COVID-19 Clinical Care FAQs–Your Questions Answered

National emergencies often spark a surge in patient admissions—as seen with the current COVID-19 pandemic—which can quickly deplete medical resources, including the availability of essential staff. Emergency credentialing can support the increased and immediate need for providers, while still ensuring proper credentials and privileges for staff and maintaining regulatory compliance. When expedited credentialing is needed, medical staff are responsible for developing criteria for an expedited process, and in these circumstances the governing body may delegate its authority to finalize credentialing and privileging decisions. To be eligible for consideration for expedited credentialing or privileging, an applicant must have submitted a complete application. However, if a medical staff committee previously made a final recommendation that is adverse to the applicant or has limitations, the applicant is ineligible for the expedited process.

In our response, we summarized actions by federal agencies to ease restrictions on federal laws affecting healthcare facility and provider response to the pandemic, including:

• CMS waivers for Medicare and Medicaid participation and the CMS act Sheet
• Telehealth use CDC, Telehealth use ECRI article
• Emergency Medical Treatment and Labor Act
• Credentialing and privileging deadlines
  Other agencies have issued waivers, including OSHA with regard to respirator fit-testing and the HHS Office of Inspector General with regard to certain cost-sharing and fee-waiving decisions. This CDC planning guide is useful.

Before turning to donated supplies, an organization's first priority should be to preserve and extend the available supply of more traditionally procured supplies. Although there is little guidance about vetting the supplies, the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have provided some resources; they are somewhat tangential, concerning for instance, receiving cargo from affected countries. Several organizations are asking for donations of unopened/sealed, unused supplies in good condition that can be dropped off at designated sites or mailed to the organization in order to centralize receipt of donated goods. How to process these donated medical supplies is unclear; however, Cambridge Health Alliance indicates that "items will be delivered to our Central Storeroom, which will inspect and clean them and distribute them across our hospitals and primary care centers as needed.

We recommend working with the practice's local and/or state public health department for immediate assistance as a first option. The National Association of County and City Health Officials provides a searchable directory of local health departments on its website. Strategies for Optimizing the Supply of N95 Respirators: Crisis/Alternate Strategies, and recommendations for extended use and reuse of N95 respirators. See also the recording of ECRI's March 25, 2020, program COVID-19 and Medical Devices: Safe Respirator Usage When Supplies Are Short; around 18 minutes into the program, ECRI addresses considerations surrounding the N-95 respirator shortage. View a recording of the live-streamed lab webcast on safe respirator usage when supplies are short. ECRI is continuing to monitor the situation and will publish additional information on our COVID-19 Resource Center. Additional guidance from The Centers for Disease Control and Prevention (CDC) on Strategies for Optimizing the Supply of PPE.

When combined with real-time emergency response exercises, table top drills can enhance an organization's EP Provision 4 Training and Testing efforts. It is important to conduct simulations in-situ, that is, in the areas and in the manner in which you will need to physically react. As in sports, "practice like you will play." A collection of influenza, epidemic, and pandemic related training and exercise resources can be found at:

• ASPR TRACIE
• ASPR Tracie Mystery Drill Exercise

No, kiosks are high-touch areas, so it’s best to avoid the intentional use of high-touch check-in options.

Please see a complimentary evidence report on scrubs that will help address this question.

Ideally, care will be organized in a regional capacity with each facility doing their designated part. Decisions to continue or cease care delivery must be made very carefully and should take into account many factors that range from a provider's ability to provide medically-indicated and standards-based care, potential risk of harm to persons served, and the effects such a decision has on other providers and the community health system at large. In making such decisions, the potential for infection-based harm due to unavailability of specific PPE or safe substitutions should be weighed against the potential for patient harm by not treating other illnesses, etc. Closing could compound problems, both directing more patient volume to already stressed resources, and exposing patients who could have received care at a site with less risk. Some providers may consider the use of telemedicine for certain types of care. To help control the spread of the pandemic, the U.S. federal government recently loosened regulations regarding which electronic devices and platforms can be used to conduct telemedicine visits. See ECRI's recent Alert on telemedicine use.

It's great that you are establishing lines of communication with community leaders. Focusing on efficiencies and process improvement within your sphere of control will make forward progress together easier in the future.

• To help your first responders get started, visit HHS' ASRP TRACIE Resource Center. This is an excellent resource for the integration of provider emergency preparedness efforts with federal, state, and local EMS systems.
• Available resources include various EP plans, policies and procedures, drill and testing approaches, and other resources.

Currently, there is no published research in this area. Our team of medical librarians is continuously evaluating new information.

While ECRI does not have a definitive recommendation about limits for group activity size, social distancing practices are strongly recommended and encouraged. Various municipal, county, and state governments are setting size thresholds for group activities. Social distancing is being encouraged as a control measure. As of April 3, 2020, In the United States, no gatherings are acceptable in many places, and guidance states that people should only be in contact with those they live with, and at least 39 states have mandatory (or other) stay-at-home orders in place.

Please contact your local/state health department for test availability.

Active research is currently in progress. Please refer to the ECRI COVID-19 Resource Center for next steps.

Please refer to your local, regional and federal health department for recommendations. As of April 3, 2020, some travel restrictions are in place. Most non-essential travel is being discouraged and even prohibited. In some places, travelers are being required to self-quarantine for 14 days in their new locations.

Please refer to question directly above.

