Alexandra Ward

 titled “The Road to a New Normal: COVID-19’s Impact on Infection Prevention” with presenter Sharon Ward-Fore, MS, MT(ASCP), CIC. As part of the program, which you can register to watch for free 

, Ward-Fore responded to submitted audience questions, but we received so many that she could not cover all topics in the allotted hour. In order to best serve our readers, 

 has compiled all the questions submitted during the webinar and Ward-Fore has provided answers here. Read below to get the answers to your most important questions regarding COVID-19’s impact on infection prevention and reopening efforts.

Q:  Do you have any recommendations on how often you should change HEPA filters in the room air purifiers in dental office surgical suites?

  HEPA filters should be changed per the manufacturer’s instructions.

Q:  I have seen that a pre-rinse in dental isn’t effective if it is Listerine for COVID, but a hydrogen peroxide is recommended. What are your thoughts?

 has been approved as a rinse by the American Dental Association (ADA) for COVID-19 because of its viricidal activity, commercial availability, and taste. The 

 states rinsing with Listerine does not kill COVID-19. “LISTERINE

 Antiseptic is a daily mouthwash, which has been proven to kill 99.9% of germs that cause bad breath, plaque and gingivitis. LISTERINE

 mouthwash has not been tested against the coronavirus and is not intended to prevent or treat COVID-19.” 

The ADA has a lot of great resources about how to safely re-open during the COVID-19 pandemic:

NEW | COVID-19 Hazard Assessment & Checklist

Return to Work Interim Guidance Toolkit (Updated 5/7/2020)

Online Course: Return to Work Interim Guidance Toolkit Q&A

And the US Centers for Disease Control and Prevention’s (CDC) 

Q:  You mentioned that healthcare staff should be tested for COVID “regularly.” 

  Unfortunately, the Centers for Medicare & Medicaid Services does not define “regularly” but did state that as testing becomes more available, healthcare providers (HCP) at the highest level of risk should be tested. Testing availability in your area will help determine frequency along with discussions with HR and other policy makers in your institution. Also, “regular” testing comes with some caveats. Here is a good 

 that talks about testing HCP-“Testing Healthcare Workers for COVID-19: Issues and Challenges.”

Also, it is important to keep in mind that if you test negative for COVID-19, you are probably not infected at this time. However, testing negative at the time of the test does not ensure that you will not come into contact with the virus and become infected after the test is administered. Additionally, it can take up to 14 days after exposure for illness to occur. If you have been exposed, you might test positive at a later time. Continue to practice all protective measures, including practicing social distancing, washing your hands often, avoiding touching your face, and avoiding large social gatherings according to local guidance. As long as the virus that causes COVID-19 is spreading in your community, continue to follow guidance from your state and local health departments.

Q:  Is a gown required for an overnight sleep study for a sleep tech?

Unless the sleep study is urgent/emergent, you should not be providing care for a patient positive for COVID-19. The use of BiPAP/CPAP is considered an aerosol-generating procedure. There is some concern that using BiPAP/CPAP could spread the virus through the exhalation port, which allows carbon dioxide to escape from the mask. This port may also release smaller virus-containing particles as “aerosols,” which can remain suspended in the air for a few hours, so full personal protective equipment (PPE) with an N95 mask, and a negative air flow room, if available, is recommended if you enter the room of a COVID-positive patient during the sleep study.

Q:  You mentioned temperature screening patients when they enter a facility. What would you recommend as proper PPE for the staff members performing the task of taking the temperature?

  Remember, you are re-opening to provide care to non-COVID patients unless you are equipped to provide care for COVID-positive patients. Prior to having patients enter your facility, try to ask screening questions about symptoms-fever, cough, shortness of breath-and ask patients to arrive wearing a face mask. Follow recommended infection control practices to prevent transmission of infectious agents. For temperature screening of asymptomatic patients, I recommend staff wear a face mask or surgical mask, eye protection (face shield/goggles), gloves, and perform hand hygiene. For symptomatic patients, I recommend an N95 mask (if available), gown, gloves, and hand hygiene.

Q:  What resource are you using for the adaptation to PPE usage for endemic methicillin-resistant

 about strategies to optimize the supply of isolation gowns. Healthcare facilities should refer to that guidance and implement the recommended strategies to optimize their current supply of gowns.

Q:  Is it required for all patients and staff to be tested in free-standing outpatient surgery centers?

