Latest / The SHEA Podcast / COVID-19: Long-Term Care Post-Vaccination, 3/18/21

Transcript

COVID-19: Long-Term Care Post-Vaccination, 3/18/21 · The SHEA Podcast

• 0:08
  SPEAKER_02: Welcome to the Rapid Response Podcast brought to you by the Society for Healthcare Epidemiology of America, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:21
  SPEAKER_02: I'm Dr.
• 0:22
  SPEAKER_02: Christopher Cernich, Chief of Medicine and Hospital Epidemiologist at the Madison VA Hospital, and I will serve as your moderator today.
• 0:29
  SPEAKER_02: The discussion on the podcast does not reflect Shay's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:37
  SPEAKER_02: Shay is excited to launch this episode of the podcast COVID-19 updates what we know now.
• 0:44
  SPEAKER_02: Today's discussion will focus on long-term care with a specific focus on long-term care in the post-vaccination phase.
• 0:51
  SPEAKER_02: We're fortunate today to have our speaker as Dr.
• 0:54
  SPEAKER_02: Mohammed Salman Ashraf, who's an associate professor in the Department of Internal Medicine, Associate Medical Director of Antimicrobial Stewardship, and Associate Medical Director of Infection Control and Epidemiology at the University of Nebraska Medical Center.
• 1:07
  SPEAKER_02: He has been a leader in developing and implementing antibiotic stewardship strategies in nursing homes and has played a key role in nursing home responses to COVID-19 in his home state of Nebraska.
• 1:17
  SPEAKER_02: Thank you for joining us today.
• 1:18
  SPEAKER_02: Before we start a discussion, I'd like to turn it over to Dr.
• 1:21
  SPEAKER_02: Jennifer Hanrahan to get us started with brief news and guidance update for the week.
• 1:27
  SPEAKER_00: As of March 16, 2021, there have been almost 120 million confirmed cases of COVID-19, including 2,656,822 deaths reported to the World Health Organization.
• 1:40
  SPEAKER_00: A total of 363 million six hundred and ninety-one thousand two hundred and thirty eight vaccine doses have been administered globally.
• 1:47
  SPEAKER_00: Almost one-third of those doses have been administered in the United States.
• 1:51
  SPEAKER_00: In the news this week, there have been reports of European countries halting vaccination with AstraZeneca COVID-19 vaccine due to concerns over possible adverse events.
• 1:59
  SPEAKER_00: AstraZeneca issued the following statement on March 14th.
• 2:02
  SPEAKER_00: Following a recent concern raised around thrombotic events, AstraZeneca would like to offer its reassurance on the safety of its COVID-19 vaccine based on clear scientific evidence.
• 2:12
  SPEAKER_00: Safety is of paramount importance and the company is continually monitoring the safety of its vaccine.
• 2:17
  SPEAKER_00: A careful review of all available safety data of more than 17 million people vaccinated in the EU and UK with COVID-19 vaccine, AstraZeneca has shown no evidence of an increased risk of pulmonary embolism, deep vein thrombosis, or thrombocytopenia in any defined age group, gender, batch, or in any particular country.
• 2:34
  SPEAKER_00: So far across the EU and UK, there have been 15 events of DBT and 22 events of pulmonary embolism reported among those given the vaccine based on the number of cases the company has received as of March 8.
• 2:46
  SPEAKER_00: This is much lower than would be expected to occur naturally in a general population of this size and is similar across other licensed COVID-19 vaccines.
• 2:54
  SPEAKER_00: The monthly safety report will be made public on the European Medicines Agency website in the following week in line with exceptional transparency measures for COVID-19.
• 3:03
  SPEAKER_00: Furthermore, in clinical trials, even though the number of thrombotic events was small, these were lower in the vaccinated group.
• 3:09
  SPEAKER_00: There also has been no evidence of increased bleeding in over 60,000 participants enrolled.
• 3:14
  SPEAKER_00: The British Medical Journal website reports that doctors have warned of the risks associated with pausing or delaying vaccination programs against COVID-19, as the number of European countries that have halted use of Oxford University and AstraZeneca vaccine rose to 16.
