Presented in collaboration with Nebraska ICAP, Nebraska DHHS HAI Team, Nebraska Medicine, and The University of Nebraska Medical Center

Moderated by Mounica Soma

Guidance and responses were provided based on information known on 9/29/2020 and may

become out of date. Guidance is being updated rapidly, so users should look to CDC

and jurisdictional guidance for updates.

Questions and Answer SessionUse the QA box in the webinar platform to type a question. Questions will be read aloud by the moderatorIf 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

Panelists today are:Dr. Richard Starlin, MD rick.starlin@unmc.eduKate Tyner, RN, BSN, CIC ltyner@nebraskamed.comJody Scebold, Ed, MSH, RN jodscebold@nebraskamed.comSarah Stream, MPH, CDA sstream@nebraskamed.com

https://icap.nebraskamed.com/coronavirus/https://icap.nebraskamed.com/covid-19-webinars/

Infection Prevention and ControlOffice Hours

Monday – Friday 7:30 AM – 9:30 AM Central Time2:00 PM -4:00 PM Central Time

Call 402-552-2881

Questions and Answer Session

Use the QA box in the webinar platform to type a question. Questions will be read aloud by moderator, in the order they are received

A transcript of the discussion will be made available on the ICAP website

Panelists:

Dr. Richard Starlin, MD

Kate Tyner, RN, BSN, CICSarah Stream, MPH, CDA

Jody Scebold, Ed, MSH, RN

Moderated by Mounica Soma, MHA

Supported by Sue Beach and Margaret Deacy

https://icap.nebraskamed.com/covid-19-webinars/

Infection Control Challenges During the COVID-19 Outbreak

Terry Micheels, MSN, RN, CIC, FAPIC

September 29, 2020

Infection Control

The COVID-19 outbreak has turned

infection control (IC) upside down.

• Reusing ‘single-use’ respiratory protection

• Making our own disinfectants

• Using hand sanitizer made in a distillery

• No expiration date on some products

Emergency Use Authorization (EUA)• The FDA may allow unapproved medical products or

unapproved uses of approved medical products to be used in an emergency to diagnose, treat, or prevent serious or life-threatening diseases or conditions.

• A product • must be used for COVID-19

• must be approved, licensed, or cleared by FDA

• Examples of EUA medical countermeasures:• Use of in vitro diagnostics for detection and/or diagnosis of the

virus that causes COVID-19

• PPE and related medical devices

• Ventilators and related medical devices

• Drug and biological products

Top Infection Control Challenges related to COVID

1. Patient Placement - Airborne Rooms, Dedicated Units

2. Respirators & PAPRs

3. COVID Testing

4. Face masks, Eye Protection, Gloves, Gowns

5. Hand Sanitizer

6. Disinfectants

7. Electronic Health Record (EHR) Flags

8. Visitor Guidelines

9. COVID Guidance & Policies

Patient PlacementBiocontainment Unit Activation

– Dedicated, trained volunteer staff

– Infection Preventionists provided “just in time” PPE Training while ruling-in or ruling-out COVID

• Emergency Departments

• Nursing Units

• Immediate Care Clinic

Five Dedicated COVID Units– Engineering controls

– Airborne Infection Isolation rooms – AII • ANSI/ASHRAE/ASHE Standard 170

– PPE Training

– Contingency plans for HVAC downtime

– Ongoing validation of COVID AII patient rooms

PPE Extender ProgramIdentified needs

– Ongoing PPE training

– Dedicated trained staff

Training Topics– Hierarchy of Controls

– Donning sequence

– Doffing sequence

– Self-contamination risks

– PAPR training

– Safety First - courage to speak up to all disciplines

– Cleaning/Disinfection

Deployed our surgical staff to this role– Skilled at wearing PPE, availability

Microsoft TEAMs Account – PPE Extenders communicated daily with IC Manager

PPE Training

Respirators & PAPRsAerosol generating procedures (AGPs)

• Standard definition of AGPs• Respiratory protection equipment• Policy guidance

PAPRs-• Four different manufacturers • When to use a PAPR vs N95• PAPR hood re-use • Decontaminate between users

N95• Tracked supply and usage daily• Medical vs Industrial particulate respirators• UV Decontamination & re-use

Lose seal with re-use White and Brown bags, name & unit label

Reprocessing Respirators

COVID TestingInfection Preventionists (IPs) partnered with Infection Control Medical Directors, transitioned IP partnership to COVID ID Service

• Infection Preventionists provided COVID Testing Guidance

Travel history, Exposure, Signs & Symptoms

• Directed inpatient placement

COVID testing in ED, where to admit patient

Symptomatic vs Asymptomatic

Pre-procedural testing, admission testing

• Patient discharge from COVID unit

Inpatient and Outpatient isolation duration

Immunologically normal vs Immunosuppressed

Face MasksASTM face mask barrier protection standards

• Level 1: Low barrier protection. General use for low-risk, non-surgical procedures and exams that do not involve aerosols, sprays and fluids. Ear loop masks are level 1.

