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Infection Prevention and Control Post-COVID-19 PHERecommendations for Health Care Professionals

Learning Objectives
1. Identify changes to post-COVID-19 infection prevention and control guidance
2. Explain the rationale for changes to post-COVID-19 infection prevention and control guidance
3. List strategies to maintain effective infection prevention and control practices after a public health emergency ends
1 Credit

The federal Public Health Emergency (PHE) for COVID-19 ends on May 11, 2023, which will prompt planned updates to data reporting and surveillance of SARS-CoV-2. As a result, the Centers for Disease Control and Prevention (CDC) has updated infection prevention and control recommendations for health care facilities, which were informed by these data.

In this town hall, hosted by CDC’s Project Firstline, CDC officials will review the updates to these recommendations and the infection control actions that continue to be effective at stopping the spread of respiratory viruses in health care. This town hall will also feature a panel of health care professionals that will discuss how they will operationalize these updated recommendations in their diverse facilities.

This is a live event that will occur on the date and time indicated above. Click the “RSVP” button above to proceed with event registration. If you cannot attend the live event, an on-demand recording will be available.

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Welcome to the Centers for Disease Control and Prevention's Project First Line Town Hall on the end of the COVID-19 Public Health Emergency, and what that means for infection prevention and control within health care facilities. Project Firstline provides innovative and accessible infection control education for all frontline health care professionals. This particular webinar is a joint effort between the Centers for Disease Control and Prevention, the American Medical Association and the Society for Healthcare Epidemiology of America.

I'm Erica Kaufman West, the Director of Infectious Diseases at the AMA. The Federal COVID-19 Public Health Emergency ended on May 11th, 2023. As a result, the CDC has updated select infection prevention and control recommendations for health care facilities, which had previously been informed by levels of SARS-COV2 transmission in the community. While surveillance and the data reporting may look different, we know COVID-19 is still a reality and that other respiratory viruses and infection risks need to be considered as well.

As healthcare workers, we can rely on proven strategies and existing IPC measures to keep our health care spaces safe for ourselves, our patients, and our fellow health care professionals. Today I'm honored to be joined by several leading experts in the field of infection prevention and control. Dr. Alexander Kallen is chief of the Prevention and Response Branch in the CDC'S Division of Healthcare Quality and Promotion.

His branch is responsible for responding to health care outbreaks and developing and implementing guidance to prevent healthcare associated infections and slow the spread of antibiotic resistant organisms. He's been at the CDC for 17 years. We also have Janet Glowicz with us today. Janet is a nurse and an infection preventionist at the CDC Division of Healthcare Quality Promotion. She has practiced infection prevention in a variety of health care settings.

At the CDC, Janet serves as the hand hygiene and health care setting subject matter expert and supports the Project Firstline program. She has frequently participated in onsite assessments of health care facilities in collaboration with the outbreak response team. Janet is a fellow of APIC and the immediate past president of the certification board of Infection Control and Epidemiology.

Our event today will focus on hearing from CDC officials and a distinguished panel of healthcare professionals with varying backgrounds and expertise. We understand that the day-to-day IPC work looks different for each of you listening, and we wanted to bring experts from the field who can speak to your specific questions. We have gathered questions from when you registered, and we will have our chat open to see what topics are top of mind today.

Let's hear first from Dr. Kallen on what the end of the public health emergency means and the updates to tho to those IPC recommendations. Dr. Kallen. Great. Thanks so much. Good afternoon everyone. I am just going to quickly cover some of the changes that were, can be found in the infection control guidance that were updated as a result of the end of the public health emergency.

So, most importantly, C D C will no longer be able to collect all the data necessary to publish the metric that we had previously used to inform some of our infection control recommendations, which was called community transmission levels. In addition, this metric as testing and people's response to the, to becoming infected has changed over time, has become less reliable. In addition, there's been a desire to broaden some of our recommendations to encompass a broader array of respiratory viruses beyond just SARS-COV-2.

So, in order, so in light of these changes, we, this required updates to several recommendations. One is the admission testing in nursing homes, recommendation, and also some changes to guidance on the facility-wide use of source control or masking. I do wanna point out that we have three main infection control documents. First is our infection control, our main infection control page, which is listed first.

That's where all the changes occurred. There weren't any changes made to our managing health care personnel with exposures or the mitigating staff shortages document. So into the changes. So again, these are the infection control recommendations that were linked previously to this community transmission metric that we will no longer be able to calculate. This includes the recommendation to test folks admitted to nursing homes at higher levels of community transmission.

This now, this recommendation now is that this will be done at the discretion of nursing homes as it is for other health care settings, and I'll, I would direct you to the guidance if you're interested in a broader discussion of that topic. Now, for source control or masking, there several things have not changed. CDC still recommends that even if a facility doesn't recommend masking for source control, that it allows individuals to use a mask or respirator based on personal preference.