• 3:28
  SPEAKER_00: Denmark, Norway, Bulgaria, Iceland, France, Germany, Italy, Spain, Portugal, Slovenia, and Cyprus have suspended all use of the vaccine, and Austria, Estonia, Latvia, Lithuania, and Luxembourg have paused the use of a single batch of a million doses of the vaccine.
• 3:42
  SPEAKER_00: The World Health Organization and the EMA have said that there does not seem to be an increased risk of blood clots with the vaccine and have advised that vaccinations should continue.
• 3:52
  SPEAKER_00: Belgium, Poland, Ukraine, and the Czech Republic have followed advice from the UK's regulators to keep vaccinations going.
• 3:58
  SPEAKER_00: Stephen Griffin, associate professor in the School of Medicine at the University of Leeds, said that although reports of a small number of blood clots should be investigated, the response of many countries to halt vaccinations was disproportionate.
• 4:09
  SPEAKER_00: Since many European countries are currently experiencing another resurgence of SARS-CoV-2 infections and yet are lagging behind in terms of the rollout, the importance of continuing the vaccination programs cannot be overestimated, and the harm caused by depriving people of access to a vaccine will likely vastly outweigh even the worst case scenario if any link to the clotting disorders is eventually found.
• 4:30
  SPEAKER_00: It should also be noted that nationwide gestures such as this are bound to fuel hesitancy or more extreme anti-vaccine sentiment, further undermining the vaccination effort, Dr.
• 4:40
  SPEAKER_00: Griffin said.
• 4:41
  SPEAKER_00: An article published in Clinical Infectious Diseases on March 10th describes the impact of the COVID-19 vaccine on asymptomatic infection among patients undergoing pre-procedural COVID-19 molecular screening.
• 4:52
  SPEAKER_00: Authors conducted a retrospective cohort study of consecutive asymptomatic adult patients within a large United States healthcare system who underwent 48,333 procedural SARS-CoV-2 molecular screening tests between December 17, 2020 and February 8, 2021.
• 5:09
  SPEAKER_00: The primary exposure of interest was vaccination with at least one dose of a messenger RNA COVID-19 vaccine.
• 5:15
  SPEAKER_00: Positive molecular tests in asymptomatic individuals were reported in 1.4% of 3,006 tests performed on vaccinated patients and on 3.2% of 45,327 tests performed on unvaccinated patients.
• 5:30
  SPEAKER_00: Compared to unvaccinated patients, the risk of asymptomatic SARS-CoV-2 infection was less than half among those more than 10 days after the first dose and lower still after the second dose.
• 5:40
  SPEAKER_00: The authors conclude that COVID-19 vaccination with a messenger RNA-based vaccine showed a significant association with reduced risk of asymptomatic SARS-CoV-2 infection as measured during pre-procedural molecular screening.
• 5:52
  SPEAKER_00: The results of this study demonstrate the impact of vaccines on reduction in asymptomatic infections, supplementing the randomized trial results on symptomatic patients.
• 6:01
  SPEAKER_00: And that's the news this week.
• 6:02
  SPEAKER_02: Thank you, Dr.
• 6:03
  SPEAKER_02: Hanrahan.
• 6:04
  SPEAKER_02: I now want to move into our discussion with our speaker.
• 6:06
  SPEAKER_02: Thank you again, Dr.
• 6:07
  SPEAKER_02: Ashroff, for joining us today.
• 6:09
  SPEAKER_01: Thank you, Dr.
• 6:09
  SPEAKER_01: Sonic, for allowing me to be present today and talk about this very important topic.
• 6:14
  SPEAKER_02: So I have got a lot of questions for you, but I first wanted to kind of ask from your perspective, how do you feel the vaccine rollout has been going in nursing homes?
• 6:23
  SPEAKER_01: So in the beginning, there were some confusions with the federal partners program with the pharmacies on scheduling and whether they will be coming in and providing vaccination to residents who are in quarantine, et cetera, and those kind of logistical issues.
• 6:34
  SPEAKER_01: But once those things were sorted out, things went well, in my opinion.
• 6:38
  SPEAKER_01: And we were able to vaccinate around 80% or more of the long-term care residents.
• 6:43
  SPEAKER_01: So the challenge, I think, now is how to maintain that higher rate of resident vaccinations in the long-term care facilities since the pharmacy partners program has ended.
