RSSAll Entries in the "COVID-19" Category

We advance, masked!

In the topsy turvy world of Personal Protective Equipment (aka PPE), there are some developments on the decontamination/reprocessing of masks that I wanted to bring to your attention, if you’ve not already scoped them out.

First up, a little more information from our friends at the Occupational Safety & Health Administration, where we find that the guidance issues to surveyors is to be somewhat judicious in how they chase issues relating to PPE, but the basic expectations of employers look like this:

  • Make a good-faith effort to provide and ensure workers use the most appropriate respiratory protection available for the hazards against which workers need to be protected. Efforts should be consistent with flexibilities outlined in OSHA’s previous COVID-19 enforcement memoranda.
  • When respirators must be decontaminated to facilitate their reuse in ways consistent with OSHA’s previous COVID-19 enforcement memoranda and the U.S. Centers for Disease Control and Prevention (CDC) Strategies for Optimizing the Supply of N95 Respirators, ensure that decontamination is accomplished according to the methods described above and detailed in CDC’s Decontamination and Reuse of Filtering Facepiece Respirators using Contingency and Crisis Capacity Strategies.
  • Ensure users perform a user seal check each time they don a respirator. Employers should not permit use of a respirator on which the user cannot perform a successful user seal check. See 29 CFR § 1910.134, Appendix B-1, User Seal Check Procedures.[11]
  • Train employees to follow appropriate precautionary measures prior to using a decontaminated filtering facepiece respirator (FFR). See cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html.
  • Train employees using decontaminated respirators to understand that if the structural and functional integrity of any part of the respirator is compromised, it should not be used by that individual as respiratory protection. The inability to achieve a successful user seal check could be an indicator that the integrity of the respirator is compromised.
  • Visually inspect, or ensure that workers visually inspect, the FFRs to determine if the structural and functional integrity of the respirator has been compromised. Over time or as a result of the decontamination process, components such as the straps, nose bridge, and nose foam material may degrade, which can affect the quality of the fit and seal.
  • Train employees on the procedures for the sequence of donning/doffing to prevent self-contamination. See cdc.gov/niosh/npptl/pdfs/PPE-Sequence-508.pdf.
  • If no manufacturer or third-party guidance or procedures are available to support the specific decontamination method(s) employed, avoid the use of decontaminated FFRs when healthcare personnel perform surgical procedures on patients infected with, or potentially infected with, SARS-CoV-2 or perform or are present for procedures expected to generate aerosols or procedures where respiratory secretions are likely to be poorly controlled (e.g., cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum induction). If decontamination methods degrade FFR performance, including filtration and fit, or otherwise affect structural integrity, the decontaminated FFR may not provide the level of protection needed or expected during aerosol-generating procedures.

I suspect that, in general, folks are being sufficiently attentive to their PPE (perhaps more than has ever been the case) that they are checking for integrity (though they may not be as familiar with the User Seal Check Procedure—could be a teachable moment). And the missive covers some decontamination methodologies that may be of interest, particularly in light of the FDA’s altered stance on decontamination and reprocessing of masks.

I guess the questions become those related to available supplies of PPE. I get the sense that some folks are still relying to a fair degree on the use of masks that are not NIOSH-approved and so this latest development could potentially mean that, in the absence of being able to decontaminate and reprocess, the supply chain is going to have to be considerably more robust in either providing more non-NIOSH masks or more NIOSH masks that can be appropriately decontaminated, etc. I’d be curious to hear of any experiences (good or not so) that you’ve had in this regard. It seems likely that, even as we try to get to the “new normal,” we’re going to be dealing with this for a while, so we might as well share the good, the bad, and the ugly.

Speaking of which (sort of), as a closing thought for this week, now that I am hanging out in airports again, one thing that I’ve noticed is the phenomenon of the smile that doesn’t reach someone’s eyes. Pre-mask, I don’t know that I analyzed transient interactions with folks, but I find myself responding to folks based on their “eye language” and I’ve found that it can turn what would typically be a (more or less) neutral transaction into a positive or negative. I suspect that most customer service training involves reminding folks to smile, but now that our smiles have been temporarily removed from the occasion, the eyes are all we have for first impressions. Don’t know if that’s useful to you, but something to ponder.

