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Welcome! We Will Get Started MomentarilyThank you for joining Telligen QI Connect for today’s event. We haveparticipants joining from across the country. Please welcome each otherby sharing your name, organization, and state in “Chat.”How to use “Chat:”» Click on the “chat” icon» Select who you want to send your message to (individual or everyone)» Type and send your message1

!) C! Telligen QI Connect 'l\r.Partnering to improve health outcomes through relationships and dataCAH and Rural Hospital Office Hours: COVID-19 Support“Essential Employee Testing and Return to Work Best Practices”Facilitator: Rachel Megquier, RN, BSN, Quality Improvement Facilitator, Telligen HQICGuest Panelists: Dr. Andy Wilson, MD and Dr. Lon Young, MDThis material was prepared by Telligen, the Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of theU.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. This material is for informational purposes only and does notconstitute medical advice; it is not intended to be a substitute for professional medical advice, diagnosis or treatment. HQIC-TO1-12/15/20-0014

Telligen QI Connect HQIC Partners» Alaska State Hospital & NursingHome Association» Idaho Hospital Association» Nebraska Hospital Association» Oklahoma Hospital Association» Wyoming Hospital Association» Mountain Pacific Quality Health» Collaborative Consulting3

Disclaimers»»Today’s content and answers to participants’ questions reflect Telligen’s best understanding based oncurrently available information about COVID-19 as of Tuesday, December 22, 2020.However, COVID-19 is an emerging, rapidly evolving situation. Therefore, it remains criticallyimportant to continually check the CDC’s most up-to-date guidance, as well as the guidance fromyour state/local health department. CDC guidance for COVID-19 may be adapted by states and localhealth departments to respond to rapidly changing local circumstances.4

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Telligen QI Connect Hospital Quality Improvement Contractor (HQIC)» Small, rural and CAHs» Data to drive decisions» COVID-19 support» No cost assistance» Previously HEN / HIIN6

Join Telligen QI Connect and HQIC» Email us at HQICTeam@Telligen.com» Contact your associated Telligen QI Connect HQIC Partner» Sign-up online here7

You Have Our Respect and Admiration“We will only get through this becauseof you. Know that we are behind you,supporting you, and cheering youon Thank you for your selfless giving.Thank you for caring so much. Thankyou for taking care of all of us.”Words of Encouragement from Strangers Across the PlanetBy Angelina Walker8

Topics for Today’s Discussion» Overview:» COVID-19 exposure and transmission» Essential employee testing best practices» Staffing challenges» Case Study:» Testing protocol for a high-risk group» Current State:» Recent CDC guidance9

We Want to Hear from You!» Throughout the presentation, please use the chat function to drop inyour questions» How to use “Chat:”» Click on the “chat” icon» Select who you want to send your message to (individual or everyone)» Type and send your message10

Guest PanelistsDr. Andy Wilson:» Co-founded and served as CEO, of CapRockHealth System11Dr. Lon Young:»» Provided leadership and/or clinical care at morethan a dozen health systems in TN, GA, FL, andTX - from rural and critical access health systemsto large Level 1 and Level 2 Trauma Centers»»Paramedic Academy and is the Medical Directorfor a SWAT Team in Texas.»» Served as a Medical Director for the TEEX» Appointed as an Assistant Clinical Professor ofEmergency Medicine in the Texas A&M Collegeof MedicineGraduated from Baylor College of Medicine inHouston, and completed a residency inEmergency Medicine from Maricopa MedicalCenter in PhoenixPracticed Emergency Medicine for 10 yearsCo-founded and currently serving as the CMOof CapRock Health SystemDr. Young is passionate about improving theexperience and quality of patient care andprotecting the independence of physicianpractice

Case Studies and Unique Considerations» Made the news with a handful of cases» Late March / early April» Created and implemented an aggressive testing and “test to clear”protocol (with negative case return to work acceleration)» Arrested transmission, however, protocol too conservative in positivecases to be functional» New data emerges regarding testing positive vs. being infectious12

Case Studies and Unique Considerations (continued)» New data emerges on when exposed asymptomatic cases becomedetectable by testing Late March / early April» Developed amended protocol (KISS Principle)» To date protocol has saved thousands of work hours and averteddepartmental and jail crisis/shutdowns13

appropriate PPE Used?: If so . NOT AN EXPOSURENO PPE?:· Was contact within 6 feet for 15 min? If not . NOTAN EXPOSUREAvoid STAFFING NIGHTMARES . .Make appropriate PPE Mandatory!Cllil"EOORY 2-Sympti,matic'W /Drw/ o e:q:NJSUre CAJEGORY 3Po5i!M:COVIDtt:eit door BJ Cl!.t.111!! withcillt IP E for lo15 - , 6tt, within 4 d:.ys aF OOVID p:rti nt {or Wl ed oovro p:itient rs:] fim P(mfJ1:,Dm:s or pasitive tt!!rtR l'1!IKII! me: Crrit fnr Return to WDirlri iN- He- i1f1G:n! Pesrsonnel with Coinfinned or Su!:p d COVID-19 pnterim Guid:ma re.vieweG M:udi 16 20200.1 /24/202011. coc Rttum m worle sym-:rtam oiteria (:1/:1 /2.olD]:1.At lm:?it 3 d!ff!i (72 hc,rJ ) hiwe :iazclf since n::envi:ry defim:d 1H n:mlution a1' m"e:r willlout the: use a1' fewie:r-n: Jcin5l.!.t ,e;ut 10 dl!l'fS t:bea.lhj;OIIO,ve dgncl!! .sym'JtomslfB,:ap:ie.nredt:dicnticm ar.d im;:irovi:mcnt in n:s:::iim'IDl'y :rymptD'TIS c: ·6· coL.5h, sllortnes.!i DI14

