And welcome to today's COVID-19 Infection Control and PPE Update. This educational activity was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services. The contents of this resource center do not necessarily represent the policy of CDC or HHS and should not be considered an endorsement by the federal government. My name is Marilyn Bullock. I'm an Associate Clinical Professor of Pharmacy Practice and the Director of Strategic Operations at the Auburn University Harrison College of Pharmacy and an Adjunct Associate Professor at the University of Alabama School of Medicine and an Adjunct Associate Professor at the University of Alabama College of Community Health Sciences in Tuscaloosa, Alabama. I'll be moderating today's webcast. This webcast is being recorded. The recording will be available to registrants within 48 hours of today. To access, please go to covid19.sccm.org backslash webcast. A few housekeeping items before we get started. To submit questions throughout the presentation, type them into the question box located on your control panel. I'll be monitoring them throughout today's presentation. The presentation is for educational purposes only. The material presented is intended to represent an approach, view, statement, or opinion of the presenter that may be helpful to others. The views and opinions expressed herein are those of the presenters and do not necessarily reflect the opinions or views of SCCM. SCCM does not recommend or endorse any specific test, position, product, procedure, opinion, or other information that may be mentioned. And now I'd like to introduce our speakers for today. Marcy Drees is the Chief Infection Prevention Officer and Hospital Epidemiologist for Christina Care in Newark, Delaware. She completed her medical training at the University of Chicago Vitzger School of Medicine, the University of Colorado Health Sciences Center, and Tufts Medical Center. She is a board-certified physician in internal medicine and infectious disease. Our next speaker is Kyle Invert. He is an Associate Chief Medical Officer of Critical Care at the University of Virginia in Charlottesville, Virginia. In addition to his work in the Medical Intensive Care Unit, he is the Co-Director of Special Pathogens Unit at UVA, which was developed to care for patients for the Ebola virus, which morphed and expanded in the setting of the SARS-CoV-2 pandemic. Dr. Invert previously worked as an Assistant Hospital Epidemiologist and in the Society for Healthcare Epidemiologist Outbreak Response Training Program Team. And now I'll turn our talk today over to our panelists. Thank you, Dr. Bullock, for the introduction, and thank you to the Society for inviting me to come and share this time with you. And of course, thank you for everyone who took time out of your day to attend this webinar. We're going to talk about COVID in the setting of this hierarchy of controls, which is really used for any possible workplace hazard. And it really, and we'll keep coming back to this diagram through the course of the talk, because I think it's a nice framework to think about how we implement different things and why we do so. So it really goes from, you know, the most effective at the top being elimination of the hazard, whatever that hazard may be, down to the least effective PPE at the bottom. And that's not to say that PPE is not effective. It obviously is very effective, but it's on the bottom of this hierarchy because it relies so much on kind of individual knowledge and compliance. And there's just, it's much more error prone than the elimination and the things that are higher up on the hierarchy. When we think about what are ways that we can eliminate COVID from the workplace when we're thinking about healthcare? So things like entry screening, so telemedicine and vaccination. All right, there we go. So when we think about entry screening, you know, it's not only for, obviously, people with COVID symptoms, as well as COVID exposure. So, you know, people are coming in with symptoms, patients, but can we eliminate, you know, we want to identify them as early as possible so that we're not exposing people unnecessarily, but also visitors. You know, we've had very strict visitation policies that have waxed and waned over the course of the pandemic in response to what's been happening in the community around with COVID. So having processes in place to prevent people from bringing COVID into the hospital unnecessarily. And then, of course, you know, with healthcare personnel, they, you know, they need to come into work, but, you know, we have a longstanding issue with people coming into work sick, which we call presenteeism, the opposite of absenteeism. And it's, you know, and I think people don't do it, you know, people do it out of, you know, not wanting to burden their coworkers. They, you know, they want to be, they don't want to call out from work unnecessarily, but it does raise the risk that they're bringing COVID or flu or any other respiratory illness or other illness into the hospital and exposing people. So, you know, having a process where, you know, healthcare workers attest that they're not having symptoms, things like that are really important to keep as much COVID out of your hospital as possible or your healthcare system. Another way to eliminate COVID is the use of telemedicine, which has really moved, you know, leaps and bounds in the pandemic much more rapidly than it would have otherwise. And in many cases, you know, probably most appropriate for low acuity settings like ambulatory where you can do entire patient visits remotely. But of course, we have, you know, tele-ICU services, and the picture is from my institution, our medical ICU director, Dr. Benninghoff there with one of our telemedicine robots. I know, Dr. Enfield, you have extensive experience with this as well. Would you like to comment? Yeah, I think people should be thinking about how they can use EICU platforms in new ways to monitor patients to decrease entry into rooms. And we developed that when we were thinking about how to care for Ebola patients and really expanded it so that we can look in every single room that has a COVID patient in it, talk to the nurse, see the patient, and pull the vital signs out and lab values so that we can do more rounding like we would do in traditional settings, but with fewer room entries. Yeah, and we're doing something very similar as well. And then lastly, another way of eliminating COVID from the workplace is vaccination. So, you know, as many, the more people we can get vaccinated, the less likely they