Be well and stay safe ’til next time!

A little mo’ from the Mighty O (ccupational Safety & Health Administration)

As they are wont to do, the folks at OSHA periodically issue safety alerts and it would seem that the ongoing challenges of managing the ongoing occupational health and safety aspects of COVID-19 is ripe for alerting. You can find the complete list of alerts on OSHA’s COVID-19 homepage.

Interestingly enough, OSHA has not (as of this writing) issued an alert specific to hospitals, but they did recently issue an alert aimed at nursing homes and long-term care facilities, the elements of which are, at the very least, instructive for other folks in the healthcare demographic; you can find the alert in its entirety here. I just wanted to plant a seed relative to a few of these:

  • Maintain at least 6 feet between workers, residents, and visitors, to the extent possible, including while workers perform their duties and during breaks.
  • Stagger break periods to avoid crowding in breakrooms.
  • Always follow good infection prevention and control practices. Consult OSHA’s COVID-19 guidance for healthcare workers and employers.
  • Provide handwashing facilities and alcohol-based hand sanitizer with at least 60% alcohol throughout facilities.
  • Regularly clean and disinfect shared equipment and frequently touched surfaces in resident rooms, staff work stations, and common areas.
  • Use hospital-grade cleaning chemicals approved by the Environmental Protection Agency (EPA) from List N or EPA-approved, hospital grade cleaning chemicals that have label claims against the coronavirus.
  • Ensure workers have and use any personal protective equipment (PPE) they need to perform their jobs safely.
  • Continually monitor PPE stocks, burn rate, and supply chains. Develop a process for decontamination and reuse of PPE, such as face shields and goggles, as appropriate. Follow CDC recommendations for optimization of PPE supplies.
  • Train workers about how to protect themselves and residents during the pandemic.
  • Encourage workers to report any safety and health concerns.

I don’t know that there’s anything on the list that doesn’t make sense, but I do think it might be useful/beneficial to keep an eye on these (and the other elements) to ensure you and your folks are not at elevated risk for exposure. Admittedly, there is still a lot we don’t know about the epidemiological aspects of COVID-19 and it may result in additional levels of guidance and/or protection (remember those halcyon days when masks were not required—seems like only months ago—oh, wait, I guess it was…). I also think it’s important to hear folks out if they voice frustrations with process, etc. A fair amount of this stuff is learning as we go—and making the best decisions we can based on the available information—in full recognition that being a leader in healthcare can mean having to put up with some unpleasant feedback. I think some folks in the field remain super concerned and super attentive to the decisions others are making on their behalf, so it’s important to keep things on an even keel.

Until next time, continue to stay safe—and keep rocking it!

Possibly making the impossible, possible…

As I look back over the years, particularly my time as a consultant, I continue to be fascinated by requests to safety/facility professionals to (channeling Jean-Luc Picard) “make it so,” even when the “so” they are requesting was not considered in the design of whatever system/process that is the target of the request. Just last week, I fielded a question from a facility manager who had been requested to make an OR procedure room negative for procedures on COVID patients. Unfortunately, it wasn’t a direct reach-out so I wasn’t able to dialogue with this individual, so I’m not sure of the particulars (availability of negative pressure procedure rooms in the facility, etc.), but it did get me to thinking about how many impossible things have been done over the last eight to 10 weeks in hospitals all over the country.

As of this writing, the first week in June is bringing about my first onsite client visit since mid-March and I am keen to see what’s been happening “in the field.” Fortunately, through the 1135 waiver process, there have been some instances in which we’ve been able to “bend” the regulatory statutes to some degree, but I think (hope?) we can all agree that there have been (and likely will continue to be) gray areas that are not (at least currently) covered by a waiver and may be so funky in the execution that you could never do more than ask forgiveness when this is all done (recognizing that directly targeted permission has not been abundant). My consultative advice is to keep track of some of the more ingenious (and you can read that as “a little crazy”) solutions to challenges you’ve experienced at your facility—the worst thing that could happen would be for all this stuff to get lost in the slipstream of “getting back to normal” and never get shared with the world at large.

