COVID-19 Guidance for Outpatient Facilities

Guidance and responses were provided based on information known on 3/12/2020 and may become out of date. Guidance is being updated rapidly, so users should look to CDC and NE DHHS guidance for updates. COVID-19 Guidance for Outpatient Facilities

Dr. Salman Ashraf, MBBS and Kate Tyner, RN, BSN, CIC Nebraska ICAP Dr. Maureen Tierney, MD,MSc NE DHHS HAI-AR Nebraska Updates as of this Morning (March 11, 2020)

• UNMC: 2 in biocontainment • Active monitoring, self-isolation all returning travelers from all Level 3 countries • Persons under investigation (PUI), Negative SARS-CoV-2 testing: 47 Awaiting testing results 16 Positive cases 5 (2 are family members of case 1) US Cases->1000, 31 deaths CDC Infection Prevention Interim Guidance 3-10 Mode of transmission:

Early reports suggest person-to-person transmission most commonly happens during close exposure to a person infected with COVID-19, primarily via respiratory droplets produced when the infected person coughs or sneezes. Droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs of those within close proximity. The contribution of small respirable particles, sometimes called aerosols or droplet nuclei, to close proximity transmission is currently uncertain. However, airborne transmission from person- to-person over long distances is unlikely. Be prepared Stay informed. Monitor the CDC COVID-19 and your state + local health department website Develop or review your facility’s emergency plan Establish relationships with key healthcare and public health partners in your community Create an emergency contact list. Include the local or state health department

https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/steps-to-prepare.html Communication Communicate with your staff- include recommendations for best information (such as cdc.gov, local public health, trusted sources) and about facility plans Communicate with patients: changes to appointments, provision of non-urgent care via telephone. If you have a website or patient portal, use it to share recommendations and directions

https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/steps-to-prepare.html Call in or Info Lines

Nebraska Medicine If you are experiencing other symptoms of a respiratory illness, we ask that you call 800.922.0000 prior to appt or ER CHIhealth.com 8AM to 8PM Click link on Coronovirus link If answer questions suggestive of coronavirus exposure or symptoms You are directed to an MD or ANP Methodist Hot Line 24/7 402-815-7425 Protecting the workforce • Screen patients and visitors for symptoms of acute respiratory illness (fever, cough, difficulty breathing) before they enter your facility • Ensure proper use of personal protective equipment. HCW that come into contact with confirmed or possible COVID-19 patients should wear the recommended PPE • Encourage sick employees to stay home. Ensure sick leave policies are consistent with public health guidance and that employees are aware of the policies

https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/steps-to-prepare.html Screen Patients Before They Arrive When scheduling, instruct patients and persons that accompany them to – call ahead or inform healthcare personnel upon arrival if they have respiratory infection symptoms – Wear a facemask upon entry to contain cough – Adhere to respiratory hygiene and cough etiquette throughout the visit • Post signage • Make respiratory hygiene supplies available (tissues, waste bins, hand sanitizer) https://www.cdc.gov/flu/pdf/protect/cdc_cough.pdf Patient Flow

Nebraska Medicine has developed a door-to-door user guide applicable to outpatient settings. Multiple resources are listed and could be considered as templates for facility- specific plans.

NEBRASKAMED COVID19 PAGE: https://www.nebraskamed.com/COVID19 PPE training resources

• Use Standard Precautions, Contact Precautions, and Airborne Precautions and eye protection when caring for patients with confirmed or possible COVID-19

• Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19) • https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

• Practice how to properly don, use, and doff PPE in a manner to prevent self-contamination • https://repository.netecweb.org/files/original/990a7390ef46288fd7fe8df94bc2e2e4.pdf Supply Disruptions

Do NOT attempt to horde or stockpile PPE, disinfectants, or hand sanitizing products Do NOT attempt to reuse PPE unless indicated by national guidance DO anticipate that orders will take additional time to be filled. – Be proactive about reasonable par levels (monitor supplies routinely) – Consider entering supply orders earlier than usual to account for delay Strategies to limit use of PPE

