Pandemic Influenza Planning for the Long-Term Healthcare Workplace

Pandemic Influenza Planning for the Long-Term Healthcare Workplace

Pandemic Influenza Planning for the Long-Term Healthcare Workplace Georgia Tech OSHA Consultation Program GHCA Annual Convention June 2008 Information Provided under OSHA Susan Harwood Grant #SH-16620-07-60-F-13 GTRI_B-1 Agenda Day 1 Definitions Transmission Projections Break Current Status Surveillance Principles; ICS & NIMS Introduction to Exposure Reduction Part A Workshop and Homework

GTRI_B-2 Filename - 2 Agenda Day 2 Exposure Reduction (continued) Personal Protective Equipment Respiratory Protection Break Development/Implementation of Business Continuity and Preparedness Plan Part B Workshop and Game GTRI_B-3 Filename - 3

Seasonal Flu Cause Virus strain changes every year. Transmission Sneezing and coughing (droplets); surface contact Avian Flu Pandemic Flu Severity Target Population 5 years old and 65

years old Immunity Some immunity; prior disease or vaccination Current Status Flu season is usually December March GTRI_B-4 Filename - 4 Seasonal Flu Cause Virus strain changes every year.

Transmission Sneezing and coughing (droplets); surface contact Severity 5-20% US population infected Avian Flu Pandemic Flu >200,000 hospitalized 36,000 die Target Population

5 years old and 65 years old Immunity Some immunity; prior disease or vaccination Current Status Flu season is usually December March GTRI_B-5 Filename - 5 Seasonal Influenza Symptoms Fever (usually high) and chills Body aches Sore throat

Non-productive cough (dry) Runny or stuffy nose Headache Extremely tired (fatigue) Diarrhea Symptomatic: 1-4 days (exposure to onset); average = 2 days Infectious: 1 day before to 5 days after symptomatic illness Recovery: 3-7 days GTRI_B-6

Filename - 6 Seasonal Flu Avian Flu Cause Virus strain changes every year. H5N1 is current virus strain Transmission Sneezing and coughing (droplets); surface contact Bird to bird; some bird to human (rare);

secretions Severity 5-20% US population infected. 348 human cases, 216 deaths >200,000 hospitalized (Jan. 2008) Pandemic Flu 36,000 die Target Population

5 years old and 65 years old Working population Immunity Some immunity; prior disease or vaccination Limited immunity Current Status Flu season is usually December March Limited human cases in 14 countries (as of 1/2008)

GTRI_B-7 Filename - 7 Avian Influenza Birds (wild and domestic poultry) are natural reservoirs of all influenza A viruses Rarely infect humans Flu types can be either be of low or high pathogenicity (ability to cause disease) Low pathogenic strains: wild can mutate domestic transmission; Highly pathogenic strain: high bird death rate (example

H5N1 virus) with rapid spread among domesticated fowl. Bird to human transmission possible. GTRI_B-8 Filename - 8 Seasonal Flu Avian Flu Pandemic Flu Cause Virus strain changes every year. H5N1 is current virus strain

Unknown, highly pathogenic virus Transmission Sneezing and coughing (droplets); surface contact Bird to bird; some bird to human (rare); secretions Unknown probably droplet, contact, possibly aerosol Severity 5-20% US population infected.

348 human cases, 216 deaths (Past Pandemics) >200,000 hospitalized (Jan. 2008) 36,000 die 30% US population infected 8,300 to 500,000 deaths in US; 700K to 40 million worldwide Target Population

5 years old and 65 years old Working population All; primarily 18-35 years old Immunity Some immunity; prior disease or vaccination Limited immunity No immunity Current Status Flu season is usually December March

Limited human cases in 14 countries (as of 1/2008) No Pandemic GTRI_B-9 Filename - 9 GTRI_B-10 Filename - 10 Shifting from Avian Flu to Pandemic Flu Expecting H5N1 (or a similar virus) to give rise to next Human flu pandemic When the avian flu virus changes its genetic

structure so that it is capable of infecting humans AND It can be easily spread from human to human: Pandemic Influenza occurs GTRI_B-11 Filename - 11 Pandemic Influenza A disease outbreak that spreads rapidly and affects many people world wide. Characteristics New virus that spreads easily as most people are susceptible (no natural resistance or immunity)

