Pam Koman-Podolak is immunocompromised, with multiple health conditions, including rheumatoid arthritis. She falls squarely into the category of people most at risk during the COVID-19 pandemic. When the state of New Jersey, where she lives, issued stay-at-home orders, she says, “I was so sad, thinking I had to cancel appointments. And I was scared to go in because my rheumatologist works in a big medical center and I’m on immunosuppressant meds. But I really needed to talk to him and see him.”

Koman-Podolak is lucky: Her rheumatologist is “really into technology,” so she was able to talk with him via computer. Although this was her first experience with telemedicine, it turned out to be a good one. “It was immediately obvious that he was comfortable using this technology,” Koman-Podolak says. “It felt very personal and professional. I was impressed that he noticed my knuckles were swollen by examining my hands through the app!” Her rheumatologist (she calls him a “rheumy rockstar!”) “saved the day for me by offering this wonderful solution.” 

But despite 20 years of real-life experience and growing popularity, telehealth and telemedicine (which is usually defined as clinical interactions) still aren’t as widely used as might be expected. According to 2019 data fromDefinitive Healthcare, an analytics firm, only one-third of inpatient hospitals and 45% of outpatient facilities provide telehealth solutions or services. Iowa, Utah, and South Dakota-which have large rural swaths-have the highest implementations, with 64% or more of the state’s hospitals reporting a service.

 Northeastern states reported the lowest level.

That’s changing, as the coronavirus disease 2019 (COVID-19) pandemic has wrought changes in everything from routine care to triage. Between erratic supplies of personal protective equipment for practitioners and patients who don’t want to risk their health, telemedicine is proving a boon. 

Last year, the Infectious Diseases Society of America (IDSA) updated its position statement to educate its membership on the use of telemedicine and telehealth technologies to provide “evidence-based, cost-effective, subspecialty care” (the list of established-use cases for infectious diseases includes infection prevention and control).

 Most acute care facilities have infection prevention (IP) specialists, but many community hospitals and long-term care facilities, now overwhelmed by the flood of pandemic-related cases, may not have had the time, money, or expertise to develop and manage IP programs. In those cases, IDSA encourages use of telehealth tools as a potential solution: Where an IP specialist isn’t available, the authors say, telehealth platforms can be used to connect infectious disease physicians and other experts with local providers.

The American Hospital Association (AHA) also thinks telehealth is particularly crucial now. On March 5, Richard Pollack, AHA’s president and CEO, wrote a letter to US Department of Health and Human Services Secretary Alex Azar headed “action needed to support hospitals’ ability to respond to COVID-19.”

 Ensuring safe care for patients, protecting healthcare professionals providing patient care, and supporting the health and safety of communities “are the main priorities for hospitals and health systems preparing for and responding to COVID-19,” the letter said. 

To that end, “We urge the administration to take the following regulatory actions to support these efforts…” Among them, to enable broader use of telehealth. “Hospitals want to enable individuals who are experiencing symptoms and may suspect they have COVID-19 to consult with a care provider without going to the hospital.…” That was followed on March 19 by a joint letter to Congress from the AHA, American Medical Association, and American Nurses Association, again detailing urgent needs to combat coronavirus, including training on telemedicine and telehealth capacities.

The Veterans Administration (VA), an early adopter of telehealth, is among those leading the way. It began offering telehealth services in 2003, and has experience based on nearly 3 million healthcare interactions with (as of 2019) more than 900,000 veterans. The VA has been beefing up its telehealth system and is getting more money to help fight COVID-19. Roughly $16 billion of the emergency funding passed last month in the Coronavirus Aid, Relief, and Economic Security (CARES) Act is going to the VA to expand its telehealth services.

 CARES also includes some expanded authorities for VA officials to respond to the coronavirus crisis, such as new agreements with broadband internet suppliers to increase telemedicine options for veterans. 

The Definitive Healthcare data reveal some possible reasons why providers have been slow to implement telehealth: Fear of fraud is one. In February, 2 telemedicine companies were charged with conducting a complex $56 million scheme to convince Medicare beneficiaries that they needed such items as back or knee braces regardless of medical necessity.

Another is federal policy. The US Centers for Medicare and Medicaid Services (CMS), according to Definitive Healthcare, only finalized expansion of provider reimbursement for telehealth and virtual care services in late 2018.

 CMS also issued a new ruling that, as of this year, Medicare Advantage members will have more access to virtual care visits. DH speculates that providers might have been waiting for the new ruling to go into effect before investing in new technologies. Cost, of course, is always a barrier. Virtual technologies may only apply to a small percentage of patients, making it an investment that some providers may feel outweighs the benefits. 

And, as AHA’s Pollack noted in his letter, hospitals have concerns that these technologies may not be compliant with Health Insurance Portability and Accountability Act (HIPAA) privacy and security requirements. Still, the AHA urged HHS to waive HIPAA privacy requirements and to loosen reimbursement rules to allow coverage of services for telehealth. In early April, the HHS eased HIPAA enforcement “during this public health emergency.”

Among other things, the updated rule allows healthcare providers to use FaceTime, Zoom, Skype, and other approved applications for the provision of care.

Finally, there’s a prevailing concern, Definitive Healthcare concludes, about whether providers can gather the “personal insight that comes with consistent treatment by the same caregiver over time.” 

