Preventing COVID-19 Transmission in Ambulatory Surgery Centers · organizations planning to resume...
Transcript of Preventing COVID-19 Transmission in Ambulatory Surgery Centers · organizations planning to resume...
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Preventing COVID-19 Transmission in Ambulatory Surgery Centers
• Sylvia Garcia-Houchins, MBA, RN, CICDirector, Infection Prevention and Control
• Lorrie Cappellino, RN, MS, CNORSurveyor, Ambulatory Health Care
• Herman A. McKenzie, MBA, CHSPDirector of Engineering, Standards Interpretation Group
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2© 2020 The Joint Commission. All Rights Reserved.
Intended AudienceThis webinar is being presented to help organizations planning to resume elective procedures.
Focus on key issues and prevention strategies to consider prior to resuming elective procedures in ambulatory surgical centers based on what we know about COVID-19.
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Acknowledgement
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4© 2020 The Joint Commission. All Rights Reserved.
The Joint Commission DisclaimerThese slides are current as of May 5, 2020. The Joint Commission reserves the right to change the content of the information, as appropriate.
These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.
These slides may not be further used, shared or distributed without permission of The Joint Commission. Distribution of the speaker’s presentation other than in PDF format is expressly prohibited.
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5© 2019 The Joint Commission. All Rights Reserved.
COVID-19
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Remember How Transmission Occurs
−Person to person via droplets (6 feet)
−Airborne transmission (aerosol generating procedures)
−Transmission via surfaces− viable for hours to
days on surfaces
Source: CDC\Brian Judd https://phil.cdc.gov/details.aspx?pid=11161
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− 23 of 76 (30.3%) surveyed tested positive for COVID-19− 10 had symptoms (8 typical; 2 atypical)− 13 had no symptoms
− 10 developed symptoms (mean interval 3 days)− 3 did not develop symptoms
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Presymptomatic and Asymptomatic Spread
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Use What We Know to Stop Transmission
− Elimination – limit visitors
− Substitution – block vs general anesthesia
− Engineering controls –smoke evacuator
− Administrative controls –take staff temperatures
− PPE – source control
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Use What We Know to Stop Transmission
− Source Control
− Social Distancing
− Appropriate PPE
− Hand Hygiene
− Clean and disinfect surfaces
Modified from : CDC\Brian Judd https://phil.cdc.gov/details.aspx?pid=11161
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Source Control: Universal Masking
− Patients/Visitors− Face covering
− Healthcare Workers− Leaving home - face
covering − Direct patient care –
medical mask− No direct care – face
coveringhttps://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/infection-prevention-and-hai/covid19/universal-masking-statement-04232020.pdf
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Source Control: Modify PracticesRespiratory Etiquette:
ConventionalSource Control :
NEW
Poster Available at: https://www.jointcommission.org/-/media/tjc/documents/covid19/universal-masking-statement-04232020.pdf
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Source Control: Face Coverings and Masks
Reduces Droplet DispersalVariable Filtration
Depending on MaterialNOT PPE
Reduces Droplet Dispersal“Standard” Filtration
PPE: Needed for direct patient careASTM 1: Minimum for Surgical Care
Resource:: https://www.fda.gov/media/137121/download
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Resources
Poster Available at: https://www.jointcommission.org/-/media/tjc/documents/covid19/universal-masking-statement-04232020.pdf
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Social Distancing
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Adequate Supply of PPE Available
Joint Statement: Roadmap*
Principle: − Adequate PPE
Policies:− Adequacy of PPE− Training and use: follow
non-crisis standards− Conservation
Summarized from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html
CDC: PPE Optimization Strategy
* Available at https://www.facs.org/covid-19/clinical-guidance/roadmap-elective-surgery
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Estimate PPE Use
− The rate of use depends on multiple factors including− Number of patients− Number of staff− Types of procedures− Processes in place to
conserve PPE− Availability https://www.cdc.gov/coronavirus/2019-
ncov/hcp/infection-control.html
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Routine Patient Care
− Practice source control− Follow standard and
transmission based precautions− Switch to medical
facemask if PPE is indicated
− Type of gown is dependent on type of exposure anticipated
− Eye protection should have solid sides
Face\ Eye Protection
Gloves
Face Covering at all times
Gown
https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html
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Aerosol Generating Procedures
Examples of aerosol-generating procedures:− Intubation − Extubation− Nebulizer treatments− Cardiopulmonary
resuscitation− Manual ventilation− Open suctioning
− Bronchoscopy
Face\ Eye Protection Respirator
Gloves
Gown
Modified from: https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html
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Filtering Facepiece Respirators
N95 (or higher) maskDisposableFilters airborne particlesRequires fit testing
Elastomeric Filtering Facepiece
Reusable deviceRequires fit testingMay be disinfected
Powered Air-Purifying Respirator (PAPR)
Reusable deviceBattery operatedHalf or full facepiece
Confirm safe to use in area of sterile environment