Effective human to human transmission is necessary Measured by how fast the virus spreads Wide geographic spread Not predictable Outbreaks lasting 8-12 weeks with 1-3 week wave cycles GTRI_B-12 Filename - 12 Pandemic Influenza Anticipated Illness A severe form of seasonal flu symptoms H5N1 cases in Asia reported seasonal flu symptoms with LOWER respiratory infection (rather than traditional UPPER respiratory infections) Shortness of breath, viral pneumonia, abdominal pain, diarrhea, and vomiting in higher prevalence

than seasonal flu GTRI_B-13 Filename - 13 Influenza GTRI_B-14 Filename - 14 Photo credit: A. Davidhazy 2002 Pandemic Influenza Transmission Not yet known which of three routes of transmission will be MOST important Possibilities Droplet (large droplets produced during coughs and

sneezes) (eg seasonal flu) Airborne (very small infectious particles able to travel long range distances) (eg TB) Contact (hand to mouth and/or nose contact; contact with contaminated surfaces) GTRI_B-15 Filename - 15 Projections: What Lies Ahead What are the projected numbers? What is the projected magnitude of impact? What to expect? GTRI_B-16

Filename - 16 Impact of Pandemic Flu United States (ESTIMATES for TODAYS WORLD) Characteristic Moderate (1958/68-like) Severe (1918-like) Illness 90 million (30%) 90 million (30%)

Outpatient medical care Hospitalization 45 million (50%) 45 million (50%) 865,000 ICU care 128,750 9,900,000 (11%) 1,485,000 Mechanical ventilation Deaths

64,875 745,500 209,000 1,903,000 GTRI_B-17 Filename - 17 Whats this mean for Georgia? How many licensed hospital beds in Georgia? 23,000 How many of those beds are staffed? 16,000 How many people are anticipated to be sick in Georgia? 3 million

How many of those sick will need hospitalization? 60,000 to 330,000 How many of those hospitalized will need ventilators? 4500 to 24,750 How many ventilators do we have in Georgia? 1500 Who is operating these ventilators and performing the work when 40-60% of the workforce is absent? GTRI_B-18 Filename - 18 Pandemic Waves Pandemics occur in multiple waves of disease outbreaks

The first wave in a local area is likely to last six to eight weeks The time between pandemic waves varies and can not be easily predicted. Anticipate 1-3 waves GTRI_B-19 Filename - 19 What to Expect Crisis for extended period of time in multiple locations Daily routines will be affected from personal, community, and professional changes Isolation/quarantine guidelines or requirements?

Cancellation of public events and schools? Non-essential work activities limited? Commerce Patterns changed? Elements of personal action will be required Absenteeism from pandemic flu expected to be 40-60% Lost availability for those who are ill (or caring for ill family) is projected at 2-4 weeks GTRI_B-20 Filename - 20 Impact on the Health Care System Extreme staffing shortages Shortages of beds, facility space, key supplies (ventilators, drugs) Hospital morgues, Medical Examiner and mortuary

services will be overwhelmed Extreme demands on social and counseling services Long-term: demand will outpace supply GTRI_B-21 Filename - 21 Specific Risks to Long-Term Health Care Community Potentially already immune-compromised Living in close proximity Visitors from outside Surfaces Activities Employees GTRI_B-22

Filename - 22 Is a Vaccine Available? A vaccine to protect people from pandemic flu is not available now. A vaccine may not be available at the start of a flu pandemic (~ 6-8 months after start) The best protection is to practice healthy hygiene to stay well now and during a flu pandemic. GTRI_B-23 Filename - 23

Current Status Where are we now? What preparation has been done so far? Federal level State level What available tools do we need to understand to prepare better at the local level? GTRI_B-24 Filename - 24 Is there a Pandemic now? As of 3 January 2008: Reported to World Health Organization (WHO); cumulative total confirmed human cases of Avian Influenza A H5N1 virus: 348 cases

