(Tanesha) Welcome to our presentation,
"Preventing COVID-19 in Primary Care Health Centers."
Speakers in order of appearance are myself, Tanesha Lindsay,
Army Nurse Corps fellow at the Joint Commission,
(Amanda) Amanda Nelson, Army Dentist and fellow at the Joint Commission.
(Diane) Diane Cullen, Associate Director of Standards Interpretation Group
and Certified Infection Preventionist.
(Tanesha) In addition to our speakers today,
we want to acknowledge the time and research
that others also put into this presentation.
This presentation was a collaboration of many
and represents hours of work.
In the creation of this presentation,
we focused primarily on the safety of your staff
with the belief that keeping staff safe
is essential to the ability of Primary Health Centers
to provide for patient safety.
We want to acknowledge the sacrifices
that many Primary Health Centers have made by stopping or reducing procedures,
providing supplies and equipment
to the care of COVID-19 patients in acute care settings.
In the move forward to resume elective procedures,
we thank you for your commitment to keeping your staff and patients safe.
Thank you for taking time to join us today.
These slides are current as of July 8, 2020.
Please note that all information is timestamped
and should be reviewed to be in accordance with DMS,
your state and local laws and guidance.
This presentation should not be shared or distributed
without the consent of the Joint Commission.
Any distribution of the presentation must be in PDF format.
The purpose of this presentation is to inform your organization
of some valuable resources available to you
from the Joint Commission,
to mention some key points about transmission in general,
to discuss community transmission,
and finally, we will go into detail
about strategies to prevent transmission of COVID-19 in your organization
in the context of the hierarchies of control.
The Joint Commission has created a large number of resources
which are listed on this slide that relates to ambulatory care clinics
about COVID-19.
The Joint Commission has issued a Position Statement:
Preventing Nosocomial COVID-19 Infections
as Organizations Resume Regular Care Delivery
updated on June 22nd, 2020.
This guidance was revised to address customer questions and concerns.
The statement now includes FAQs and explanations of clarifications.
The Joint Commission has also created a number of webinars
concerning COVID-19 in the ambulatory care clinic setting.
These are listed on the slide:
Preventing COVID-19 Transmission,
Preventing COVID-19 Transmission in Ambulatory Care Centers,
and Dentistry in the Time of COVID-19.
Key points about the transmission of COVID-19 included in these resources
are summarized on this slide.
COVID-19 is spread primarily by droplet transmission
but also through contaminated surfaces.
The risk of exposure increases during aerosol generating procedures.
The virus spreads more readily and sustainably from person-to-person
than seasonal flu but less so than measles.
Most people who have been tested for COVID-19
have had fever, cough and shortness of breath,
but that is because we have been focusing testing on people with symptoms.
Now that testing is becoming more readily available,
we see people without symptoms who test positive for the virus.
We now know that these asymptomatic or pre-symptomatic people
can be a source of infection to others,
including to health care workers.
In health care, a risk assessment helps organizations manage risk.
It considers people, where the work is done,
the tasks to be completed,
and puts measures in place to keep people safe in their environment.
As you're considering reopening and ramping up services,
it is important to consider re-evaluating or redoing
your organizational risk assessment.
Understanding the level of transmission of COVID 19 in your community
is important for primary care clinics
as they reopen or consider increasing services during the pandemic.
The CDC provides the definitions to state and local health authorities
to describe levels of disease prevalence of COVID-19 transmission in a community.
Local health authorities make a determination
about the level of disease transmission in their individual communities
based on local data.
Please use this link
to see how this information will drive your risk mitigation strategy.
Be sure to stay connected with your state and local health authorities.
Risk assessments are not one-and-done.
They will need updating based on changes in your community.
Remember that one size does not fit all.
If you have clinics located in different communities,
it will be important to consider the level of transmission
and guidance from health officials in those communities.
In addition to considering community spread
in your facility risk assessment,
also consider your health care capacity.
Please remember circumstances that guide your risk assessments change often.
These factors will change and your risk assessment will also.
As organizations begin to reopen their clinics and provide care
closer to pre-pandemic levels,
they must balance the need to provide clinic services
with minimizing the risk to patients and staff.
The hierarchy of controls provides you with a framework
for thinking about strategies to mitigate risks
identified in your risk assessment.
The National Institute for Occupational Safety and Health,
which is part of the CDC,
has developed an initiative called Prevention through Design.
The premise of this program is that the best way
to control injuries and illness in the work environment
is to minimize hazards.
A safe environment is accomplished by eliminating hazards
and controlling risks to workers at the source,
and proactively including prevention considerations
in all designs that impact the worker.
The Hierarchy of Controls pyramid depicted here
is a product of this program.
The rationale behind the pyramid
is that a series of control measures, when implemented systematically,
can effectively eliminate the risk to health care workers.
The most effective control measures, both at the top of the pyramid,
should be considered and implemented first.
An organization would then move through other levels of the pyramid
to develop strategies which would build on previous levels
in order to further ensure the safety of the worker.
For example, elimination, or the removal of hazards,
is by far the most effective method of keeping health care workers safe.
