Helpline Q&A

Brass Tacks from Derrick A. Denis of CSC:

1. Providers can still be cited right now for violations of 29 CFR § 1910.134. There is NO STOP ENFORECEMENT directive.
2. Shortages of respirators and fit testing equipment is not really an issue any more, so expect enforcement actions to increase.
3. Fit testing is cheap.
   As an example…CSC does it for $25.00 per employee if you gather more than 5 people and come to us.
   b.  (Note: I have seen prices as high as $100.00 per fit test.)
4. As an industrial hygienist, we are experts in conducting fit tests, but there is no reason that an Provider cannot designate a person to carry out this activity internally.
5. There is no certification to become a fit test provider, but OHSA has requirements of the process of fit testing and the topics covered in educating the testee.
6. We and other industrial hygienists can train-the-trainer if this is in line with the Providers risk tolerance and internal capabilities.
7. Costs to train the trainer will vary, but our rate is $190.00 per hour and the class takes around 4 hours.
8. If there are multiple participants, we would not double charge, but would charge a nominal addition for each attendee.
9. If a facility has multiple respirator types (because of preference or because of supply chain COVID-19 disruption), they should fit test each employee on each type of respirator they expect to have in their PPE arsenal.

Answered by DR EPIC Consultant: Derrick A. Denis

Attached is the Maricopa County guidance for Long Term Care it includes, if a facility has a resident that develops COVID-19 in the building (not admitted with and not acquired within the first 14days after admission) the facility is required to use COVID-19 isolation precautions for all residents, until 28 days have passed with no new cases. Please see below:

“Isolation of residents without respiratory symptoms or laboratory-confirmed COVID-19 can be lifted after 28 days (2 maximum COVID-19 incubation periods) have passed with no new cases identified in the facility who might have been exposed in the facility (i.e., resident was in the facility at any point during the 14 days before they became symptomatic/were tested). This does not include those who were known to be positive upon admission.”

Siru Prasau from Maricopa County provided some clarification for the guidance. Please see below:

All recommended COVID-19 PPE should be worn with all residents in the building, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. She also included those facilities should work with their local health department to determine when these isolation precautions should be lifted.

Answered by DR EPIC Consultant: Kay Huff

Below, I have outlined the key points to understanding disinfection, cleaning, fogging and clearing regarding COVID-19.

Disinfection:

1. Disinfection means rendering some pathogens on a surface non-viable, or unable to cause disease. For our discussion it means rendering the virus SARS-CoV2 unable to produce the disease COVID-19 in humans.
2. All disinfectants are not effective against every pathogen, and those that can be effective against SARS-CoV2 must be used correctly or they may not be effective.
3. Environmental Protection Agency (EPA) registered disinfectants are recommended by the DR EPIC Team because they offer the user some liability protection and because they are state-of-the art or best-practice.

There are EPA registered disinfectants that should be used against SARS-CoV2, because they are either

1. Specifically registered for use against SARS-CoV2, or they are
2. Approved for use against emerging pathogens such as SARS-CoV2.

As of 7-6-2020 the EPA has approved only two disinfectants as EPA Registered for use against SARS-CoV2

1. Lysol Disinfectant Spray (EPA Reg No. 777-99) and Lysol Disinfectant Max Cover Mist (EPA Reg No. 777-127), are the first two disinfectants to be approved for their ability to kill the virus.
2. This is based on laboratory testing that shows the products are effective against SARS-CoV-2.
3. The Lysol Disinfectant Sprays have a dwell time against SARS-CoV-2 (the virus that causes COVID-19) of two (2) minutes.

As of 8-25-2020 there are 482 disinfectants on the EPA “List N: Disinfectants for Use Against SARS-CoV-2 (COVID-19).”

1. This list can be found at https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19
2. List “N” includes products that meet EPA’s criteria for use against SARS-CoV-2, the novel coronavirus that causes the disease COVID-19.
   Disinfectants must be used according to the manufacturer’s recommendation. Most include the following:

Pre-cleaning – Disinfectants are more effective on clean surfaces.  So all surfaces you intend to disinfect should be cleaned.  EPA claims are for nonporous surfaces only.  You can go “off label” and clean porous surfaces like carpet, fabric upholstered furniture, clothing, etc. and then disinfect them, but you will not get the EPA registration claims.

