Answering Your Infection Prevention Questions Regarding COVID Reopening

On May 13, 2020, Infection Control Today^® and Metrex hosted an educational webinar titled “The Road to a New Normal: COVID-19’s Impact on Infection Prevention” with presenter Sharon Ward-Fore, MS, MT(ASCP), CIC. As part of the program, which you can register to watch for free in full here, Ward-Fore responded to submitted audience questions, but we received so many that she could not cover all topics in the allotted hour. In order to best serve our readers, ICT^® has compiled all the questions submitted during the webinar and Ward-Fore has provided answers here. Read below to get the answers to your most important questions regarding COVID-19’s impact on infection prevention and reopening efforts.

Q:  Do you have any recommendations on how often you should change HEPA filters in the room air purifiers in dental office surgical suites?

A:  HEPA filters should be changed per the manufacturer’s instructions.

Q:  I have seen that a pre-rinse in dental isn’t effective if it is Listerine for COVID, but a hydrogen peroxide is recommended. What are your thoughts?

A:  Only 1.5% hydrogen peroxide has been approved as a rinse by the American Dental Association (ADA) for COVID-19 because of its viricidal activity, commercial availability, and taste. The Listerine website states rinsing with Listerine does not kill COVID-19. “LISTERINE^® Antiseptic is a daily mouthwash, which has been proven to kill 99.9% of germs that cause bad breath, plaque and gingivitis. LISTERINE^® mouthwash has not been tested against the coronavirus and is not intended to prevent or treat COVID-19.” 

The ADA has a lot of great resources about how to safely re-open during the COVID-19 pandemic:

·       NEW | COVID-19 Hazard Assessment & Checklist

·       Return to Work Interim Guidance Toolkit (Updated 5/7/2020)

·       Online Course: Return to Work Interim Guidance Toolkit Q&A

·       COVID-19 Digital Events

Also look at the state-by-state mandates and recommendations:

And the US Centers for Disease Control and Prevention’s (CDC) Dental Settings page. 

Q:  You mentioned that healthcare staff should be tested for COVID “regularly.” Define "regularly.”

A:  Unfortunately, the Centers for Medicare & Medicaid Services does not define “regularly” but did state that as testing becomes more available, healthcare providers (HCP) at the highest level of risk should be tested. Testing availability in your area will help determine frequency along with discussions with HR and other policy makers in your institution. Also, “regular” testing comes with some caveats. Here is a good article that talks about testing HCP-“Testing Healthcare Workers for COVID-19: Issues and Challenges.”

Also, it is important to keep in mind that if you test negative for COVID-19, you are probably not infected at this time. However, testing negative at the time of the test does not ensure that you will not come into contact with the virus and become infected after the test is administered. Additionally, it can take up to 14 days after exposure for illness to occur. If you have been exposed, you might test positive at a later time. Continue to practice all protective measures, including practicing social distancing, washing your hands often, avoiding touching your face, and avoiding large social gatherings according to local guidance. As long as the virus that causes COVID-19 is spreading in your community, continue to follow guidance from your state and local health departments.

Q:  Is a gown required for an overnight sleep study for a sleep tech?

A:  Unless the sleep study is urgent/emergent, you should not be providing care for a patient positive for COVID-19. The use of BiPAP/CPAP is considered an aerosol-generating procedure. There is some concern that using BiPAP/CPAP could spread the virus through the exhalation port, which allows carbon dioxide to escape from the mask. This port may also release smaller virus-containing particles as “aerosols,” which can remain suspended in the air for a few hours, so full personal protective equipment (PPE) with an N95 mask, and a negative air flow room, if available, is recommended if you enter the room of a COVID-positive patient during the sleep study.

Q:  You mentioned temperature screening patients when they enter a facility. What would you recommend as proper PPE for the staff members performing the task of taking the temperature?

