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COVID-19: Staff Policies, 5/14 · The SHEA Podcast

• 0:08
  SPEAKER_00: Welcome to the Rapid Response Podcast brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:24
  SPEAKER_00: I'm Dr.
• 0:25
  SPEAKER_00: Jennifer Hanrahan from University of Toledo College of Medicine and Life Sciences, and I will serve as your moderator.
• 0:31
  SPEAKER_00: 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.
• 0:42
  SPEAKER_00: Shay is excited to launch the 13th episode of this podcast, COVID-19 Updates, What We Know Now.
• 0:49
  SPEAKER_00: Today's episode will focus on staff policies.
• 0:52
  SPEAKER_00: Our speaker is Dr.
• 0:54
  SPEAKER_00: Mark Rupp, Professor and Chief of the Division of Infectious Diseases and Medical Director, Department of Infection Control and Epidemiology at the University of Nebraska Medical Center and past president of SHA.
• 1:06
  SPEAKER_00: Thank you for joining us today.
• 1:08
  SPEAKER_00: I would now like to get us started with a news and guidance update of the week.
• 1:13
  SPEAKER_00: A great deal of news coverage this week has dealt with states reopening.
• 1:17
  SPEAKER_00: Dr.
• 1:18
  SPEAKER_00: Anthony Fauci testified during a Senate hearing that reopening too quickly could lead to a resurgence of cases and reminded us that vaccines and treatments would not be available by fall when schools reopen.
• 1:30
  SPEAKER_00: Speaking of school reopening, pediatric cases of COVID-19 are being reported, but there are relatively fewer cases of COVID-19 among children compared to cases among adults.
• 1:40
  SPEAKER_00: In the United States, 2% of confirmed cases of COVID-19 were among persons aged less than 18 years.
• 1:47
  SPEAKER_00: Signs and symptoms of COVID-19 in children may be similar to those for common viral respiratory infections or other childhood illnesses.
• 1:54
  SPEAKER_00: It is important for pediatric providers to have an appropriate suspicion of COVID-19, but also to continue to consider and test for other diagnoses.
• 2:03
  SPEAKER_00: Of note, Kawasaki disease has been reported and has been linked to COVID-19.
• 2:08
  SPEAKER_00: 85 cases compatible with multisystem inflammatory syndrome have been identified in children in New York and are being investigated.
• 2:16
  SPEAKER_00: These are being characterized by persistent fever and features of Kawasaki disease andor toxic shock syndrome with abdominal symptoms being common.
• 2:25
  SPEAKER_00: Cases may require intensive care unit admission for cardiac andor restroid support.
• 2:29
  SPEAKER_00: Polymerase chain reaction testing for SARS-CoV-2 may be positive or negative, but antibody testing may be positive, especially 14 days after onset of symptoms.
• 2:39
  SPEAKER_00: In Michigan, children with three days or more of fever, rash, and GI symptoms are recommended to have blood tests for C-reactive protein, troponin, and D-dimer and consider early admission or at least observation as being recommended.
• 2:52
  SPEAKER_00: Early recognition and specialist referral are essential, including to critical care if warranted.
• 2:57
  SPEAKER_00: In regard to testing, IDSA released guidelines on SARS-CoV-2 nucleic acid testing and included recommendations for both symptomatic and asymptomatic individuals.
• 3:08
  SPEAKER_00: One of the groups for which testing asymptomatic individuals is being recommended is for patients who will be undergoing immunosuppressive procedures.
• 3:16
  SPEAKER_00: The document states that limited data indicates that immunocompromised patients have increased risk of severe outcomes from COVID-19 disease.
• 3:24
  SPEAKER_00: Therefore, testing asymptomatic patients at the time of hospital admission or within 48 hours before initiation of immunosuppressive therapy or transplantation surgery is warranted.
• 3:34
  SPEAKER_00: Patients in the outpatient setting who require frequent clinic or infusion room visits should be screened regularly with the standardized questionnaire for symptoms and known exposures in between visits.