I suspect you are all way too busy to be thinking about this now, but (as an amateur student of history) a response to an unprecedented event would make for an interesting and compelling story for future generations. I hope that we’re not bound for a repeat any time soon, but there are lessons (or, dare I say, teachable moments) for all of us. And with the slow decline of the oral storytelling medium, I want to make a case for capturing this…

Until next time, please stay well and safe—and keep rocking it!

The trouble with normal: Some things to consider as we ease back into recovery

I think we can all agree that there are a lot of stressors in motion as we navigate the unknowns of the pandemic; some of which one might not normally encounter and others are just an amped-up version of “business as usual.” As we near the end of May, it does seem like there is a little bit of movement towards a return to normalcy (recognizing that we’ve probably bid adieu to the “old” normal), which has prompted some consideration of the demands placed on our facilities’ systems and how best to position ourselves to safely engage the recovery phase of this historic emergency response.

Another point of agreement (hopefully) would be that elements relating to infection control are going to be scrutinized more than ever as the accrediting organizations get back to it. I suspect that at least part of that scrutiny will involve the overarching management of utility systems and their components. Fortunately, there is much to be learned from/shared by folks I consider to be excellent sources of information and insight.

As was the case before the onset of COVID-19, I think the management of building water systems is going to come into play and, particularly if you’ve had to reduce usage in some areas of your facility, bringing things back online represent some real challenges. Certainly, the focus on managing the risks associated with waterborne pathogens goes back more than just a few months, but the following should be enough for you to get ahead of the curve.

The first two articles, penned by Matt Freje from HCInfo, focus on some key planning/prevention considerations that, at the very least, should be a part of your planning risk assessment going forward. It’s all completely sensible and clear in direction, particularly as work towards appropriate management of environmental conditions for our most at-risk patient populations, and both articles are definitely work a look. They cover building water systems and Legionella concerns.

Finally, for this week, we have a webinar covering potential Legionella risks as we ramp our buildings up to normal speed, sponsored/presented by the good folks at the ScalingUp!H2O podcast. Lots of good information presented by Dr. Janet Stout of Special Pathogens Laboratory. There’s a slide presentation, hence its availability on YouTube, but (again) worth the 35 or so minutes of your time to check it out.

Please continue to stay safe and productive during the pandemic. Thank you for your hard work and dedication to keeping things on an even keel!

CMS provides yet a little more flexibility for the management of the physical environment

In the ever-unfolding saga of pandemic response, the folks at CMS have issued another couple of waivers relating to the physical environment. Of course, these continue to be published with rest of the granted waivers, so I’ve copied and pasted the new stuff here:

  • Alcohol-based Hand-Rub (ABHR) Dispensers: We are waiving the prescriptive requirements for the placement of alcohol based hand rub (ABHR) dispensers for use by staff and others due to the need for the increased use of ABHR in infection control. However, ABHRs contain ethyl alcohol, which is considered a flammable liquid, and there are restrictions on the storage and location of the containers. This includes restricting access by certain patient/resident population to prevent accidental ingestion. Due to the increased fire risk for bulk containers (over five gallons) those will still need to be stored in a protected hazardous materials area. Refer to: 2012 LSC, sections 18/19.3.2.6.  In addition, facilities should continue to protect ABHR dispensers against inappropriate use as required by 42 CFR §482.41(b)(7) for hospitals; §485.623(c)(5) for CAHs; §418.110(d)(4) for inpatient hospice; §483.470(j)(5)(ii) for ICF/IIDs and §483.90(a)(4) for SNF/NFs.
  •  Fire Drills: Due to the inadvisability of quarterly fire drills that move and mass staff together, we will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area. Refer to: 2012 LSC, sections 18/19.7.1.6.
  •  Temporary Construction: CMS is waiving requirements that would otherwise not permit temporary walls and barriers between patients.

I’m going to guess that some folks have already “taken advantage” of these items (with the possible exception of the fire drills, more on that in a moment). It would seem more than likely that some additional hand sanitizer dispensers have sprouted up all over your facility (hopefully you’ve been keeping reasonable track on these locations). Once this is over, you’ll probably need to either do an analysis of how much you’ve got floating around or remove them before you run afoul of allowable amounts. I also can’t imagine that temporary walls haven’t sprouted up (lots of sprouts this week!) in all sorts of spots. Those are probably a little simpler to track, but there is one instructive element to this allowance, that being the interpretive difference between TJC and CMS when it comes to temporary barriers: While TJC allows them to be smoke-tight, the feds are really looking for temporary barriers to be fire-rated, particularly for construction separations. Something about which to be mindful when things get back to “normal.”

