[ Music ]
>> Good afternoon, everyone.
Thank you for joining us for our latest installment
in the series, "What Physicians Need to Know About COVID-19,
and Other Pressing Issues in Healthcare" -- excuse me.
I'm Dr. Susan Bailey, President
of the American Medical Association.
In previous webinars, we hosted representatives from the Food
and Drug Administration and the CDC.
We explored aspects of COVID-19 vaccine development,
allocation, and distribution.
Now, if you weren't able to join us for those sessions,
I encourage you to watch replays of the videos,
which are available for free on our website
at ama-assn.org/covid-19-webinars.
Or you can simply visit our main page and look
for COVID-19 webinars.
Today's webinar is a little different,
as we'll be introducing Project Firs Line,
the CDC's new comprehensive infection control training
initiative for millions of physicians
and healthcare personnel in the United States.
The goal of this new CDC-led collaborative is
to help prevent the spread of infectious diseases
in U.S. healthcare settings, including hospitals,
outpatient centers, nursing homes, and other facilities.
Healthcare professionals will learn
about effective infection control practices
through a series of online training modules,
town hall discussions, and telemonitoring
to empower physicians with the knowledge of how
to apply these control methods into their daily practices,
as well as the science and the reasoning behind them.
In fact, the training modules will soon be available
in the AMA Ed Hub, our online learning platform that is home
to hundreds of videos, audio files, podcasts,
and interactive CME training modules across specialties.
I also urge you to check out everything on the AMA Ed Hub
that the AMA has to offer, amaedhub.com.
As we all know, COVID-19 has exposed many significant gaps
that exist in our nation's health system
which have really hampered our ability to contain this pandemic
as cases once again begin to surge across the country.
Among the most important tools we have to prevent
and contain the next outbreak is improved infection prevention
and control strategies.
Project First Line is the result of collaboration
between the CDC, the AMA, and other healthcare, public health,
and academic partners, as well as dozens of state
and local health departments.
Today we are joined by Dr. Mike Bell, Deputy Director
of the Division of Healthcare Quality Promotion at the CDC.
Dr. Bell's career has focused on investigating
and preventing transmission of healthcare-associated illnesses
for hospital patients and staff.
He's here to answer your questions
so you can confidently apply infection control principles
and protocols to protect yourselves, your family,
your facility, and your community.
Thanks to everyone who has already submitted questions.
So I'm just going to go ahead and just jump right into it.
Dr. Bell, our first set of questions relates
to the transmission of SARS-COV2.
So our first question is
from Steven Pharaoh [assumed spelling]: "Should we assume
that COVID-19 has an effective airborne transmission?
If so, how do we go about this,
and how do we educate others about it?"
>> So, great starting question.
The transmission mode
of respiratory infections is something
that I think has been evolving for about 20 or 30 years.
Many of us were trained back in the day when the approach
to transmission description was very black and white.
It was a binary description of either direct splashes
"within 3 feet," you remember that.
That is actually quite outdated.
In fact, the original 3-foot range, some of you may recall,
was based on meningococcal carriage in school students.
They showed that carriage levels increased dramatically
when the desks were 3 feet apart or closer.
And so, beyond 3 feet was an initial range for that kind
of respiratory droplet transmission.
That got moved over to medical care back
when we had open wards.
And we had multiple beds within a ward.
And the very practical question was:
How many can we squeeze in here?
How much space do you need?
And it was actually a very rational thing to say, "Well,
let's say at least 3 feet between beds," right?
Fortunately, we don't have to deal with that reality
in our hospitals today, at least not very much,
but it's also important to remember that spacing people
who are not facing each other or interacting is very different
from what it means to be taking care of a patient,
and 3 feet is very, very close when it comes to the ability
of my respiratory secretions to splash onto somebody else.
So first and foremost, the 3-foot thing is gone.
We now talk about a range of about 6 feet,
which is a little more realistic.
But I'll say more about what the meaning behind that really is.
The other thing that's changing in addition
to that distance piece is what actually transmits infection.
And as opposed to the big splash of droplets that we used
to describe, right, big goobers that land in my eyes, nose,
or mouth and cause an infection -- that can still happen.
In all fairness, anybody who's held up a toddler recently
and been sneezed at in close proximity knows
that you can get droplets in your eye very easily.
But we generate much more than those big droplets,
whether we're speaking, coughing.