216 deaths No sustained human to human transmission identified = currently NO pandemic GTRI_B-25 Filename - 25 Risk Classification Structure Whos Who: World Health Organization (Phases 1-6) US Government (Stages 1-5) Centers for Disease Control and Prevention CDC (Categories)

OSHA Risk Pyramid GTRI_B-26 Filename - 26 U.S. Government and WHO: A Comparison U.S. Government Stages 0 1 2 New domestic animal outbreak in atrisk count Suspected human outbreak overseas Confirmed human outbreak overseas

3 Widespread outbreaks overseas 4 First human case in North America 5 Spread throughout U.S. WHO Phases Inter-pandemic phase New virus in animals, human cases Pandemic alert New virus causes human cases

Pandemic Low risk of human cases 1 Higher risk of human cases 2 No or very limited human-tohuman transmission 3 Evidence of increased humanto-human transmission 4 Evidence of significant humanto-human transmission

5 Efficient and sustained humanto-human transmission 6 GTRI_B-27 Filename - 27 CDC Severity Index Pandemic Severity Index Interventions by setting 1 2&3 4&5 Home: Voluntary isolation of

ill Recommend Recommend Recommend Voluntary quarantine of household members in homes with ill Generally not recommend Consider Recommend School: Child social distancing (dismiss schools,

close childcare) Generally not recommend Consider Recommend Workplace/Community: Adult social distancing Generally not recommend Consider Recommend GTRI_B-28

Filename - 28 What is surveillance? Ongoing, systematic collection, analysis, and interpretation of healthrelated data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control. GTRI_B-29 Filename - 29 Information Loop of Public Health Surveillance Public Reports

Summaries, Interpretations, Recommendations Health Care Providers Health Agencie s Analysis Source: Denise Koo, MD, MPH Epidemiology Program Office, Centers for Disease Control and Prevention GTRI_B-30 Filename - 30 GTRI_B-31 Filename - 31

Pandemic Influenza Surveillance Responsibility at all levels: Globally- World Health Organization WHO Global Influenza Surveillance Network National Influenza Centres (NICs) WHO Collaborating Centres (WHO CCs) Nationally- Health and Human Services National Influenza Surveillance System Influenza Surveillance coordinators State and Local governments Support national and global surveillance systems GTRI_B-32 Filename - 32 Surveillance Recommendations for Interpandemic and Pandemic Alert Periods State and local responsibilities:

Continue to employ state influenza surveillance coordinators to oversee improvements in influenza surveillance Conduct influenza surveillance year round, where possible. Implement enhanced surveillance for detection of the first U.S. cases of novel virus infection. State and large local public health laboratory responsibilities: Isolate and subtype influenza viruses year round. Improve capacity for rapid identification of unusual influenza strains GTRI_B-33 Filename - 33 Recommendations for the Pandemic Period If an influenza pandemic begins in the United States or another country:

State and local responsibilities: Implement enhanced surveillance for detection of the first cases. Enhance all influenza surveillance components (virologic, outpatient, hospitalization, and mortality). Communicate to all partners the heightened need for timely and complete surveillance data. HHS responsibilities: Provide technical support, as requested, to ministries of health and WHO to track the pandemic virus and gather epidemiologic data on risk factors for infection or severe illness. Issue updated case definitions and guidance for laboratory testing and enhanced surveillance.

Assist state and local health departments, as requested. Analyze influenza surveillance data on a regular and timely basis. For more information: GTRI_B-34 Filename - 34 OSHA Surveillance Recommendations for Healthcare Providers Keep records of and monitor: Who cares for sick patients Which employees Show signs of disease Become ill Recover Absenteeism Encourage self-reporting of symptoms by employees

Educate employees about Perform Serologic testing on employees, where possible Prioritize employees with serologic evidence of pandemic flu for care of patients Remove employees with increased risk of complications due to pandemic flu transmission

GTRI_B-35 Filename - 35 Incident Command & Health Care Workers When pandemic flu arrives & starts to manifest itself, many original discoverers of infected & seriously ill people will be public safety first responders Public safety, especially fire & EMT services, work within Incident Command System (ICS) that utilizes standardized terminology & concepts in order to efficiently & safely address emergencies and other kinds of incidents GTRI_B-36

