Pandemic Influenza Preparedness

Part 3: Strategies to Support Continuity of Operations

Occupational Safety and Health Course for Healthcare Professionals

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

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• 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?

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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?

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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!

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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.

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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!

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• Engineering controls involve making changes to the work environment to reduce work-related hazards.

• Work practice controls are procedures for safe and proper work that are used to reduce the duration, frequency or intensity of exposure to a hazard.

• Administrative controls include 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.

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Keys to success with all of these strategies:

* Consistency

* Individual accountability

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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.

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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.

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

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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.

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• 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.

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• 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.

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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

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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.

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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).

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Occupational Risk Pyramid for Pandemic Influenza

Respirator Recommended:Consider higher level respirator (e.g., PAPR)

Facemask Recommended;Consider a Respirator

Facemask or Respirator Not Recommended

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Respirator Recommended

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

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Respirators versus 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.

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Facemasks

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).

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• 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.

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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”29

Labeling on a Surgical N95 Respirator

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Respirators – Other Considerations

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.)

Elastomeric respirators for workers who may have to decontaminate and re-use respirators in case of a shortage of N95s.

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.

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Respiratory Protection for Very High Exposure Risk Workers

A written respiratory protection program is required as part of the Respiratory Protection standard* and must include procedures for:

Selection of respiratorsMedical evaluation of workersFit testing of workersProper use by workers Maintenance and care by workersEnsuring adequate air quality, quantity and flow of air for atmosphere-supplying respirators Training of workers in proper useRegular program evaluation Recordkeeping

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Respiratory Protection Program

*29 CFR 1910.134

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.

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Strategies for Each Exposure Risk Level

For All Exposure Risk Levels: Good daily hygiene practices, cleaning of work spaces, awareness of their potential exposures, use of facemasks or respirators.

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.

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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?

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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!

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• 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.

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

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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.

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• 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.

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• 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.

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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.

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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.

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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)

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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?

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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.

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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)

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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.

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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.

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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.

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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.

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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.

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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.

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Sharing the facts. Making the vaccine easily available. Enlisting the aid of other employees, employee health

staff to talk with employees. Assuring that patients and visitors receive the factual

information about the vaccine.

Let’s try this!

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A vaccine against a specific pandemic influenza takes months to develop, once the exact strain is identified.

Vaccinations against seasonal influenza and pneumonia (for select groups) can reduce co-infections and minimize pandemic effects.

2009 H1N1 vaccine availability is now widespread. A limited amount of H5N1 avian influenza vaccine is

being stockpiled.

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Not always a simple process! Guidelines provided by CDC and local health

departments. High risk groups initially. There is more than enough H1N1 vaccine for anyone

who wants it. How will you encourage others to access the H1N1

vaccine?

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Look at locations/processes in your community where people come together:

Stores, schools, churches, restaurants, banks, pharmacies, gas stations, transportation systems (buses, trains, airplanes, and airplane terminals) – many others.

To reduce non-occupational exposure: Awareness, good hygiene practices, avoiding high traffic times in locations that we must access, use of drive-through options, home delivery, web-based groups, discussions on internet/conference calls, avoidance of hand-shaking and usual greeting protocols.

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Critical importance of education. Avoid fears and misinformation. Consider increased use of internet and phones. Need to be realistic and proactive in our planning. Consider new ways of conducting business and social

connections with reduced exposure for everyone.

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Avoiding close contact; promote social distancing. Discourage sharing of phones, equipment, computers, I-

pods, etc – this will be particularly important with young people.

Minimize crowded close contact, such as meetings – what could you do instead?

Reduce unnecessary direct, in-person social interactions.

Promote health-enhancing activities: exercise, healthy eating habits, smoking cessation.

Encourage stress reducing activities.

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If your community has an Influenza Pandemic Preparedness Plan: review it, discuss it with community leaders, what is your part in it?

Be a part of updating the plan. If a state-wide plan exists: be aware of how it impacts

your business/community. Consider/discuss what the community has learned over

the past few months of this pandemic. Support education for the community – the more facts

people have, the better our efforts will be to minimize risk and illness.

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Need for regular review and updating: what has changed in your community, what are the demographic changes, service/industry changes?

Community agency response to individual business needs may be hampered in a Pandemic event – staff shortages, focus on keeping basic services available.

Transportation needs and vehicle maintenance will be important for every business and community.

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Key Strategy: Talk with your family in advance * Facts about influenza pandemics. * Plan for stockpiling certain foods/materials. * If schools are closed: what is our strategy? * If parents become ill: support structures and

help. * Need for good internet capability and

communications.

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Checklist of key questions/steps. Update when changes occur. Be realistic, but proactive. Family planning will make a great deal of

difference in our communities’ ability to minimize the impact of a pandemic event.

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Changes in how we deliver services, what services we deliver.

Changes in policies, procedures. Changes in equipment, both use and availability. Changes in care routines. Changes in workforce. Life style changes.

CHANGE IS NOT EASY!

Many different approaches

“To put your ideas into action is the mostdifficult thing in the world.” Goethe

“Make it so.” Jean Luc Picard, Captain, Starship Enterprise

How do we feel in the midst of a change? If the change does not affect us, how do we feel? If the change is forced on us, how do we feel? If the change does not fit our usual routine, how do we

react?

In a Pandemic, we will be forcing changes on employees, patients, families, our communities, that

will create a variety of reactions!

Every system is perfectly designed to get the results it gets.

Every change has both a technical and a social aspect. Technically rational changes can fail if the social aspects

of change are not handled well.

“ It’s not so much that we’re afraid of change, or so in love with the old ways, but it’s that place in between that we fear…it’s like being between trapezes. It’s Linus when his blanket is in the dryer. There is nothing to hold on to.”

Marilyn Ferguson, American Futurist

Usual approach to change in healthcare is……

Time frame for change is………

Immediate action is considered good for………

Spend time with innovators and early adopters. Make the “attractors” to changing obvious – WIIFM? Reduce barriers to compliance – make it easy to do the

right thing. With those that resist change – listen, mandate if you

must, but move on. In a Pandemic Influenza Event, we will all have a strong

personal motivation – protecting our health and the health of our families!

Technically good ideas will fail to be sustained if we ignore social aspects.

Ideas that are sustained are advantageous, compatible, simple, can be tried easily, and outcomes can be observed.

Work with attraction for change rather than always fighting resistance.

A sense of urgency! In a Pandemic, we will not lack a sense of urgency – or

panic. Recognize the emotional and physical constraints the

changes will impose. A spirit of teamwork. Information – everyone needs to know the latest,

accurate information!

Let’s do some planning. Select one focus area for a Pandemic Preparedness

Plan (for your department/organization). Discuss with the person next to you one or two specific

actions you can take. What resources will you need? What changes will

these actions mean for you and other employees?

• Develop, reassess and update a disaster/business continuity plan that addresses an Influenza Pandemic.

• Strongly encourage and facilitate seasonal flu vaccinations.

• Monitor and promote good hygiene practices.

• Community planning and family planning efforts.

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