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Q: What security measures should I consider when preparing for vaccine distribution?

A: When administering the vaccine to the public, consider the following security measures:

• Access to the property and facility including traffic control and patient flow.
• Need for buffer zones or security perimeters for crowd and/or traffic control.
• Delivery of the vaccine and storage within the facility.
• Procedures for staff, patient and visitor identification.
• Procedures for staff to report suspicious activities.
• Guidance on when to request assistance from local law enforcement.
• Communication procedures for local fire or emergency medical services response.

Hospital and health system leaders, including facilities management professionals, will be critical to help engender public trust in a COVID-19 vaccine by promoting transparency, leading community-wide planning efforts, communicating clearly and regularly with internal and external stakeholders and, above all, remaining heavily invested in the health and safety of those in their care.

Q: What power supply recommendations are there for vaccine storage?

A: The states that precautions should always be taken to protect the vaccine storage unit’s power supply. �����Թ�recommends performing a risk assessment to determine which branch of the electrical system to use for the vaccine storage units, in addition to the following recommendations from the CDC: 

• Post “DO NOT UNPLUG” warning signs at outlets and on storage units to alert staff, custodians, electricians and other workers not to unplug units.
• Plug in only one storage unit per electrical receptacle to avoid creating a fire hazard or tripping the circuit breaker.
• Use a safety-lock plug or a lockable outlet cover box to prevent the unit from being unplugged.
• Label fuses and circuit breakers. 
• Avoid using:
  • Built-in circuit switches (may have reset buttons).
  • Outlets that can be activated by a wall switch.
  • Power strips.

Regarding the last item on this list, the CDC states:

If built-in circuit switches or power strip surge protection must be used, make sure the power strip is rated to carry the maximum current as specified by the manufacturer of the refrigerator or freezer. Contact the unit manufacturer for any additional questions or guidance regarding circuit switches, power strips, or surge protection. 

Q: What should contractors consider when working in a health care setting during the pandemic?

A: In addition to educating employees about the unique requirements intrinsic to working in a health care setting during a pandemic, employers should ensure employees understand proper hygiene techniques which should be followed while on-site to minimize exposure. These techniques include hand-washing, social distancing, mask usage and PPE required when social distancing cannot be followed in the performance of their work. Contractors should also consider the amount of staff on-site in accordance with local and state guidelines. For additional education suggestions for those working in health care refer to ASHE’s Certified Health Care Physical Environment Worker certification.

Per the CDC guidance, screening employees is an optional strategy for employers to ensure a safe working environment. However, performing screening or health checks will not be completely effective due to asymptomatic individuals or individuals with mild nonspecific symptoms who may not realize they are infected and may pass through screening. Screening and health checks are not replacements for the other protective measures listed above.

Consider encouraging individuals planning to enter the workplace to self-screen prior to coming on-site and not to attempt to enter the workplace if any of the following are present:

• Symptoms of COVID-19.
• Fever equal to or higher than 100.4 F*.
• Under evaluation for COVID-19 (for example, waiting for the results of a viral test to confirm infection).
• Diagnosed with COVID-19 and not yet cleared to discontinue isolation.

*A lower temperature threshold (e.g., 100.0 F) may be used, especially in health care settings.

Q: Someone has tested positive or is suspected to have COVID-19 on my health care construction project. What guidance is there on this?

A: If an employee tests positive, first follow all procedures required by the health care organization for isolating the area and notifying the local public health authority.

If the employee is on-site, procedures may include that he/she should be isolated immediately. Additionally, you may need to isolate any areas in which the employee was working. Individuals identified to have been in close contact with the effected employee, as defined by the CDC, should be notified and sent home for the recommended quarantine period to self-monitor for potential symptoms. Prior to returning to the construction site, the individual should adhere to all procedures required by the health care organization.

It is important that the infected individual is not identified by name when notifying potential contacts. Once all notifications are made, project management should evaluate the need for a third-party vendor to fully sanitize the job site and common areas before resuming work in the relevant areas.

Q: What are some things to consider as I start a construction project at a health care facility during the pandemic?

A: Facilities and project management teams should consider amending project risk assessments to add additional requirements based on:

- Risk of exposure to adjacent clinical care areas.
- Number of workers on-site.

Evaluating the risks of exposure will help define returning to work procedures. Procedures should be amended based on CDC, local public health authority and/or the health care organization’s requirements. These should be reviewed frequently due to the changing aspects of the pandemic.

Consider the potential benefits of preemptively engaging a third-party vendor for job site sanitation and become familiar with mobilization and sanitization timelines in order to plan the response for potential exposures.

Q: Should all contractors and service providers be restricted from working within the facility?