Resource: https://www.cdc.gov/coronavirus/2019-ncov/hcp/elastomeric-respirators-strategy/index.htmlhttps://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/powered-air-purifying-respirators-strategy.html
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Respiratory Protection Program
OSHA Requirement−Depends on type of
respirator −May include− Medical Evaluation− Fit Testing− Fit Check
Resource Link: https://www.osha.gov/Publications/3384small-entity-for-respiratory-protection-standard-rev.pdf
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PPE ChecklistFace
Covering/Mask*
Gown Gloves Eye/Face Protection
Screening AreaPatient Staff
Reception AreaPatientStaff
Preop HoldPatientStaff & Providers
ORPatientPerioperative Team
Present for AGP
PACUPatientStaff
*1 – Face Covering; 2 – Medical Mask; 3 – Surgical Mask; 4 – RespiratorAGP = Aerosol generating procedure(Vendor and escort screening at point of entry and appropriate face covering/PPE per facility protocol)
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Sample PPE ChecklistFace
Covering/Mask*
Gown Gloves Eye/Face Protection
Screening AreaPatient 1Staff 1/2 X
Reception AreaPatient 1Staff 1
Preop HoldPatient 1Staff & Providers 1 Per standard precautions
ORPatient 1Perioperative Team 3 Per operative attire policyPresent for AGP 4 X X X
PACUPatient 1Staff 1/2/3/4 Per standard precautions /AGP
*1 – Face Covering; 2 – Medical Mask; 3 – Surgical Mask; 4 – RespiratorAGP = Aerosol generating procedure(Vendor and escort screening at point of entry and appropriate face covering/PPE per facility protocol)
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Sample PPE ChecklistFace
Covering/Mask*
Gown Gloves Eye/Face Protection
Screening AreaPatient 1Staff 1/2 X
Reception AreaPatient 1Staff 1
Preop HoldPatient 1Staff & Providers 1 Per standard precautions
ORPatient 1Perioperative Team 3 Per operative attire policyPresent for AGP 4 X X X
PACUPatient 1Staff 1/2/3/4 Per standard precautions /AGP
*1 – Face Covering; 2 – Medical Mask; 3 – Surgical Mask; 4 – RespiratorAGP = Aerosol generating procedure(Vendor and escort screening at point of entry and appropriate face covering/PPE per facility protocol)
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Training and Competency of Staff
−Lots of resources− Joint Commission site− Videos − YouTube− Posters
EVERYONE needs the same message
Source: https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
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Disinfection of Hard Surfaces
− EPA-registered, hospital or healthcare disinfectant
− If not available, consider EPA-registered Institutional or residential disinfectants
(https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2)
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Disinfection of Soft Surfaces
− Clean− Remove visible contamination, if present − Clean with cleaners for soft surfaces
− Disinfect− If able to launder, follow manufacturer’s instructions
warmest water setting for the item and dry completely− Products with the EPA-approved emerging viral
pathogens claims (https://www.americanchemistry.com/Novel-Coronavirus-Fighting-Products-List.pdf) for porous surfaces
From: https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/cleaning-disinfection.html
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Are You Ready To Resume Elective Cases?
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Human Resources – Our #1 Priority
−Availability−Readiness−Commitment −Outside stressors
©Sylvia Garcia-Houchins
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Staff
−Face covering−Screening for symptoms− Illness−Personal and family safety
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Starting Point - Resuming Elective Cases
−State rules and local requirements−Supplies−Physical Plant−Patients−Testing, if required
Resource: (https://www.ascassociation.org/asca/resourcecenter/latestnewsresourcecenter/covid-19/covid-19-state)
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Recommendations for Testing
− #1 follow state requirements− If NO state requirements, consider CDC guidance
− If regional presence is high: consider testing− If little or no regional presence
− Proceed if no symptoms− Delay if symptoms
https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html
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Patients with Positive Test
− #1 - follow local health authority requirements− If no local health authority requirement consider CDC
recommendation− Delay elective procedure until:
− two negative results ≥ 24 hrs apartOR− at least 72 hours since symptom resolution and at
least 7 days since symptoms first appeared
https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html
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Additional Considerations
−Recommendations and guidance−Prevalence of community COVID-19−Priority cases −Resources/skills match case selection
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Consideration for Case Selection
−Prioritize cases− Backlog
−High risk procedures− Aerosol generating procedures− Proximity to airway
−Patient health criteria selection
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Ambulatory Surgery Centers
−Cardiac/vascular intervention labs*
−Eye surgery centers*−Radiology suites−Telehealth
organizations−Pain clinics
−Endoscopy centers−ENT centers−Dental surgery centers
Higher Risk of AGPLower Risk of AGP
*This population may have higher risk factors based on demographics
AGP – Aerosol Generating Procedures
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Allocation of Time and Resource
−Time between cases−Modified hours−Staff needs time to recover and prepare−Adjust operating pace
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Ramping Up
−Test processes−Rehearsal and dry-run−Document processes & lessons learned− Implement changes −Reassess once open
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Identify Your Weakest Link
− Do your staff know how COVID-19 is transmitted and how to prevent spread?