A:  Remember, you are re-opening to provide care to non-COVID patients unless you are equipped to provide care for COVID-positive patients. Prior to having patients enter your facility, try to ask screening questions about symptoms-fever, cough, shortness of breath-and ask patients to arrive wearing a face mask. Follow recommended infection control practices to prevent transmission of infectious agents. For temperature screening of asymptomatic patients, I recommend staff wear a face mask or surgical mask, eye protection (face shield/goggles), gloves, and perform hand hygiene. For symptomatic patients, I recommend an N95 mask (if available), gown, gloves, and hand hygiene.

Q:  What resource are you using for the adaptation to PPE usage for endemic methicillin-resistantStaphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), etc.?

A:  CDC has released information about strategies to optimize the supply of isolation gowns. Healthcare facilities should refer to that guidance and implement the recommended strategies to optimize their current supply of gowns.

Q:  Is it required for all patients and staff to be tested in free-standing outpatient surgery centers?

A:  No, testing is not required but recommended where available. Screening of all patients prior to arrival to your facility, via phone telephone advice lines, patient portals, and online self-assessment tools, or calling and speaking with an office/clinic HCP (CDC Phone Advice Line Tools) is highly recommended. The American College of Surgeons has a checklist called “American College of Surgeons Post-COVID-19 Readiness Checklist for Resuming Surgery.” The checklist is organized into 2 parts: Part I addresses the "Core" facility items. Part II addresses the "surgery specific" items. 

Q:  Research is showing that contact precautions are not necessary for multidrug-resistant organisms (MDROs), and many hospitals have gone to no isolation precautions. Do you support this research?

A:  I think each hospital has to look at its own patient population and decide what their own policies are for implementing and removing precautions. However, the CDC still recommends the use of contact precautions in inpatient acute care settings for patients known to be colonized or infected with epidemiologically important MDROs including MRSA. I do believe we need to work harder to discontinue isolation precautions that meet the guidelines presented by the Society for Healthcare Epidemiology of America (SHEA).

Q:  When reusing gowns for COVID patients under investigation and in confirmed COVID-19 rooms with negative airflow vs negative pressure, is it appropriate to have the gown remain in the room (clean side out)?

A:  Disposable isolation gowns are not designed to be reused because the ties are usually broken when doffing them. Cloth gowns can be reused after laundering. Rather than reusing gowns, consider bundling patient care activities to conserve gowns. Donning a gown that has already been used can be tricky, and a source of contamination to the user.

Q:  How many times can you reprocess N95 masks?

A:  Follow CDC strategies for optimizing the supply of N95 respirators. 

Q:  Some research is saying 80% alcohol is not as effective. What are your thoughts?

A:  I’m not sure which alcohol (ethanol or isopropanol) this question is about, so I will explain how alcohol-based products, in general, work. Alcohols work by denaturing proteins, and proteins are denatured more quickly in the presence of water. Some bacteria are better eliminated with the use of a less concentrated alcohol because higher concentrations cause an external injury that forms a protective wall that shields these organisms, making the disinfectant unable to reach them.

Another reason for not using a very high concentration of alcohol is that alcohol solutions tend to evaporate quickly when applied to surfaces which then limits the contact time. Disinfectants rely on a contact time to be effective. The rate is similar for either isopropyl alcohol or ethyl alcohol, but the higher the concentration of alcohol, the quicker they will evaporate.

Q:  Are you using UV-C disinfection systems to kill pathogens in whole rooms?

A:  The use of ultraviolet light systems is becoming more widely used in healthcare facilities for disinfecting patient and operating rooms. At my former hospital, we were using UV-C as part of discharge cleaning for Candida auris patient rooms. We also used it for our VRE cohort rooms upon discharge. One thing to keep in mind with UV-C is that all items must still be cleaned prior to using UV-C because any bioburden present on surfaces will not be penetrated by UV-C light. It should only be used as an adjunct to thorough cleaning. At this time, the efficacy of UV light on COVID-19 is currently unknown.

Q:  What is the recommendation for what the infection growth rate should be before reopening?

A:  This information comes from COVIDACTNOW.org. The recommended infection growth rate should be 1.0 for 2 weeks prior to opening.

Q:  It has been reported that the COVID-19 virus is active in dust. What happens when floors are vacuumed? 

