Pandemic Influenza Preparedness Part 3: Strategies to Support Continuity of Operations

1. Pandemic Influenza Preparedness Part 3: Strategies to Support Continuity of Operations Occupational Safety and Health Course for Healthcare Professionals

2. Risk Assessment • Reducing risk of employee exposure • Strategies related to each aspect of the Plan • Employee involvement • Community connections • Prevention • Reviewing and updating plans • Resources

4. Very high exposure risk : Exposure to high concentrations of suspected or confirmed sources of pandemic influenza during specific medical or laboratory procedures. • High exposure risk : High potential for exposure to suspected or confirmed sources of pandemic influenza virus. • Medium exposure risk: Requires frequent, close contact (within 6 feet) exposure to others. • Lower exposure risk (caution): No frequent close contact (within 6 feet) with others. Where do your staff/employees fall on this list?

5. Critical first step • Assess each task for potential risk. • Determine how close does the employee need to be to other workers or customers, how often does this happen, and do they have contact with individuals who are suspected or confirmed to have the pandemic influenza virus?

6. Work with your planning team to assess: * How much public contact do your individual employees (by role) have? * Do you have employees that need to leave the primary location to deliver materials or provide services to the public? * How frequently (and in what numbers) does the public visit your primary locations? Reassess your Risk Assessment whenever you add/change a service or new department!

7. Important to collaborate with employees on this assessment – they know their roles, how they carry out their tasks and routines. • Employees in the same workplace may have different exposure risks. • Reassess whenever you change or add a service, new department or location.

8. Once risk assessment is completed: Next Step: Developing/implementing strategies to reduce employee exposure. Time to reconsider the Hierarchy of Controls and focus attention on multiple ways to help employees stay healthy!

9. Engineering controlsinvolve making changes to the work environment to reduce work-related hazards. • Work practice controlsare procedures for safe and proper work that are used to reduce the duration, frequency or intensity of exposure to a hazard. • Administrative controlsinclude controlling employees' exposure by scheduling their work tasks in ways that minimize their exposure levels. • Personal Protective Equipment (PPE) includes all clothing and other work accessories designed to create a barrier against workplace hazards.

10. Keys to success with all of these strategies: * Consistency * Individual accountability

11. Current challenge with this: improper and infrequent hand-washing or use of alcohol-based cleansers. • Strategies to encourage: * Demonstrate proper technique * Make the materials/supplies/facilities easy to access, close to all work areas. * Monitor compliance. * There will be more motivation to comply, in the midst of an Influenza Pandemic.

12. Encouraging this with all employees and customers. • Consistent messages! • Providing adequate facilities and materials. • Monitor use and consistency of practices. • We all need to practice this every day.

14. Individual to individual • What is the usual business distance? • How do you make this happen in your business?

15. Assess/enhance air handling systems as needed. • Installing physical barriers in appropriate locations (clear plastic sneeze guards). • Encouraging cleaning of work surfaces by employees every day – computer keyboards, telephones, desk surfaces, etc. • Consider how many shared work surfaces/equipment you may have! • Alcohol based hand cleansers, hand washing facilities – provide easy access and teach proper technique. • Control of entry and egress to the facility.

16. Develop policies that encourage ill employees to stay at home without fear of any negative consequences. • Screening of employees upon entry/at start of their work day for S&S of influenza. • Support less face-to-face contact between employees such as meetings – encourage use of e-mail, web-conferencing and teleconferences.

17. Be creative and inventive: encourage flexible work arrangements such as telecommuting or flexible work hours to reduce the number of employees on any one site; carefully assess IT capacity to support any change. • Share information and updates on policies, procedures, and supplies with employees. • Maintain a forum for answering questions and addressing employees‘ concerns.

18. OSHA provides up to date guidance on personal protective equipment including respiratory protection. • Risk assessment guide. • Use of masks and respirators based on tasks. • Important to review OSHA standards on PPE: 29 CFR 1910.132-1910.138

19. Selected based upon hazard to the employee. • Properly fitted, some must be refitted periodically (respirators). • Conscientiously and properly worn. • Regularly maintained and replaced as needed. • Properly removed and disposed of to avoid contamination of self, others, or the environment.

20. Must provide PPE at no cost to employee. • Must assess all work environments for potential hazards. • Must provide training to any employee who uses any PPE. • Must pay for replacement of any required PPE (some exceptions apply).