• Level 2: Moderate barrier protection for low to moderate levels of aerosols, sprays and fluids.

• Level 3: Maximum barrier protection for any situation that has potential for exposure to heavy levels of aerosols, sprays and fluids.

Infection Preventionist approval prior to purchase

EUA - Re-use and Extended use protocols

Storage options for re-use– paper towels, paper bags

Visitors

• Steri drape masks

• Cloth masks

Eye Protection

Infections can be introduced through the mucous membranes of the eye (conjunctiva)

• Direct exposure

• From touching eyes with contaminated fingers or objects

ANSI/ISEA Z87.1-2015 • This standard sets forth eye protection criteria related to general

requirements, testing and impact protection.

NIOSH • Protective eyewear appropriate for a given task

• Provides national guidelines for healthcare personnel

Types of Common eye protection (barrier)• Goggles - appropriately fitted, indirectly-vented goggles with minimum

gaps

• Face Shields – protects other facial areas

• Safety glasses – do not provide the same level of splash protection as goggles

• Full-face respirators

Eye Protection

Universal Eye protection is required by all staff members interacting directly with a patient without a physical barrier present or prior to entering a patient room or procedure area where patient exposure is anticipated.

Eye Protection

PPE: Gloves & Gowns

Donning & doffing sequence • Signs posted inside and outside

• Problem-prone procedure

• Self-contamination risk

Cloth Reusable gowns• Untie at neck, not overhead

• Supply with knotted ties

• Levels of gowns I, II, III, IV,

• Alternatives - bags, aprons, reuse

Supply Shortages• Surgical gowns, Infusion gowns

Supply issues• Infection Control consultation

• New vendor contract

Hand Sanitizer

Hand sanitizers are over-the-counter (OTC) drugs regulated by FDA• Temporary Policy for Manufacture of Alcohol for Incorporation

Into Alcohol-Based Hand Sanitizer Products During the Public Health Emergency (COVID-19), Updated August 7, 2020

• Enables pharmacies and registered outsourcing facilities to temporarily compound certain alcohol-based hand sanitizers

• Denatured Ethanol or Isopropyl alcohol only

• FDA provides approved labels, no outdate

• Expiration Date: “Hand sanitizer produced under the temporary policies may not have an expiration date listed because they are expected to be used during this public health emergency.”

• Dedicating wall mounted refills to point of care locations

• Collecting bottles for refill, no topping off.

• Sanitize bottles prior to filling.

DisinfectantsSanitizers, disinfectants, and sterilants are regulated• EPA regulates disinfectants and sterilants

used on environmental surfaces

EPA ‘N’ List – all products kill SARS-CoV-2 if used according to the label directions

• FDA regulates those used on critical or semicritical medical devices

National shortages• Dedicated germicidal tub wipes to point of

care wall brackets

• Partnered with Procurement Director to approve disinfectants for purchase

‘N’ List products, short contact time• Diluted bleach and wipes for general use

Mixed & distributed centrally

Labeled containers

COVID Flags Electronic Health RecordCOVID Flags on the EHR

• Symptomatic Rule Out COVID - Person under investigation, test in process

COVID – positive PCR test

• Asymptomatic Pre-surgical testing

Admission testing

Transplant recipient

• Patient admission under quarantine –how to identify?

Airborne & Contact precautions tied to flag

PCR tests allowable for flag placement

Automated vs manual process

Manual flag removal by Infection Preventionist

Flag dictates inpatient placement, transfer

Cohorting patients

Visitor GuidelinesScreening at entrances

• CMS IC COVID Assessment Tool

• Sticker system, date

Visitor restrictions for all inpatient care units

• End of life exceptions

• Clergy in Airborne rooms

• Visitors in quarantine

Opening up visitation

• Unchanged on COVID units

• One designated visitor per patient

Face mask requirements

Cohorting patients

COVID Guidance & Policies

• Developed early guidance

• PPE – Videos, posters

• Testing Criteria

• Patient Transportation

• Equipment at Point of

Use

• Tiered Environmental

Cleaning

• Acute Care, Ambulatory

• Isolation Guidelines

• Policies centrally located for easy reference

https://www.nebraskamed.com/for-providers/covid19

A wise saying…Don't be afraid to ask questions. Don't be afraid to ask for help when you need it. I do that every day. Asking for help isn't a sign of weakness, it's a sign of strength. It shows you have the courage to admit when you don't know something, and to learn something new.

– Barack Obama

QUESTIONS?

1. Pandemic Planning

a. Multidisciplinary teams

b. Public Health involvement

2. Organizational culture

a. Remain curious, ask questions

b. Assume positive intent

3. National guidelines

a. CDC COVID guidelines

b. Review international, federal, regulations & guidelines

4. Learn from each other – community support