A: During an emergency, it is prudent to restrict access to the facility. Restricting contractors is definitely something that should be considered at this time. However, with the potential duration of this emergent situation and possibility that facility changes may need to be made rapidly, facilities should examine individual access levels for each contractor/service provider based on their specific work and the facility areas needed to access the work.

Q: Are there any enhanced COVID-19 safety recommendations for contractors?

A: Recommendations would be specific to the project or work being provided, but consider restricting contractor access into COVID-19 units, developing a specific check-in/out procedure and identifying what personal protective equipment will be necessary.

Other recommendations to consider may include:

- Follow social distancing practices during breaks and lunch.
- Limit use of hospital cafeterias and restaurants.
- Ensure proper maintenance of air scrubbers on-site, including proper handling of HEPA filters.

Q: What should contractors working in hospitals expect? Are there any additional measures contractors should take?

A: During this situation, contractors should expect circumstances to be dynamic, possibly changing on a daily basis, and that ultimately it may be necessary to suspend all construction activities unrelated to the emergency response. Communicating and working with the project manager and contracting officer at the facility will be essential to assuring that that proper contract procedures are followed and contractor employees are properly protected.

Q: In order to "do no harm," should construction projects be suspended during this crisis?

A: Suspending construction projects should be considered on a project-by-project basis. Consideration should not be limited to the protection of the patients and should include what is needed to protect those working on the project.

Q: With the ongoing state of emergency, how can I best help my staff?

1. Be open and transparent. Ensuring open and transparent communication among staff is important at all times but is vital during emergencies. One of the best ways to communicate with transparency is by meeting the staff “on their turf.” Making yourself available is one thing, but being available by visiting the staff is even better.
2. Make sure that your staff understands the risk and how to best mitigate it. The National Institute for Occupational Safety and Health (NIOSH) has developed a  that helps guide implementation of mitigation strategies. Helping staff understand that it is better to focus on eliminating the risk than only focusing on temporary measures to protect ourselves from the risk will possibly help them see strategies that they can implement to keep themselves and patients safer.
3. Provide them the resources they need. There is nothing more frustrating than wanting to do a great job and not being able to because of a lack of resources. While it is true that there are always limited resources, making sure that the available resources are used efficiently and effectively can make all the difference for a job well done.

Q: When can I return to work after first identifying I have COVID-19 symptoms?

The CDC recommends a for determining when health care professions (HCP) can return to work.

Workers with mild to moderate illness who are not severely immunocompromised:

• At least 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

If you have no symptoms, you can be with others after 10 days have passed since you had a positive viral test for COVID-19. Most people do not require testing to decide when they can be around others; however, if your healthcare provider recommends testing, they will let you know when you can resume being around others based on your test results.

If you develop symptoms after testing positive, follow the guidance above for “workers with mild to moderate illness”.

Q: What physical environment considerations should I know about storage and handling of reusable PPE?

One of the many operational changes made necessary by the pandemic involves the logistics of processing reusable PPE, such as gowns. The collection and distribution of these items can pose a significant challenge.

Properly collecting soiled gowns may require a separate collection process from the typical soiled linen receptacles as they may be processed through different streams. However, receptacles used to collect gowns will still be considered "soiled linen receptacles,” which must comply with health care and ambulatory care occupancies to requirements under the adopted CMS Conditions of Participation. K-tag 754 specifically states the following:

Receptacles shall not exceed 32 gallons in capacity.
Density capacity shall not exceed 0.5 gallons per square foot.
No more than 32-gallon capacity shall be within any 64 square feet.
Mobile receptacles greater than 32-gallon capacity shall be located in a protected hazardous area.

These requirements mean that containers greater than 32 gallons cannot be used, and containers greater than 16 gallons cannot be placed next to each other and must be kept more than eight feet apart. Finally, mobile solid linen containers greater than 32 gallons have to be located in a hazardous area, commonly known as a Soiled Linen Room, which requires a 1-hour separation and sprinklers. K-tag 754 references NFPA 101®, Life Safety Code®, 2012 edition, Sections 18/19.7.5.7 Soiled Linen and Trash Receptacles.

Q: What should be considered while preparing for cold weather during the pandemic?

Consider evaluating current practices for normal cold weather preparations to include additional measures around:

• Heating and protection of external screening and testing locations.
• Snow removal measures around testing and screening locations.
• Outside air temperatures and the impact to air-handler coils.
• Room exhaust from HEPA units directly to outside and the impact to room comfort.
• Impact of 100% outside air on the ability of an air handler to properly condition space served.

By using a multidisciplinary team to develop cold weather preparations, a thorough risk assessment can be developed to help assure that proper actions are taken prior to colder weather events.

