Infection Prevention Updates for Acute Care and Outpatient Settings
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Guidance and responses were provided based on information known on
5/12/2021 and may become out of date. Guidance is being updated rapidly,
so users should look to CDC and NE DHHS guidance for updates.
Infection Prevention Updates for
Acute Care and Outpatient
Settings
May 12, 2021
Questions and Answer Session
• Use the QA box in the webinar platform to type a question.
• Questions will be read aloud by the moderator as time allows.
• If your question is not answered during the webinar, please e-mail it to Nebraska ICAP or call
during our office hours to speak with one of our Infection Preventionists (IPs).
• A transcript of the discussion will be made available on the ICAP website
• https://icap.nebraskamed.com/coronavirus/
• https://icap.nebraskamed.com/covid-19-webinars/
Presenters :
Gary Anthone, MD gary.anthone@nebraska.gov
Matthew Donahue, MD matthew.donahue@@nebraska.gov
Mark Rupp, MD merupp@unmc.edu
Rebecca Martinez, BSN, BA, RN, CIC remartinez@nebraskamed.com
Sarah Stream, MPH, CDA, FADAA sstream@nebraskamed.com
Panelists:
Daniel Brailita, MD dabrailita@unmc.edu
Richard Hankins, MD richard.hankins@unmc.edu
Kate Tyner, RN, BSN, CIC ltyner@nebraskamed.com
Jody Scebold, EdD, MSN, RN jodscebold@nebraskamed.com
Lacey Pavlovsky RN, MSN, CIC lpavlovsky@nebraskamed.com
Moderator:
Margaret Deacy mdeacy@nebraskamed.com
Learning Objectives During this series, participants should be better able to: 1. Recognize infection prevention and control issues for application of the recommendations to mitigate these issues. 2. Identify resources on infection prevention and control that will be helpful to mitigate infection prevention and control challenges. 3. Describe latest updates on COVID-19 pandemic related to infection prevention and control practices in acute and outpatient settings. Target Audience Healthcare professionals working in acute and outpatient settings. To include medical directors, nursing staff, directors of nursing, infection preventionists, quality program leaders, administrators, consultant pharmacists or other staff working in long-term care settings.
Mission and Goals To provide an educational venue that connects infection preventionists and providers from acute and outpatient facilities across Nebraska with the objective of promoting the latest research and best practices in infection prevention and control. These educational webinars are aimed to help promote and strengthen the Nebraska infection prevention and control infrastructure. The goals for this educational activity include: 1. Increase knowledge of infection control processes for acute and outpatient settings. 2. Increasing awareness of specific infection prevention and control issues that may be confronted in acute and outpatient settings. 3. Provide resources to attendees to help them with infection prevention and control efforts in their own facilities. 4. Provide resources to attendees on the most up to date COVID-19 pandemic related guidance and recommendations.
Continuing Education
1.0 Nursing Contact Hour is awarded for the LIVE viewing of this
webinar
Nebraska Medicine is approved as a provider of nursing continuing
professional development by the Midwest Multistate Division, an accredited approver by
the American Nurses Credentialing Center’s Commission on Accreditation.
In order to obtain either contact hour, you must be present for the entire live webinar
and complete the post webinar survey
No conflicts of interest were identified for any member of the planning committee,
presenters or panelists of the program content
This CE is hosted by Nebraska Medicine and UNMC along with Nebraska ICAP and
Nebraska DHHS
Continuing Education
1.0 AMA PRA Category 1 Credit™ for Physicians offered by UNMC is awarded
for the live viewing of this webinar
In support of improving patient care, University of Nebraska
Medical Center is jointly accredited by the Accreditation Council
for Continuing Medical Education (ACCME), the Accreditation
Council for Pharmacy Education (ACPE), and the American
Nurses Credentialing Center (ANCC), to provide continuing
education for the healthcare team.
The University of Nebraska Medical Center designates this live
activity for a maximum of 1 AMA PRA Category 1 Credit™.
Physicians should claim only the credit commensurate with the
extent of their participation in the activity.