• 6:52
  SPEAKER_01: It has been up to the states now to come up with protocols on how to vaccinate new residents and even newer staff in the building or those who may have refused the vaccination earlier but now want to proceed with the vaccination.
• 7:03
  SPEAKER_01: This is an area where we are now seeing challenges.
• 7:06
  SPEAKER_01: Mostly this part is up to the state to decide and sometimes even for the local health department to take steps.
• 7:11
  SPEAKER_01: We probably need to make sure that we continue to have a solid program to keep this momentum going.
• 7:16
  SPEAKER_01: But overall, I think, apart from some confusion that were there in the beginning, we've seen pretty good rollout.
• 7:22
  SPEAKER_02: So I want to come back to some of those challenges that you alluded to.
• 7:25
  SPEAKER_02: But I guess the question I want to kind of ask you before we get to that is at this point, do we have compelling or strong evidence that vaccination is kind of bending the curve, so to speak, in nursing homes?
• 7:37
  SPEAKER_02: And if so, what does that look like and how optimistic should we be that the vaccination is really kind of having the impact we were hoping for in long-term care?
• 7:46
  SPEAKER_01: That is a good question.
• 7:47
  SPEAKER_01: And I can tell you that we have seen a few things that are telling us some good news.
• 7:50
  SPEAKER_01: Since the vaccination has started and became more widespread in the long-term care facilities, we have seen a sharp decline in the number of COVID-19 cases.
• 7:58
  SPEAKER_01: Yeah, it is true that community cases have also declined, which may also be contributing to the lower case count in the long-term setting.
• 8:06
  SPEAKER_01: However, the decline in the nursing home cases appears to be more than what we are seeing in the community, which point towards the possible positive impact of the vaccination in these settings.
• 8:17
  SPEAKER_01: You know, one of my personal observations over the last couple of weeks in our state is that we are seeing much less resident cases than the staff cases.
• 8:26
  SPEAKER_01: And most of the cases that we are seeing are among those who are not vaccinated.
• 8:30
  SPEAKER_01: Less resident cases than the staff cases reflects the reality that many more residents are vaccinated as compared to the staff.
• 8:38
  SPEAKER_01: It may also mean that even when staff are positive and COVID-19 is introduced into the building, residents are not probably easily getting the infection and it is not leading to large-scale outbreaks.
• 8:49
  SPEAKER_01: Having said all of that, I want to point out that we have a very vulnerable population in the long-term care facilities, and there will definitely be a small minority of the residents who may not develop robust immunity and may still get COVID-19.
• 9:01
  SPEAKER_01: So it will be our responsibility to take all the recommended infection control measures, even in those facilities where all, you know, most of the residents are vaccinated.
• 9:10
  SPEAKER_01: In addition, we need to continue to work on encouraging all of our staff to get vaccinated too.
• 9:15
  SPEAKER_01: In my opinion, we will probably see best results in those long-term care facilities that have higher vaccination rates in both staff and residents.
• 9:25
  SPEAKER_01: So all good news.
• 9:26
  SPEAKER_01: I think we still need to be careful and do our due diligence with infection control measures and follow them.
• 9:31
  SPEAKER_01: But I'm seeing good trends.
• 9:32
  SPEAKER_02: That kind of leads into, I think, a topic that has been discussed a lot, kind of not just in nursing homes, but overall has been kind of the issue of vaccine hesitancy.
• 9:40
  SPEAKER_02: And you kind of alluded to the fact that the cases that you are seeing in your facilities appear to kind of be related among staff who haven't gotten vaccinated.
• 9:50
  SPEAKER_02: Where do you think that is going?
• 9:52
  SPEAKER_02: And do you feel like there's enough evidence or kind of urgency to kind of be moving towards a mandatory vaccination for staff, at least in long-term care?
• 10:04
  SPEAKER_01: So as a nation, we are encountering vaccine hesitancy to some degree everywhere.
• 10:09
  SPEAKER_01: You know, in the one part, I'm actually glad that long-term care residents have low rates of vaccine hesitancy and high vaccination uptakes.
