Video: Infection Control and PPE use for Healthcare Workers due to COVID-19

Transcript: Infection Control & PPE Use for Healthcare Workers During the COVID- 19 OutbreakTitle pageHello, and thank you for taking the time to listen to my presentation on Infection control and PPE use for healthcare workers during this COVID-19 Outbreak. I am Dr. Melissa Pinke. I am a disaster preparedness specialist and the CEO of Code Pinke Crisis Planning; a woman owned business in Florida that focuses on helping organizations with their emergency preparedness training, plans and exercises.My goal here for this presentation is to provide you with a summary of the key points being disseminated related to protecting your workers, from an occupational safety and health perspective, as well as discuss some of the alternatives to assist with response during this pandemic. Let’s jump right in.Slide 1Let me tell you a little bit about myself so you might feel more comfortable about my education and experience and how this might support my reasoning. I started out in healthcare as a medical assistant when the HIV epidemic evolved, so within five years of me graduating college, I had to learn to draw blood wearing gloves and could not recap needles. These are things you might take for granted today. I have been doing occupational safety and health ever since.I have been the Safety Director for several companies. My bachelors’ degree is in health administration, and my masters’ degree is in health education and I have been developing safety programs, training, investigations and audits for my entire career. I was involved with implementing respiratory protection, training and fit testing for school nurses back in 2009, to prepare for response to H1N1.My doctorate degree is in Emergency management, where my dissertation and over two years of research focused on hospital emergency preparedness and training. I also teach HAZMAT classes for a private company as well as instruct emergency preparedness health-care classes at the Center for Domestic Preparedness in Anniston, Alabama, in addition to teaching at Waldorf University in their emergency management program. My focus is health and safety of workers, in particular, responders; along with helping companies put the right programs in place to protect their people, property, presence and profits.Slide 2As of right now, we know that COVID-19 is a virus that is transmitted by droplets- primarily from coughs, sneezes and contact with items that may have these germs on them. Our older populations and those people with underlying health conditions are most at risk. There has been a growing concern about people who may be asymptomatic and can spread this disease. There is still much more for us to learn about this disease that will just have to come with time. Some of my recommendations may also address individuals that fall into this last category. Inthe meanwhile, Let’s take a look at the hierarchy of controls to see how we can better manage safety and avoid the spread of illness in our health care systems.Slide 3In the hierarchy of controls followed by the majority of health and safety people, there is an order to controlling worker exposures. These start with elimination, then work their way down to substitution, engineering controls, administrative controls, and then finally PPE. Let’s discuss each.Slide 4While elimination is the best method, it is not always an option. If we could make COVID-19 go away, then it would not be an issue for us. Vaccines are our next best option when it comes to elimination of diseases.Substitution, using something less hazardous is also not an option, as we have no control over diseases. Neither of these are an option at this time.Slide 5Our best and first response then falls on good engineering controls. Engineering controls are methods that physically prevent the hazard from coming in contact with workers. Having separate entrances for ill and non-ill patients as well as for your staff to enter your facility in is the first step.Use clear plexi-glass as a barrier at workstations. Physical barriers stop droplets from contacting workers.Slide 6Proper use of your HVAC system is essential. Make sure you have good HEPA filtration in your buildings that includes an air exchange of at least 12 times per hour. Ensure rooms are set up to allow for optimal air exchange and efficiency of your HVAC systems. Make sure filters are changed regularly and frequently. Test and prepare any back up systems at this time.I would also suggest you consider portable HEPA air filter machines for use in crowded areas or in work areas that your current ventilation system is not ideal. Make sure these units are monitored and maintained by your facility staff to ensure good air exchange and efficiency.Slide 7Now we move to administrative controls, or the way we set rules and procedures for your organization. I am sure you all know that the success of your programs start at the top. I certainly hope and expect leadership at all levels is on board with reducing disease transmission and keeping the workplace safe.While you may not be able to physically lock many internal doors due to fire code, you can clearly identify with signage