However, that's not always possible
or may be done with varying levels of success.
Organizations then consider mitigation practices
in the next level of the hierarchy,
substitution and so on through the pyramid
until they move to the least effective control measure, PPE.
The next several slides include examples of elimination, substitution,
engineering and administrative controls as well as PPE,
for you to consider as you continue to care for COVID-19 patients
while ramping up your clinical operations.
Please note the following slides have examples that are suggestions only
and not to be used without a proper risk assessment
based on your organization's unique situation.
Let's look first at the elimination component
of the Hierarchy of Controls.
Elimination is the most effective control as it aims to eliminate the hazard.
Specific to COVID-19, elimination refers
to preventing the virus from entering your facility in the first place.
This slide lists several elimination strategies
your organization may choose to implement to achieve this objective.
We will go into detail on the following slide.
Develop a strategy for prioritizing services and patients.
Many organizations have continued face-to-face appointments
for those with an acute need such as dental emergencies.
So, as your organization plans to offer more routine face-to-face appointments,
consider how best to prioritize patients
based on your patient population and community needs.
Decisions about restarting or expanding services
should take into account the local epidemiology
and recommendations from state and local health officials.
Prioritize services that, if deferred, are most likely to result in patient harm.
In order to test out any new systems you put in place,
you should consider ramping up services gradually
to allow you to reassess your processes.
While at first glance deciding to resume treating diabetic patients
versus routine pediatric patients sounds most rational,
organizations have to determine
what is most effective for their community.
If your community is attending school or allowed to have gatherings,
preventing a measles outbreak with immunizations may take priority.
Consider the risk of putting off well patient checks carefully.
The well patient can become the unwell patient
if preventive measures are delayed too long.
The CDC has provided a general framework for provision of non COVID-19 health care
during the COVID-19 pandemic.
This takes into account the potential for patient harm
and the degree of community transmission.
Although this framework is helpful in guiding the establishment
of patient care priorities,
your organization will need to tailor its approach
to consider your staff and individual patient
and community needs.
Of special note, CDC advises that during the pandemic,
health care providers should prioritize immunizations and newborn care.
Another important example of an elimination control
is screening of patients and staff.
This slide lists some common questions you might consider asking,
for example, during a pre-appointment telephone screening process.
These questions focus on exposures that may have occurred to individuals
prior to entering your facility
and therefore, their risk of being infected.
Ask if they have been advised to self quarantine
because of exposure to someone with a COVID-19 infection.
In the last bullet point when we refer to close contact we mean:
Has the patient been within six feet of a person with COVID-19
for 15 minutes or more
from 48 hours before they were diagnosed or when symptomatic?
In the case of staff, without a mask on the patient
or appropriate PPE for the staff member.
This slide lists symptoms to consider including in your screening process.
Non-respiratory symptoms of COVID-19 such as gastrointestinal symptoms,
neurologic symptoms, or fatigue,
or body and muscle aches
may appear before fever and lower respiratory tract symptoms.
Children with COVID-19 may have fewer symptoms than adults.
Although most children with COVID-19 have not had severe illness,
clinicians should maintain a high index of suspicion
for this infection in children,
particularly infants and children with underlying medical conditions.
The CDC is continuously updating this list.
There is limited information regarding factors for severe illness
resulting from COVID-19.
Further, there's insufficient information on COVID-19
to determine the level of risk for each underlying medical condition.
Based on what we know now, however,
those at high risk for severe illness from COVID-19
are listed on this slide.
You know your patient's overall health and how well their conditions are managed.
Use your clinical judgment to evaluate your patients on a case-by-case basis.
Your organization may consider
closer follow-up of patients in these categories.
For example, work with patients to manage their underlying conditions,
including ensuring they have sufficient medication and supplies.
Explain to all patients which symptoms of their chronic conditions
require emergency care or in-person visits.
Stress the importance of obtaining emergency care as needed.
Reassure your patients
by reinforcing your emergency room infection prevention plans
that protect them from acquiring COVID-19.
Additionally, CDC has provided a list of those who might be at higher risk
of severe illness from the new coronavirus,
including pregnancy.
The CDC also has a list of populations who need extra precaution.
These are racial and ethnic minorities, people with disabilities,
those with developmental or behavioral disorders,
people who are experiencing homelessness
and newly resettled refugees populations.
All of the individuals who fall into these categories
may also require additional follow-up.
While the process for screening for symptoms among patients
depends on facility layout and staffing,
consider the following:
Ensure that patients are aware that they will be pre-screened
prior to scheduling and re-screened upon arrival.
Consider asking patients to check their temperature at home
before leaving for their appointments.
Advise them they should put on a cloth face covering
regardless of symptoms before leaving their home or car.
Instruct patients to notify the facility before arriving
if they have fever or symptoms of COVID-19.
Consider using automated communication
to remind patients about reporting symptoms.
If patients have symptoms,
they should discuss them with the health care provider
before leaving their home.
Advance notice gives the facility time to prepare for the patient's arrival
or, if indicated based on symptoms, to refer them to a higher level of care.