• 10:17
  SPEAKER_01: In Nebraska, you know, at least whenever I'm asking a facility about their resident vaccination rates, I'm hearing again and again 90% or above.
• 10:25
  SPEAKER_01: And it appears that, you know, the similar trends of higher resident vaccination rates are uniform across the country.
• 10:30
  SPEAKER_01: However, I'm concerned about the vaccine, as you said, vaccine hesitancy rate among the nursing home staff.
• 10:36
  SPEAKER_01: And there are a few steps that I think can be taken, and I've advised nursing homes to consider some of those steps.
• 10:43
  SPEAKER_01: I think mandatory vaccination is probably a step that we can take sometime in the future, you know, once the vaccinations are more FDA approved and things like that.
• 10:51
  SPEAKER_01: But in the meantime, I think we can take a few steps that I have discussed with some of our nursing home leadership.
• 10:57
  SPEAKER_01: First of all, what I've told them is that the nursing home leadership should provide all the relevant education about the vaccines to their staff.
• 11:03
  SPEAKER_01: They should inform them about what the facts are and what are the myths.
• 11:07
  SPEAKER_01: And then, secondly, arrange the session with them to answer their questions publicly, like a town hall setting in the building or even virtual town hall, they can do that.
• 11:15
  SPEAKER_01: And then the third is after those two things, if there are still staff members out there that are not on board yet, consider one-on-one sessions with those staff who are still hesitant and find out what their one fear is, what they are really hesitant about.
• 11:30
  SPEAKER_01: And maybe on a one-on-one setting, you can identify it better and you can answer that better.
• 11:35
  SPEAKER_01: And maybe after that conversation, they will change their mind.
• 11:38
  SPEAKER_01: The fourth thing that I have kind of mentioned to the facilities, and some have found that useful, is making vaccination a cool thing to have.
• 11:47
  SPEAKER_01: So making it something that everybody is looking forward to.
• 11:50
  SPEAKER_01: So what we have said is that you know the leadership to publicly take the vaccine, identify champions who want to share their story of why they choose to get the vaccine, and also highlighting the story of those staff members who changed their mind about vaccination, as long as they're willing to share that story.
• 12:07
  SPEAKER_01: It's all good thing.
• 12:08
  SPEAKER_01: So when I said that to a group of nursing homes to make vaccination a cool thing, I heard back from one of them, and they said when they thought about that, they then went back and made their vaccination day as a celebration day and have a party-like atmosphere in the building while still maintaining all the infection control practices.
• 12:25
  SPEAKER_01: They said that it was like a party day, they have music on, and you know, and everybody was high-fiving in the air with each other, and that kind of helped them get that energy going toward into the vaccination where people wanted to get the vaccine.
• 12:39
  SPEAKER_01: And then finally, at the local and estate levels, I think recognizing the efforts of those facilities where staff came together and make a decision to get vaccinated, it's also important, you know, even at the state and local health department level to recognize where the effort has been made and celebrate their success.
• 12:57
  SPEAKER_01: So in Nebraska, you know, our team has initiated what we call a vaccine wall of honor program, where any facility that have achieved either 70%, 80%, or 90% staff vaccination rate can get a bronze, silver, and gold recognition.
• 13:11
  SPEAKER_01: And their stories get shared on the social media, their names come on our website, they do get a certificate from us, and anyone can basically they can self-report.
• 13:20
  SPEAKER_01: And if they don't choose to do that, that's fine.
• 13:22
  SPEAKER_01: But if they want to, and we encourage them to kind of share their success story with us.
• 13:26
  SPEAKER_01: And every week we announce their name on a live webinar who those facilities are and whether they have achieved those status.
• 13:33
  SPEAKER_01: And I think that that is kind of helping us.
• 13:35
  SPEAKER_01: We have over probably over 30 or 40 facilities that in our state that we have already announced as one of those honors that they have received.
• 13:44
  SPEAKER_01: And there's on our website, on the Nebraska ICAP website, you can find the names of those facilities.
• 13:48
  SPEAKER_01: So I think those are the ways where you can make an effort to encourage people to get vaccinated.
• 13:53
  SPEAKER_01: And then mandatory vaccination, maybe later on.
• 13:56
  SPEAKER_01: People have done influenza vaccination as mandatory in the past.
