Presented in collaboration with Nebraska ICAP, Nebraska DHHS HAI Team, Nebraska Medicine, and The University of Nebraska Medical Center Prepared by Margaret Drake Presented by Kate Tyner Guest: Moderated by Mounica Soma Susie Damman, RN Panelists: Dr. Salman Ashraf, MBBS Angie Vasa, RN, BSN Guidance and responses were provided based on information Kate Tyner, RN, BSN, CIC known on 4/28/2020 and may become out of date. Guidance is Margaret Drake, MT(ASCP),CIC being updated rapidly, so users should look to CDC and Teri Fitzgerald RN, BSN, CIC jurisdictional guidance for updates.
Questions and Answer Session Use the QA box in the webinar platform to type a question. Questions will be read aloud by the moderator If your question is not answered during the webinar, please either e-mail it to NE ICAP or call during our office hours to speak with one of our IPs A transcript of the discussion will be made available on the ICAP website https://icap.nebraskamed.com/coronavirus/ https://icap.nebraskamed.com/covid-19-webinars/ Panelists today are: Dr. Salman Ashraf, MBBS salman.ashraf@unmc.edu Dr. Maureen Tierney, MD, MSc Maureen.Tierney@Nebraska.gov Kate Tyner, RN, BSN, CIC ltyner@nebraskamed.com Margaret Drake, MT(ASCP),CIC Margaret.Drake@Nebraska.gov Teri Fitzgerald RN, BSN, CIC tfitzgerald@nebraskamed.com Angie Vasa, RN, BSN avasa@nebraskamed.com Susie Damman, RN susie.damman@mhcs.us
COVID in Critical Access Susie Damman, RN Infection Prevention and Control Seward Hospital (NE)
• Central team for planning and policy implementation • meets at least 3 times per week • Family Medical clinic and Hospital • The meetings are led by our CEO. • Huddle team responds to testing concerns and clinical situations • Administrative policy changes daily involving: • hospital visitors and screening • Masking • Testing • PPE, • staff screening & temperature monitoring. • Telehealth and virtual visits. • Changing the flow of clinic visits to well visits in the am and URI visits in the pm.
• Education • PPE • patient care • Housekeeping • Dietary • Child care • COVID testing. • Frustrations initially on the limited testing. We now have a little more testing available. Also limitations in receiving supplies such as PPE, testing supplies and cleaning products.
Reopening Facilities to Provide Non-emergent Non-COVID-19 Healthcare- Phase I
Reopening Facilities to Provide Non-emergent Non-COVID-19 Healthcare- Phase I • As states and localities begin to stabilize it is important to restart care • Procedural care-surgeries and procedures • Chronic disease care • Preventive care • If states have or regions have passed the Gating Criteria (symptoms, cases and hospitals) announced on April 16, 2020 they may proceed to phase I
Resources • https://www.aorn.org/guidelines/aorn-support/roadmap-for- resuming-elective-surgery-after-covid-19 • https://www.whitehouse.gov/openingamerica/#criteria • https://www.cms.gov/files/document/covid-flexibility-reopen- essential-non-covid-services.pdf
Gating Criteria https://www.whitehouse.gov/openingamerica/#criteria SYMPTOMS CASES HOSPITALS Downward trajectory of influenza- Downward trajectory of Treat all patients without crisis like illnesses (ILI) reported within a documented cases within a 14-day care 14-day period period AND AND OR Robust testing program in place for Downward trajectory of covid-like Downward trajectory of positive at-risk healthcare workers, syndromic cases reported within a tests as a percent of total tests including emerging antibody 14-day period within a 14-day period (flat or testing increasing volume of tests)
https://nebraska.maps.arcgis.com/apps/opsdashboard/index.html#/4213f719a45647bc873ffb58783ffef3
General Considerations • Maximum use of all telehealth modalities • Care that cannot be accomplished virtually may use the following recommendations to guide as they consider resuming in-person care of non-COVID-19 patients should be consistent public health information and with state public health authorities • Must have: • Adequate facilities, workforce, testing, and supplies • Adequate workforce across phases of care (such as availability of clinicians, nurses, anesthesia, pharmacy, imaging, pathology support, and post-acute care)
https://nebraska.maps.arcgis.com/apps/opsdashboard/index.html#/4213f719a45647bc873ffb58783ffef3 https://www.npr.org/2020/04/26/845224105/nebraska-governor-on-decision-to-partially-reopen-state-in-may
General Considerations • In coordination with State and local public health officials, evaluate the incidence and trends forCOVID-19 in the area where re-starting in-person care is being considered. • Evaluate the necessity of the care based on clinical needs. Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary. • Consider establishing Non-COVID Care (NCC) zones that would screen all patients for symptoms of COVID-19, including temperature checks. • Staff would be routinely screened as would others who will work in the facility (physicians, nurses, housekeeping, delivery and all people who would enter the area). • Sufficient resources should be available to the facility across phases of care, including PPE, healthy workforce, facilities, supplies, testing capacity, and post-acute care, without jeopardizing surge capacity. • Facilities in the state are safely able to treat all patients requiring hospitalization without resorting to crisis standards of care. • Does the facility have appropriate number of ICU and non-ICU beds, PPE, ventilators, medications, anesthetics and all medical surgical supplies?