Rescreening upon arrival should preferably include another temperature check.
The facility should make sure triage and pre-screening procedures
are compliant with HIPAA guidance
and consider a multi-step screening process
to ensure patients with symptoms are not missed
prior to entering the treatment area.
Your staff may need extended time
for routine pre-appointment calls to every patient.
These calls are your opportunity to assess for recent illness,
exposure to illness
and any travel to areas with higher infectivity than your area.
They also give you an opportunity
to educate the patient on the new processes,
who can accompany them, any billing or consent form processes
that might now be electronic or done in advance,
and how to wear a face covering.
Screening patients, health care providers,
visitors, vendors, contractors and volunteers
entering the health care facility
for symptoms consistent with COVID-19,
or exposures to others with COVID-19 infection
ensure they are practicing source control.
If climate permits, consider outdoor access
and triage patients for patients with respiratory symptoms.
Require your patients to wear face coverings
when entering your facility.
If they arrive without one, ensure that you can provide one.
Health care workers are familiar with the CDC's recommendation
for respiratory etiquette,
which is the poster on the left, Cover your Cough.
It shows a means to stop the spread of respiratory illness.
These recommendations are based on the presence of respiratory symptoms.
However, we now know that COVID-19 can be transmitted by people
who do not have noticeable symptoms.
Therefore, the best way to stop COVID-19 transmission
requires stopping the dispersal of respiratory droplets
and preventing exposure to respiratory droplets.
Preventing exposure is synonymous with universal precautions
and it's termed Source Control.
Source Control describes measures intended to prevent
infected individuals from spreading the disease.
This means that our conventional posters like the one on the left
need to be revised to something like the poster on the right,
which emphasizes that anyone outside of their home
or entering a health care facility wears at least a cloth mask,
as a means to prevent transmission in the community and in your organization.
Also emphasizes that hand hygiene and diligent cleaning
remain a cornerstone of infection prevention.
If you follow the link to our statement in support of universal masking,
you can print this poster.
You will notice that we are using the term face covering versus mask.
A face covering is a warrant to prevent droplet dispersal.
A medical or surgical mask is worn to prevent droplet dispersal
and as personal protective equipment.
Surgical masks are class 2 devices that cover the users nose and mouth,
and provide a physical barrier to fluids and particulate matters,
and are tested for flammability and biocompatibility.
Organizations need to be careful as this public health emergency
has resulted in the sale of face masks
that resemble a surgical or procedural mask,
but do not meet that standard.
As part of the positive assessment required by OSHA,
organizations must identify when a face covering is sufficient
and when a face mask must be worn as personal protective equipment by staff.
It is important to evaluate that for all job duties
in the area of health care,
as part of their infection control risk assessment,
organizations must also identify face covering requirements for patients.
For those organizations who require a switch from cloth covering
to medical or surgical face masks,
the organization should develop a process for storing.
Many organizations utilize brown bags and label them with the person's name.
They have the individual perform hand hygiene,
take the masks off by the ear loops or ties,
carefully place the mask in the bag and then repeat hand hygiene.
When we discuss COVID-19, we have to remember
that basic principles in infection prevention and control
still need to be applied.
Hand hygiene for all patient care is an essential strategy
to eliminate the virus and to protect yourself and your patients
from transmitting infections.
It's important that organizations consider increasing the availability
of hand hygiene products throughout their facility.
Organizations should assess whether putting hand sanitizer
in additional locations in patient care areas is needed.
To protect everyone,
provide those entering or working in the clinic
with a pump or squirt of alcohol-based products,
especially in high-traffic areas.
Check-in would be a good location to remind patients
and provide that opportunity.
We know that some organizations are having problems
getting hand hygiene supplies.
So, if necessary, consider relocating product location
from places where it is less needed
to places where it is needed more because of increased activity.
If alcohol-based hand rubs are running low,
consider washcloths with soap and water if there are no sinks nearby.
Make sure that tissues and touch-free trash containers
are available to patients and staff.
Meticulous environmental cleaning and disinfection are key
to stopping transmission of the virus.
Remove all items that either cannot be cleaned
or are difficult to clean.
Throughout the day,
high touch surfaces will need to be disinfected to prevent spread.
Effective disinfectants for use against COVID-19
can be found at the Environmental Protection Agency link provided.
If your usual product is not available,
check list in to make sure your new product is effective.
Avoid mixing disinfectants with different chemical bases.
Soft surfaces should be cleaned to remove soil or visible contaminants
and then laundered or disinfected
in accordance with the manufacturer's instructions.
See the CDC's recommendations for household cleaning and disinfection.
The link is on the slide.
Your control of your environment goes a long way
towards building patient and [inaudible] confidence.
Remember to discourage staff
from sharing desk-based computers and phones
as much as possible,
as these are sometimes difficult to clean.
If you decide to test patients prior to appointments or procedures,
the CDC has provided extensive guidance on how to establish testing sites
in a way to best prevent transmission of COVID-19
from ill patients to staff.
Be sure to check this guidance regularly
as recommendations regarding testing change periodically.