Eliminate PPE waste – Bundle care in rooms where PPE is indicated – Use a buddy system (for example, plan to call for a HCW out of isolation to round up additional supplies as situation dictates) Exclude all healthcare personnel not directly involved in patient care Limit face-to-face healthcare personnel encounters with the patient Utilize telemedicine https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators- strategy/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Frespirator- supply-strategies.html Limited Capacity of N-95s

It is imperative that providers know and practice the strategies for preserving the supply of N95 respirators as outlined by the CDC https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html

• During times of limited access to respirators or facemasks, facilities could consider having HCP remove only gloves and gowns (if used) and perform hand hygiene between patients with the same diagnosis (e.g., confirmed COVID-19) while continuing to wear the same eye protection and respirator or facemask (i.e., extended use). • Risk of transmission from eye protection and facemasks during extended use is expected to be very low. HCP must take care not to touch their eye protection and respirator or facemask . • Eye protection and the respirator or facemask should be removed, and hand hygiene performed if they become damaged or soiled and when leaving the unit. Testing

Availability of Testing-Capacity Expanding

• NPHL is performing the CDC-approved test. • 20 specimens per run may be able to expand to about 100/day. Approval via LHD through the state DPH is necessary

• The University of Nebraska Medical Center has a separate test which is now available through their Regional Pathology Laboratory (RPL), for clinics and providers within the Nebraska Medicine/UNMC system. Currently limited to a similar capacity per day.

• LabCorp and Quest have announced the availability of commercial tests through their portals. Published turnaround time is 3-4 days. Any patient (+) for COVID-19 virus should be immediately reported to their local/state public health office. All such (+) tests are provisional pending confirmation at NPHL. Request the commercial lab send the specimen to NPHL for all positive tests Testing Risk Groups:

If you want to test someone potentially fitting the PUI definitions from the CDC that is requested to be tested must call their LHD who will contact one of the team at DHHS who makes the decision about testing. a) Major groups of PUIs are travelers returning from China, Italy, S.Korea, Iran, Japan and Hong Kong, Seattle, NYC, California, Taiwan, Thailand who develop symptoms b) Contact of a PUI or known case c) HCW with exposure (new guidance on levels of risk of HCWs d) Patients with severe pneumonia/ARDS without underlying cause after full work-up e) New PUI definition –next slide New CDC Person Under Investigation Definition

Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Decisions on which patients receive testing should be based on the local epidemiology of COVID- 19, as well as the clinical course of illness. Most patients with confirmed COVID-19 have developed fever1 and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing). Clinicians are strongly encouraged to test for other causes of respiratory illness, including infections such as influenza. CDC: Criteria to Guide Evaluation and Lab Testing for COVID-19

Additional Criteria to Guide Evaluation and Laboratory Testing for COVID-19. Priorities for testing may include:

1. Hospitalized patients who have signs and symptoms compatible with COVID-19 in order to inform decisions related to infection control. 2. Other symptomatic individuals such as, older adults (age ≥ 65 years) and individuals with chronic medical conditions and/or an immunocompromised state that may put them at higher risk for poor outcomes (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease). DHHS HAN 3-11-2020

Specimen Collection Advice for Clinics and EDs Evaluating Patients with Febrile Respiratory Illness

• Patients presenting to HCFs for evaluation of any febrile respiratory illness should be fitted with a surgical facemask upon arrival and should be segregated from other patients (e.g., immediately moved to an exam room). This is to prevent transmission of respiratory pathogens including flu and COVID-19. • If the clinical presentation and the epidemiologic risk factors create a HIGH index of suspicion of COVID-19 (this is a clinical judgement-further guidance above) personnel who collect NP (nasopharyngeal) swabs should don full personal protective equipment (PPE) prior to specimen collection. • N95 respirator, eye protection, disposable gloves, and a gown. • If N95 respirators or equivalent PPE are not available, the patient should be referred to a location where the person undertaking specimen collection has all CDC-recommended PPE.

