Masking Policy

PURPOSE

To ensure the health and safety of our patients, employees and visitors and provide written guidelines for the use of face masks.

SCOPE

This policy applies to healthcare personnel (HCP), paid and unpaid, working in NCH Healthcare System settings who have the potential for exposure from the community, staff, patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces or aerosols generated during certain medical procedures.

HCP include, but are not limited to, physicians, nurses, clinical technicians, therapists, technicians, emergency medical service personnel, pharmacists, laboratory personnel, contractual personnel and persons not directly involved in patient care (e.g., clerical, dietary, housekeeping, laundry, security, maintenance, billing, chaplains and volunteers) who may potentially be exposed to infectious agents that can be transmitted to and from HCP and patients.

In addition, this policy addresses masking for anyone entering the NCH Healthcare System’s facilities.

POLICY STATEMENT

This policy applies to all patients, visitors two years of age and older and employees. Facial covering and other PPE recommendations and/or requirements may be reviewed and reassessed with national and state standards, and state and federal laws, rules, requirements and regulations in the event of a community outbreak.

The practices in this policy will apply in the event the use of facial coverings is required at any NCH location. Unless otherwise noted, all other hospital policies, procedures and guidance that encourage or require the use of facial coverings are subject to the practices outlined in this document.

This Policy does not apply to the use of personal protective equipment that are recommended and/or required for chemical or physical hazards.

DEFINITIONS

1. Locations – Any of the hospital owned or leased, campuses, facilities, premises and locations.
2. Patients – Any person receiving treatment, care or other services.
3. Healthcare personnel – Any person that is a hospital employee, volunteer, student, resident, independent contractor, vendor, member of the Board of Hospital or any other person who provides any care, treatment or other services (including clinical staff and physicians) to patients at any NCH location.
4. Professional Staff Members – Any person who is an appointee to the Professional Staff, including Allied Health Professionals, Medical Staff, Associate Staff, Locum Tenens and any other person or provider with permanent or temporary privileges.
5. Visitors – Any person visiting any of the NCH locations that is not a Patient, Employee or Professional Staff Member.
6. Contractors – individuals approved to conduct work upon the request of NCH.
7. Masks – Any cloth or surgical face mask, a face shield or any other facial covering that covers the mouth and nose that is compliant with Hospital’s current masking.

PROCEDURE

Healthcare personnel

HCP to wear a mask when caring for a patient on transmission-based precautions or whose treating health care practitioner has diagnosed the patient with or confirmed a condition affecting the immune system in a manner which is known to increase risk of transmission of an infection from employees without signs or symptoms of infection to a patient and whose treating practitioner has determined that the use of facial coverings is necessary for the patient’s wellbeing.

Patients

Patients may only have to wear masks if they are in the communal area of the health care setting and are exhibiting signs or symptoms or have been diagnosed with an infectious disease that can be spread through droplet or airborne transmission.

Visitors

Visitors may also have to wear a mask if they are headed to a sterile area of a facility or if they are coming to see a patient who has been diagnosed with an infectious disease or has a condition affecting their underlying immune system. Visitors will be asked to wear a surgical mask whenever they have signs and symptoms of respiratory infection regardless of the patient’s condition.

NCH reserves the right to require the use of facial coverings at any NCH location in other circumstances consistent with national and state standards, and state and federal laws, rules, requirements and regulations.

OPT-OUT OF FACIAL COVERINGING PROCEDURES

In the event that NCH encourages or requires the use of Facial coverings at any of its locations, then Visitors, Patients, HCP and Professional Staff may opt-out from wearing facial coverings as follows:

1. If an alternative method of infection control is available, Patients and Visitors may opt-out of any existing facial covering requirements by notifying a provider, and such request will be reviewed consistent with infection control procedures.
2. Employees may opt out of any facial covering requirements by notifying their director, and such requests will be reviewed by the infection prevention team.

