(Sylvia) So thank you, everybody, for joining us today.
We're going to be talking about
Preventing Coronavirus Transmission in Nursing Care Centers.
I'm Sylvia Garcia-Houchins.
I'm the Director of Infection Prevention and Control
here at The Joint Commission.
As far as background, I've been an infection preventionist
for over 30 years.
I've published extensively related to infection control
in a variety of health care settings.
And I've been a practicing infection preventionist
in a long-term care setting.
I'd like to now introduce you to Linda Wilkerson.
(Linda) Hello, my name is Linda Wilkerson.
I've been a registered nurse for over 35 years.
I have degrees in nursing, education, and gerontology.
I've been with The Joint Commission five years
and predominantly surveyor, nursing care centers.
(Beverly) Good morning. My name is Beverly Belton,
and I am currently a Field Director
for the hospital and Nursing Care Center program
here at The Joint Commission.
I've been a nurse for much longer than I'm willing to admit,
and during that time,
I have served in the infection prevention role
as well as conducting national research around infection control-related topics.
(Sylvia) So that's our faculty for today, and we'll be copresenting,
and hopefully providing you with actual resources
that you could put into place,
not just about coronavirus
but also prevention strategies for the nursing care centers.
So today, we're going to be covering the two topics in specific sections,
to make it possible for you to be able to decide
which part you would like to view.
So the first part is epidemiology and the symptoms of coronavirus,
and what it means for the long-term care in the nursing care center.
And then prevention strategies for nursing care centers
that we hope you will find helpful in looking at things a little differently
in how you implement all the recommendations
that you are seeing.
Before we get started,
I'd like to acknowledge all the work that everyone is doing.
We want to thank you for taking the time to join us
and acknowledge your work, and the work of all health care providers,
and support personnel, who are working together to provide care.
We are truly learning how important everyone--
from the food delivery staff to the frontline provider--
are in maintaining a safe and nurturing environment
for our residents and patients.
So thank you.
We also normally would provide a disclaimer
for any presentation that's provided by The Joint Commission.
We do want you to know that these slides are current
as of March 30th.
Since this is an ever-evolving situation and that we learn new things every day,
we ask you to please keep up with the latest literature and information
that's being provided by national organizations
such as the Centers for Disease Control and Prevention.
We will be providing resources at the end of this presentation to those links.
So please remember,
we are using these only as cue points and examples.
So the first thing I'd like to do is talk about coronavirus
and the important background information
that you and your staff and your facility needs to know
in order to try to move forward toward preventing this disease.
So the first thing I wanted to talk about
was progression of cases in the United States.
You could see back in the beginning of March,
we were seeing some cases, very few in the US,
but worldwide, the cases were definitely spreading.
Just eight days later,
the number of cases had almost doubled worldwide,
but in the US they were almost ninefold higher.
And if you look just at the progression in the last 19 days,
worldwide, we are over seven times where we started,
and just since yesterday, we have moved by 100,000 cases
being identified.
So we are now, as of today, April 1st,
at 877,000 cases worldwide.
So this is a fast-moving disease.
If we look at progression in the United States,
just in less than a week we have gone from sporadic cases
across the country to really seeing widespread cases.
And we've all been hearing in the media, New York is an epicenter of cases.
They have over 60,000 cases in New York
and are experiencing an increased number of deaths
related to those cases.
As this moves, the world is tracking,
and we are tracking its progression to other cities,
and that's really what we're hoping not to see.
As far as infections, what we have, as far as background information,
is as this situation is evolving,
we have data that has been collected from what happened in China,
which is the largest dataset that we have
where over 55,000 cases were analyzed.
And in China, what they found was that the majority of cases
have mild to moderate disease.
And I think we need to take a step back
when we think of the nursing care center as a setting.
Traditionally, in the community,
we would think of mild to moderate diseases,
including pneumonia.
In our situation,
pneumonia, for our patients, could be a very serious situation.
So included in that 80% is pneumonia and non-pneumonia cases.
So as we think about that,
we need to think about the risk that places our patients in.
In the US, we have not yet had the opportunity
to analyze a large number of cases.
So these graphs are based on only approximately 2,500 cases
that have been seen through March 16th.
As we work through this presentation, you will notice that we have provided you
with the links to where we got this information.
So if you want to know more,
you can actually find that information and move forward.
But what you can see from this graph
is that we're seeing basically the same thing.
We're seeing not so serious disease in about 80% of the population.
About 20% of the population is getting hospitalized,
and of those 20%, about 5%,
which is a little higher than what was expected,
are requiring ICU care or critical care.
When we look at case fatality rate by age,
and we look at the information, again from China,
we can quickly see that people who are most at risk
are over the age of 60,
and that is what we are seeing in the United States also.
We are seeing that risk is highest for those people over the age of 60.
The breakpoints that have been used in the United States
and I'm sure you've been hearing this in the media,
they moved it to 65, 65 and older.
But if you look at this trendline,
55 and up is really the risk point.
So we need to make sure we think about how do we protect those people,
where are these people congregating,
where do we see the majority of these?
Really, in nursing care centers, we have congregate settings
where we have largely at-risk people.
The other thing that people have been asking about
is what else increases your risk?
And we don't yet have good information for the US.
What we do have, though, is preliminary data that says
that's very similar to what we've seen in China.
Underlying medical conditions
does increase the risk of a severe outcome,
either the need for critical care and/or death.
It's very important that you look at what the risk factor is
and realize that it's not just our residents
but also our staff who may be at risk,
and so we need to do everything possible to protect them.
There has been some experience in long-term care,
and we're very fortunate
that this information has now been made publicly available
so that we can dig into it a little farther,
and really try to analyze what is happening
in the long-term care setting.
So the CDC uses the Morbidity and Mortality Weekly Report
as a conduit to provide information to health care providers.
So it's a great resource for all of us as we provide care.
CDC has provided this summary
of an outbreak that occurred in Washington State.
In that situation, on February 28th,
a case of coronavirus was identified in a woman
who was a resident of a long-term skilled nursing facility.
What the investigation found was that in mid-February--
so weeks before this patient was identified--
in mid-February, the organization started to experience
what they noticed was a cluster
or an increase in febrile respiratory illnesses
amongst their patients.
They did test those patients for influenza and found them to be negative.
But at that point,
there wasn't coronavirus transmissions happening in the US.
So when they saw that these were negative,
they thought, "Common cold? Something else."
It wasn't until an 81-year-old patient developed progressive respiratory failure
and was transferred to an acute care setting
and was found to be coronavirus positive.
At that point, when she was found to be positive,
testing of patients and staff in that clinical criteria was done.
They tested all residents, all of the staff,
and what they found out of 130 residents and 170 health care providers
they found 129,
so almost half of the people who were in that facility were positive.
Eighty-one of them were residents, 34 of them were health care personnel,
and 14 were visitors.
When you look at who developed illness and who required hospitalization,
the majority of the people who required hospitalization
were the residents.
Important thing to note there is the age.
Age is a great predictor of whether or not someone will require increased care.
It's not to say that someone younger won't,
but when you look at age,
and you look at who had to be hospitalized,
the median age of the residents who had to be hospitalized
was 81 years of age.
Visitors also, five of the visitors had to be hospitalized,
and their median age was 62,
but only two staff members needed hospitalization
and their median age was 42.
So age makes a difference.
Sadly, 23 people died as a result of this outbreak--
22 of them were residents and one was a visitor.
Some of the issues that were identified as part of that outbreak
was delayed recognition of cases.