A negative pressure room is not essential for testing. DHHS HAN 3-11-2020 If it is determined that the risk of COVID-19 is low • Facilities lacking a supply of N95 respirators should substitute a surgical mask on persons collecting the specimen. • Eye protection is also essential. If available, a face shield would be preferable to goggles. • At the time of specimen collection, the patient’s surgical facemask should be lowered sufficiently to expose the nares, and a proper swabbing should commence per the instructional video cited below. • The patient’s surgical facemask should be properly repositioned immediately upon completion of specimen collection. DHHS HAN 3-11-2020

Specimen Collection It remains CRITICALLY IMPORTANT that staff responsible for collecting nasopharyngeal (NP) swabs be thoroughly trained and strictly compliant with specimen collection protocols. Failure to collect a proper specimen could result in a FALSE NEGATIVE test which could have major consequences for controlling COVID-19. A training video can be found here: https://www.youtube.com/watch?v=hXohAo1d6tk

Use only synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain substances that inactivate some viruses and inhibit PCR testing. Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media. Refrigerate specimen at 2-8°C and ship overnight to CDC on ice pack.

Nasopharyngeal swab: Insert a swab into the nostril parallel to the palate. Leave the swab in place for a few seconds to absorb secretions. Resources (Testing)

Written instructions from NPHL and CDC on handling samples:  http://www.nphl.org/documents/NPHL%20Alert%20COVID- 19%20Collection%20and%20Handling%20in%20NE%20v2020%2 002%2012.pdf  https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines- clinical-specimens.html

Video for collecting a NP swab:  https://www.youtube.com/watch?v=hXohAo1d6tk  I think this is the best video- also shows proper PPE donning and doffing  https://www.youtube.com/watch?v=c20CfI-Cr8M Testing Sites NM-3 CHI -1 Aggressive Planning underway for other testing sites. Summary of Changes to the Interim IP Guidance

Updated PPE recommendations for the care of patients with known or suspected COVID-19: • Based on local and regional situational analysis of PPE supplies, facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand. Available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which pose the highest exposure risk to HCP. – Facemasks protect the wearer from splashes and sprays. – Respirators, which filter inspired air, offer respiratory protection. • When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19. • Eye protection, gown, and gloves continue to be recommended. – If there are shortages of gowns, they should be prioritized for aerosol-generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP. Between the Facilities Notify facilities prior to transferring a resident with an acute respiratory illness, including suspected or confirmed COVID-19, to a higher level of care. Transfer form: http://dhhs.ne.gov/HAI%20Documents/Interfacility%20Infection%20Con trol%20Transfer%20Form.pdf

Report any possible COVID-19 illness in residents and employees to the local health department Listing of the local health departments and contacts: http://dhhs.ne.gov/CHPM%20Documents/contacts.pdf Care provider screening for COVID-19 CDC Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19) https://www.cdc.gov/coronavirus/2019- ncov/hcp/guidance-risk-assesment-hcp.html. Table to identify risk category (can be found in document above) – see next slide

HCP in the high- or medium-risk category should undergo active monitoring, including restriction from work in any healthcare setting until 14 days after their last exposure.

HCP in the low-risk category should perform self- monitoring with delegated supervision until 14 days after the last potential exposure.

HCP in the no identifiable risk category do not require monitoring or restriction from work. Community transmission of COVID-19 in the United States has been reported in multiple areas. This development means some recommended actions (e.g., contact tracing and risk assessment of all potentially exposed HCP) are impractical for implementation by healthcare facilities. In the setting of community transmission, all HCP are at some risk for exposure to COVID-19, whether in the workplace or in the community. HCPs should report recognized exposures, regularly monitor themselves for fever and symptoms of respiratory infection and not report to work when ill.

