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COVID-19: Reopening Ambulatory Practices · The SHEA Podcast

• 0:08
  SPEAKER_01: Welcome to the Rapid Response Podcast brought to you by the Society of 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.
• 0:25
  SPEAKER_01: I'm Dr.
• 0:25
  SPEAKER_01: Wali Chavez, hospital epidemiologist at the Montanaai Downtown, and I'll serve as your moderator.
• 0:33
  SPEAKER_01: The discussion on this podcast does not reflect Shea's perspective but facilitates communication as we go through this challenging time together.
• 0:42
  SPEAKER_01: She is excited to launch the 17th episode of this podcast COVID-19 update, what we know now.
• 0:50
  SPEAKER_01: Today's episode will focus on reopening ambulatory practices.
• 0:55
  SPEAKER_01: Our speakers today include Dr.
• 0:58
  SPEAKER_01: Jennifer Hannerhand, a Chief Infection Specialist at the University of Toledo.
• 1:03
  SPEAKER_01: We have Dr.
• 1:04
  SPEAKER_01: Kelly Cassano, Dean of Clinical Affairs and Senior Vice President of Ambulatory Operations at Mount Sinai Health System.
• 1:12
  SPEAKER_01: And Dr.
• 1:13
  SPEAKER_01: Bernard Kamen, Medical Director of Infection Prevention at Mount Sinai Health System.
• 1:18
  SPEAKER_01: Thank you for joining us today.
• 1:20
  SPEAKER_01: I would like to turn it over to Dr.
• 1:22
  SPEAKER_01: Hennerhan to get us started with a brief reviews and guidance update for this week.
• 1:28
  SPEAKER_00: Thank you.
• 1:29
  SPEAKER_00: On June 4th, the U.S.
• 1:31
  SPEAKER_00: Department of Health and Human Services announced new guidance that specifies what additional data must be reported to Health and Human Services by laboratories along with COVID-19 test results.
• 1:42
  SPEAKER_00: The guidance standardizes reporting to ensure that public health officials have access to comprehensive and nearly real-time data to inform decision-making in their response to COVID-19.
• 1:53
  SPEAKER_00: The Health and Human Services Secretary Alex Azar states that Health and Human Services and the entire Trump administration are deeply concerned that COVID-19 is having a disproportionate impact on certain demographics, including racial minorities and older Americans.
• 2:07
  SPEAKER_00: The requirement to include demographic data like race, ethnicity, age, and sex will enable Health and Human Services to ensure that all groups have equitable access to testing and allow more accurate determination of burden of infection on vulnerable groups.
• 2:22
  SPEAKER_00: Among multiple guidance documents, CDC has added some guidance for running essential errands for people who are at higher risk for severe disease.
• 2:30
  SPEAKER_00: It reminds people first and foremost to stay home if sick, use online services when available, wear a cloth-face covering when running errands, use social distancing, use hand sanitizer after leaving stores, and if possible, use touchless payment.
• 2:45
  SPEAKER_00: But if people have to handle money or a credit card, they should use hand sanitizer right after paying.
• 2:51
  SPEAKER_00: And then when people get home, they should wash their hands with soap and water for at least 20 seconds.
• 2:55
  SPEAKER_00: One of the important points that they make is that there is no evidence that food or food packaging play a significant role in spreading the virus in the United States.
• 3:04
  SPEAKER_00: This is an important point because people have been asking whether they need to disinfect their groceries on returning home.
• 3:10
  SPEAKER_00: Another topic that has been in the news quite a bit is the multisystem inflammatory syndrome in children.
• 3:17
  SPEAKER_00: So there have been a lot of questions from colleagues who deal with pediatrics about the multisystem inflammatory syndrome that has been described.
• 3:24
  SPEAKER_00: A case series was published June 8th in JAMA describing the clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2.
• 3:36
  SPEAKER_00: There was also another series of 17 children from New York that was published on the same date.
• 3:41
  SPEAKER_00: The series included hospitalized children, a subset of whom required intensive care and met criteria for pediatric inflammatory multisystem syndrome, including fever, inflammation, and organ dysfunction.
• 3:52
  SPEAKER_00: Of these children, all had fever and nonspecific symptoms such as abdominal pain, rash, and conjunctival injection, half developed shock and required inotropic support or fluid resuscitation.
• 4:03
  SPEAKER_00: 22% met diagnostic criteria for Kawasaki disease, and eight of 58 had coronary artery dilatation or aneurysms.