The staff was working diligently and were doing what we do,
basically, for influenza season,
which is watching for patients who might have influenza.
So they were testing, they were following up on these patients,
they were testing them for influenza, but the influenza results were negative.
At that point, those residents did not meet the clinical case criteria
created by CDC for testing for coronavirus.
That has now changed.
That criteria has now changed.
At that point, that sentinel event
of sending someone to the health care facility
was what prompted testing.
We want to make sure that you are aware
that if you suspect coronavirus is being transmitted in your organization,
we need to jump on it.
That delayed recognition of cases could lead to more cases.
The other thing that this investigation found
was that staff were still working while symptomatic.
It's just a little cough, just a little dry cough,
otherwise, feeling well.
The spectrum of symptoms is important,
and I'll be talking about that in a couple of minutes.
There was inadequate knowledge and compliance with precautions.
Even though they had implemented precautions
for [ruling out] influenza,
they weren't being done to the level they might have been done.
So there was some confusion about when do we stop them,
when do we start them, how do we implement them.
And there were also challenges
in implementing basic infection control practices.
One of the other interesting things that was found in Washington State
was that staff worked at more than one facility.
And so if you read the media reports of what happened in Washington State,
they very quickly identified many nursing care centers
who were experiencing cases of coronavirus,
and the thought was that because staff were working
amongst different facilities, they became the conduit for transmission
to multiple care settings.
So what caused the delay of recognition?
Well, the symptoms of coronavirus, as they have been described thus far,
are very common in this patient population.
Cough caused by COPD, underlying respiratory conditions,
postnasal drip is not unusual in this patient population.
When you add fever to it,
yes, that could be more of a sign of something really is happening.
And then many of our patients and residents
experience shortness of breath.
So the symptoms are very common in this health care setting.
When we look back at that data from the China experience,
that large dataset,
what this found was that 90% of the people who developed coronavirus infection
have either fever and/or a dry cough, so very common symptoms.
Again, not everybody developed fever, and that's part of the conundrum here.
So when another outbreak was identified
at yet another nursing care facility in Washington State,
there was an investigation conducted.
In this case, the source of this outbreak
is believed to have been a health care provider
with undiagnosed coronavirus.
In this case, the CDC and the Public Health Department
came into the facility and surveyed the residents and the staff for symptoms.
Rather than only focusing on testing those people who had symptoms,
they obtained consent from the residents to test anyone in the facility.
And in this case, out of potentially approximately 80 residents,
they were able to test 76 of the residents.
So they surveyed these residents, asked them if they had symptoms,
went over all of the possible symptoms, and then tested them.
What they found was 23 of the 76 residents tested
were positive for coronavirus.
And this is where it gets interesting.
Only ten of those 23 had symptoms consistent with coronavirus.
So only ten, and of those ten, eight had the typical symptoms.
They had shortness of breath, cough, and/or fever.
Two of them had atypical symptoms:
malaise, diarrhea,
generally not feeling well, aches,
things that we wouldn't have typically thought
as happening with coronavirus.
They also found that 13 of those residents had no symptoms.
Ten of those residents went on to develop symptoms.
It took them a mean of three days.
So in general, three days later, people who tested positive out of these 13
developed symptoms consistent with coronavirus:
fever, dry cough, malaise,
something that would indicate they were unwell,
or they developed increased symptoms.
So they had an underlying cough and now they had more of a cough.
What is interesting in this investigation is that three did not develop symptoms
but were, yet, still positive.
This has led to the terminology
of asymptomatic or presymptomatic infection,
and this has caused a lot of concern amongst health care providers.
CDC, at this point,
for investigation of persons who may have been exposed to coronavirus,
is saying that we need to take precautions
when coming into contact within six feet of these potential cases.
So the other thing that people are asking about is,
why is coronavirus spreading so quickly?
We've been dealing with influenza in the nursing care center for years,
and we all know that there are particular strategies
that help in the nursing care center.
Vaccination is incredibly important.
Early recognition of symptoms and segregation from the other residents
is another measure that we take in the nursing care center.
Yet, why are we seeing, when it was coronavirus,
how could we end up with almost half the population,
including the health care providers and visitors, getting coronavirus?
Well, one of the things you'll need to look at is the difference in spread.
So when we look at the transmission of influenza,
we need to think about how easily is it spread.
So if someone has influenza,
the likelihood of them transmitting their disease
to a close contact is one to two people.
So if I have influenza,
I'm likely to transmit it to one to two people.
So if we look at the potential for one person to spread the disease,
one person after five cycles, so here's that first person,
and now this is another cycle of transmission,
and yet another cycle of transmission,
then the next cycle of transmission,
and then yet another cycle of transmission,
we start to see progression.
As compared to coronavirus,
where if we start with one person and we go through cycles,
we start to see even more transmission.
So at the end of five cycles,
one individual with influenza can infect about 45 to 48 people.
If one individual with coronavirus is not recognized early
and transmission is stopped,
after five cycles that one person with coronavirus
can infect an average of two to four people,
so that after five cycles there's a potential for them
to have infected 345 people.
Now, think of those 345 people
spreading out from that nursing care center,
or that mall, or that other public place.
The other important part in this, so how easily is it transmitted,
but we need to remember how transmission occurs.
So I know there has been a lot of confusion,
and this is a very important thing to remind your staff.
Yes, initially there was a lot of confusion.
The recommendations initially were that we practice airborne precautions,
meaning that we wear N95 respirators
when caring for patients who are suspected to have coronavirus.
The evidence is now pointing to
there is very little likelihood of airborne transmission,
that airborne transmission
is really associated with aerosol-generating procedures--
things that create coughing and large amounts of aerosols.
So this picture is a great representation of what happens when someone sneezes.
You can see, as someone sneezes, the droplets they have created
are spewing out from that person.
These droplets, as they come through the air,
the air itself is going to start to dry those droplets,
so they're going to evaporate,
and they're also going to fall from the weight.
The thought is that if you are within about six feet
of someone who has a disease that is spread by droplet spread,
you could potentially be infected
by exposure to your eyes, your mouth, or your nose.
So you could breathe them in, they can land on those surfaces,
and they can thus infect you, so two ways that infection could occur.
I'd like to put this in perspective.
So when we think about coronavirus versus other airborne disease,
and I say this because it's a very difficult concept
for people to think about
when people are using terminology on the news
about airborne droplets.
If you think airborne droplets, then it's airborne.
That's actually not the case.
When we think about airborne transmission,
we need to think about things like measles and chickenpox,
truly airborne diseases.
If you are within 100 feet of someone who has measles,
your risk of getting measles is over 90%.
If you are within 100 feet of someone who has chickenpox,
your risk of getting chickenpox is 67 to 77%.
If you are within 100 feet of someone who has coronavirus,
you are not at risk of getting the disease.
The risk of coronavirus is about 1 to 5%
if you are a household contact of that person.
Why does household contact make a difference?
Because there's transmission at close proximity, six feet,
from your family member, and then transmission on surfaces.
This is incredibly important in long-term care settings
and aggregate care settings
because we are in more of a familial situation
where people are in close contact.
So it's important to allay fears,
to be able to explain this to your staff and people coming into your facility.
Knowledge really is power here.
So the other thing you keep hearing about in the media is flattening the curve.
No matter when you turn on the television,
someone's talking about flattening the curve.
"It's so important to flatten the curve."
Well, during a pandemic,
if you allow the disease to progress at its normal rate,
what will happen is what you're seeing here in yellow,
there will be a quick escalation of cases,
people will get sick,
and some of them, we know, at least 20% will get very sick
and require intense health care.