are to become patients, right? So we know that, you know, even in the setting of Omicron, we know that being fully vaccinated doesn't prevent every infection, but it does prevent the majority of hospitalizations and certainly deaths. So keeping as many people with COVID out of the hospital is really important. And then, of course, you know, this could be an entire talk about vaccination, which it's not going to be. So, but, you know, how you manage your staff, you know, we've had a vaccine mandate, and as we have many other institutions, others have done, you know, other ways to incentivize healthcare personnel to get vaccinated. You know, there's a lot of controversy now about, you know, well, what about boosting, do we mandate that as well? But I think, you know, fundamentally, you want to make getting vaccinated as easy as possible for your healthcare workers to obtain. They shouldn't have to go out into the community to get it, and really, you know, communicating as openly and thoroughly as you can so that their questions are answered and they feel comfortable getting vaccinated. All right, so we've talked about elimination. You know, there really isn't a way to substitute for COVID in this setting, so we're going to move down to engineering controls, which are ways to isolate people from the hazard. And those are things like negative pressure rooms, having well-maintained ventilation, physical barriers, and source control. So when we talk about airborne infection isolation rooms, or AIIR, you know, also known as negative pressure rooms, there's a specific definition. They're always single occupancy rooms. They're negative pressure, obviously, so the air flows under the door gap into the room. They have to directly exhaust the air from the room, either outside or have it be recirculated to have a filter. And then they have to have a certain number of air exchanges per hour. So for new construction or renovation, they have to have 12 air exchanges, and for existing structures, they need to have six air exchanges. And the picture on the right is, if you're not sure if your AIIR is working properly, a quick trick is to take a really light piece of tissue paper, and with the door closed, it should get sucked right in there, and you can easily tell that the room is functioning. And so with COVID, you know, we, you know, we haven't, we obviously don't have enough negative pressure rooms to put every COVID patient in. That would be impossible. So the CDC has recommended that, you know, you should focus on, for patients with COVID, using them for patients who are undergoing aerosol-generating procedures. We'll talk a little bit more about it in a minute, if possible. And for non-aerosol-generating procedure COVID patients, you know, really a single-person room with the door closed, if it's safe to do so, and a dedicated bathroom. If you don't have sufficient AIIRs, even for those aerosol-generating procedure patients, you know, we have portable HEPA filter machines. You can make entire units negative pressure, which we haven't done, but I know, I think Dr. Enfield has, and other institutions have. And even, you know, if last resort, just a regular room, keeping the door closed, and having all staff use respirators during the procedure and for one hour after the procedure. And these strategies may work differently, whether you're talking about a continuous aerosol-generating procedure, like BiPAP, versus an episodic one, like an intubation. And so, yeah, go ahead, sorry. Yeah, so when we think about that, it's important, as you think about your institution, how you would prioritize different patients for your AIIR rooms, because it's unlikely that you're going to have enough for every patient who has COVID-19. As Dr. Drees pointed out, you know, we were fortunate enough to be able to change our air handling units within some of our floors to make the rooms negative to the environment. But this does not meet the same specification as a true AIIR room. And so, while it is an engineering control, it is not the perfect engineering control. Our institution developed a prioritization matrix that gave the highest priority to those patients with confirmed COVID-19, both with and without HEPs, and then prioritizing other patients differently. So those patients that were exposed to COVID-19, we didn't prioritize them in all four rooms, even if they were getting aerosol-generating procedures, unless we were just fortunate enough to have many open rooms. And so then we had to rely on those other metrics, measures like HEPA filters in the room, using N95 masks for all people in the room during and for one hour after the procedure. So this is an important step to take as you think about how you can use engineering controls to contain the virus. So, you know, one of the things that I think, you know, before COVID that we all thought we knew is what is an AGP? And it turned out that there was very little agreement about what actually was an AGP. So, you know, and I put some of the examples there that, you know, if you just look at the published evidence, there's relatively few procedures that have been definitively shown to, you know, generate higher concentrations of whatever infectious respiratory aerosol you're worried about. The World Health Organization has its own list. The CDC has its own list, which is similar, but not quite the same. And certainly, especially early on in the pandemic, you know, it seemed like every professional society was saying, you know, their procedure was an AGP. Whether it was just walking a patient or, you know, or, you know, speech therapy, there were lots of examples, and managing that was really challenging. So, and I think, you know, I don't think there's a definitive answer even yet, but it really goes to, you know, it's, and there's probably isn't, you know, a strict cutoff yes or no, it's a continuum, right? And I think as COVID has gotten more contagious, you know, we certainly have gotten more worried about, you know, really procedures that we probably wouldn't have been as worried about early on. All right, come on. All right, and then another thing, again, that I think was confusing at first is, you know, what do we even mean by airborne? And I like this table that was published last year, because it came to, it really brought up the fact that when an infection preventionist talks about airborne, they mean one thing, or a clinician, versus if an aerosol scientist talks about airborne, they mean something totally different, but they use the same word. And so, I think it became really concerned, you