Concentration – If the agent is not ready-to-use (RTU), then it is usually mixed on site from a concentration.  Mixed too lean and they won’t work. Mixed too rich they may be dangerous for the applicator.

Dwell time – All disinfecting agents have a dwell time or contact time, which is the amount of time a surface has to be wet with the agent applied to a cleaned surface to achieve the desired kill rate. Spraying a surface and wiping it off won’t result in the kill ratio you desire.  Fogging the air will not allow the appropriate dwell time on surfaces. The same goes for use of hand sanitizer.  It must be on your hands in a liquid form for a specific time or it will have reduced efficacy.

1. Cleaned: Cleaning refers to the removal of soil. In COVID-19 context it refers to removal of viral particles and the removal of other surface dust or debris that might reduce the efficacy of applied disinfectants.
2. Porous items are generally cleanable to one degree or another, but the cleaning method is dictated by the object. Clothes and linens are generally laundered, carpets are generally steam cleaned, books are often HEPA vacuumed, etc.
3. EPA claims are for nonporous surfaces only. You can go “off label” and clean porous surfaces like carpet, fabric upholstered furniture, clothing, etc. and then disinfect them, but you will not get the EPA registration claims.
4. If the cost of cleaning exceeds the cost of replacement, it is generally best to defer to replacement to end the liability stream.
   Fogging:
   1. Fogging refers to the delivery of a disinfecting product that is in liquid form into a fine mist or aerosol.
   2. Depending on the product, the required dwell times usually range from 1 to 15 minutes.
   3. Fogging is generally not a method for applying disinfectants to a surface in response to SARS-CoV2, because they deliver such low volumes of product as not to be able to deliver a dose of disinfectant that will remain on surfaces for the required dwell time.
   4. Foggers can wet surfaces but they take more time to adequately wet surfaces than other means of application such as wet mopping, wet wiping, airless spraying, etc.

Cleared:

1. Clearing is a term that implies the room is safe or ready for occupancy by people not wearing personal protective equipment. A cleared room is one that has been cleaned, that has had disinfectants applied per the manufacturers specification and that has had enough air exchange to reduce aerosolized viral loads below the concentration of concern.
2. Cleaning can be verified in house or by 3rd party industrial hygienists using UV challenge stamps and ultraviolet light, ATP swabs and bioluminometers, even SARS-CoV2 swabs and RQ-PCR analysis, etc. Each method of cleaning verification has pros and cons such as cost and time considerations.
3. Disinfection can be verified in house or by 3rd party industrial hygienists using visual assessment, biological coupons, colorimetric tags, etc. Each method of disinfection verification has pros and cons such as cost and time considerations.
4. Air changes can be verified in house or by a or by 3rd party industrial hygienists by measuring air changes per hour, viewing the outside air dampener settings, confirming HEPA filtration rates, etc. and comparing those to the facilities desired air change minimum for re-occupancy.I said all that to say… The answer to your question “What is the recommended disinfection time of a patient room that was cleaned after a COVID positive patient has been discharged?” Is going to be unique to your facility.

Answered by DR EPIC Consultant: Kay Huff & Derrick A. Denis

I have said for years that carpet is a terrible building finish for SNFs.

1. I recognize that carpet has pros such as providing a homey perception, that it feels soft under foot and that it absorbs sound.
2. But, porous flooring materials are hard to clean, hard to disinfect and are a trip hazard to non-ambulatory residents.
3. Furthermore, carpet in SNF populations is often affected by bloodborne pathogens (BBPs) and other potentially infectious material (OPIM) due to the resident’s battles with incontinence, regurgitation issues, bowel control issues and such.
4. Lastly, disinfectants are not EPA registered for use on porous products, so you lose the protection afforded to you if the floors were nonporous.
5. Regardless of the floor finish, if you had a COVID-19 positive resident in a room, the EPIC Team recommends cleaning with a surfactant and disinfecting all accessible surfaces during a turn over using an EPA “List N: Disinfectants for Use Against SARS-CoV-2 (COVID-19)” and/or a product EPA Registered for use against SARS-CoV2.
6. A nonporous floor finish would also need to be cleaned and disinfected, which is much easier and offers EPA registration protection.
7. Consider designating a few COVID-19 rooms as airborne infection isolation rooms (AIIRs) and changing carpet for hard surfaces that can be more easily addressed in future turnovers.I said all that to say… The decision to have carpet in your facility means you must clean and disinfect carpet in your facility during a COVID positive room turnover.