A:  The CDC specifically recommends the following process for cleaning carpets: 

For soft (porous) surfaces such as carpeted floor, rugs, and drapes, remove visible contamination if present and clean with appropriate cleaners indicated for use on these surfaces. After cleaning, use products with the EPA-approved emerging viral pathogen claims that are suitable for porous surfaces. 

The risk of transmitting or spreading SARS-CoV-2, the virus that causes COVID-19, during vacuuming is unknown. At this time, there are no reported cases of COVID-19 associated with vacuuming. If vacuuming is necessary or required in a school, business, or community facility that was used by a person with suspected or confirmed COVID-19, first follow the CDC recommendations for Cleaning and Disinfection for Community Facilities that apply, which includes a wait time of 24 hours, or as long as practical.

After cleaning and disinfection, the following recommendations may help reduce the risk to workers and other individuals when vacuuming:

·       Consider removing smaller rugs or carpets from the area completely, so there is less that needs to be vacuumed.

·       Use a vacuum equipped with a high-efficiency particulate air (HEPA) filter, if available.

·       Do not vacuum a room or space that has people in it. Wait until the room or space is empty to vacuum, such as at night, for common spaces, or during the day for private rooms.

·       Consider temporarily turning off room fans and the central HVAC system that services the room or space, so that particles that escape from vacuuming will not circulate throughout the facility. Make sure PPE is worn when changing vacuum filters – gloves, mask, eye protection.

Q:  I do electrolysis where 95% of patients are receiving the treatment to the lip or chin area. They are not able to wear a mask during the procedure, and I work within 6 inches of their faces. Is there a way to safely return to work if I cannot access enough N95 masks?

A:  Screen clients prior to scheduling an appointment, and only accept clients that have no signs or symptoms. Also ask they arrive masked. Consider a thermal thermometer to scan them upon arrival. You wear gloves, a mask, and face shield (preferred) or goggles (second choice); there is no need for an N95 mask, as you are providing care for non-COVID-positive patients ONLY. 

Q:  What studies can I use to show my hospitalist how long a patient is contagious?

A:  The time from exposure to symptom onset (known as the incubation period) is thought to be 3 to 14 days, although symptoms typically appear within 4 or 5 days after exposure.

We know that a person with COVID-19 may be contagious 48 to 72 hours before starting to experience symptoms. Emerging research suggests that people may actually be most likely to spread the virus to others during the 48 hours before they start to experience symptoms. 

Further reading:

·       Temporal dynamics in viral shedding and transmissibility of COVID-19

·       Comparative pathogenesis of COVID-19, MERS, and SARS in a nonhuman primate model

Q:  What precautions should a healthcare worker take when returning to their home?

A:  I found an interesting article in The New York Times that answers general questions about contamination. So little is known about COVID, but we do know the droplets can survive on surfaces. With COVID or any other potential exposure to a communicable disease, you should probably shower and change your clothes at work and bag your work clothes to bring home to wash separately from your other laundry. If you wear your work clothes home, remove your clothes as soon as possible prior to entering your home and wash them. Definitely change your shoes or, even better, dedicate a pair for work. If you wear your work clothes home, you might also consider wiping down your car, as COVID can live up to 3 days on plastic and steel. Until we know more, I would err on the side of caution.

Q:  Do you have any special recommendations for an inpatient psych unit? 

A:  Each facility will probably have its own policies and procedures, but the basics might be the same:

-Screen or test (where available) patients prior to admittance to the unit;

         -Try to have private patient rooms;

-Keep patients in their rooms as much as possible;

-Mask patients when leaving their rooms;

-Perform temperature monitoring at least every shift;

-In milieu areas, allow a reduced number of patients and require adherence to masking, social distancing, and hand hygiene with soap and water for patients;

-Increase cleaning in milieu areas and other areas patients may congregate;

-Move symptomatic patients off the unit as quickly as possible.

Q:  Is the testing of staff for antibodies or for acute illness?

A:  CDC has prioritized testing of staff for acute illness when symptoms are present.