That’s a worry that Koman-Podolak also had. “My doctor had me hold my hand up to the camera, make a fist, and rotate my fist so he could examine my joints. But I usually get a full physical exam of my shoulders, elbows, wrists, knees, ankles, hips, and back. It’s simply too much to accomplish in a telehealth visit.” And Michael Petrucelli, a New Jersey retiree who had his first telehealth visit with his regular doctor recently, says it was quick and to-the-point, which he enjoyed. But, he says, “I think it would be difficult for a medical professional to diagnose anything without meeting the patient in person.”

IDSA notes that a patient’s comfort level with their healthcare provider affects their health outcomes and quality of life. “The practice of medicine has a tradition of establishing a trusting, therapeutic relationship with patients,” the IDSA statement says. “There can be a perception amongst inexperienced providers and patients that technology lacks intimacy.”

There are ways around the lack of in-person interaction. Brook Calton, MD, MHS; Nauzley Abedini, MD, MSc; and Michael Fratkin, MD, of University of California, San Francisco, and ResolutionCare Network, offer some practical pointers on making the virtual visit more “lifelike.”

 Based on their experiences, they advise clinicians to, among other things:

·       Create “a therapeutic telemedicine environment,” with a quiet, private, well-lit space. When possible, choose a space with a professional, neutral, and uncluttered background. 

·       Use a laptop or desktop computer if possible, to avoid the distracting-or even nauseating-sensations of a moving handheld smartphone. 

·       Look at the camera to ensure good eye contact and foster rapport and trust.

·       Reassure the patient that the conversation is private by showing them the room, and asking the patient to do the same.

·       Pay close attention to subtle comments made by patients and caregivers and their body language.

The authors also suggest looking for “unique opportunities” to learn more about the patient via telemedicine. For instance, meet their pet virtually, or have them share family photographs. And, particularly relevant in the current pandemic, “A simple question early in the telemedicine visit like, ‘I know we are facing really scary, uncertain times right now. How are your spirits?’ can be effective.” Moreover, they add, clinicians can brainstorm what parts of the physical exam can be performed by video: “[I]t’s surprising to most clinicians how much is possible.” 

Patients could help drive the uptake of telehealth services. Published data and anecdotal evidence suggest patients like telemedicine, although as recently as last year a survey found only 10% of patients nationwide had tried it. 

 When they do, they give it high marks for saving them time, travel, and close contact with the germs rife in public and healthcare areas. Koman-Podolak’s rheumatologist visits mean a 3-hour round trip, for instance. She also says in-person visits are too dangerous right now; she feels “100% safer with a telehealth option.” 

Dan W., a veteran in rural Idaho who did not want to give his last name, has been using video appointments with his psychiatrist-who lives in Minnesota-for several years now. In fact, the VA telehealth program was started mainly as outreach to meet the needs of rural veterans, who make up more than half of the VA patient population. Dan considers the system a “tremendous service. I couldn’t be happier.” He’s not alone: In a 2016 survey, VA telehealth scored high in veteran satisfaction: 92% for clinical video telehealth and 88% for home telehealth.

Practitioners, too-even those who might have been anti-telehealth or on the fence-are acknowledging the benefits, particularly now. Haider Warraich, a Boston cardiologist, for instance, was a skeptic at first. But now he hopes that one thing that comes out of the pandemic will be an increased reliance on telemedicine, “something that should have happened long ago.” In an opinion piece in the 

, Warraich says, “Physical exams are the bedrock of how doctors and nurses assess patients…Physical contact, I’d always thought, was at the heart of how doctors and patients communicate.”

His mind has been changed, though, not only by experiences with telemedicine, but by practicality. “Hospitals have been notorious petri dishes for deadly bugs since long before COVID-19,” he notes, “and this pandemic has brought that risk into crystal-clear focus.”

Once tried, telehealth may change usual habits for the better. “When this pandemic has passed, I will probably keep a mix of in-person and telehealth visits,” Koman-Podolak says. “I plan to use it for endocrinology, primary care, and emergency medical (that is, virus or flu), if needed. I don’t think I would rule anything out.” 

Anything that helps keep patients safer and gives practitioners a chance to stay in touch without actually being in touch is a good thing. Could be that telehealth is a silver lining to the dark cloud of the COVID-19 crisis.

Janet Dyer is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

1.     Telehealth adoption in the US: 2019 trends. Definitive Healthcare. 04-29-20. 

https://blog.definitivehc.com/us-telehealth-adoption-2019

2.     Infectious Diseases Society of America Position Statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases. 

https://academic.oup.com/cid/article/68/9/1437/5372646

3.     American Hospital Association. AHA urges HHS to take regulatory actions to help hospitals respond to COVID-19. Letter. 03-05-20. 

https://www.aha.org/lettercomment/2020-03-05-aha-urges-hhs-take-regulatory-actions-help-hospitals-respond-covid-19

4.     American Hospital Association. AHA, AMA and ANA send letter to Congress on COVID-19 funding. Letter. 03-19-20. 

https://www.aha.org/lettercomment/2020-03-19-aha-ama-and-ana-send-letter-congress-covid-19-funding

5.     CARES Act expands telehealth coverage for Medicare, FQHCs and the VA. mHealth Intelligence. 03-30-20. 

https://mhealthintelligence.com/news/cares-act-expands-telehealth-coverage-for-medicare-fqhcs-and-the-va