Answered by DR EPIC Consultant: Kay Huff & Derrick A. Denis

The Maricopa County guidelines for residents who develop COVID-19 in the facility include (ATTACHED):

“Encourage residents to remain in their room and restrict movement except for medically necessary purposes. If residents leave their room, residents should wear a surgical facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing (stay at least 6 feet away from others).”

So, YES, at minimum a surgical facemask should be worn by the resident/patient.

Answered by DR EPIC Consultant: Kay Huff & Derrick A. Denis

There are several questions asked in each sentence above.  Below, I address each individual perceived question related to the “One Solution Systems”, which includes both a product Vital Oxide Disinfectant (EPA Registration #82972-1) and a semi-portable electrostatic spray machine.:

1. Most of the EPA List N disinfectants are easy to use, this product is no exception.
2. It is only “approved” for use on hard nonporous surfaces. You can apply it to other surfaces (e.g. porous) in an “off label” capacity as is commonly done in emergency (e.g. pandemic) situations, but this is at your own risk.
3. The product instructions should guide you as to the need for personal protective equipment (gloves, respirator, etc.) and engineering controls (e.g. well ventilated area, etc.). Users should refer to and maintain a copy of the product safety data sheet (SDS), which will note what PPE is required.
4. The “System” refers to both a product and an applicator in concert. The product is Vital Oxide semiportable electrostatic spray machine.  The disinfectant product needs to be applied to a cleaned surface and remain wet for 10 minutes of dwell time and any application method (e.g. flat mop, rag, hand pump sprayer, electrostatic sprayer, etc.) can meet the criteria.  Electrostatic sprayers are best for low volume applications to sensitive items such as monitors, keyboards and phones.  Electrostatic sprayers are not generally the best tool for applying product to large areas such as floors and walls since these areas must remain wet for 10 minutes and the electrostatic delivers a fine mist.

Answered by DR EPIC Consultant: Kay Huff & Derrick A. Denis

If ever there was a time to engage the professional services of an industrial hygienist with extensive experience in indoor environmental quality the design and implementation of Airborne Infection Isolation Rooms (AIIR) scores quite high on the list.  But, to answer your question briefly…

On the whole, buildings should be positive in pressure to the outdoors. That is to say that air should move out of the interior of a facility via open pathways, such as doors, penetrations, cracks and such.   If it were the other way around (with the building under negative pressure) air would be drawn into the occupied building spaces through the attic, through walls, under doors and in extreme cases from water heater exhaust pipes, chimneys, chemical storage, biohazard storage, sewer systems and the like.   There are some specialty rooms in buildings that should, however, be negative compared to the adjacent areas.

Some common examples of localized rooms that should be depressurized include kitchens, janitor closets, restrooms, biohazard storage rooms, indoor pool enclosures, etc.  Negative pressure helps prevent whatever is in a room of concern from migrating out into other areas.   Another type of room that can be depressurized is an isolation room, or what we call an Airborne Infection Isolation Room (AIIR).

Creating an Airborne Infection Isolation Rooms (AIIRs) or even an Airborne Infection Isolation Wing requires thoughtful planning and a team approach.  Design and implementation requires considerations to temperature control, humidity management, security, fire life and safety plans, noise, workforce divisions, PPE, air changes per hour (ACH), negative pressure (in Inches of water), air barriers, localized inlets, make up air (MUA),  and many others.

The Standard Operating Procedures and Protocols will vary based on the needs and capability of the site. CSC recommends consulting the following official documents in establishing COVID-19 specific SOPs:

• CDC: 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007, 2019) https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html
• WHO: Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care. (2014) https://www.who.int/csr/bioriskreduction/infection_control/publication/en/
• March 17, 2020 Arizona Department of Health Services (ADHS) letter from Cara Christ, MD, MS, Director, Arizona Department of Health Services to Arizona Long Term Care Facility (LTCF) partners regarding COVID-19 (see attached).