Q: My organization is considering doing employee self-screening. What guidance is there regarding this?

Per the CDC guidance, screening employees is an optional strategy for employers. Performing screening or health checks will not be completely effective because asymptomatic individuals or individuals with mild nonspecific symptoms may not realize they are infected and may pass through screening. Screening and health checks are not a replacement for other protective measures such as social distancing.

Consider encouraging individuals planning to enter the workplace to self-screen prior to coming on-site and not to attempt to enter the workplace if any of the following are present:

• .
• Fever equal to or higher than 100.4 F*.
• Under evaluation for COVID-19 (for example, waiting for the results of a viral test to confirm infection).
• Diagnosed with COVID-19 and not yet cleared to discontinue isolation.

*A lower temperature threshold (e.g., 100.0 F) may be used, especially in health care settings.

For an example of one organization’s employee self-screening program, see the following documents:

Self Temperature Reading SOP

Employee Screening Thermometer Guidance

Q: Can I use telethermographic systems as my screening process for COVID-19?

The FDA provided guidance for the use of telethermographic systems during the coronavirus. The FDA states, “The available scientific literature supports the use of telethermographic systems in the context of initial human temperature measurement during such a triage process.” When using these devices keep in mind the drift and accuracy of individual devices, especially when measuring moving subjects. It is recommended that chosen devices be evaluated to verify for drift and accuracy before implementing usage for screening purposes.

The recommends screening patients and staff before they enter the facility. Screening helps:

• Reduce exposures for other patients and healthcare personnel
• Prevents the spread of disease within the facility
• Ensures personal protective equipment (PPE) is used effectively

A multidisciplinary team should develop the screening process for patients and staff to ensure that all safety measures are implemented to protect public health. The CDC also recommends that patients are sent to the appropriate waiting areas, which should be organized to divide patients with symptoms from patients without symptoms. Patients should also be separated at least 6 feet, and the area for patients with symptoms should be at least 6 feet away from the area for patients without symptoms. See ASHE’s Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase 1 supplemental guidance for further best practices.

Q: At what point should clinical care requirements supersede the life safety requirements that are normally enforced?

A: During an emergency, responding organizations are faced with complex, unpredictable events which could impact patient care and pose the risk of catastrophic losses. Traditional command and control structures of decision-making may need to be revised to accommodate greater flexibility and creativity by response teams. Timely evaluation and decision-making is vital and improvisation becomes a necessary tool to determine the most appropriate response. Yet, during an emergency response it is important to remember that risk assessments can be a great tool to assist in the decision-making process. The use of risk assessments coupled with current information and team communication can help determine the best plan of action.

Q: Since the inspection and testing of fire life safety systems is a proactive compliance requirement, should this service be suspended?

A: �����Թ�is currently working with AHJs to establish guidelines regarding the ITM of fire and life safety systems and equipment. Once guidelines are determined, �����Թ�will communicate this information. Regardless, if a delay or suspension is provided, �����Թ�wants members to understand the importance of these systems. Each organization should evaluate what measures could be implemented to assure the functionality of these systems.

Q: What do I need to consider regarding increasing environmental temperatures for temporary sites for COVID-19?

A: There are not any specific standards that cover working in hot environments. Nonetheless, under the Occupational Safety and Health Act, employers have a duty to protect workers from recognized serious hazards in the workplace, including heat-related hazards. There are several areas of concern when it comes to protecting staff from heat-related illnesses. The Occupational Safety and Health Administration (OSHA) provides significant resources in relation to this issue including a developed by the National Oceanic and Atmospheric Administration (NOAA). Some things to consider are the construction and use of the structure, the exterior temperature, the relative humidity level, the amount of personal protective equipment (PPE) required to be worn and the number of staff within the space.

Regarding structure type and use of temporary facilities for COVID-19 care, there are three main areas to be considered:

• Alternate care sites (ACS) for patient care and/or monitoring
• Testing sites within temporary structures or tents
• Work sites that are outside with limited coverage

ACS for patient care and/or monitoring: These sites should be designed and established to meet the basic requirements of patient care areas and should have a ventilation system that provides heating and air-conditioning to maintain appropriate temperatures and humidity within the structure. While it may not be possible to meet all of the requirements listed in ASHRAE/�����Թ�Standard 170, Ventilation of Health Care Facilities, it would be expected that temperature would be able to be maintained within the recommended ranges provided within this standard, which is generally 70-75 F (21-24 C).