For HCPs returning from travel - HCP should inform their facility’s occupational health program that they have had a community or travel-associated exposure. Add’l Guidance during “Community Transmission of COVID-19” When possible, manage mildly ill COVID-19 patients at home. Assess the patient’s ability to engage in home monitoring, the ability for safe isolation at home, and the risk of transmission in the patient’s home environment. Caregivers and sick persons should have clear instructions regarding home care and when and how to access the healthcare system for face-to-face care or urgent/emergency conditions. If possible, identify staff who can monitor those patients at home with daily “check-ins” using telephone calls, text, patient portals or other means. Engage local public health, home health services, and community organizations to assist with support services (such as delivery of food, medication and other goods) for those treated at home.

https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/guidance-hcf.html Add’l Guidance during “Community Transmission of COVID-19” Reschedule non-urgent outpatient visits as necessary. Consider reaching out to patients who may be a higher risk of COVID-19-related complications (e.g., elderly, those with medical co-morbidities, and potentially other persons who are at higher risk for complications from respiratory diseases, such as pregnant women) to ensure adherence to current medications and therapeutic regimens, confirm they have sufficient medication refills, and provide instructions to notify their provider by phone if they become ill. Consider accelerating the timing of high priority screening and intervention needs for the short-term, in anticipation of the possible need to manage an influx of COVID-19 patients in the weeks to come. Symptomatic patients who need to be seen in a clinical setting should be asked to call before they leave home, so staff are ready to receive them using appropriate infection control practices and personal protective equipment. Eliminate patient penalties for cancellations and missed appointments related to respiratory illness. https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/guidance-hcf.html Environmental Cleaning: General

Transmission of coronavirus in general occurs much more commonly through respiratory droplets than through fomites. Current evidence suggests that novel coronavirus may remain viable for hours to days on surfaces made from a variety of materials. Cleaning of visibly dirty surfaces followed by disinfection is a best practice measure for prevention of COVID-19 and other viral respiratory illnesses in community settings.

https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/cleaning-disinfection.html Environmental Cleaning/Medical Waste

• Routine cleaning and disinfection procedures are appropriate for COVID-19 in healthcare settings, that is frequent daily cleaning with an EPA-registered, hospital-grade disinfectant of commonly touched environmental surfaces to decrease environmental contamination. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control- recommendations.html • Medical waste (trash) coming from healthcare facilities treating COVID-2019 patients is no different than waste coming from facilities without COVID-19 patients. • CDC’s guidance states that management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures. • There is no evidence to suggest that facility waste needs any additional disinfection. Environmental Cleaning: PPE Selection

• HCP entering the room soon after a patient vacates the room should use respiratory protection • Restrict unprotected individuals, including HCP, from entering a vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles Airborne Contaminant Removal CDC Environmental Infection Control in Healthcare Facilities (2003)

Air Exchanges per hour Time (in minutes) required for Time (in minutes) required for removal 99% efficiency removal 99.9% efficiency

2 138 207 4 69 104 6 46 69 8 35 52 10 28 41

Values apply to an empty room with no aerosol-generating source. With a person present and generating aerosol, this table would not apply. Removal times will be longer in rooms or areas with imperfect mixing or air stagnation. Caution should be exercised in using this table in such situations.

https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1 Environmental Cleaning: Product Selection & Use EPA’s List N: Registered Antimicrobial Products for Use Against Novel Coronavirus SARS-CoV- 2, the Cause of COVID-19 Date: 03/03/2020 (link below) • Follow product label for contact time • Train all employees on proper disinfection practices: Environmental Cleaning in Healthcare Training Video Series https://www.epa.gov/sites/production/files/2020-03/documents/sars-cov-2-list_03-03-2020.pdf

• Especially recommend Part 7. All videos available in 4 languages Resource Summary

CDC COVID-19 Main page https://www.cdc.gov/coronavirus/2019-ncov/index.html CDC COVID-19 for Healthcare Professionals https://www.cdc.gov/coronavirus/2019- ncov/hcp/index.html Nebraska DHHS http://dhhs.ne.gov/Pages/Coronavirus.aspx Nebraska Medicine COVID19 page: https://www.nebraskamed.com/COVID19 Nebraska ICAP https://icap.nebraskamed.com/resources/ Infection Prevention and Control Office Hours

Monday – Friday 7:30 AM – 9:30 AM Central Time 2:00 PM -4:00 PM Central Time Call 402-552-2881 Questions and Answer Session