• 3:45
  SPEAKER_00: The recommendations are made recognizing that testing availability may be limited in some settings, but the risk of not testing this patient population and the subsequent risk for nosocoblin transmission andor rapid progression resulting in death outweighs the benefit of not testing.
• 4:00
  SPEAKER_00: On a lighter note, CDC has released guidance on what to do if your pet test positive for the virus that causes COVID-19.
• 4:08
  SPEAKER_00: The recommendations state that if your pet tests positive, isolate the pet from everyone else, including other pets.
• 4:14
  SPEAKER_00: Do not wipe or bathe your chemical disinfectants, alcohol, hydrogen peroxide, or any other products not approved for animal use.
• 4:22
  SPEAKER_00: Only a few pets have been confirmed to be infected with the virus that causes COVID-19.
• 4:27
  SPEAKER_00: Some pets did not show any signs of illness, but did get sick, all had mild disease that could be taken care of.
• 4:32
  SPEAKER_00: None have died from the infection.
• 4:34
  SPEAKER_00: You think your pet has COVID-19, call a veterinarian first to discuss what you should do.
• 4:39
  SPEAKER_00: Pets with confirmed infection with the virus should be restricted to isolation in the home until a veterinarian or public health official has determined that they can be around other pets and people.
• 4:49
  SPEAKER_00: On a personal note, as someone who has dogs and cats, these recommendations would be nearly impossible to follow.
• 4:56
  SPEAKER_00: I now want to move on to the discussion with Dr.
• 4:59
  SPEAKER_00: Mark Rupp.
• 5:00
  SPEAKER_00: Dr.
• 5:01
  SPEAKER_00: Rupp, thank you so much for talking today.
• 5:04
  SPEAKER_01: Yeah, it's a real pleasure to be with you, Jennifer.
• 5:06
  SPEAKER_01: Thank you.
• 5:07
  SPEAKER_00: How do the healthcare personnel end their shifts and know when they come home they're safe for their families?
• 5:14
  SPEAKER_00: We're getting tons of questions about this.
• 5:16
  SPEAKER_00: You know, people are really worried that they're potentially putting their families at risk.
• 5:21
  SPEAKER_00: So there's lots of questions about should they shower, can they hug their kids, can they prepare food, should they live in the basement or the garage?
• 5:29
  SPEAKER_00: What do you say to all of this?
• 5:31
  SPEAKER_01: Yes, Jennifer, this really is a concern amongst healthcare providers.
• 5:35
  SPEAKER_01: And you know, the first observation is that by and large, healthcare providers are on the front lines and they're doing just an amazing job.
• 5:44
  SPEAKER_01: I know in our COVID units, in our emergency departments, and other areas where we're encountering these patients, I'm just incredibly impressed with the calmness and the professionalism that we see evidenced every single day.
• 5:59
  SPEAKER_01: People are doing their job and they're doing it well, and they're just so magnanimous and brave.
• 6:06
  SPEAKER_01: The issue that is been expressed obviously is how do we do this and do it in the most safe manner so that people don't need to be as concerned about taking this home to their families.
• 6:19
  SPEAKER_01: And obviously, there is some level of concern, but we can do a lot to minimize that level of concern.
• 6:26
  SPEAKER_01: And what I tell our workers is that the best way to protect their families when they go home is what they do at work, and they have to be very, very conscientious and careful with the application of the PPE and the safe care of their patients.
• 6:42
  SPEAKER_01: We've done an awful lot here at our medical center to make sure that we're offering the safest environment we can.
• 6:49
  SPEAKER_01: So we've turned whole units into negative pressure COVID units.
• 6:54
  SPEAKER_01: We thankfully have a pretty good supply of PPE.
• 6:58
  SPEAKER_01: So the standard PPE on those units is a N95 respirator or higher level of respiratory protection and a face shield.