6.     Owners of telemedicine companies charged in $56M Medicare fraud scheme. Becker’s Hospital Review. 02-06-20. 

https://www.beckershospitalreview.com/legal-regulatory-issues/owners-of-telemedicine-companies-charged-in-56m-medicare-fraud-scheme.html

7.     US Department of Health and Human Services. HIPAA, civil rights, and COVID-19. 

https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-covid19/index.html

8.     Calton B, Abedini N, Fratkin M, Telemedicine in the time of coronavirus. 

https://www.jpsmjournal.com/article/S0885-3924(20)30170-6/fulltext

. Accessed April 24, 2020. [note: don’t know how to style this, no vol or page info. It was published online]

9.     Telehealth: best consumer healthcare experience you’ve never tried, says J.D. Power study. JDPower. 10-28-19. 

https://www.jdpower.com/business/press-releases/2019-us-telehealth-satisfaction-study

10.  US Department of Veterans Affairs. VA telehealth services. 

https://www.newengland.va.gov/nhvision/VATelehealthServicesFactsheet.pdf

rraich HJ. Op-Ed: As a doctor, I use telemedicine. With the coronavirus threat, it could revolutionize healthcare. 

https://www.latimes.com/opinion/story/2020-03-17/op-ed-as-a-doctor-i-use-telemedicine-with-the-coronavirus-threat-it-could-revolutionize-healthcare

Articles

The Infectious Diseases Society of America updated its position statement to educate its membership on the use of telemedicine and telehealth technologies to provide “evidence-based, cost-effective, subspecialty care.”

Telehealth in the Time of COVID-19: A 20-Year Overnight Success

Lisa Brosseau, ScD, is a nationally recognized expert on infectious diseases. Brousseau taught for many years at the University of Illinois at Chicago. She may be retired from the university, but she’s not retired from teaching. She recently cowrote an 

that drew a lot of notice: In it Brousseau argues that cloth masks offer no protection from COVID-19. As one might imagine, it drew a lot of attention and caused a fair amount of controversy. She recently sat down with 

to talk about her strong feelings about cloth masks and that data she used to reach her conclusions.

The article started out with the goal of trying to look at the literature related to cloth masks in healthcare. And then it got expanded way beyond that to cloth masks and surgical masks and respirators for healthcare and for the community. It was much more comprehensive than I expected it to be. Took me a little longer to write but at the end of the day, I was looking at cloth masks and surgical masks and respirators from several points of view. First of all, for healthcare and community, but also do they work as source control? Or do they work as personal protective equipment? Or both? And at the end of the day, cloth masks in my opinion don’t work in any form. They aren’t very good at source control, except for maybe very large particles. And they should not be used in healthcare settings for a number of reasons. Surgical masks, I decided, based on the literature, might have a role as source control for people who have symptoms. Say if they’re staying home and they have some symptoms. They shouldn’t be something you’d wear if you have symptoms going out into the public because you shouldn’t be going out into the public service. But it’s a good option for patients to wear in healthcare settings where they-especially for those who are experiencing symptoms-to what I would call diminish the viral load. Basically, decrease the amount of particles, infectious particles in the air in a healthcare setting. So, at the end of the day, the only thing that provides personal protection for the person wearing the mask is a respirator. And that is the thing that healthcare workers should be wearing. Particularly if we’re worried about the small aerosols, small particles that people will generate when they’re infectious. And in fact, people generate particles, whether they’re infectious or not. But particularly when they’re infected and infectious, that will be present in the vicinity of a patient. The best protection in that case is for the healthcare worker to wear a respirator. And I’ve got asked a little bit to think about respirators for the community. You know, if we had a lot of respirators, that might be a good idea, but we don’t have very many of them. And so, for the purposes of saving those respirators for the people who really need them, I recommended that the public not be wearing respirators and not be buying respirators. And if they had them, please donate them even to healthcare workers. That’s a good summary.

You did a deep dive into the literature. I saw you had many, many references. So, the mystery to me is why did the CDC say to people go out and wear cloth masks if you want to? 

What’s interesting to me is if you look at the references that were listed on under their recommendation, none of them have anything to do with masks or the performance of masks or the performance of their filters or any of that. They’re all references related to pre-symptomatic or asymptomatic transmission. I didn’t get the message there entirely, but I was glad to see is that they recognized that asymptomatic and pre-symptomatic transmission are happening. My message would have been if those were the references I was looking at, is maybe we should actually be encouraging people to stay home more. My biggest problem with telling people they can wear masks is it gives you this false sense of security. And it might even encourage you to think that now you’re protected and you’re protecting people around you. My husband and I try to take a walk every afternoon, just to get out, get a little bit of fresh air and exercise. And I’m seeing more and more people now wearing cloth masks on the streets. And I don’t go to stores anymore, but my understanding is they’re wearing them there as well. I don’t have a problem with people wearing them. I just want them to understand that they aren’t very much more protective than if they weren’t wearing them. And they’re really not doing a whole lot of good for the people around them. So, we should continue to do social distancing as much as we possibly can. I have places that are saying that you actually have to wear them. New York where you’re supposed to wear them anytime you’re in contact with people. I don’t know. I just think it’s not recognizing that the mode of transmission for this organism is likely small aerosols and close range and wearing a cloth mask shouldn’t give you any feeling of safety for being close to people. It shouldn’t make you feel that you’re not generating small particles because you still are. And since we none of us know if we’re infected or infectious, many of us probably are and aren’t going to have symptoms because we know that that’s the case for at least some fraction of the population that we’re putting everyone around us at risk. And especially the people I most care about are the workers. Our essential workers are really key to our success in flattening the curve. And they’re the ones who make it possible for us to stay home and be isolated those of us who are privileged enough to have that opportunity. But we go out and think that we are doing something good for the public and the workers, and we’re actually not. I think we put them at more risk. So, I don’t understand the CDC’s recommendations for this. My guess is that there’s a lot of political pressure. And no government agency is entirely immune from political pressure. There’s pressure to open, right? There’s pressure to restart the economy. I understand that entirely. And so I think the feeling was, probably if we give everybody a mask, we can just reopen and everything’s going to be fine. I think we’re going to be shocked to find that that’s not going to work. And I mean, I won’t be shocked, but there will be lots of people who will be shocked. And in fact, I read an article recently about a funeral. A number of people who attended the funeral. They were all wearing masks. They were taking photos next to each other. They were talking and a number of people got infected. So, it’s very clear these things do no good.