know, people were really concerned about why aren't we using respirators for all COVID care when this is airborne? And I think, you know, I've said multiple times, if there was one thing I wish we had known early on is how frequent, you know, asymptomatic transmission was, you know, and so, because I think it would have played out much differently if we had been aware that, you know, up to 50% of transmission was happening in the setting of no symptoms. And certainly, what the general public understands about airborne is also completely different and often than what we're talking about. So, I think it's just added complexity to the entire discussion. I did want to talk a little bit about source control, because again, it's one way of eliminating exposures or reducing exposures. So, when I talk about source control, it's the use of a respirator, a well-fitting face mask, or even a well-fitting cloth mask to cover the nose and mouth of a person to prevent them from spreading when they talk, when they sneeze, or when they cough. You know, and I think that's been a really important thing, you know, again, that I wish we had known earlier on that I think if we had started masking a little bit sooner into the pandemic, things again might have not played out quite the same way. But I like this table, because it really talks about, you know, if you have, if both the person with COVID and the person without COVID, neither of them has anything covering their mouth, it takes about 15 minutes for them to, you know, potentially transmit to another. And then as you move from cloth to surgical masks to a non-fit-tested N95 to a fit-tested N95, you know, it really reduces the amount of time or increases the amount of time that these two people can be together without transmitting one to the other. And if both are wearing an N95, you know, it goes from 15 minutes up to 25 hours. So it's all about, you know, relative risk. But it really goes to the importance of source control as well as wearing masks to protect yourself. And so, you know, we've had a universal masking, you know, mandate from really since probably May of 2020, and have kept it up entirely since then, as well as adding eye protection. Dr. Enfield, did you want to comment on that at all? Yeah, I was going to say the same thing, that we very early adopted that universal mask mandate because it allowed for source control if the employee did not know that they were sick when they were coming to work that day. Yeah. Yeah, and we had a number of examples where, you know, people were at work and then they became symptomatic the next day or the day after that. And those, you know, you can be contagious ahead of time. So moving from engineering controls down to administrative controls, so changing the way that people work. So that's things like cohorting, minimizing staff in the room, remote monitoring, and other physical distancing. So cohorting, you know, early on, you know, we felt like, you know, we had a very limited number of units that accepted COVID patients. Like our medical ICU took our first patient and many of our early patients. And that was really to allow us to focus on, you know, having the right PPE and having them trained properly. We couldn't do that across a huge institution all at once. So being able to focus those efforts to a limited number of people. But I think as things have evolved, you know, we've obviously had more time to train more people. PPE access has been better. And we realized that some of our COVID positive patients really do benefit from specialized care. So whether it's a cardiac ICU, you know, we have had trauma patients come in who incidentally have COVID, they're obviously better served in a trauma ICU than in our medical ICU. And even, you know, our pregnant OB patients, you know, traditionally would go to our surgical ICU because physically it's much closer to labor and delivery. That's where all the OBs typically are. Our medical ICU is way on the other side of the health system. But we had them initially in our medical ICU. So we had to change that. In terms of minimizing the staff, you know, obviously, again, it was not only to decrease risk but to conserve PPE because of all the constraints we had earlier on. You know, we initially excluded students and trainees. That has changed over time. You know, remote monitoring, you know, in addition to the tele-ICU that we already talked about, you know, having a nurse don PPE to go in to look at a screen really didn't make a lot of sense. So can you move your devices that are caring for the patient, you know, even using extra long tubing and cables to allow the machines to be out of the room so that nurses could fiddle with them without having to don and go in. And unfortunately, you know, sometimes it involved nursing taking on additional tasks like taking out the trash, you know, bringing the meals in because it didn't make sense, again, to have an EVS worker or a nutrition worker don and off just to do that relatively simple task. Did you want to add anything? No, I think that was great. All right. All right. And then last but not least, PPE. So, you know, we talk about, you know, masks, gown, gloves, eye protection, and then all sorts of different respirators. So, you know, again, which PPE should we use, droplet versus airborne? Another big controversy early on. The WHO was recommending droplets that felt like the bulk of the epidemiologic evidence supported that this being transmitted to droplets. CDC is typically is more conservative. This is a new pathogen. We didn't know enough about how it was being transmitted, was recommending airborne. All of this in the setting of very constrained N95 supply. So, you know, we personally used droplets at our, a droplet at our institution other than for aerosol-generating procedures, because we just never had enough supply to use respirators for everyone. But ultimately, you know, it is a false dichotomy. It assumes that it's black or white, yes or no, but it really is more of a range. And I think the diagram shows that reasonably well, because, you know, yes, we think that the majority of spread happens from these larger droplets that tend to fall to the earth fairly quickly through gravity. But when someone coughs or sneezes, there are large and small particles that are being transmitted, you know, at least in close range. You know, we know at this point that, you know, COVID doesn't spread like measles, where, you know, it can be out the hall and down the room, three doors down and get measles if you're susceptible. It doesn't