Testing sites within temporary structures or tents: While most of these structures come equipped with fans or other devices to provide cooling, it may be necessary to coordinate with the rental company for additional or alternate cooling devices, such as spot coolers or misters, when exterior temperatures rise into the mid- to high 80s. When doing this, also consider the utility sources for these devices. The NAOO heat index guide provides guidance on what temperature and relative humidity combinations can cause increased risks for heat-related illnesses. It is recommended that, when possible, the temperature within these structures should be maintained within the same range as ACSs – generally 70-75 F (21-24 C).

Work sites that are outside with limited coverage: When working outdoors there are two main considerations. First, the environmental conditions obviously have a major impact; but second, the amount of internal heat generated by the worker’s physical labor and the amount of PPE that is required must also be considered. OSHA has four risk levels based on the heat index and provides detailed guidance for protective measures to be taken at each level on the webpage.

A final consideration for any of these areas is the impact that the cooling devices could have on the spreading of the SARs-CoV-2 virus. Strongly consider including the infection preventionist in the discussions of cooling these areas to assure that appropriate measures are taken to avoid negative impacts within this area of concern.

Q: How should an infected area be cleaned and disinfected?

A: Normal protocols for daily and discharge cleaning of isolation rooms prevails (airborne or droplet and appropriate PPE) using an , adhering to the dwell time. Where visibly and heavily soiled, clean with a detergent solution before disinfecting.

In general, only essential personnel should enter the room of patients with COVID-19. Health care facilities should consider assigning daily cleaning and disinfection of high-touch surfaces to personnel who will already be in the room. Personnel should wear all recommended PPE when in the room. PPE should be removed upon leaving the room, immediately followed by performance of hand hygiene.

After patient discharge, terminal cleaning should be performed. Personnel should delay entry into the room until a sufficient time has elapsed for enough air changes to remove potentially infectious particles per . After this time has elapsed, personnel may enter the room wearing a gown and gloves when performing terminal cleaning. A facemask and/or eye protection should be added if splashes or sprays during cleaning and disinfection activities are anticipated or if otherwise required based on the selected cleaning products. Shoe covers are not recommended at this time for personnel caring for patients with COVID-19.

Q: What are the decontamination protocols for occupied hospital public spaces, such as waiting rooms, cafeterias, etc.?

A: Continue to clean and disinfect public spaces like waiting rooms and restrooms following the normal pattern of cleaning high to low, cleanest to dirtiest and emphasize high-touch surfaces such as handles, knobs, arms of chairs, faucet handles, etc. Use of a disinfectant from the is advised for routine disinfection of public spaces.

Q: We have put a trailer out in front of our hospital to test for COVID-19. Are there special protocol for cleaning and disinfecting this space?

A: The same cleaning and disinfection protocols that would be used for an emergency department or triage area should be followed, with frequencies based on volumes and focus on high-touch areas using an approved disinfectant.

Q: Are there special requirements for COVID-19 trash disposal?

A: No – CDC states “that management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures.”

Q: Are there special disinfection requirements for air handling units that are used to create COVID-19 units?

A: While there are not any additional disinfection requirements for these AHUs, it should be noted that upon terminating the dedicated use of the unit, the entire unit should be ventilated a sufficient time for enough air changes to remove potentially infectious particles per , based on the least amount of air changes in any given space within the unit.

Q: Are there special considerations for wastewater and sewage from units that are used to create COVID-19 units?

A: No – CDC states, “Waste generated in the care of PUIs or patients with confirmed COVID-19 does not present additional considerations for wastewater disinfection in the United States.”

Q: With the potential shortages of PPE, should disinfection of PPE be performed?

A: Ideally no. Extended use is the preferred method for optimizing PPE supplies. Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several different patients, without removing the respirator between patient encounters. This type of usage should be determined by the professionals who manage the institution’s respiratory protection program, in consultation with their occupational health and infection control departments and with input from the state/local public health departments. For additional information, see the .

Q: Do filtering face-piece respirators (FFRs) not approved by the National Institutes of Occupational Safety and Health (NIOSH), provide the same protection as NIOSH-approved respirators?

A: As mentioned in , other countries approve respirators according to their approved standards. These devices are evaluated using methods similar to those used by NIOSH, and are still expected to provide adequate protection for healthcare personnel, given shortages of FFRs resulting from the COVID-19 pandemic. Under these circumstances, FDA believes these devices may serve as suitable alternatives for personal respiratory protection during this period of shortage caused by the COVID-19 pandemic.

Q: Since the SARS-CoV-2 virus is smaller than 0.3 microns, why are HEPA filters recommended for it?