• 13:59
  SPEAKER_01: Or at least, you know, there have been organizations in the acute care setting, if not all the long-term care setting that have made influenza vaccination mandatory.
• 14:06
  SPEAKER_01: So one day can we also make COVID-19 vaccine mandatory?
• 14:10
  SPEAKER_01: I think with the effectiveness we are seeing and all those things, it probably can be.
• 14:14
  SPEAKER_02: Those are all good suggestions.
• 14:16
  SPEAKER_02: And I certainly think it makes sense to hold off until we've got full FDA approval before we go down with mandates.
• 14:23
  SPEAKER_02: So kind of like to slightly pivot, you know, now that we are seeing case rates bending downwards so rapidly in nursing homes, again, as you point out, whether that's a combination of decreased activity in the community coupled with a vaccine effect, I think is not entirely clear.
• 14:39
  SPEAKER_02: But I guess I want to get your opinions and insights on, you know, how should nursing homes kind of move forward with relaxing a lot of the restrictions that were appropriately put in place, particularly around visitations and group activities in particular.
• 14:53
  SPEAKER_02: As you're probably aware, Centers for Medicaid and Medicare services kind of updated their visitation and group activities guidelines a week or two ago.
• 15:02
  SPEAKER_02: And I'm just wondering if you can kind of summarize what has changed and how that's affecting things in your state.
• 15:09
  SPEAKER_01: Well, the biggest change that I've seen in that memo is allowing indoor visitation, even in the red counties that are seeing high rate of transmissions in the community.
• 15:20
  SPEAKER_01: They are allowed to have indoor vegetation as long as they have more than 70% of the residents who are vaccinated.
• 15:26
  SPEAKER_01: So before they were not allowed to have indoor vegetation except the compassionate care situation, but now they are allowed to have visitation as long as they achieved the higher rate of vaccination in the residents.
• 15:36
  SPEAKER_01: So that's that's one big change.
• 15:37
  SPEAKER_01: Another big change, I think, for the purpose of coming together is that they are allowing visitors to come into close contact with fully vaccinated residents while you still have to wear the mask and have to adhere to hand hygiene practices, but they can they can have that close touch, hugging, things like that while wearing the mask.
• 15:56
  SPEAKER_01: So those are two big, I think, changes.
• 15:58
  SPEAKER_01: Then another change that was outlined in that memo was during an outbreak settings.
• 16:04
  SPEAKER_01: They continue to now allow indoor visitation as long as the outbreak has been determined to be in a particular set of the building, a particular area of the building, and the rest of the area is not seeing any cases, then you can have the visitation even in those areas other than to shut the entire facility down.
• 16:19
  SPEAKER_01: Actually, in compassionate care situations, you can always have that visitation in an outbreak setting.
• 16:25
  SPEAKER_01: I think we are talking more about regular visitation.
• 16:27
  SPEAKER_01: And then you were asking about, you know, like group activities, also, I think.
• 16:31
  SPEAKER_01: And what I have noticed is that those things may have not seen big changes.
• 16:35
  SPEAKER_01: That the communal dining, the group activities, those are still the same standards as we had before.
• 16:41
  SPEAKER_01: They have at least yet, they have not changed those things.
• 16:44
  SPEAKER_01: So you can still have small group activities, try to social distance.
• 16:48
  SPEAKER_01: You can still have a communal dining, but try to social distance or have some, you know, barriers between the residents, the Plexigas barrier while they're having the meal together.
• 16:58
  SPEAKER_01: So I think some of those things have not have not changed that much.
• 17:01
  SPEAKER_01: Those are the main, I think, summaries.
• 17:03
  SPEAKER_02: So we're seeing some kind of return backwards, but not quite back to kind of pre-COVID precautions.
• 17:09
  SPEAKER_02: And I guess my question is, do you think we're ever going to get back to kind of pre-COVID visitation group activity levels?
• 17:17
  SPEAKER_02: Is that going to happen?
• 17:18
  SPEAKER_02: And if so, what's going to need to happen to get us there?
• 17:20
  SPEAKER_01: Well, I think it's probably a difficult question, but I do believe that visitation policies will return back to pre-COVID standard at some point in future.