We're learning more and more about things like singing
and shouting thanks to COVID.
We generate a wide range of small droplets and big ones,
and many of those small droplets can float around for minutes.
And while it's not the same as tuberculosis or measles,
which can float around for hours and stay infectious,
even with something like COVID-19, those small droplets
that float around, minutes is long enough if I'm face to face
with you, within about 6 feet, for you to inhale something.
And so it's probably a spectrum of exposure
that includes a little bit of direct splashing
if you're very unlucky and your timing is terrible,
but also probably a lit bit of near-range inhalation.
This is something that you can't tease apart just
by the epidemiologic patterns.
So we can do the opposite.
We can show based on epidemiologic patterns
when something is like measles.
Because when something is transmitted like measles,
then an entire building will become at least seropositive
if not actively sick all at once.
Think about the chickenpox outbreaks related
to summer camps, right?
Everyone comes back from summer camp, and exactly a day
and a half later, every kid starts erupting
with little vesicles.
That is extremely efficient airborne transmission.
Tuberculosis is harder to pin
down because the incubation period is so long,
and we don't actually detect the onset the same way that we do
with measles or chickenpox.
But certainly, it is a very durable,
long-distance transmission.
With these respiratory viruses like SARS, SARS-COVID number 2,
but also original SARS, MERS that came by a few years back,
pandemic influenza, there's another factor that I wanted
to underscore when it comes to how we think about transmission.
That is the fact that we don't have a specific highly effective
antiviral treatment,
and we don't have an effective vaccine yet.
That means that there's a large proportion of people
who can become very sick without recourse to very easy treatment,
and also the number of people who are still susceptible.
We have seroprevalence data even from heavily affected locations
that are around 5%, which means over 90%
of Americans are still susceptible.
What that means for our hospital systems, and those of you
who are actually manning the front lines
in acute care centers, emergency departments, ICUs, you're seeing
that our health system is already very stretched.
And so we take more precautions when it comes
to recommending respiratory protection, for example,
for those types of infections
where we don't have a safety net.
I bring this up because a very rational observation would be
to say, "Well, for seasonal flu we don't do any of this," right?
But for seasonal flu, we tend
to have residual population immunity.
We have vaccines.
They vary in effectiveness.
I got mine yesterday.
And we also have antiviral treatment.
And so the likelihood
of seasonal flu absolutely swamping our health system
or affecting huge numbers of people and not allowing us
to take care of them well, that is much less with seasonal flu.
So getting back to the original question --
I know that was long, but I wanted
to give you the background of how we're thinking about this.
This isn't a black-and-white, cut-and-dried,
we've changed our mind kind of situation.
This is an evolution of understanding that is showing us
that you can inhale small things in close proximity.
A lot of the time we're not as concerned.
But when something is severe and not treatable, we are concerned.
Which is why if you go back each time
to these very concerning outbreaks,
we're consistently recommending the use of something
like a respirator -- in fact, specifically a respirator --
when you're taking care
of somebody you think is infectious.
And that is because there is a possibility
of inhalation within close range.
Okay, I'll stop.
>> Okay. Along those lines, going from distance to time,
this is a question from Dr. Trey Pegram [assumed spelling]:
"Is there any validity to limiting time spent in the room
with each patient to minimize the likelihood of transmission?"
>> Absolutely.
The risk of infection is a combination
of how much infectious material is being generated.
And so this is a reflection
of whether the individual who's ill is manifesting symptoms.
we have data that some people are able
to generate a lot more droplets, a lot more aerosols,
even when they're speaking quietly, not even from coughing.
We've all seen a range of sneeze and cough behaviors, I'm sure.
there are some people who can cough very discreetly,
and others who are fairly heroic in their manifestation.
That's usually the guy who's behind me in line
at airports for whatever reason.
But depending on who you're with
and what the infection source looks like, that's one factor,
people generating a lot of material.
Related to that is the pathophysiology
for the infected individual themselves.
Is there a large amount
of infectious virus being generated, right?
So are you making a lot, and then are you projecting a lot?
So that's the source piece.
The environment piece is the second step.
Are you in a very-well ventilated outdoor location,
or are you in a small space with very little air exchange?
Those are the two extremes.
And in the former, your risk is much lower.
Dilution is a very effective means of reducing risk.
In the latter category, your risk is much higher.
What we're seeing is that in enclosed places, and in places
with poor exchange, we are much more likely to see transmission
from a source patient to multiple individuals.
