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The trouble with normal?

It always gets worse!

While I can’t say with absolute certainty, it seems likely that I’ll be employing relatively brief missives over the next couple of weeks as we do seem to be shifting gears a bit as far as the “return to normal.” As I write this, it’s been a couple of weeks since my last air travel and (based solely on my own observations) I have every reason to think that the COVID surge being reported is going to be a disruptive factor—I am hoping that this is the last wave before we reach safe harbor, but I’m not just seeing noses in enclosed public spaces, I’m seeing lots of full faces. I received my second dose of the vaccine about 10 days ago, but I’m going to keep masking up for the foreseeable future when I’m traveling. I will be happy to be proven that it was more than I needed to do, but I’m still waiting on the data…

So, just a couple of resource items for moving into the next phase of normalcy. First up, I was always (OK, since last June) surprised by the variability of screening practices and that surprise continues today. But if you want to get a sense of what I’m seeing in the field, this would be a good starting point. I don’t know that there’s a whole lot of data regarding how effectively screening helped stem the tide of COVID or even how often cases were identified through that process, but maybe someday there will be some sense.

Another element for consideration is visiting folks in nursing homes and other care facilities. I don’t think there’s anyone who would argue that there has been a significant emotional toll since the onset of COVID, which, I suppose has given the powers that be a fair amount of time to come up with how to transition safely on the visitation front. In September 2020, CMS issued some guidance in that regard and, a few weeks ago, updated that guidance in light of vaccinations, etc. Again, if we get another spike, this might be the best we get for a while, but at least it’s something…

And that, as they say, is that—at least for this week. Who knows what might come flying out of nowhere to create havoc, so stay tuned.

Be well and stay safe. Every day brings us a little closer to the end of this thing!

Stay Centered and Carry On: PHE likely to persist through 2021!

As any of the Peanuts gang might opine: AAUGH!

In a letter to the governors, Norris Cochran, the acting secretary of HHS, indicated that it had been determined that the Public Health Emergency (PHE) will likely remain in place for the entirety of 2021, but there would also be a 60-day notification prior to the termination or expiration of the PHE.

Ostensibly, this removes at least some of the uncertainty of the quarterly updates of the PHE status and appears to provide a 60-day window for organizations to attain compliance with any regulatory requirements covered under the 1135 waiver process, including the blanket waivers currently in effect. I suspect this also means that support at the federal level will remain in place relative to response activities—the letter also indicates that this should be considered evidence of the government’s commitment to ongoing response to the pandemic.

Presumably, there is a cross-section of folks in the field who either didn’t adopt any of the waivers or have been able to move things back to “business as usual” in terms of inspection, testing and maintenance activities, so this may not mean that much from a practical standpoint. That said, if there are any of you out there who have been able to make good use of, you probably need to start thinking about a turnaround within 60 days. Maybe you start to reach out to your vendors—there’s probably going to be a queue for services once this whole thing breaks loose—and the indication is that the accreditation organizations are not going to be flexible once the PHE expires/terminates. I’m trying to think of what processes would take longer than 60 days to get back on track and nothing is springing to mind. Again, I suspect that scheduling the work is going to be the “sticky wicket” if there’s going to be any issue, so if there’s anything you can do to pre-load that process, it’s probably time well-spent.

Until next time, hope you are well and staying safe!

From the sky we look so organized and brave

Once again (I’m thinking there’s no surprise to this), the public health emergency wrought by the impact of COVID-19 on just about anything you’d care to name has been extended. You can find the somewhat reiterative announcement here (apparently, there’s no one at the federal level that proofreads this stuff—go figure). If the past sequence of review and extension continues to hold true, we can expect the next extension to “drop” sometime in April. It would be delightful to think that distribution of the vaccine would somehow interrupt a further extension, but I suspect we probably have at least one more after that, as we move ever closer to whatever is going to constitute the “new normal” (based on the latest numbers from CMS, things do seem to be retreating/receding from red, so to speak).

As we continue our slog through the pandemic, our good friends in the CMS workshop have been busy establishing a portal for all things waiver-related. It may be that there’s too much information (there are a whole bunch of links to various sites, etc.), but on the off chance that you folks might find something useful contained therein, you can check it out here.

There are a couple of YouTube videos in the mix to help complete the online waiver request forms (if you would feel so inclined, you can go directly to the waiver request site by using this link).

Ultimately, it’s all about being able to continuously provide appropriate care to our patients; sometimes that means going from one moment to the next—which, as we’ve learned over the last little while, breeds its own special brand of exhaustion…

I encourage you to make the most of what little “down” time you have to recharge your batteries as much as you can. The vaccination process seems to be gathering some momentum, but we’re still a ways away from the finish line. I guess this is one race we’ll all be finishing at the same time…

Until next time, please stay well and be safe!