Additional Information:

If you need a recommendation for an Industrial Hygienist here is a consideration:
Derrick Denis, Clark Seif Clark, Inc.
Work:  480-460-8334   Cell: 602-757-8907
e-mail: derrickdenis@csceng.com 
Website: www.csceng.com

Answered by DR EPIC Consultant: Derrick A. Denis

Ensure you have a written respiratory program and that every employee who will wear a respirator has a medical release and a current fit test for every respirator they may wear at your facility.  Look to 3rd party or environmental health and safety (EH&S) professionals for guidance in achieving these 3 goals. (EPIC Consultant Derrick Denis and his company Clark Seif Clark, Inc, represent such environmental health and safety firm. Derrick can be reached at derrickdenis@csceng.com or 480-460-8334. ) The costs for this service vary.  Fit testing one person is more expensive per person than fit testing ten people and it is more expensive on site. You want to fit test each employee with each type of N-95 you expect to have in your arsenal.  If you don’t do so, OSHA may cite.  They are already doing so. If staff do not pass the initial fit test, you (or your environmental health company) should work with them to adjust the device.  If they still cannot pass the fit test an alternate respirator can be selected.  Employers must provide this, even if it takes an upgrade to a 1/2 face, full face or other.  The only other option is to have the employee work in a setting where respirators are not required.

Additional Information and Resources:

1. Compliance with OSHA Respiratory Protection Standard 29 CFR § 1910.134 is a mandate and is important to ensure the health and safety of your team. Compliance will also limit liability and prevent regulatory citations, which are commonly enforced.
2. What if I have multiple brands or models of respirators?
   Get everyone fitted with each of the potential respirator brands you might have in your arsenal. The fit test form can then list each of the respirators that employees is “fitted” to wear.  This will prevent citations.
3. What about my KN95s?
   You must fit test with the N95 because it is required by the OSHA Respiratory Protection Standard 29 CFR § 1910.134.  You should fit test the KN95, because it is best practice.  But, do not use KN95 masks when N95 respirators are required.  Of course, if KN95s are all you can get due to supply chain interruptions, then you do what you must, but you do so at the peril of noncompliance and a reduced protection to your team.  We are all keenly aware of the challenges skilled nursing facilities currently face with supply chain interruptions at this time. These interruptions should also be carefully documented.
4. Can I reuse my N95s?
   Do not reuse disposable N95 respirators, unless your supply chain is interrupted, and we do recognize that this is the case for many skilled nursing facilities.  There are guides for disinfection of disposable respirators.  But, it is best to avoid the need for such measures.
5. How do I approach compliance with respiratory protection standards?

There are many ways to approach getting compliance with federal respiratory protection standards 1910.134. These are noted in the following section (#6).

6. If you are not already set up to handle this internally through your environmental health and safety (EH&S) department, you will want to retain an outside industrial hygiene firm or another 3rd party environmental health and safety vendor to provide some or all of the following services:You must have a written Respiratory Protection Program (RPP) that describes how you will handle respirators at your facility.

Assistance with creating this plan can include:

1. Composition of an RPP with a little facility-specific help from your team members, who would provide all the site and company specific   information as a collaboration.
2. Service as an advisor to your in-house RPP developer in a collaborative effort.
3. Assistance in peer review of your in-house produced RPP.
4. All employees, who are required to wear a respirator must have a Fit Test to show the device is offering adequate protection and ensuring employees understand the limitations and hazards of respirators. Fit tests are is good for 1 year from the date of the test. The fit test must be performed on each types of respirator an employee may wear.

Assistance with fit testing can include:

1. Environmental health and safety firm conducting fit testing at their site (usually a 1 hour group class and 10-15 minutes to fit test each employee)
2. Environmental health and safety firm conducting fit testing conducted at your facility (usually a 1 hour group class and 10-15 minutes to fit test each employee).
3. Environmental health and safety firm can conduct Train-the-Trainer fit testing class for your in house EH&S team, so they can then confidently conduct in-house fit tests on demand. (Usually a1/2 day class includes fit testing theory, practical matters and hands on training).
   1. All employees, who are required to wear a respirator must have a Medical Evaluation. This is required to be conducted one time, but most firms have this repeated annually as part of their RPP, since people change (weight gain/loss, health degradation, etc.).