Use the QA box in the webinar platform to type a question. Questions will be read aloud by the moderator, in the order they are received

A transcript of the discussion will be made available on the ICAP website Panelists today are:

Dr. Salman Ashraf, MBBS Dr. Maureen Tierney, MD,MSc Kate Tyner, RN, BSN, CIC Ishrat Kamal-Ahmed, M.Sc., Ph.D Margaret Drake, MT(ASCP),CIC Teri Fitzgerald RN, BSN, CIC https://icap.nebraskamed.com/resources/ Nebraska DHHS HAI-AR and Nebraska ICAP

Outpatient facility call on COVID-19 3/12/2020

1. We had no COVID-19 prior to about November 2019. Given the rapid production of this test kit, do we have a sense of the sensitivity and specificity of testing for COVID-19? I am concerned the number of false positive could be significant particularly if as availability increases, they get applied to patients with mild or minimal symptoms. Dr. Tierney: Good question, Nebraska Public Health Lab - over 90% for both of those; Commercial lab is just being reported. 2. Can a patient test negative early in the exposure then test positive later? Dr. Tierney: Answer is yes, as found with first patients returning from Wuhan, found that if tested before they are symptomatic, they could show negative and later test positive when become symptomatic, so just become someone tests negative early, not sure won't be positive only. 3. If a patient calls ahead with suspicion of being exposed to COVID-19 and is having mild symptoms and able to manage it at home, is it acceptable to encourage them to stay home and self- quarantine, unless symptoms advance? Do we need to notify the health department of this, if they don't come to get tested? Dr. Tierney: 2 parts - if they have mild symptoms they can be managed at home, but if they have been exposed to a case, then they should call their local health dept. to find out whether and where they should go for a test. In reverse, if there is a case, local health department doing contact tracing, but this info may help the local health department 4. If we have a high suggestive case and call our Local Health Department will they have the information needed for us to get the specimen to the NPHL for testing? Dr. Tierney: All the local health departments should have info on how to get specimen to NPHL. NPHL website has instructions on how to test. By calling in ahead, you can get help you walk through this an alert the NPHL to use their statewide courier system to get the test processed more quickly. KT: If you believe your facility is one that would be testing patients; have the appropriate PPE and now is the time to look at training and prepare ahead of time instead of [trying to] react in the moment. 5. "Given that the common coronavirus(229E NL63 OC43 HKU1) are seasonal, and that the activity of these virus’ drop sharply, some can begin the second week of January, all begin to drop by the second week of March, is there any reason to believe that the COVID-19 strain would do anything else? Dr. Ashraf: I think it correct to at least hope that these virus will follow the other Coronavirus pattern and do the same; however, we are dealing with the unexpected, but we should be prepared that it may last longer. Dr. Tierney: MERS actually did not abate in warmer weather. I think that really aggressive community mitigation is really essential. Will be a lot of discussion about how we can do that. In places that have instituted aggressive mitigation like Singapore, etc., they really saw cases coming down. Need to be prepared for that; cancelling