No, testing is not required but recommended where available. Screening of all patients prior to arrival to your facility, via phone telephone advice lines, patient portals, and online self-assessment tools, or calling and speaking with an office/clinic HCP (CDC Phone Advice Line Tools) is highly recommended. The American College of Surgeons has a 

 called “American College of Surgeons Post-COVID-19 Readiness Checklist for Resuming Surgery.” The checklist is organized into 2 parts: Part I addresses the "Core" facility items. Part II addresses the "surgery specific" items. 

Q:  Research is showing that contact precautions are not necessary for multidrug-resistant organisms (MDROs), and many hospitals have gone to no isolation precautions. Do you support this research?

:  I think each hospital has to look at its own patient population and decide what their own policies are for implementing and removing precautions. However, the CDC still recommends the use of contact precautions in inpatient acute care settings for patients known to be colonized or infected with epidemiologically important MDROs including MRSA. I do believe we need to work harder to discontinue isolation precautions that meet the 

 presented by the Society for Healthcare Epidemiology of America (SHEA).

Q:  When reusing gowns for COVID patients under investigation and in confirmed COVID-19 rooms with negative airflow vs negative pressure, is it appropriate to have the gown remain in the room (clean side out)?

:  Disposable isolation gowns are not designed to be reused because the ties are usually broken when doffing them. Cloth gowns can be reused after laundering. Rather than reusing gowns, consider bundling patient care activities to conserve gowns. Donning a gown that has already been used can be tricky, and a source of contamination to the user.

Q:  How many times can you reprocess N95 masks?

 for optimizing the supply of N95 respirators. 

Q:  Some research is saying 80% alcohol is not as effective. What are your thoughts?

I’m not sure which alcohol (ethanol or isopropanol) this question is about, so I will explain how alcohol-based products, in general, work. Alcohols work by denaturing proteins, and proteins are denatured more quickly in the presence of water. Some bacteria are better eliminated with the use of a less concentrated alcohol because higher concentrations cause an external injury that forms a protective wall that shields these organisms, making the disinfectant unable to reach them.

Another reason for not using a very high concentration of alcohol is that alcohol solutions tend to evaporate quickly when applied to surfaces which then limits the contact time. Disinfectants rely on a contact time to be effective. The rate is similar for either isopropyl alcohol or ethyl alcohol, but the higher the concentration of alcohol, the quicker they will evaporate.

Q:  Are you using UV-C disinfection systems to kill pathogens in whole rooms?

  The use of ultraviolet light systems is becoming more widely used in healthcare facilities for disinfecting patient and operating rooms. At my former hospital, we were using UV-C as part of discharge cleaning for 

 patient rooms. We also used it for our VRE cohort rooms upon discharge. One thing to keep in mind with UV-C is that all items must still be cleaned prior to using UV-C because any bioburden present on surfaces will not be penetrated by UV-C light. It should only be used as an adjunct to thorough cleaning. At this time, the efficacy of UV light on COVID-19 is currently unknown.

Q:  What is the recommendation for what the infection growth rate should be before reopening?

. The recommended infection growth rate should be 1.0 for 2 weeks prior to opening.

Q:  It has been reported that the COVID-19 virus is active in dust. What happens when floors are vacuumed? 

 the following process for cleaning carpets: 

For soft (porous) surfaces such as carpeted floor, rugs, and drapes, remove visible contamination if present and clean with appropriate cleaners indicated for use on these surfaces. After cleaning, use products with the EPA-approved emerging viral pathogen claims that are suitable for porous surfaces

The risk of transmitting or spreading SARS-CoV-2, the virus that causes COVID-19, during vacuuming is unknown. At this time, there are no reported cases of COVID-19 associated with vacuuming. If vacuuming is necessary or required in a school, business, or community facility that was used by a person with suspected or confirmed COVID-19, first follow the CDC recommendations for 

Cleaning and Disinfection for Community Facilities

 that apply, which includes a wait time of 24 hours, or as long as practical.

After cleaning and disinfection, the following recommendations may help reduce the risk to workers and other individuals when vacuuming:

Consider removing smaller rugs or carpets from the area completely, so there is less that needs to be vacuumed.

Use a vacuum equipped with a high-efficiency particulate air (HEPA) filter, if available.

Do not vacuum a room or space that has people in it. Wait until the room or space is empty to vacuum, such as at night, for common spaces, or during the day for private rooms.

Consider temporarily turning off room fans and the central HVAC system that services the room or space, so that particles that escape from vacuuming will not circulate throughout the facility. 