• 17:28
  SPEAKER_01: It will depend on the community vaccination rates and us achieving a herd immunity and the cases going down significantly.
• 17:35
  SPEAKER_01: You know, another factor that we have to look for is how the vaccine is performing in the long-term care setting and its impact on individual resident outcomes and overall outbreaks in the building.
• 17:47
  SPEAKER_01: If we continue to find the vaccine to be highly efficacious, as we are seeing right now in nursing home population, and also in preventing transmission within the building, also hospitalization and deaths, then that combined with low community prevalence of COVID-19 can be the trigger to more normalcy.
• 18:02
  SPEAKER_02: That's great.
• 18:03
  SPEAKER_02: Looking forward to that.
• 18:05
  SPEAKER_02: So obviously, one of the other strategies that nursing homes implemented is active surveillance of staff for colonization or infection with COVID-19.
• 18:16
  SPEAKER_02: And I guess I'm trying to understand, you know, how that is going to change if at all moving forward.
• 18:23
  SPEAKER_02: And do you have any sense of kind of what you're doing in your state related to routine staff surveillance testing?
• 18:30
  SPEAKER_01: Yeah, so so active surveillance testing in our state, and I think in most of the places in the country, is currently dependent on the level of community transmission of COVID-19 in the in the basically in the community.
• 18:41
  SPEAKER_01: So I do believe we need to continue those active surveillance at this point based on the community level of transmission.
• 18:47
  SPEAKER_01: So we can initiate our outbreak response as soon as we identify a case in the building while we are kind of gathering all this other data that I just talked about.
• 18:56
  SPEAKER_01: And even though, you know, the early indications are good that if there are high resident vaccination rates in the building, we may not see widespread outbreaks, but we are still awaiting more data over time to be sure about that.
• 19:08
  SPEAKER_01: And that's what we are waiting for.
• 19:09
  SPEAKER_01: In addition to the lower community transmission of COVID-19, the other factor that may decrease our reliance on surveillance testing will be the higher staff and resident vaccination rates, especially when the data becomes clear that by itself, this combination ensures resident safety and eliminates transmission of COVID-19 in the building.
• 19:27
  SPEAKER_01: As of this point, because the staff vaccination rates are not that high, not as high as what we are seeing in the residents, I think it still makes sense to continue to do the active surveillance, especially within the communities that are seeing what we call the red counties and the yellow counties right now.
• 19:43
  SPEAKER_01: It will make sense to do active surveillance in those communities while we are gathering data on how the vaccination is impacting the long-term care as a whole.
• 19:51
  SPEAKER_02: Do you think that there will be a policy that kind of ties surveillance to kind of staff vaccination rates, or do you think they're going to keep it kind of completely tied to community levels of COVID-19 to make that determination?
• 20:05
  SPEAKER_01: Let me answer this way.
• 20:06
  SPEAKER_01: I think it would be reasonable as we go forward to take into consideration the vaccination rate and make decisions based on the vaccination rate.
• 20:15
  SPEAKER_01: Whether they are going to do it now or it will take more time before we do that, it is yet to be seen.
• 20:21
  SPEAKER_01: I think we have seen in some of our assisted living facilities that are not really mandated by the CMS and have been recommended to do surveillance testing, but not kind of put a mandate on them.
• 20:32
  SPEAKER_01: And some of them have decided that they're going to continue to ask their non-vaccinated staff members to continue to get testing, but not going to test their vaccinated staff.
• 20:42
  SPEAKER_01: They have made their decision because I think they can.
• 20:45
  SPEAKER_01: Right now, the the nursing homes are, you know, especially the ones that are under CMS, they don't have that capacity to make those decisions.
• 20:52
  SPEAKER_01: But I think at some point of time, if they if they switch to that more, it will make sense.
• 20:55
  SPEAKER_01: I don't know when that's going to happen, though.
• 20:57
  SPEAKER_01: I have no idea right now.
• 20:59
  SPEAKER_02: Well, that's interesting.
• 20:59
  SPEAKER_02: And then kind of the last, you know, beyond kind of the masking issue, kind of intervention that's been implemented in nursing homes, at least I've heard, has kind of been an issue from the start, has been this issue of quarantining patients that are being transferred from the hospital to the skilled nursing facility.