Filename - 36 Incident Command & Health Care Workers During a pandemic, private HCWs will not be able to work in a vacuum by themselves Will have to coordinate & interface with public safety Will have to understand the language & be able to work within the ICS Private entities have compliance responsibilities under National Incident Management System (NIMS)

GTRI_B-37 Filename - 37 Through the use of NIMS/ICS, all types of response activities, to include in-house management of infected people, will be more efficient and ultimately safer for all involved GTRI_B-38 Filename - 38 National Incident Management System (NIMS) and Incident Command System (ICS) Incident Command System (ICS) Public safety, especially fire & EMT services utilizes standardized terminology & concepts in order to efficiently & safely

address emergencies and other kinds of incidents National Incident Management System (NIMS) Private entities have compliance responsibilities under NIMS is mandated for adoption across all spectra of response organizations public & private; government; non-governmental organizations; and private businesses GTRI_B-39 Filename - 39 Exposure Reduction and General Infection Control Practices GTRI_B-40 Filename - 40

HHS & CDC Plan GOAL: Slow the spread to reduce incidence of illness and death Hospitals/Healthcare System Overloaded Use social distancing, targeted antiviral treatment, isolation and quarantine to buy time to increase: Antiviral supply

Vaccine availability Impact Unprepared Prepared Week s GTRI_B-41 Filename - 41 Hierarchy of Controls Avoid the need Source Substitution Procedures Preference

Source Reduction Reduce the need Reduce exposure Ventilation Dilute and Divert Personal Protection Personal barriers GTRI_B-42 Filename - 42 Tiered Readiness Approach Personal Readiness

Family and Community Readiness Workplace Readiness Multiple Level Impact requires Multiple Level Planning INFORMATION = POWER Example: Personal Readiness planning now to care for yourself or loved ones who get the flu = better equipped to respond in Workplace Readiness Example: encourage employees to obtain a seasonal flu vaccine (as normal flu will probably continue to circulate). GTRI_B-43 Filename - 43

Variable Guidance Depending on Risk Classification Level Lower Exposure Risk Medium Exposure Risk High Exposure Risk OSHA Guidance on Preparing Workplaces for an Influenza Pandemic (OSHA 3327-02N 2007) Expect majority of American workforce will be in these 2 categories GTRI_B-44 Filename - 44 Healthcare employees performing aerosolgenerating procedures on

known or suspected patients Healthcare delivery & support staff entering known or suspected patient rooms GTRI_B-45 Filename - 45 Stratifying Risk: How Likely Will I Be Infected? In Healthcare settings: ++++ Aerosol generating procedures performed on ++++ Resuscitation of a patient with influenza

influenza patients (i.e., emergency intubation, CPR, etc.) ++/+++ Direct patient care for a symptomatic (ill) patient have influenza ++ Direct routine patient care for all other patients ++ Home care for a family member ill with influenza ++ Non-patient-care activities in a healthcare setting suspected to GTRI_B-46

Filename - 46 Workplace Readiness Surface Cleaning, Facility Hygiene and other Environmental Measures Cough Etiquette Hand Hygiene Social Distancing Limiting Face-to-Face Meetings Employee and/or visitor screening Personal Barriers Contingency Planning/Business Continuity GTRI_B-47 Filename - 47

Potential for Contact Transmission and Surface Cleaning Surfaces can include items such as: Influenza virus can survive on surfaces at room temperature and moderate humidity: Steel and plastic: 24-48 hours Cloth and tissues: 8-12 hours Tabletops Doorknobs Tools Computer keyboards and Telephone handsets

Cloth, tissues, paper or currency infected with the virus Faucets, toilet flushers GTRI_B-48 Filename - 48 Potential for Contact Transmission Effectively inactivated by: Detergents Alcohol-based products (hand gels) Bleach solutions Household disinfectants (virucides) GTRI_B-49 Filename - 49