Make sure PPE is worn when changing vacuum filters – gloves, mask, eye protection

Q:  I do electrolysis where 95% of patients are receiving the treatment to the lip or chin area. They are not able to wear a mask during the procedure, and I work within 6 inches of their faces. Is there a way to safely return to work if I cannot access enough N95 masks?

Screen clients prior to scheduling an appointment, and only accept clients that have no signs or symptoms. Also ask they arrive masked. Consider a thermal thermometer to scan them upon arrival. You wear gloves, a mask, and face shield (preferred) or goggles (second choice); there is no need for an N95 mask, as you are providing care for non-COVID-positive patients ONLY. 

Q:  What studies can I use to show my hospitalist how long a patient is contagious?

  The time from exposure to symptom onset (known as the incubation period) is thought to be 3 to 14 days, although symptoms typically appear within 4 or 5 days after exposure.

We know that a person with COVID-19 may be contagious 48 to 72 hours before starting to experience symptoms. Emerging research suggests that people may actually be most likely to spread the virus to others during the 48 hours before they start to experience symptoms. 

Temporal dynamics in viral shedding and transmissibility of COVID-19

Comparative pathogenesis of COVID-19, MERS, and SARS in a nonhuman primate model

Q:  What precautions should a healthcare worker take when returning to their home?

 that answers general questions about contamination. So little is known about COVID, but we do know the droplets can survive on surfaces. With COVID or any other potential exposure to a communicable disease, you should probably shower and change your clothes at work and bag your work clothes to bring home to wash separately from your other laundry. If you wear your work clothes home, remove your clothes as soon as possible prior to entering your home and wash them. Definitely change your shoes or, even better, dedicate a pair for work. If you wear your work clothes home, you might also consider wiping down your car, as COVID can live up to 3 days on plastic and steel. Until we know more, I would err on the side of caution.

Q:  Do you have any special recommendations for an inpatient psych unit? 

:  Each facility will probably have its own policies and procedures, but the 

-Screen or test (where available) patients prior to admittance to the unit;

         -Try to have private patient rooms;

-Keep patients in their rooms as much as possible;

-Perform temperature monitoring at least every shift;

-In milieu areas, allow a reduced number of patients and require adherence to masking, social distancing, and hand hygiene with soap and water for patients;

-Increase cleaning in milieu areas and other areas patients may congregate;

-Move symptomatic patients off the unit as quickly as possible.

Q:  Is the testing of staff for antibodies or for acute illness?

 has prioritized testing of staff for acute illness when symptoms are present.

Q:  I work at an outpatient hemodialysis center that has an isolation shift at the end of the day for COVID-positive patients and patients under investigation (PUI). We have LIMITED N95 masks. What PPE would you recommend for unknown/asymptomatic patients versus COVID-positive patients?

, all patients, regardless of symptoms, should put on a cloth face covering at check-in (if not already wearing) and keep it on until they leave the facility. If patients do not have a cloth face covering, a face mask or cloth face covering should be offered (if supplies allow). If the patient is unable to tolerate a cloth face covering, then they should be separated by at least 6 feet from the nearest patient station (in all directions). 

For PUI and positive COVID-19 patients, HCP should wear an N95, if available, and a gown, eye protection, and gloves. If an N95 is not available, a face mask may be used.

Q:  If the World Health Organization, CDC, and the Infectious Diseases Society of America say it is droplet isolation and a gown should be worn, why is the use of overalls/coveralls shown in pictures? 

:  Coveralls may be used if there are no gowns available. Typically, isolation gowns are more readily available. Whichever you use, you should train your staff on the PPE specific to your facility.

Q:  There has been much discussion on aerosol-generating medical procedures (AGMP) vs non-AGMP procedures. What are your thoughts on performing bag valve mask ventilation (BVM) while wearing an N95 mask? Also, would cardiac compressions (CPR) be considered an AGMP without bagging?

Make sure bag-valve masks and other ventilatory equipment are equipped with HEPA filters. Rapid sequence intubation with appropriate PPE is the preferred method of intubation. In general, aerosol-generating procedures (eg, bag-valve mask, nebulizers, non-invasive positive pressure ventilation) should be avoided per recommendations attributed to the Anesthesia Patient Safety Foundation and World Federation of Societies of Anesthesiologists. The CDC considers CPR an aerosol-generating procedure.

Q:  What PPE should be used for non-COVID visits knowing that there is asymptomatic transmission of COVID?

You wear a face mask and eye protection. Patient wears a cloth mask or face mask.

Q:  If a staff member is COVID-19-positive, when can I reopen his personal office after cleaning and disinfection? 