Critical Personnel Factors» Household contacts (repeated exposures, covered on next slide)» Infected patient masking challenges in austere (Fire, EMS, Police) and/or hostile (Fire, EMS, Police, ED Staff) environments15» New CDC quarantine recommendations (7 and 10 day quarantines) to mitigate staffing crises» CDC Estimates of Median Post-Quarantine Transmission Rates with and without testingEstimated residual post-quarantine transmission risk Plannedday afterwhichquarantineiscompletedand canbe discontinuedResidual post-quarantine transmission risk (%) with and without diagnostic testing of aspecimen within 48 hours before time of planned discontinuation of quarantineNo testingMedianRT-PCR testingRangeMedianAntigen 3.00.00.0-1.20.10.0-2.9» If you can get by without them do it!» Liability discussion and documentation most good for the most people!Return-to-Work Criteria for Healthcare Workers CDCStrategies to Mitigate Healthcare Personnel StaffingShortages CDCOptions to Reduce Quarantine for Contacts ofPersons with SARS-CoV-2 Infection Using SymptomMonitoring and Diagnostic Testing CDC

Exposure- Non-Employee HouseholdMember-CDC t0l 1'9/2020- nttpcs;/lwww ooc gov(oorona'Jtirus/201 P:oc9Ylnq,/durati O;Tll:1SOt8 iOD html16

Exposure- Infected Memb,e r10 day viral shedding P.:eriod of infected household memberDa.y 1 o,f Exposure(regardless of employeereport date),17

Summary» In a limited resource environment, the need for critical personnelprotection is amplified» Instituting a simple and conservative process can somewhatcounterintuitively save global costs, decrease time off work by criticalstaff, and increase facility readiness» Exposure questioning and the testing process needs to be thoroughand based on known science to accomplish the intended results» Critical services personnel need tailored protocols» Crisis processes need to be considered carefully and in advance18

New Topics »»Therapeutics: Beyond the scope of this webinar, but nothing trulygroundbreaking has emergedVaccines!19

Questions?»»Contact: Andy Wilson, MDEmail: aw@the3LM.com20

COVID-19IN THEWORKPLACELon Young, MD FAAEMChief Medical OfficerCapRock Health System

How To Approach a COVID employee 1) Determine if you actually have a positive 2) Determine your “exposures” 3) Have the exposed employees screened 4) Develop a back to work plan

1) Do I Even Have COVIDin my workplace?Has the employee been screened and determinedto be positive or particularly high risk? A test is not necessary in all casesConfirm this before testing anyone else in the company

Timing2) Exposure vs. Casual ContactMaskHealthSymptomsSingingThousands ofViruses RequiredMaskDistanceDurationOutdoors

Effectiveness of MasksInfectedTransmission%90%75%5%1.5%Noninfected O O

Definition of “exposure” 1) Indoors 2) Within 6 feet 3) Cumulative 15 minutes 4) Without masksAssessing this limits the number of employees that are effected.

3) Screening Process Clinical Health status of the employee Timing of exposure Nature of exposure Current disease burden in the community Nature of Job duties Nature of home life Laboratory Which test How many tests When to test

Test Timing is Critical1.00Day 7LT TSymptomsSource: https://www.acpjournals.org/doi/10.7326/M20-1495

Getting the Testing Provider chooses appropriate test based on: Timing of exposure Test availability Timing of return to work Type of work Home circumstances

Length of Contagiousness20Q)25::::J 30035- 4007142128Days since symptom onset10 Days from symptom onset14 days from exposureNo need for negative test before returningSource: Fig1

4) Return to Work Considerations Consider how the infection is spread Consider the nature of other employees Consider the nature of the duties Consider factors outside of work Often people can safely return sooner than thought

Updated CDC Guidelines (12-2-20) No Test Strategy – Return after 10 days1-10% failure rate (Enhanced precautions)Test Strategy (PCR) – Return after 7 days if negative after 5 days 5-12% failure rate (Enhanced precautions) Day 7 testing 14-day quarantine period Symptomatic Strategy – Return 10 days after symptoms began

Health Care Workers (HCW) For critical shortages, exceptions may be made Early return as for non-HCW’s Continue working as follows”1.duties where they do not interact with others2.direct care only for patients with confirmed infection3.direct care for patients with suspected infection.4.direct care for patients without suspected or confirmed infection.

34Questions?