Be afraid, be very afraid…but do it anyway!

Something of a mixed bag this week: Basically a couple of brief items with some interpolative commentary.

First off, in what is probably not really a surprise, the feds have not updated the status of the Public Health Emergency (PHE) (here’s the most recent correspondence in this regard) in a little bit, but I am hopeful that our sprint towards the New Year will prompt a revisitation. I guess one of the key thoughts moving forward is at what point are regulatory surveys impacted. It would seem that we are in a bit of a spike in cases (though how one can tell definitively is something of an art form), based on the information provided to folks traveling in and out of Massachusetts (which would include yours truly). While I can’t say that I’m getting used to being swabbed, I suspect that between now and Christmas, I’ll have a few more opportunities to embrace the swab.

At any rate, I’d be curious as to how folks are “falling” within their normal accreditation survey cycle. Early? Late? Pretty much on time? At some point, something’s going to have to give (and maybe that something involves virtual building tours and the like). I guess at this point all we can do is “stay the course,” and wait for the vaccine distribution challenge (we know it’s coming sometime)…

In other news, our friends in Chicago announced a revision to one of the performance elements dealing with the life safety implications of maintaining fire suppression systems. You might recall we chatted a bit about this back at the beginning of July, at least in terms of the whole spare sprinkler thang. If you accept (as I pretty much have at this point) that any change to a physical environment standard or performance element is “designed” to provide an opportunity for generating more findings (the sterling being the impending focus on the ambulatory care environments), then I think it would be prudent to really kick the tires on your spare sprinkler maintenance program to ensure that you are meeting not just the requirements of the revised performance element, but also the other related requirements. (The blog post above should serve as a good starting point, if you are so inclined.)

As always, please be well and stay safe. I appreciate everything you are and everything you do!

A cautionary tale for travelers: The only nose you’ll want to see this week…

I’m not sure how many folks will be traveling this week (the CDC is advising folks to refrain from travel). But having spent a goodly portion of the past few months traversing airports and the like, I can tell you, from personal experience, that compliance with the wearing of masks is better than it was, but there are still quite a few schnozzes on display. So, if you are traveling by public means, please be vigilant within your own practice and don’t be one of those folks that can nurse a 6-ounce bottle of water for a four-hour flight. Interestingly enough, United Airlines has started to call out folks for using consumption of food/beverage as a basis for leaving their masks off. I noticed it a lot this summer and it still seems to be a more common practice than I would prefer to see.

That said, please accept my sincerest wishes to you and yours for a most joyous Thanksgiving holiday and safe, definitely want you all to stay safe!

And as to the nose you want to see

Happy Thanksgiving!

Masking Tape/Taping Masks: Essential PPE is still in the mix…

As 2020 continues to roll along with no apparent respite from dealing with COVID on the horizon, it’s probably not a bad idea to share some PPE-related resources with folks. I suspect that pretty much no one out there in the studio audience has the time to bolt down the rabbit holes of the interweb, but here are a few links to some (hopefully) useful resources:

When it comes to PPE, it’s always important to keep an eye on the folks at the Occupational Safety & Health Administration, who have provided some guidance relative to the use of PAPRs for personal protection. It has the appearances of being somewhat flexible in certain instances, but enforcement is still enforcement, so if you’ve got PAPRs in the mix, worth checking out.

Next up, the good folks at ECRI have pulled together a number of PPE-related resources to ensure that we’re providing appropriate/effective PPE to those folks on the front lines who are at the greatest risks of occupational exposure. If you think all this stuff kind of sounds like a risk assessment opportunity, I would be inclined to agree. At some point (hopefully sooner rather than later), when move on to the new “new” normal, our regulatory friends are going to be curious to find out how we “knew” that we were adequately protecting folks and, since they’ve been rather reluctant to accept performance data without some sort of assessment framework, these should work well within the confines of the documented risk assessment process.

Here they are:

While shoe covers don’t really fall under the PPE category in general (though sometimes they can), for anyone who has ever struggled with putting on shoe covers before “bunnying up” to go in the OR, I thought this might be a good for the end-of-the-year holiday wish list (I know it’s on mine—as soon as they make one that’s portable), check out the Bootie Butler. I’ve only seen this item in a pharmacy clean ante room, but I found it intriguing.

As always, I hope this finds you well and staying safe. I figure every day brings us closer to the end of this (and I suppose there’s a certain inescapable logic to that). I hope…

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!