• 21:16
  SPEAKER_02: And these individuals are expected to be quarantined to their rooms for 14 days before they they get released to kind of the general population in the facility.
• 21:25
  SPEAKER_02: Do you kind of see anything different about that, or is it kind of the same thing?
• 21:29
  SPEAKER_02: It's going to be tied to community rates, and we'll kind of see that being relaxed around the same time that we see visitation and some of these other issues relaxed by CMS.
• 21:39
  SPEAKER_01: So I can tell you what we did in Nebraska.
• 21:41
  SPEAKER_01: We just rolled out, our team just rolled out a suggested plan for the facilities for residents who are coming to the building, either as new admission, readmission, or community outing after they have been fully vaccinated.
• 21:53
  SPEAKER_01: We have suggested that the fully vaccinated residents without any known exposure to COVID 19, known exposure.
• 22:00
  SPEAKER_01: Exposure to COVID-19 do not need to quarantine empirically.
• 22:04
  SPEAKER_01: However, we have suggested that the nursing homes consider testing them twice weekly for two weeks after they have returned back.
• 22:12
  SPEAKER_01: Now, this includes, as I said, admission, readmission, or community outing.
• 22:16
  SPEAKER_01: The reason we came to that conclusion is that we we we know from the experience we had so far, and we call it gray zone in our state, those observation units.
• 22:26
  SPEAKER_01: So the reason that we came to this conclusion is that we have not seen a high number of cases in our gray zone among those we were empirically quarantining there.
• 22:34
  SPEAKER_01: And then secondly, with the vaccination, that risk is now already lower than before.
• 22:39
  SPEAKER_01: And then third, most of our facilities have high vaccination rates among residents, which will provide additional protection from widespread outbreaks.
• 22:47
  SPEAKER_01: So there will still be some risk that every now and then someone will come in the building that will develop COVID-19.
• 22:52
  SPEAKER_01: However, you know, we are balancing that small risk with a testing program in place that will at least identify that case early and with the outbreak measures, then we can put in place right away to avoid any further spread in the building.
• 23:06
  SPEAKER_01: You know, I think our plan is to continue to monitor the data right now and see whether testing is adding the value that we think we might add to overall outbreak prevention and containment effort.
• 23:16
  SPEAKER_01: And then, you know, after that, some time has gone by, we can look back and see whether whether we were able to identify cases through those testing or prevent some outbreaks through that testing or not.
• 23:27
  SPEAKER_01: And if it comes out that the testing was not even identifying any other additional cases at all, anyhow, then maybe that will be the time when we will even go away with that relaxation.
• 23:35
  SPEAKER_01: So the CDC has come out and they have said already that on admission, empowered quarantine is not needed.
• 23:42
  SPEAKER_01: And that was the trigger when CDC came out with this recommendation.
• 23:46
  SPEAKER_01: I had some discussion with some of our CDC colleagues about what made them proceed with that recommendation.
• 23:51
  SPEAKER_01: And then we made that decision after that conversation that we can probably safely allow people to go out after fully vaccination and come back, but have some measures right now so that kind of graded fashion we can go away with that recommendation.
• 24:04
  SPEAKER_01: So I think some facilities have liked this, other facilities have gotten a scale with that.
• 24:10
  SPEAKER_01: So we're kind of getting a mixed feeling from the facilities right now.
• 24:13
  SPEAKER_01: But we have also said to the facilities that you can do individual risk assessments on a visit.
• 24:18
  SPEAKER_01: You can do individual risk assessments.
• 24:19
  SPEAKER_01: If somebody is gone out in a wedding of 100 people where everybody was massless, and you are really concerned that even though they are fully vaccinated, this is much of a high risk.
• 24:28
  SPEAKER_01: You can make individual decisions based on the risk assessment that you can ask that person to be in the gray zone.
• 24:34
  SPEAKER_01: Individual decisions can be made.
• 24:36
  SPEAKER_02: That trepidation is something I imagine I'm going to feel, you know, trying to go back to a restaurant after this all ends.
• 24:42
  SPEAKER_02: So I certainly understand that feeling.