  Consider severity of illness and the duration of time spent in the room while ill. If the staff member occupied the room for a long time while ill, you should keep the office door closed for at least 69 minutes, based on 6 air changes/hour (ACH) with removal of 99.9% of airborne contaminants, according to 

Staff, wearing appropriate PPE (gown, gloves, mask, eye protection) may enter the office to clean it with an approved LIST N disinfectant.

If the staff member was not coughing or sneezing and only spent a few minutes in the office, the risk to anyone entering is greatly diminished. PPE needed to clean the room would be minimal-gloves, mask, eye protection if indicated on the disinfectant.

Q:  Should a terminal cleaning be performed after all visits of positive or highly suspected COVID patients?

  Yes, healthcare facilities should consider assigning daily cleaning and disinfection of high-touch surfaces to nursing personnel who will already be in the room providing care to the patient. If this responsibility is assigned to environmental services personnel, they should wear all 

 when in the room. PPE should be removed upon leaving the room, immediately followed by performance of hand hygiene.

Q:  Do you have an opinion on the use of Air Ionizer Technology for disinfection

  Air ionizers rely on the chemical properties of ions. Air ionizers create negative ions using electricity and then discharge them into the air. These negative ions attach to positively charged particles in the room, such as dust, bacteria, pollen, smoke, and other allergens. Ionizers can be less effective than HEPA air purifiers at completely removing allergens and other particles from the atmosphere. Evidence shows that air ionizerspurify the air of bacteria, dust, cigarette smoke, molds, soot, pollen, and household odors. This has a significant impact on people suffering from hay fever and other seasonal allergies.

Q:  Is it mandatory to test all contacts of a positive case by PCR test?

No, not even recommended at this time due to lack of testing availability and resources for contact tracing. CDC states that “healthcare facilities should consider foregoing contact tracing in favor of universal source control for HCP and screening for fever and symptoms before every shift.”

Articles

Sharon Ward-Fore: "Rather than reusing gowns, consider bundling patient care activities to conserve gowns. Donning a gown that has already been used can be tricky, and a source of contamination to the user."

Answering Your Infection Prevention Questions Regarding COVID Reopening 

Brooke Decker, MD, is the director of infection prevention at the VA Pittsburgh Healthcare System.

’s Editorial Director Alexandra Ward recently spoke to Decker about the many demands placed on infection preventionists during the COVID-19 pandemic. Decker talked about those demands and challenges, but she also spoke about how the crisis might reinforce the importance of infection prevention and infection preventionists in healthcare settings. Decker: “I think the best advice I can give is, ‘Hey, this is what we trained to do.’ Keep your spirits up, help keep the spirits up of the other people in your hospital.”

Can you start off by telling us a little bit about what your day-to-day is like in the middle of this pandemic?

Absolutely. And thank you so much for inviting me. So, I tried to think about what does my day look like? Like any other infection prevention person, you really never know what your day is going to look like. But in general, I come in, I check with the on-call infection preventionist RN to find out what happened overnight. Sometimes I might already know, but there might be some additional things that we can go over. The next thing I do is I sit down and generate some data. As the hospital epidemiologist, I have to provide my leadership team with some information. They want to know how many cases came in, how many tests the lab ran. Really many different things might be on my agenda for what kind of data they’re looking for, for their morning meetings. The next thing I do is we have an IP team huddle every single day. And we get together and go over what we plan to do, make sure we’ve divvied up the labor, every meeting is covered. And then we also go over any questions. Of course, the clinical teams are asking us all kinds of excellent questions that maybe we haven't encountered, or we just want to make sure we consistently answer them when there isn’t clear guidance, and it's somewhat based on judgment. We want to make sure we’re producing the same judgment every time it’s asked. So, we have a wonderful huddle call. I highly recommend a morning huddle call with your IP team if you can have one. And after that, it’s on to the telemeeting marathon.

COVID has really put the spotlight on infection control as an industry. Have you seen this as an opportunity to educate and, in some cases, maybe re-educate healthcare workers on the importance of infection control and prevention?