Disclosure Declaration As a jointly accredited provider, the University of Nebraska Medical Center (UNMC) ensures accuracy, balance, objectivity, independence, and scientific rigor in its educational activities and is committed to protecting learners from promotion, marketing, and commercial bias. All faculty, planner and others in a position to control continuing education content participating in an accredited continuing education activity are required to disclose all financial relationships with ineligible companies. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. The accredited provider is responsible for mitigating all relevant financial relationships in accredited continuing education. Disclosure of these commitments and/or relationships is included in these activity materials so that participants may formulate their own judgments in interpreting its content and evaluating its recommendations. This activity may include presentations in which faculty may discuss off-label and/or investigational use of pharmaceuticals or instruments not yet FDA-approved. Participants should note that the use of products outside currently FDA-approved labeling should be considered experimental and are advised to consult current prescribing information for FDA-approved indications. All materials are included with the permission of the faculty. The opinions expressed are those of the faculty and are not to be construed as those of UNMC. The accredited provider has mitigated and is disclosing identified relevant financial relationships for the following faculty, planners, and others in control of content prior to assuming their roles: FACULTY The faculty have nothing to disclose: Matthew Donahue, MD Mark Rupp, MD Gary Anthone, MD Richard Hankins, MD Rebecca Martinez, BSN, BA, RN, CIC Sarah Stream, MPH, CDA, FADAA PLANNING COMMITTEE The planning committee members have nothing to disclose: Kate Tyner, RN, BSN, CIC Jody Scebold, EdD, MSN, RN Jean Ellis, DHHS Lacey Pavlovsky RN, MSN, CIC
COVID-19 in Nebraska
Nebraska DHHS Updates
Dr. Gary Anthone, MD
Chief Medical Officer, DHHS
• Decrease 17 pts (+11,-14,0,+36,+29) • 7 day average of 3.3% of staffed hospital beds occupied by Covid Pts (3.4,3.7,4.2,4.2,3.2) • 29% of COVID pts are in ICU (30;36;24;24;30) • 29% of COVID pts in ICU are on vents (25;36;41;41;38) • 10% of statewide ICU pts are COVID pts (11;12;11;14;12) • Average of 12 COVID pts Admits statewide 1 Day
11/22 ---
135/Da y
Nov 22,
2020---
135/Da y
4/2
4
26 18 19 21 14 13 13 12 14 20 22 16 16Variants in Nebraska
Nebraska DHHS Updates
Dr. Matthew Donahue, MD
Medical Epidemiologist Intelligence Service Officer , DHHSVariant, Reinfection, and Vaccine BT Updates
• 875 variants of concern (VOC) identified among Nebraska residents
• 764 B117, 12 P1, 6 B1.351, 87 B1.429/427, 6 B1.526
• Sequencing roughly 200 specimens per week, ~10% of positive NE specimens
• >90% of sequencing runs are VOCs; B117 remains predominant
• 214 possible reinfections, no substantial trends relating to outcome or VOCs
• 380 possible vaccine breakthroughs (BTs), most confident in 146 of these; 9
hospitalized, 1 died
• Two potential signals
1
Public Health Fusion Cell |
4COVID-19 Update: Vaccine-
Induced Thrombocytopenia
and Thrombosis, Vaccine
Hesitancy, and Vaccination in
Pregnancy
Mark Rupp, MD
Professor and Chief, Division of Infectious Diseases
Medical Director, Dept of Infection Control & EpidemiologyPfizer EUA expands to
ages 12 and older
Rebecca Martinez, BSN, BA, RN, CICFDA EUA Expansion on May 10th
• On May 10th, the Food and Drug Administration (FDA) expanded the emergency
use authorization (EUA) for the Pfizer-BioNTech COVID-19 Vaccine to include
adolescents 12 through 15 years of age
• https://www.fda.gov/news-events/press-announcements/coronavirus-
covid-19-update-fda-authorizes-pfizer-biontech-covid-19-vaccine-
emergency-use
• Advisory Committee on Immunization Practices (ACIP) meets 5/12/21
• Anyone handling or administering COVID-19 vaccine is to read the Fact
Sheet for Healthcare Providers Administering Vaccine (Vaccination
Providers) which is separate from the Fact Sheets given to patients and is
specific for each COVID-19 vaccine brand
• Fact Sheet for Healthcare Providers for Pfizer-BioNTech COVID-19
Vaccine
• https://www.fda.gov/media/144413/download
• It is very important to review the Fact Sheet to ensure safe vaccine storage and
handling, dose preparation, dosing and schedules, contraindications, vaccine
administration, and reporting requirements.