Have you gotten much feedback from healthcare workers or healthcare experts themselves? 

Oh, yeah. There are a number who don’t agree, but there are a lot of people who didn’t agree with my first article about aerosol transmission either. I’m sort of used to it. The important thing is to say, here’s what the science tells us. My conversations with people these days, I often point out that what we’re seeing is a lot of magical thinking. A lot of wishful thinking. Cloth masks are wishful thinking. And people saying, well, they worked in Asia. There’s no evidence that they worked in Asia. In fact, it’s very clear that the healthcare workers in China, they may have been wearing cloth masks to start with, but when you look at pictures of what they were wearing later, they were wearing respirators. They were wearing full face gear and body gear and gloves. It was clear that even surgical masks weren’t working in healthcare settings or controlling COVID-19. I don’t understand it. The Asian countries wear masks for societal and cultural reasons, not because they actually think they’re protecting. I’m not an expert in epidemiology. So, I will leave the modeling to the to those who know more about how this is going to work, but I do know my history. And if you read about the 1918 influenza and the pandemic, it took almost two years for that to be completely done with. They did a lot of similar things. They closed down. They opened again. Then they had to close down and then they had to open again. Now, granted, they didn’t have a lot of what we have today. But in some ways, we’re not all that different from 1918. We don’t have any testing. We don’t have any contact tracing. They didn’t either. They didn’t even really know about that. They didn’t know much about viruses. So, we have huge amounts of scientific information. But we have almost no infrastructure anymore in public health. Without our infrastructure in public health and our resources to do contact tracing and testing…. And testing, I mean with tests that really work that are both highly specific and highly sensitive. And we don’t have any of those yet. In many ways we’re being forced to make many of the same decisions that were made during the 1918 influenza pandemic. And the results are going to be similar. We are trying to decide when to open it back up. No one really knows the perfect answer to that. The models, they’re not perfect, right? I know infection preventionists are often pulled in two directions. One is they have to worry about patients. The other is they have to worry about workers. And sometimes the things you do for patients don’t work for workers and sometimes the other way around. That’s why I recommend including your health and safety people, industrial hygienists, and others, because they can give you that perspective about workers that will help you make good decisions for both. And really, it should be a hand-in-hand decision making that goes on.

I would really strongly encourage hospitals to stop asking people to send them cloth masks and instead asked for respirators. I don’t necessarily discourage the public from wearing them if it makes them feel comfortable, but I hope they don’t think that they’re protecting themselves.

This interview has been edited for clarity and length.

Lisa Brosseau, ScD: "What we’re seeing is a lot of magical thinking. A lot of wishful thinking. Cloth masks are wishful thinking."

Cloth Masks Are Useless Against COVID-19

For many in healthcare and infection prevention, discussions regarding pandemics always land on the “it’s a matter of if, not when” statement. We often don’t truly appreciate that we’ll be living and working in the moment of a pandemic, and yet here we are. Then came SARS-CoV-2/COVID-19 and, all too suddenly it seems, the future is now. COVID-19 dramatically changed not only the lives of everyone around the world, but the very nature of infection prevention and control itself.

Shortages of personal protective equipment (PPE) and an overwhelmed healthcare system have become the new reality. It has been challenging to strike the balance between the changing guidance and testing delays. This pandemic though, has shed light on some critical lessons and ways that hospitals and healthcare in general can better support infection prevention programs.

Perhaps one of the biggest challenges and, frankly, changes from normal practices, has been the extended use and re-use of N95 masks and other PPE. This goes against the grain for many IPs and feels awkward. Guidelines for extended/re-use have existed for a while, but IPs just never had to actually employ them. This established, but new-to-most, approach, not only impacts training and education, but also alters practices within most healthcare facilities. 

Ensuring proper storage between use and emphasizing that staff not touch the front of the mask are not necessarily innate practices. Storing masks in paper bags and even establishing protocols for disinfecting measures to extend use also buck years of training and practice. 

For IPs, this reveals a critical need to be flexible in times of heightened stress. Most IPs are accustomed to having to critically think in high-stress environments, but having to train other scared healthcare workers about how to do things not in the manual? Well, this makes maintaining trust and transparency a crucial goal. 