This is, of course, informed by the perceived level of risk for infection based on the person's recent activities and their potential for developing severe disease If they're exposed, second, CDC continues to recommend source control or masking for people who have suspected or confirmed SARS-COV2 infection or other respiratory infections as part of respiratory hygiene and cough etiquette, and also those who have had close contact or higher risk exposure with someone as SARS-COV2, usually within 10 days after their exposure.

And it is also recommended when masking is recommended in the community, and more on that in a second. Now as far as broader masking, the current, the recommendation as I said is no longer linked to the community transmission metric where we previously recommended masking when community transmission levels were high in your county and it now is more aligned with CDC's core practices, which we'll hear about more in a minute. And, and really is recommended in several situations.

One is in a situation, if you're in a facility that's experiencing a SARS-COV2 outbreak, then universal source control should be considered as a mitigation measure until the outbreak is over, which is usually defined as about 14 days of no new cases. And it also can be used facility wide or targeted within a facility during periods of higher levels of community SARS-COV2 or other respiratory virus transmission. This could be targeted toward higher risk areas, so places like emergency departments or urgent care where you're more likely to come across someone with a respiratory viral infection or could be targeted to patients at higher risk for developing a severe illness, like including people who are moderately, severely immunocompromised.

I will point out that the second metric that was also used to, besides community transmission to guide the use of masking the community, which was the COVID community levels has also been replaced by the COVID-19 hospital admission levels. This metric just replaces one for one, the CCLs and again would recommend and is available on the COVID data tracker, CDC's COVID data tracker. This, when COVID hospital admission levels are high, then the general recommendation for CDC is masking within the community, and of course, if masking is recommended in the community, would also be recommended in health care settings.

In addition, some of you are in jurisdictions that their public health authorities also have recommendations specific to their jurisdiction, and those would supersede these recommendations. So facilities should consider doing a risk assessment to identify themetrics and situations in which masking might be recommended in their facilities. And these are just a list of some of the things that should be considered when making those decisions, including the types of patients cared for, the facility, input from stakeholders, consideration of aligning with other facilities in the jurisdiction, and also what data sources are available to make decisions.

Some things that we have heard that other, that folk, how this is being operationalized in some facilities, and I know you'll hear more from our expert panel on this, upcoming, is considering the use of masks during the typical respiratory virus season. Again, this could be targeted or facility wide. And again, that's generally from October till April. Again, when COVID hospital admission levels, which is the metrics that is used to define masking in or used to help identify when masking in the community is useful when that's high, which is defined as greater than 20 new COVID-19 admissions per 100,000 population over the last seven days.

That would be also a situation when masking is recommended. And of course, the COVID hospital admission levels is available in the COVID data tractor and is the one metric that is still available for now, at least at the county level. In addition, there's a number of other data sources that are available on the CDC website to help inform decisions and include some of the ones listed below. I will point out, however, that none of these are available at the county level and all of the, and all of them have some limitations and less data to support them than was available for the community transmission levels that were previously recommended.

So just a few examples of the data that are available to you to help you inform your decisions includes the RSV-NET or the Respiratory Virus Hospitalization Surveillance Network. This provides national level incidence rates for hospitalizations for three respiratory viruses, including influenza, RSV, and SARS-COV2. And it's based on reporting from select counties in 12 states. As you can see, you get a national kind of trend level for each of the respiratory viruses as well as the combined of the three.

And if you're in one of the 12 states that has, provides data, you can actually get data for those surveillance areas within those states as well. The National Emergency Department Visits for COVID-19, influenza and RSV system provides weekly national counts for ED visits or emergency department visits for diagnoses of infection with any of the three respiratory viruses listed there, influenza, RSV, and SARS-COV2. As you can see on the picture on the left, the dark blue represents counties that have at least one facility contributing data in the first part of this year from January till April.

And as you can see, it's a fairly broad coverage. But again, on the right you can see this provides national level data for each of the individual respiratory viruses and combined, so not county level information. And lastly, I wanted to highlight the ILI net, which is the US outpatient Influenza-like Illness Surveillance Network. So this monitors the percent of outpatients with visits for influenza-like illness, which again is fever and a cough or sore throat.

So again, this could be represent a number of different viruses that might cause this syndrome. Jurisdictional specific data are compared to a baseline which is generated weekly based on the site's reporting to generate an ILI Activity Indicator Map, which shows the levels, which are based on a standard deviation from the mean of a non-influenza weeks. And that's available both at the state level, as you can see on the left, and also for some core base statistical areas.

So again, although this does provide more granular information down to a smaller areas like the state. It is important to recognize that this, you know, a one outbreak in one part of the state might cause a state to have a higher, be in a higher category than it, and might not be applicable across the entire state. So these are just some of the data sets that are available to help make decisions. And with that, let me turn it back to our moderator for our next speaker.

Thanks. Thank you Dr. Kallen. Now Janet Glowitz is gonna refresh our minds as to the CDC'S core IPC practices and their importance for continuing strong IPC work. Janet. Thank you Dr. Kallen.