As to the fire drill waiver, I absolutely understand the first part of the statement—inadvisable is as good a descriptor for trying to conduct fire drills at the moment, particularly as a function of moving and massing staff together. But I’m not exactly sure what they mean by the latter portion, but I think we can parse this for a bit. Especially if the physical space has been altered in efforts to provide “new” pressure relationships for some units, then, in all likelihood, there are elements of egress that have been impacted and, in some instances, that impact is to a degree that probably requires modification of existing unit-based fire response plans. I think it’s good to be able to alert folks to the “reality” that if the alarm goes off “this is not a drill,” but how do we make sure that folks can take full advantage of the compartmentalization features of our facilities? And then, how do we “document” that education? I don’t think it needs to be particularly complex (in fact, I suspect the less complex, the better) and could perhaps be communicated through whatever lines of communication are in place with your incident command structure. If anyone has any thoughts they’d be inclined to share, that would be delightful.

And for you folks who might be interested in what’s happening in the fulcrum of state and federal response, you can find your state’s waiver requests, etc., here.

I won’t say it’s good reading, but one can never have too much insight into the process during times of chaos.

Stay well and take care!

When you get to the end, you get to start all over again…

I know you folks have (more or less) been under a constant bombardment of facts, figures, strategies, etc., relating to COVID-19 and, as every day brings us a little closer to a return to some sort of normalcy (It will be interesting to look back on how things changed as the result of the current emergency), I wanted to chat this week about one of those “other” things that is likely to be on the to-do list when we get to the recovery phase of this emergency. Not that long ago (OK, two weeks ago), we covered the potential for an intensification of scrutiny in the outpatient setting. And, as it should turn out, one of those areas of potential is the management of behavioral health patients in that setting. Last month (March 2020) our friends in Chicago posted an FAQ aimed at “hospital and hospital clinic settings” that talks about expectations relative to risk assessments in non-psychiatric units/areas in general hospitals. Of particular interest to me is the invocation of competency as a function of conducting the risk assessment “in areas where staff do not have the training to do this independently” and referencing “on-site psychiatric professional” as a potential resource. To me, that likely means that (and this may be the case of any risk assessment upon which you’ve modified practice, the environment, etc.) there will be questions about the risk assessment process, including “How do you know that the folks involved with the assessment were competent?” or something akin to that. I don’t know that everyone who has to (at least periodically) manage behavioral health patients is going to be able to access “on-site psychiatric professional” assistance, in which case it’s probably a good idea to clearly establish the credentials of the team or individual crafting the assessment. You can see what elements you’ll want to include here.

To aid in ensuring an appropriate environment for behavioral health patients, you might find the information assembled by the Center For Health Design to be useful. There is (almost literally) a ton of resources, from interviews, webinars, and podcasts to discussions of design elements, etc. As we have seen over the past few years, the management of the behavioral health environment is very much a moving target and the more information we have at our disposal, the more (dare I say) competence we can obtain. Every one of us is a caregiver to one degree or another and this is another useful resource that will help provide the most healing environment possible.

Please stay safe and (reasonably) sane ’til next time!

Will it go ’round in circles? A couple more pieces of the COVID-19 pie

As I try to embrace brevity as the soul of wit (which is likely to be as close to Shakespearean as this space is ever likely to venture), I have just a couple of resources to share with you folks this week. I do hope this finds you settling in (at least somewhat) to the current reality and the “new” stressors have subsided a bit.

Clearly, there’s been a lot of discussion regarding the protection of healthcare workers, mostly as a function of providing essential personal protective equipment (and the struggles that folks have faced in procuring said PPE). What is somewhat sketchier at the moment it to how organizations/employers are going to be held accountable for worker protection in the aftermath of the pandemic condition. But you might be able to gain some sense of things by consulting our friends at the federal Occupational Safety & Health Administration. While the OSHA website does speak of “discretion” in enforcement activities when considering an employer’s “good faith” efforts, I think it will be of critical importance that we be able to speak to a risk assessment to determine where folks jobs/tasks fall on the exposure continuum. OSHA indicates a spread of low, medium, high, and very high as risk categories with the enjoinder “(u)ntil more is known about how COVID-19 spreads, OSHA recommends using a combination of standard precautions, contact precautions, airborne precautions, and eye protection (e.g., goggles, face shields) to protect healthcare workers with exposure to the virus.” They also encourage the use of the Centers for Disease Control & Prevention as the primary source of current strategies, etc., so we can all work from the same source.