Absolutely. And I think every good infection preventionist uses every opportunity to educate. I can say that this pandemic has really made people a lot more receptive to infection control practices when they may not have been before and we have to use that energy. There are people bringing me great questions. Sometimes those questions, I’m going to answer in a way that maybe isn’t where they were going. But I really try to validate their concerns, even when they’re asking me can I wear a spacesuit to go pick up my mail? I say things like, “Wow, you’re really thinking like an IP now? Here's what we should do.” And that way, you’re sort of more agreeing with them and then moving them where you need them to be to align with appropriate guidance and PPE usage. Rather than feeling like you’re shutting them down. I really think we have to use that enthusiasm and complement them and say while you’re doing it, here’s where we’re going to go. I think IP has got to take an active role in teaching, evaluating, reinforcing policies. Obviously, many of us…. I’m especially chained to my desk. But fortunately, my RNs are not as chained to their desks. They’re able to go out to the units and see what’s going on. Hear those frontline people saying, “You know, I know that policy you made really sounds great on paper, but here’s my problem.” And we need to be there to say, “Oh, goodness, OK, we’ll rewrite that and here’s how we can make it work.” I think there are a lot of IP programs that are doing more telework. I say that I am fortunate to have a good sized team and some of my people are teleworking at any time, but I still have people on the ground every single day in order to be there with those frontline providers to see what they’re going through and answer their questions. It’s been very challenging as well to address some of the concerns of the frontline staff, because from their perception, things are changing all the time. I think we don’t know a lot about this pathogen. And I admit that I say, we’re going to know a lot more in two to three years. Unfortunately, we need to make a decision today. Here’s the decision that we're making. And I always also like to reassure people I know … I know everyone in IP is busy right now. And people are often reaching out to us saying, “I’m so sorry to bother you. And I say, “No, no. IP is here to help.”

What do you think the new normal of infection prevention will look like? Will this sort of pandemic level of IP sustained even after the case count starts to drop?

It’s really hard to predict what’s going to happen in the next month, year, or multiple years. I do think there are going to be things that are going to change indefinitely. I’ve been starting to think and talking to colleagues who’ve been here longer and gone through past epidemics. Thinking like the HIV epidemic. Before the HIV epidemic, we didn't have standard precautions. Standard precautions came out of that. Obviously, I can’t predict for sure what’s going to happen. But one thought I have is perhaps we’re going to have a new standard precaution. It’s going to incorporate more respiratory precautions. But I think we're just going to have to see what we learn and what happens.

How do you assess barriers to infection prevention within your healthcare system?

I have to say that I am incredibly lucky in my healthcare system that I have an incredibly strong connection with my leadership team. I participate as the subject matter expert in our hospital incident command. For this outbreak, I recommend that all IP departments advocate for at least a weekly meeting with their leadership official. If it isn’t already happening right now. IP is crucial for ensuring quality patient care. Most hospital systems will recognize that and make themselves available. If not, you have to remind them that they make themselves vulnerable by not having a strong IP program. This is a time where you need to advocate for the people you need. If before this pandemic happened, you were saying, “Well, if only I had one more infection preventionist here to help me.” “If only I had a data person.” “If only I had a physician medical director.” I’m sure you’re hurting right now. And this is the time to bring that to your leadership person and say I need this position now. This is not going to end in the next week. It’s not going to end in the next month. It’s going to go on until we have an active vaccine. So, this is a great time to bring that up and get the people that you need.

How can infection preventionists ensure that protocols are being updated to reflect any new guidance coming out?

The first thing I have to say is read, read, read. A large portion of my day is reading all of the new guidance that is coming out. Wherever you get your information … certainly you have to read the CDC. Any policies coming from your policy or from your hospital system. But also looking at infection prevention journals that you like to read. Looking at whatever listserv. I think if you’re not involved in an infection prevention listserv forum, or other group that allows you to talk to your peers and offer sort of those questions that maybe aren’t in the guidelines, you need to be on one and then keep up to date with them and see what’s being said. Then the next step after you read, read, read is update, update, update. If you have any policies, I would look at them every week at a minimum. I think there are always a few things when I review policies that I could update on them. I send them to my team when I update them. And I make sure that I get thoughts from other people. You know, if you’re writing a policy about what to do in the emergency room, you probably need to have not just the emergency room medical director, but make sure you have the head nurse in the ER. Make sure you have respiratory therapy. Make sure you have other groups that are going to be involved and affected by that policy. And then I think anything you have.… If you have a policy that’s dated-and, of course, all your policies are dated-if it’s dated any more than two weeks, I probably need to update that. I will admit that the frequency at which I make tweaks to policies might drive some people crazy. But I think that we need to also make sure, because we don’t know everything about this disease right now. We're going to learn new things and those new things are going to probably impact how we want to approach it and I think that’s the right thing to do. I would not stick to a policy just because we’ve already trained everybody on this. That’s not the right approach in my mind.

Has your institution faced any shortages of PPE? And, if so, how do you navigate that?