Aside the opt-out conditions outlined, in the event that NCH requires the use of facial coverings at any of its locations, the following exclusions shall apply:

If there are no alternative methods of infection control or infectious disease prevention, a patient may not opt-out of facial covering requirements in the following circumstances:

• A Patient has been diagnosed or is exhibiting signs or symptoms of an infectious disease that can be spread through droplet or airborne transmission.
• Opting out has been identified by a provider as being medically contraindicated for medical or safety circumstances.
• Opting-out would otherwise infringe on the rights and would risk the safety or health of other patients, individuals or staff/employees of NCH.

If there are no alternative methods of infection control or infectious disease prevention, a Visitor may not opt-out of any Facial covering requirements in the following circumstances:

• The Visitor has been diagnosed or is exhibiting signs or symptoms of an infectious disease that can be spread through droplet or airborne transmission.
• Opting-out would otherwise infringe on the rights and would risk the safety or health of other patients, individuals or staff/employees.
• There are no alternative methods of infection control or infectious disease prevention.

An employee may not opt-out of any facial covering requirements if the employee is:

• Conducting a sterile procedure, including aseptic procedures or surgeries, which call for practices that minimize the risk of microbial contamination to reduce the rate of invasive or surgical site infection.
• Caring for a Patient or being present while sterile procedures are being performed, including aseptic procedures or surgeries.
• Working in a sterile area of any Hospital Location, including where surgeries or procedures that require aseptic techniques are performed.
• With a Patient who is on transmission-based precautions (contact, droplet or airborne isolation).
• Working with a Patient whose treating health care provider has diagnosed the patient with or confirmed a condition affecting the immune system in a manner which is known to increase the risk of transmission of an infection to the Patient from others without signs or symptoms of infection; and whose treating provider has determined that the use of a facial covering is necessary for the Patient’s safety.
• Engaging in potentially hazardous activities that require a facial covering to prevent infection, injury or harm in accordance with national, state and industry standards, and state and federal laws, rules, requirements and regulations.

NCH reserves the right to consider other exclusions from the opt-out provisions in order to comply with applicable state and federal laws, rules, requirements and regulations.

PURPOSE

To provide written Infection Control guidelines for the care and management of patients with suspected and/or confirmed SARS-CoV-2 virus (COVID-19) at all NCH facilities and locations.

SCOPE

This policy applies to healthcare personnel (HCP), paid and unpaid, working in NCH Healthcare System settings who have the potential for exposure to the Covid-19 virus from the community, staff, patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces or aerosols generated during certain medical procedures.

HCP include, but are not limited to, physicians, nurses, clinical technicians, therapists, technicians, emergency medical service personnel, pharmacists, laboratory personnel, contractual personnel and persons not directly involved in patient care (e.g., clerical, dietary, housekeeping, laundry, security, maintenance, billing, chaplains and volunteers) who may potentially be exposed to infectious agents that can be transmitted to and from HCP and patients.

Background

COVID-19 is an illness caused by the SARS-CoV-2 virus. Spread in the healthcare setting can occur through person-to-person transmission.

General Practices to Prevent Transmission of COVID-19 in the Healthcare setting.

Patients

Patients with symptoms consistent with COVID-19 or other respiratory illness will be asked to wear a medical mask (unless there are medical contraindications or younger than 2 years of age). This is consistent with the Standard Precautions/Respiratory Hygiene practices applied to all patient encounters.

Healthcare Personnel

Healthcare Personnel who develop COVID-compatible symptoms or have a positive COVID-19 test should:

• Not report to work or should at once stop working
• Notify their supervisor
• Seek prompt medical evaluation and/or testing
• Report illness to occupational health

Visitors

Visitors, including caretakers, with symptoms consistent with COVID-19 or respiratory illness will   ideally be asked to leave and return when well.

Essential visitors/caretakers with symptoms who cannot leave will be asked to wear a medical mask (unless there are medical contraindications or younger than 2 years of age).

Universal Source Control Measures:

Masking

Healthcare personnel

HCP caring for a patient on transmission-based precautions or whose treating health care practitioner has diagnosed the patient with or confirmed a condition affecting the immune system in a manner which is known to increase risk of transmission of an infection from employees without signs or symptoms of infection to a patient and whose treating practitioner has determined that the use of facial coverings is necessary for the patient’s.