And then they'll be done.
The problem here is the mortality rate
and the amount of help that those 20% will need.
Without adequate medical resources,
the anticipated number of deaths in the United States,
we believe, would be somewhere around two million people would die.
And to put that in perspective
and why we are asking everybody to participate
in this important flattening of the curve,
is when you think about two million people,
if you think about putting it in perspective,
the State of Hawaii has 1.5 million people.
We could literally lose an entire state,
the equivalent of an entire state of US residents.
So that's what would happen if we don't take these measures.
Now, if we can flatten that curve, if we can spread out those cases,
yes, many of them are still going to occur,
but if we can flatten out those cases
and really try to not have cases amongst our most-at-risk population,
then the healthcare system can respond and provide adequate care
and give people the best chance.
I'm sure you've been hearing the President talk about
maintaining the current measures,
social distancing, locking down,
what's happening in the different communities,
flattening that curve gives us our best chance.
The current estimate is that even with those measures,
even with the desperate measures that we are taking,
over 100,000 US residents are still at risk.
We want to give them the best chance possible
to allow the healthcare system to be able to provide care that they need
and also develop prevention methods like vaccines.
So we need to make sure that we're all practicing this in all settings.
Does this work?
Can flattening the curve work?
And this is a great example if we just look back in history.
History tends to repeat itself.
And when we look at the 1918 Spanish influenza,
when we look at that and we look at,
does social distancing and other measures work?
Does wearing a mask if you are within six feet of somebody,
does it work?
When you look at that evidence, here's what you find.
With the 1918 pandemic,
there are some great resources on the National Geographic website.
We've given you this.
By city, someone went back and look at what cities implemented
as far as decreasing cases.
So one of the most stunning situations that occurred was in one city,
and I'm trying not to call attention to particular cities,
but in one city the mayor or the governor had decided
that they were going to social distance.
And yet, two days later, they allowed a huge parade to occur.
As the result of that parade, transmission spread like wildfire
and the death rate very quickly increased.
What you will see in these two graphs,
that even if a city implemented social distancing,
if they didn't do it for long enough,
they ended up with a second wave of deaths.
So that's the example of San Francisco.
And there, during the pandemic flu,
there were over 673 deaths per 100,000 people.
Now, if you look at cities like St. Louis, who had a much lower death rate,
almost half,
they implemented strong social distancing measures
and had an overall low death rate.
When they temporarily relaxed, they had another peak.
So we all need to expect that this is going to be a long ride.
We're going to have to be doing this for a long time.
So we need to remember that we are protecting ourselves,
and all of our residents, and all of the people we hold dear,
when we are implementing as strictly and as stringently as possible.
Now, that is going to get us to the second part of this presentation.
And myself and Linda Wilkerson and Beverly Belton
will be now providing measures that you can take
in the nursing care center to prevent the spread of coronavirus
to not just your patients, not just your residents,
but also your staff.
So there are steps that the Centers for Disease Control say
that you should be taking now.
Even if you don't yet have cases,
even if there are not cases being identified
in your neighborhood or your city,
which is becoming very unusual,
you need to be restricting all visitation at this point, all visitation,
except for certain compassionate care situations.
And we're going to be talking about those as we move through this presentation.
You need to be restricting all volunteers and non-essential personnel.
And when we're thinking about this,
and Linda will be talking about this a little bit more in depth,
when we're thinking about this,
when we're talking about restricting volunteers,
we really need to think about who is truly a volunteer
and who is an essential person who is working for your facility.
They may not be paid,
but who is essential to the care and services
that you need to provide at this time.
CDC has strongly come out with a statement
that you need to cancel all group activities and communal dining,
and we know the implications that would have on the cognitive
and mental health of some of your residents.
So we're going to try to give suggestions on how that might be done safely
and alternatives and ways that you can think about.
The other thing that needs to happen, and be happening now,
and be happening aggressively
is active screening of residents and health care providers
for fever and respiratory symptoms.
We know from what I've just spoken about earlier
about asymptomatic and presymptomatic people,
but if we can get an early start in identifying people who are ill,
and monitoring them and making sure that they are getting--
and we're prepared to provide the medical care that they need,
that will be important in their outcome.
One of the things that we are learning from the experience in New York,
and also in other cities,
is for some patients or some people,
they have very rapid onset.
So someone who was chugging along,
a little bit of cough, little bit of fever, on and off fever,
can all of a sudden become very seriously ill,
including respiratory and cardiac failure.
So we need to make sure that we have the staff in place
to be monitoring those patients, and those residents,
and those health care workers, may actually seem okay,
they're progressing and they're fine, but really checking up to make sure,
"Hey, you're breathing okay? You don't feel short of breath?"
And checking in at a regular interval
and making sure that they do not suddenly become unwell.
The key topics that we're going to cover as part of this presentation
are things that you're hearing in the media:
social distancing, respiratory etiquette, keeping up with hand hygiene,
and then cleaning and disinfecting surfaces.
In this setting, social distancing takes on a whole new meaning.
We need to think about the impact that this will have on your residents
and the services that you can provide.
We need to think about respiratory etiquette
and the goal of respiratory etiquette.
Respiratory etiquette is needed to stop the dispersal of droplets.
So anything that is going to stop those droplets--
remember that picture of someone sneezing or coughing,
spewing out droplets--
anything that is going to stop those droplets is important.
You may be seeing in your local grocery stores now
where they are putting up a plastic shield
between the person who is [bringing] up your produce and your groceries, and you.
Why? Because just that barrier
is going to provide an adequate barrier from droplets
of getting to the other person.
So we need to think about how to make it easier for residents
to practice respiratory etiquette.
Making Kleenex available, putting it in your pocket,
here's your Kleenex.
Every time you cough, "Oh, you don't have Kleenex?
Cough into your elbow,"
those techniques that we have been trying to do all along.
And if you make it part of the routine for many of your residents,
it's going to really make a difference.
Our children are now entrenched in respiratory etiquette
as part of schooling.
We need to remember that entrenchment.
You need to make sure that you have something available
to facilitate hand hygiene by residents.
And we know that organizations
are experiencing difficulty in getting supplies.
Something as easy as a wet washcloth with some soap and water.
What do they do on planes if you're in the business section?
The first thing they do before they serve you a meal
is they pass out the wet washcloths.
Just that is going to decrease the likelihood
that you have something infectious on your hands.
So before meals, hand hygiene, things like that.
We need to think about ways we can do that.
And finally, routine, detailed cleaning of the locations where you provide care,
food service areas, and other communal areas.
You cannot clean often or disinfect often enough.
In my own home, where I have a 90-year-old father,
I get up every morning, and it sounds silly,
but we have two college students at my home,
I have a nurse who's living with me in my home,
people who have to go out
and do the work that they need to do to support the community,
we wipe down all the common touch surfaces
every morning and every evening.
Think about your shifts coming on, your staff coming in the door.
Wipe that doorknob as they're coming in the door
because who knows who touched it.
Wipe the handrails and things like that.
And we will be talking more about that as we go on.
I'd like to now turn over the presentation to Linda.
(Linda) Social distancing is a key mitigation strategy
to stop transmission of the coronavirus.
Social distancing is really spatial distancing
or physical distancing.
It does not mean social isolation.
We still need to maintain safe interaction with our residents,
ensure stimulation and social engagement,
and continually make contact with our residents.
It's important to realize residents depend on interaction
to decrease their loneliness and their fear,
and maintain their cognitive function.
Organizations can think of ways to maintain safe interactions
that you keep residents stimulated and socially engaged in a number of ways,
which we'll talk about in a moment.