− Do you have the supplies and equipment to protect your staff and patients?
− Can you provide supplies and equipment needed to care for the patient in all phases of care?
− Are your staff and patients committed to decreasing the risk of transmission?
− Are you depending on a test that has false negatives?
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ASC Specific Prep
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Safety When Masking Not Possible
− Meals− Examples− Grab and go− Pre-packaged meals− Staggered breaks and lunches
− Changing masks− Staggering times− Distancing
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Contractors
−Educate on new procedures−Report to designated area−Screening −Face covering vs PPE
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Support After Discharge
Medical equipment
Physical therapy
Home visits
Livi
ng S
itua
tion
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Limit Exposure: Patient Flow
Before Arrival
• Call Patients• Virtual triage or visits• Plan for ill patients
Upon Arrival
• Symptomatic vs asymptomatic patients
• Source control: Limit droplet dispersal (e.g. homemade mask)
• Care of suspected COVID patient
After Visit
• Clean and Disinfect
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Ambulatory Surgery Phases
Scheduling
Intake
Pre-op
Intra-op
Post-op
Discharge
Follow-up
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Scheduling
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Patient Assessment/Education
−Patient questionnaire−Update instructions
−Face covering−Notify of illness
https://www.cdc.gov/coronavirus/2019-ncov/downloads/DIY-cloth-face-covering-instructions.pdf
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Time and Resources
−New method for first case priority−Timing facilitates physical distancing−Adequate cleaning and disinfecting ORs−Safe number of cases-patient-staff ratio
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Calls
−Consider calling all scheduled patients
−Virtual phone triage − Initial patient
assessment− Education − Resources
−Administrative options
Resource: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html
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Intake
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Initial Screening
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Arrival
− Patient: Face covering and hand hygiene
− Screening− Temperature/symptoms− Current/recent illness − Recent exposure− Social distancing
− Determine PPE for staff
Poster Available at: https://www.jointcommission.org/-/media/tjc/documents/covid19/universal-masking-statement-04232020.pdf
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53© 2020 The Joint Commission. All Rights Reserved.
Check-in
−Face covering−Elimination – consider
online payment−Engineering control -
physical barrier−Practicalities of no touch
environment
https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html)
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Escorts
Consider− Limits− Driving distance− Communication
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55© 2020 The Joint Commission. All Rights Reserved.
Waiting Area
- Remove remote controls, magazines, toys, drinks
- Monitor high-touch areas- Bathroom accommodation- Environmental cleaning
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Preop
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57© 2020 The Joint Commission. All Rights Reserved.
Preop Holding Area Processes
−Changing clothes −Securing patient
valuables
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58© 2020 The Joint Commission. All Rights Reserved.
Preop Holding Area Processes
−PPE expectations−Space, flow and
distancing−Supply management−Airway assessment
https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html#Patient_Placement
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59© 2019 The Joint Commission. All Rights Reserved.
Intra-op
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60© 2020 The Joint Commission. All Rights Reserved.
Types of Procedures
−Cardiac/vascular intervention labs*
−Eye surgery centers*−Radiology suites−Telehealth
organizations−Pain clinics
−Endoscopy centers−ENT centers−Dental surgery centers
Higher Risk of AGPLower Risk of AGP
*This population may have higher risk factors based on demographics
AGP – Aerosol Generating Procedures
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61© 2020 The Joint Commission. All Rights Reserved.
Aerosol Generating Procedures
Things to consider:−Limit personnel−Ventilation−Distancing−Equipment−PPE
Source: Intubation of suspected COVID-19 patients https://www.youtube.com/watch?v=iIGAmdyZr4Y
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62© 2020 The Joint Commission. All Rights Reserved.
Anesthesia Risk Points
− Clean/dirty workflow− Hand hygiene− Environmental cleaning
This Photo by Unknown Author is licensed under CC BY-SA
X
X
X
X
XX
X
X
X
x – anesthesia machine with high touch points
Resources: https://www.apsf.org/novel-coronavirus-covid-19-resource-center/
https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2763452
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63© 2020 The Joint Commission. All Rights Reserved.
Examples of Engineering ControlsBarrier
Mask over tube
Intubation Box
Smoke evacuator, fluid reservoir and sterile suction tip
Source: Twitter: Ed Mariano MD, Stanford Medical
Source: Source Smoke Evacuator Picture-Vol.36, No5 May 2020, OR Manager, Page 19
Source-Extubation of patients with COVID-19BJA: British Journal of Anaesthesia. 2020 April 9
Source: -Taipei Times-Virus Outbreak: Local doctor’s invention adopted in Philippines. March 25, 2020
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64© 2020 The Joint Commission. All Rights Reserved.