• 4:11
  SPEAKER_00: Differentiation from Kawasaki disease was based on clinical and laboratory data.
• 4:15
  SPEAKER_00: Another point that has raised a lot of questions is whether patients or whether people can self-collect swabs, as is being done in some outpatient settings and in commercial settings.
• 4:27
  SPEAKER_00: There was a brief study published in the New England Journal of Medicine demonstrating that self-collected swabs, including tongue, nasal, and mid-turbinate swabs, correlated with nasopharyngeal swabs collected by healthcare workers, with the highest correlation coefficient demonstrated with the mid-turbinate swabs, and concluded that this may be an acceptable method for specimen collection that could reduce PPE use and provide a more comfortable patient experience.
• 4:53
  SPEAKER_00: And finally, one of the most important public health questions is whether schools should reopen in the fall.
• 4:59
  SPEAKER_00: An editorial was published in JAMA on June 1st titled The Urgency and Challenge of Opening K-12 Schools in the Fall of 2020 and described some of the measures that will be needed to safely open schools and planning that should be taking place now.
• 5:14
  SPEAKER_00: It is thought-provoking and something that all of us should be paying attention to.
• 5:19
  SPEAKER_01: Thank you very much, Dr.
• 5:20
  SPEAKER_01: Han.
• 5:21
  SPEAKER_01: I now want to move into discussion with Dr.
• 5:23
  SPEAKER_01: Cassano and Dr.
• 5:24
  SPEAKER_01: Kamins on reopening ambulatory practices.
• 5:28
  SPEAKER_01: So we will get into screening questions first.
• 5:30
  SPEAKER_01: So, Dr.
• 5:31
  SPEAKER_01: Cassano, how are you screening patients coming into ambulatory care?
• 5:35
  SPEAKER_01: Are we doing any symptoms screening or temperature taking?
• 5:39
  SPEAKER_01: What are the processes?
• 5:41
  SPEAKER_03: Good afternoon, everyone.
• 5:42
  SPEAKER_03: Thank you.
• 5:42
  SPEAKER_03: So, yes, we are screening all patients who come to any of our ambulatory practices, regardless of the size or location of the practices.
• 5:50
  SPEAKER_03: We do begin with really three main components of the screening.
• 5:54
  SPEAKER_03: One is a temperature check using an infrared thermometer.
• 5:57
  SPEAKER_03: The second would be a series of symptomatic symptom checks, so asking whether or not they had been diagnosed or exposed to COVID in the past 14 days, and then a series of questions around fever chills, cough, shortness of breath, body aches, loss of taste or smell, or change in appetite, or GI symptoms.
• 6:16
  SPEAKER_03: We'll also offer them a surgical mask as a face covering should they have a homemade mask or any mask other than a surgical mask.
• 6:24
  SPEAKER_03: And those are the three steps that we're taking as patients are entering our practices.
• 6:30
  SPEAKER_01: Thank you.
• 6:30
  SPEAKER_01: Dr.
• 6:31
  SPEAKER_01: Caymans, are you handling visitors coming in with patients to ambulatory care practices?
• 6:38
  SPEAKER_02: At this point, we are actually not allowing any visitors to come in with patients.
• 6:44
  SPEAKER_02: The only exception to that is that we are screening healthcare aides who need to accompany a patient who may have some disabilities or who may need help getting around, or potentially family members who are the primary caregivers of patients who need extra care.
• 7:02
  SPEAKER_02: They are all screened for symptoms as well, and their temperature are also being taken.
• 7:07
  SPEAKER_02: But otherwise, we are limiting the number of visitors to any of the practices just to prevent our healthcare workers and other patients from being exposed to COVID-19.
• 7:18
  SPEAKER_01: So we're going to get into some PPE and social distancing questions, and I'll ask Dr.
• 7:23
  SPEAKER_01: Cusano what is the PPE that providers are using in ambulatory care settings?
• 7:29
  SPEAKER_03: Sure, of course.
• 7:29
  SPEAKER_03: So our universal masking policy is the surgical mask, so that anybody in our practices, regardless of their role, title, position, clinical, or non-clinical, will be in a surgical mask throughout their entire time in the practice.
• 7:43
  SPEAKER_03: That same mask again is offered to all of our patients.
• 7:46
  SPEAKER_03: With regard to the PPE being used for anything other than general interactions, really varies by type of interaction and perhaps the specialty.
• 7:56
  SPEAKER_03: So we've established a series of guidelines in partnership with uh Dr.