And I will be talking about core practices at the end of the public health emergency. So as the COVID-19 public health emergency ends, we find ourselves in a new yet familiar space within health care. Each emerging infection that has spread to health care personnel has led to improvements in infection control practices, and there have been significant improvements in infection control during the pandemic. We must use this moment to ensure that infrastructure developed during the COVID-19 public health emergency stays in place as we encourage practices that have long been recommended by CDC.

Source control, as you know, is the use of respirators or well fitting face masks to prevent the spread of respiratory secretions, and it is included as a part of standard precautions and will remain an important intervention to decrease the spread of respiratory viruses. But before we discuss standard precautions, I'd like to review the core practices developed by HICPAC in 2014 and updated in 2022 during the pandemic. You will likely refer to the core practices along with the other IPC guidance as you respond to local conditions.

In contrast to changing guidelines during the emergency, the core practices have remained fundamental standards that are stable and not expected to change. The core practices are a collection of guideline elements compiled by HICPAC because of their inclusion in multiple guidelines. Of the eight core practices, four are particularly pertinent to this discussion. The first three core practices will be foundational to the success of infection control interventions, when and if local conditions indicate that the facility should return to broad-based source control measures.

This is needed during outbreaks of respiratory illnesses in the community as described, such as annual influenza outbreaks like Dr. Kallen said, October to April, during respiratory virus season. These three core practices, leadership support, education and training of health care personnel and patient, family and caregiver education underlies successful, effective implementation of infection control actions, including source control.

Senior and unit-based leaders are key decision makers whose responsibility for implementation should be based on current and historical local data. As the public health emergency ends leaders and those charged with implementing control measures should identify metrics or scenarios that align with the measures Dr. Kallan mentioned on which to base infection control decisions, particularly if broad-based infection control actions are needed.

Proactively identifying appropriate data sources and signals to initiate action will help them support facility-wide or unit-based actions and adherence. Early in the public health emergency healthcare personnel became emotionally exhausted by shortages of PPE. Training in the core practices should emphasize the stability of these practices and their role in preventing the spread of infections. The core practices are implemented situationally based on an individualized risk assessment and community risk.

When the local situation indicates high levels of transmission, clear communication of response guidance can help personnel understand that the community is working together to slow the spread of respiratory viruses. Facility specific protocols to inform healthcare personnel about community transmission levels and associated actions should be developed and discussed during safety huddles so that personnel remain aware of community-based infection risks.

Personnel should receive ongoing education about implementation of local strategies so that these are not perceived as changing guidelines, and they should have training and information needed to help them choose the right PPE at the right time. During the public health emergency, family members experienced exclusion from critical moments in the lives of their loved ones. Again, proactive communication that encourages the use of source control for individuals whose personal health conditions place them at greater risk due to respiratory infection and protocols for communicating broad-based source control when it is needed are examples of core practices.

Standard precautions within the core practices includes a broad suite of actions, some of which are listed here that protect patients and healthcare personnel. Each of these actions requires critical thinking about the planned care and reasonably anticipated risks. Health care personnel select needed PPE based on this individualized risk assessment. Project Firstline has spent the last year developing resources to help health care personnel recognize infection control risk.

Consistent use of standard precautions when the risk of transmission through the respiratory route is present should precede the use of broad-based source control. Successful implementation of standard precautions requires easy access to all elements of personal protective equipment in all areas where patients receive care. And infrastructure developed during the public health emergency, including access to needed supplies, should remain in place so that eye protection, respirators, and well fitting face mask, tissues, waist receptacles, and alcohol based scan sanitizer remain available to all working and all entering the facility Within standard precautions, respiratory etiquette is described as minimizing potential exposures.

Because the core practices apply to all healthcare settings and all types of facilities, variation in the precise methods of implementation is expected. Scalability of broad-based source control measures will vary depending on the circulating virus, the facility type and the population served. In long-term care facilities with frail elderly residents, it is much more likely that during times of in increased community transmission of respiratory viruses, a whole facility approach may be required.

In acute care settings, source control may be implemented as a whole health to action or targeted among populations with particular risks like the emergency department, NICUs, bone marrow transplant units, even trauma units. Relationships developed during the emergency phase of the pandemic often resulted in close collaboration between public health agencies and acute and long-term care facilities.

While national databases are available to assist with outbreak awareness, local public health may have access to state and county-based data that can be used to inform decisions about broad-based masking initiatives. Continued collaboration between facilities and health care associated infection programs within local and state health departments can provide situational awareness for facilities. So as we transition to hearing about how others are thinking through various ways of evaluating risk and implementing post public health emergency guidelines, please consider which elements might be most applicable to your facilities.

And as we move to the panel, I would like to pause and just personally thank all of the health care personnel that have provided care endured and helped guide others to enhance a safe health care, environment during the public health emergency. Thank you. Thank you, Janet, for reminding us of those key principles. While they might seem simple and obvious, it's so important to commit to these practices for the safety of all of our patients and ourselves.