have that long-range aerosol route, but certainly kind of in that shorter range, you know, it is kind of droplet and aerosol. It also, you know, we've continued to emphasize the importance of eye protection. We struggle with compliance with that, you know, it's not ideal. They fog up, they're uncomfortable, but we definitely have seen exposures related to lack of eye protection. You know, I think in this day and age, you know, early on, we had people, you know, not only using gowns, but using disposable scrubs, covering almost every square inch of their skin. You know, I think at this point, we know that that's really not how COVID spreads. Gowns are certainly still part of the recommended PPE, but I think, you know, there's much less evidence for wearing gowns than there is for the respiratory protection and eye protection. And again, this has evolved over time as well. OSHA in last June really recommended COVID for all, or respirators for all COVID care. But, you know, at the time, we were a little bit resistant to that because we had been very successful in preventing spread to our caregivers using droplet precautions. I think in retrospect, you know, with Delta, now with Omicron, you know, I'm kind of glad that we moved to that because I think, you know, certainly the virus has become more contagious over time. But still, I think, you know, any mask is important than whether it's a respirator or a well-fitting surgical mask. In terms of respirator types, you know, traditionally, we've used disposable N95s or up to N99s, you know, this again, because of the supply chain issues, you know, we've had to come up with policies to allow for extended use, wearing them from patient to patient to patient without removing or even reuse. We had a while that we were reprocessing ours. We were using UV light to clean them, get them back to the same person, you know, up to three or four times. Luckily, we're very happy we don't have to do that anymore. We have had to use non-medical N95s because that's what we could get at the time. So these were, and those are shown at the bottom there. They're not fluid resistant, and they're not, and some of them were valved. So we had to often wear surgical masks on top of it. And then, of course, the complicating thing is they're not interchangeable. Each model, you know, a few of them might be interchangeable with others, but for the most part, each model type must be fit tested to be protective. So it becomes very complicated when you can get model A this month, but then, you know, that one runs out, and you can only get model B next month, you know, having the fit testing resources to go back and redo for everyone is really a challenge. We actually moved on to, you know, again, part of, because of the supply challenges, we moved to using elastomeric reusable respirators. Again, they're assigned per person, and they must be fit tested. That's one of our ICU nurses modeling. We call them wrappers. You know, they're nice in that they prevent, you know, kind of the frequent use of these disposable N95s, but they do obviously impede communication. And so, you know, we're working as our other supplies have gotten better, we're working at moving away from, but they were definitely very useful at the time to get us through kind of the supply crunch. Do you want to mention that many of those also have exhalation valves, and so therefore, while they protect the user really well, they do pose risk to people outside of the user who may not be wearing masks, which can also become very important if they're being used during procedures where you're wanting to have a sterile feel like putting in central lines. So the wearer needs to be aware of that exhalation valve on them. Yeah, thank you. So yeah, we do require them to have a surgical mask over them for sterile procedures. You know, the valved N95s have been evaluated and do seem to provide adequate source control, but there just really hasn't been an evaluation of these that I'm aware of. And then the last, of course, are the powered air purifying respirators, the PAPRs. You know, many different models are available. You don't need to do fit testing, but they are relatively expensive, and they need maintenance, charging, battery loss. You know, we had a great supply, and we're constantly, they're disappearing. They're, you know, or their batteries are no longer able to be found, or they're not charged. So it's a lot more maintenance involved. All right. And so I think, you know, what I kind of alluded to is, you know, back in June, you know, there became kind of a distinction between, you know, the traditional infection prevention guidance is, you know, if you're using a respirator, it's because you're using airborne precautions. The person's in a negative pressure room, and those two things are always linked. We don't use respirators in any other situation. But for COVID, you know, we've now moved to this place where we're using respirators really much beyond the need for negative pressure rooms. Part of that is because there simply aren't enough negative pressure rooms. And so, you know, there's this expectation that we're wearing, or we are wearing respirators much more broadly throughout the hospital. So, you know, we had spent many years trying to pare down our number of staff who needed fit testing, and now it's greatly expanded. And so the, you know, we, again, we, CDC recommends it's for all care of COVID-19 patients if you're in a setting, and if you're in a setting of substantial or high community transmission, which basically all of the United States still is at this point. They recommend using a fit-tested N95 for all AGPs, all higher-risk surgical procedures, so, you know, intubations or surgeries involving, you know, nose or pharynx or respiratory tract. And then others, they say other situations where additional risk factors are present. So that could be, you know, if you're in a situation where the ventilation is relatively poor, where people can't use source control. So that one's a little bit pretty vague. And then, you know, and you could even consider using respirators for all patient care or in specific units that have higher risk of transmission. So we have not moved to that point yet, but we are, you know, we are using them for all COVID care and then additional situations as needed. Have you, Kyle, have you moved toward, or where have you been with respirators? We're basically in the same place. We use them for all COVID care, and then for our, particularly our AGPs, we have them used, and that really is the ones that you're