where people can and cannot go. Use partitions or curtains to physically separate the various groups of people when ever possible.Slide 8I had heard the statement before, “inspect what you expect.” This is a great example of explaining that what management is tuned into will get done by employees. Put in place formal inspections to monitor conditions and make changes as needed, but also get your management team out there to see what is going on. Use camera systems if you need to, but in order to manage effectively, your management team needs to know what is going well and what isn’t working.Recognize workers that are following good practices with praise. Correct workers that are not adhering to procedures so they get it right; do not reprimand them. If they are not following steps, this is a management, training or enforcement issue for you to work on.Make sure your sick leave policies, scheduling practices and management attitude support employees that need to stay homeSlide 9Now is a good time to evaluate where you all stand on your NIMS/ICS preparedness measures and training you have all taken. You should have an ICS team in place and operational. You should be meeting daily to discuss and strategize. Your goal here is to “protect the house” including staff, from COVID-19.Where else have you heard that phrase- HERT training – Hospital Emergency Response Team training. HERT is used in response to CBRNE events. Chemical, Biological, Radiological, Nuclear and Explosive events. In case you are not aware, we are facing a biological event, and HERT practices can be used! If you are behind in this area, get it started now. A pandemic is a good reason to activate your emergency response plan and teams. If your operations need some streamlining, now is the time to pause and re-assess, and make changes starting with your next shift.The two staff positions that are your biggest assets at this time, besides your emergency manager, are your safety and infection control officers. Engage these experts and follow their advice.Slide 10I am also going to tell you that one of the differences from Hospital Emergency Response Team training and a Pandemic is that for an off-site mass casualty event, the hot zone is at another location, and the hospital becomes the warm zone, where decon is done. Then, once patients are clean, they come into the hospital, or the cold zone for treatment. This is done to “protect the house” from contamination. During a pandemic, the sick patients or “hot zone” comes to you, inside the facility, so the dynamics change but the principles do not.One step I can recommend is that since the hospital is now the hot zone, it is time to protect the house by establishing hot, warm and cold zones, just like we do for other CBRNE events. This is a critical component in preventing disease transmission.The hot zone is where the hazard is. This area is restricted to authorized personnel wearing the proper PPEThe warm zone is also restricted, and is where PPE is donned and doffed. The goal here is to contain the hazard and to prevent it from getting out into the facilityThe cold zone is considered “hazard free” and should not require any PPEThis entire activity is supervised to ensure proper containment is achieved.Slide 11Screening your staff for signs and symptoms of illness will keep everyone honest. Some workers may feel the need to still report so they can be helpful. They may also not recognize these symptoms as the first signs of illness, but rather consider it due to fatigue.It is important to do a quick history and at least a temperature on each staff coming in.While the CDC guidance is to remove workers if they have a 100-degree temperature, once you have baseline information on your workers, don’t wait until their temperature gets to 100 degrees. Once there is a deviation from their baseline, this should signal the bodies response to infection and these employees should be prevented from working.Slide 12I realize this picture is a bit busy, but rather than taking another day or two make this prettier, I wanted to get the information out, so let me explain it.Set up your patient screening outside your facility along with a hand hygiene station that every patient should be instructed to use and be supervised. Your screener should be in full PPE. There should be two separate entrances for patients. One for patients with signs and symptoms of Covid related illness, and another for all other types of care. When the patient presents with illness symptoms, give them a mask and explain how to use it. Tell them to keep it on until staff asks them to remove it. Supervise the patient putting on the mask before entering the facility. Anywhere there are “ill” patients is considered the “hot” zone and requires staff to wear full PPE to enter. Once patients are seen, they should either be directed out to home or travel through a dedicated path to your dedicated ward for care. This path should also be restricted and requires full PPE and is continued up to the patient room. There should be an area set up for staff to donn PPE. There should be a person here to assist.There should also be a separate doffing area with an assistant to ensure proper decon is done. Hand