• 8:00
  SPEAKER_03: Cayman's where really following a simple algorithm of whether or not the patient themselves is asymptomatic or known to be COVID positive, we then go through again another level of algorithmic questions and then determine the PPE really in combination of the type of patient and type of procedure or interaction that that's planned.
• 8:22
  SPEAKER_01: So, Dr.
• 8:23
  SPEAKER_01: Cayman's, what mayors are you recommending to providers to avoid transmitting to other staff when not in direct patient care?
• 8:31
  SPEAKER_02: We actually have established a mandatory universal masking of all employees, regardless of their involvement in patient care or not.
• 8:41
  SPEAKER_02: So that includes our corporate offices and our call center employees as well.
• 8:48
  SPEAKER_02: So everybody within the Mount Sinai Health System are provided a surgical mask when they start their day and they need to keep them the surgical mask on for the rest of the day.
• 8:59
  SPEAKER_02: They are allowed to change masks if they're soiled or wet.
• 9:02
  SPEAKER_02: And then we also give them another mask for them to take home during their commute.
• 9:07
  SPEAKER_02: Also, in addition to social distancing for our healthcare workers, we are also making sure that when they go on their breaks, that they also stay away from each other, at least six feet apart.
• 9:18
  SPEAKER_02: And also during lunchtime, we have kept our cafeteria closed to the public and it's only open to employees.
• 9:25
  SPEAKER_02: And we have arranged the seating arrangements are such as that they are at least six feet away from each other, and we are encouraging our employees not to eat lunch together and to eat lunch on their own.
• 9:38
  SPEAKER_01: And I will add here that we also are looking into social distancing in terms of waiting rooms, in terms of other areas as well.
• 9:46
  SPEAKER_01: So it has been pretty interesting to look at patient schedules and other modalities as well.
• 9:51
  SPEAKER_01: So it has been a pretty involved process and it continues to evolve.
• 9:56
  SPEAKER_01: But I think as Dr.
• 9:57
  SPEAKER_01: Kamins and Dr.
• 9:58
  SPEAKER_01: Cassano has mentioned, all these processes are kind of being implemented across the system.
• 10:04
  SPEAKER_01: Now we'll talk a little bit about testing.
• 10:06
  SPEAKER_01: So Dr.
• 10:07
  SPEAKER_01: Kamans, how are you approaching testing of patients who are previously diagnosed with COVID-19 who are returning for care?
• 10:15
  SPEAKER_02: At this point, we are actually not retesting people who have had a positive PCR test in the past.
• 10:23
  SPEAKER_02: Mind you, it still happens every now and then, but our official recommendation from infection prevention is that once they had a positive PCR test, they should not be retested.
• 10:34
  SPEAKER_02: Some exceptions to that is if the patient needs to go to a nursing home, our state health department has required that they have a negative PCR test prior to being transferred.
• 10:45
  SPEAKER_02: But majority of the time in the ambulatory side, we have actually used the symptom-based strategy or the time-based strategy in terms of taking patients off isolation, which has been recommended by the CDC and also adopted by the New York State Health Department, which pretty much states that for patients who have been diagnosed with COVID-19 by PCR, they can come off isolation as long as it has been 10 days from symptom onset and that they have been ephebril for 72 hours without the use of antipyretics and that their respiratory symptoms have markedly improved.
• 11:24
  SPEAKER_01: So apart from that, do you do anything specific for pre-admission testing?
• 11:30
  SPEAKER_02: Yes, that's a really good question.
• 11:32
  SPEAKER_02: We are actually testing anyone undergoing intubation or moderate sedation for COVID-19 by PCR.
• 11:41
  SPEAKER_02: We also have a policy that if they've been tested positive in the past, that we wouldn't require another test.
• 11:49
  SPEAKER_02: And also that we would then have a waiting period instead of 10 days.
• 11:54
  SPEAKER_02: We thought that with patients undergoing major procedures, that we would have a waiting period of at least 14 days before they undergo the procedure from the time of their positive tests.
• 12:07
  SPEAKER_01: Perfect.
• 12:07
  SPEAKER_01: And I believe we don't retest them after that 14-day period, they can they are clear to go for surgery.
• 12:14
  SPEAKER_02: Yes, we don't test them anymore as there's more and more data showing that having a positive PCR may only be associated with non-vival virus.
• 12:24
  SPEAKER_01: Great.
• 12:25
  SPEAKER_01: So before we get into procedures, I have a question for Dr.