a large gathering, religious services, etc. is something we need to be prepared for. 6. In a related question, even if the activity of the virus drops off seasonally and soon, should we expect positive test numbers to continue to rise, perhaps dramatically, only because the number of tests being done would perhaps rise exponentially due to fears in the community?" Kate: No list yet, but also planning to have those testing locations listed when available, but all facilities need to be prepared to offer masks, PPE, etc., and have some degree of readiness. Dr. Tierney: if it is a patient with high suspicion and you don't now have appropriate PPE, then need to send them to a place. The Nebraska Medicine Public site will have the information available on testing sites. All that information is coming, but in the meantime, triage patients with respiratory illness, having them wear masks and if you have the appropriate PPE, you can do the tests (N95, PAPR) but if not, send them to a place where they have it. 7. Do we have the numbers and locations to the clinics doing the testing right now? Okay to filter patients that we triage by phone to these locations if we do not have the proper PPE to complete testing? Kate: No list yet, but also planning to have those testing locations listed when available, but all facilities need to be prepared to offer masks, PPE, etc., and have some degree of readiness. Dr. Tierney: if it is a patient with high suspicion and you don't now have appropriate PPE, then need to send them to a place. The Nebraska Medicine Public site will have the information available on testing sites. All that information is coming, but in the meantime, triage patients with respiratory illness, having them wear masks and if you have the appropriate PPE, you can do the tests (N95, PAPR) but if not, send them to a place where they have it. 8. What is a clinic to do if they have a suspected case, but do not have testing capabilities? See questions above; if don't have appropriate PPE for testing, send them to places where they do. 9. What is your recommendation for excluding staff who have traveled? Just if they've traveled to hot spots including the US states highly affected? I have many staff asking about where or if they can travel. Dr. Tierney: CDC has specific guidance on this; Kate noted that this is on the slide set with CDC strict criteria outlined. Dr. Ashraf: Non- essential travel should be avoided altogether. Other factors (a lot of nonessential and business travel already being cancelled). Decisions about other travel should be made case-by-case. Dr. Tierney pointed out other areas and countries where you will have to self-monitor or self-quarantine for 14 days on your return. Healthcare workers need to follow these same rules. 10. If a HCP/MD travels to an area of the United States with known COVID-19 cases, is it recommended that they self-quarantine for 14 days to ensure no s/s before returning to work? See response for #9 11. In outpatient clinics, do you recommend separating the clinic into well visits and ill visits to eliminate potential exposure. OR is it best to dedicate certain clinics for ill visits at this time Dr. Tierney: One of the issues here is to protect healthcare workers AND other patients. Start planning to potentially postpone all non-essential visits. May carry over to non-elective surgeries. Crucial that someone coming with travel history, symptoms, they need to enter with a mask on, and pre-calling and prescreening will help with that.