Also, it's very important to maintain contact with family and friends
and key health care providers.
Many residents in nursing care facilities have favorite staff members,
and if those staff members are no longer assigned to their hall,
they'll become very concerned.
So it's important to continually communicate with our residents
about what the changes are in the staffing situations
on the halls that they reside,
and how they can continue to interact or communicate
with those health care providers.
Social distancing also includes meals.
So some of the ways that we can ensure social distancing
would be to spread out during mealtime.
Are we ensuring that we have the six-feet social distancing
between residents in our dining rooms, at our dining room tables?
Are we looking at increasing meal shifts or mealtimes?
Instead of having tray service every 30 minutes,
should we consider tray service every 15 minutes to fewer residents?
What about hallway dining, is that an option?
Can residents be spaced spatially out in the halls?
Is that safe in your organization?
What about residents, maybe, that are allowed to eat in their doorways
where they can still be monitored?
Are we considering or looking at brown bag lunches for some residents?
Or maybe even using outside spaces that we don't normally use for dining
during this time.
What about dining and meal services for our staff?
When staff are usually eating or eating their meals in the facility,
and then taking them to the break rooms,
are they allowing social distancing between themselves in the break room?
Are we looking at that and making sure that our staff are also safe
and providing that social distancing opportunities where we can?
What about social distancing in other activities in the facility?
What about social distancing during activities?
How can we modify the organization's activities
where residents are still socially engaged and interactive?
One of the favorite activities in nursing centers
is the beloved bingo,
so how can we ensure this beloved activity still continues?
Some organizations are allowing residents to come to the doorways
and then having a caller in the hall call out bingo numbers,
and that seems to be successful and residents are enjoying that.
Some facilities are allowing residents to stay in their room
and a roaming caller goes room to room and calls the numbers out,
and that seems to be successful.
What about individual crafts and puzzles?
Do we have the supplies to provide those?
What about doorway exercises?
Some organizations are providing doorway exercises
in a private room where a resident can come to the threshold of their door
and participate in activities.
Now, that would probably only work for a private room,
but maybe you could modify that for a semi-private room
where residents maybe are on either side of the door.
What about increased separation during group activities?
Again, the CDC recommends that we restrict all group activities,
but can those group activities be modified somewhat
where there's really no longer a group but spatially separated?
Residents may still have the desire to wander,
and how do we deal with that?
How do we educate staff and residents
what social distancing and spatial separation really looks like?
Some facilities are providing tape on the floors
to show and demonstrate what six feet looks like.
I know I was in a Walgreens yesterday evening
and Walgreens had placed tape, before you reached the register,
every six feet,
and I was really surprised how far apart that looked
when it was actually taped.
So visual cues are very helpful.
Some facilities are using stickers on handrails and on the floor
to show what six-feet separation looks like.
Some facilities are implementing physical barriers
so that you have to maintain six-feet spatial separation.
Some of the other activities facilities have been successful with
is sending each resident a coronavirus valentine
to let the other residents in the facilities know
that they're doing okay or that they're thinking about them.
And instead of letting the residents take these in their room,
they're actually just hanging these over the doorknobs,
similar to what you would see in a hotel, a Do Not Disturb or No Services Needed,
so residents can still have that interaction,
that activity, and knows someone's thinking about them,
or that they're thinking of someone else.
On the previous slide, going back to resident room setup,
so how can we evaluate our resident rooms
to ensure social distancing is being applied
and that we're following the CDC recommendations for social distancing?
So an evaluation of the resident's room is very important,
especially when we're looking at semi-private rooms.
Some organizations actually have four-bed rooms,
and some have six-bed wards.
So we really need to look at the use of privacy curtains
in between residents that are in semi-private rooms or more.
If privacy curtains are being taken down to be cleaned,
do we have another set of curtains readily available to hang up immediately,
so we don't have to wait until those curtains are laundered
and brought back to the resident room?
What about rearranging the resident's bed in semi-private or higher resident rooms?
Would that be a possibility?
Can we possibly rearrange the bed where it's pushed as far as possible
away from each resident?
Maybe one on the wall and one closer to the restroom,
or to the other wall, is that a possibility in your facility?
If we're doing that, are we creating hazards for fall risk?
Do we need to revise our policy during this time
to ensure that we are not using this arrangement in any way
to restrict the resident's activities
or that the wall is now preventing the resident from rising
and could be considered a physical restraint?
Is that something that the organization needs to look at?
And what potential hazards have we now created?
Can we look at those risks as well?
Is the call light still within reach?
Has the resident's night light now been covered
with the bed that we moved?
Are the resident's personal items now out of reach?
How do we rearrange the nightstand, the overbed table?
Have we created more of a safety risk now with the residents ambulating
or using the wheelchair to get to the bathroom?
Do we need to practice with the resident on the new path to the bathroom
so that the resident is aware of the new arrangement
and knows how to navigate the bathroom without increased risk?
So those are some of the areas that we need to look at
for the room setups.
Memory care unit certainly present challenges.
Many facilities have memory care units
or secured units for residents that have wandering behaviors.
And during this time of change, the difficult time,
residents can sense changes in staff, the anxiety in staff,
the changes of staff and their facility,
and sometimes that exacerbates their behaviors.
Maybe they're wandering more,
they're exhibiting more repetitive questioning,
their behaviors are becoming more aggressive.
So what can we do to continue to allow residents
to wander with supervision and keep them safe
and still allow that six-feet spatial separation
or that social distancing during wandering?
One of the things that we can do is when residents wander,
maybe we supervise those residents
with the staff that we have in small numbers.
Maybe one staff person to provide two or three residents at a time
down the hall with spatial separation, if that is safe for the resident.
That's one of the arrangements that could be made during this time.
What about involving therapy and assessing the resident's ability
to continue to wander safely?
Therapy may have some ideas.
They have equipment, perhaps, that can be reallocated to the units
where wandering residents reside,
such as the individual bicycle pedaling devices
that can be used when residents are seated.
Also, there can be exercises with the activity department,
or with therapy inside, as far as how we can mimic wandering behaviors,
or how we can mimic walking exercises.
So therapy and activity personnel can help us with those.
What are some of the other activities that may be helpful on memory care units
to provide to our confused residents?
We could encourage the use of masks.
What about having residents on these units participate in activities
where they make their own costume or their own mask--
if that's a safe activity for the resident?
How can we engage those residents in sanitizing and hand hygiene activities
often throughout the day?
Have we considered these residents
to be wearing gloves outside of their rooms?
Is that a possibility on your unit?
Are we cleaning those high-touch surface areas
that those residents may come in contact with,
such as those handrails, doorknobs, nurses' stations, those areas?
Are we removing items that cannot be cleaned?
Maybe we have activity boxes on those memory care units
that residents normally have access to.
Are we evaluating those activity boxes to see can those items be cleaned,
and if not, should we remove those items
and maybe replace those items with other activity supplies
that can be cleaned?
Are we increasing our cleaning frequency?
And do we need to limit those patients who wander to maybe a smaller area
so that they can be better supervised and ensure social distancing?
Those are all ways that we can consider social distancing
and activities for those special residents.
What about end of life?
Social distancing is important in all activities
in the nursing care center.
Social distancing is still very important for visitors
that may come into the facility.
This is very difficult, very sensitive, and very difficult at this time.
How can we present this information to our families and others
and to our residents?
We need to clearly communicate what the expectations are
to the families that may have access to residents during end-of-life time,
during this compassionate time.
So what are the supplies that we have available
for family members?