Facility Hygiene Practices and Policies GTRI_B-50 Facility Hygiene: Supplies and Equipment Dishes and Eating Utensils Handled by Pandemic Influenza Patients Linens and Laundry potentially contaminated with pandemic influenza Wear gloves Wear gloves

Wash reusable items in Place linens in laundry bag dishwater Consult local health codes for water temperature Disposable dishes and utensils may be discarded in general waste Contain bag to prevent opening during transport Do not shake or handle linen or

laundry to promote disease transmission Wash and dry in accordance with infection control standards ***Always practice hand hygiene after removal of gloves*** GTRI_B-51 Filename - 51 Facility Hygiene: Patient Care Equipment Standard practices for handling and reprocessing used patient care equipment, including medical devices, should be followed: Wear gloves Wipe heavily soiled equipment with registered

disinfectant before removal from patients room Clean, disinfect, and sterilize according to procedures Wipe external surfaces of portable equipment with registered disinfectant ***Always practice hand hygiene after removal of gloves*** GTRI_B-52 Filename - 52 Facility Hygiene: Cleaning and Disinfection PPE Required: Gloves that are chemically resistant to the disinfectant being used

Typically wear a surgical mask Gowns not routinely necessary Wear face and eye protection if <3 ft from patient Store supplies and equipment >3 ft from patient Use only registered disinfectant Focus on frequently touched surfaces: Bedrails, bedside or over-bed tables, TV controls, call buttons, telephones, safety/pull-up bars, doorknobs,

lavatory surfaces, ventilator surfaces, etc. After patient is discharged or transferred: Clean and disinfect all surfaces Follow standard post-discharge cleaning or isolation room ***Always practice hand hygiene after removal of gloves*** GTRI_B-53 Filename - 53 Facility Hygiene: Disposal of Solid Waste Wear gloves Discard non-contaminated

supplies in routine waste Contaminated medical waste must be disposed of in accordance with: Facility procedures State and local regulations And in compliance with OSHAs Bloodborne Pathogens standard ***Always practice hand hygiene after removal of gloves*** GTRI_B-54 Filename - 54 Additional Resources

Guidelines for Environment Control in Health-Care Facilities: pdf EPA registered disinfectants: Department of Health and Human Services: Supplement 4 GTRI_B-55 Filename - 55 GTRI_B-56 Filename - 56 Hand Hygiene Provide resources and work environment that

promote personal hygiene. Tissues; no-touch trashcans, sinks, towel dispensers; hand soap; hand sanitizer; disinfectants for work surfaces Train on the expectation that employees will follow these guidelines Make it a habit NOW Make it an institutional priority NOW GTRI_B-57 Filename - 57 Social Distancing Encourage sick employees to stay home Avoid close contact with coworkers and customers (>6 ft

apart) Avoid shaking hands (and wash after) Discourage sharing of phones, desks, offices, work tools and equipment Minimize face-to-face meetings. Utilize email, telephone, texting capabilities Reduce or eliminate unnecessary social interactions (including others coming onsite) GTRI_B-58 Filename - 58 Patient Isolation

Dependent on transmission route Single-patient room or designated room/area for cohorting patients with confirmed pandemic influenza Con-current circulation of other respiratory illnesses Separate suspected and confirmed cases Avoid staff-floating Limit # of entrants into restricted area Limit patient transport Use airborne isolation room during aerosol-generating procedures GTRI_B-59 Filename - 59 Personal Barriers: Personal Protective Equipment

and Respiratory Protection GTRI_B-60 Filename - 60 Personal Protective Equipment For Long Term Health Care Facility Workers During a Pandemic Influenza GTRI_B-61 Personal Protective Equipment (PPE) Designed to provide a barrier to microbial transfer Involves respiratory protection (respirators) dermal protection (gloves, gowns) protection of mucous membranes (face shield, eye protection)

GTRI_B-62 Filename - 62 Barriers to PPE Use Barriers in Industry Communication interference Physical discomfort Additional Barriers in Healthcare Patient interactions (e.g. Split-second actions) Patient needs come first GTRI_B-63 Filename - 63 Hindering Protectiveness Scarce data on the

transmission of influenza Impossible to definitively inform HCW about: What PPE is critical What level of protection the equipment will provide in a pandemic Challenges in training and equipping HCW with effective PPE GTRI_B-64 Filename - 64 Importance of PPE Use