Q:  I work at an outpatient hemodialysis center that has an isolation shift at the end of the day for COVID-positive patients and patients under investigation (PUI). We have LIMITED N95 masks. What PPE would you recommend for unknown/asymptomatic patients versus COVID-positive patients?

A:  According to CDC, all patients, regardless of symptoms, should put on a cloth face covering at check-in (if not already wearing) and keep it on until they leave the facility. If patients do not have a cloth face covering, a face mask or cloth face covering should be offered (if supplies allow). If the patient is unable to tolerate a cloth face covering, then they should be separated by at least 6 feet from the nearest patient station (in all directions). 

For PUI and positive COVID-19 patients, HCP should wear an N95, if available, and a gown, eye protection, and gloves. If an N95 is not available, a face mask may be used.

Q:  If the World Health Organization, CDC, and the Infectious Diseases Society of America say it is droplet isolation and a gown should be worn, why is the use of overalls/coveralls shown in pictures? 

A:  Coveralls may be used if there are no gowns available. Typically, isolation gowns are more readily available. Whichever you use, you should train your staff on the PPE specific to your facility.

Q:  There has been much discussion on aerosol-generating medical procedures (AGMP) vs non-AGMP procedures. What are your thoughts on performing bag valve mask ventilation (BVM) while wearing an N95 mask? Also, would cardiac compressions (CPR) be considered an AGMP without bagging?

A:  Make sure bag-valve masks and other ventilatory equipment are equipped with HEPA filters. Rapid sequence intubation with appropriate PPE is the preferred method of intubation. In general, aerosol-generating procedures (eg, bag-valve mask, nebulizers, non-invasive positive pressure ventilation) should be avoided per recommendations attributed to the Anesthesia Patient Safety Foundation and World Federation of Societies of Anesthesiologists. The CDC considers CPR an aerosol-generating procedure.

Q:  What PPE should be used for non-COVID visits knowing that there is asymptomatic transmission of COVID?

A:  You wear a face mask and eye protection. Patient wears a cloth mask or face mask.

Q:  If a staff member is COVID-19-positive, when can I reopen his personal office after cleaning and disinfection? 

A:  Consider severity of illness and the duration of time spent in the room while ill. If the staff member occupied the room for a long time while ill, you should keep the office door closed for at least 69 minutes, based on 6 air changes/hour (ACH) with removal of 99.9% of airborne contaminants, according to CDC.

Staff, wearing appropriate PPE (gown, gloves, mask, eye protection) may enter the office to clean it with an approved LIST N disinfectant.

If the staff member was not coughing or sneezing and only spent a few minutes in the office, the risk to anyone entering is greatly diminished. PPE needed to clean the room would be minimal-gloves, mask, eye protection if indicated on the disinfectant.

Q:  Should a terminal cleaning be performed after all visits of positive or highly suspected COVID patients?

A:  Yes, healthcare facilities should consider assigning daily cleaning and disinfection of high-touch surfaces to nursing personnel who will already be in the room providing care to the patient. If this responsibility is assigned to environmental services personnel, they should wear all recommended PPE when in the room. PPE should be removed upon leaving the room, immediately followed by performance of hand hygiene.

Q:  Do you have an opinion on the use of Air Ionizer Technology for disinfection.

A:  Air ionizers rely on the chemical properties of ions. Air ionizers create negative ions using electricity and then discharge them into the air. These negative ions attach to positively charged particles in the room, such as dust, bacteria, pollen, smoke, and other allergens. Ionizers can be less effective than HEPA air purifiers at completely removing allergens and other particles from the atmosphere. Evidence shows that air ionizerspurify the air of bacteria, dust, cigarette smoke, molds, soot, pollen, and household odors. This has a significant impact on people suffering from hay fever and other seasonal allergies.

Q:  Is it mandatory to test all contacts of a positive case by PCR test?

A:  No, not even recommended at this time due to lack of testing availability and resources for contact tracing. CDC states that “healthcare facilities should consider foregoing contact tracing in favor of universal source control for HCP and screening for fever and symptoms before every shift.”