Many patients may have already been tested in the community.
Be sure to ask for those results.
The closest to the appointment they are tested, the better,
preferably within two to three days.
Following any testing,
patients should be advised to avoid any potential exposure
to ensure that the test represents their current status.
Now Amanda will discuss the next three levels of the hierarchy:
substitution, engineering and administration.
(Amanda) Thanks Tanesha.
The second level of protective measures in the Hierarchy of Controls
is substitution.
Substitution entails looking for safer alternatives
to current practices,
including substituting low-risk procedures for high-risk procedures.
Aerosol generating procedures present a higher risk
than ones that do not produce aerosol.
Your organization should assess
what aerosol generating procedures are performed in your clinics,
and then consider what other options might be available to you.
For example, in the dental clinic,
you can use hand scaling for dental cleanings
rather than ultrasonic scaling which is an aerosol generating procedure,
and therefore it represents a risk of exposure to your staff.
Telehealth and teledentistry
is another example of a substitution control,
as this decreases risk to staff and patients
by substituting a visit supported by technology
for a face-to-face visit.
Organizations should research which DMS waivers apply to them
for reimbursement.
Telehealth services can facilitate public health mitigation strategies
during this pandemic by increasing social distancing
and reducing potential infectious exposures
by substituting for a face-to-face visit.
Recent studies on the use of telehealth services
have shown that 70% of patients are comfortable communicating
with their health care providers via text, email or video
in lieu of seeing them in person.
Telehealth services can also decrease the strain on health care systems
by minimizing the surge of patient demand on facilities
and reduce the use of PPE by health care providers.
At the same time, maintaining continuity of care through telehealth
can avoid additional negative consequences
from delayed preventative, chronic or routine care.
Remote access to health care services may increase participation
for those who are medically or socially vulnerable
or who do not have ready access to providers,
and help to preserve the patient-provider relationship
at times when an in-person visit is not practical or feasible.
Some organizations have implemented a virtual or telehealth process
to triage symptomatic patients,
where a provider assesses patient symptoms from a remote location
and then provides recommendations to the patient for further action.
There is a lot of information on the CDC website
about care of COVID-19 patients.
It is well established that most infected patients
can be allowed to recover at home.
Essentially, you're substituting care at home for a face-to-face visit,
caring for the COVID-19 patient remotely instead of them coming into the clinic.
Don't forget that some symptoms that are consistent with COVID-19
such as fever and shortness of breath could be caused by non COVID-19 reasons.
So, triage needs to be assigned to clinicians
who can adequately assess the situation
and determine if the patient needs to be seen.
For patients who call your organization concerned about their symptoms,
CDC provides a nurse telephone triage script
for your staff to use.
Many in-office appointments can be triaged with teledentistry
to alleviate patient's concerns about something benign
like these mandibular tori, a benign bony growth
that the patient's girlfriend pointed out and he thought they appeared overnight,
when in fact, they have been there since he joined the military
five years earlier.
Or this patient who thought his teeth turned dark overnight,
but when encouraged to look through his photographs,
he could see that it has been present for years,
and although it can be treated in the absence of pain or swelling,
it can be treated electively.
In both of these cases,
the patients thought something very serious was happening,
and if we had utilized teledentistry,
they could have been put at ease much quicker
and without any lost time at work or unnecessary use of PPE.
Teledentistry options reduce the time taken by employees
to see dental providers in person.
In fact, though appointments can take hours out of an employee's day,
only 20 minutes of that time is spent actually seeing the doctor.
Utilizing teledentistry for consults, routine follow-ups and patient concerns
will free up time for more in-office appointments
for patients who really need to be seen urgently.
Engineering controls eliminate or reduce exposure to hazards
through the use of engineering solutions.
Examples of engineering controls are listed on this slide.
One question frequently asked by clinics
is how long should an examination room remain vacant
after being occupied by a patient with confirmed or suspected COVID-19?
The amount of time that the air inside an examination room
remains potentially infectious is not known
and may depend on a number of facts,
including the size of the room,
the number of air exchanges per hour,
how long the patient was in the room,
if the patient was coughing or sneezing,
and if an aerosol generating procedure was performed.
For patients who were not coughing or sneezing,
did not undergo an aerosol generating procedure
and occupied the room for a short period of time,
maybe a few minutes,
any risk to health care providers and subsequent patients
likely dissipates over a matter of minutes.
However, for a patient who was coughing
and remained in the room for a longer period of time
or underwent an aerosol generating procedure,
the risk period is likely longer.
For these higher-risk scenarios,
it is reasonable to apply a similar time period
as that used for pathogens spread by airborne route,
like measles and tuberculosis,
and to restrict health care personnel and patients without PPE
from entering the room until sufficient time has elapsed
for enough air changes to remove potentially infectious particles.
General guidance on clearance rates under different ventilation conditions
is available through the CDC website.
Additionally, organizations would have efficient and effective ventilation
with a supply of clean outdoor air
and a minimum of recirculating air for all areas.
Facilities will need to consider these factors
when deciding when the vacated room can be entered by someone
who is not wearing PPE.