As Alex mentioned, the updated recommendations provide a framework for healthcare facilities to implement IPC practices based on their individual circumstances. I wanna introduce our panel now so that we can hear how they are thinking about implementing the updates in their different facilities. As a reminder, if you have questions or comments, please join the chat and post them there. First, we have Ms.

Linda Behan, who is currently a consultant and president of Long-Term Care Infection Prevention LLC. She served as the corporate Vice President of Infection Prevention and Control for Genesis Healthcare and has been certified in IPC since 2011. Ms. Bean is a member of the faculty for AHCAs infection preventionist specialized training, contributing modules on antibiotic stewardship in nursing homes and water management plans.

Next we have Dr. Lynn Ramirez. Dr. Ramirez is a professor of pediatrics in the Division of Infectious Diseases and Global Health at UC-San Francisco. She's also the medical director of hospital epidemiology and infection control at the UCSF Benioff Children's Hospital. Dr. Erica Shenoy is medical director for infection control for Mass General Brigham Healthcare System.

She's an associate professor of medicine at Harvard Medical School and an infectious diseases physician at Massachusetts General Hospital, where she is an Associate Chief of the Infection Control Unit. Dr. Shenoy is a fellow of IDSA and SHEA. She's currently chair of SHEA's Public Policy and Government Affairs Committee and co-chair of the Sterilization and High Level Disinfection Guidelines Committee.

Lastly, we have Dr. Thomas Talbot, who is a professor of medicine at Vanderbilt University School of Medicine, and also serves as the Chief Hospital Epidemiologist for Vanderbilt University Medical Center in Nashville, Tennessee. Dr. Talbot has served as a member of the CDC's Healthcare Infection Control Practices Advisory Committee, and currently serves as the president-elect for SHEA.

I'd like to start this conversation with two general ideas. First, while thinking about the updates to IPC recommendations, we can talk through the thought processes or plans for implementing these updates within your facilities. And second, without the typical transmission levels that we're used to, we can look at what metrics or data each of you might use going forward and how to plan to make decisions about masking within your facilities.

I'd like to start with Linda. You work in long-term care and we've had a lot of questions about that sphere of health care facilities come through. Have you made any policy decisions and what factors went into making those decisions? Well, thank you. And it's good to be with everyone this afternoon. So when I think about the changes with the end of the public health emergency for long-term care, there's four main things that I've been thinking of.

So the first one is updating, it sounds very basic, but updating your policies and procedures that you've had for covid. You know, as we all know, surveyors will look to your policies and procedures when they are making visits to your centers. And so making sure that those reflect the current guidances that have been put out is absolutely vital. Also, you need to consider any state or local requirements that you have also.

So let's think about one of the changes, which is for admissions, new admissions and residents that leave the facility for 24 hours or greater. The guidance now says that testing is at the discretion of the facility. So what does that mean? So I think this is where it's very important that the facilities have discussions with their medical director and center leadership to say, what does this mean for us?

What are going to, what are the parameters that we're going to be using when we do have a new admission or someone does leave the facility. And whatever parameters or determinants that you decide, those have to be clearly spelled out in those policies and procedures. So everyone reacts the same way within this building. And making sure that you go through each P and P. Some facilities broke it down into very separate policy for testing, a policy for vaccinations.

So make sure you go through each one of those to make sure they reflect the current guidance. The second part is standard precautions. We just heard a discussion about standard precautions and the past few years we've been so focused on the precautions for COVID, whereas standard precautions supplies to everybody, right? So we really need to go back and really go back to the basics in a way and reeducate the staff on what exactly is standard precautions.

Unlike other precautions, let's say contact, where there's very distinct rules, right? You must put on a gown and gloves before you enter the room for any reason. Standard precautions requires critical thinking. What, you know, what are signs and symptoms or risk factors that this patient has, and therefore, what kind of PPE do I need to wear? And so it is that thought process that we need to ensure that our staff can really accomplish.

So when we go back and train the staff, what kind of training method are you going to use, right? So I think about if I walk up to a staff member and I wanna validate, did the training that I just did actually achieve what I wanted? I challenged people to use scenarios, rather than just walk up to a staff member and say, "so tell me what standard precautions is" and have them rattle off "well, I wash my hands and put on some gloves." Right?

Actually challenge them with some scenarios. So what if you go in the room and you're gonna do a wound dressing? Maybe vary the type of wounds you're talking about and the amount of drainage. Or maybe to insert a urinary catheter. So do it in scenario form and listen to their responses as to what kind of PPE they would be using. So I think that standard precautions is a really big one.

Third is source control as we've just been talking about. And so here again, since we know that the community transmission metric is gone, and Dr. Kallen mentioned several different metrics that we're available to look at, as well as your county may have some. I'd also encourage you to have discussions with your referring hospitals. And find out from them, is there maybe a weekly report that you would have access to that would reflect increasing admissions with viruses.