Patients

Patients may only have to wear masks if they are in the communal area of the health care setting and are exhibiting signs or symptoms or have been diagnosed with an infectious disease that can be spread through droplet or airborne transmission.

Visitors

Visitors may also have to wear a mask if they are headed to a sterile area of a facility or if they are coming to see a patient who has been diagnosed with an infectious disease or has a condition affecting their underlying immune system. Visitors will be asked to wear a surgical mask whenever they have signs and symptoms of respiratory infection regardless of patient condition.

Hand Hygiene

1. HCP should perform hand hygiene frequently, including before and after all patient contact, contact with potentially infectious material, contact with the patient environment and before putting on and upon removal of PPE, including gloves.
2. When hands are not visibly soiled hand hygiene can be performed with alcohol-based hand rubs.
3. If hands are visibly soiled, use soap and water, not alcohol-based hand rubs.

Identification and evaluation of patients with possible COVID-19 infection:

1. Early identification of patients with possible COVID-19 infection.
2. Rapid identification of individuals with compatible symptoms and institution of appropriate isolation measures are critical to reducing the risk of COVID-19 transmission.
3. COVID-19 testing is available and does not require approval.
4. Consult the adult and pediatric ID services to assist with clinical management, as necessary.

COVID-19 Testing

• Use COVID-19 microbiology laboratory-based nucleic acid amplification testing (NAAT) or COVID-19 antigen tests for the diagnosis of COVID-19.

Testing should be guided by the following COVID-19 testing criteria and does not require additional approval.

• Diagnostic testingis intended to identify current infections. It is performed when a person has signs or symptoms consistent with COVID-19 or is asymptomatic but has recent known or suspected exposure to someone with COVID-19.
• Screening testing is intended to identify people with COVID-19 who are asymptomatic or do not have any known, suspected or reported exposure to someone with COVID-19.

Appropriate PPE to wear during test collection:

• Obtaining a nasopharyngeal (NP), mid-turbinate (MT), anterior nares (AN) or oropharyngeal (OP) specimen is not considered an aerosolizing procedure and a negative pressure/airborne infection isolation room is not required.
• Perform testing in a room with the door closed.
• Healthcare personnel obtaining swabs for COVID-19 testing must perform hand hygiene and don:
  • Fit-tested N95 respirator OR powered air purifying respirator (PAPR)
  • Eye protection
  • Gloves
  • Gown

Precautions for Emergency Department (ED) and OB Triage

• To rapidly identify and isolate patients who may be infectious, providers should evaluate each patient presenting with symptoms concerning COVID-19.
• Management of symptomatic patients with suspected COVID-19, COVID-19 exposed and confirmed COVID- 19 positive patients will be similar.
• Place patient on “COVID-19 Isolation”.
• PPE for all health care personnel will include:
  • Fit-tested N95 or PAPR
  • Goggles or eye protection
  • Gloves
  • Gown
• Room placement:
  • If the patient is not receiving a continuous aerosol generating procedure, place them in a private room with the door closed.
  • For patients receiving continuous aerosol generating procedures, place them in AIIR/negative pressure room.
  • Examples of continuous AGPs include high flow oxygen, non-invasive ventilation, mechanical ventilation, tracheostomy in place.
  • If an AIIR/negative pressure room is not available, place patient in private room with door closed until room is available.
  • Do not place a patient with suspected or confirmed COVID-19 in a positively pressured room.
• Signage: Post the ‘COVID-19 Respiratory Isolation’ sign on the door of the patient’s room. Keep doors to the AIIR/ATD rooms, including anteroom doors, closed except when healthcare personnel or patients enter or exit the room.
• If patient is admitted communicate infection status to receiving floor and continue COVID-19 isolation protocol.

After patient leaves the ED:

• Clean room with approved hospital disinfectant including reusable equipment, stretcher, counters, bedside table etc. Discard contaminated supplies.
• If an AGP was performed, keep exam room empty with door closed and maintain appropriate isolation signage for one (1) hour after the last AGP was performed.
• If the patient support assistant wears the appropriate PPE described above, they can clean the room prior to the one-hour wait time since the last AGP.