During a continued stream of information overload, IPs have had to work overtime to disseminate accurate information and dispel poor information that often leads to fear. For many, this means attending huddles to not only train and education on PPE, but also answer questions staff have regarding the pandemic and the implications for their safety. Holding “open office hours” to encourage staff to stop by and talk through concerns or ask questions has been helpful in ensuring that all staff can ask no-fault questions.

COVID-19 media coverage, especially of the sensational variety, can overwhelm staff, making it so much more vital for IPs to offer sound guidance and resources. While infection prevention efforts have always involved education and communication, the current pandemic has highlighted this role even more. 

One other lesson is in the role of IPs in pandemic preparedness. While this might seem like an obvious relationship, there has historically been little resources sunk into supporting and encouraging infection preventionists to allot time for preparedness. The 2014 Dallas Ebola cluster revealed the critical role of infection prevention efforts in healthcare preparedness, but also that emerging infectious diseases are something healthcare professionals need to be thinking about.

It’s not enough to develop processes retrospectively, but rather incorporate these efforts into our continued practices. The disruption that occurs due to a lack of preparedness can be devastating to a hospital, and if we can’t maintain our continued HAI surveillance and prevention efforts during such events, IPs do patients and staff a disservice. Incorporating preparedness for these events into annual infection prevention programs and efforts is critical to adjust to not only the reality that emerging infectious disease outbreaks will continue to occur, but also that programs must adapt to meet the news of ever-changing healthcare and patient safety. Infectious diseases evolve, shouldn’t we?

In the midst of this pandemic and moving forward, it is critical that healthcare and hospital administrators work to better support their infection prevention and control (IPC) programs and the IPs that man them. 

Experiences, like Ebola in 2014 and SARS-CoV in 2003, have demonstrated the ability for hospitals to amplify the spread of disease and the critical role IPC programs play in response.

 COVID-19 has been a wake-up call for public health and healthcare alike. For those leaders in healthcare, as they continue to respond to COVID-19 and even after the dust settles there are things that should be considered. 

First, support IPC programs in general, expanding them so that they can address biopreparedness within the facility. Encourage efforts that expand the scope of HAI monitoring and treatment, so that they are not solely or primarily tied to those HAIs that have Medicare reimbursement implications. Train, educate, and drill staff to be able to address critical gaps in preparedness known to exist. IPs are the subject matter experts in healthcare response to biological threats and they should be empowered to better prepare the healthcare facility and staff. 

Second, as IPs and other healthcare professionals will likely be dealing with COVID-19 for a while, it’s important to support IPC programs throughout this pandemic. This has been challenging for everyone and will likely be for a while. For those in infection prevention, it has been particularly difficult as changing guidance, limited PPE, fear and hysteria, and delays in testing have stressed our ability to protect patients and staff.

Novel situations create novel problems, but erosion of trust from our frontline healthcare workers is something that should not be taken lightly. A feeling that they are not being protected or supported due to inconsistent guidance or a constant barrage of poor information, is heartbreaking. IPs need to ensure their safety and that of patients, but these are particularly challenging times. 

Hospital administrators should involve infection prevention teams in higher-level response and decisions. Meet with them to address concerns and how there can be more collaborative efforts. Round on the units with them. Lastly, ensure that they get breaks. 

Most of the IPs have been working around the clock since February. As impossible it may seem to part with their presence on the floor, they do all need a break from time to time, even if it’s short. It’s only through collaboration and coordination that IPs and all other healthcare professionals will be able to get through the COVID-19 pandemic and when IPs asks questions or push back against hospital administrators, those administrators need to know that IPs are not trying to be difficult, but rather they want to ensure that all things are accounted for and the hospital is providing the best possible care under historically trying circumstances. 

Through continued efforts and vigilant dedication to patients and staff, IPs will help healthcare workers, patients, the nation, and the world defeat COVID-19. 

Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in both pediatric and adult acute care facilities. 

1.     Centers for Disease Control and Prevention. “Coronavirus Disease 2019 (COVID-19) Cases in U.S.,” April 11, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

2.     Morgan DJ, Braun B, Milstone AM, et al. Lessons learned from hospital Ebola preparation. 

3.     Popescu, S. Roadblocks to infection prevention efforts in health care: SARS-CoV-2/COVID-19 response. 

4.     Heinzerling A, Stuckey MJ, Scheuer T, et al. Transmission of COVID-19 to health care personnel during exposures to a hospitalized atient - Solano County, California, February 2020. 

Infection prevention sustainability isn’t easy and everyone is exhausted, but now is the time that practice makes permanent.

What the COVID-19 Pandemic Teaches Infection Preventionists

I was recently asked whether I think coronavirus disease 2019 (COVID-19) will change regulations within long-term care facilities (LTCFs)LTCFs). I decided I wanted to look at it from the perspective of what went wrong in the utilization of current US Centers for Medicare and Medicaid Services (CMS) regulations. The current regulations are written in a way where, on paper, the regulations are easy to survey, but what is missing is the ability to ensure LTCFs have a strong infrastructure that supports infection prevention and control success in the LTC arena. 

First, I decided to see what is happening across the United States related to outbreaks of COVID- 19 in the nursing homes. I have been working as an infection prevention and control consultant for LTCFs and other healthcare arenas since 1992. I would have predicted that LTCFs would be on the losing end of COVID-19 if someone did not step in early to educate and assist these facilities. LTCFs could not handle this type of a communicable disease on their own. 