The examples that we've seen so far include things
like exercise classes that were in small,
not well-ventilated locations, where one person
who was shouting and breathing hard during exercise managed
to infect a large proportion of the people in that small space.
We don't see that systematically,
but we can when the conditions are right.
Similarly, in a choir practice --
there have been a couple of examples of this now --
we've seen places where, without great air exchange,
somebody who is aggressively generating aerosols by singing,
not intentionally, was able to infect
to infect a large number of people nearby.
So the environment that you're in is the second factor.
And then the third factor is what sort
of mitigation actions are being taken?
If the person who's the source is wearing a mask,
that vastly reduces the efficiency of release.
I'll say a little bit more about source control later.
I think there's another question coming up.
But also, if you're wearing a barrier,
even if it's not a fit-tested N95 respirator,
there is some of that.
We're starting to data that shows that the range goes
from really great with a fit-tested respirator to not 0,
maybe 40 or 50%, with something like a surgical mask.
So there's some benefit to wearing protection,
as well as keeping from exposing others to your own secretions.
So those are sort of the three factors.
There are probably additional things
like your inherent susceptibility based
on your genetic makeup,
but those are the factors that I think about.
And with that in mind, the time that you spend
in that context is also related to your likelihood
of receiving enough of a dose to initiate an infection.
There's always an infectious dose threshold.
So, you know, a single virion probably isn't going to do it,
but with each different pathogen,
you see a different level of infectious dose requirement.
And the longer you're in that exposed setting,
the more likely you are to hit that threshold.
We use the number 15 minutes
because this was initially proposed
as a single 15-minute exposure time.
There's a little bit of discussion underway right now,
and you'll be seeing more about this in the coming weeks,
related to an outbreak that occurred in a prison setting.
And what we saw there was that there was a relationship
with time, but it wasn't just a single episode.
It was cumulative.
It makes sense that a cumulative series of exposures
to shorter periods would add up to the greater risk.
It's not as though you breathe for 14.99 minutes,
and then only once you cross the threshold do you become
infected, right?
That's not how it works.
And so sequential exposures.
Basically, if you think about it from a probability perspective,
if you're spending two minutes with, you know, eight people,
there's a possibility that one of those people is going
to be shedding a ton of virus, and you might be unlucky enough
to become infected in that two-minute segment.
And so if you're having lots of segments, that's probably bad
as well as having one big one.
>> And one last question about exposure before we go
on to PPE questions, Dr. Melissa Enriquez [assumed spelling] asks
about fomites: "Are we still worried
about transmission via fomites?"
>> So at the beginning of this outbreak, we included a lot
of attention to surfaces and contaminated equipment.
We still think it's important.
The virologic evidence shows
that COVID-19 virus can actually persist and be infectious
for many minutes, in some cases hours, or longer.
So that is true.
On the other hand, if we think about what needs to happen
for something that's a surface contamination source
to create a risk for me,
in terms of catching a respiratory virus,
I really do need to somehow pick that up
and inoculate my eyes, knows, or mouth.
We're not seeing anything in the sense of --
for example, hantaviruses, where we know that sweeping
or aerosol generation by, you know, hosing out the back
of a truck or something, we're not seeing examples
of that kind of transmission.
But we believe that it's possible
that if you touch a surface, don't clean your hands,
and then rub your eyes, your nose, or mouth,
you could self-inoculate.
I think it's worth being careful.
And frankly, it's because there's so many other things
that are transmitted that way as well that we really don't want
to be picking up other cold viruses
or anything else, especially right now.
So breaking the transmission change from a surface
to your face is really all about commonsense things, and hygiene.
Proper glove removal, I know that this is the audience
that already knows all of this, but I do tend to point out that
when you see colleagues wearing gloves
and not taking them off properly, there is an escalation
of risk to themselves.
They can accidentally, you know, rearrange their hair
and touch their faces, not thinking
about what they're doing,
but they can also contaminate surfaces around them
and put other healthcare workers and patients at risk.
So prompt appropriate glove removal
and hand hygiene is something that we
like to remind people about.
>> Great. Well, let's move on to some PPE questions.
Dr. Robert Froehlke [assumed spelling] asks:
"Are regular surgical masks adequate
for routine patient encounters, or should we
and our staff always wear N95 masks?
>> So our recommendations right now are tiered.