Assistance with medical evaluations fit testing can include:

1. Environmental health and safety firm can conduct individual or group assistance with filling out the OSHA MEDICAL QUESTIONNAIRE either at our office or at your site, which usually takes one hour regardless of the size of the audience.
2. Environmental health and safety firm can assess medical evaluations, since these documents must be reviewed and approved (or not) by a physician or other licensed health care professional
3. Your in house medical professional with appropriate credentials can assess medical evaluations, since these documents must be reviewed and approved (or not) by a physician or other licensed health care professional (EPIC Recommendation for an Environmental Health & Safety/ Industrial Hygiene firm to serve as a 3rd Party:

Derrick Denis CIAQP, CAC, CIEC
Vice President of Indoor Environmental Quality, Clark Seif Clark, Inc. (CSC)
work:  480-460-8334    cell:  602-757-8907
e-mail derrickdenis@csceng.com
www.csceng.com

Answered by DR EPIC Consultant: Derrick A. Denis & Dr. Buffy Loyd-Krejci

The answer is from Dr. Siru Prasai from Maricopa county: “If the staff worked in the facility 2 days prior to the onset of symptoms this will be considered an exposure and facility  will be in OB (outbreak) status . If the staff was asymptomatic and worked in the facility in the 2 days prior to the test date- this will also be considered exposure and OB status.

Outbreak testing requirements for both staff and resident is on page 4 if the attached QSO memo.

Answered by DR EPIC Consultant: Kay Huff

Quarantine and isolation are 2 very different things. If a person is isolated then they are presumed or known to have Covid19. But, if they are quarantined, as stated in the question, then their status is unknown. So, the answer to the question specific to quarantine is…

You can reoccupy the room zero minutes after cleaning if the quarantined person tested negative or completed their quarantine without becoming sick.

If the person did become sick or tested positive, then their quarantine room status changes to an isolation room status, which will have a different (more robust) cleaning, disinfection and ventilation response and time frame.

If additional information is needed regarding cleaning post isolation, please let us know.

Answered by DR EPIC Consultant: Derrick A. Denis

Annual fit testing and training is inexpensive and can be conducted by outside vendors, who have specific expertise, experience and the tolls required.

That said, there is no reason that a Provider cannot designate, equip and train a person to carry out these activities (annual fit testing and annual training) internally.

There is no certification to become a fit test provider, but OHSA has specific requirements for the process of fit testing and the topics covered in educating the teste (see OSHA standard 20 CFR 1901.134).

The EPIC team or other industrial hygienists can train-the-trainer if such training is desired and if it meets the Provider’s risk tolerance and internal capabilities.

Costs to train the trainer will vary.

The class takes around 4 hours.

It is useful for you to purchase the fit testing equipment (nebulizers, fit test solution, hood, etc.) in advance of the class, so students have these tools available for hands on training

If you are scheduling a training class for an internal team member, make sure you train multiple people at your site I case of vacation, illness, turn over, etc.

Answered by DR EPIC Consultant: Derrick A. Denis

Step 1: is to decide is you will be conducting qualitative or quantitative fit testing.  For N95s most people are conducting qualitative (pass or fail) fit testing. Ultimately this is a risk management decision.  Your choice should be clearly listed in your Respiratory Protection Program (RPP).

Step 2: is to determine which challenge solution you will be using to conduct the fit testing.  For N95s, Bitrex (a bitter tasting solution) or Saccharine (a sweet tasting solution) are generally chosen.  It may behoove you to have both solutions on hand, since some individuals will not be able to taste/detect Bitrex and others will not be able to taste Saccharine.  If you have both, you have an option besides, turning them away if they cannot detect the single challenge solution you have. The process of using the Saccharine kit is substantially similar to use of the Bitrex Kit (sensitivity solution and challenge solution), so no significant additional training should be needed other than adding both procedures to your Respiratory Protection Program (RPP) and reading the directions.