Some may not have believed COVID-19 was a big deal and they could handle it like they do influenza. Others may have not wanted an outsider to suggest they do something different from how they always do things. Some people don’t like change and may not have been able to wrap their head around the extreme changes they would have to make to deal with this type of a pandemic. 

Recent publications are reporting the elderly are more likely to experience severe complications stemming from COVID-19 infection. We have known this from the beginning of the pandemic, but it does not appear that anyone was proactive enough when it came to concentrating on how LTCFs could deal with an outbreak. Did they have enough staff? Did anyone reach out to assess LTCFs needs related to staffing, personal protective equipment (PPE), or disinfectants? Many outbreaks were happening in LTCFs before anyone was paying attention to them. 

According to the National Center for Health Statistics there are more than 1.3 million residents in nursing homes; 811,500 residents living in res- idential care communities such as assisted living and intermediate care facilities and an estimated 1.5 million individuals are employed in these facilities.

 CMS released guidelines to reduce the effect of COVID-19 on these types of facilities. This guidance included visitor restrictions, infection control guidelines, and designating separate areas for those who were diagnosed with COVID-19. 

But it fell short of the federal requirements to report COVID-19 outbreaks. Only during the week of April 19 did information start being released to the general public regarding how nursing homes have been affected by COVID-19. 

reports at least 2300 nursing homes have reported cases of COVID-19. The impact on nursing homes is far greater than what is being reported by the federal government. 

 reports that 37 of the 50 states have reported cases of COVID-19 and more than 3000 deaths among long-term care residents. It has been reported that neither the US Centers for Disease Control and Prevention (CDC) nor CMS were tracking the number of US nursing homes with COVID-19 cases. The case fatality rates are also not being tracked. Reports have shown when states such as Florida were asked for data they did not respond. Florida is known for its high number of elderly residents, as well as millions of seasonal visitors during the winter months. These millions of visitors typically return to their home states in April. If they have become colonized or are sick with COVID-19, they will take it back to their home states and more outbreaks will continue. Thirteen states could only provide partial data and could not differ- entiate residents infected or staff infected. 

Even during non-pandemic times, many nursing homes across the country have received infection control citations. 

Healthcare workers in LTCFs deserve to have honest communications from their administrators so they can also protect themselves and their families. Like acute care facilities, LTCFs need help obtaining PPE. Many LTCFs and assisted living facilities are privately owned. Is this the reason reporting is lacking with this group of LTCFs? 

On April 19, 2020, 4 months after the pandemic began, CMS released guidance requiring nursing homes to report cases of COVID-19 to the CDC. The death rate that have been reported as of April 23, 2020: More than 10,000 residents and staff died because of COVID-19. Yet very few states are being proactive in testing all residents and staff in these facilities. Many hospitals haven’t had access to testing. How would LTCFs get access without states stepping in and providing the support? 

CMS requires that all LTCFs must follow accepted national standards. The infection prevention and control program (IPC) shall include at a minimum:

·       A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement.

·       Written standards, policies, and procedures for the IPCP, including but not limited to a system of surveillance designed to identify possible communicable disease or infection before it can spread to other persons in the facility; reporting requirements for possible incidents of communicable disease or infection; standard and transmission-based precautions to be followed to prevent spread of infection; circumstances in which generally, isolation should be used for a resident; the circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if the contact is likely to transmit the disease; and the hand hygiene procedures to be followed by all staff as indicated by accepted professional practice. 

·       Require that the facility designate an Infection Prevention and Control Officer (IPCO) who is responsible for the IPCP and who has received specialized training in infection prevention and control.

The above is just the section of the CMS regulations that should have been used during the COVID-19 pandemic. Many LTCFs have interpreted the require- ment for them to have an IPCO, as this person must be a permanent hire and it excludes them from relying on an expe- rienced infection prevention consultant who can provide mentoring, training and advice to an inexperienced IPCO. 

The requirement for IPCO training was basic training related to infection prevention, but it was lacking any mea- sures for determining competence of the IPCO. The area lacking in LTCF regulations is the issue of the inexperience of the facilities’ IPCO related to understanding how to identify infection issues. 

Some facilities lack administrative sup- port for a good understanding of what to do when infection prevention issues arise yet if asked, they will state they know everything about infection prevention and do not need help, lacking the insight that infection prevention is more involved than just the basic knowledge of washing your hands and putting PPE on. 

Sick-call policies in many healthcare arenas are based on disciplining employees who call off sick requiring a physician note to return to work. Many times, employees can obtain a physician note to return to work before they are cleared of a commu- nicable infection. In some cases healthcare settings as well as LTCFs have let staff work with respiratory tract infections because of limited staff or an inability to pay overtime. This practice has been linked to flu outbreaks every year. It’s unfortunate that this time it was not the flu, but in the case of COVID-19 which, if practices are reviewed when the pandemic is under control, some of these LTCF outbreaks were due to letting employees work sick because of poor staffing. Also in play was the inexperience of the facilities’ IPCO to be able to identify an outbreak of COVID-19 or because of lack of testing of healthcare workers (HCWs) who were asymptomatic carriers. 

Many IPCOs are assigned multiple tasks such as wound care, director of nursing, unit charge nurse, or unit super- visor, which can interfere with performing proper infection prevention and control. Many facilities cannot get physicians to see residents in LTCFs because they do not get reimbursed enough to make it worth their time. Pay in some LTCFs is also exceptionally low and does not match the quality of nursing care seen in acute care facilities. 