• https://www.cdc.gov/vaccines/covid-19/info-by-
product/pfizer/downloads/prep-and-admin-summary.pdfhttps://www.cdc.gov/vaccines/covid-19/info-by-product/pfizer/downloads/diluent-poster.pdf
Pfizer-BioNTech COVID-19
Vaccine – Withdrawing Vaccine
https://www.cdc.gov/vaccines/covid-19/info-by-product/pfizer/downloads/diluent-poster.pdf
Do NOT ever combine remaining vaccine from multiple
vials! Not for COVID-19 vaccine or any vaccine!U.S. Pharmacopeia (USP) COVID-19
Vaccine Handling Toolkit
• https://www.ashp.org/-/media/assets/pharmacy-practice/resource-
centers/Coronavirus/docs/FAQ-optimizing-covid-vaccine-prep-safety
• https://www.usp.org/covid-19/vaccine-handling-toolkitQuestions and Answer Session Use the QA box in the webinar platform to type a question Questions will be read aloud by the moderator in the order they are received A transcript of the discussion will be made available on the ICAP website Panelists: Mark Rupp, MD Daniel Brailita, MD Richard Hankins, MD Sarah Stream, MPH, CDA, FADAA Rebecca Martinez, BSN, BA, RN, CIC Kate Tyner, RN, BSN, CIC Jody Scebold, EdD, MSN, RN Lacey Pavlovsky RN, MSN, CIC
Nebraska ICAP
Updates
Nebraska ICAP Acute & Outpatient Assessments
Office Hours & Phone NumberRespiratory Protection Taskforce https://icap.nebraskamed.com/nebraska-respiratory-protection-task-force/
Respiratory Protection Taskforce https://icap.nebraskamed.com/nebraska-respiratory-protection-task-force/
PPE Requests from NE DHHS
Use this link to request support with PPE:
•PPE Request from NE
DHHS https://form.jotform.com/Nebras
kaDHHS/PPERequestForm
•This form goes to both the local health
department and NE DHHS
•Requests are for PPE needs for next 2
weeks.
•Requests must be made by
Wednesday 11:59 AM for next week
delivery.
•Local Health Departments are
responsible for approving requests,
work with them directly for urgent
needsAcute and Outpatient Services by Ne ICAP
ICAR Reviews for Acute and OP
• Infection Control Assessment and Response (ICAR) tools are used to
systematically assess a healthcare facility’s infection prevention and
control (IPC) practices and guide quality improvement activities (e.g.,
by addressing identified gaps)
• ICAP is offering COVID-19 virtual assessments to both Acute and
Outpatient Settings
• ICAP is offering Full, on site, Infection Control ICAR Reviews for
Outpatient Settings
• Contact NE ICAP at 402.552.2881 to be connected with an IP
• ICAP Request for Assessment and
Email Distribution:
https://nebraskamed.formstack.com/forms/
add_me_to_email_distribution_listInfection Prevention and Control
Office Hours
Monday – Friday
8:00 AM – 10:00 AM Central Time
2:00 PM -4:00 PM Central Time
Call 402-552-2881
Like us on Facebook by
scanning this QR code!Coming up! • The Acute and Outpatient webinar will be hosted on the Second and Fourth Wednesday of every month at 12:00 CST, Next Webinar: May 26, 2021 at 12:00 CST • If you have infection control topic suggestions, feel free submit them to Rebecca Martinez or Sarah Stream at remartinez@nebraskamed.com or sstream@nebraskamed.com • Register through the Facebook Event page or at: https://icap.nebraskamed.com/covid-19-cah-webinar-invite/
Webinar CE Process
1 Nursing Contact Hour is awarded by NE Medicine *
* Nebraska Medicine is approved as a provider of nursing continuing
professional development by the Midwest Multistate Division, an accredited
approver by the American Nurses Credentialing Center’s Commission on
Accreditation.
1 AMA PRA Category 1 CreditTM for Physicians offered by UNMC
CNE Nursing Contact Hours: AMA PRA Category 1 Credit™
➢ Completion of survey is required. Completion of survey is required.