This concludes the questions and answers that were on the live call.

12. Is there any age related information that would be useful? I am unable to assess if the risk to Pediatric patients is different than that of the general population. Per the CDC https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/children-faq.html The symptoms of COVID-19 are similar in children and adults. However, children with confirmed COVID-19 have generally presented with mild symptoms. Reported symptoms in children include cold-like symptoms, such as fever, runny nose, and cough. Vomiting and diarrhea have also been reported. It’s not known yet whether some children may be at higher risk for severe illness, for example, children with underlying medical conditions and special healthcare needs. There is much more to be learned about how the disease impacts children. See this additional link from the American Academy of Pediatrics from 3/12/2020 https://www.aappublications.org/news/2020/03/12/coronavirus031220 Symptoms of COVID-19 in children include fever, cough, congestion, rhinorrhea and sore throat, according to Kate Woodworth, M.D., M.P.H., from the CDC's COVID-19 Response Maternal Child Health Team. Some have reported vomiting and diarrhea. Testing criteria for children are the same as adults. Clinicians should consider the presence of symptoms, travel history, contact with a confirmed COVID-19 patient and local epidemiology, and should rule out other potential causes of illness. 13. When stated that 20 tests are done per run, does that mean that only 20 tests are run a day? See slide 14 from the Webinar. 20 tests per day represents the Nebraska Public Health Lab (NPHL) and they may be able to expand to about 100 per day. Several other locations have capacity to run tests, including UNMC/Regional Pathology Laboratory, LabCorp, and Quest. All laboratories are trying to increase capacity. 14. If our facility doesn't have an N95 mask and the patient is high risk am I correct in saying that the patient needs to be transferred to CHI or Ne Med for testing? We are located close to the South Dakota boarder. Each facility should work with their local public health department when testing is considered and learn of the nearest testing site through that consultation. 15. Just for clarification, if our clinic has a low-moderate risk patient with fever and cough, are we supposed to test for influenza in our clinic prior to notifying/sending for COVID19 testing? Because we now have community spread and we continue to have testing supply and PPE shortage, we highly recommend that testing be limited to severely ill and hospitalized patients. If COVID-19 is suspected, clinic staff will be instructed to collect a nasopharyngeal (NP) swab for testing. This swab should first be tested for flu and common pathogens using the respiratory pathogen panel (RPP) and if negative, then the swab could be tested for the COVID-19 causing virus. After testing, if the patient is stable and would normally be discharged to home, it is acceptable to do so, even with tests pending. It is not recommended to keep patients in the clinic or ED if there is no clinical criteria for hospital admission. https://www.nebraskamed.com/for-providers/covid19/door-to-door-user-guide/after- collecting-the-specimen 16. What are the recommendations in Nebraska regarding large group gatherings at this time and in the next month or longer? Size of group? Governor Ricketts held a press conference on Friday 3/13 and discussed this: No groups larger than 250. CDC has just recommended moving to less than 50 people on 3/16. 17. Should we have any concern with our N-95 masks shipping from China being contaminated? No. Per the World Health Organization, the likelihood of an infected person contaminating commercial goods is low and the risk of catching the virus that causes COVID-19 from a package that has been moved, travelled, and exposed to different conditions and temperature is also low. https://www.who.int/news-room/q-a-detail/q-a-coronaviruses 18. If a patient is positive for COVID-19, are they immune or can they get the virus again. The immune response to Covid-19 is not yet understood. Patients with MERS-CoV infection are unlikely to be re-infected shortly after they recover, but it is not yet known whether similar immune protection will be observed for patients with Covid-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html 19. What is the percent of people with the disease who will have no symptoms? That is not clearly known, we know about 80-85% will have mild to moderate disease and 15-20% more severe. About 5% require hospitalization. No one knows the % of asymptomatic folks since widespread testing o asymptomatic populations have not been teste. 20. Should our screening questions for patient include 14 days or 1 month of travel high risk areas those areas included in the states and internationally? Also inlcuded exposed to a positive COVID- 19 case as well. 14 days CDC has this algorithm: https://www.cdc.gov/coronavirus/2019-ncov/downloads/public-health- management-decision-making.pdf CDC has this guidance for clinical criteria; https://www.cdc.gov/coronavirus/2019- ncov/hcp/clinical-criteria.html 21. If we have patients that have traveled to California, NYC or Seattle do they need to report to the health department? As of March 15, the CDC has extended travel restrictions to about 28 countries and counting-see this link. NE also considers travelers from NYC, Washington state and California as potential high risk. Please see updated information that will be coming out later today (Monday-3-16) on the NE DHHS website. 22. In the interest of rescheduling "non-essential" or "non-critical" appointments, as an ASC, should we require patients with a chronic cough, regardless of fever, to reschedule to keep from entering the building, or is the risk low enough to continue with the procedure in the absence of fever. (Presuming they have no knowledge of exposure to a COVID-19 confirmed or suspected patient). For now would put off elective procedures for anyone with a cough chronic or not. 23. Can this whole presentation and the LIVE ANSWERS TO THE QUESTIONS also be made available to all? Thanks very much for the very helpful presentation, highly appreciated. Yes, and you are very welcome. 24. What is the risk of transmission before symptoms develop -- For example, somebody has been in contact with somebody in isolation because they were exposed but this person does not have symptoms, should they take precautions or isolate for any reason? Individuals 25. If we have limited N95 masks and are not having multiple to get tested in a row, can we store the used N95 masks and reuse them? Similar to the extended use but it would involve taking the mask on and off. Guidance for the reuse of n-95 respirators are at: https://www.cdc.gov/coronavirus/2019- ncov/hcp/respirators-strategy/index.html The difference between extended use and reuse are defined in detail, with additional guidance at https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html