There are certain things
for which we think you should always be using an N95,
assuming we have them.
And full disclosure, we're painfully aware
of the supply chain challenges that many facilities
and institutions are experiencing.
This is a very frustrating situation in the context
of something like the COVID pandemic.
There are currently recommendations that say that if
for any reason you're not able to use respirators
in a single-use, disposable kind of way,
we have available crisis standards.
And this isn't intended to be normal practice.
But if you're up against the wall and you're needing
to do something, we have suggestions for how
to extend the use of respirators.
In other words, keep them on and go from patient to patient.
Or if you're absolutely out, using surgical masks
as a temporary alternative.
They're not as good, but they're definitely better than nothing.
And so we have some of those crisis recommendations
that you can see on our website.
Getting back to the current recommendation,
we do recommend N95 respirators or better -- [inaudible] --
whatever you are using and are fit tested for,
using those for any aerosol generating procedures,
and those are things like bronchoscopies,
induced sputums, that kind of thing.
And in addition, if you're taking care
of a patient directly who you think has COVID
or who you know has COVID,
then we would recommend an N95 respirator
in addition to eye protection.
That having been said, surgical masks for routine patient care,
when you don't think the person has COVID-19, is fine.
If you're in a place where the community incidence has been
high or the prevalence is high,
then we recommend considering eye protection as well just
because you're likely to bump into somebody
who may not be symptomatic yet, but could be infectious,
just based on community rates.
>> So that brings us to the next question
from Dr. Elite Bor-Shavit [assumed spelling]
about eye gear when treating patients in the office:
"What type of eye gear is really recommended, a face shield,
goggles, just regular old glasses?"
>> Right, so these are not good enough.
And, you know, for those of you who work
in the emergency department and similar settings,
the safety glasses often aren't perfect in terms
of covering your eyes from splashes.
I've seen a couple of colleagues end up with, you know,
blood splatters on their eyelids,
despite having been wearing their safety glasses.
Some of them have little gaps,
and they're not quite as reliable.
So in terms of what we recommend,
goggles are very, very effective.
They completely cover your eyes.
They are also miserable to wear.
I personally am an expert at fogging up two layers
of lenses in a heartbeat.
And frankly, if things are foggy, you run the risk
of needlestick injuries to yourself or to others.
There are some downsides that are quite dangerous.
So that brings us to face shields.
So goggles are fine if you're able to wear them.
If you've got good ones that don't fog up, that's terrific.
Do remember that goggles need
to be reprocessed appropriately between use.
So if you've been wearing a pair, you take them off,
before you use them again -- or someone else does --
they need to be cleaned and disinfected according
to the manufacturer's instructions.
Face shields are a lot more pleasant to wear in my opinion.
And we have many disposable types that are handy to wear.
They have the sponge across the forehead, the elastic strap,
and the transparent, thin barrier in front of your face.
When you're using face shield, it's important to take a look
at them and see how far around the sides they go.
If they stop right here, and you're at risk of being splashed
from the side, that's not a good thing.
And similarly, if they go barely below your nose,
and you're doing a task that involves --
you know, for example, you're discarding irrigation fluid
in a sink or a hopper, there's risk
of splashing upwards, right?
And so if you're doing something like that, having something
that goes further down is very important.
Similarly to the goggles,
if you're using the really nicely built official reusable
face shields, the ones that look like a welder's mask,
only they're not black, those too need to be cleaned
and disinfected again before reuse,
just like with the goggles.
>> And it should go without saying,
but we should say it anyway, that a face shield
without a mask is not super helpful.
Now, what are the optimal procedures
or PPE that's necessary when we do have a vaccine
and start to administer that?
That question's from Dr. Lynn Taylor [assumed spelling].
What are the optimal procedures for vaccination,
phlebotomy, things like that?
>> So phlebotomy and vaccine practices are really part
and parcel of any routine medical care.
There's not anything magical about that.
But what I would say is that just as I said earlier,
at a minimum, everyone doing anything
in a healthcare facility right now needs to have a mask
over their nose and mouth.
That's for source control.
And if I may digress momentarily since I brought it up, you know,
the impact of not releasing secretions
into the surroundings is tremendous.
There are some mannequin studies that show
that having a respirator over the source of a cough
versus not doing that and having a respirator on the recipient,
having the source contained is far more protective.
And that is beneficial not only for one person,
but for everyone around you.