Step 3: is to buy a Fit Test Kit that contains all the bits and bobs needed (e.g. sensitivity solution, challenge solution, sensitivity solution nebulizer, challenge solution nebulizer, hood system, etc.).  Once you buy the kit, you can buy refills for the solutions as needed.  There are various manufacturers of fit test kits (3M, Allegro, etc.).  There are many local and national retailers of these products. Locally I use:
Ruben Aviles
ABATIX
3011 East Broadway Road, Suite 300
Phoenix, AZ  85040
Tel: 602-323-1941
Fax: 602-323-1942
M: 602-696-0744

Answered by DR EPIC Consultant: Derrick A. Denis & Dr. Buffy Loyd-Krejci

The CDC has not directed facilities to stop extending the use of PPE such as masks and eye protection, the CDC guidance for extended use of PPE can be found here. The CDC recommendations for PPE use includes “Implement strategies to optimize current PPE supply even before shortages occur, including bundling resident care and treatment activities to minimize entries into resident rooms.” The CDC recommends facilities know their burn rates to assess their PPE supply and needs. The CDC guidance includes “Facilities should continue to assess PPE supply and current situation to determine when a return to standard practices can be considered.” The CDC is currently leaving it up to the facility to determine when they are able to return to standard use of PPE.

Additional Resources:

• Gowns: “Strategies for Optimizing the Supply of Isolation Gowns” updated Oct. 9, 2020 and found at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html
• N95 Respirators: For N95 respirators (which are not masks) see CDC “Implementing Filtering Facepiece Respirator (FFR) Reuse, Including Reuse after Decontamination, When There Are Known Shortages of N95 Respirators” updated Oct. 19, 2020 and found at:   https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html
• Masks: For additional information, check out the following links:
  o CDC “Considerations for Wearing Masks, Help Slow the Spread of COVID-19” updated Nov. 4, 2020  https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html
• CDC “How to Store and Wash Masks” updated Oct. 28, 2020 and found at: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-to-wash-cloth-face-coverings.html

Answered by DR EPIC Consultant: Derrick A. Denis & Kay Huff

From Hospital:

The Governor’s Executive orders 2020-22 includes that “Nursing Care institutions…All COVID-19 positive and COVID-19 unknown residents admitted and readmitted to the facility should be isolated in their room for 14 days unless it is a COVID-19 positive resident in a COVID-19 positive facility.”

RESOURCE LINK: CDC Considerations for new admissions or readmissions to the facility.

Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19.

All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown.

• Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic SARS-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE.From Outpatient Appointments and Dialysis:The CDC guidance includes that all patients/residents to outpatient hemodialysis facilities should wear masks.Liz Kim the Healthcare-Associated Infections Program Manager for ADHS stated that there is no strict guidance regarding residents who need to leave the facility regularly for dialysis or other medical appointments. We do advise that facilities may want to be conservative with these patients and treat them as they would admissions/readmissions since these residents are at higher risk due to their community exposure. I want to also point out this MMWR that was recently published that identified a significantly higher prevalence of COVID-19 among residents receiving dialysis (47%) than among those not receiving dialysis (16%); 72% were asymptomatic at the time of testing.The same MMWR also included that the mortality rate for dialysis patient compared was 40% as compared to non-dialysis who rate was 27%. Here is the link to the MMWR https://www.cdc.gov/mmwr/volumes/69/wr/mm6932e4.htm?s_cid=mm6932e4_w.

  Will this loosen up?
  This is the current guidance, with the vaccine new guidance will becoming but until then we should follow the above recommendations.

Answered by DR EPIC Consultant: Kay Huff

You asked: “Is this acceptable or do I need to do something different?”

You should consider doing something different.

Structural issues:

• The tape to building bond on your temporary barrier will either be so weak the sheeting will fall OR will be so strong it damages damage the building finishes resulting in costly repairs.
• The modified Z-flap door is inefficient and the stress of passing through it a few times will delaminate your barrier.

Infection control issues:

• Alone, the plastic barrier in your photograph, is not adequate for COVID-19 positive resident isolation.
• Besides a simple plastic barrier, effective isolation of COVID-19 positive residents from healthy residents requires many considerations (e.g. Infection control, HVAC zones, building pressures, air changes per hour. outside air supply, air filtration, aseptic techniques, dedicated staff, etc.).
  • Be advised that the barrier itself poses risk to the staff and residents. (e.g. fire life and safety, security, etc.)

You asked: “Also. Does it matter if staff go thru the plastic door”

Yes, it matters if staff go through the plastic door because:

• They will tear it down with normal use because it is not robust.
• They can become cross contaminated by unavoidable contact with the sheeting.
• They cannot don and doff PPE aseptically without an anteroom.