Surge capacity cannot be met if HCW are ill HCW are absent due to concerns about PPE efficacy PPE will save lives, just as other critical medical devices do! GTRI_B-65 Filename - 65 Gloves Should be latex, vinyl, nitrile, or other synthetic Use when there is contact with blood or other bodily fluids, including respiratory secretions Recommendations If use latex, use powder free and low protein to reduce risk of latex

sensitization No need to double glove Do not touch face or eyes while wearing gloves Remove and discard after patient care Gloves should not be washed or reused Hand hygiene should be done after glove removal GTRI_B-66 Filename - 66 Proper Glove Removal GTRI_B-67 Filename - 67

Gloves, cont Glove supplies my be limited in event of pandemic influenza. Other barriers should be used when there is limited contact with respiratory secretions. Ex. use disposable paper towels when handling used facial tissues. Practice hand hygiene consistently in this situation. GTRI_B-68 Filename - 68 Gowns Isolation gowns:

Can be disposable and made of synthetic material Can be reusable and made of washable cloth Should be the appropriate size to fully cover the areas requiring protection Most routine pandemic influenza patient encounters do not necessitate gown use. GTRI_B-69 Filename - 69

Gowns, cont Isolation gowns are needed: When it is anticipated that soiling of clothes with blood or other bodily fluids may occur. Ex. Procedures such as intubation or when closely holding a pediatric patient. After patient care is performed, remove gown and place in laundry or waste. Hand hygiene should follow. GTRI_B-70 Filename - 70 Goggles / Face Shield However, if sprays or splatters of

infectious material are likely, goggles or face shield should be worn HHS Pandemic Influenza Plan does not recommend the use of goggles or face shield for routine contact with patients with pandemic influenza. Ex. If a pandemic influenza patient is coughing, any healthcare worker needing to be w/in 3 feet of the infected patient is likely to encounter sprays of infections material. GTRI_B-71

Filename - 71 Goggles / Face Shields cont Selection Depends on circumstances of exposure, other PPE used, and personal vision needs. Must be comfortable, allow for sufficient peripheral vision, and be adjustable to ensure a secure fit. May be necessary to provide several different types, styles and sizes. GTRI_B-72 Filename - 72 Goggles

Most reliable & practical for protection from splashes, sprays, and respiratory droplets: Indirectly-vented goggles Anti-fog coating Fit snugly, particularly from the corners of the eye across the brow Some goggles seem to fit adequately over prescription glasses with minimal gaps, but are not efficacious. While highly effective as eye protection, goggles do not provide splash or spray protection to other parts of the face. GTRI_B-73

Filename - 73 Face Shields Used as an alternative to goggles Provides protection to other facial areas. May be more comfortable than goggles when used in combination with respiratory protection. For optimum protection: Should have crown and chin protection Should wrap around the face to the point of the ear Sub-optimum protection: Disposable face shields made of film that are attached to surgical mask or fit loosely GTRI_B-74

Filename - 74 PPE for Aerosol-Generating Procedures Examples of aerosol-generating procedures: Endotracheal intubation Diagnostic sputum induction Aerosolized or nebulized Bronchoscopy Airway suctioning Positive pressure ventilation via medication administration face mask (e.g., BiPAP and CPAP) During these procedures, personnel should wear:

Face/eye protection Respiratory protection (N95 or better) Gloves Gowns GTRI_B-75 Filename - 75 PPE Use in Infection Control Precautions Tier 1: Standard Precautions Primary strategy for preventing transmission of infectious agents among patients and healthcare personnel Tier 2: Transmission-Based Precautions USE IN ADDITION TO STANDARD PRECAUTIONS Intended to be combined for protection from diseases with

multiple modes of transmission Contact precautions Droplet precautions Airborne Precautions Tie r2 Tier 1 GTRI_B-76 Filename - 76 All Tiers Involve: Hand Hygiene, Mask, Gloves Eye Protection, Face Shield