What about nurse liaisons as another way. Some of the nursing homes may have nurses that go into the hospitals and screen the patients prior to admission. Since those nurse liaisons are in the hospitals all the time, could they be the data collectors for you? And again, this is a big place where your medical director and having conversations as to, so at what point. Right. Is it as soon as we hear that the hospitals are having admissions.

Well, maybe if I have a vet unit or dialysis dense, I may wanna immediately put something in place. Is it two weeks of increasing rates and then it's for the whole facility? Again, those kind of determinants need to be made. And then finally really using your electronic health record, whether it's point click care, or some other form of electronic health record. For early risk recognition in your facility.

Looking at the 24 hour reports, new admissions, hospital transfer reports so that you can put those important IPC practices in place, whether it's source control or having to use transmission based precautions, vaccinations, or social distancing as other forms of containment. So those are the things that I'm thinking of at least right now.

Thank you for sharing those processes. I think it's important, you focused on the critical thinking aspect of IPC and I I think that's a great point to get back to. Dr. Shenoy, if we can turn to you and ask how you're thinking about implementing these updated IPC recommendations. Thank you and thanks to our CDC colleagues for laying it out and I think that what Linda said is so true and what I'm thinking about is we've had a week right to look at these new guidances, but in fact, when you look at the core practices and what standard precautions means, we've, we have the tools and we need to focus on those tools and perhaps reboot those tools and reeducate around them.

Because the last three years, we all know, have been very challenging on so many levels that coming back to those core practices and really understanding them and making standard precautions, not just something that you read on a piece of paper, but something we have muscle memory on can really do us very well. I think from a healthcare system perspective, many of the points that were already made are really important. I just wanna emphasize a few.

One is the choice of metric. And, you know, several have been raised and they all have pros and cons. And I think it, this is the time when we're fortunately in somewhat of a lull, right? We don't have much virus transmission out there. And many of these sorts of interventions are going to be triggered by increases in those in those metrics. So we've got some time to get this right and to do a few things.

One, choose metrics. Choose metrics, and then choose the actions associated with those metrics. So Linda was mentioning, you know, do you wait two weeks for this metric to be increasing before taking an action. And are those actions focused on particular patient populations or units? I think we have to be as crystal clear as we can in our discussions in our health system and laying it out so that when you have an increase in metric A by this amount, we know the next phase means X, Y, and Z.

I think the challenge is also with choosing what those X, Y, and Z things are. We know that with standard precautions we can get very far in terms of preventing transmission and risk, but there are many other things that we should be thinking about as we escalate in terms of the amount of community virus transmission that might be out there. And some of these were mentioned in terms of vaccination clinics.

You might also takes efforts to reduce presenteeism, which we clearly are concerned about. There may be laboratory testing strategies. And then the other piece of this, which kind of gets to the part about hospital admissions, focuses on the additional strain that the health care system might be feeling at various points in time. And so there may be parts of a plan that are somewhat tangential to IPC, but related, which deal with establishment of respiratory illness clinics or other ways to offload the health care system limited capacity that might present itself if we have a really high level of virus transmission resulting in a burden on the health care system.

And I think the second point I wanted to emphasize behind the metrics is the communication piece. I think when we are choosing a metric and an action or a series of actions, we have to be able to communicate very clearly the why of each intervention. And while there are some proposals to use more broad-based approaches, for example, you could say between these months, these are the strategies we're gonna use, including masking for source control.

Each season can be somewhat different. And I think having a targeted approach as a couple advantages, one of which is its, I think, easier and more straightforward to communicate a particular intervention for a particular scenario. And second, I think it does reemphasize the critical thinking part of the interventions that we have at our disposal and communicating that is not easy. I think most of the things can, things can break down in terms of communication.

But we've got some time between now and the fall to really work on that as a health care system and learn from each other. And I will pass it on to the next presenter. Thank you. Thank you, Erica. Dr. Talbot, we'll move on to you. Um, Dr.

Shenoy talked about, you know, different metrics that might be helpful and how different facilities might choose to focus on different pieces of data as they create, make their own decisions and create their own policies. What metrics do you think might be helpful for you in your facility to make some of those decisions? Yeah, thanks Erica, and thanks for inviting me to the panel. Great points about it by the speakers. I will give a disclaimer that I am in a part of the country that is actively antagonistic towards some of our interventions in terms of masking.

And so that definitely has colored our approach. And in fact, one of the guidances, "if the community starts masking, that's a trigger." That won't be a trigger in Tennessee. That just won't be. So we've had some experience all along, even before the changing guidance of using some other metrics to be really conservative in ratcheting down our precautions. We had some community hospitals that as soon as the community level, not transmission level, dropped, they stopped masking even though that was not per guidance.

And so we've been using metrics such as, you know, we will use things like the hospital admission metrics, the ILI metrics. We're fortunate to be a very large reference testing lab in the state and the region. So we have a very robust set of our own respiratory viral testing data that we can use to look at positivity rates and trigger those as well. I think Erica mentioned a really key point that we have used previously, we will continue to use is signs of strain on the health system.