As is the case with many viruses, there are many determining factors that come into play about how long a virus can survive on surfaces including the type of surface (e.g., hard, soft, cloth), temperature, and humidity of the environment to name a few. While the World Health Organization (WHO) reports that current studies suggest that coronaviruses may persist on surfaces for a few hours or up to several days, evidence about SARS-CoV-2 continues to be gathered.

If you are mandated to screen for COVID-19 at entry points, then you must do so. But knowing the lack of efficacy of temperature screening and/or questionnaires, you may want to consider deploying the minimum amount of resources necessary to screen and focus on other measures to reduce infection risk as previously noted. Read ECRI's Clinical Evidence Assessments on Infrared Temperature Screening to Identify Potentially Infected Staff or Visitors Presenting to Healthcare Facilities during Infectious Disease Outbreaks and Safety of Extended Use and Reuse of N95 Respirators to learn more on the topic.

• Core body temperature of 100.4°F or 38°C is considered a fever. | - The temperature threshold for fever in individuals older than age 60 is lower: 99.6°F.
• Again, any temperature screening practice would identify only individuals with a fever, but not those who are infectious and asymptomatic. And this assumes the devices work accurately to detect temperature in the environment in which they are used.

Yes, we will look for evidence that addresses both questions. Read ECRI's Clinical Evidence Assessments on Infrared Temperature Screening to Identify Potentially Infected Staff or Visitors Presenting to Healthcare Facilities during Infectious Disease Outbreaks and Safety of Extended Use and Reuse of N95 Respirators to learn more on the topic.

Whether you decide to temperature screen involves considerations in addition to the evidence about how well these programs work.

• We want to ensure people do not have a false sense of security in thinking these programs effectively weed out infectious individuals.
• One important issue to consider is the resources you are putting into these screening programs, given their lack of efficacy. It can take a lot of resources to perform temperature screening as a part of an infection reduction strategy, and it doesn't really achieve the desired goal.
• Could these resources be better used somewhere else? There may be ways to better use finite resources, such as aggressive disinfection procedures in high traffic areas coming into your institution, ensuring social distancing at entry points, eliminating visitors, elective procedures, and reducing the number of people who need to enter your facilities.

Self-reporting of temperatures may be inaccurate because of variations in the devices used or how an individual takes his/her temperature. Contact thermometers with a cover provide the most accurate reading. Keep in mind you will miss at least half of those who are infected. With COVID-19, even one infectious person who enters your facility can cause an outbreak. Read ECRI's Clinical Evidence Assessment on Safety of Extended Use and Reuse of N95 Respirators to learn more on the topic.

It's an additional layering strategy, but whether it reduces risk is unclear because surgical mask materials vary, and the ability of SARS CoV2 microbes to penetrate masks or to escape and aerosolize when a person sneezes is unclear. We have seen data showing that virus ability to escape a mask varies greatly by mask model. Also, wearing them properly and avoiding touching the mask and face once donned affect efficacy. So consider what your goal is, the resources needed to achieve it, and whether evidence supports it. Read ECRI's Clinical Evidence Assessment on Infrared Temperature Screening to Identify Potentially Infected Staff or Visitors Presenting to Healthcare Facilities during Infectious Disease Outbreaks to learn more on the topic.

In all the studies examined, an oral thermometer was used as the standard reference—that is, the correct measure of a fever. The IR thermometer was the test device for which the diagnostic statistics were being evaluated. For IR devices, the ability to detect a fever is around 80%. So, the oral thermometer worked better but must have a cover, just like tympanic thermometers. But infected, asymptomatic individuals will not be identified, and data thus far indicate that up to half of people tested and found to have SARS CoV2 infection were asymptomatic. Having even one infected person come through who is believed to not be infected is a significant risk. During this pandemic, every person entering a facility should be treated as though they are infectious until effective methods are available to be able to determine who has immunity.

Tympanic thermometers with a cover provide a more accurate reading than non-contact thermometers.

Unless you use a disposable cover, contact devices have potential for disease transmission. In the published studies about mass screening programs, noncontact infrared (IR) thermometers were used along with questionnaires. Our report details the problems with those screening programs. Noncontact IR thermometers are not a risk for virus transmission unless the equipment becomes contaminated with virus and then comes in contact with a user. Contact thermometers are a risk, but the risk is lower when disposable covers are used. Even then, if the screener’s gloves have come into contact with the virus during temperature taking (e.g., from an infected person), they could transmit infection.

Our response applies not only to your setting, but to all healthcare facilities. We have had several questions about the proper cutoff temperature for determining when an individual has a fever. Core body temperature of 100.4° F or 38°C is considered a fever. The Centers for Disease Control and Prevention (CDC) recommend that any person with a temperature at or above 100.0°F should self-isolate. 100.0° F is a useful cutoff, but this will not prevent asymptomatic carriers of the COVID-19 infection from entering your facility, because screening would only identify individuals with a fever. Also, the fever threshold for individuals older than age 60 is lower: 99.6°F.

Contact thermometers provide a more accurate reading than noncontact thermometers. So, if you are using thermometers with disposable covers, you are reducing transmission risk, but understand the caveats about temperature screening overall.

ECRI researchers found that temperature screening programs using IR alone or with a questionnaire for mass screening are ineffective for detecting infected persons. Read ECRI's Clinical Evidence Assessment on the topic.

Yes, ECRI staff continues to focus its efforts on providing healthcare professionals and healthcare organizations with the most current information on COVID-19. Please visit ECRI's COVID-19 Response Center and Events page for new information and future webinars.