Gown Housekeeping, BBP, Patient Placement It is the circumstances of the disease that dictate how/when to use them. GTRI_B-77 Filename - 77 Tier 1: Standard Precautions Gloves: Wear when touching blood or Other Potentially Infected Materials (OPIM) Remove immediately after use and practice hand

hygiene Mask / Eye protection / Face Shield: Wear during activities likely to generate splashes or sprays of blood or OPIM GTRI_B-78 Filename - 78 Tier 1: Standard Precautions Gown: Wear to protect skin and avoid soiling clothing when contact with blood or OPIM is anticipated. Remove gown and perform hand hygiene before leaving the patients environment.

Other: Practice standard procedures in regards to hand hygiene, cleaning patient equipment, care and disposal of soiled linens, protections regarding Blood Borne Pathogens, and patient placement. GTRI_B-79 Filename - 79 Tier 2: Contact Precautions Intended to prevent transmission of infectious agent spread by direct or indirect contact with the patient or the patients environment. GTRI_B-80 Filename - 80

Tier 2: Contact Precautions Gloves: Wear whenever touching the patients intact skin or items in close proximity to the patient. Don gloves upon entry into the room. Gown: Wear whenever anticipating that clothing will have direct contact with the patient or items in close proximity. Don upon entry into the room. Remove gown and observe hand hygiene before leaving the patient-care environment. GTRI_B-81

Filename - 81 Tier 2: Droplet Precautions Intended to prevent transmission of infectious agent spread through close respiratory or mucous membrane contact with respiratory secretions. In addition to Standard Precautions, droplet precautions require: Mask: Don upon entry into the patient room or cubicle. GTRI_B-82 Filename - 82

Tier 2: Airborne Precautions Intended to prevent transmission of infectious agents that remain infectious over long distances when suspended in the air. In addition to standard precautions, airborne precautions require: Respiratory Wear Protection: a fit-tested NIOSH-approved N95 or higher level respirator when entering the room or home of a patient who is

suspected or confirmed to have an Filename - 83 GTRI_B-83 Respiratory Protection GTRI_B-84 Prepared, Not Scared Creating Your Workplace Pandemic Influenza Response Plan GTRI_B-85 Expect to be Asked: Does MY employer have a plan: for employees who get sick during a pandemic and need to stay home? to keep the business functioning if key staff cant

come to work? for sick leave, benefits and wages when employees are asked to remain at home? GTRI_B-86 Filename - 86 GTRI_B-87 Filename - 87 Top 10 Errors in Workplace Planning Lack of Upper-Management support

No employee buy-in Poor or no planning Exclusion of OSHA regulations Contingency plan for facility equipment Limited training/practice No roles and responsibilities No designated leader Pandemic Specific: non- Communication failure

occupational exposure risk GTRI_B-88 Filename - 88 Approaching the Planning Process Define the community Identify a plan Determine risks and hazards Set goals for planning Determine current capacities and capabilities Develop plan Include: communication planning

Mental health planning Vulnerable populations Funding Training, exercises Improve GTRI_B-89 Filename - 89 Planning Team (example) Human Resources Safety IT Security Sourcing/Purchasing Facilities Legal Communications

Operations 3rd Parties Vaccine/antiviral distributors State and local health depts. GTRI_B-90 Filename - 90 Example Plan Overview Organizational Structure Assumptions Payroll Administration Business Continuity Training Employee Health

Employee Services Management of Ill Staff Workplace Practices Attendance and Leave Recovery policies GTRI_B-91 Filename - 91 Plans should address Disease surveillance Isolation & quarantine Occupational health for

employees Communication Surge capacity Education Access and use of antivirals Triage Clinical evaluation & diagnosis Security Facility access and infrastructure and vaccines Supply chains

Access to critical inventory supplies Mortuary services & demand GTRI_B-92 Filename - 92 Planning for Protection of Human Capital Emergency staffing plans Continued delivery of essential services Auxiliary support to Primary Healthcare Maintaining Essential Business Activities Who are the core employees? What are their skills? Planning for absence Prioritizing services