Ambulatory Areas

• If an ambulatory patient arrives to the site and is noted to have symptoms concerning for COVID-19 or has a known COVID-19 diagnosis:
• Room the patient immediately with door closed
• Place ‘Covid-19 Isolation’ sign on door
• Healthcare personnel entering the room must wear PPE consistent with COVID-19 Isolation.

Procedural and Operative Areas

COVID-19 Confirmed/Suspected/Exposed Patients requiring COVID-19 Isolation:

Decisions around the timing of surgery for patients with COVID-19 should be based on the surgeon’s assessment of potential risks and benefits. When possible, procedures should be delayed until official results of COVID-19 testing are available (for suspected patients) or the patient clinically recovers. At all sites, the case should be scheduled as a “last case” whenever possible.

Inpatient Management

Inpatient management of symptomatic patients with suspected COVID-19, COVID-19 exposed and confirmed COVID-positive patients. To rapidly identify and isolate patients who may be infectious, providers should evaluate each patient for signs or symptoms concerning COVID-19.

• Place patient on COVID-19 Isolation. PPE for all health care personnel will include:
  • Fit-tested N95 or PAPR
  • Goggles or eye protection
  • Gloves
  • Gown
  • Room placement

For patients with suspected or confirmed COVID-19 not receiving a continuous aerosol generating procedure, place them in a private room with the door closed and adhere to COVID-19 isolation precautions.

For patients with suspected or confirmed COVID-19 who are receiving continuous aerosol generating procedures, place the patient in an AIIR/ATD room and order COVID-19 Isolation.

• Examples of continuous AGPs include high flow oxygen, non-invasive ventilation, mechanical ventilation, tracheostomy in place.
• If an AIIR/ATD room is not available, place the patient in a private room with the door closed until the room is available.
• Do not place the patient in a Protected Environment room that is positively pressured.

During periods with high prevalence and or during local outbreaks, NCH facilities may consider implementing cohort isolation following the criteria below

• Confirmed infection – patients with the same confirmed pathogen are grouped together during the infectious period.
• Suspected infection – patients suspected to have an infection caused by the same pathogen are cohorted separately from those confirmed to have the infection and separately to those not suspected of having the infection.
• No identified infection risk – patients not suspected of having the infection, or those deemed to be cleared of a previous infection, are grouped together.

Staff caring for patients with suspected or confirmed infections, where possible, should be cohorted. Each cohort should be assigned to work with either suspected or confirmed patients to minimize the risk of transmission.

Discontinuation of isolation criteria for COVID-19 confirmed patients:

For COVID-19 positive patients refer to the following guidance for duration of isolation. If questions arise, contact Infection Prevention.

Patients with mild to moderate illness who are not moderately to severely immunocompromised:

• At least ten (10) days have passed since symptoms first appeared and
• At least 24 hours have passed since last fever without the use of fever-reducing medications and
• Symptoms (e.g., cough, shortness of breath) have improved

Patients who were asymptomatic throughout their infection and are not moderately to severely immunocompromised:

• At least ten (10) days have passed since the date of their first positive viral test.

Patients with severe to critical illness and who are not moderately to severely immunocompromised:

• At least ten (10) days and up to 20 days have passed since symptoms first appeared and
• At least 24 hours have passed since last fever without the use of fever-reducing medications and
• Symptoms (e.g., cough, shortness of breath) have improved

• The test-based strategy as described for moderately to severely immunocompromised patients below can be used to inform the duration of isolation.

If the date of symptom onset cannot be determined, or the patient is asymptomatic, the date of the first positive COVID-19 PCR test should be used.

Laboratory

• All clinical specimens for patients who have pending COVID-19 testing or confirmed infection should be handled using Standard Precautions in accordance with routine procedures.
• No need for separate labeling of specimens as suspected/confirmed COVID-19.
• No need for double bagging of specimens.
• Acceptable to submit specimens via the pneumatic tube system.

Food service

• Nutrition and food services staff should not enter COVID-19 Isolation’ rooms.
• Food trays will be delivered to the nursing the nurse assigned or designee will deliver food tray after donning appropriate PPE.
• Manage food service according to routine procedures. Nutrition and food services staff can receive the soiled tray wearing gloved hands directly outside of the patient room. Place the soiled tray in the soiled food service cart. Remove gloves and perform hand hygiene.
• The use of disposable trays is not recommended.