hygiene should be the last step.Feel free to modify this a bit. However, containment is necessary to avoid further spreading of this illness.These areas must be clearly marked and restricted to only those necessary to work in these areas. Custodial and other staff should also follow the procedures while in these areas.Slide 13After weeks or even a month or so with facilities providing care to patients with this disease, staff are working double shifts, extended shifts and even working without days off. Your staff are likely to be very stressed and fatigued at this point. When your staff are not working under their best performance, their capabilities to follow procedures will be reduced, putting your infection control and other procedures atrisk. If you haven’t already begun planning for rest and rotation of your employees, now is the time to do so.Slide 14I am sure all of you are already performing some sort of screening and cohorting patients. Keep this up! Make sure tissues and trash receptacles are available. If you issue masks to patients, they must be instructed on how to use them and remove them. Give them an instruction sheet for them to refer to. Do not rush through this process. The safety of your staff relies on patients doing their part too.Slide 15While the thought of doing training while you are all so busy, is I am sure, the last thing on your mind. However, now it is even more important to make sure your staff knows how to follow procedures, including infection control and PPE. Please don’t expect a worker to remember from a year ago how to properly put on or take off a respirator or mask.Many workers and even managers are panicking and insisting on unreasonable and even unnecessary precautions. This is a sign you need to beef up your education and assure your staff they are protected.On your educational channels, include videos of proper donning, doffing and use of PPE, Infection control practices and other important information. You would be surprised how many will watch it if a question comes up. Believe me, your employees are paying attention now. Also hang posters of hand hygiene and respiratory etiquette everywhere, especially in patient areas. Make sure the posters are in multiple languages. One missed person could compromise your system. Don’t forget to do regular checks for compliance too.Slide 16Just to further emphasize the importance of training, make sure each group is given proper training for their safety and the safety of others. Remember, the purpose of training is to develop competency, not just make a check that information was provided. Good quality training is needed now, more than ever. The use of PPE and infection control practices are skills based. This means they need to “demonstrate” competency. In other words, they must be able to show someone they can do the task capably and proficiently.No Computer based training multiple-choice answer can validate if an employee can properly doff a contaminated respirator or mask. There needs to be human interaction and evaluation to ensure this.Slide 17Cleaning and disinfection cannot be emphasized enough. Procedures should have staff minimize contact with potentially contaminated items when ever possible. Those that are ill should keep their hands to themselves. Make sure your cleaning workers are all trained to minimize disease transmission based on the activities they perform and that they too have proper protections in place. Your infection control programs are only as good as your weakest link.Slide 18Yes, we have heard hand hygiene so many times, and all of us are washing constantly. But there are two sides to this coin. In order to make sure employees and visitors are washing their hands properly and following your posters, make sure all of your bathroom components are in good working order.Are your sink handles, faucets and drains working properly? Do the sensors work for automatic systems? Is the water too hot or too cold? Does your soap have a bad odor, which may discourage people from using it? Does your paper towel dispenser work? Does your trash receptacle allow for just-cleaned hands to stay clean? Do the used towels fit in the bin? Is the bin large enough or changed often enough for the increased demand? A little attention here can go a long way to improve hand hygiene.Slide 19When you look at the levels of precautions, they increase as you go down the list. Airborne precautions require a respirator to prevent inhaling the tiniest particles of droplet. This can be done by using an N95 or higher respirator. With the limited quantity of n95’s consider increasing this level of protection to half face or full-face respirators, or even PAPRs, especially for your highest risk workers, especially respiratory therapists. We will talk about that more in a bit.If patients have been screened and separated, there is no current need for health care workers to wear masks outside of the hot and warm zones. Save the masks for when and where they are needed.Slide 20Please keep in mind that PPE is the least preferred method for controls. All of the actions we have already reviewed should be in place. There are some people and some tasks that require close contact or have