So particularly our health care workers who are out, if we start to see that start to climb and we don't know the reasons, but if that starts to go up, we know that's a safety challenge. We know that we have to then stretch staffing. We know that that risks harm to our patients. That has been a metric in the past where we actually held back on releasing some interventions because we saw an initial surge health care workers going out.

We don't have a robust wastewater data set in our state. That could be a metric. And the last thing we have is, is not one that we'll rely on to trigger, but it is a safety net metric is that we have been tracking nosocomial COVID across our enterprise. So that is also a marker of, have you, you know, I'm a big believer in all the layers of Swiss cheese that we put in place, all these precautions. And if those line up in a hole happens and we have transmission.

Are we seeing those events? Are we seeing clusters of events using that? As you know, we don't wanna use that to guide turning on things, but it also tells you if you failed or need to do more strengthening of those layers of cheese. So that's kind of how we've approached even before this, and we'll continue. I don't know the exact number, you know, certain X andY, but that's it.

And I think the last point goes back to communication, that several have mentioned is we've been very clear when we relaxed our masking back on April 11th, that it was a relaxation, but it will come back. It's not, you know, it's not gone away forever. Now we had some happiness with no masking, but also people were bemoaning that that will come back. But it will need to, based on what activities happen in the community, that we need to strengthen our layers of Swiss cheese.

I always appreciate food metaphors at lunchtime, so thank you for that. Lastly, I'd like to turn to you, Dr. Ramirez, in thinking about the pediatric world. Is there anything with some of the things that you've talked about here with metrics and some of the different policy changes that others are looking at that, that you anticipate implementing in your facility? Yeah.

Thank you for that question. And thank you for the points made by Linda, Eric, and Tom. It very much resonates with some of the conversations we've had here at our facility. In terms of some of this pediatric specific considerations, I feel like we learned a lot with the respiratory viral surge that happened in the fall. The combination of first it was rhinovirus, RSV, flu, COVID. It was very reminiscent around some of the surges that we've had with COVID in the past.

So I think it, a really important point will be in developing some of the metrics for your institution to make sure you consider folding in some of the other respiratory viral pathogens because they can cause as heavy as a strain on your health system as COVID has, during the heights of of the surges that we've had in the past. So I think that's a really important consideration and there are a number of resources as Dr. Kallen outlined in his presentation that are available, have it be ILI surveillance, have it be RSV hospitalizations, and even thinking about some of the local metrics you might have available at your institution.

Like for example, we track the number of positive tests across our respiratory viral panel, so can get a sense of increases over time. We also have some availability around wastewater data beyond COVID, including for things like flu, that would also allowed us to get a sense of how we are trending over time. There's also a lot to be said around coordinating with other hospitals in your area, in terms of learning some of their trends and coordinating responses.

As well as more broadly, in your state as well. I think those are some of the pediatric specific recommendations. I did wanna go back and generally just talk about metrics. Cause I feel like that's is a big focus in this panel. And I think it's important to think about the metrics beyond, you know, when do you need to change your approach to source control, but using the metrics to think more broadly.

Have it be re-implementation of asymptomatic screening or, you know, for for admissions or high-risk procedures if your institution has done away with those. Also, needing to change your approach to visitor inpatient screening. I know at our institution we've reverted back to passive screening when in the past we are doing active screening at points of entry. So there are some things that might go along, as your institution develops different metrics.

I can share a little bit about some of the work that UCSF has done in the past. And I look forward to contributing to conversations that our institution will have moving forward with these changes. But in the past we developed different tier levels that were based on three things. Not surprisingly, we were using the number of new COVID cases per a hundred thousand over the last seven days. We will no longer have that available, as we all know.

The other thing we were looking at were the number of COVID admissions in our greater San Francisco Bay Area over the last seven days per a hundred thousand. And we were also looking, to Dr. Talbot's point, around the number of employees and learners who were reporting new COVID cases. And I think the utility around that third element is that it gives you a sense of the transmission going on in the community and that, you know, as the community rates go up, so, you know, so were the number of new cases amongst our employees.

So we use those three metrics to define three different tier levels. Moving forward, as our institution has those conversations, I think we can learn from that experience of tracking especially the second and the third metric in terms of how they correlated with some of the periods of increase covid transmission to help define our future tiers. In addition to what I mentioned, the coordination with other hospitals, our own lab data, as well as some of the wastewater information that we also have available.

Thank you, Lynn, for sharing some of those insights and your thoughts on some metrics that might be useful. I wanted toask, perhaps go back with Erica and ask about sort of some definitions. So the CDC's core practices, as Janet brought up before, looks at the broader source control, could be, you know, at a facility-wide level, or it could be at a more targeted approach for like high risk areas or high risk patients.

How would you think about maybe high risk in this context? I think one way to think about high risk is to think about what is the risk that an individual entering into your facility is actually infectious at that point. And so obviously that's driven by how much virus is out there in the community cuz people are coming in from the community. But there may be certain areas in your facility that those people come to.