Trash and Linen

• Ensure accessibility to trash receptacles inside and outside the patient’s room.
• Coordinate with EVS to hand off soiled linen and trash at times other than daily room clean to prevent overflow.
• EVS will handle trash and linen according to routine processes.
• Sharps and non-hazardous pharmaceutical containers will be handled according to routine processes

Cleaning and Disinfection of Environment

• Everyday high touch and other surfaces in the healthcare facility can be cleaned and disinfected by following these instructions:
  • Wear disposable gloves to clean and clean surfaces using hospital approved disinfecting wipe.Follow this by using a disinfectant on EPA List N: Disinfectants for Coronavirus (COVID-19).
  • Follow the instructions on the label to ensure safe and effective use of the practice routine cleaning of frequently touched surfaces including tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, sinks, etc.
• Cleaning of the COVID-19 patient room post discharge can start immediately after a prior COVID-19 patient has been discharged.
  • EVS worker wears N95 mask, eye protection, bown and gloves to enter room and performs manual ‘isolation’ clean of room and bathroom.
• If available, and following the manual clean, the Xenex Robot operator enters room, wearing an N95 mask, eye protection, gown and gloves and cycles robot (five minutes bathroom and five minutes on each side of bed).
  • A new patient may now occupy room immediately if Xenex cycles are completed.
• If no Xenex robot is used, allow room to be vacant of prior COVID patient for one hour total, before placing another patient in the room.
  
  • • Discard PPE, regular trash, non-fluid-impermeable pillows, or mattresses and disposable privacy curtains into regular trash for disposal.
    • Discarded items and trash saturated with body fluids must be disposed of in biohazard Sharps will be disposed of in sharps containers.

Cleaning and Disinfection of Equipment

• Perform hand hygiene before putting on and after removing PPE.
• Clean equipment and/or devices that are not disposable to remove any blood or body fluids and disinfected with hospital-approved detergent-disinfectant.
• Cleaning and disinfection must be completed before the equipment is stored in the clean equipment area and before being used for other patients.
• Clean and disinfect equipment in the patient’s room or in the anteroom unless space constraints make this impossible.
• Thoroughly wet equipment surface(s) with hospital approved detergent-disinfectant and allow to remain undisturbed for the contact time specified by the disinfectant.

Transport of Person Under Investigation (PUI) and Confirmed COVID Patients

The patient should always remain in his/her room with the doors closed unless emergency diagnostic or therapeutic procedures (e.g., CT scan, surgery, etc.) are required and cannot be performed in the patient’s room.

• Notify the receiving area to which the patient is being transported that the patient is on ‘COVID-19′.
• Transporters will wear PPE as directed on the isolation sign prior to entering the patient’s room and before transferring the patient to a wheelchair or stretcher.
• Before leaving the room, the patient should clean their hands, put on a clean hospital gown and put on a medical mask.
• Use a clean sheet not stored in the room to cover the patient’s body before leaving. If the patient is a younger child, cover the crib during transport if safe.
• Once the patient has been transferred to a wheelchair or stretcher, the transporter should remove gowns and gloves in the anteroom or patient room if there is no anteroom, clean hands, and keep face protection on during transport (N95 and face shield or PAPR). If direct patient care is expected, the transporter can use their clinical judgement and leave the gowns and gloves on during transport. If this is done, then staff cannot touch buttons, railings, and their surroundings with gloved hands.
• Receiving personnel (e.g., in radiology) and the transporter (if assisting with transfer) should perform hand hygiene and wear the PPE indicated for the study (i.e., N95 and face shield or PAPR, addition of gown and gloves if direct contact with the patient is anticipated).
• If still wearing their original face protection, the transporter should take care to avoid self-contamination when donning the remainder of the recommended PPE.
• Patients traveling to the Operating Room must be transported directly to the OR from their rooms.

Visitation Guidance

• Detailed recommendations are available in the NCH site visitation guidelines.