• 7:08
  SPEAKER_01: We're taking particular care with aerosol generating procedures, and we do also have a good supply of papers that are necessary or used with some of those aerosol generating procedures.
• 7:19
  SPEAKER_01: So that's the very first thing is just to provide a safe environment for the workers.
• 7:25
  SPEAKER_01: And then the workers just need to be incredibly conscientious to use their PPE, to be meticulous with their hand hygiene, to make sure that they're not touching their face.
• 7:34
  SPEAKER_01: And then when they go home, you know, they can be fairly assured that the risk of having acquired COVID-19 in the workplace is very low.
• 7:43
  SPEAKER_01: What I tell folks is when they get home, they should do hand hygiene.
• 7:47
  SPEAKER_01: They should change their clothes, which I think is you know pretty standard practice for most folks.
• 7:52
  SPEAKER_01: They sort of get out of their work clothes and change into their play clothes, if you will.
• 7:57
  SPEAKER_01: Likewise change their shoes, but we're not recommending anything beyond that.
• 8:02
  SPEAKER_01: So they're certainly not having to treat themselves with some sort of a disinfectant.
• 8:07
  SPEAKER_01: We're not recommending that people shower before they go home.
• 8:11
  SPEAKER_01: So just doing some common sense things when they get home, I think, can minimize the risk as well as careful attention to what they're doing at work.
• 8:19
  SPEAKER_01: Certainly they uh are encouraged to have contact with their family.
• 8:23
  SPEAKER_01: That's so important at this time that everybody maintains their support network and that they can prepare food.
• 8:30
  SPEAKER_01: They don't have to have a special sequestered uh living arrangement away from their family.
• 8:35
  SPEAKER_01: And so I think that you know, if they're careful at uh at work and they do a few common sense things when they get home, they should be safe.
• 8:43
  SPEAKER_00: So it basically sounds like as long as people are following the recommended procedures and they're being safe at work and they use common sense when they come home, then they should feel good that their families are safe.
• 8:55
  SPEAKER_01: Yeah, I think so.
• 8:56
  SPEAKER_01: And you know, a few other common sense things that can be done at uh in the home place is you know, don't share eating utensils and cups and plates and bowls and things like that with other family members.
• 9:08
  SPEAKER_01: You know, obviously, if somebody develops any type of uh symptoms, even if they're mild, as a healthcare provider, it's extremely important that they get tested promptly.
• 9:17
  SPEAKER_01: And then if they've worked out a plan, you know, just in case for that contingency where they do start to develop symptoms of how to go about sequestering themselves in the home until they can get tested and to try to minimize any risk of transmission, that I think also will help to alleviate uh anxiety so that they know if they're lucky enough to have a spare bedroom and a bathroom that they're going to go to that and sort of uh self-quarantine until they can get those test results.
• 9:45
  SPEAKER_01: That helps people if they have that contingency plan as well.
• 9:49
  SPEAKER_00: So, are you routinely testing high-risk healthcare workers in COVID units or emergency departments?
• 9:55
  SPEAKER_00: What do you think about that idea?
• 9:58
  SPEAKER_01: Well, clearly our posture towards testing has evolved over the course of the pandemic.
• 10:03
  SPEAKER_01: And I can remember just a few months ago where we had just precious few tests that we could offer anybody, and obviously we're developing additional capacity as time goes on.
• 10:14
  SPEAKER_01: Currently, we are testing only symptomatic healthcare providers, but I can certainly see a point where if we started seeing a clustering of providers or patients that had nosocomial transmission, that we would certainly consider doing testing on a broader basis on a particular unit or in a particular group of healthcare providers.
• 10:38
  SPEAKER_01: I think the other thing that will be extremely interesting is as we start to have greater prevalence of serologic testing, that we'll be able to go into groups of high-risk healthcare providers and really see if we've had any kind of transmission into the group of providers.