So very fortunately, we are in a conservation mode, but we went into conservation mode early. My approach was seeing this coming you can’t conserve after you run out. An example would be that at the VA Center, we are still isolating for MRSA and VRE. Fortunately, our national office came out with guidance saying, “If you want to walk back from that MRSA and VRE contact precautions in order to conserve your materials you can.” We jumped right on and said, OK. I’ve talked to colleagues who also have gone away from MRSA and VRE contact precautions and other centers and had really good outcomes based on that. Certainly, looking at other hospitals, where providers are having to wear non-standard PPE, breaks my heart and I never want to be there. And fortunately, we’re not there. Pittsburgh is also not a very hard-hit location. Our cases have been very manageable. We are not out of any PPE. And the VA is also very fortunate in having a very large established network. And we have great coordination in getting supplies to areas with greater needs, and specifically, our facility has been able to share with other harder hit facilities on the east coast.

There was a recent article piece in a peer-reviewed journal that proposed universal face shields even out in the community. What are your thoughts on some of those other containment measures?

We’re currently using face masks as the ideal face covering, including the fabric mask for the patients, family members, and non-patient care employees that we have. For people who aren’t able to wear face masks, we are approving a full-face shield. Reasons to not be able to wear a mask would include pulmonary issues, PTSD and other things that would prevent you from being able to wear a face covering. We are adding the caveat that a full-face shield is not acceptable in patient care. You do need to be wearing a mask and then to try and stay six feet away from other people. Because a face shield will certainly cover what’s coming at you. But it’s possible that your respiratory droplets could fall down and go to the side. We don’t see it as the equivalent to a face mask. But, certainly it’s a great measure. And I think, also dealing with patients, I think that's a challenge. I think most patients are going to be able to wear a face mask when they come into the hospital, but some patients aren’t. And having that secondary idea of, well here, let’s give you a face shield. It’s better than nothing. I think that’s where I kind of see it as better than nothing.

And lastly, what is your advice to your fellow infection preventionist professionals and healthcare workers right now?

I think the best advice I can give is, “Hey, this is what we trained to do.” Keep your spirits up, help keep the spirits up of the other people in your hospital. Remember, if you’re not having fun, I’m sure they're having a lot less fun because this isn’t their area of expertise. And also keep in mind that right now you’re generating those stories that you’re going to be telling junior colleagues for decades to come. Probably until they’re bored of it. I would sort of approach this from like, “You’re making history right now. You’re doing things that you’re going to reflect on for the rest of your career.” If you have junior IPs in your in your group, and I do, I try and say, “Oh, this is wonderful. You’re learning so much. You’re learning all of IP in a short period of time. Wonderful!” But I think trying to see the bright side of things and appreciate the small victories that you get. You know, if you get another position from this, if you get an opportunity to talk to leadership, if you get to participate in a group that you hadn’t … if you make that connection with someone in a department that you didn’t know before, but now you’re like: “OK, next time I have a problem when the ceiling starts leaking, I’m going to be calling that guy.” You know, you may be able to meet people and other IPs to that you didn’t know before, and they may help you in the future. 

This interview was edited for clarity and length.

Brooke Decker, MD: "Keep in mind that right now you’re generating those stories that you’re going to be telling junior colleagues for decades to come."

Q&A: Everybody’s Looking to Infection Preventionists for Answers These Days

Kalia Murray, an emergency medical technician with the Richmond County Ambulance based in Brooklyn, New York. Can you start off and share with us what it has been like working as an EMT on the frontlines during a global pandemic?

Can you share with us what it has been like working as an EMT on the frontlines during a global pandemic?

One thing I think that’s a little bit different from maybe other people you’re speaking with, like doctors and nurses who are with these patients for longer periods of time, we are the first ones to arrive on a scene, often having no idea what we're walking into. It’s hard to say sometimes, if it’s necessarily a COVID-related incident. It could be a call for somebody who fell and broke their ankle. And while you’re on the scene, you realize there’s more going on than just their injury. And sometimes you go, and you think it’s going to be a COVID-related call and it turns out not to be. It’s sort of an interesting situation being the first one there. You never have the full story. And unfortunately, I don’t get to follow up often and get the rest of the story.

But you still have to be prepared and probably treat every case as though it’s a COVID case, in terms of your personal protective equipment and that sort of thing, right?

Yes, we treat every call as if it’s a COVID-19 call. We have to gear up the best that we can and try to protect ourselves regardless of what the call is. 

Has there been any discernible change in the volume of non-COVID calls?