The other thing that I'll say is that even though we tend
to focus a great deal on the infection risk from patients,
we're seeing a great deal of transmission
within healthcare between colleagues.
We're seeing it in break rooms.
We're seeing it in hallways.
We're seeing it in, you know, carpools, you name it.
And that is, I think, a good reminder for all of us
that we all have to be constantly thinking
about source control, especially when we're in the work setting.
The other thing that I'll share with regard to source control is
that you're probably seeing a wide range
of products being used.
And the early data that we have --
some of this I believe is in press right now,
so you'll be able to see some of this in writing soon --
but it ranges from really excellent source control
with a fit-tested N95 respirator, nothing gets
out really that is likely to reach others.
It's 98% effective.
But that drops down to things like surgical masks,
procedure masks, which are in the 50 or 60% range, roughly,
down to maybe the 45% range for the cloth masks
that everybody has been using in public settings.
And then, for the face shield, as Dr. Bailey mentioned,
if you're just wearing a face shield, it's down at the 2
to 5% containment rate.
It doesn't do much at all.
But then, also, anyone being phlebotomized
or vaccinated really needs
to be maintaining source control as well.
The other piece of early evidence that I'll share
with you anecdotally is that we have modeling data that's
suggesting that even if you're wearing a 50% effective control
thing, and only half of the community is doing it,
you can have a profound impact
on the transmission dynamics of this infection.
Once again, we would suggest considering eye protection.
That is just out of a greater sense of caution
since some people can be shedding virus
without any symptoms.
This is also the rationale for being really persistent
in source control implementation amongst colleagues, because we,
again, have seen multiple healthcare personnel not
realizing they're ill.
I had two surgical residents just yesterday
who finished a case.
One of them got picked up by fever screening
when they came back from lunch, and it turned out both
of them were COVID positive, no symptoms at all.
So ensuring that everyone
in the healthcare facility is always using source control is
absolutely [inaudible].
>> Okay. There are a number of questions
from outpatient facilities about the use of HEPA filters
in office settings, especially in small exam rooms,
many of which will not have windows.
How helpful is a HEPA filter in this setting?
>> So it's not a blanket easy answer, you know, they're great
and they'll solve all your problems.
I wish it were.
The HEPA filter is likely to help.
It kind of depends on where it is and how much
of the air is moving through it.
So, you know, if you have a small unit
that is only filtering a small proportion of air
in a large room, then that benefit is likely to be limited.
If, on the other hand, you have a HEPA filter that's able
to process the air within a space very efficiently,
and a lot of that air is getting through the filter,
then you might have a better impact.
I think that HEPA filters are really worth thinking
about when you have no other option,
but it's also very important to be thinking about your facility
at large, whether it's an outpatient facility,
a clinic setting, or anything else.
I know that when I was in practice, I never even thought
about the air handling system unless maybe the temperature was
somehow not warm enough or cold enough.
But in reality, I think it's a great reminder that we all need
to be talking with our facilities management team,
whether it's a leased facility
or a large tertiary care facility, having a conversation
with people who maintain the HVAC system
and asking the very simply question of :
What are the air exchanges?
How much outdoor air is being added
to our mix on an hourly basis?
There are clear standards that are recommended.
We have them on our website.
ASHRAE maintains them as well.
So there are many resources for ensuring
that you've optimized the air handling.
And really, right now, going into winter and flu season,
would be a terrific time to make that phone call and make sure
that anything that can be done to optimize the air handling
in your clinic is done now.
In addition to that, if it turns out that the best
that can be done doesn't quite reach optimal air exchanges,
and if you don't have a window,
then adding a HEPA unit is not a bad idea.
Just make sure that, you know,
the HEPA unit is well-maintained.
If the filter is not well-maintained,
and the air's not going through it anymore, then, you know,
you're not going to get the benefit.
Lastly, one word of caution.
If you're in a facility that decides to add HEPA filters
to the HVAC system, make sure
that somebody is paying attention to the air balance.
This is true in facilities that have negative pressure rooms,
airborne isolation rooms.
So if you're in an acute care facility,
an emergency department, something of that sort,
and you have a negative pressure room,
if someone adds a HEPA filter to the outflow, then the pressure
against the exhaust is going to go up,
and the air is not going to fight that.
It's going to go out the door instead, right?
And so you can completely change what happens
to your air handling with a HEPA filter in the HVAC system.
