FAQs June 26 TOWN HALL (REHAB)
- Staff have been asked to change their clothes on site to support patient safety. How often are the locker rooms being cleaned to support staff safety?
- We have put in lots of enhanced cleaning on site and will update this answer with the actual frequency.
- Are the cleaning staff, meal services, and maintenance staff separated between rehab and long term care?
We do have staff that are separate to both sides of the facility. But at the same time, we have shared staff and that includes housekeeping, facilities and food services. It's very important, as much as possible, to separate those staff. Most of you will be aware of the single site order that applies to long-term care facilities. Any staff at an outbreak facility, or at any long-term care facility, should only work at that facility in the time of COVID. There are exceptions to the current order for physicians, nurse practitioners and pharmacists, but we make every effort to ensure those individuals don't put others at risk.
The EOC (Emergency Operations Centre) was key to us figuring out how to tease apart each one of those separate services, make sure we have separate staff flow, make sure we keep people on separate floors. We've taken our time to make sure they're completely separate.
The reason we've waited as long as we have is because we want to make sure we got a full incubation period under our belts with no new cases and none identified on the rehab side. And we want to make sure that the full incubation period is from the time when we are confident enough that we have separated the facilities, including all the staff, so that there is no risk upon reopening to those in the public.
Testing, Symptoms & Transmission
- Myself and a number of my colleagues from HFH Rehab have not been contact-traced during this outbreak. Should all staff have been contacted?
- Contact tracing refers specifically to people who may have been exposed to the virus. Typically at the start of an outbreak we do endeavor to call every single staff member who works in that building to make them aware of the outbreak situation, to provide education and counseling, and inform them how they would get tested if they needed to. It is possible that we didn't reach everybody. If there are people that haven't been reached, they can call us at our local public health number: 604-675-3900. You can ask to speak to one of our public health nurses and let them know that you work at Holy Family Hospital rehab.
- What policies/supports do we have in place to ensure patients that are pending swab results (or are positive) stay inside their room and reduce risk of spread?
Every case is different and it's important that we communicate to our patients when we're doing the testing, the reason for it. We try to communicate that clearly and use all the different strategies, working with the patient and their family, so they understand why testing is done and the importance of preventative measures, including physical distancing, to reduce spread.
There are challenges with patients who have cognitive impairments. We need to look at the use of alternative methods, such as iPads or other communication devices, to allow patients to connect with their family members, especially if we're not sure of their status and swabs are pending, or if they are identified as positive cases.
This speaks to a much more complicated process where input from everybody will be required. How do we work with these patients to ensure precautionary isolation and also reduce the potential for spread to other patients in the same setting? It is a fair question, and one that we haven't necessarily been able to answer. As we all recognize, the same process can’t be applied to every patient. We need to sit down and draw up a strategy for harm reduction and risk mitigation so we can move forward.
- If it could spread on cruise ships (central air system) and best practice for SARS patients is to use negative pressure rooms, how can we ensure it does not spread in the ECU?
There have been a lot of media headlines about cruise ships. People often refer to the Diamond Princess. As they saw more people on that cruise ship become infected, there were initial concerns that it was related to the heating, ventilation and air conditioning system. However, those were hypotheses. And while it's still a possibility that that occurred, the most recent research published, although not yet peer reviewed, says that the majority of cases on cruise ships that developed over the period of the outbreak were related primarily to contact and fomite transmission as well as respiratory droplet transmission, as opposed to airborne transmission from heating, ventilation and air circulation systems. At Holy Family Hospital we confirmed early on from facilities management that the air intake is 100 percent fresh air and exhausted through filters without recirculation. That was in place when the outbreak was declared.
As for negative pressure rooms, we have identified those rooms for individuals where we are performing aerosol generating medical procedures where the risk is higher. With each procedure, the risk is different and these are all determined based on previous studies of how procedures can generate aerosols, although the science continues to evolve. We've done our best to create negative pressure rooms in situations where aerosol generating medical procedures are required. At the facility we did so yesterday when it was determined that one of our residents in the extended care unit was positive for COVID. And so that change in the physical infrastructure in the environment occurred.
- The BCCDC has guidelines on risk of transmission between health care providers/patients, including both parties wearing masks. Why are inpatients not wearing masks?
- For baseline personal protective equipment for providers or staff, the mask is one of one of the pieces of personal equipment that’s indicated. For patients, at least for the acute care side, when patients have symptoms and are having an interaction, if the patient can tolerate wearing a mask, that also can be offered. However, we don't force individual patients to wear masks because they may have circumstances that may make it challenging, including respiratory problems. So masks aren’t mandated for acute care patients, except those for those who have symptoms and are having close interactions, then it can be offered.
- Long term care is getting an environmental swab. Will it include the previous shared entrances/ washrooms/ locker room? Will rehab be swabbed as well?
Vancouver Coastal Health has had a number of outbreaks. Some outbreaks have been more extensive than others. After we put all the outbreak measures into place and we've gone through an incubation period, it’s useful for our public health staff to go in and take swabs of high touch areas and equipment that may have virus on it, depending on PPE practices. That can be very useful because it helps us target any reservoirs of virus that still exists in the facility. We can narrow in where we need to improve, we can figure out where some of the risks may be, and that helps tailor our approach to curb the outbreak faster than we would otherwise.