Many healthcare facilities, not only LTCFs, have turned to online training for staff and then designate the employee as competent to do their job. Online training does not prove competency; it provides training. The survey process does not look at competency of staff, it looks to ensure all employees have completed their annual training require- ments for infection prevention. There is no measurement of competency. Many employees in LTCFs are task-orientated individuals who work extremely hard and long hours and will do as they are instructed. If the person instructing them does not identify when there is an outbreak of any disease, whether flu or COVID-19, and provide clear instructions with follow-up with those employees that what was being requested was actually done, there will continue to be breaks in infection prevention practices. 

Many CMS surveyors have basic training in infection prevention but they also have limited experience doing infection prevention and it is easy to miss where infection prevention breaks are that enable facilities to identify when they have a problem before it gets to be a big issue. 

As for the COVID-19 pandemic and what is happening in LTCFs-many were destined to fail at infection prevention. Because much of the focus was on hospitals in need of PPE and ventilators, no one was checking in on LTCFs and determining what their needs were. Many LTCF staff did not show up for work. LTCFs that did try to get disinfectants and PPE were last on the list because acute care took priority. 

Many LTCFs work with one vendor to obtain their PPE and facility disinfectants. If their vendor does not have what they need or decides to sell to acute care first because they can sell to acute care at a higher rate, then LTCFs lose out. Many do not know what other companies they can buy supplies from. 

So where do we go from here to make sure LTCFs are set up for success in the future? I believe there needs to be a thorough assessment of all LTCFs in each state after this pandemic to identify answers to many questions and identify what is needed to set them up for success. COVID-19 is our influenza pandemic of 1918. What haven’t we learned and what do we need to do now to be ready the next time there is a pandemic? How are we going to deal with the next round of COVID-19? 

My suggestion is each state needs to retrieve data from all LTCFs:

·       When did the facility go into lockdown?

·       When did the facility start putting in orders for more PPE and disinfectants?

·       Who and how many vendors did they contract with?

·       What education was given to the employees and when did that education happen? Reviewing exactly what education information was provided.

·       When did staff start wearing masks?

·       How often were masks changed?

·       What was the first date that an employee or resident became sick?

·       What was the first date that the facility considered they had a problem with COVID?

·       When did the facility reach out for help?  

·       Who did they ask help from?

·       What response did they get when they asked for help or reported illness within their facility?

·       How many staff did not come to work because of fear?

·       Did the facility have access to a physician or physicians coming into the facility to help manage and prepare for COVID-19?

·       Did the facility reach out to the local hospitals?

·       Did anyone reach out to LTCF and if so, what happen?

Did they reach out to anyone to ask to transfer their residents and were refused?

·       When did they notify their local department of health to ask for help with sick residents or to obtain PPE and disinfectants?

·       Did they reach out to local emergency preparedness agency?

·       Do they qualify for federal or state help if they are privately owned?

The answers to these questions and many more could help build stronger infection prevention programs within LTCFs as well as trouble shoot problem areas not identified before the pandemic, so they are set up for success. Is the elderly in the US seen as an important part of the community or are they vulnerable because they are ignored and left to die during a pandemic? Let us prepare LTCFs for success, but owners of these facilities must want to participate, put up the money, and provide protection for residents and employees. 

Linda Spaulding, RN, CIC, BC, CHEC, CHOP, is an infection prevention consultant and founder of InCo and Associates International, Inc. 

Many healthcare facilities, not only LTCFs, have turned to online training for staff and then designate the employee as competent to do their job. Online training does not prove competency; it provides training.

COVID-19 Reveals Fatal Infection Prevention Flaws at Long-Term Care Facilities

The topic of appropriate personal protective equipment (PPE) is continuously in the media and trade articles thanks to the COVID-19 pandemic. PPE supply and use is a daily topic for those who work in infection prevention and one of the main tools used to prevent the spread of infection in healthcare facilities. The use of N95 respirators, and their equivalent, is currently a subset of the PPE focus that has many facilities scrambling to provide the best PPE available to staff and keep their stock in hand. 

Respiratory protection programs mandated by the Occupational Safety and Health Association (OSHA) include the process of training, providing medical clearance, and fit testing for respirator use in healthcare facilities. These programs are often run by an occupational or employee health department in collaboration with safety, emergency management, infection prevention, and human resources. Several requirements include ensuring that health care providers (HCP) know how to use respirators, how to don and doff appropriately, when to use the respirator, and how to maintain their PPE to maximize the lifespan of that respirator. 

Traditionally, these are accomplished via an annual fit test through occupational health, which is done for HCPs who may have contact with infectious agents that require airborne precautions (ie, tuberculosis, measles, chicken pox). 

Typically, the fit testing depends on the annual anniversary of hire date, department-specific dates for testing, or some other pre-determined timeframe to have staff come through on a scheduled basis so as to not overwhelm the occupational health department. In a pandemic situation of a respiratory illness, when many staff members need to have quick access to appropriate respirators, the process for fit testing has to change to a different model of operationalization.