tracking there, but intubations, use of non-invasive, and a couple of other ones where we've asked people to use them in those situations. But I think we had the same experience you did with a large expanded use of N95s throughout the institution, or respirators throughout the institution, and the need to fit test those, and then the refit test as supply chain changed over time. All right, so I wanted to spend a few minutes on, you know, when people are recovering from COVID, how do you get them out of isolation? So, again, early on, we used a test-based strategy, which we found almost everybody continued to test positive. So we moved away from that to a symptom-based strategy, just because people remain PCR positive long past the time of contagious. And so, you know, now we are at a symptom-based, a symptom-based strategy is appropriate for most patients, which for 10 days, if they're not severely ill or immunocompromised, and they're afebrile, and their symptoms are improving. And I think it's important to realize that this is different from what's recommended now in the community, that it could be five days, and then five additional days of masking. So we've had patients question, like, why am I still in isolation? It's different than what's acceptable in the community. And then if someone is severely ill, and we'll talk about what that means in a moment, you could do, you know, still do at least 10 days and up to 20 days if they're severely ill, and as long as they're afebrile, and their symptoms are improving. Now, one thing that's new, and this just came out with the guidance that CDC released beginning of this month is, I think they released it actually middle of January, that if you have someone who's moderately or severely immunocompromised, they may remain contagious longer. And so they now recommend a test-based strategy with either PCR or antigen testing, starting at 20 days to remove those people from isolation. So we're in the process of implementing that, and I can say, you know, we've had a few patients that have met this criteria before, and they are often still positive at 20 days. So that will impact your ability to get people out of isolation and out of a COVID unit. And I think it's really important to hear the difference between a community isolation and healthcare isolation, because that's probably the most common question I get asked is why we're still doing something that is not the same for the community, but there are different guidance from the CDC for those situations. Yeah. And this, and the publication that just came out this month is much more clear about kind of the difference between community and hospital, and some of the rationale. So what does severely ill mean? So, you know, I think some of our IPs have said, well, if they're in the hospital, they must be severely ill. Well, we know that's not always the case, because some people, you know, there are people that are in the hospital because of COVID, and there's people that are in the hospital with COVID. And even some of the people that are because of COVID, their symptoms may be mild, so, relatively mild, so the specific criteria are listed here on the slide. I'm not going to read them all out, but basically, it's, you know, measure, different measurements of their respiratory capacity. Obviously, if they're in the ICU with respiratory failure, shock, or multi-organ failure, they would certainly be severe or critical of that patient. All right, sorry. And then one of the other comments that we get is, well, what does it mean if they're improving? So, you know, it says afebrile without the use of fever-lowering medications. Well, many patients are on pain, or they need pain control, and many of those pain-control medicines include acetaminophen. And so I think you have to, you know, you have to, you know, have some flexibility around, you know, why are they really receiving this medication? You know, COVID doesn't tend to cause long, you know, days and weeks of fever. You know, even if they have fever in the beginning, it's not like someone who's, you know, being treated for endocarditis who can remain febrile for a really long time. That isn't typically what COVID does. And certainly people, you know, especially like in our hematology, oncology setting, they can have many non-COVID causes of fever that may persist for some time. So I think you always have to take the clinical situation of the patient into account, as opposed to strictly applying the definition sometimes. And then, you know, and sometimes it's even difficult to know if their symptoms are improved. You know, they specifically mentioned cough and shortness of breath, but if you have someone who's on a ventilator, you know, it may be difficult to differentiate lung damage from COVID versus an ongoing COVID infection. So they may still be on the ventilator, but still be able to come off of isolation because, you know, we don't think that they still have active infection. How are you managing that in your ICU? Yeah, so our ICU patients tend to be, we tend to use a test-based strategy for clearance. That evolves over time, because I think it is really difficult to know which of those patients are ready for clearance and which are not. It's so much easier on the severely ill as opposed to the critically ill to figure out exactly when they are. And almost all the ICU patients then of course fall into that 20-day category. So that sometimes helps out because some of the ones that have slightly milder illness, you know, it's pretty clear that their P to F ratio is coming down, their infiltrates are still persisting, their fever's recovered, and so we use all those factors together. All right. And I wanted to add something about exposed patients, just because it's a little bit different than the infected patients. So again, isolation is used for people who have an infection, and quarantine is used for people who are exposed to the infection. But those terms are often used kind of interchangeably. But if you have patients that have had close contact with another COVID patient, so say they were roommates, we do recommend that they be put into isolation themselves, transmission-based precautions, either for 10 days from their last exposure, or you can get them out earlier at seven days as long as you test them within 48 hours, so day five or six, and they test negative. So we've been implementing that to try to get some of these exposed patients out of isolation sooner, free up some bed. You obviously wouldn't want to cohort exposed patients together, because one might have