We do have a public health team swabbing the long-term care side. The reason for that is because that is where we have the transmission network. We have tested extensively and we do not see COVID on the rehab side so there’s no particular benefit in swabbing rehab at this point.
Swabbing will include things such as washrooms, staff rooms, any kind of shared areas. Examples of things we've found virus on during previous outbreaks are blood pressure cuffs, water coolers. This has helped us remove things that were high risk, and it's helped us apply learnings to this outbreak such as dedicated blood pressure cuffs, or disposable pressure cuffs for all the patients, to continue to decrease that risk and to get this outbreak under control.
The standard of practice of continuous decluttering, basic hand hygiene practices, basic adherence to our infection control practices, those are probably our bigger wins. This outbreak has magnified the importance of some of this ongoing routine work that we need to engage in.
- Patients who get discharged are following the self-quarantine rule for 14 days. Is it safe for rehab staff to go to public places?
Patients who are discharged from rehab at this point are followed along by public health for 14 days because they've been in a facility that’s currently under outbreak so there is a small risk that they could have been infected and would be incubating. We follow them to make sure they stay healthy and if they are to develop symptoms we make sure that we connect them with testing and proper assessment.
As to the question of whether it's safe for rehab staff to go to public places, yes. The reason being is that everyone going to work now is using PPE and that protects them, provided that it's used appropriately. And so if people are using PPE in the context of an outbreak situation where there is transmission, we do not consider those people exposed, and therefore there is no risk of them incubating.
Nothing is perfect and we always want to keep improving our IPAC and PPE practices. But given that we maintain that firewall between us and any chance of being infected in a facility, then it's absolutely safe for people to go to public places. That's also true for their family members.
- What education do different departments/contracted services (e.g. housekeeping, lab etc.) have to ensure their staff are following proper infection control measures?
- There’s all-staff orientation, and one of the modules is infection prevention and control. Our focus goes back to the basics of hand hygiene, the use of PPE and point-of-care risk assessment. Our contracted service housekeeping, through Crothall, also has in-house training for basic infection prevention and control procedures, and we rely on working with them. They have their own orientations, as well as check-ins with the IPAC team. For lab staff, during orientation they have the basics of infection control, and there are regular in-services throughout all departments that we conduct on a routine basis prior to this outbreak. Once the outbreak was declared, IPAC staff and staff from the Rapid Response Team, were there to assist with questions and remind staff members of proper donning and doffing of PPE.
Patient Health and Safety
- Can we have increased support when patients are in isolation? Patients have left their rooms because they forget or they choose to not follow the rules.
With rehab patients, a big part of our intervention revolves around how we restore their functional capacities. A lot of that revolves also around giving them a naturalistic environment within our center as possible so that they are engaged in various daily activities. That involves socialization with their peers, whether it's in the dining room or common space. Since the outbreak was declared, and even since the COVID response was initiated back in March, we’ve been strategically looking at physical distancing, altering our environment to ensure that we maintain an opportunity for patients to have social interactions, while also following physical distancing and infection control measures.
We do have some challenging cases. There are patients who smoke, who go outside and risk coming together in close proximity. We have done a lot of education one-on-one. We have had very diligent practice from our nursing staff in terms of not just encouraging hand hygiene, but also having ongoing discussions with particular patients around the need for physical distancing and wearing masks wherever possible.
We ask them to do these things not because we are enforcers of rules or we're trying to take away their rights, but because we are genuinely concerned about their care and well-being. It’s about adopting a caring approach, and also being transparent about the risks involved. We have learned in the past that having a one-to-one sitter, having someone follow them, these are not successful measures. In fact, they create more pushback from our patients.
There are challenges related to some of the cognitive and behavioral issues and we do have to really take a case by case approach and see what works.
Staff Health and Safety
- If LTC staff are all wearing proper PPE, what were the possible reasons the eight staff caught the virus?
We know that PPE is effective when used perfectly, but we don't always do everything perfectly. We can always be better with our infection prevention and control practices. On the whole, we have brought COVID transmission down to incredibly low levels, and we've kept it largely out of our acute care facilities. Every now and then, we do have breaks in PPE. People can make mistakes here and there and that’s how it's possible that staff may have infected themselves. And there is transmission in the community too. Individuals who may have caught it in the community can bring it into care facilities if they're not careful.
The reason this virus is as successful as it is, is because the symptoms are very mild. It's challenging for people to recognize those symptoms, and they may not notice that they are getting sick until about a day after they've started shedding the virus to others.
The main message here is that we know PPE works, we need to recognize that we can always be better with our infection control practices. That is the key to preventing infections and ending outbreaks.
None of these interventions alone is going to be 100 percent effective and that's why they have to be used in conjunction. The important thing is to remember all those interventions that are occurring will interact and hopefully successfully control this outbreak. We can't isolate one intervention and just assume that PPE alone is going to be the main thing that's going to protect individuals.