GTRI_B-93 Filename - 93 Planning for Protection of Human Capital (cont) Resident Population Needs Communication: altered mental status; dementia Basic Personal Care Functions: feeding; hydration; medication; hygiene needs Behavioral Patterns: disorientation GTRI_B-94 Filename - 94 GTRI_B-95 Filename - 95

Decision Logic: http:// c/agency/decisionchart .asp GTRI_B-96 Filename - 96 pandemic/agency/ planning.asp GTRI_B-97 Filename - 97 pandemic/agency/ index.asp

GTRI_B-98 Filename - 98 pandemic/agency/ agency.asp GTRI_B-99 Filename - 99 Business/Infrastructure Continuity Planning Human Resource Issues: Workplace open or closed? Why? How Long? Risks to employees and others

reasonable? Short and Long-Term Planning Influenza Management Team Communication Maintaining Essential Business Activities Who are the core employees? What are their skills? Who? Planning for absence Activation of plan?

Prioritizing services Infection Control: residents, staff, visitors, volunteers GTRI_B-100 Filename - 100 Business/Infrastructure Continuity Planning What affect of shortages of supplies/raw materials/personnel have on operations? Interrupted supply/delivery? How will staff and visitors be protected? Restricted entry? Personal hygiene (handwashing)? Workplace cleaning?

Ventilation system (HVAC)? Social distancing? Becoming ill at work? Deceased care? Personal Protective Equipment? GTRI_B-101 Filename - 101 If we are pandemic prepared then we are prepared for anything. GTRI_B-102 Filename - 102 GTRI_B-103

Filename - 103 Risk Communication Start with knowing your audience Develop FAQ list (example: Pre-Event Pandemic Message Maps) Communicate policies: Staff, residents, families Policies will be easier to accept if justification and rationale are explained BEFORE a crisis GTRI_B-104 Filename - 104 Training Fact:

Staff that are trained and comfortable with policies and expectations will be more likely to experience reduced stress and provide quality care during a crisis event GTRI_B-105 Filename - 105 Training - Example Hand Hygiene Step 1: Know your audience and key message Step 2: Brainstorm barriers or hurdles Poor adherence with hand hygiene: Handwashing agents cause irritation and dryness Too busy/insufficient time Patient needs take priority Lack of knowledge about guidelines/protocols No role model from colleagues or superiors Skepticism regarding value of hand hygiene

GTRI_B-106 Filename - 106 Training Example (Cont) Step 3: Develop training (and provide resources) to address identified hurdles Handwashing agents cause irritation and dryness Methods to maintain hand skin health Change hand hygiene agent Lack of knowledge about guidelines/protocols Reminders in the workplace Routine observation and feedback Administrative sanction/rewarding GTRI_B-107 Filename - 107 Who to TrainWhat to Train

Staff (Patient-care providers) Cross-train Volunteers/back-up staff Food services Facilities Housekeeping Human Resources Families of employees Residents Infection Control PPE use Respirator usage and requirements Occupational safety and health protocols Risk levels Facility policies Facility expectations

Families of residents GTRI_B-108 Filename - 108 GTRI_B-109 Filename - 109 Psychological and Behavioral Health Support Whats the need? Conflicting messages Conflicting actions: community vs work-related Ethical dilemmas Overwork and extra work vs. restricted work Stigma GTRI_B-110 Filename - 110 WORKSHOP Using HSC National Strategy for Pandemic Influenza Implementation Plan (HSC Stage 0,1) Develop planning and decision-making strategies for response: define roles Understand how to access state and federal information and supplies Set-up communication pathways Identify supply chain issues

Calculate needs GTRI_B-111 Filename - 111 Key Resources GTRI_B-112 Filename - 112

Contact Information Hilarie Schubert Warren, MPH Industrial Hygienist Health Sciences Branch Georgia Tech Research Institute 430 10th St NW, North Building Atlanta, GA 30332-0837 PHONE (404) 407-6255 FAX (404) 407-9256 email: [email protected] website: Information Provided under OSHA Susan Harwood Grant #SH-16620-07-60-F-13 GTRI_B-113 Filename - 113

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