Do we need to require that they wear a mask when they come in
and they're with their loved one?
How about hand hygiene activities?
Have we educated these family members during this time
about the importance of hand hygiene?
Because remember, these family members are still very concerned.
There's a lot going on with that family member.
Their loved one is sick, may be dying,
there's all these fears, and then now they're receiving education
about hand hygiene and wearing a mask, and what's going on in the facility
as far as restrictions.
So communication is essential.
Hospice providers during end of life are still very, very important.
They are key team members,
definitely integral team members of the interdisciplinary team
of a nursing care center.
So hospice providers still should be allowed access into the facility.
In fact, CMS feels very strongly about this
and has issued a waiver to nursing care centers
that hospice team members should be allowed to visit the residents
during end-of-life care, during compassionate care
and hospice services.
So the hospice should determine what are essential visits,
and that would be in collaboration with the nursing facility.
So it's important to partner with your hospice providers
to determine the visits that they are providing.
Those are essential,
so hospice can provide the organization with that information.
If those visits are not considered essential,
can there be other alternatives for those visits, such as telehealth?
So that's a conversation that should be held
with your hospice providers before they come into your organization.
(Sylvia) Thank you, Linda. That was great.
(Linda) Thank you.
(Sylvia) Yeah. Excellent suggestions, and I can't emphasize enough
as we move back and forth between Linda and I,
we need to remember these are people,
and we need to remember that compassionate care,
and really look at how we can do it safely and look at alternatives.
And Linda provided some excellent examples
of ways to restructure or relook at what you're doing today,
in a way that makes it safe for your staff and for your residents.
And remember, we're not trying to keep people away from their family.
And we need to make sure that we're communicating that well,
and where these outbreaks are occurring--
that communication has been crucial to relieving those situations,
and especially at end of life.
These may be the last memories that someone will have of their loved one.
We don't want it to be, "They didn't let me touch them"
or "They made me wear a mask for that last kiss."
We need to weigh that with the moment and make it safe.
So how do we make it safe, as Linda said?
When they're walking through the facility to get to that room,
have them wear a mask there
so we know they're not exposing others.
When they are leaving the room, put the mask on and do hand sanitizing.
Provide that support.
If we need to go in the room and anyone is unmasked,
then we need to put on the mask
when we're within six feet of those people.
Please remember it's a really important time
and we need to be flexible at the same time as safe.
And using that as the transition to the next part
is respiratory etiquette and hand hygiene.
We want to make sure that you know what the CDC is recommending
and the why about why CDC is recommending this.
So CDC is recommending universal masking by staff
if there are cases in the community.
Why? Because just going to the grocery store could expose
one of the health care providers
who could then, unknowingly, be either presymptomatic or asymptomatic,
bring it into your facility.
So anybody,
if there are any cases happening in your community,
and sometimes that's a little hard to know,
but keeping in contact with your local Public Health,
reading your newspapers--
your local newspapers, especially, will say we had a case--
is very important to knowing it's time to start universal masking
if you are not already doing it.
The other thing we need to think about is keeping those masks functional
and available.
So some of the things that have been talked about with masks
include extended use and reuse of masks.
So when we think about the difference,
extended use means I put on the mask when I come in the door,
and I keep that mask on until I have to do something,
like eat, or drink my cup of coffee at break,
I keep my mask on until that point.
And then when I take that mask off, I stay six feet away from anybody else.
That means a co-worker, that means a resident,
that means a contractor, a vendor, anybody else,
I'm always six feet away when I take off that mask.
And then I'm done eating my lunch or drinking my coffee,
and I put the mask back on-- that would be considered reuse.
I reused the mask, I put on the same one.
Or I could discard.
If there's a sufficient number of masks available,
I could discard it and put on a new one
and practice extended use for the rest of the day.
There are pluses and minuses to doing extended use
versus reuse the mask.
So one of the things we know is that as the mask becomes moist,
it becomes less of a filter.
So for our health care providers
who are providing care to coronavirus patients,
we want to make sure that their mask is optimal.
If their mask becomes soiled or wet, they should be changing the mask.
If they're wearing the mask down the hallway for bingo,
that's a different situation.
The other thing the mask can do is it prevents droplet dispersal.
So we can stop people from putting droplets out,
when they're talking or singing
they're making a little mist in front of themselves.
By wearing a mask over their face,
that works the same way as a Kleenex will,
it's going to prevent those droplets from spreading.
And some of the things that some organizations have done
is they've started to make-- because of the shortage-- homemade masks.
Homemade masks, there's a variety out on the web
on what can be made.
Some of them have some filtering ability
and they actually have claims of 81% effective
compared to a surgical mask, versus nothing [on].
So the real important thing here is,
what is the purpose that you are wearing the mask for?
So if it's to prevent dispersal
and keep everybody from dispersing the virus into the air,
then wearing a homemade mask
is going to stop those droplets from going out.
If you're wearing it for protection,
it is recommended that as long as they remain available,
that you provide surgical masks for the people who are providing care
to those patients and they're getting within six feet.
So that's the difference.
We also need to think about decorating or modifying those masks.
As people get very creative and they put little flowers on their mask
and they draw on the mask,
if they're truly a surgical mask as defined by the FDA,
or a procedure mask, and it comes from a vendor
who is saying this is a procedure or surgical mask,
we really discourage drawing or writing on the actual face mask.
The reason is it could compromise the barrier.
So don't want to do anything that could compromise the barrier.
Now, if you want to put something on the little edge,
where it's just an edge, to do some decoration,
that's a little different.
So really think about modifying the mask or how you would use homemade masks.
And also, remember some of our residents are great seamstress people.
They can sew, and that would be an activity.
Start a group activity, get them sewing machines or hand sew,
make some masks as an activity.
How can they contribute to their community?
That's a way to give back, so think about that.
The other thing the CDC is recommending
is alcohol-based hand rub inside and outside of the resident rooms.
Now, we need to remember fire safety when we're doing this.
We don't want to put so much that we create a fire hazard.
And the other thing we want to know
is that people know how to use the alcohol-based hand rub.
So most manufacturers recommend a certain amount be applied to the hand.
If you read the label,
most of them will say 5 ml or 5 cc need to be applied to the hands.
First, because of how the FDA approves and tests the product.
But most cases, those manufacturers have instructions that say one pump.
So normally read what the manufacturers have put out
but ask, "How many pumps of this do I need to use?"
if you need more information.
So normally it's one pump.
And then you want to look at how they're applying it.
We want to make sure it covers all the surfaces on the hand.
CDC has put out great resources on how to use alcohol-based hand rub,
as has the World Health Organization.
We need to ask our staff and our residents
to demonstrate their knowledge of hand hygiene,
how to use alcohol-based products:
sing the Happy Birthday song
when they're doing handwashing with soap and water.
We need to make sure
that there's soap and paper towels available.
Think of the important parts.
It's great to put soap and paper towels out,
but if the residents in a wheelchair can't reach them, that's a problem.
So really look at this in detail.
Are people able to access it?
Do you have a way to restock it? How often?
Is someone assigned to checking on a regular basis,
going into resident rooms and saying,
"Yes, they have soap and yes, they have paper towels"
or "The alcohol-based hand rub is coming out."
Is someone looking at the supply chain part of this?
"Hey, do we have enough? Are we starting to run out?"
Because as we increase usage, we're going to need more products.
Now, in the case of facility or sustained spread in the community,
CDC has recommended not just that you implement
use of the face masks by all health care providers,
but also for any residents when they are not in their room.