So a very clear example might be if you're hosting respiratory virus illness clinics or some sort of way that you're trying to remove that patient population or target your evaluation and management of those patients. Another area might be an emergency department or urgent care or those kinds of locations. So I think if you're thinking where is the risk greatest of infection entering into our facility, that may be one way to think about it.

I think the other piece is that, you know, we live in our communities and I, and Tom, when you were talking about this, I was thinking, you know, much of what we can do is driven by what's happening in the community and the interventions that individuals are willing to take in the community. And so in some places, I think and also thinking back, I think it's very unlikely that we're gonna go back to masking in the community circa, you know, 2020, 2022.

I think it'll be a rare location where that might actually be possible. So that means that we're kind of all in the community together. And then I think ups the ante around targeting our interventions to the place where they're most likely to have the biggest impact. So that's how I'm thinking about risk. Great.

And Tom, since Erica brought you up, in looking, when thinking about inside the acute facility, are there areas within the acute facility that you might consider high risk from a, from the other standpoint, instead of people bringing it in, in the patients that are highest risk for perhaps advanced and more severe disease. And how might you target those particular areas? Yeah, so we, it goes back to the Swiss cheese. I know I'm bringing up food again, but, so we, when we scaled back our asymptomatic testing about two months ago, we did just this and look it, there were some units where you had a higher collection of immunocompromised patients, combined with ventilation standards, like positive pressure units, that if I had an asymptomatic case on that unit, I've lost a whole layer of Swiss cheese.

Right. And even those patients, if they're on other units, would have that ventilatory protection that they wouldn't have on those units. So that's how we approached it, was, you know, are any of our slices or interventions remarkably weakened? And if so, do we strengthen testing? So we actually still will continue to do asymptotic testing on our positive pressure units.

Today we still do that. Because we don't have that strengthening intervention of ventilation. So that's one way. I think it is a balance because you can argue there is some very high risk immunocompromised patients throughout the entire institution. And are they still protected? And I think it goes back to the messaging about really emphasizing our basic precautions.

Really the onus is on us to make sure we're not coming, you know, bringing in illness, coming work, visitors coming in, masking, hand hygiene if we need to, environmental cleaning, all those things to really communicate why we would do it differently in one area than the other. And we had that come up. One of our units was upset that they weren't included, and we had to have that conversation. And once we did that, that made sense to them and said, can you please strengthen these basic IP core practices, and that'll be, that'll be protective on your unit.

And that was helpful. Great. Thank you for that. Linda, if I could come back with you, within the long-term care sort of arena, there are a lot of different types of facilities. Do you see one particular area of the long-term care responding differently than another to these new guidelines? Yeah, I do.

I think that, you know, assisted living communities are more social, although they have medical, you know, their regulations are different. And so I think, you know, looking at them as a true community, they have, you know, people have the ability to go out, many of them in their cars, right? So, being out in the community and bringing disease in, no matter whether it's the RSV or the flu or the COVID. Right.

So I do think that assisted living, for example, or just plain residential facilities do need to strategize based on their specific resident populations. Yes. So I think what we're hearing is that a one size fits all is not gonna happen, now that we're post 2020. Going sort of back to definitions and maybe I can bring you in, Lynn. We know in the pediatric population and as well as the adult, that some patients are considered immunocompromised, some immunocompetent.

Is there a sort of standard that you use to differentiate what that immunocompromised population would be? Yeah, no, thanks for the question. I would say on the pediatric side, and I imagine that our, my adult colleagues will agree, a lot of it does. I don't think about that question as, you know, someone has a bone marrow transplant or a solid organ transplant. I feel like, you know, there are populations within on the pediatric side that don't have those traditional, you know, being high risk immune compromised that are high risk for bad outcomes, have it be our premature patients or patients with chronic lung disease.

So I think it's a little bit difficult and it kind of brings me back to the point Erica and Tom, that both you were making, that feel like, if you're in the, if you're inpatient, you probably are high risk. And, you know, using some of these traditional, traditional definitions of what that might encompass might be too narrow. In addition to recognizing that for those traditionally what's considered high risk patient populations, they're kind of sprinkled throughout our health system, you know, so we don't like, in terms of the way that many hospitals are set up, including ours, we have solid organ transplant patients throughout the hospital.

So I think it, I would say that, we need to be comprehensive in terms of how we think about patients who are high risk for bad outcomes, with not just COVID, but other respiratory viral pathogens. And I think understanding that because these patients are found through our health system, from the perspective of implementation, in terms of targeted versus universal approaches, that is something for your institution to consider.

Consider that balance. No, it's, this is a really good point. I would like to acknowledge that we're coming close to the end of the allotted hour limit. Now we did get started late, so we'll continue to stay on for a few extra minutes. I've got one more question I'd like to just sort of present to the panel that has come through the chat. But I did want to just acknowledge for the rest of the audience that we will stay on for a little bit longer, if you're able to as well.