COVID, one might not. And they do say you can potentially think about excluding people that are up-to-date on their vaccinations. We have not excluded them. Or people that have had COVID themselves in the last 90 days, because they're unlikely to be reinfected after an exposure. Yeah, I think we've been in the same area. I think with Omicron, we have not adopted the asymptomatics that are up-to-date with their vaccinations, because we've seen the breakthrough infections with that. Though prior to Omicron, we were definitely considering that process. All right, well, I think this is the end of our prepared slides, so we'll both be happy to take questions. Thank you both, it was absolutely wonderful. I don't see any questions in the question box yet, but I do have some questions for you. For those who are still joining us, if you have a question for either Dr. Drees or Dr. Infa, please put it in the question box, and I'll be happy to relay that to them. But I do have a couple of things that I just found very interesting in the presentation, and hope we can maybe discuss. So it was interesting to see how different the World Health Organization and the CDC differ with regards to what's an AGP. So at your institutions, what do you prioritize as these procedures, given the difference in guidance that we have? Well, so we mostly based our recommendations off the CDC list. For the most part, they're actually pretty similar. The ones where we really struggled with were high flow nasal oxygen and nebulizer treatments. And nebulizer I know is stated that it's possible, but the data is not really definitive. So our respiratory therapists actually helped out a lot by, they kind of reviewed the literature in detail and in terms of what they could determine. And we decided that for us, a nebulizer was not an AGP, and neither was high flow nasal oxygen. It did take a lot of communication with staff to make them feel comfortable with that. But those particular ones, we left off the list. And that kind of brings me to the next question for either one of you. I know there was a lot of concern about nebulizers up front. I know we shifted a lot of things to some more expensive MDIs, which can be very difficult on budgets. So are your emergency rooms or even your ICUs, are they now using nebulizers or are you still using MDIs? What do you think is best for these patients? So we use a lot of nebulizers. They're actually, I mean, if people have really high concerns, there are some nebulizers that have some electrostatic shields on them to decrease the aerosolization. And so there are some products on them that have been marketed to further reduce any concern. But I think one of the things that people need to think about is that patients that are having breathing difficulties may have a challenge coordinating the use of MDIs, as well as generating enough truly, the inspiratory force to get the medication from the MDI to the areas where it needs to be delivered. So I think you have to think about what's gonna be best for the patient as well. I think there are some patients where MDIs work really well and can be used. And we've actually done that at times due to problems getting enough nebulized solution for these patients. And so you have to kind of balance also your supply chain for the medications. But we definitely have, we definitely pulled away from MDIs for a long time, particularly on our acute care floors, but we're back to using both nebulizers and MDIs based on patient characteristics. So our next question comes from the audience as well. Sometimes we have patients that we just need to keep a closer eye on and maybe not necessarily critically ill. We have the nice big window door available to us. And so the question is, does the door always need to be closed, particularly if they're just in quarantine rather than isolation? If you have patients that are at increased risk for falls, who are just worried about it, is there any opportunity to leave the door open for certain patients? Yeah, I mean, I think that was one of the things that was really confusing early on. Because if we're saying it's a droplet transmitted disease, then there's no reason to have the doors closed. But again, there was that uncertainty. What extent was it airborne and at what distance? So I think you have to obviously balance the safety of the patient. And so we, again, if we felt it was safe to close the doors, we recommended that. But if there was a fall risk or other risks where they really just needed to have closer eyes on the patient, we did allow them to have the doors open. Obviously not for the aerosol-generating procedures or patients who truly needed to be under pressure by the patients. I think this is an area where people should also look at things that are available to them to monitor patients, as Dr. Drees talked about before. There are a lot of platforms now for doing remote patient monitoring for using video. We've done that actually for some of our patients who need sitters as well, because it's hard to get patient companions. Placing a patient companion in a room with someone who has COVID is a double challenge. And so that's an area where people in telemedicine might be a source, but there are also some platforms specifically designed for remote patient monitoring that people should investigate to have both the engineering control of the door closed, but also still be able to monitor the patient closely. Dr. Infield, that's exactly what we do at my institution. It's been very successful and it's a great resource to have. I want to shift gears here for a question from one of our participants who wants to know about fit testing with N95 masks. They're asking you what recommendations do you have for developing countries? Although I would even say rural areas within the United States that just don't have the ability to do fit testing. What's the best practice for using these N95s? Yeah, no, I mean, that's a challenge. I think, you know, there's obviously quantitative and qualitative fit testing, you know, and to be honest, the majority of people do pass, but I think, you know, one of the things about, you know, when we think about annual fit testing, in some ways we feel like, you know, it's not a great use of resources because people's faces don't change that much, but it is an opportunity to go back and re-educate people on how to adopt it correctly. And I think most importantly, how to do a seal check. So if I didn't have access to any fit testing at all, I would certainly at least make sure that people knew how to do a seal check every