Surgical Room Turnover
− AGP procedure performed− Limit entry− Time based on air
exchanges to clear aerosols
https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html What PPE should be worn by environmental services (EVS) personnel who clean and disinfect rooms of hospitalized patients with COVID-19?
https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1
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65© 2019 The Joint Commission. All Rights Reserved.
Postop
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66© 2020 The Joint Commission. All Rights Reserved.
Recovery
– Aerosol generating examples– Oral\nasal airways – Suctioning– Pulmonary toileting– Nebulizer treatment Photo: COURTESY OF KELLI
DUNHAM-Guest Writer on HUFFPOST March 31, 2020
Modified from: https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html
PPE for Aerosol Generating Procedure
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67© 2020 The Joint Commission. All Rights Reserved.
Standard Protocols
− Source control− Distancing− Curtains and doors− Escort restrictions− PPE− Environmental
cleaning
BEFORE COVID-19
Modified from Photo above
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Discharge
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69© 2020 The Joint Commission. All Rights Reserved.
Discharge Planning
Traffic pattern: leaving building
• Car• Bus/Ride Share/Taxi
Transportation back to residence
• Follow-up phone call• Screen for possible COVID-19
Follow up:
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70© 2019 The Joint Commission. All Rights Reserved.
Follow Up
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71© 2020 The Joint Commission. All Rights Reserved.
If Case Identified in Patient or Staff Member
−Notify public health immediately−Review measures to prevent transmission− Identify potential exposure points− Patients not masked− Staff not masked− Aerosol generating procedures
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72© 2020 The Joint Commission. All Rights Reserved.
Exposure Monitoring and Return to Work
1- Level of exposure2- PPE used
3-Symptom monitoring4- Work restrictions
1 2 3 4
https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
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73© 2019 The Joint Commission. All Rights Reserved.
Physical Environment
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74© 2020 The Joint Commission. All Rights Reserved.
Inspection, Testing and Maintenance (ITM)
− Inspection, testing, and maintenance− Up to date on fire alarm and sprinkler system
testing and inspection?− Ventilation filtration− Confirm manufacturer recommendation is
followed− rH and temperature− Air exchange rates
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75© 2020 The Joint Commission. All Rights Reserved.
Reopening Tasks
Although not exhaustive, recommend evaluating the following issues prior to re-opening
−Reestablish contracts/agreements: cleaning, shredding, etc.
−Sterilizers maintenance and quality controls−Fire extinguishers inspection
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76© 2020 The Joint Commission. All Rights Reserved.
Reopening Tasks
−Refrigerated medications maintained−Flush all water fixtures*−Perform maintenance on ice machines*−Ensure medical equipment is functional− Defibrillator− Anesthesia machines
−Notify insurance carrier−Notify local authority having jurisdiction
*https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html#d
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77© 2020 The Joint Commission. All Rights Reserved.
Fire Drills
−Quarterly− What if the building has been closed?− Review protocol for staff
− What if the building is now a hospital?
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78© 2020 The Joint Commission. All Rights Reserved.
Aerosol Generating Procedures
− Standard OR Procedures− Limit personnel to those
needed− Keep door closed
− Not Required− Create temporary ante-room
(ASHRAE)− Use of point source control− Rebalance room (not
recommended by ASHE**)
Picture Source: *ASHRAE COVID-19 Guidance http://tc0906.ashraetcs.org/documents/COVID%2019%20%20GUIDANCE%20-%20ASHRAE%20Revised3-25-2020.pdfAccessed April 6, 2020
**ASHE: https://www.ashe.org/covid-19-frequently-asked-questions?utm_source=General%20Announcements&utm_medium=email&utm_campaign=4%2E10%2E20%20COVID%2D19%20Resource%20Roundup
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79© 2019 The Joint Commission. All Rights Reserved.
Staff Health and Wellbeing
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Mental Well Being
− Communication− Updates/process changes− Share good news− Provide staff way to voice
concerns− Limit non essential email,
alerts− Encourage self-care
− Meditation− Extracurricular activities
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81© 2020 The Joint Commission. All Rights Reserved.
Provide Reassurance and Reducing Stigma
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/reducing-stigma.html
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82© 2019 The Joint Commission. All Rights Reserved.
Resources
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83© 2020 The Joint Commission. All Rights Reserved.
https://www.jointcommission.org/covid-19/
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84© 2020 The Joint Commission. All Rights Reserved.
Questions?
Use the Standards Interpretation Sitehttps://web.jointcommission.org/sigsubmission/sigquestionform.aspx