• 10:55
  SPEAKER_01: So the simple answer to your question is we're not doing testing of asympatic healthcare providers at this point.
• 11:01
  SPEAKER_01: But if I had ready availability of testing, I might consider it in particular groups.
• 11:06
  SPEAKER_01: And then again, we'll be waiting for the serologic test to come on to gain some additional information.
• 11:12
  SPEAKER_00: Yeah, I think the serologic testing results are going to be interesting, even though it's hard to know what to do with some of that information, but I think we're all interested to see what that's gonna show us.
• 11:23
  SPEAKER_00: You know, one of the problems that we have seen quite a bit, especially I'm in Lucas County, Ohio.
• 11:29
  SPEAKER_00: We've had a lot of cases in skilled nursing facilities among both staff and residents of skilled nursing facilities.
• 11:37
  SPEAKER_00: What are your thoughts on addictive spread among healthcare workers in those settings?
• 11:42
  SPEAKER_01: Yeah, well, clearly uh long-term care facilities have sort of been our canaries in the coal mine for society.
• 11:49
  SPEAKER_01: You know, it's easy to see where that is such a high-risk area where we've got a congregation of elderly people who uh oftentimes are infirm, you know, without sometimes the best infection control practices, at least historically, in those settings.
• 12:05
  SPEAKER_01: And so we have seen uh here, as well as you pointed out throughout the country, uh, spread in nursing care, long-term care facilities, largely fueled by healthcare providers or those workers coming into the nursing homes and spreading the disease.
• 12:22
  SPEAKER_01: I think it really, really emphasizes the need for the workers in long-term care facilities to be incredibly conscientious and they should not be at work if they have any kind of symptoms.
• 12:35
  SPEAKER_01: They should be screened prior to coming onto a shift, that at the very least, with regard to any symptoms.
• 12:41
  SPEAKER_01: If a nursing home can check temperatures, I think that that is uh reasonable.
• 12:47
  SPEAKER_01: And you know, to have very readily available testing for any kind of worker in a long-term care facility.
• 12:54
  SPEAKER_01: That might be, you know, like your previous question, if we saw you know workers in a long-term care facility that were sick, that might be an indication to more broadly test the uh the cadre of workers in a particular long-term care facility and really be careful with that.
• 13:10
  SPEAKER_01: The other uh issue that this brings up is you know, what is the asymptomatic uh spread amongst healthcare providers and is that an entity that we need to be particularly cognizant of?
• 13:22
  SPEAKER_01: Clearly, the data on that continues to evolve, and what I see is that you know, somewhere between maybe a low of 6% to as high as 40% that I've seen in the literature of transmission of COVID-19 is due to that pre-symptomatic spread.
• 13:38
  SPEAKER_01: And so, you know, there's little that we can do to guard against that, but again, most of these people do go on to develop symptoms.
• 13:45
  SPEAKER_01: If those symptoms are in long-term care facility workers, it's just absolutely critical that they pull themselves off the line of duty, that they get tested, that HR policies don't penalize them and doesn't encourage them to work while they're sick.
• 14:00
  SPEAKER_01: And that's true for healthcare providers in all settings.
• 14:04
  SPEAKER_00: So, you know, one of the other questions that comes up constantly is when is it safe to bring patients back into the healthcare setting after they've been diagnosed with COVID-19?
• 14:13
  SPEAKER_00: So we get questions around, you know, the ambulatory setting, when is it okay for patients to be seen in person after they've been discharged from the hospital, or patients get discharged from the hospital and they get readmitted?
• 14:26
  SPEAKER_00: Do they need to go back into the same isolations precautions as they were in previously?
• 14:30
  SPEAKER_00: So, what are your recommendations regarding those situations?
• 14:34
  SPEAKER_01: Yeah, I think this is evolving as well.
• 14:37
  SPEAKER_01: Um, clearly the guidance from the CDC has changed a bit, going from uh, you know, a seven days with three days being asymptomatic, being safe, and they've evolved just a little bit to a 10-day period with uh three days being ephebrile and symptomatically improved.