time they don a respirator so that you are holding it close to the face and making sure that there's no air moving in and out. And that, you know, hopefully you have more than one model available so that if people can't really get that seal check on a certain model, they can try it. I think that's very helpful because I tell you, I don't know the last time I did a fit test and it was before COVID. So I have an idea of what I need. How often do you feel that facilities need to conduct routine fit testing? I think it's probably changed since the start of the pandemic. Well, that is all regulated by OSHA. So, and they do require annual fit testing for whether using a disposable N95 or one of the elastomeric ones like I showed. So early in the pandemic, they did relax that because we knew we had to fit test so many new people that they said you didn't have to do it annually. Then I think over this past summer, that requirement went back into place. With Omicron, we did end up having to temporarily halt our annual fit testing, just because again, we needed to get so many new people fit tested. And you only have so many machines and so many, it's not hard to train a staff person to be able to fit test others, but you just need a body of someone who's available to do it. So that was a big career plus. Let's shift gears a little bit now to filters. Do you require the use of a HEPA filter for all of your mechanically and manually ventilated patients just to be able to protect the staff around them? Or is that something that you take on a case by case basis? So we actually had electrostatic filters in line with our events prior to COVID. It's been sort of our practice. So that was not really a major change for us. We do use it when we're bagging patients that we know have COVID immediately post or if it's an unknown, we'll do that. Is it really totally necessary? I think that that's probably a great academic debate. Does it really make the rest, does it help everyone in the room feel a lot more comfortable with what's going on? Yeah, and the incremental cost is not huge. And so that's, we've maintained that at our institution. Yeah, we do as well. And I think one thing we really, like when there are accidental vent disconnects, that was getting people really anxious because they're in the room and the vent got disconnected. But when we were able to say like, if it's past the filter, like you're not really being exposed. So I think they were very helpful to have in the institution. Now, once things finally settled down a little bit more than they have for the past two years, and we're able to start thinking about future facility planning and building, would you advocate for a higher percentage of negative pressure rooms in inpatient units? For example, this particular audience member wants to know what percentage of the rooms would you recommend that they be AIRR, sorry. So I think it's gonna be really hard to give you a percentage of rooms, but I will tell you that for us, even before the pandemic, we were limited in our rooms that could be AIRR rooms with almost every flu season, for mechanically ventilated patients. So our ICUs were always resource constrained in that situation. So what I would encourage, and I'm looking forward to hearing what Dr. Drees says, but what I would encourage people to do is look at their past utilization and then increase from there. I think that having the flexibility of having a room that can be used in that capacity does increase the number of different kinds of patients you can take care of. And so in the future, I'm hoping that that's where we will go is that a majority of rooms will have the ability to sit in that situation. And I agree, I don't really have anything different. I mean, we're still at the point where we're trying to get more private rooms, get people in shared rooms, which is a huge source of experience as well. And there's just so many building constraints for both of those issues. Yeah, that's very interesting for me to see kind of what the hospital of the future looks like and how they made us to adapt some of the things that we've learned and what our needs are for that. The next question from our audience is a little bit different. And as a pharmacist, this is one that I've had to deal with myself. They wanna know if you can speak more with the impact of locating the large volume IV pumps outside the rooms for patients with COVID. So we did not do that because we had a problem. So for the majority of rooms that we have COVID patients in, the distance between the door and the patient was significant and the supply chain issues to get pump tubing that would really accommodate that made it unfeasible, even though we've moved our ventilator control system outside of the room, because that was easy to facilitate. So I have no experience with that. I don't know if anyone else does either. Yeah, we did that a little bit. And honestly, like I'm not the one working in the ICU, so I can't really go into detail, but I know we definitely experimented with it. And to some extent we were able to implement it, but we had the same kind of, like at one point IV tubing was in terms of supply as well. I think it was limited. Yeah, it certainly is something we've done at our institution and runs into other risks with correct medication delivery and other infectious risks, depending on where that tube comes into contact with. So our other audience member wants to talk about nebulizers again, AGPs. They require a respirator, but not a negative pressure room for patients who are requiring those. And they allow a single room. The concern is staff confusion about who needs what. What's the best insight you can provide our audience about reassuring staff regarding which PPE is appropriate for one patient versus another? Yeah, I mean, that was honestly one of the biggest challenges with PPE is getting, because again, it was always, especially now as we're using respirators much more broadly, it used to be relatively straightforward. If there was an airborne isolation sign on the door, everyone had to wear a respirator. Now we had people using respirators for extended use. So they might be in a negative pressure room, but then they were going to a regular room, but they still have their respirator on. So other staff members would look in that room and see that patient or that healthcare provider with a respirator and like, well, don't I need a respirator? So I think having clear signage around what is required, and then it just took a lot of education in terms of don't base your need on what you