Just-in-time (JIT) fit testing allows a healthcare organization to offer evaluation, training, and fitting of HCPs during rapid intervals, as needed, based on specific patient care assignments. Many institutions have JIT fit testing as part of their plans for pandemic influenza or Ebola preparations. In order to implement JIT programs, many key components need to be considered. Also, in March 2020, OSHA issued a temporary guidance that allows healthcare facilities to suspend annual fit testing due to shortages, as long as staff have a prior fit test with the same model respirator.

 This allows for JIT fit testing to be accomplished for staff in a rapid pace needed to keep up with patient care needs.

Another way to better implement JIT fit testing is to utilize qualitative test methods versus quantitative. The more commonly used qualitative method involves the use of a sweet, saccharin solution sprayed into a hood while the HCP wears the respirator. If the HCP can taste the sweet solution, then essentially, they fail the fit test for that respirator. 

Quantitative fit testing involves modifying the respirator to allow access for a sampling port, therefore damaging the respirator so that it cannot be used after the fit test. Again, in recognition of PPE shortages (so glaringly revealed during the COVID-19 pandemic), OSHA recommended using qualitative fit testing over quantitative to conserve respirators and making JIT more feasible. OSHA did so in the same March 2020 temporary guidance.

Occupational health programs historically control the fit testing process. However, in an emergency situation, occupational health would likely not have the capacity to offer JIT fit testing at all times for HCPs, therefore a cadre of staff need to be trained into the roles and assigned a schedule to have the service available 24/7. 

Occupational health departments can train staff, make sure they are certified to teach the process, thereby making a labor pool of fit testers available in the facility for the times and days needed. Often in pandemics-and, again, as we’ve seen recently with COVID-19-job roles need to be adjusted, so there may be staff from low work-load areas that comprise the JIT fit testing team. 

Having this resource staffed consistently meets the needs of HCPs and can reduce the anxiety about finding the appropriate size mask in a moment. Another method of training staff for fit testing that has been shown to be effective is through a video.

 If occupational health is not available, or there are a large number of locations and staff that need training, having a video option for training with a competency would be a reasonable alternative. 

Part of the JIT process needs to include a tracking mechanism for staff. Having a searchable database of all the sizes that staff have fitted would be a helpful tool. Along with a database that is kept by the JIT program staff, develop a way for staff to also track their own mask types and sizes that they can fit. This can be accomplished by having a sticker or badge accessory so that staff will always have it written on their badges and available whenever at the facility. During pandemic situations, the usual masks that an organization uses for annual fit testing and patient care may not be available, so new products will be brought in regularly as alternatives. Having a log of which sizes work for HCPs and also a document that shows comparable products that tend to be similar in size is helpful as well to decrease guessing and wasting masks that may not fit staff.  

Similarly, working with logistics support to review the options available for respirators, tracking usage and days on hand, projecting volumes, estimating how a surge of a certain percentage would impact supply, and reporting those data regularly creates a successful program. Other supplies needed for JIT include the hoods or test kit components and the saccharin or bitter testing solution. During pandemics, these supplies can also be in high demand and integrating those into the tracking helps prevent any unforeseen delays in JIT testing. 

Part of the JIT process is to prioritize or delineate the HCPs who would need to use respirators. This can be accomplished by looking at job roles and departments that would interact with patients who require airborne precautions and tasks that are done by the various job roles. Cross training staff, such as having nurses perform phlebotomy or administer nebulizing treatments, can limit staff who need to interact with patients in airborne precautions when PPE are in demand. 

Also, adjust when some processes should be implemented. For instance, only have the room cleaned by housekeeping after discharge. In addition, wait the allotted time for appropriate air exchanges in the room so that environmental services staff won’t need to don N95 respirators to perform their duties. Also, cohort patients and staff so that the JIT fit testing can be focused on that select group who will have the most need.

The use of JIT fit testing is essential to providing HCPs with the appropriate PPE during outbreaks, pandemics, and emergent respiratory illness disasters. Part of the planning for emergency preparedness can involve developing JIT guidelines and program guidance so that can be used in training and be available when the next outbreak occurs. Currently, many organizations are using JIT testing as part of their response to the COVID-19 pandemic. Documentation of operations of those programs will be key and any lessons learned from current experiences can be utilized for future planning.

Rebecca Leach, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a regular contributor to Infection Control Today®, currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers.

1.      US Department of Labor, Occupational Safety and Health Administration. Temporary enforcement guidance-healthcare respiratory protection annual fit-testing for N95 filtering facepieces during the COVID-19 outbreak. 

https://www.osha.gov/memos/2020-03-14/temporary-enforcement-guidance-healthcare-respiratory-protection-annual-fit

2.     Harper et al. Comparison of three respirator user training methods. 

Just-in-time (JIT) fit testing allows a healthcare organization to offer evaluation, training, and fitting of HCPs during rapid intervals, as needed, based on specific patient care assignments. 

Just-in-Time Fit Testing Allows for Rapid Response During Pandemics Like COVID-19

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today.

Infection Control Today, June 2020 (Vol. 24 No. 5)

Telehealth in the Time of COVID-19: A 20-Year Overnight Success

Cloth Masks Are Useless Against COVID-19

What the COVID-19 Pandemic Teaches Infection Preventionists

COVID-19 Reveals Fatal Infection Prevention Flaws at Long-Term Care Facilities

Just-in-Time Fit Testing Allows for Rapid Response During Pandemics Like COVID-19

Bug of the Month: You Don’t Want COVID-19 Following in My Footsteps