• 14:53
  SPEAKER_01: We've had just a little bit of a more aggressive stance on that, so that when somebody is in home isolation, so they've been tested positive and they're at home and they're coming back into the clinic, or recommendations for you know when they can safely go back into society.
• 15:11
  SPEAKER_01: For immune-competent patients, we're actually using a 10-day and five-day rule where uh 10 days since the beginning of their symptomatology, and we recommend that five of those last days be without fever and clearly symptomatically improved.
• 15:27
  SPEAKER_01: For immune compromised patients, we're actually stretching that out a little bit more and we're using a 14-day period from the onset of symptoms and seven days without fevers.
• 15:37
  SPEAKER_01: And then for those patients that are having to come back into the clinic, we're trying to recommend that if it's safe and we can postpone their clinic visit to 21 days from their onset of symptoms.
• 15:49
  SPEAKER_01: That's what we're trying to do.
• 15:51
  SPEAKER_01: If they come back in the clinic or the hospital before that 21-day period, if they're asymptomatic, we're having them come back in without special precautions.
• 16:01
  SPEAKER_01: But if they are having symptoms, then we actually use our COVID PPE in either ambulatory or the inpatient setting until uh presumably, obviously, inpatient we would repeat their testing.
• 16:14
  SPEAKER_00: All of these things are obviously evolving and they raise a lot of difficult questions, including you know how to balance the risks and benefits to both healthcare workers and patients.
• 16:26
  SPEAKER_00: One of the issues that has come up a lot is the N95 shortage, and you mentioned that you're not having PPE shortages, but are you having to reprocess N95 masks or are you having any issues with that?
• 16:41
  SPEAKER_01: Absolutely.
• 16:41
  SPEAKER_01: And so, although we we've had a good supply of PPE, it's certainly not inexhaustible.
• 16:47
  SPEAKER_01: And the reason that we have a good supply is that uh we almost immediately as we started to encounter patients, we introduced the extended use of N95s and PPE, and we also put in practice a ultraviolet germacidal irradiation program.
• 17:06
  SPEAKER_01: We have preferably people using extended use of N95s rather than reuse, and so really uh what we're telling folks is wear it.
• 17:14
  SPEAKER_01: Typically, we're seeing folks uh being able to wear an N95 maybe two to three hours before they really need to take a break and take it off.
• 17:24
  SPEAKER_01: At that point, we have them put it into a brown paper bag that's our dirty bag, and we have a facility here in the organization where we subject the N95s to ultraviolet uh irradiation.
• 17:39
  SPEAKER_01: We've done some testing on it and we feel it's a very safe and effective way of providing decontamination of the N95s.
• 17:47
  SPEAKER_01: That's on our website.
• 17:49
  SPEAKER_01: I would encourage anybody who wants a really detailed protocol of how to do this to go to our website and look that up.
• 17:55
  SPEAKER_01: But we have it go through the decontamination process, and then the decontaminated N95s go into a white bag with the specific healthcare provider's name on it, and those white bags then get transmitted back to the units where the healthcare providers work, and so the next time they come on shift, they've got a supply of decontaminated N95s.
• 18:19
  SPEAKER_01: Now we strongly suggest that as they use a decontaminated N95 that they inspect the respirator carefully, they check the elasticity of the bands that hold it to their face, and that if there's any question about the fit or the elasticity of the bands, you know, again, do a really good seal check.
• 18:41
  SPEAKER_01: And if it's not functioning up to standard, that they go ahead and at that point pitch the N95 and uh throw it away.
• 18:50
  SPEAKER_01: What we're finding is that we typically will have about five to six decontaminations or reuses of the N95s prior to the healthcare providers detecting any kind of functionality problem.
• 19:05
  SPEAKER_01: So we've really been able to extend the life of our N95s dramatically that way.