26. Is there a list of the testing locations as far as addresses that we can refer adults to

Nebraska Medicine, Bellevue Hospital

COVID-19 Info hotline and referral - 800-922-0000

CHI (Creighton University Medical Center Bergan Mercy, Immanuel Hospital, Lakeside, St. Elizabeth’s, St. Francis, Good Samaritan, and others)

https://www.chihealth.com/

coronavirus link 8am to 8 pm /Virtual Care 24/7

Methodist Health

Available 24/7 COVID-19 hotline 402-430-0759

Bryan Health

https://www.bryanhealth.com/

Available 24/7 COVID-19 hotline 402-481-0500

EZ Visit-if for coronavirus questions will be provided free of charge

27. Will you be typing up guidelines for staff that have traveled that we can refer to.... now that some states in the USA has been added? The risk assessment for healthcare workers is available at this link: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html There is no current requirement for reporting to public health about travel to specific US states. Current guidance for Nebraskans to report according to the information at this link: http://dhhs.ne.gov/Pages/DHHS-Asking-Nebraskans-With-Travel-in-Past-14-Days-to-Countries- With-Community-Transmission-of-COVID-19-to-Contact-Local-HD.aspx 28. If a suspected case enters your facility, and it is discovered at the front desk they have active symptoms, we send them to another location for testing, but what concern should the clinic have about the possible residual [contamination]? Nebraska Medicine has created a nice guidance document that you could use as a reference or template: https://www.nebraskamed.com/for-providers/covid19/door-to-door-user- guide/cleaning-the-room Local wet-time for the disinfectant should be considered, as well as the length of time the room should be vacant, according to air exchanges (see slide 34) 29. What are the recommendations in Nebraska as far as large group gatherings? Group Size? See #16. 30. How do we get UNMC to place patient masks in all our buildings to allow patients to have access to masks before getting into outpatient clinics? The IP for the system was contacted. Masks are available at the front desks to all clinic areas. Unfortunately, when the masks were kept at entrances, they were being stolen.

31. I am from a small critical access hospital. We are screening for influenza and RSV at our lab. Per protocol we are then sending the sample to our reference lab for the RSV panel. Our reference lab does not perform RVP but forwards the sample to the Nebraska Medical Center. If that is negative, how does the sample get to NPHL for COVID-19 testing? This is a question for your contracted lab services provider. If there is a current protocol to send out respiratory pathogen panels to Nebraska Medical Center, then you should communicate with the contracted service provider that you need directions about how to trigger COVID-19 testing. 32. Is there a way to become a testing site? Yes-especially if you are going to use the commercial labs for testing. You can email Dr. Tierney. 33. Confused, the above question about if a HCP/MD travels to an area of the united states with known COVID-19 cases, is it recommended that they self-quarantine for 14 days to ensure no s/s before returning to work? this was answered yes... but I thought that they were to call occupational health and have a self screen and if no direct exposure or s/s that they could return to work. Does this apply to all staff that work with patients? please clarify thanks Please see response to number 9 above- this referred to the CDC risk assessment for healthcare workers providing care to positive patients. The risk assessment for healthcare workers is available at this link: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html There is no current requirement for reporting to public health about travel to specific US states. Current guidance for Nebraskans to report according to the information at this link (high risk international travel): http://dhhs.ne.gov/Pages/DHHS-Asking-Nebraskans-With-Travel-in-Past-14-Days-to-Countries- With-Community-Transmission-of-COVID-19-to-Contact-Local-HD.aspx 34. As a healthcare provider we haven’t been able to order masks for 2 weeks. How are patients supposed to mask up before coming in if Upper resp symptoms if we can’t even get masks It would be the expectation that clinic staff, wearing the appropriate PPE would meet the patient and provide them a mask 35. What meetings are on M-W-F at Noon? COVID-19 Update for Acute Care Hospitals Including Infection Prevention, Screening, and Testing Audience: Acute Care Facilities, IPs Purpose: To provide guidance on infection prevention for COVID-19 relating to acute care facilities Date: Monday, Wednesday, Friday (Reoccurring March 13th- April 3rd) Time: 12:00 – 1:00PM CT Dial-In Number: (415) 655-0003 Meeting Number: 924 627 702 WebEx Link: https://nvcn-cio.webex.com/nvcn- cio/j.php?MTID=md5fcd24134331584bdcd0bf6106059ad [nvcn-cio.webex.com] Meeting Password (for WebEx Link): ACU20 36. Can you repeat the phone number? Nebraska ICAP is taking questions at 402-552-2881