• Yearly influenza epidemic strategies are useful

now• Surveillance for respiratory infection in the local community

• Active, daily surveillance in facility

• When a case is suspected or confirmed, notify local public health

• Implement isolation strategies immediately

• Communicate with internal staff to implement isolation procedures (dietary, housekeepers, etc.)

Prepare the Clinic

• Know which of your patients are at higher risk of adverse outcomes from COVID-19.

• Provide telemedicine appointments.

• Know how to contact your health department.

• Stay connected with your health department to know about COVID-19 in your community. Step up precautions when the virus is spreading in your community.

• Assess supplies now and on a regular schedule• Daily counts

• Extend use per national guidance

• Secure storage

CLINICS

Communicate with patients.

• Ask patients about symptoms during reminder calls.

• Reschedule non-urgent appointments.

• Post signs at entrances and in waiting areas about prevention actions.

Prepare the waiting area and patient rooms.

• Provide supplies—tissues, alcohol-based hand rub, soap at sinks, and trash cans.

• Place chairs at least 6 feet apart. Use barriers (like screens), if possible.

• If your office has toys, reading materials, or other communal objects, remove them or clean them regularly.

Clinics

When Patients Arrive

Place staff at the entrance to ask patients about their symptoms.

• Provide symptomatic patients with tissues or facemasks to cover mouth and nose.

• Limit non-patient visitors.

Separate sick patients with symptoms.

• Allow patients to wait outside or in the car if they are medically able.

• Create separate spaces in waiting areas for sick and well patients.

• Place sick patients in a private room as quickly as possible.

Clinics

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

Clinics

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.

Long Term Care

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/

Long Term Care

Plan where you will be caring for a COVID-19 positive patient

• Do you have negative pressure rooms?

• Do you have more than one hallway or unit in your facility?

• Can you place COVID patients on one end of a hallway or unit?

• Think about air flow- work with your facility management staff to determine airflow so air is not flowing from COVID area into area where medical/OB patients are housed

CAH Layout

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

CAH Staffing

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.

CAH

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.

Dialysis

Planning for Employee Absenteeism

• Ensure sick leave policies or furlough to stay home if they have symptoms of respiratory infection

• Have a plan to bring in temporary staff, perhaps through an agency, when there is insufficient staffing due to illness or increased burden of care

• We strongly recommend healthcare facilities develop staff policies to allow and account for potential absenteeism during community-wide outbreaks

• We recommend frequent daily cleaning with an EPA-registered, hospital-grade disinfectant of commonly touched environmental surfaces to decrease environmental contamination. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

• If an individual meets the CDC case definition of a suspected case and an airborne isolation room is not immediately available, we recommend facilities place the individual in a single room

Caring for Individuals with SUSPECTED COVID-19

At present CDC is recommending that healthcare facilities use:

Standard Precautions, Contact Precautions, Airborne Precautions, (if no N-95 use surgical facemask) and Eye Protection . This means wearing a gown, gloves, facemask, and goggles or a face shield. If using surgical facemask a face shield is preferable togoggles.

Support hand and respiratory hygiene, as well as cough etiquette by residents, visitors, and employees

• Ensure employees clean their hands according to CDC guidelineshttps://www.cdc.gov/handhygiene/index.html

• Encourage frequent hand hygiene among residents and visitors

• Put alcohol-based hand rub in every resident room (ideally both inside and outside of the room)

• Make sure tissues are available and any sink is well-stocked with soap and paper towels for hand washing

• Audit and feedback handhygiene and PPE use

• Make PPE, including facemasks, eye protection, gowns, and gloves, available immediately outside of the resident/patient room.

• Position a trash can near the exit inside any resident/patient room to make it easy for employees to discard PPE

• Post signs on the door or wall outside of the resident/patient room that clearly describe the type of precautions needed and required PPE

Provide the right supplies to ensure easy and correct use of PPE

• Routine cleaning and disinfection procedures are appropriate for COVID-19 in healthcare settings, that is frequent daily cleaning with an EPA-registered, hospital-grade disinfectant of commonly touched environmental surfaces to decrease environmental contamination. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

• Medical waste (trash) coming from healthcare facilities treating COVID-2019 patients is no different than waste coming from facilities without COVID-19 patients.

• CDC’s guidance states that management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures.

• There is no evidence to suggest that facility waste needs any additional disinfection.

Environmental Cleaning/Medical Waste

Prevent the spread of respiratory germs BETWEEN facilities

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

Between the Facilities

• Use Standard Precautions, Contact Precautions, and Airborne Precautions and eye protection when caring for patients with confirmed or possible COVID-19

• Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19)

• https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

• Standard infection prevention for healthcare associated infections

• https://www.cdc.gov/hai/prevent/prevention.html

• Perform hand hygiene frequently and encourage compliance with HH around facility

• Practice how to properly don, use, and doff PPE in a manner to prevent self-contamination

• https://repository.netecweb.org/files/original/990a7390ef46288fd7fe8df94bc2e2e4.pdf

How You Can Protect Yourself when caring for patients with confirmed or possible COVID-19?

Do NOT attempt to horde or stockpile PPE

DO anticipate that orders will take additional time to be filled.

• Be proactive about reasonable par levels

(monitor supplies routinely)

• Consider entering supply orders earlier than usual to account

for delay

DO eliminate PPE waste

• Bundle care in rooms where PPE is indicate (for example, schedule mail, linen, and meal tray delivery when a HCW will be in the room providing care)

• Use a buddy system (for example, plan to call for a HCW out of isolation to round up additional supplies as situation dictates)

Supply Disruptions

Prioritize Urgent and Emergency Visits

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

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/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

Airborne Contaminant RemovalCDC 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.

Nebraska Medicine N95 Decontamination ResourcesExtended 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)

Resources

Dr. Salman Ashraf, MBBS

Dr. Maureen Tierney, MD,MSc

Kate Tyner, RN, BSN, CIC

Ishrat Kamal-Ahmed, M.Sc., Ph.D

Margaret Drake, MT(ASCP),CIC

Teri Fitzgerald RN, BSN, CIC

Panelists

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

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

1. Should CAH require a negative test prior to admitting an asymptomatic swing bed patient?

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

other respiratory debt distress, etc. The test only proves the patient was not positive for COVID

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.

2. Are you saying now that outpatient settings like a clinic that all of our staff should wear masks

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.

3. Some of the information I have reviewed says you remove sick people from LTC (residents).

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

other patients safe) or COVID is much more widespread within the facility, then many patients

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.

4. Is housekeeping considered non-clinical staff?

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

on the Acute Care DHHS Monday-Wednesday-Friday calls transcripts). Because of PPE

shortages, plan the entrances to the room carefully to conserve PPE and minimize the number

of staff entering these rooms. You could consider doing linen changes and dusting less

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

well. A recent NETEC call addressed this in ways to put tasks together. The recording is

available at https://www.youtube.com/watch?v=Md2Qb3cdyeM&feature=youtu.be.

5. Is the recommendation for clinics that we not have patients come in for any ""well care""

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.

6. What is the recommendation of sterilization wrap added to the fabric mask? Is there guidance

on how many layers?

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.

7. How should we respond to a long-term care facility who insists on a negative COVID test

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

test. We recommend that every patient transferring from a hospital to a long-term care facility,

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.

8. Is there a specific list of who is considered clinical and non-clinical staff?

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.

9. If a PUI LTC resident needs nebulizer treatments, should he/she be transferred to an acute

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.

10. Our critical access hospital has not required healthcare workers to don a mask at the start of a

shift. We have some nurses who also work at larger hospitals and have cared for COVID-19

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.