➢ The survey must be specific ➢ The survey must be specific to
to the individual obtaining the individual obtaining credit.
credit. (i.e.: 2 people cannot (i.e.: 2 people cannot be listed
be listed on the same survey)
on the same survey)
➢ One certificate is issued monthly
for all webinars attended ➢ One certificate is issued monthly for
all webinars attended
➢ Certificate comes directly from
ICAP via email ➢ Certificate can be downloaded from
➢ Certificate is mailed by/on the 15th the UNMC CCE system directly,
of the next month they will email you access
➢ Survey functionality is lost on ➢ Survey functionality is lost on
mobile devices mobile devicesCOVID-19 Update: Vaccine-Induced
Thrombocytopenia and Thrombosis, Vaccine
Hesitancy, and Vaccination in Pregnancy
Mark E. Rupp, MD
Professor & Chief, Division of Infectious DiseasesPotential COI Dr Rupp reports serving as co-I on Novavax vaccine trial and PI on upcoming Covaxx vaccine trial; Dr Rupp has served as a consultant for 3M (maker of N95 respirators and other PPE)
COVID 19 Pandemic (05/10/2021)
• US/India/Brazil/
France/Turkey/
Russia
• US:
• Cases: 32.7M
• Deaths: 582K
• 40,000 new cases
per day in US
• 700 deaths per day
in US
https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6World COVID-19 Hot Spots
• ~160M cases
• 3.3 M deathsCOVID-19
United
States
7 Day averages (12/21/20) Hospitalizations:
New Cases: 216,163/d 12/21: 113,912
Deaths: 2680/dhttps://nebraska.maps.arcgis.com/apps/opsdashboard/index.html#/4213f719a45647bc87
Nebraska 3ffb58783ffef3 (05/10/2021)
New Cases
Hospitalizations
(~200/day; ~10 cases/100k/d)
(~120 current)
% Positive
(~4%-5%)Transmission of SARS CoV-2 Variants in USA
Clinical manifestations of COVID-19
Thrombosis with
Thrombocytopenia (TTS)
or Vaccine-Induced
Thrombocytopenia and
Thrombosis (VITT)Cerebral Venous Sinus Thrombosis (CVST) Following COVID Vaccination
T Shimabukuro. CDC COVID-19 Vaccine Task Force. ACIP 4/23/2021
T Shimabukuro. CDC COVID-19 Vaccine Task Force. ACIP 4/23/2021
T Shimabukuro. CDC COVID-19 Vaccine Task Force. ACIP 4/23/2021
T Shimabukuro. CDC COVID-19 Vaccine Task Force. ACIP 4/23/2021
Epidemiology of Cerebral Sinus Thrombosis (CVST) & Splanchnic
Vein Thrombosis (SVT) in United States
• CVST annual incidence of 14.5-28.5 per million
• Higher risk in women age 18-49
• Other risk factors: obesity, oral contraceptives, hereditary thrombophilia, etc
• Morality ~5%-10%
• SVT annual incidence of 84-179 per million
• Higher incidence in men and increases with age
• Incidence with thrombocytopenia much lower than without thrombocytopenia
• CVST with thrombocytopenia 0.7-1.6 per million
• CVST associated with COVID-19
• 5-6 cases per million infections
• Pathogenesis different than CVST after vaccine (do not have thrombocytopenia)
Source: S Oliver. CDC. ACIP Meeting. 4/23/2021.M Mammen. Janssen. ACIP Meeting. 4/23/2021.
Source: S Oliver. CDC. ACIP Meeting. 4/23/2021.
UK Experience with AstraZeneca Vaccine
• As of April 14: 168 reports of blood clotting with low platelets
• 77 cases of CVST, 91 cases of clots in other major veins; all with low platelets
• 93 women, 75 men; 32 deaths
• Rate: 7.9 per million doses
• Benefits outweigh risks
• Careful consideration given to those at higher risk of blood clotting
• Recommend ages 18-29 at low risk of infection to be offered other vaccines
Source: S Oliver. CDC. ACIP Meeting. 4/23/2021.Black Box Warning
Black Box Warning
Clinical manifestations of COVID-19
Vaccine HesitancyCOVID-19 Vaccination in the United States
COVID-19 Vaccination in US 5/10/21: 152.1 M (46%) population have received at least one dose; 114.3 M (34%) fully vaccinated. 83.6%/71.3% of population over age 65. 58%/44% of population over 18.