see other people wearing in a given room, but based on the signage. And we actually had a way to, we flag every COVID positive patient in our EMR. So it's very transparent who the COVID patients are and therefore what PPE is needed to be used. And that comes up on people's handhelds. And so that makes it a little bit easier, but it's still, it's a lot of reassurance of just a lot of confidence and re-education. The signs I think are probably a very key component of all of that. So everything's all in one place. One audience member wants to know if you can just provide a little bit more clarification on de-escalation of isolation in critically ill patients. You know, talk a little bit more about, you know, what is better in terms of it being time-based, if that's always accessible, or if you really do need to integrate testing-based or can you do sort of a cycle threshold? Yeah, I mean, we're struggling with that right now. Mostly, we're mostly focused on our immune-compromised patients, but even then, you know, we don't currently have in-house antigen testing. Like we, everything's PCR. And so we've talked about, well, if we test with PCR at 20 days, the vast majority of people are going to still be positive. So do we look at cycle thresholds, which are very, you know, they're not really standardized across different instruments or even across the same instrument in different institutions. So there isn't any specific guidance about how to use cycle thresholds for this instance. So we're talking about, you know, implementing antigen testing, but that has its own problems, which is, you know, the rapid tests, you know, they have a different swab. They have a very short turnaround time, 15 minutes. If you can't just send the swab down to the lab, it will never get there in time to be accurate. So we're just working through some of those details right now. CDC doesn't state for critically ill patients that you have to do a test-based strategy. They say you can consider using a test-based strategy. We're still using the time-based strategy for our critically ill patients. And basically when it comes, when it gets close to 20 days, one of the infection preventionists really reviews the case in detail, determines, you know, they've determined that they meet that 20-day criteria, and then they'll look and see, like, are they still febrile? Are they improving? You know, if they're still on the vent, you know, what does the clinical team think is going on in terms of why they're still needing a ventilator? And does it seem like it's more of a chronic, you know, lung damage sort of issue, as opposed to like an active pneumonia, for example? So they'll kind of work back and forth with the team on a case-by-case basis. Yeah, I would say it ends up being a case-by-case discussion for many of the critically ill patients. And I think that it just speaks to the importance of good infection preventionists working alongside the primary team and hospital epidemiology to make good decisions. So I don't have a great answer at this point in time, so I think it's an area where we're still having active dialogue about what's best. And our last question for both of you involves the emergency room. Emergency rooms across the United States are overwhelmed right now. Sometimes even if there's beds in the hospital, you don't have the staff to necessarily get them to a bed. And so we're just having a lot of our patients remaining in the emergency room for longer durations of time, sometimes in the hallways. So are you seeing an increase in exposures, not necessarily transmissions, but just exposures because of this? And how are you handling the need to quarantine patients or staff that may have been exposed because of just the backlog of patients that we have in our emergency departments? Yeah, I mean, that's really tough. At one point, we obviously try to keep anyone who's being considered for COVID out of the hallways, if at all possible, and get them into the room. At one point, we really lost the ability to do contact tracing for staff because you just couldn't keep up. So we really focus on if they were roommates or not. But during the height of the Omicron surge, we had our ED physicians going out to the waiting rooms to evaluate patients, because there just wasn't room to bring them back. So yeah, it was very hard to keep track of any of the exposures at that point. Yeah, I think Dr. Dries said that it's a similar experience for us. All right, I thought you had, that was the last question, I lied. One just came through, and I think it's worth talking about. When do you start your 10 days? Some of our patients test positive out in the community before they reach us in the hospital. Some institutions are starting it when symptoms begin versus when they were testing. What's the best time to start it? So it's supposed to be day zero is the day that your symptoms started or the day that you tested positive, whichever was first. And then so 10 days starts the day after that. But again, implementing that is not always straightforward. People maybe aren't clear on exactly when their symptoms started, or they did a home test, but we don't really have documentation of it. So sometimes we just end up retesting and using that as day zero, it's not exact. This is where I think you have to be a good investigator. And I'm lucky to work in an academic medical center where sometimes the interns are the ones tracking down that home test or the test that was done someplace else and getting it into the record. You have to talk to the patients and really try to define that. But yeah, day zero is when symptoms start or the positive test. And unfortunately, sometimes what that means is exactly, they test when they come into the hospital and that's their day zero. Even though they had a test three days before at home, we can't identify that because we're pretty cautious about making sure that we have good documentation of that first, when day zero applies. Well, I wanna thank both of you. That concludes our question and answer session. So Dr. Enfield, Dr. Dries, thank you very much. And thank you to the audience for attending today. Again, this webcast is being recorded. The recording will be available to you within 24 to 48 hours. And to access it, please go to covid19.sccm.org backslash webcast. You can see that address for you on the slide. That concludes our presentation for today. Thank you. Thank you everybody.

COVID-19

infection control

PPE

hierarchy of controls

respirators

fit testing

negative pressure rooms

source control measures

patient flow