Oh, for sure. All calls are up. I’m on emergency calls, and I have dispatch asking me how soon I can be finished because they have another one waiting for me. It’s not uncommon that people are home by themselves watching the news, and they get scared. And they think that they’re sick and they’re calling for help. And oftentimes, they’re not showing any signs or symptoms and they’re totally seemingly healthy. And also people are home by themselves; people are finding themselves in trouble a little bit more. They’re drinking more than they should be and falling. Cooking related accidents: They’re burning their hand on the stove and things like that. So, all around, the calls are definitely up.

What infection prevention measures and precautions does your team take while working in the field that’s maybe different from prior to the COVID pandemic? 

We have N95 masks that we use. Unfortunately, we use them for at least a week at a time. We’re very low on them so they try to stretch it out as long as possible. We’re known to stapled them back together when they break. Yeah, it’s crazy. But we layer it then with the surgical mask if we can find one. We have goggles that we wear. And recently we’ve been given shields that we can use to cover our entire faces. We have gloves always. That was something that we did prior to this situation. So that’s no change. Gowns are the one thing that we don’t really have on stock on our ambulance. We have just a couple. We sort of rely on hospitals and nursing homes to help provide that if they can when we’re there.

We hear a lot about the toll that this is taking emotionally on healthcare workers. Can you speak to that at all?

Yeah, of course. It’s exhausting. It’s mentally and physically exhausting. A lot of our first responders got sick early on, and they’re home recovering. There are fewer people on the road. I mean, more calls for the people that are on the road. Overtime is not even an option anymore. It’s a definite. Some people do two or three shifts in a row. And I know the nurses and doctors are doing the same thing just around the clock working. Everyone is all-hands-on-deck.

What do you want your colleagues to know about what’s going on on the frontlines? If you could share one piece of advice right now what would that be?

I appreciate them so much. We are definitely working as a team. More than ever, we always have known that we need to work as a team. But I definitely see a stronger united front from everybody. We’re all in this together. We’re scared too. We have families that we have to come home to every day that are terrified that we’re going to bring something home with us and make them sick too. We are physically and mentally drained. It’s not uncommon to have a devastating call, knowing that your patient isn’t going to make it through the rest of the day. And to hide in the corner of the ambulance for a few seconds and just cry it out because we’re tired and it’s very, very depressing.

What sort of precautions are you personally taking when you get off a shift and you come home?

If I can, I try to wash my uniform as soon as I can. When I get to my apartment, I take off all my clothes and it’s either in a garbage bag or I just leave it on the floor outside and go immediately into the shower and wash. 

Is there anything else that you would like to add?

I really appreciate how supportive the New York community has been. A lot of people have been coming forward and just stopping us on the street to thank us for being there and for doing our part. But it’s my job. I’m happy to be doing it. I really appreciate that people have been really supportive. It’s very touching. And I hope that that continues because it’s scary times. And it’s hard to come home after a 12- or 15-hour day, and you don’t have time to take a break. There’s no time for food. There’s no time for water. We’re just running around trying to take care of everybody else. I hope that that appreciation continues and that people will stay home and continue to social distance because I know it’s getting warmer outside and people don’t necessarily want to do that at this time. 

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Nursing homes can present a challenge for infection prevention efforts when teams must balance resident quality of life with the need for measures such as room restrictions and use of personal protective equipment (PPE). 

These facilities are ripe for transmission of multidrug-resistant organisms (MDROs), but new evidence suggests use of traditional Contact Precautions may not be adequate. 

To fill the gap, the US Centers for Disease Control and Prevention (CDC) has recently unveiled a new approach called Enhanced Barrier Precautions (EBPs), which rank in between Standard and Contact Precautions, and “require gown and glove use for certain residents during specific high-contact resident care activities that have been found to increase risk for MDRO transmission,” according to the CDC. 

, Kara M. Jacobs Slifka, MD, MPH, and Nimalie D. Stone, MD, MS, both physicians with the Long-term Care Team in the Prevention and Response Branch within CDC Division of Healthcare Quality Promotion, provide an in-depth overview of EBPs and how to implement them. 

Why do multidrug-resistant organisms pose such a threat in nursing homes, in particular, as opposed to other healthcare facilities? 

Multidrug-resistant organisms (MDROs), especially those for which we have limited antibiotic treatment options, pose a threat in healthcare because they colonize individuals for prolonged periods of time, silently spread, and cause invasive infections with high morbidity and mortality. As healthcare delivery keeps shifting away from hospitals, nursing homes are providing more care to medically complex and frail individuals who are more vulnerable to the harms from MDROs. The combination of the long lengths of stay, exposures to indwelling medical devices and antibiotics, and the increased dependence of nursing home residents contribute to the spread and acquisition in this setting. 