• 12:28
  SPEAKER_01: Cassano.
• 12:29
  SPEAKER_01: So how are you handling patients that had suspected COVID-19 but were never tested?
• 12:35
  SPEAKER_03: So, yes, of course.
• 12:37
  SPEAKER_03: For any of our patients being seen back in our practices or having a visit via a virtual care visit, if they report having had symptoms consistent with COVID-19 and are now symptom-free, and at least 21 days have passed, we are recommending that they be antibody tested.
• 12:54
  SPEAKER_03: And we can arrange for that either in the practices or if they have a virtual visit.
• 12:58
  SPEAKER_03: We do have testing sites that they can come to and receive a COVID-19 antibody test.
• 13:04
  SPEAKER_01: I'll talk a little bit about procedures as we have discussed some testing that are related to procedures.
• 13:10
  SPEAKER_01: So, Dr.
• 13:11
  SPEAKER_01: Cayman's, how are you handling uh what is potentially considered as an aerosol generating procedure in an ambulatory care setting, for example, nevolizations, some ENT procedures, andor nasopharyngeal swaps, etc.
• 13:26
  SPEAKER_02: In terms of aerosol generating procedures in the ambulatory setting, these are potentially minor procedures such as procedures in the ENT clinic or even the oral surgery clinic.
• 13:39
  SPEAKER_02: We are not testing patients prior to their appointments for COVID-19.
• 13:45
  SPEAKER_02: We have instituted though a recommendation in terms of the providers wearing a full PPE, as if the person was COVID positive, meaning they would wear gowns, gloves, and 95 and eye protection when handling these patients, especially since they would not undergo pretesting before the procedure.
• 14:07
  SPEAKER_02: We have used the definition from the CDC in terms of what constitutes an aerosol generating procedure.
• 14:14
  SPEAKER_02: And while there's some question if nebulizer treatments are considered aerosol generating, we erred on the side of caution and will provide N95 and the rest of the full PPE for our providers who do administer nebulizing treatments in our outpatient setting.
• 14:33
  SPEAKER_01: Similar to that question, our membership has asked us questions regarding stress tests and diagnostic imaging.
• 14:40
  SPEAKER_01: Any thoughts on that?
• 14:42
  SPEAKER_02: So there was a lot of discussions among infection preventionists and the healthcare epidemiologists within our system.
• 14:50
  SPEAKER_02: And while this may cause a lot of stress and anxiety among our healthcare workers, they are not necessarily aerosol-generating procedure.
• 15:01
  SPEAKER_02: And when we looked into this, heavy breathing is not necessarily any more aerosol generating than coughing or sneezing.
• 15:11
  SPEAKER_02: And so we did recommend that as long as a patient can keep their mask on, a surgical mask would be adequate protection.
• 15:20
  SPEAKER_02: But in case a patient cannot keep the mask on, that we would then provide or recommend eye protection as well for our healthcare workers.
• 15:29
  SPEAKER_02: The additional protection and justification we use is that we always tell our healthcare workers that our patients are screened for symptoms.
• 15:38
  SPEAKER_02: So we would not have anyone who are symptomatic to undergo stress tests or any diagnostic imaging without having the appropriate PPE.
• 15:47
  SPEAKER_02: But in situations where patients may be asymptomatic carriers, the risk for transmission is really low.
• 15:54
  SPEAKER_02: The eye protection would give them the extra benefit of protection then at this point.
• 15:59
  SPEAKER_01: That sounds good.
• 16:00
  SPEAKER_01: Dr.
• 16:00
  SPEAKER_01: Cassano, have you started any ambulatory surgical procedures?
• 16:05
  SPEAKER_03: Yes, we have.
• 16:06
  SPEAKER_01: And any specific challenges or thoughts?
• 16:09
  SPEAKER_01: Uh we discussed already some testing, but any other thoughts on ambulatory surgical procedures, or is it similar, like pretesting and all?
• 16:16
  SPEAKER_03: Yeah, very similar.
• 16:17
  SPEAKER_03: You know, one thing to keep in mind, all of our patients are reminded of symptoms and screening at any entry point into the scheduling process.
• 16:26
  SPEAKER_03: So whether they're calling for an appointment, being scheduled for a procedure, entering a practice, we are always screening for symptoms.
• 16:32
  SPEAKER_03: As Dr.
• 16:33
  SPEAKER_03: Kim has mentioned, we do have a policy in place around anybody undergoing a procedure or surgery in the main OR, endoscopy, interventional radiology, something like cardiac categorization or EP, all do receive COVID PCR testing within 72 hours of the procedure.