21. Occupational Risk Pyramid for Pandemic Influenza Respirator Recommended: Consider higher level respirator (e.g., PAPR) Respirator Recommended Facemask Recommended; Consider a Respirator Facemask or Respirator Not Recommended

22. Respirators Designed to reduce workers’ exposure to small airborne contaminants Both disposable and reusable respirators are available NIOSH-Certified Facemasks (e.g., Surgical Masks) Worn by workers as a physical barrier to protect against splashes of large droplets of blood or body fluids Worn by healthcare workers to prevent contamination of patients’ wounds Placed on ill persons (if tolerated) to limit the spread of disease FDA-Cleared Respirators versus Facemasks

23. Facemasks • FDA-cleared surgical, medical, procedure, dental, laser and isolation masks (surgical masks are the most common type). • FDA-cleared facemasks have been tested for their ability to resist blood and body fluids. • Provide a physical barrier to protect workers from splashes of blood and bodily fluids. • Do not provide respiratory protection. • Do not provide a tight seal. • Not designed or certified to prevent inhalation of small airborne contaminants.

24. Respirators reduce an employee's exposure to airborne contaminants. • Most respirators are designed to provide a tight seal between the respirator's edge and the wearer’s face. • Respirators must be used in the context of a comprehensive respiratory protection program (see OSHA’s Respiratory Protection standard – 29 CFR 1910.134).

25. Entire facepiece is comprised of filter material. • Different classes: N, R, or P based upon resistance to oil. • N –Not oil-resistant; • R – Somewhat oil-Resistant; • P – Oil-Proof • N95s are the most commonly used class. • Some filtering facepiece respirators have an exhalation valve; reduces breathing resistance and moisture buildup. • Not to be used when there is a need to protect others from possible contamination by the wearer.

26. Labeling on a Surgical N95 Respirator Manufacturer’s name and part number Name of device “Health Care Particulate Respirator and Surgical Mask” An abbreviation to indicate class and filter efficiency (e.g., N95, P100, etc.) Certified by “NIOSH”

27. Respirators – Other Considerations Elastomeric respirators for workers who may have to decontaminate and re-use respirators in case of a shortage of N95s. PAPRs for workers who may have to re-use respirators, wear them for a long time and/or be exposed during very high exposure risk tasks (e.g., intubation of patients, culturing the virus, etc.)

28. Respiratory Protection for Very High Exposure Risk Workers • Use NIOSH-certified N95 or more protective respirators (i.e. Powered Air-Purifying Respirators) • For aerosol-generating procedures • For laboratory procedures that involve handling and/or manipulating viral cultures.

29. Respiratory Protection Program A written respiratory protection program is required as part of the Respiratory Protection standard* and must include procedures for: • Selection of respirators • Medical evaluation of workers • Fit testing of workers • Proper use by workers • Maintenance and care by workers • Ensuring adequate air quality, quantity and flow of air for atmosphere-supplying respirators • Training of workers in proper use • Regular program evaluation • Recordkeeping *29 CFR 1910.134

30. Strategies for Each Exposure Risk Level • Very High & High Exposure Risk: provide fit testing, medical evaluation, and adequate numbers of respirators for each employee; provide training in use, re-use, replacement, disposal. • Medium Exposure Risk: provide facemasks in adequate numbers for employees; provide training in appropriate use, length of use, disposal. • Low Exposure Risk: facemasks or respirators not recommended. For All Exposure Risk Levels: Good daily hygiene practices, cleaning of work spaces, awareness of their potential exposures, use of facemasks or respirators.

31. 29 CFR 1910.134 (k) – very specific requirements on education and training materials/content. • The education and materials must be easily understood by employees. • Available in the language of the employee. • At the appropriate literacy level. • Need to document the training.

32. Does everyone who should wear this, do so, every time? • Are they fit properly? • Are they checked to be sure they are in good condition? • How do we encourage their use?

33. Notifying your customers & visitors: changes, procedures, access points to your organization and employees, hand cleanser use. • Signs for visitors: signs and symptoms of the flu, provide access to evaluation/care sites. • If necessary, limit access for customers: drive through and/or home delivery options where applicable; web/phone access for orders/questions; plastic guards in front of employees in areas where they interact with customers; hand cleanser materials easily available. • Work with employees to identify new ways to conduct your business and deliver your services!

34. Avoid close contact where possible (6 feet rule). • Keep work surfaces clean; provide cleaning materials to employees. • Discourage sharing of phones, desks, computers, etc. • Minimize crowded situations (e.g. meetings). • Reduce unnecessary social interactions. • Promote healthy lifestyle (nutrition, exercise, smoking cessation). Share information with all employees.