This is when you really have to start thinking about how do you serve meals.
Can you keep people six feet away?
If you can't keep them six feet away,
then you need to think of alternative strategies for meals.
You can't bring them into the dining room if you can't keep them six feet away
because they're going to have the mask off.
How do you think of that patient or that resident who's wandering?
How do you keep a face mask on them?
Making it an activity, making it part of a costume,
things that Linda talked about earlier.
The other thing we need to think about
is considering health care providers
wearing the recommended personal protective equipment
throughout the care of all residents,
regardless of the presence of symptoms.
Think about that asymptomatic or the presymptomatic resident
or health care provider.
And here the devil is in the details.
We talked a little about extended use of masks,
what about extended use of glasses or face shields?
First thing we want to make sure is that we have
the right kind of eye protection.
So you can see in these pictures, the one on the top right,
they have a face shield.
And what you will notice is it not just protects the front of the eyes
but the side of the eyes.
So we want to make sure people are wearing
the appropriate personal protective equipment.
The picture on the bottom is actually not appropriate eye protection.
It's their personal glasses.
It does provide some overall protection, but it really should have side shields.
How can you do that?
A piece of plastic cut in a triangle
that you cut a hole through and slide onto those sides
so you're fully protecting the eyes.
The other thing to think about is these resources are becoming scarce,
they're getting harder to get.
So as you think about implementing
because you are seeing cases in your facility,
or you're seeing sustained transmission in the community,
the supply chain is going to get tighter.
So think about extending the use of eye protection and face masks,
and how you would do that,
and how you're going to communicate to your staff,
"We want to keep you safe.
This is a scarce resource.
This is a safe way to conserve the scarce resource."
We need to be sending the message that their safety is number one,
and this is an appropriate way to do this.
The other thing we need to think about is housekeeping.
And we have surfaces in our nursing care centers
that are hard surfaces and there are soft surfaces,
and they need to be managed in a way that makes them safe for everybody.
But there's some general principles that we need to make sure
that we are all aware of and are practicing.
If a surface is dirty, you cannot disinfect it.
It must be a clean surface in order to disinfect.
So if a surface is dirty, you need to clean it with a detergent,
or soap and water, or whatever the manufacturer is recommending
prior to disinfection.
Many of the disinfectant wipes
that we have available to us in health care
will say on the label, "Clean with a disinfectant wipe
and then disinfect with a second wipe,"
because of that principle of if it's not clean, you cannot disinfect.
We want to reinforce that you need to follow
the manufacturer's instructions
for all cleaning and disinfection products.
The concentration, if you're mixing it yourself,
how you are applying it and that contact time
become really essential because efficacy, the ability of this disinfectant to work
is based on contact time,
and the correct application and concentration.
The other thing we want to warn organizations about
is mixing products.
In this time, when there is heightened concerns,
sometimes our staff and even our residents will do a little bit extra.
They think, "Well, if I mix this with this,
the combination will make this even safer."
And in fact, what they could end up with
is a chemical reaction that puts people in danger.
That happens-- many of us have heard of it--
when we mix ammonia with bleach products,
you create chlorine gas,
and many of our pop-up lights are made with ammonia-containing products,
so if we start adding bleach,
we have a dangerous chemical reaction that could occur
and could send your residents to the hospital,
and your staff to the hospital.
So please, please, please emphasize with your workers,
with your contractors that you cannot mix products
unless it is instructed by the manufacturer.
And the other thing we find is sometimes staff and residents
think that more is better.
When you are thinking of disinfectants and detergents,
more is not better.
In fact, what you can leave is a dangerous residue.
For example, if you put too much soap on a surface,
then how do you rinse it off?
You end up with a sticky mass
that's going to actually attract more organisms
rather than prevent them.
And it's not going to allow the disinfectant to work.
Some disinfectants, if you use too much,
can have a similar reaction
and actually will not be effective to kill.
So we want to make sure that we're practicing
those basic housekeeping principles.
When we talk about disinfecting hard surfaces,
the current recommendation is that healthcare facilities
provide hospital-grade disinfectants.
We have provided you with a link
to common disinfectants that will work against coronaviruses,
and they're the disinfectants that we are currently using
in the healthcare environment.
So this isn't the time that you need to go out
and buy something special.
Just look on the website, click the link and see if you find your product.
If you don't find your product on that list,
there's usually a number on the product label,
call it, call the number and say,
"Hey, I'm using this product, is this okay?
We're worried about coronavirus, is this going to work?"
This is an easy virus to kill
as long as you are applying the disinfectant appropriately.
If you are having supply chain issues, there is no more product,
or it's on back hold, you can't get to it, what are your alternatives?
There are common household disinfectants
that are effective against coronavirus.
We have provided you with a link to that list of disinfectants,
things that you can use in your home.
An important point here is to read the label.
If the label says it is a cleaner,
a cleaner, it means it is only meant for cleaning surfaces,
it is not a disinfectant.
So it's very important that you read the label
because many of these household products,
some of them made by the same manufacturer,
could be household cleaner versus a household disinfectant.
So reading the label is important.
If worse comes to worst
and you can't get your hands on a disinfectant,
either a hospital-grade or a household disinfectant,
you still have another alternative, which is a bleach solution.
You need very little bleach to be able to kill this virus.
The dilution of bleach is five tablespoons or a third of a cup of household bleach
per gallon of water,
or four teaspoons of bleach per quart of water.
Now, the important part here is think about what happens
when you add bleach to water.
When you go to a public pool,
you will quickly see that the bleach smell starts to dissipate.
You get close to the pool, what do you smell?
You smell the bleach.
As you make these solutions,
you need to make them either in a closed container,
so keep your container closed, or make them up fresh daily.
If you're using a closed container,
there are studies that say in a closed container,
you can use your solution for up to a week.
So you want to make sure you put a date on it and say,
"Remake after this date," if you're making a larger quantity.
As far as laundry, we know laundry can often be an issue for our residents.
My mother-in-law was in a nursing care facility
on and off for eight years,
and also working in the nursing care facility,
and we know that some families and some facilities
structure their laundry according to the needs
of that resident or the family.
In some cases, laundry may be going home with the family,
it may be being done in-house by our service providers,
or it may be being done through a contractor.
So there's some basic principles with laundry
that we want to make sure that we're following.
One is, basic principle is don't shake the laundry out.
I know that a lot of times with my mom and my mother-in-law,
the Kleenex would end up in the pockets, so you'll want to put on your PPE,
your gloves and your gown, and you want to reach into the pocket
and take those out and throw them out
so that you don't end up with Kleenex all over your laundry.
But don't shake the laundry,
wear your PPE when you're handling dirty laundry.
Items should be washed in accordance with the manufacturer's instructions
at the warmest setting for the item.
And then we want to use the dryer.
Why? Because heat is an effective way to inactivate this virus,
and viruses in general.
Dirty laundry that has been in contact with even someone who is sick
can be washed with other people's items because the laundry process will work.
It does provide safe clothing, safe surfaces.
So if you think of those curtains that you're washing,
because they got dirty, something splattered on it,
the laundry process will work
so long as you are following the recommended laundry process.
In some states, there are regulations about time and temperature.
Please make sure that you are following those instructions.
If you have in-house laundry,
you want to remember to clean and disinfect your laundry room surfaces,
your washers and your hampers.
If you're sending things out,
you still want to make sure whatever collection bin
is getting regular sanitizing.
In nursing care centers, we often allow our residents
to bring in things that they feel more comfortable,
make it more of a home-like environment
because this is their home in many instances.