The room can be cleaned sooner
if the person doing the cleaning was already caring for the patient
and is still wearing complete PPE.
Also, if someone new is coming in to clean,
they can enter to clean if wearing recommended PPE
to include an N95 respirator.
The table on the left shows how fast or slowly room air will clear
depending on your air changes per hour.
This slide shows an example of the use of ventilatory controls
in a dental operatory.
Air flow should be from cleaner air to less clean air.
Positioning of the chair, patient and equipment in this configuration
shows the clinical staff being in the cleaner portion of the room
with respect to airflow.
The addition of the portable HEPA unit facilitates the one-way flow
from supply in the hallway
to return air register on the far wall.
Be sure your HVAC fan is set to always be in the on mode,
not the auto mode.
This will ensure consistent air flow.
Also, installing high efficiency air filters, such as HEPA filters,
will capture coronavirus particles.
Before allowing patients into a clinical area,
consider running through a soft opening
to determine if there are any ways to improve patient safety and care.
Review planned patient movement in and out of clinic areas,
reception, check-in entry points and bathrooms.
The way the patients will move through the facility
has a large impact on what services can be resumed.
Reviewing the layout of the facility and developing a plan
of how many can safely distance in each area
is pertinent to maintaining physical distancing
after services ramp up.
Review air flow with the intent of ensuring the air is not being cycled
between areas designated for high and low risk population.
In waiting areas, remove remote controls, magazines, toys,
and block off or remove chairs to help maintain 6 feet.
Separate entrances for asymptomatic patients is also advised.
Administrative Controls are policies and procedures
to minimize exposure to the hazards,
and changes to the way people work
with the goal of reducing the duration, frequency and severity
of exposure to hazardous situations, in this case, exposure to COVID-19.
A first step in using administrative controls in the pandemic
is to review your Emergency Operations Plan.
Then make an organizational decision to make changes to your processes.
After you have put your new processes in place,
document the changes including the following:
What changes did we make?
How did we make them?
Did we educate and train staff?
How did we ensure compliance?
These changes should be documented in policies and procedures
if they are intended to be permanent.
But if the changes are designed to be new temporary operations
required by the pandemic,
documentation could be placed in an addendum
to your Emergency Operations Plan
or other appropriate policies and procedures,
with the intent of returning to the original policies and procedures
once we are through the pandemic.
An example of this may be your fit testing policies.
Your organization may make the decision to temporarily suspend annual fit testing.
Make the change, educate and train your staff,
ensure competence and compliance,
document this information in an addendum to your Emergency Operations Plan.
This slide shows examples of processes which will likely change,
at least on a temporary basis, during the pandemic.
Altering patient scheduling as well as work schedules
can be an important process to change to help facilitate social distancing.
Infection control processes will change with new PPE requirements
during the pandemic.
Likely, new screening processes have been implemented.
Many organizations are revisiting their sick leave policies
to make them more flexible and non-punitive.
Similarly, policies which might penalize patients
for missed appointments may need to be revised,
as some patients may be confused about new schedules, may be ill,
or may be reluctant to enter any health care facility.
One of the major changes that organizations will experience
includes allowing more staff to work from home.
If not already in place, allowing more staff to work from home
will require implementing new policies and procedures.
New administrative controls regarding managing clinic access
will probably need to be revised.
These new processes may inform the actions required
to implement other hierarchy of control measures.
For example, the active screen patient is an elimination control.
However, the policy, training and enforcement that governs the screening
is an administrative control.
Remember that policies and procedures do not necessarily need to be revised
through a formal revision process.
An addendum may well serve the purpose.
Additional information about managing operations
during the COVID-19 pandemic from the CDC
is available through the link provided on this slide.
Alternating schedules is an administrative process
that may decrease potential exposure within your organization.
There are many ways to alter schedules to meet patient needs
while facilitating social distancing.
Many examples of ways to decrease the amount of people in your organization
at the same time are listed on this slide.
Appointment schedules should be adjusted to the new pace,
as staff need time to recover and prepare for the next patient visit.
And despite some potential inconvenience to patients,
revamping schedules is an opportunity for you to help the patient understand
and confirm with them your commitment to keep them safe.
Organizational leadership should establish a clear chain of authority and reporting
with an open non-punitive line of communication.
Whoever is designated to lead should understand
that communicating to staff the changes and the new safety protocols
that your health care organization is implementing
are key to your success in navigating new ways of operating during the pandemic.
Encourage staff to report any concerns
during this public health emergency.
Swift closed loop communication and addressing these concerns is key.
This includes making sure that the outcome of decisions
related to staff concerns are relayed in a timely manner,
including the rationale.
Consider establishing regular opportunities
to facilitate communication during these challenging times.
Open communication decreases the anxiety staff members may have
regarding their own protection from the virus.
Include staff in scheduling conversations to ensure it can be supported.
This communication goes a long way
in building the team cohesion and continuity
that is needed during this time.
Assess your patient population and determine the most effective way
to communicate your new procedures with your community.
Keep in mind the different communication needs of your community,
such as your homeless population, some undocumented patients,
patients with language barriers,
or those with limited health care literacy.