35. Essential Functions: * Financial/Operations * Supply Chain * Security • Human Resources • Communication • Information Technology • Community connections and government agency support • Employee Needs & Education

36. Electronic access for all financial management processes. • Securing cash at any site. • Operations – who will manage, who is back up, how will hours and locations of operations be affected: what could we do differently? Will some services decrease in need/size, will others increase? Who will need more of your service/goods? • Operations – work closely with HR on accessing necessary staff or volunteers; explore creative options! • Cross-training of current staff – providing training, tracking & scheduling.

37. Identify what you will need on hand for supplies: * can any of these items be safely stockpiled? * who will manage them? * consider shelf-life, storage facilities, and usage rate. • Storage capacity: be creative and realistic. • Remember: suppliers will not be able to maintain “business as usual” deliveries/amounts.

38. Are there other locations/businesses that you can partner with in your community? • Plan how your employees will manage deliveries – safety precautions. • Opportunity to look closely at all of the supplies you use and will need to use.

39. Will be dealing with visitors who are afraid; less accessibility to services, staff, and potentially their loved one; dealing with a frightened and potentially combative public. • Manage entry and exit from your business – will it be open to all, what security do you need, what signage/supports will be needed? • Secure supplies and materials. • Provide training to security personnel. • Coordinate with local and state agencies.

40. Strategies: Human Resources • Participate in assessing employee’s risk exposure level. • Revise employee policies as needed: sick leave policy, time off, working from home, payroll, benefits, etc. • Communicate necessary precautions to employees. • Provide materials and education. • Communicate, communicate, communicate! • Monitor compliance with policies, planned strategies/approaches.

41. Strategies: Human Resources • Dealing with staff shortages: who can fill in, what resources can you access, what qualifications or training will they need? • Policy considerations – if day care and schools close, what can you offer employees? • If you ask employees to work longer hours/more days: what convenience services can you provide? (food, rest areas, bank access, etc)

42. Providing facts and updates to: Employees Customers Patients/visitors Suppliers Community leaders/agencies Consider how many ways you can communicate and how often can you do updates….who will be responsible?

43. Frequent communication with all employees. • Use of a wide variety of communication media. • Share public health communications about the Influenza Pandemic with employees. • 5 X 5 approach: communicate each message 5 times in 5 ways! • Open forum option so that employees can ask questions – web, dedicated phone line, postings on bulletin boards with FAQ’s.

44. Plan in advance for easy connectivity/compatibility with emergency services, law enforcement, public health services, government agencies. • During an Influenza Pandemic, all businesses and employees will increase their reliance and use of information technology – for updated information, to replace meetings, to access resources, contact family, etc. • Plan now for the increase in use of all information technology! (Examples)

45. Critical importance of education for all employees in each business: * the hazards they may encounter. * definitions and facts. * exposure reduction measures. * use of PPE. * their organization’s pandemic influenza plan. * their accountability for complying with Standard Precautions as well as anything specific to their role/responsibilities.

46. Special focus: a. Training of Environmental/Housekeeping employees on cleaning procedures, careful hygiene and use of PPE. b. All employees will need access to cleaning supplies for their individual and shared work spaces/surfaces (alcohol wipes) and information on what, how, and when to clean surfaces.

47. Encourage all employees to get the annual flu vaccine; while no one is sure of the ultimate effect, it is thought that the regular flu vaccine may provide some protection. • Encourage employees who are at risk for complications due to the flu such as those over 50 or with a chronic health condition such as asthma to get the pneumonia vaccine. • In a pandemic, many people have died from the post-influenza pneumonia.

48. Seasonal Influenza: 1. VACCINATION!! * This is the primary prevention strategy. * Developed each year with the best knowledge of potential viral strains included. * Available in intranasal form (live attenuated) and injectable form (inactive attenuated). 2. Adherence to good daily hygiene practices.

49. Seasonal Flu vaccine is widely available most years. • Many healthcare organizations offer it free or at minimal cost to employees. • Available at community clinics, pharmacies, doctor’s offices, etc. • Current statistics: approximately 40% of US citizens get the flu vaccine.

50. History – I have never had the flu! • Beliefs in stories of the past. • One experience (misinterpreted) may decide the future for an individual! • I don’t like needles. • Availability – timing, access, simplicity of the process.