greater exposure to hazards, and thus PPE is the final layer of defense.The use of PPE requires training to ensure competency in how to use the equipment, how to take it off, what it works to protect the wearer from and what it doesn’t. As someone who has managed respiratory protection programs for 30 years, and has performed over 5,000 fit tests, the biggest limitation with respirators is getting a good fit, especially for n95 respirators.Slide 21This slide just shows the comparison between a mask and a n95 respirator.It is important to get as good of a seal as possible with your surgical mask. The World health organization has some good instructions and print outs for donning and doffing surgical masks that I have included in the slide.Somen95s have an exhalation valve on the front. The exhalation valve is for personal comfort, allowing your moisture and hot air to escape the mask, making it a bit more comfortable to wear. However, an exhalation style N95 should not be worn on someone who is sick, as it will allow droplets to escape. This should not be an issue if those that are sick stay home, but do not give a mask with an exhalation valve to a sick patient.Slide 22These “one size fits most” is a particular challenge to women and workers with smaller facial features. Before you train workers for any respirator, they must be medically cleared. Breathing through a filtering device does require physical effort, and not everyone can do it. After the medical clearance, then good training is next. Part of that training is on how to do a fit check or a seal check I will explain the fit check in the next slide.If the worker can pass a fit check, then a fit test can be done. Qualitative fit tests only take a few minutes, so do them. If the worker does not pass, a different style of respirator is needed. There is no reason the worker cannot save the respirator they were trained and fit tested in for use on the floor as long as it is stored in a clean container.Keep in mind that the OSHA standard does not permit an employer to allow a worker to wear or be fit tested if the worker has facial hair that comes in contact with the seal. While some people may not like this, facial hair prohibits a good seal, which is exactly the reason they are wearing it. A small moustache or goatee is ok, as long as it does not interfere with the mask.Slide 23The only way workers can be sure they have a good seal when they wear a respirator is for them to do a fit check or seal check. Once the wearer has molded the mask to fit their face, they should make sure air does not come in or out through the sides anywheres on the mask. When they have a good fit, then they should to their fit check.The wearer cups their hand around the mask, and exhales slightly. The air should stay in the mask and not escape. Then the wearer inhales. The mask should collapse of suck into their face without air being drawn in from the sides. If the wearer does not get a good seal, readjust and try again. If they cannot get a good seal, they cannot wear the respirator. This user fit check must be done EACH time a mask is applied.If masks are being re-used, the wearer must have gloves on when doing this step and then the gloves must be discarded.Slide 24I am including this link to a great info graphic that shows the differences between masks and n95s. I cannot get the whole graphic on the slide, so please refer to the link for the rest of the information. You may want to print it out or have it available during your respirator training.Slide 25There is other ppe that can be very helpful. I strongly recommend the use of face shields and safety glasses. One interesting difference between health care and general industry is that in general industry; no one uses a mask for face protection. If there is an issue of splashing into eyes and face or mouth, a face shield and safety glasses or goggles are used.Wearing a face shield will physically protect your face with a very large barrier. If you are wearing a mask or respirator, the face shield will protect this too, allowing longer use.Shoe covers will keep your shoes from bring this and other viruses home with your staff.Slide 26What are some other things we can do to extend PPE and worker safety.Consider wearing high quality lab coats instead of gowns.I also bet that many of your facilities have scores of HAZMAT suits and PAPRs available. Now would be the time to break these out and start using them for staff doing activities with greater risk. Combine activities so workers are wearing them for longer times between changing. While this provides a very high level of protection, heat stress and fatigue will need to be monitored and combined with task rotation.One very important point when comparing respirators is that a full face respirator will provide five times more protection than an n95 and a PAPR provides time 200 times better respiratory protection than an N95 and even 20 times better protection than a full face respirator. So when we are really concerned about protection, go higher, not lower.Also consider wearing a heavier type of glove over surgical gloves for additional protection.For any protocols your facility puts in place, create simple procedures that