COVID-19 Risk Management 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.
• See the full Ask HRC: Emergency Credentialing amid National Emergencies.

In our full 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 Fact 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.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act, signed into law (Public Law No. 116-136) by President Donald J. Trump on March 27, 2020, contains a provision (§ 3215) to give full immunity from liability to volunteer health professionals assisting with the COVID-19 emergency response. Summarizing the law's protections, the MPL Association, which represents medical professional liability companies and entities, listed the following conditions that must be in place for the volunteer health professional to receive full immunity (MPL Association):

• The act or omission involved the actual provision of healthcare services
• The act or omission occurred during the declared COVID-19 public health emergency
• The act or omission occurred while providing care to COVID-19 patients or suspected COVID-19 patients
• The services provided fell within the scope of the volunteer's licensure
• If the act or omission occurred in a state other than the state of licensure, the services fell within the scope of practice of a substantially similar health professional
• The volunteer was not compensated for the services provided
• There are exceptions to the protections. See more detailed information.

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.

• May consider removing the mask periodically and only when able to maintain social distancing, (The more on and off happens the more chance to self-inoculate.)
• Change the mask every 8 to 9 hours. Please follow CDC guidelines: https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
• Hypoallergenic option
• Homemade is not recommended
• Do non-health care team members gown up differently than healthcare provider staff?
• Staff who work in areas where PPE is required should follow the guidelines of the PPE required for the containment area. If you have an isolation room, then each person entering the isolation room would need to use the PPE required to enter the room. All staff should don PPE as appropriate for the room or area they are entering, and the procedures or tasks they are undertaking while in the area.

No, according to the CDC laundering suspected contaminated linens, clothing, etc. is no different than other type of washing procedures with laundry that is contaminated with potentially infectious waste, see procedure below:

• A temperature of at least 160°F (71°C)
• 25 minutes is commonly recommended for hot-water washing.
• The use of chlorine bleach assures an extra margin of safety.
• Please follow the CDC guidelines.

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.

• Send the employee home immediately if the employee is at work
• Encourage the employee to contact his or her medical provider for next steps.
• You should not disclose the identity of the employee who has a confirmed or suspected case.
• Do communicate to your staff about the confirmed or suspected case
• Ensure that appropriate cleaning and disinfecting of the work areas are taking place and reassure staff and residents of the steps taken.

ECRI emphasizes that, with the situation changing rapidly, organizations should stay abreast of recommendations on return-to-work scenarios from the Centers for Disease Control and Prevention (CDC). Importantly, relying on CDC's guidance helps organizations avoid the stigmatization or discrimination that could be present if they made determinations of risk based on race or country of origin. Likewise, the organization should be sure to preserve the confidentiality of staff or other individuals with confirmed COVID-19. Based on CDC's guidance, ECRI encourages organizations to take the following steps.

• Encourage sick workers to stay home
• Separate sick employees
• Emphasize respiratory etiquette and hand hygiene to all employees
• Enhance environmental cleaning procedures
• Emphasize employee travel precautions
• Manage employees exposed at work or home
• See the full Ask ECRI: Staff Isolation or Quarantine after COVID-19 Exposure response.

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

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.

Organizations should work with their legal counsel regarding state-specific requirements. In addition, if organizations are considering partnering with third parties (e.g., local churches, who may provide volunteer childcare), they should ensure they understand those third parties' insurance coverages and requirements. The organization should designate an individual who is responsible for program oversight, and that person should consider the following issues in establishing an emergency program.

• Staffing
• Security
• Enrollment and daily operations
• Environmental safety
• Testing and /or screening for change in workers’conditions
• Notification from workers who become ill
• See the full Ask ECRI: On-Site Childcare for Employees during COVID-19 Pandemic response.

• According to the CDC on what facilities should do now (Preparing for COVID-19: Long-term Care Facilities, Nursing Homes | CDC):
• Screen all HCP at the beginning of their shift for fever and respiratory symptoms
• Actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat.
• In accordance with previous CMS guidance, every individual regardless of reason entering a facility (including staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked.
• Here is an ECRI clinical evidence assessment regarding temperature screening.

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.

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.

• 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.

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.

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.

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.

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.

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.

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

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

ECRI recommends several resources that can help organizations conduct drills specific to outbreaks of communicable diseases. Examples include:

• The World Health Organization
• The New York City Department of Health and Mental Hygiene
• The California Department of Public Health
• See the full Ask ECRI: Tabletop Exercises for Outbreak Preparedness

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.