• 16:51
  SPEAKER_03: So, yes, we are vaccine patients in our procedure and uh ORs and do have policies around screening and uh and testing.
• 16:59
  SPEAKER_01: Thank you so much, Dr.
• 17:01
  SPEAKER_01: Cassano.
• 17:01
  SPEAKER_01: One quick question.
• 17:02
  SPEAKER_01: Like in shared patient spaces where visitors or patients can be, what kind of cleaning processes have you implemented?
• 17:11
  SPEAKER_03: So we do have our usual cleaning processes depending on the location or or situation.
• 17:17
  SPEAKER_03: We have a series of wipes that are recommended, and probably more just exceptions that patient has been symptomatic or tested positive.
• 17:26
  SPEAKER_03: We will do a terminal clean of that room and take it out of commission.
• 17:30
  SPEAKER_03: Otherwise, we adhere to our usual cleaning processes with adequate time in between patients.
• 17:36
  SPEAKER_01: And Dr.
• 17:37
  SPEAKER_01: Cayman's just going into a little bit more detail on the environmental cleaning procedures.
• 17:41
  SPEAKER_01: Have you changed anything specifically, like what kind of products we are using, for example, the EPA registered product?
• 17:49
  SPEAKER_01: And then also, is there anything specific that comes in your mind that we should be doing differently for environmental cleaning in the ambulatory care areas in general?
• 17:58
  SPEAKER_02: So I think what we have done is that we're just disinfecting frequently touch areas more frequently than usual, as opposed to just the end of the day.
• 18:08
  SPEAKER_02: Our EVS staff are doing that.
• 18:10
  SPEAKER_02: Nothing special though.
• 18:12
  SPEAKER_02: In fact, as everybody knows, there is a shortage of hospital or healthcare disinfectant wipe.
• 18:18
  SPEAKER_02: We now had to resort to purchasing commercially available disinfectant wipes, which are effective against human coronavirus, coronavirus as well.
• 18:27
  SPEAKER_02: It's just that the contact time is a lot longer of four minutes.
• 18:31
  SPEAKER_02: We have added into our policy that if the patient was COVID positive or at least a PUI and underwent aerosol generating procedure, is that you would want to wait at least 30 minutes or more, depending on the air exchanges, before it is disinfected or terminally clean.
• 18:51
  SPEAKER_01: Perfect.
• 18:52
  SPEAKER_01: Some other general concerns.
• 18:54
  SPEAKER_01: Dr.
• 18:54
  SPEAKER_01: Cassano, have you approached situations when providers are uncomfortable returning to patient care using recommended PPE and other infection prevention strategies?
• 19:06
  SPEAKER_03: Yes, you know, we we as we get more and more physicians returning to practice, we have indeed had lots of questions around the PPE and how we've arrived at our recommendations.
• 19:16
  SPEAKER_03: Early on in the process of us putting together our return to practice guidelines, Dr.
• 19:21
  SPEAKER_03: Cayman's and his team and uh each of the ambulatory representatives did meet with the departments and walk through all of the specialty requirements and concerns.
• 19:30
  SPEAKER_03: And so as we've had to have more individual conversations, we've really referenced those meetings and really have stuck to a lot of the data that's been made available to us through DOH, CDC, and of course our epidemiologists.
• 19:43
  SPEAKER_03: So although sometimes the conversations take a little time, ultimately most of the physicians uh arrive at an understanding of what those recommendations are.
• 19:53
  SPEAKER_01: And I'll add to that that I was really very impressed by the high level of communication that occurred between the leadership and listening to the providers beforehand, having the forum available, sometimes actually daily calls that were occurring on a regular time.
• 20:10
  SPEAKER_01: Everybody needed to communicate and were bringing up their questions, and then questions were addressed at a very global level, as this alleviates a lot of fears or concerns.
• 20:20
  SPEAKER_01: I think the communication was also key in getting everybody on board to this point when people get a little bit more comfortable in coming to the ambulatory practices.
• 20:31
  SPEAKER_01: Dr.
• 20:32
  SPEAKER_01: Cayman, have you addressed any prior guidance on older or immunocompromised staff who are returning to work in ambulatory settings?
• 20:42
  SPEAKER_02: That is a really good question that we also struggled to as we prepare for reopening of our ambulatory practices.