A: This is due to Brownian motion, which is the random motion of particles suspended in a fluid such as air. Particles smaller than 0.3 microns are subjected to Brownian motion, which causes them to flow in a zig-zag motion as indicated in the illustration. Even though the particles could fit through the fibers of the filter, the particles’ motion and size causes them to come into contact with the fibers and are captured by the filter media due to diffusion. Since particles that are 0.3 microns and larger are not impacted by Brownian motion, HEPA filters are tested at the 0.3 micron size, which is the most difficult particle size to capture. Therefore, even though the SARS-CoV-2 virus is smaller than the tested micron size, HEPA filters are even more efficient at capturing particles of this size than particles at 0.3 microns.

Q: What MERV rating is effective in capturing the SARS-CoV-2 virus?

A: A MERV 16 rated filter is 95% or better efficiency for particles of 0.3 to 1.0 micron sizes. MERV stands for the Minimum Efficiency Reporting Value of a filter. It is a method of stating the filter’s efficiency based on particle size and is determined by testing filter performance when exposed to particles of a known size in the air stream. Due to the Brownian motion particles smaller than 0.3 microns are trapped within filter media more efficiently than those of the 1.0 to 0.3 micron size thus the MERV 16 is the rating most effective in capturing the SARS-CoV-2 virus.

Q: At what efficiency rate do HEPA filters work against COVID-19?

A: While HEPA filter efficiency is not tested with individual viruses, filters are tested by manufacturers according to methodologies as outlined in Recommended Practices (RP) as published by the Institute of Environmental Sciences and Technologies (IEST) and filter test methods by the International Organization for Standardization (ISO). Filters are challenged with particles or aerosols of specific size and the penetration of each filter is recorded. HEPA filters are labeled based on their efficiency with various particle sizes.

Q: What safety and PPE measures should be taken when changing and transporting filters from air handlers serving COVID-19 patient areas?

A: Due to the air flow through the filter, the SARS-CoV-2 virus will quickly desiccate and die. Additionally, the virus should adhere pretty well to the filter unless the filter is beaten or dropped. If this is a concern, then the use of a fixate, such as hairspray, on the filters could be considered. Disposal should be performed by bagging the filters and disposing them in normal trash.

Q: How often do you need to change HEPA filters on a negative air machine?

A: Filters should be changed based on the facility’s current policies and procedures and the negative air machine manufacturer’s recommendation. After patient discharge the room should be left vacant long enough to allow sufficient number of air changes to remove potentially infectious particles per the . Due to the air flow through the filter, the SARS-CoV-2 virus will quickly desiccate and die and the filter change can be performed with normal maintenance PPE. Additionally, the virus should adhere pretty well to the filter unless the filter is beaten or dropped. If this is a concern, then the use of a fixate, such as hairspray, on the filters could be considered. Disposal should be performed by bagging the filters and disposing them in normal trash. 

Q: What guidance is available to address a COVID-19 surge?

A: First and foremost during emergencies, such as the COVID-19 pandemic, it is important that activities be coordinated through the organization’s incident command system. Activities outside of the organization’s command structure, such as a hotel or convention center, should be coordinated with the local, county and state incident command systems. This enables effective and efficient incident management within common organizational structures. Specifically, �����Թ�has provided several resources in relation to alternate care sites available on ASHE’s Converting Alternate Care Sites webpage. Some key considerations are:

• Since care will be provided in a non-traditional environment, it is critical to ensure these facilities can support the implementation of recommended infection prevention and control practices.
• Determining the level of care that will be provided at an alternate care site. Developing a facility to manage low-acute COVID-19 patients is very different than creating a large scale intensive care site.
• Layout of the care site and specifically what spacing between patients or will individual rooms be provided The ability to provide medical gas distribution systems at alternate care sites where ventilator care will be provided
• Ventilation of the care site - can the site provide air movement from clean to less clean spaces
• Storage areas, floors and surfaces, sanitation/disinfection, food services are just a few things to be considered.

For a more in-depth guidance see the resources available on ASHE’s Converting Alternate Care Sites webpage.

Q: Should medical gases be provided at an alternate care site?

A: The answer to this question really depends on the level of care that will be provided at the alternate care site. Consideration for the use of oxygen, medical air and suction needs to be well-thought-out if ventilators will be used. As an example some ventilators do not have on board air pumps which would require medical air to be provided. Additionally, a piped suction system could be considered or the use of portable suction devices could be used instead. Some specific guidance on sizing of medical gas systems for COVID-19 alternate care sites is provided by Beacon Medaes. Additionally, Kaiser Permanente has provided some guidance on ventilator capacity for existing medical air and oxygen systems. Both of these guidance documents can be found on ASHE’s Converting Alternate Care Sites webpage under the Medical Gas Considerations section along with a video regarding safe practices for cylinder handling and connection.