Vaccine Hesitancy & Vaccine Roll-Out •Convenience •Misinformation •Distrust due to past experience and abuse •Politicization •Foreign meddling
Vaccine Hesitancy & Vaccine Roll-Out
• Convenience
• Need for greater convenience
• Vaccine going to the individual vs individual going to the vaccine
• Opt out vs opt in
• Misinformation
• Trusted information sources with transparent data – good & bad
• Debunk the myths: microchips in the vaccine, female sterility,
regulation of menstrual cycles/miscarriage due to vaccine
shedding, alteration of DNA, etc
• Distrust due to past experience and abuse
• Acknowledge the past abuses
• Don’t let past mistakes create a new mistakeApproach to the person with vaccine hesitancy • Simply telling someone that their fear or hesitancy is irrational will not lessen their fear/reluctance • Ask open-ended questions and listen; treat person with respect; try to understand where the other person is coming from • Transparency and Accuracy • Acknowledge uncertainty; stress what is known • Emphasize desire to do good and protect others • Emphasize vaccination is the norm – people generally wish to belong to the larger group • Serve as a good example: Relate that you, your staff, and your family have been vaccinated
Vaccine Hesitancy & Vaccine Roll-Out
• Politicization
• Attempt to decouple public health issues from
political issues
• Elections matter- elect representatives who
support public health and science
• Meddling
• Educate public re: how social media is
manipulated
• Expose efforts to create controversy and
undermine democracyClinical manifestations of COVID-19
Vaccination in PregnancyCOVID-19 and Pregnancy
• Absolute risk for severe COVID-19 for pregnant women is low but higher than general population
• CDC data: 88,880 pregnant women in database; 15,004 hospitalizations (21%); 401 ICU admits; 99
deaths (0.1 %).
• 43 institutions, 18 countries. 706 pregnant women with
COVID19 compared to 1424 pregnant women without
COVID19.
• Higher risk for pre/eclampsia (RR 1.76), severe infections
(RR 3.38), ICU admit (RR 5.04), mortality (RR 22.3),
preterm birth (RR 1.59), severe neonatal morbidty index
(RR 2.66).
• Fever and dyspnea associated with increased risk of
complications (RR 2.56)
JAMA Pediatrics. April 22, 2021COVID19 Vaccination and Pregnancy
• CDC Guidance:
• “Pregnant people are more likely to get severely ill with COVID-19 compared with
non-pregnant people. If you are pregnant, you can receive a COVID-19 vaccine.
Getting a COVID-19 vaccine during pregnancy can protect you from severe illness
from COVID-19.”
• “Based on how these vaccines work in the body, experts believe they are unlikely
to pose a risk for people who are pregnant. However, there are currently limited
data on the safety of COVID-19 vaccines in pregnant people.”
• ACOG Guidance:
• “The American College of Obstetricians and Gynecologists (ACOG) recommends
that pregnant individuals have access to COVID-19 vaccines.”Shimabukuro, et al. April 21, 2021
• 35,691 pregnant V-safe participants aged 16-54
• “Preliminary findings did not show obvious safety signals among pregnant persons who received
mRNA Covid-19 vaccines. However, more longitudinal follow-up, including follow-up of large
numbers of women vaccinated earlier in pregnancy, is necessary to inform maternal, pregnancy, and
infant outcomes. “
“Injection-site pain was reported more
frequently among pregnant persons than
among nonpregnant women, whereas
headache, myalgia, chills, and fever were
reported less frequently.”Clinical manifestations of COVID-19
Vaccination in AdolescentsFDA EUA for Adolescents (age: 12-15) May 10, 2021 • May 10, 2021: Coronavirus (COVID-19) Update: FDA Authorizes Pfizer-BioNTech COVID-19 Vaccine for Emergency Use in Adolescents in Another Important Action in Fight Against Pandemic • Pfizer-BioNTech COVID-19 Vaccine is authorized for use in individuals 12 years of age and older. • 2,260 adolescents (1,131 Pfizer-BioNTech COVID-19 Vaccine; 1,129 placebo) were 12 through 15 years of age. Of these, 1,308 (660 Pfizer-BioNTech COVID-19 Vaccine and 648 placebo) adolescents have been followed for at least 2 months after the second dose of Pfizer- BioNTech COVID-19 Vaccine. • Adverse reactions in adolescents 12 through 15 years of age included pain at the injection site (90.5%), fatigue (77.5%), headache (75.5%), chills (49.2%), muscle pain (42.2%), fever (24.3%), joint pain (20.2%), injection site swelling (9.2%), injection site redness (8.6%), lymphadenopathy (0.8%), and nausea (0.4%).
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