Now, in rehab centers, they're more transient,
but in nursing care centers
where they're going to be their extended care of living place,
it's very important that we think about
how do we provide that feeling of home and that feeling of security.
That often results in soft surfaces being in the patient's room.
My mom always had her blankie, as she called it, she had a blanket.
She didn't feel comfortable unless that's what was on the bed
when she went to sleep.
And we need to think about those types of surfaces.
If they still can have a carpet or a rug.
It's not a trip hazard? How do you deal with those?
Think about removing the visible contamination if it's present,
and then clean it with the appropriate cleaners
that are indicated for that surface.
If you are trying to disinfect the soft surface,
now, a rug is not going to be the source of coronavirus.
It's not.
But that pull curtain is a soft surface.
That's when you need to think about is it going to be used by others.
That blanket, again, is not going to be the source
for other residents, unless other residents are using it.
If you are able to launder it,
do it in accordance with the manufacturer's instructions.
And there are products,
and the EPA, again, has put out a great list for us
of products that will work with emerging viral pathogens.
So if you look at those websites, take a look,
it depends on the soft surface and how it's being used.
So we want to also talk about contract services,
and I'm going to turn it over to Linda to really talk about those
that are specific to the nursing care centers.
(Linda) Thank you, Sylvia.
Nursing care centers often use contract providers
as part of their interdisciplinary team.
Contract service providers may include
all of the service areas you see on the slide:
housekeeping, laundry, radiology, wound care,
hospice, which we discussed, respiratory services.
So there are an array of contract services that could be provided externally,
or through an agency.
The process used for contract providers should be the same exact process
used for all staff in the facility.
So that's very important to have a standardized process.
So it's important that we provide standardized teaching
to those contract providers
or those vendors that are coming into our facility.
Are we using standardized teaching forms
to have the contract provider read and sign
that they acknowledge that they received information
about the organization's policies and procedures
and what is expected?
Are we including instructions for how to use hand sanitizers,
as Sylvia indicated?
How do they wash their hands?
Are they aware of the 20-second handwashing rule?
Are they aware that cough etiquette is important in our setting,
as well as mask use,
if there are cases in the facility or within the community?
It may not be enough for the organization just to have the contract provider
provide a read and sign that they've read the information,
they acknowledge they read it.
They may need to have someone accessible,
so if there are questions, that contract provider can seek
further clarification on those instructions.
Maybe they're not quite sure how to put on PPE or to take off PPE
and need further instructions on that.
It's important that we also include our contract providers
in our daily alerts.
Any daily alerts or meetings that we're having with our staff,
it's important that we also include our contract providers
to make sure they're receiving this updated information.
It's also very important
after our contract providers have been educated about handwashing,
cough etiquette, use of PPE, social distancing,
that we, in the facility, are reinforcing that education
and supplementing any knowledge deficits that we may observe.
It's very important also that contract providers
are knowledgeable about any substitute products
that may be being used.
Maybe they're bringing in a product that was substituted,
maybe a cleaning product or another product
that they're not quite sure of about the instructions of that product.
Maybe we have housekeeping staff
that have run out of their normal cleaning supplies
that are provided by their facility, and so we have substitute products.
Have they been educated and instructed on that new cleaning product?
Is this the right product for the right surface?
Do they understand the wet time for that product?
Are they comfortable using that product?
Do they know what's included in the safety data sheet
for use of that product?
So education is very important for contract providers.
It's also very important that we instruct our contract providers
also that we assess their competency.
And ways that we can do that is just observation.
We can observe our contract providers,
ask them if they understand what's going on with the facility,
the restrictions, the new products.
So it's very important to assess their competency.
It's also very important that we ask our contract-providing companies
to have input into the education and the competencies
that we're expecting from our contract providers.
Are they offering input into the content of the instructions?
Also, it's very important in educating our housekeeping staff
on any new procedures being used,
or new areas that they're asked to be cleaned
that they haven't cleaned before.
If residents are rearranged into other rooms or they're relocated,
activity rooms are different than they were before,
do housekeeping staff know that they're now to go into those rooms
and clean those areas?
Maybe because that room was previously closed before
and now it's open and used in a different capacity.
What about our laundry staff?
Do they know it's important not to shake clothes and laundry
when they're processing the laundry?
Have they been instructed
or have we revisited the education with them
about cleaning their work area, particularly surfaces in the laundry area,
and the importance of using that PPE?
Often laundry has PPE available.
There's usually one set hanging on a hook in the laundry
in nursing care centers--
a gown, a face shield, or a mask, and gloves--
but often it's not really used consistently.
So now it's an important time to re-educate our laundry staff
and any contract staff the importance of using that PPE
when processing laundry.
What about other contract service providers?
What about dental providers?
If dental hygienists are coming into the nursing care centers
to provide routine dental cleaning, is this the appropriate time to do that?
Again, the CDC recommends canceling any non-essential care.
So is routine dental care recommended at this time?
Probably not, only for emergencies.
What about other elective care
such as eye exams and mammographies?
Those are also discouraged at this time.
Knowing that radiology and lab services are highly sought after
by multiple healthcare facilities during this time,
the services the facility uses may be strained.
Lab services, radiology providers may no longer be as accessible
as they were before.
Are we thinking about alternatives?
What about our routine lab phlebotomists
that comes to our nursing facility routinely all the time,
and now they're no longer available or accessible?
Maybe they're ill or sheltering at home.
Have we trained our staff on how to draw blood if it's appropriate?
At this point, to train our staff, do we have designated staff
that can do this?
What about our radiology provider,
what if they're no longer accessible?
Have we looked at our backup contracts
to see if there are other radiology providers still available?
Have we actually contacted them to see if they could come if needed?
What about our transportation providers?
Are they still accessible?
Are we ensuring that they are educated on our procedures,
particularly ensuring that residents have a mask on
when the residents are being picked up or when they're dropped off?
Do we have masks available for this service?
What about pharmacies?
We don't want to wait until we're out of medications,
which sometimes happens in facilities.
Are we partnering with our pharmacy provider
to make sure that we have the stock that we need?
Are we ensuring that our automated dispense systems,
our Pyxis, PassPort, Omnicell are stocked in order to provide
consistent medication delivery?
What about respiratory?
Most facilities routinely don't have a respiratory therapist
that comes in as part of staff.
They're actually a contract provider,
and sometimes they're only contacted if there is a need.
Have we checked to see if that respiratory therapy provider
is still accessible?
If not, do we have a contract
for a substitute respiratory therapy provider?
If they do come in and are not familiar with our facility,
do they understand the precautions and the policies
and what the expectations are?
So these are all contracted services that we need to be reviewing.
Will that contract service provider have the staff they need
to provide continuity of care?
Have they received basic infection control training?
A lot of these providers,
if they're not used to our nursing care center,
and they don't come to our facilities often,
they may not know about basic infection control training.
Do they know how coronavirus is spread,
and their role in preventing the spread?
Are they competent to implement the knowledge and training?
How do we expect to educate them on our policies quickly
and ensure their competence?
And what do we do if they're not available?
What do we do if nursing staff is no longer available?
Or what if staff is non-compliant, how do we handle that?
So these are all areas that we need to look at.
Meals. Routine food service sanitation procedures
are considered to be adequate
that we're using now for surfaces and utensils.
(Sylvia) So I'm going to jump in at this point,
and just let you know that routine food sanitation
that you are doing
is effective for routine,
whatever you've been doing before is going to work,
and Linda already talked about food distribution.
There's other services that you are providing
that you need to think about, like dialysis,
and there, same thing applies.