• 20:51
  SPEAKER_02: During the peak of our pandemic, at least in New York City, you know, some of our acute care hospitals reached what 90% proportion of patients who were diagnosed to have COVID-19.
• 21:03
  SPEAKER_02: And so pretty much the entire hospital had COVID-19 patients.
• 21:08
  SPEAKER_02: So we created a policy in which healthcare workers who are potentially at risk or complications from COVID-19 were actually redeployed or potentially even were allowed to work from home.
• 21:22
  SPEAKER_02: But now that we are reopening New York City and the number of cases have decreased, we have actually updated our policy and that have now asked that our potentially high-risk healthcare workers, as long as we don't assign them to work with a COVID positive patient or asymptomatic PUI, and that as long as they are part of our universal policies in terms of PPE, such as the universal masking or wearing eye protection for patients who are not able to keep a mask on, I think it it is safe for them to come back to work.
• 22:00
  SPEAKER_02: Work and as long as they take the proper precautions.
• 22:03
  SPEAKER_01: Thank you, Dr.
• 22:04
  SPEAKER_01: Caymans.
• 22:05
  SPEAKER_01: I'm gonna just ask another question because I know that Dr.
• 22:08
  SPEAKER_01: Cassano and Dr.
• 22:09
  SPEAKER_01: Cains, along with other leaders, created this brilliant document, ambulatory guidance document, that is actually an online live document, continues to improve and we add to it.
• 22:21
  SPEAKER_01: And do you want to say anything?
• 22:22
  SPEAKER_01: What was the part behind this creation and then also how helpful it has been?
• 22:28
  SPEAKER_03: Sure.
• 22:29
  SPEAKER_03: What we did was we actually took a lot of the lessons learned as we moved through the initial preparation for the COVID crisis and many of the things that we had to put in place and compressing some of the practices, changing the way we were offering care, and then in some ways prioritizing care as we became more and more embedded in helping support the inpatient care.
• 22:51
  SPEAKER_03: We basically took all of that and then proactively developed a series of guidelines on how we would reopen.
• 22:59
  SPEAKER_03: Tried to take into consideration really the journey of the patient and what takes place from the moment somebody decides they need care all the way through their registration process, arrival to the practices, throughput in the practices, and then being uh discharged home.
• 23:15
  SPEAKER_03: And so along the way, any and all operational activities tied to that patient journey were really put in the guide, and we tried to walk through all the recommendations.
• 23:24
  SPEAKER_03: So things that we've touched on in a conversation earlier, but things around our phone scripts and screening patients for symptoms, how we register our patient social distance our waiting rooms, devised our scheduling templates to allow for proper social distancing.
• 23:38
  SPEAKER_03: We're leveraging IT platforms that we hadn't used before to help with registration prior to patients arriving.
• 23:44
  SPEAKER_03: We really tried to think through all of the things that come during a patient encounter.
• 23:50
  SPEAKER_03: And on the other side of that were all the things that our staff would be impacted by.
• 23:54
  SPEAKER_03: So how they interact with the staff, how do we keep them safe?
• 23:57
  SPEAKER_03: I would mention that really safety was the cornerstone of all the things that we put into the guide, really making sure that no matter what we're doing, we're doing it with the absolute safety of patients and staff in mind.
• 24:09
  SPEAKER_03: The document is uh actually a living document so that we can iterate on it as we return to practice and new things come up that we may not have considered.
• 24:18
  SPEAKER_03: As new recommendations come out, we certainly add to the document to make sure that we're addressing all of those things.
• 24:24
  SPEAKER_03: So the document we hope is comprehensive.
• 24:27
  SPEAKER_03: We know it will change over time.
• 24:29
  SPEAKER_03: Many of the practices are using it on.
• 24:32
  SPEAKER_03: We can see that every day we still have about two to three hundred people referencing the document.
• 24:38
  SPEAKER_01: And I also want to mention here is Mans and I will make the ambulatory guidance document that we just discussed about available for SHA membership.
• 24:46
  SPEAKER_01: With this, I'll thank both of our speakers for sharing their perspectives and experiences, and a sincere thank you from Shay to all healthcare personnel for all that you are doing to respond to COVID-19.
• 25:00
  SPEAKER_01: This podcast can be accessed on Shay's online education center, Learning CE, under the Rapid Response Program.
• 25:09
  SPEAKER_01: You will also find additional resources such as recorded webinars, healthcare facility outbreak preparedness, as well as SHAY COVID 19 townhouse.
• 25:20
  SPEAKER_01: Thank you so much for tuning in.