One of the other common threads of discussion relates to the disinfection of surfaces, etc., for which I would encourage you to check out the Environmental Protection Agency’s list of approved disinfectants (hopefully whatever your organization is using is on the list; not necessarily a deal-breaker if it isn’t, but there are always risks when one goes off-list). I keep reflecting on the reality that, in all likelihood, we won’t know what worked/didn’t work, etc., until this is long past it’s point of criticality, so it’s important to make sure that we can evidence a thoughtful process in identifying strategies. As of this writing (April 21), there does seem to be a growing unrest to get things back to normal, with some states opting to employ less restrictive strategies for distancing (in all its many permutations—who knew?). I am hopeful that we won’t be having this same discussion a month (or two months) from now if there is a resurgence, but it does seem inopportune to try and short-circuit a process before we have enough data to support easing up on things. I guess it all goes back to what they say about time—it will tell!

Stay safe!

Why pay full price for the right thing…

…when you can get an approximation for a lot less money!

I’ve been sitting on this particular line of thought for quite some time—long enough for the world to get to a place where having to “make do” is not only the order of the day, but a philosophy that is being endorsed by the various and sundry regulatory folks as work to hold the line on PPE and other operational necessities. It seems almost daily, the hard lines that existed in the compliance world have blurred to the point of vanishing. And while we know that things will eventually return to whatever normal awaits us, there are some indications of what that world might look like (again, looking purely at regulatory compliance as a function of surveys).

While there has been no formal public announcement yet (though I am anticipating something or other in the not too distant future), it seems that something we chatted about almost a year ago is going to manifest itself during surveys conducted by our friends in Chicago to the tune of an additional scheduled survey day, with the intent being the opportunity to really kick the environmental tires (so to speak) in your outpatient locations. As we discussed last year, I believe that there’s the potential for any number of vulnerabilities in the outpatient settings that may not manifest themselves so readily in the hospital setting, but if you look at what has been driving the numbers when it comes to the survey of the physical environment, it is clear that a lot of the same potentials exist—loaded sprinkler heads, issues with door hardware, gaps in inspection, testing and maintenance activities, depending on the environment, even air pressure relationships, and the management of temperature and humidity can be in the mix. The cynic in me is quite certain that there is no surprise in moving further afield with the survey process when it comes to generating findings—think of how much stuff they found in hospitals, where we exercise the most “control”! At any rate, I’m sure we’ll be getting the official word soon, but I’ve been thinking about what this is all gonna look like post-COVID and I think this is an important piece to be thinking about in terms of preparation.

In closing for this week. I wanted to share a piece on inspirational quotes. I personally don’t hate inspirational quotes as a going concern, but I hadn’t run into to a few of these before, so I figure it can’t hurt to share with the group.

Hope you all are safe and (reasonably) sane—you’ve got this!

Feeling pretty psyched: Some good news to share!

In full recognition that the longer the COVID-19 condition persists, the crazier it gets to folks on the front lines, so my intent is to (try—we’ll see how this works out—you know me) limit editorializing and provide you with brief episodes of useful content.

This week, it gladdens my heart to let you know that the good folks at the American Society for Health Care Engineering (ASHE) published a template (and guidance information) to facilitate facilities and safety professionals’ requests for an 1135 Waiver relating to the potential for compliance gaps relative to inspection, testing, and maintenance of fire safety and other equipment. You can find the template and table at the ASHE website. It’s a fairly straightforward process and the template (and corresponding table) really simplifies the thought process; I would encourage each and every one of you to check out these materials and get your waiver requests in the queue. To my way of thinking, this will make things a whole lot easier as we deal with survey activities in the aftermath of COVID-19 and, in the short term, allow you to focus on the important things: Supporting patient care at your organization.

Stay safe and stay in touch as you can—you guys rock!