PPE Considerations • Continue with source control- all healthcare workers are masked – procedure mask or surgical mask- N95 for aerosolizing procedures • Patients procedure mask or surgical mask; at a minimum cloth mask • Every effort should be made to conserve personal protective equipment. • https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe- strategy/index.html
Workforce Considerations • Staff should be routinely screened for symptoms of COVID -19 and if symptomatic, they should be tested and quarantined. • Staff who will be working in these “ Non- COVID- 19 Care Zones” (NCC) zones should be limited to working in these areas and not rotate into “COVID - 19 Care zones” (e.g., they should not have rounds in the hospital and then come to an NCC facility). • Staffing levels in the community must remain adequate to cover a potential surge in COVID-19 cases.
“PPE FATIGUE” • Healthcare workers have been operating in an enhanced PPE and IPC posture for extended periods of time • Maintaining stringent adherence to these practices in the absence of COVID-19 cases can begin to create complacency • Reinforcement of SOPs with rationales is critical to sustain preparedness and response efforts • Universal masking as a source control method • Extended use practices to conserve PPE and maintain staff safety • Reuse of PPE items as a crisis strategy
Facility Considerations • In a region with a current low incidence rate, when a facility makes the determination to provide in-person, non-emergent care, the facility should create areas of NCC which have in place steps to reduce risk of COVID-19 exposure and transmission; these areas should be separate from other facilities to the degrees possible (i.e., separate building, or designated rooms or floor with a separate entrance and minimal crossover with COVID-19 areas). • Within the facility, administrative and engineering controls should be established to facilitate social distancing, such as minimizing time in waiting areas, spacing chairs at least 6 feet apart, and maintaining low patient volumes. • Visitors should be prohibited but if they are necessary for an aspect of patient care, they should be pre-screened in the same way as patients.
Other Considerations • Ensure that there is an established plan for thorough cleaning and disinfection prior to using spaces or facilities for patients with non-COVID- 19 care needs. • Ensure that equipment such as anesthesia machines used for COVID-19 (+) patients are thoroughly decontaminated, following CDC guidelines. • Adequate supplies of equipment, medication and supplies must be ensured, and not detract for the community ability to respond to a potential surge. • When adequate testing capability is established, patients should be screened by laboratory testing before care, and staff working in these facilities should be regularly screened by laboratory test as well. • How a facility will respond to COVID-19 positive worker, COVID-19 positive patient (identified preoperative, identified postoperative), “person under investigation” (PUI) worker, PUI patient.
IP Office Hours Monday – Friday 7:30 AM – 9:30 AM Central Time 2:00 PM -4:00 PM Central Time Call 402-552-2881
Final Considerations • All facilities should continually evaluate whether their region remains a low risk of incidence And • Should be prepared to cease non-essential procedures if there is a surge. • By following the above recommendations, flexibility can allow for safely extending in-person non-emergent care in select communities and facilities.
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