must be followed and monitor for compliance.Slide 27Another area of extreme importance is the understanding and effectiveness of your decon procedures. One miss-step here can negate all of the other actions you are taking, and can put a considerable amount of people at risk. Set up decon stations or doffing areas. Make a poster in LARGE font of the steps to decon. Have a trained observer/helper oversee and assist. Then properly dispose or stage equipment for cleaning.I also highly recommend that all workers change out of their work uniforms as a last step when they leave, exiting through a “clean” area. Washing of their hands and face should follow as a last step. No sense bringing any potential germs home or to the store after work.Slide 28As far as personal protection for COVID-19 careI recommend at a minimum safety glasses, face shield, mask, lab coat or gown, shoe covers and two pairs of gloves.For staff that are in more high risk positions, caring for known or suspected COVID- 19 patients, providing respiratory treatments or procedures, increase the level of protection to a full face respirator a PAPR.The recommended removal of PPE goes from most contaminated to least contaminated. Therefore, shoe covers come off first, then outer gloves, followed by the face shield, lab coat/gown or suit, safety glasses, the mask or respirator, then inner gloves. Hand hygiene is the final step.Feel free to modify this a bit. You all know or can quickly determine who should be in this higher protection category.Slide 29There has been a lot of discussion on the use of expired PPE. In my doctoral dissertation research, I came across this specific topic, which I recommended for further study. My thought process is that if PPE is stored in a clean, climate- controlled environment, we could get several extra years use out of it. Apparently the CDC also agrees with this. Just have your safety officer visually inspect the PPE to make sure it is sill in good condition, and then use it!Slide 30While the health care industry is up in arms about re-using respirators after cleaning, everyone in the HAZMAT world re-uses theirs. Yes, N95s are typically a one time use even in general industry. This is another reason to go up to a higher level of respiratory protection. A full-face respirator provides excellent face protection and can be cleaned and reused. Remember employees must be fit tested for each type of respirator worn.There has been discussion about cleaning of n95s. I sat in on their webinar presented on 3/27/20 by NETEC, and I felt very comfortable with their science and explanations on cleaning n95. However, I would also do everything else first, especially going to a higher level of protection, before I went the route to clean and reuse disposable respirators.Slide 31Home made masks. At first, I shuddered over the thought. However, with all of the cries that supplies are running low, I opted to look and see how this could be a viable option. With using the right fabrics, and interfacing, these could be helpful for patient protection against spreading droplets. The biggest challenge is quality control with the material and straps.I would strongly suggest the facilities meet within their healthcare coalitions and come up with a regional criteria for masks to be made if this is something you wish to pursue. I am sure an effort could be organized in the community for masks if needed. It would also make people in the community feel they were really contributing to the cause. A great morale booster. . If this is an option, make sure your organization specifies which instructions sewers should follow.Also, quality control checks should be done on the masks before they are put in place. They should also be cleaned before put in use. One benefit of making masks is that they could be made in different sizes. I have included a link that seems to provide good guidance here. Make sure you have instructions prepared for how to use and clean them at home and on site.Slide 32My biggest concerns right now include the following:Making sure employees get quality training on uses, limitations, donning and doffing of PPE so they are competent.Getting good control and containment of where the virus is and is not in your facility. Use the structure of hot, warm and cold zones for house protectionSafety briefings must be done with staff daily. Review procedures and address concerns.Communicate clearly and often. Don’t forget communication is a two way street. Listen to employee concerns and act on their needs.Managing worker fatigue. Make sure to schedule breaks and days off for workers when you can, inject some appropriate workplace humor to reduce some stress.Slide 33Do you have any questions? Please reach out to me if I can answer any questions or be of further assistance. I want to thank you so much for you attention. I also want to thank you all for what you do in caring for patients and taking on extra risk at this time. I hope these measures provide helpful guidance for protecting your “house” and staff from illness.On the next slides are links to some information, videos and posters, along with my references. Oh, that is me, second from left! Thank youSlides 34 & 35 have no narration