Do you have something in place to reach these patients?
Public service announcements via radio, newspapers,
facility website, letters, internet,
email, text, posters, billboards, and patient telehealth portals
are ways to notify your community of these changes.
As mentioned earlier,
staff need to be trained on any new processes.
Staff should, for example, be comfortable differentiating
symptomatic and asymptomatic patients prior to and on their arrival
and where to direct them.
Staff should know how to distinguish which patients may need to be referred
to a higher level of care,
and how patients should be directed to move within the clinic.
Practicing your planned process for patient screening, triage and check-in
until it becomes habit will be beneficial.
A link to a poster from the CDC on appropriate donning and doffing of PPE
is on this slide and serves as a great training tool.
Not all respirators are the same and staff need to be trained
on the different types of respirators that are available within your clinic.
Staff involved in cleaning need to be aware
of how to use any new products including required contact times.
Once trained, it will be important to ensure
that staff are able to demonstrate competence in their new skills
and continued compliance.
A soft opening is an opportune time to assess competency of your staff,
your demonstration, verbalization and testing.
Now Diane will talk about the final level of the hierarchy, PPE,
and other factors to consider.
(Diane) Thank you, Amanda.
The final level of the hierarchy pyramid is personal protective equipment or PPE.
And this is defined as clothing and other work accessories
designed to create a barrier against workplace hazards.
Examples include isolation gowns, masks, goggles, gloves and face shields.
As many of you may be aware,
PPE has been an urgent concern for health care organizations.
Why is that happening?
Well, first, there's a higher demand for personal protective equipment
directly related to caring for known or suspected COVID-19 patients.
Secondly, some procedures lend themselves to be at higher risk than others
because they generate aerosols which, as Amanda described earlier,
is a route of transmission of COVID.
Specifically, the CDC has recommended health care workers
to use N95 respirators or greater
when performing aerosol-generating procedures
on every patient,
because of the risk that some patients may be infected with COVID-19
but be asymptomatic or pre-symptomatic.
Also, many people who have never used PPE before
are now using PPE for their personal or business use.
This certainly wasn't the case about five months ago.
On the other side of the scale,
let's talk about availability of resources.
Organizations have been using so much PPE
that they have been depleting their in-house supplies.
And we've tapped into some of the supplies held by health departments
and the national stockpile.
Additionally, there are a limited number of suppliers who actually produce PPE.
Some of them are out of the country,
and getting the products to the hospitals may be difficult.
In summary, we're in a precarious situation
with an increased demand and competition for PPE
coupled with very limited resources.
The end result is that we need to be thoughtful
of how we manage this valuable commodity.
The CDC has published a PPE Burn Rate Calculator,
which is a spreadsheet-based model that will help health care organizations
plan and optimize the use of PPE in response to COVID-19.
This calculator takes into account several variables.
It takes into account the amount of PPE
such as gown, gloves, respirators, masks and face shields
your organization has in stock
and then, the total number of suspected or confirmed
COVID-19 patients at your facility,
and it uses both of these to determine the amount of PPE
your organization is actually using.
Now, if your organization isn't seeing COVID patients,
this tool would also be valuable.
You could substitute the number of patients that you're seeing
for the number of suspected COVID patients,
and still get a burn rate.
The end result is the same.
By using this calculator, you can understand your true usage of PPE.
This information can then be used to estimate
how long your remaining supply of PPE will last
based on your average consumption rate,
and it can help your facility make order projections for future needs.
The link for this calculator is on this slide for your reference.
The CDC has also provided some guidance for health care organizations
to optimize their PPE supplies during times of increased demand
and supply shortages.
This graphic represents the three levels of standards
on a continuum of care
reflecting the incremental surge in demand
relative to the available health care resources.
So, what does this mean?
Conventional capacity.
That isn't aligned with our standard practice of care.
Think of practice six months ago.
Conventional capacity reflects a balance of supply and demand.
Contingency capacity arises when the demand for medical staff
and equipment and PPE begins to exceed the supply.
Contingency measures may change the daily standard practices
but should not have any significant impact
on the care delivered to the patient
or the safety to your health care personnel.
Extended use has been recommended and widely used as an option
for conserving respirators as a contingency strategy
during previous respiratory pathogens outbreaks and pandemics.
So, what does that mean?
Well, extended use of face masks and respirators
is the practice of wearing the same face mask or respirator
for repeated close contact encounters with several different patients
without removing the face mask between those patient encounters.
Crisis capacity occurs when resources are so depleted
that functionally equivalent care is no longer possible.
In other words, the demand for PPE far outweighs the available supplies
and organizations are forced to implement strategies
such as limited reuse of respirators.
Limited reuse is the practice of one health care personnel
using the same face mask or respirator for multiple encounters with patients,
but removing it after each encounter.
This practice is called limited reuse because there's restrictions in place
to limit the number of times that that respirator could be reused.
It's important to consult with the respirator's manufacturers
regarding the maximum number of times that's recommended for the N95
for that reuse.