And so if that's happening, make sure someone checks to make sure
that there's not some accidental unintended consequence.
The worst I saw was when this happened in a laboratory
that was handling tuberculosis specimens.
And the next thing you know,
the entire floor was being exposed to TB.
So very, very tricky issue if it's happening.
>> As an allergist, we recommend HEPA filters to some
of our patients, and if you're an outpatient office
and are thinking about getting HEPA filters
for your exam rooms, there will be instructions on the package,
on the box, that says, "Well,
this is designed for this size room."
So make sure that you know the dimensions of the room
that you're wanting to filter.
And I've always recommended that you keep the HEPA filter
on a desktop or a countertop as opposed to on the floor
because having on the floor, especially if it's carpeted,
can really just stir up stuff,
and sometimes can do more harm than good.
But that's just the allergist's perspective on all this.
Okay, so surface cleaning.
What products are the best to clean surfaces in an office?
Tad Hall asks: "Is it hypochlorous acid?
How good is UV light?
What should I be doing in my outpatient office
to keep the surfaces clean?"
>> Well, so the good news here is that all
of the routine hospital disinfectants
that are registered with the EPA do a very good job
of destroying coronaviruses.
The things to remember -- one of them is sort of technical
and the other is more practical.
The technical thing is that if you have a large amount of crud
in which the virus is hiding, then simply spraying it
down may not do the trick, right?
There's bioburden that can protect the virus.
And so cleaning, just mechanical cleaning with, you know,
a spray-and-wipe detergent.
And some products are all in one,
which is even, you know, even nicer.
But making sure that the cleaning step isn't forgotten
so that you can get a good effect from the disinfectant,
that's the technical side.
The practical side is, who does the cleaning?
This is something that we struggle
with in many situations.
In an outpatient office, I can honestly say that, you know,
back in the '80s, I don't think I wiped a single surface.
I did use the rolling paper thing on the exam table,
as though that would magically help.
I don't think it actually does.
And so thinking about how you're going
to implement surface cleaning, and targeting the surfaces
that are most likely to be responsible
for cross transmission.
You know, procedure trays, side tables, work surfaces, and,
of course, the exam table.
A quick wipe down with the appropriate wetting time --
that's the other technical challenge,
is every product has a required wetting time.
And if it dries up before then, it's not good enough.
So whether you're using pre-saturated wipes
or a spray product, making sure that you're able
to use it the way it says it needs to be used.
There are some very nice wipes
that actually now have a much shorter wetting time,
and so you can do a single wipe.
Many dialysis facilities, in fact,
are finding that very helpful because of the practical need
to turn over the tables -- or the chairs, rather.
The other thing -- so that's the easy solution.
It's within reach of, I think, everybody.
But thinking about whose responsible for doing it is key.
Also, if you have equipment that moves from patient to patient,
whether it's a blood pressure cuff, a vital sign column,
anything of that sort, be very clear in whose job it is
to wipe it down between patients.
A lot of times, if that's not made clear,
everyone will assume it was somebody else's job,
and you might be shocked at how often it doesn't happen.
So designating whose job it is for each specific thing.
In acute care hospitals, a lot of times it's things
like ventilators, mechanical ventilators,
that the environmental services staff might be frightened
to touch.
And the respiratory therapist might not realize they should
do it.
The ICU nurse is busy.
And so pretty soon, it falls through the cracks,
and no one has wiped it in a week.
This is not good.
So thinking about whose responsibility each thing is
is important.
And then getting to the question about some
of these modern innovations.
I'm very excited about a lot of these technologies,
whether they're ozone generators, UV generators,
you know, fine-mist generators with,
you mentioned, hypochlorous acid.
>> It really sounds like, in an outpatient setting,
that patients and doctors and staff all need
to have source control, wear their masks all the time,
not just when they're within 6 feet of each other.
And yay, it looks like we've got you back.
So we're running short of time, but I'd like to --
there's some questions about, you know,
reminders for all staff.
Dr. Matilda Perrantes [assumed spelling] asks, you know:
"What are some helpful tips,
reminders so that we don't let our guard down inside
or outside, you know, healthcare settings?
What do you recommend?
What seems to work just in terms of making sure
that people just remember to do all these things?"
>> That's a great question.
Let me finish the last answer just in fairness to the person
who asked about all of the other technologies.
They're very good.
Some of them are promising about killing organisms.