• 19:10
  SPEAKER_01: We also have face shields that are being disinfected and reused, obviously, for a particular healthcare provider.
• 19:18
  SPEAKER_01: And so we've been able to extend the the N95 and face shields uh for all of our healthcare providers in that manner.
• 19:25
  SPEAKER_00: Yeah, I think a lot of us, it sounds like are doing the same things.
• 19:28
  SPEAKER_00: And thank you, by the way, for publishing that detailed guidance.
• 19:32
  SPEAKER_00: We have actually used that, so you've done a service to the rest of the country by publishing.
• 19:37
  SPEAKER_01: We've kind of taken the philosophy that uh we're going to share everything that we possibly can.
• 19:41
  SPEAKER_01: So all of our procedures and policies are on the web in an outward-facing website.
• 19:48
  SPEAKER_01: Um, again, I encourage people to use it uh as much as they feel is is uh helpful for them.
• 19:54
  SPEAKER_00: So the CDC has changed the return to work guidance for employees to 10 days from symptom onset, plus three fever-free, or continuing a test-based strategy rather than the test-based strategy being preferred.
• 20:09
  SPEAKER_00: I think reconcile vastly different time frame, which can range from 10 days to 30 plus days at your institution?
• 20:17
  SPEAKER_01: Yeah, that's a great question.
• 20:19
  SPEAKER_01: And you know, clearly it's a place where we need to gather additional data.
• 20:23
  SPEAKER_01: The studies that I have reviewed really do not show the recovery of viable virus from anybody after about nine or ten days.
• 20:35
  SPEAKER_01: And so I think that's really where the CDC has come up with their 10-day period of time from the onset of symptoms.
• 20:43
  SPEAKER_01: We again have extended that a little bit to the 14-day mark at our institution.
• 20:48
  SPEAKER_01: And you know, for our patients who are coming out of COVID isolation, we continue to use oftentimes a test-based strategy.
• 20:55
  SPEAKER_01: For our healthcare providers, we typically would not do that.
• 20:59
  SPEAKER_01: And so, you know, they would be able to come back to work uh after that period of illness, 14 days, sort of at the minimum.
• 21:07
  SPEAKER_01: And then we have a universal masking policy and soon a universal eye protection policy.
• 21:13
  SPEAKER_01: So we feel that by doing that, you know, we really are minimizing the risk of uh transmission uh in either direction.
• 21:20
  SPEAKER_01: We also use masks on all of our patients, and so we're hopefully preventing any sort of transmission from a healthcare provider to a patient or vice versa, or from one provider to another by having a very liberal universal mask practice.
• 21:36
  SPEAKER_01: But I think it's a tough question.
• 21:38
  SPEAKER_01: You know, we really don't have it fully reconciled yet with information over the long haul of what it means when somebody's uh PCR positive for a long period of time.
• 21:49
  SPEAKER_01: We certainly saw that in patients here with you know our initial patients coming from the Diamond Princess cruise ship that were in our national quarantine center, and we had some of those patients who were asymptomatic, you know, at the end of their course going out as long as 40 days with positive PCR.
• 22:06
  SPEAKER_01: You know, we don't think people are infectious out that long, and so where do you make that cut and allow healthcare providers to come back to work?
• 22:14
  SPEAKER_01: Again, we've done it uh with 14 days.
• 22:17
  SPEAKER_01: The CDC is recommending 10 days.
• 22:19
  SPEAKER_00: Thank you very much to our speaker for sharing your 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.
• 22:30
  SPEAKER_00: This podcast can be accessed on Shay's online education center, learning CE, under the Rapid Response Program.
• 22:37
  SPEAKER_00: You will also find resources such as the recorded webinars, healthcare facility outbreak preparedness, and the SHA COVID 19 town hall.
• 22:45
  SPEAKER_00: That concludes this episode of the Rapid Response Podcast.
• 22:48
  SPEAKER_00: Thank you for tuning in.