Exposure Management and Contact Tracing

Definition of Exposure:

Any contact with someone with confirmed COVID-19 during their infectious period for ≥15 minutes within six (6) feet of the infected person without appropriate PPE cumulatively over a 24-hour period, or presence during an aerosol generating procedure without appropriate PPE for any amount of time. The infectious period for the infected source begins 48 hours before symptom onset or if asymptomatic, the date of the positive test.

Responsibilities of Infection Prevention

• Review the positive culture report daily for positive COVID-19 test results.
• If needed, perform a clinical review of the case to determine additional testing recommendations.
• Inform patients with NCH healthcare-associated exposures to COVID-19, and their providers, about exposures and recommendations.
• Following identification of hospital-onset COVID-19 infections or potential COVID-19 clusters, collaborate with occupational health services to communicate follow up actions.

Responsibilities of Occupational Health Services (OHS):

• Provide self-monitoring instructions to all healthcare personnel with possible healthcare exposures to COVID-19.
• Record all exposures and exposed employee information.
• Arrange for post-exposure education and monitoring.
• Evaluate employee exposures and symptoms to determine the need for work restrictions and/or COVID-19 testing.
• Employees who have had COVID-19 infections must obtain OHS clearance prior to returning to work.

Responsibilities of Supervisors/Directors and Service Chief/Attending Roles:

• Assist OHS with identification of the services and staff/providers involved in care of patient.

Engineering Controls

Airborne Infection Isolation Rooms (AIIRs)/ATD rooms:

Ventilation requirements for these rooms include:

• A minimum of 12 air changes/hour.
• Direct air exhaust to the outside or HEPA filtration of air prior to recirculation.
• Maintenance of negative pressure relationships with the adjacent corridor confirmed.
• Regular monitoring and maintenance of engineering controls.
• Engineering controls, including all negative air pressure areas of the hospital and HEPA filtration systems, undergo regular monitoring and maintenance by the Facilities Management.

Sputum Induction and Bronchoscopy Procedures

Policies and procedures:

• During any aerosol generating procedure on a patient with suspected or confirmed COVID-19 or on COVID-19 Isolation due to COVID-19 exposure, healthcare personnel in the patient’s room must wear a gown, gloves, PAPR or N95 respirator with goggles or face shield during the procedure and whenever entering room during the hour after the AGP.
• Avoid sputum induction for patients with suspected or confirmed COVID-19.

Bronchoscopy

• Bronchoscopy can be performed on suspected or confirmed COVID-19 patients when medically necessary.
• Patients with suspected or confirmed COVID-19 requiring bronchoscopy must have the procedure performed in an AIIR, or negative pressure HEPA filtered area (e.g., Bronchoscopy Suite).
• Patients must remain in the room until coughing has subsided. Recommend that the patient cover their mouth and nose with a tissue when coughing.
• A medical mask will be worn by the patient during transport.
• The procedure room should be closed for the proper amount of time following the bronchoscopy procedure to allow for proper air clearance.

Decedent care

The risk of transmission of SARS-CoV-2 virus from human remains outside of the autopsy setting is low; however, use standard precautions, including added PPE if splashing of fluids is expected when handling and transporting human remains.

PPE that to be used:

• Fit-tested N95 respirator OR powered air purifying respirator (PAPR)
• Eye protection
• Gloves
• Gown

Standard body bagging procedures should be followed, consistent with procedures used for deaths when there is no confirmed or suspected COVID-19. Presence of sharp objects on the decedent that could cause punctures or tears (e.g., jewelry, piercings, medical instruments)

• Follow standard routine procedures when transporting the body after specimens have been collected and bagged. Disinfect the outside of the bag with a product with EPA-approved disinfectant and apply according to the manufacturer’s recommendations.
• Wear disposable nitrile gloves when handling the body bag.

Public Health Department

• Collier County:
  • 239–252-8200
  • Normal business hours: Monday–Friday, 8:00 a.m.–5:00 p.m.
  • Disease reporting: 239-252-8226
    • Fax Line: 239-896-1905
• Lee County:
  • 239-332-9501
  • Normal business hours: Monday–Friday, 8:00 a.m.–5:00 p.m.
  • Disease reporting: 239-332-9580
    • Secure Fax Line: 239-332-9553

References:

Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) | CDC