So I, I'd like to sort of go through each of you, this particular question. How do you plan with all these changes and some nervousness with different staff and some apprehension about the PHE ending and new guidelines, trying to sort of make their way through different systems and it might look different from the hospital down the street to your facility. How do each of you plan to discuss this with your staff and even patients and their families, that things are changing and it's gonna look different than it has the last couple years?

Tom, I'll start with you. Yeah. I think as we mentioned earlier, I think just be very transparent with not just the changes, but the rationale and your thinking process. Because if people understand that, in the event we have to change down the road, you can then explain that. I think a lot of folks we've dealt with, you know, they worry about losing the masking as if that's the only intervention in place.

And I think we've gotten a little tunnel vision in infection prevention. Thinking about the benefits of masking, but not really thinking about the harms of masking in terms of connection with patients, with burnout, which I think are really real issues. So we have to be very transparent as to why we would scale that back and what are we gonna do to reinforce the other layers of cheese.

Again, I keep bringing up cheese, to protect them and protect our patients, and I think that's really important as you walk through and do any kind of change. Great. Erica, any other thoughts from your side? Well, I'll just add on that, two points. I think that rationale piece is. Also tied completely with standard precautions, and I feel like sometimes I'm a broken record when I'm teaching IPC cuz I love standard precautions.

It's incredibly powerful when you internalize it and understand it and then can apply it in all the different situations that on a daily basis, our healthcare personnel are faced with. And you never know what we are gonna run into when you're walking into a room, but if you've really internalized standard precautions, you can assess it and make the right decisions in that moment. So focusing on that is really powerful.

The second piece I have zero answer for, but I know it's gonna come up across the board, which is that we live in an ecosystem of many health care systems and patients come in between. And their, those patients, their families. It can be very confusing if they go into one place or another and there's a whole different set of rules. So part of me, while understanding that each setting is slightly different, there's a plea that we all collaborate, work together, talk to each other.

Because in, you know, Massachusetts and New Hampshire where our systems are practicing, one of the benefits of the pandemic was a shared approach. Shared system policies that I think communicated to our health care personnel, our patients and our visitors, "this is how we're approaching it." And when there's discrepancies around which may be legitimate, if you haven't explained it well, I think it can cause confusion.

It could lead to mistrust, and it just makes it harder to get what we need to get done. That's really a good point. Communication, I think remains one of the cornerstones of this whole process. Linda, any thoughts on your side about how to explain this to staff and patients with their families? Yeah, I think the pandemic brought about better communication channels in long-term care.

So, you know, communicating to your staff, using your huddles. Many instituted huddles and or staff meetings. Resident councils are a great place to talk with the residents about it. And also during the pandemic, family type meetings, whether it was via Zoom or other channels, were established. And so using those to communicate directly with the families would be very helpful.

And on the subject of families, Lynn we'll end with you. Pediatrics, you know, you have the patient, but you also have the family there. Any thoughts or tips for you on how to discuss these changes with the patients and their families? No. Yeah. Thank you for that question. And I wanna go back to a point that Erica made way at the beginning of this part of the meeting and that preparation and early communication is really important.

So I think we do have an opportunity to develop our tiers, develop our approach, and start communicating and making those those different tiers, that tiers quite transparent to our families, in addition to our health care workers. In that way, it kind of reminds me of how we approach visitation. It's like we're at level one. We're at level two. It was posted when you walked into the hospital.

So, setting the expectation early, that depending on what the trends are over time, we may need to dial up or dial down our approach to preventing transmission to the hospital, hospital setting, including re-instituting if you have source control. Great. Well, I wanna thank everybody on the panel for your insights and I'd like to wrap up this amazing event with some key takeaways.

While the COVID-19 PHE is over, core IPC principles remain the same. Source control is key. Hand hygiene and PPE use is fundamental, and optimizing engineering controls and air quality should remain in focus. We've also heard from several panelists some ways to think about COVID-19 related IPC, including some ways to use data and which metrics might be helpful to make decisions about masking going forward.

Weekly hospital admissions data will be available. And routine testing of staff and long-term care residents will be done at the discretion of the facility. And return to masking may very well be necessary based on metrics facilities determined to be important to them. Thanks to our distinguished panel for sharing such valuable insights with us, and thank you to SHEA for helping coordinate this panel. I wanna also thank our CDC guides, Alex and Janet for setting the context for this event.

A recording of this town hall will be available on this page shortly. We have drafted a PDF of information, websites and links related to our discussion today, that we hope you will find helpful. You can locate this at the top left corner above the video in the resources tab. In addition, you can go to amafirstline.org for more IPC information.

One last big thank you to our audience today for your questions and continued drive to learn more about infection prevention and control. We hope that you have found this town hall educational and interesting, and we hope you'll take away some key resources you can use to keep your patients, your staff, and yourself safe. By working together, we have the power to stop the transmission of infections in our facilities.

Activity Information

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Participation Statement: Upon completion of this activity, learners will receive a Participation Certificate.


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