• 24:44
  SPEAKER_02: So before we conclude, I I'd like to get your perspective on a couple of issues around what we've learned from the COVID-19 pandemic as it relates to nursing homes and specifically how you think we might need to alter our approach to the prevention of respiratory viral infections in this setting in the future.
• 25:01
  SPEAKER_02: And so if we kind of look at that, do you feel that there's any infection prevention changes that you feel are going to become permanent in nursing homes as a result of COVID-19?
• 25:11
  SPEAKER_01: There are a few things I think that can definitely change.
• 25:14
  SPEAKER_01: I'm sure there will be more emphasis now on a respiratory protection program in all long-term care settings, with employees being asked to get fit tested on N95 respirators, and the facilities will have to keep some respirators in the stock along with other PPE.
• 25:28
  SPEAKER_01: So that was not an emphasis before, and I think that will become more of an emphasis as we go forward.
• 25:34
  SPEAKER_01: The other thing, the pandemic has also emphasized the need for a trained infection preventionist at the nursing home, and many places have to increase the hours for infection preventionists that they dedicate to spend on infection control measures.
• 25:47
  SPEAKER_01: I do believe that there will be some recommendations for IPs to maintain a higher number of dedicated hours to oversee the program.
• 25:54
  SPEAKER_01: You know, that was the part that in the past CMS have left or the facilities to kind of do their individual risk assessment and things like that.
• 26:01
  SPEAKER_01: I think there might be some changes on how we can even make a little bit better on that.
• 26:05
  SPEAKER_01: So that is another area.
• 26:07
  SPEAKER_01: You know, masking has not only helped with decreasing the case of COVID-19, but it's probably also saved life by decreasing some other respiratory illnesses, especially influenza.
• 26:16
  SPEAKER_01: So I do see the recommendations may come along that during the peak respiratory season, employees may be asked to do universal masking in the facilities.
• 26:25
  SPEAKER_01: That is a possibility.
• 26:27
  SPEAKER_01: That's something that I think people have to think about and maybe even consider.
• 26:31
  SPEAKER_01: And then, you know, one other thing that I was thinking is that nursing homes will have to pay attention to airflow in the building and will have to develop protocols for minimizing risk of airborne disease transmission taking into account their ventilation system.
• 26:44
  SPEAKER_01: It is not out of the realm of possibilities that some codes and requirements may change, also.
• 26:49
  SPEAKER_01: However, if that happens, the nursing home will need funding, guidance, technical support to make those changes.
• 26:54
  SPEAKER_01: It's not going to be an easy change to make.
• 26:57
  SPEAKER_01: So I'm not sure how confident I feel that that change will happen, but I think there will be some push towards that.
• 27:03
  SPEAKER_01: Maybe one other point that I can think of is we have also learned about point-of-care testing and its use in the nursing home, which have probably saved life also and make our response faster and things like that.
• 27:14
  SPEAKER_01: You know, maybe there can be some other push on like point of care testing as we go forward.
• 27:18
  SPEAKER_01: Again, all of these things means that we'll probably have to reimburse nursing home a little more than what we do because there will be more of expenses with all of these measures that I'm talking about.
• 27:29
  SPEAKER_01: Those are the top things that come to my mind right now.
• 27:32
  SPEAKER_01: I don't know whether you have other things that you have been thinking about.
• 27:35
  SPEAKER_02: No, I mean, you really hit a lot of the big items here.
• 27:38
  SPEAKER_02: We covered a lot of ground today, and I feel like we've all benefited from your discussion here.
• 27:43
  SPEAKER_02: I want to thank you for being our speaker today and for sharing your perspectives and experiences.
• 27:48
  SPEAKER_02: This podcast can be accessed on SHA's online education center, Learning CE, under the Rapid Response Program.
• 27:55
  SPEAKER_02: You will also find resources such as the recorded webinars, healthcare facility outbreak preparedness, and the SHA's COVID-19 town halls.
• 28:03
  SPEAKER_02: New members can now receive 50% off of 2021 SHA membership by using the coupon code WELCOME2021 until March 31st.
• 28:12
  SPEAKER_02: This concludes this episode of the Rapid Response Podcast.
• 28:15
  SPEAKER_02: Thank you for tuning in.