ICT: What are some of the current gaps in infection prevention practices in nursing homes that need to be addressed?

The key to preventing spread of MDROs comes down to consistently following basic infection prevention and control practices during care at the bedside; however, health department and CDC teams have routinely found gaps in these practices during visits to nursing homes across the country. The most common infection prevention gaps involve hand hygiene, the use of personal protective equipment (PPE) and precautions, and cleaning and disinfection of environmental surfaces and shared equipment. The implementation of these practices depends on 3 things: 1) educating healthcare staff about when and how to perform these infection prevention practices, 2) ensuring adequate supplies are available at the point of use, such as resident rooms and care areas, and 3) monitoring and providing feedback on staff adherence to practices. The incorporation of these practices is critical during all aspects of resident care from physical therapy to wound care. As an example, during our visits, we commonly hear misconceptions about the use of alcohol-based hand rub (AHBR) such as ABHR not being as effective as soap and water, or that adding ABHR dispensers will reduce the “home-like environment” of the nursing home and have the potential to be cited during the survey process. However, ABHR is the preferred method of hand hygiene unless hands are visibly soiled or during a 

or norovirus outbreak, and increasing access to ABHR, such as inside and outside of resident rooms, increases staff adherence to hand hygiene. Performing hand hygiene audits is informative for providing feedback and determining the need for education or intervention. 

ICT: In nursing home facilities, why is it challenging to rely on the routine contact isolation precautions used in hospitals when there’s an outbreak of a multidrug-resistant organism? 

The main challenge with implementing Contact Precautions in the nursing home setting is the need to restrict residents to their room, especially when the reason for Contact Precautions is a multidrug-resistant organism (MDRO). Residents colonized with MDROs are often colonized for prolonged periods of times (ie, greater than 6 months) and typically have longer stays at the nursing home than in an acute care hospital. Limiting a resident’s movement and participation in the facility for extended lengths of time can impact rehabilitation, involvement in social activities, and negatively affect their well-being. For this reason, Contact Precautions are intended to be time-limited, while Enhanced Barrier Precautions can provide a more balanced and sustainable approach to MDRO prevention. 

ICT: What are Enhanced Barrier Precautions (EBPs) and how do they differ from standard and contact precautions?

Enhanced Barrier Precautions (EBP) expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and recommends the use of gown and gloves during high-contact resident care activities that have been shown to provide opportunities for transfer of MDROs to staff hands and clothing. Enhanced Barrier Precautions falls on the spectrum in between Standard Precautions and Contact Precautions. Standard Precautions should be followed with all residents at all times, including residents for whom EBP or Transmission-Based Precautions are being used. EBP is more specific than Standard Precautions by requiring PPE use for high-contact resident-care activities, but less restrictive than Contact Precautions as PPE is not required for every room entry/activity and residents are not restricted to their rooms. 

ICT: What are some of the high-contact resident care activities where EBPs should be used?

High-contact resident care activities include: dressing, bathing/ showering, transferring, providing hygiene such as brushing teeth and combing hair, changing linens, changing briefs or assisting with toileting, device care or use (including: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care).

ICT: How can healthcare administrators ensure proper implementation of EBPs? 

Healthcare administrators can help by prioritizing infection prevention within their facility. This includes providing dedicated staff time to implement the infection prevention program. EBP will be a new concept for many nursing homes; staff, residents, and families will need to be educated. Administrators can also help by ensuring that staff have access to the supplies they need to follow recommended practices. Adherence to hand hygiene in a facility isn’t going to improve if staff don’t have access to alcohol-based hand rub at the point of care. Similarly, staff aren’t going to use PPE or clean and disinfect shared equipment after each use if they have to search the unit to find supplies. 

ICT: Anything else you would like to add about EBPs?

Using EBP to prevent the spread of MDROs helps facilities support resident safety and resident well-being but will require education of staff, residents, and families. CDC is developing additional materials to support implementation of EBP such as a list of Frequently Asked Questions. CDC recently presented a webinar introducing the need for and describing EBP, which is available online; has developed signage for EBP and Transmission-Based Precautions; and has released a comprehensive infection prevention training course for nursing homes. 

The key to preventing spread of MDROs comes down to consistently following basic infection prevention and control practices.

Author | Alexandra Ward

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