If the manufacturer is silent,
the CDC recommends limiting the reuse of respirators to five uses.
Now, CDC's optimization strategies for PPE
offer a continuum of options for use
when PPE supplies are stressed, running low
or are absent.
Contingency and then crisis capacity measures
augment conventional capacity measures,
and are meant to be considered and implemented sequentially.
Now, as PPE supplies and availability returns to normal,
health care facilities should promptly resume
their standard practices.
We've reviewed the current PPE recommendations from the CDC
and included the spread of COVID in the community to develop this chart.
The concept is that organizations should look at multiple risk factors
when deciding what PPE is most appropriate for the given situation.
First, in the green column, you must consider
if you're treating an individual
who is known or suspected as a COVID positive,
or if the patient is unknown.
Now, let's talk about the Unknown or No categories.
A negative test result may not actually reflect
the current infection status of an individual.
Many things can impact these test results.
First, the viral load of the patient at the time.
Next, the timing of the test versus
when the test was taken versus when the procedure was done.
Other things that can impact it
are activities that the patient may have been engaged in
after the test was obtained.
And finally, the sensitivity or specificity of the test.
For this reason, we've included
a No test result as well as an Unknown test result
similarly on this chart.
The next factor we look at
is what type of procedure is being performed,
and specifically, because of the high-risk nature
of the aerosol-generating procedures,
we are looking at that.
The third and final factor that this chart addresses
is the level of community spread of COVID.
This is important,
especially for individuals with a No or Unknown test category,
because if there's moderate to substantial amount of COVID
circulating in your area, there's a higher chance
that you may be caring for an individual who is asymptomatic or pre-symptomatic.
Finally, after assessing all of these criteria,
an organization can determine which PPE is most appropriate and safest
for staff to use with a given situation.
For instance, all aerosol-generating procedures
should wear a filtering facepiece respirator or an N95,
and face or an eye protection regardless of COVID status of the patient.
However, if you're caring for an individual with unknown status,
are not doing an aerosol-generating procedure,
and there is limited or minimal transmission of COVID in the community,
a mask or face covering may be appropriate barrier
during your interaction with that patient.
Here's another way to represent the information we just discussed
about the recommended PPE.
On the left side are examples of PPE to be worn
when you are caring for a patient not to be known or suspected with COVID.
On the right are examples of PPE to be worn
when providing routine for patients with COVID-19
or suspected to be infected with COVID-19.
With regard to respirators,
we've fielded many questions about the requirements
for a respiratory protection program for organizations,
especially in the ambulatory care setting.
Now, OSHA requires that each employer must provide respirators
to protect health care workers from workplace hazards during work
to prevent inhalation of hazards,
such as infectious materials,
that can't be controlled by other measures
such as the engineering and administrative controls
that we talked about.
This employer must establish and maintain a respiratory protection program.
So, if you are using respirators,
you must have a respiratory protection program
which is compliant with the OSHA respiratory protection standard.
And the employer must also provide respirators that are suitable
for the intended purpose.
OSHA's respiratory protection standard
requires that each respiratory protection program
includes a written plan
detailing how the program will be administered.
In addition to having a written program,
the employer must also be able to demonstrate
that the program is enforced and updated as necessary.
Now, the written plan includes the following elements:
a procedure for selecting the respirators,
a medical evaluation of the employees required to wear respirators,
fit testing procedures for those tight-fitting respirators
such as N95s,
procedures for proper use of respirators in routine situations,
the procedures and scheduling of cleaning, disinfecting, storing,
inspecting, repairing and discarding, and otherwise maintaining respirators.
Employers must have a training program for employees
in the proper use of the respirator,
including how it's going to be put on and how to remove them,
and any limitations on their use and their maintenance.
And these procedures need to be evaluated,
and your program effectiveness evaluated regularly.
I provided the CDC links as resources which can aid your organization
in developing your respiratory protection program
if you do not already have one.
In summary, in light of this pandemic,
it's important that your organization makes informed decisions
about PPE utilization in your organization.
This decision should be considered based on assessments
of both external risks, meaning the spread of COVID in your community,
as well as your internal needs and supplies.
Another critical component when considering your PPE decisions
is the communication with your local and state health department.
They are a great resource for your organization
as they may provide guidance on what PPE should be worn
for which procedures and encounters,
and they also provide other valuable guidance.
And they may have resources and insight to help augment your PPE supply.
Please remember before implementing these strategies,
it must be understood
when PPE becomes available,
it's expected that health care facilities
will resume their standard practices of use.
And also remember that PPE is the least effective control
in the hierarchy triangle, as we described earlier.
Facilities must maximize the use of elimination, substitution,
engineering and administrative controls,
while planning mitigation strategies for COVID.
Finally, we'll discuss some additional factors
your organizations would want to consider
related to your staff health and well-being.
So, what if a staff member becomes ill or tests positive for COVID?
The severity of symptomatic illness due to infection with COVID may vary
among persons with extensive and close contact
to vulnerable populations such as health care workers.
Even mild signs and symptoms such as sore throat or fever
should prompt consideration for testing.
Additional information is available on CDC's website,
and the link is provided on this slide.