Answered by DR EPIC Consultant: Derrick A. Denis

According to Diane Eckles, Bureau Chief of Long Term Care at the Arizona Department of Health Services hairstylist/beauticians would be considered a visitor. Please see the attached QSO Memo that says, “ High (>10%) = Visitation should only occur for compassionate care situations according to the core principles of COVID-19 infection prevention and facility policies”.

According to the CMS data Yuma is at 12.7%, based on the current guidance from ADHS and CMS the facility should wait until they are at or below 10%.

Answered by DR EPIC Consultant: Kay Huff

A facility that wants to be able to provide the COVID-19 vaccine must participate in the Arizona Immunization Program. If a facility would like to onboard as a pandemic provider, they will need to complete and submit this survey: https://redcapaipo.azdhs.gov/surveys/?s=DY8CA9LMJ8. By onboarding as a pandemic provider, the facility may be able to receive COVID-19 vaccinations to administer, if approved by the Arizona Immunization Program Office (AIPO). There are many requirements that must be met for a facility to be approved by AIPO. Providers can go to AIPO Train to learn how to order, receive, store, administer, document, and account for pandemic vaccines in the Arizona State  Immunization Information System (ASIIS).

Arizona follows a local allocator model in which the Local County Health Departments and Tribal Partners are responsible for allocating their doses to their providers within their jurisdictions. A high-level overview of this process is that the CDC provides dose counts to the State. They allocate those doses to the counties and tribes (local allocators), and they in turn further allocate their doses to the vaccinators in their communities.

Vaccines are being distributed in two phases.

• During Phase 1, there is a limited number of COVID-19 vaccines available. The doses are allocated to local jurisdictions (county health departments and tribal allocators) to distribute to the ACIP recommended populations.
• During Phase 2, doses will be widely available. The doses may be ordered by providers in ASIIS as needed to target the ACIP recommended populations.

The program is unsure of how quickly Arizona will move through each phase. In the meantime, they encourage you to work with your Local County Health Department for more information. This website has a section with county contact information. There is also a brown bag presentation on the website that has more information.

Answered by DR EPIC Consultant: Kay Huff

The answer is that the Centers for Disease Control (CDC) has not updated this topic yet. While it does make sense to be able to ease up on certain procedures or practices, we are not able to expand on procedures until they have been sanctioned by the CDC. Here is the current CDC guidance.

CDC Guidance

Some procedures performed on patients are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing. These aerosol generating procedures (AGPs) potentially put healthcare personnel and others at an increased risk for pathogen exposure and infection.

Development of a comprehensive list of AGPs for healthcare settings has not been possible, due to limitations in available data on which procedures may generate potentially infectious aerosols and the challenges in determining if reported transmissions during AGPs are due to aerosols or other exposures.

There is neither expert consensus, nor sufficient supporting data, to create a definitive and comprehensive list of AGPs for healthcare settings.
Commonly performed medical procedures that are often considered AGPs, or that create uncontrolled respiratory secretions, include:

• open suctioning of airways
• sputum induction
• cardiopulmonary resuscitation
• endotracheal intubation and extubation
• non-invasive ventilation (e.g., BiPAP, CPAP)
• bronchoscopy
• manual ventilation
• Based on limited available data, it is uncertain whether aerosols generated from some procedures may be infectious, such as:
  • nebulizer administration*
    high flow O2 delivery
    *Aerosols generated by nebulizers are derived from medication in the nebulizer.

It is uncertain whether potential associations between performing this common procedure and increased risk of infection might be due to aerosols generated by the procedure or due to increased contact between those administering the nebulized medication and infected patients.
References related to aerosol generating procedures: Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J (2012) Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to Healthcare Workers: A Systematic Review. PLoS ONE 7(4);

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3338532/#!po=72.2222external iconexternalicon

Answered by DR EPIC Consultant: Dr. Buffy Lloyd-Krejci

Water temperatures are covered in Appendix PP at F689 Accidents. Table one in this requirement includes that safe water temperatures is at 100 degrees Fahrenheit.

Table 1. Time and Temperature Relationship to Serious Burns Water Temperature

NOTE: Burns can occur even at water temperatures below those identified in the table, depending on an individual’s condition and the length of exposure.

When surveying, surveyors are instructed that temperatures between 100- and 110-degrees Fahrenheit are acceptable.

Answered by DR EPIC Consultant: Kay Huff