Social distancing, as you move through this process,
where you're going to put those patients if you have a centralized area
and keeping them six feet apart.
But really everything else remains the same.
We need to think about--
as we get more and more patients who may have coronavirus--
we need to think about the routine care that we give
that does create aerosols, and how are we doing it,
and what protection are we providing.
Please remember that anything that could create an aerosol
could put our staff or other patients at risk.
So we need to think about how is the service being provided,
making sure that they have a private room,
or that the other patient is taken out of the room
and the door is closed,
and that your staff is wearing appropriate PPE
while this is being done.
If you are doing aerosol-generating procedures
that includes the use of an N95 respirator.
If you do not have those at this point, now is the time to get one.
If they're not available to you, you need to make sure
that you're contacting your local health department for assistance,
and at least having some in your facility.
Okay, Linda.
(Linda) Okay, it's important now to plan for your capacity for admissions,
transfers, and discharges.
We need to follow any guidance from our local county, federal partners.
Department of Health may be involved in coordination
of transfers to and from acute care settings,
so we need to follow their guidance.
They may ask us to ramp up our capacity.
Are we prepared to do that?
They may mandate that we ramp up our capacity.
Again, are we ready to do that?
Do we need to look at supplies to handle an influx of patients
or infected patients, such as PPE, IV supplies, wound care?
And what about our staffing plans?
How would those change if we had an increase in patients
in our organization?
(Sylvia) So we need to think about supplies and supply chain management.
We need to plan for shortages.
If you have not yet had a case,
you have the luxury of maybe a little time,
but places are really heating up.
And so as you think about what you are going to need,
please remember to plan for shortages.
That extended use versus reuse,
think about washable gowns and what you might use
as an alternative to a disposable gown if you cannot get one.
The other thing is to make sure that if you are planning for shortages
that you have a plan in place to educate your staff
to ensure that they understand that the alternative is a safe alternative
that has been evaluated,
or is the safest that you can provide them.
We want to be transparent with our staff.
We provided you with a lot of information
and in order to implement that information,
you really need to improve your supply management.
How are you going to know if you're going to run out?
What are your power levels?
Think about that now.
How many of these should I have on stock?
The CDC has put out on their website
a great resource which is about calculating a burn rate:
how fast will you go through these
based on your number of residents or patients?
We also want to talk very briefly
about what happens if you do get a coronavirus patient.
We got to plan for that.
Where are you going to put that resident?
If you have multiple, how are you going to cohort them?
Think about cohorting them-- which means grouping them--
into locations: those who have the disease,
those who are exposed to the disease, and those who are not exposed.
One really unique thing
that we've heard about from one of our surveyors
is one organization has not had any coronavirus cases yet,
but what they have done and planned for is in order to try,
because they have a very stable population,
is they have the people who they know has been 14 days out.
They haven't been exposed to anyone except their health care providers,
who are wearing masks.
As they admit new people from the outside into the facility,
they have created an observation unit.
So for 14 days, the incubation period,
those residents go to the observation unit
where they make sure that they are not developing illness
and they are not sick,
before they are moved into the rest of the resident population.
So start thinking about that.
Start planning for staffing.
What do you do if you have 100 staff members
and suddenly 30 of them are sick?
What are you going to do?
And please, please, please remember that roommate management.
What's your plan if one of two or one of four roommates
suddenly is sick and develops coronavirus?
You need to remember that at that point,
if they've been living in the same room,
the roommates are considered exposed and could be incubating,
or could actually be one of those asymptomatic or presymptomatic people.
So we want to make sure that you have a good plan in place.
The other thing we want to make sure
is really think about your ability to address and reassure.
You, everybody who is listening to this, have the unique ability
to address potential concerns,
fears, and anxieties related to this disease.
By reiterating the simple hygienic precautions and the practices,
you can promote helpful information, you can dispel the myths,
you can manage the fear and stigma and restore that sense of calm
to the environment in which you have your residents and your staff.
So please, please, please think about your ability to be a leader
and provide that information.
Linda, do you have anything to add to that?
(Linda) Yes.
It's an important time that we support and empower
our residents and staff during this difficult time.
Communication and education are power.
So we need to educate our staff on how to identify any new emerging signs
of depression, anxiety, despair, possible suicide risk,
for residents and co-workers,
and ensure staff know how to report these signs and symptoms.
And also ensure the organization has resources
to address these areas promptly.
Do staff know how to identify their own signs of burnout
and key indicators when their anxiety is heightened?
And how do they report these indicators, and what resources are available for them?
Are we inviting everyone to our morning stand-up meetings
to discuss their feelings?
Maybe hardships they're having in the facility and at home,
and share some of the stories-- that really also helps.
Also, encourage staff to report any concerns
and opportunities for improvement.
Some facilities are using coronavirus suggestion boxes
so that staff can anonymously put in suggestions
that may improve care and services during this time.
(Sylvia) So we want to make sure that you know
when can staff come back to work.
You have 20% of your staff sick, when can they come back work?
Well, it really is a matter of when are they able to,
and when are their symptoms resolved.
So the CDC has the guidance,
this is the guidance if people are not tested.
If they're not tested,
the minimum is seven days have passed since their symptoms first started,
and they're not using fever-reducing, and their symptoms are improving.
But please be aware that this guidance can change,
so we've given you the website.
If you do have someone who's sick,
please make sure that you look at this guidance.
And then, finally, you're in the situation,
in the nursing care setting,
that all of your staff should be wearing a mask,
so that's going to cut down on transmissions.
So even if they are ready to come back to work,
the CDC is still recommending that for 14 days they treat themselves
as if they are infectious.
What's going to help there
is you're already doing the routine practices
that would prevent disease transmission.
When we talk about education and competency of staff,
we need to make sure that, ultimately,
competency is the key to everything that we have talked about.
We need to make sure that staff can actually apply.
Knowledge is great, training is great,
but can they apply what we have taught them?
There have been health care providers and nursing care centers
that have had to deal with coronavirus outbreaks,
and there have been incredible resources provided,
some of which like this article you can find
that you are in the position--
even if it happens at your organization--
you are in the position to be a leader,
to protect your staff and your residents,
to make sure that you have implemented the best prevention that you can,
and that you have a recovery plan.
If, Heaven forbid, that you do end up with cases in your facility
and transmissions, you can do this.
That's why most of us went into health care,
to help these people and to keep everyone safe.
I'm going to turn it over to Bev to talk about some resources
that we've made available to you.
(Beverly) Thank you.
There's a lot of information about COVID-19
available from a multitude of sources.
The challenge is really determining which of those sources are credible.
In the next several slides, we're going to focus on helping you
identifying credible sources
for information related to this evolving pandemic.
The slide in front of you shows the cms.gov site,
which continues to provide updated guidance
regarding infection control and prevention in nursing care centers related to COVID.
Also, another tool that we'd like to highlight
is the CDC Checklist.
We're learning from customers
that state surveyors are expecting organizations
to use the checklist to perform a self-assessment of readiness.
According to the CDC, the checklist identifies key areas
that long-term care facilities
should consider in their COVID-19 planning.
Long-term care facilities can use this tool to self-assess
their strengths and weaknesses of their current preparedness efforts.
This checklist does not describe mandatory requirements or standards,
rather it highlights important areas to review
to prepare for the possibility of having residents with COVID-19.
And then, finally, we'd like to highlight for you
The Joint Commission website.
We currently have links with solutions to common problems
associated with the COVID-19 pandemic.
And we encourage you to check the site frequently
for updates and additional tools.
Thank you very much for your attention.