- Are there plans to create a staff break area that accommodates physical distancing, that is not in a patient area, and can be used all times of the year?
Are there plans? No, not in detail at the moment. But are we thinking about this? Absolutely.
We really do need to take the opportunity now to think about what we have learned in the last three weeks. What are things that we should keep going forever? And what are things which are just temporary outbreak responses? We will be doing a debrief of what we’ve learned, what we should be doing, and also ongoing improvements.
- Do we have to self-isolate when returning from travelling (flying) to another province?
If you travel outside of Canada, there is a federal requirement for people to self-isolate for 14 days. If you did contract the virus overseas, you would develop symptoms within those 14 days. And so that's how we prevent further spread in the community.
Currently, there are no interprovincial restrictions for travel in BC. If you have been to another province that has COVID transmission, you do not have to self-isolate when you come back. People should still be vigilant. If you're coming from a province that has a high degree of transmission, like Quebec or Ontario, then, the best thing to do may be to self-isolate.
There are exceptions for some essential healthcare workers. But on the whole, if people can stay home, then they should stay home.
- Re: temp accommodation in hotels. Is it OK for staff who work in a “non-outbreak” unit to be in the same hotel as staff who work in an “outbreak” unit/area?
The entire Holy Family facility, both rehab and long term care of this point, are considered on outbreak. If people are using appropriate PPE, they are not at risk, they have not been exposed. So it is safe to stay in that same hotel. People aren't perfect, and they may get infected. And if that does happen, we would move those people to a separate hotel that is set up for COVID positive people, and we make sure that those hotels are cleaned appropriately. Once there is risk, we make sure we address it. But until that point, the majority of people will be just fine using PPE and will not get infected, so it is safe.
To clarify, the hotel offer that Providence has made is absolutely not compulsory. It is an offer for people who are within an outbreak facility, and it's just to make life, hopefully, a little bit easier for you, in recognition that it is a really difficult time.
- What are the learnings from this HFH LTC outbreak that we can apply to hopefully prevent any outbreak in HFH rehab, or to contain an outbreak if it occurred?
There have been a number of outbreaks in Vancouver Coastal Health and Fraser Health and we have learned, collectively as Team BC, from all of them. We’re continually improving our infection control practices. For instance, one of the things that was done back in March was to ensure that people only worked in one long-term care facility, with some defined exceptions. That was a very painful decision to make, it was really impactful on those staff. But it’s something that has really helped BC moving forward. There will be these ongoing learnings and we will continue to get better and better. And that's what we at Providence are about as an organization.
The hope is to start up rehab again next week and that means we would remove the outbreak from the rehab facility; it would stay on for the long-term care facility. But that doesn't mean we're going to stop doing all the things that we're doing to prevent an outbreak.
We're going to take this opportunity to really look at how we can add to this plan we have, finding and looking at how we can continually get better and become more responsive and resilient to this changing world with COVID. COVID was the platform for us to review our practices and to review where our gaps are, those same principles can be applied to any outbreak, and any sort of prevention strategies or planning moving forward.
One of the messages, as a reminder, is if you have mild symptoms please don't come to work. Assess the symptoms, report as per your usual practices if you're ill, and if your symptoms are compatible with COVID then get tested.
- Will all safeguards we put into place, and separation of physical and operations still continue, to avoid either floor from shutting down in a repeat scenario?
- We have gone through a painstaking process to make sure that we teased apart the two facilities, and we'd like to see that remain in place going forward. The learnings we had from extensive view will not only prevent COVID outbreaks, but other outbreaks as well. It makes everyone safer. It's a bit of a challenge from a staffing perspective, and so we will still have to manage that for the long term. But overall, this is the approach we will keep in place. Even when we remove the outbreak declaration from the rehab side, we'll continue to have these processes in place that they're separate.
- Will HFH staff be getting daily updates on the outbreak status again as this seems to have changed recently?
- We started off the updates on a daily basis and as things changed through the outbreak we reassessed the frequency because there could be information overload. Feedback from staff is important. If the request is to have daily updates, we can accommodate that. We also want to balance the information that goes out from IPAC, from PHC Communications, from PHC News.
- Are there any longer term strategies/plans on how to minimize the risk for another outbreak in a setting like Holy Family Hospital?
We are very early in this, and we are still in a learning phase. In the longer term, we know the fundamental issue is we have a building that is very constrained. Having long-term care residents living in four bed bays makes infection control really challenging. It also impacts quality of life. We at Providence have always had an ambition to deliver long term care for seniors in a facility where we would genuinely like to spend the last years of our life.
We have plans, which we are moving forward on, for a fundamental rebuild, renovation and creation of Dementia Villages for long term care, in which every resident has their own room, their own bathroom and lives in a facility where they can congregate with people they want to be with.
In the interim, we will absolutely think through what else we can do to prevent the likelihood of another outbreak.
- Can hand sanitizer be set up on both sides of the locker room doors?
- Yes, we will see if we can set that up.
If you need to reach PHC’s Infection Prevention and Control Team (IPAC), please call local 69357. Do not contact individual IPAC team members.