What we don't have is evidence of how good they are
when you implement them in real life.
The reality here is that some
of them don't get all of the surfaces.
Some of them need to be positioned in a certain way.
Maintenance is important because if it isn't well-maintained,
then you may not have the right effect.
So it's important to make sure
that the real-life implementation matches
the promise.
And we're still working on some of those data.
Getting to this very practical question, Dr. Bailey,
I think that my one admonition would be: Help each other.
I think that the best tools we have are one another.
And whether it's a practice partner, your nurse,
your primary clinician, your physician's assistant,
or even your receptionist, talking to each other
and keeping an eye on one another so that if someone walks
into a -- you know, into an area and doesn't have their mask on,
everyone points it out and says, "Hey, Mike, you forgot,"
and I can pause, take care of myself,
and then go back to what I was doing.
I think that is our best hope.
We can also put up things like signs
and reminders, and those are good.
But I don't know about you, but I tend to grow blind to a poster
or a sign once I've seen it a few times.
And it's much more helpful if a colleague
or a partner can just tap me on the shoulder and say, "Yep,
handwashing, you need to do that now."
I'm usually the one tapping
about handwashing, but that's just me.
>> Okay. [laughs] We've got one question that's different
in scope than the ones that we've dealt with so far.
Dr. Steve Bracington [assumed spelling] asks: "So if someone
in your office or a clinician travels by air,
and so they've been on an airliner, and they want to come
to work the day after they get back, should they self-isolate
for 14 days if they've been in that type, like, in a plane,
or a long time on a train or bus before they see their patients?
You know, should they take a test 10 days
after flying, or what?
How do you -- because, you know,
people are starting to come and go more.
And what are the guidelines on that?"
>> Well, so we don't have a specific recommendation related
to post-travel [inaudible] resuming care.
We do have a risk assessment tool on our website
that we can share to your audience, like,
that helps gauge the risk of exposures in general
for healthcare personnel with an eye towards returning to work.
But travel alone is not something
that we've identified as a specific risk.
That doesn't mean there isn't a risk.
And the reason I point you to the risk assessment tool is
if you were with somebody who might have been ill, if you are,
you know, notified later that you might have been, you know,
traveling near somebody who turns
out to have been test positive, those are things
that may actually change your approach.
The other thing that I'll share is depending
on your patient population, you may have a different threshold
for returning to work.
I have a very dear colleague who's a head and neck surgeon
who takes care of many immunosuppressed cancer
patients, and, you know, she has either canceled trips
or self-quarantined for, you know, the two-week period,
before exposing herself to those patients.
I think right now it's still very much a case-by-case
approach, but I would encourage people to look
at the risk stratification tool, just to have a sense of how
to consider some of the potential exposures.
>> Great. Do you have any last comments
or recommendations you'd like to make
about helping keep our offices free of COVID-19?
>> Well, first, before I forget, I want to thank AMA
for being one of our many partners
with Project First Line.
You know, our goal here is to saturate the waterfront
of healthcare with infection control understanding,
in part so that it's not just your AMA members trying
to remind everybody in their practices what they're supposed
to do, but also, like I said, having everyone
within the practice understand the basics in a way
that helps them also remind us.
So there's that part of it.
And having AMA as part of this is
such a wonderful benefit to us.
So thank you so much for that.
Overall, I think that, you know, the understanding
of how difficult this is on so many levels for all
of our care providers -- not just our medical professionals,
but our allied health staff, for our clerical staff, for many,
many people providing care, there are so many risks inherent
in the day to day, and yet we're continuing to show up.
And I find that the most invigorating,
inspiring thing imaginable.
I am encouraged daily by how our profession is continuing
to push forward.
Doing so safely though is something I desperately hope
everyone will do.
Please keep your masks on.
Please attend to hand hygiene, and please remember the need
to assess each person that you're caring
for as though they could be infectious.
>> Well, thank you so much, Dr. Bell.
Thanks to everyone for joining us today
and for submitting such great questions.
We very much appreciate you sharing
with us the best practices for infection control,
and to confidently apply these principles in our offices.
The AMA supports and applauds the CDC's leadership
on this issue, and we really look forward
to this collaborative effort to educate
and train frontline personnel, and to help contain the spread
of all infectious diseases.
So, thanks to our audience for joining us.
Stay safe, and we hope
to see you again virtually at our next webinar.
Thank you, and have a good rest of your day.
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