Health care facilities should have a process
for notifying the health department about suspected or confirmed cases
which occurred as a result of a likely exposure in your facility.
Health care organizations should also establish a plan
in consultation with your local health department
for how exposures in health care facilities
will be investigated and managed.
The health departments, again, are an important resource
and can help you confirm the diagnosis,
make recommendations for follow-up based on your facility's situation
and provide you guidance for how to contact trace.
If an exposure does occur at your facility,
it presents an opportunity for your organization
to review practices and the hierarchy of control measures you put in place,
so as to identify opportunities for improvement.
For example, elimination,
are your patients and staff screening processes what they should be?
For substitution, can we possibly decrease a risky procedure
for something with less risk?
Engineering controls,
are your barriers in place or do you need more?
Administrative, have all of my staff been properly trained?
For PPE, were there enough supplies?
Were some patients or staff not compliant with staff face coverings or masks?
Did staff wear the correct mask for their aerosol-generating procedure?
Better yet, have we identified all of the aerosol-generating procedures
that our facility does?
In the unfortunate event
that your staff member becomes ill with COVID,
there is some guidance as to when they may safely come back to work.
This slide is a summary of the CDC return-to-work strategies
for health care providers with suspected or confirmed COVID-19.
The first two criteria are meant to be used
for symptomatic health care workers with suspected or confirmed COVID-19.
The return-to-work testing strategies your organizations could consider
are either a symptom-based strategy or a test-based strategy.
The second scenario are based on health care workers
with laboratory-confirmed COVID but are asymptomatic.
Their return-to-work strategy that organizations can consider
include either a time-based strategy or a test-based strategy.
We've provided the link which gives you a lot more information
on the CDC's website
about the specifics of each of those strategies
and when they should be implemented.
These are CDC recommendations.
However, please check in with your state and local health authorities
for further guidance on Health Department requirements
that may be more restricted than these and from the CDC.
When it comes to assessing your vulnerability
for health care transmission of COVID in your facility,
ask yourself these questions:
Does your staff know how COVID-19 is transmitted?
Do they have reliable information from credible sources?
Have you provided training for them?
Do you have supplies and equipment on hand to protect your staff?
These includes things such as PPE and engineering controls.
Are you able to safely provide supplies and equipment
throughout the care continuum to ensure your patients are safe?
Is there a culture of safety at your organization?
Have you committed to follow the practices that you've adopted
and hold others accountable for those?
Are the tests you're relying on for screening reliable?
And have staff been properly trained on how to collect those specimens?
Are you vulnerable to false negative results?
These are just an example of some points your organization could consider
when assessing risk points.
The weakest link in any system
is the point at which the greatest chance for failure can occur.
Before you resort back to full-scale services
and continually as you operate,
it's important that you review processes and procedures,
test each process and try to poke holes in them
to see if you can identify vulnerabilities before you experience a problem.
Remember, it's much better to be prepared and address glitches proactively
rather than have to respond to an unfortunate event,
especially true when it comes to the safety of your staff.
And speaking of staff safety,
advising your staff about your plans and keeping them safe
is your No. 1 priority.
Ask yourself these questions:
Are your staff members comfortable with returning to increase patient care?
Are they worried about elderly parents at home
or about a vacation they have scheduled in August?
We encourage you to try to find ways
to show you've considered their personal situations
and demonstrate that you're committed to their safety at work.
Of course, you'll want to educate them
regarding the expectation of source control,
symptom screening, supplies,
and what your policies are going to be if they become ill.
Communicating your commitment to these policies
and how they affect the health and safety of your team members
will go a long way in helping them comply with policies
in their current environment.
We want to acknowledge just how stressful this time is
for you and your staff.
We know that the stress does not end
once you and your staff leave the facility.
Keeping informed about COVID-19 and prevention strategies
are important to relieving stress.
We encourage you to talk with your staff about what they're seeing and hearing
and what's worrying them.
You may not have all the answers,
so we encourage you to work with your staff as a team
to find the answers.
Take the time to engage in self-care at work and during your days off,
and encourage your staff to do this as well.
In summary, COVID-19 has certainly changed the way health care is delivered.
We do appreciate your commitment to providing your patients with safe care
during these challenging times.
We hope we have provided you with useful information
you can take back to your organizations.
Please remember the links to the many resources we've included,
such as the Joint Commission COVID page which contains a plethora of information,
as well as the multiple links listed within this presentation.
Remember, when working through your COVID planning,
it's so important that you proactively look at your organization as a whole,
the services you provide as well as your internal resources.
Keep in mind the importance of your risk assessment,
taking into account the transmission in your community
and the resources available
from your local and state health departments.
And then, when making decisions about mitigation,
move through the hierarchy of controls
from most effective hazard mitigation strategy
through to the least effective.
Finally, don't forget about the health care worker.
Your staff are your No. 1 resource.
It's important to take care of each other, to communicate openly,
and provide each other support during these stressful times.
We thank you again for joining us today,
and for your commitment to staff and patient safety.
If you have any questions, please feel free to follow this link.