Accreditation is a critical process to promote safety and demonstrate the safety of a facility through its compliance with rigorous standards. The COVID-19 pandemic has made all aspects of accreditation, especially infection prevention and emergency preparedness, more relevant. Patients are now more aware of these areas of clinical practice; therefore, facilities need to deal with the current emergency and prepare to adapt to the next. AAAASF’s accreditation programs assess safety and provide a framework for all facilities to pursue ongoing performance improvement, and this talk provides important guidance and lessons learned throughout the pandemic.
Lecturers: Dr. Monte Goldstein & Tom Terranova, American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
[Tom] Hello, everyone. Welcome to the Association for Accreditation of Ambulatory Surgery Facilities talk on Accreditation and COVID-19. My name is Tom Terranova, I’m Executive Director of AAAASF. And speaking with me today is Dr. Monte Goldstein. The topic of today’s talk is Accreditation and COVID-19. Before we get started, I just want to say that COVID-19 as a global public health emergency is a perfect case study for emergency preparedness, and infection control, and one that we’re currently living through. But nothing in today’s talk should be taken to be exclusively applicable to COVID-19. All of this is more generalizable and can be used in other public health emergencies, as well as other emergency situations. So use COVID-19 as an example, but try to extrapolate that out to the rest of the world.
As we get started again, I’m Tom Terranova, I’m Executive Director of AAAASF and Dr. Monte Goldstein is here with us as well. He is an anesthesiologist, a member of the AAAASF Board of Directors, and the Vice-Chair of our Investigations Committee.
Before we really get in too deep, we do want to get started with our first poll question. And what we’re going to ask just for our own perspective in helping with really targeted advice today is to ask, have you received ongoing COVID-19 guidance from your country’s health regulator? We’ll give you some time to answer those questions and then it’ll help inform the rest of our talk.
It looks like 66% of you are getting regular updates from your own country’s regulator, which is a really good indicator that the regulators are being active, and that they’re giving specific advice to your country. So again, what I’ll say is that as we go through this and provide some general topics, a lot of what we may talk about will supplement your country’s guidelines and regulations. Certainly don’t do anything to contradict them, but if you can supplement or complement what your health regulator is telling you, we hope that you’ll find some useful information here.
The objectives for today from this discussion are for you to leave with a better understanding of the benefits of accreditation in general, the importance of infection control in emergency preparedness in a time of an emergency, specifically a public health emergency. And to have a better understanding of recommended COVID-19 response, specifically as it relates to ophthalmology.
The center of this graph, of these overlapping circles, is what we could consider the heightened sensitivity in our world today, due to COVID-19. And again, we’re using COVID-19 as a case study. But there’s certainly going to be other infectious diseases in the future, and natural and man-made disasters that will prove out the value of accreditation, preparedness, and responsiveness to evolving guidance that is released from health regulators, accreditors and the like.
Centers, hospitals, might risk being shut down if they’re not prepared to deal with emergencies. Either because the government doesn’t think that it’s safe to continue care because you, as a facility, may experience your own outbreak if you have a rash of infections of COVID-19. Obviously, that may stop your operations. And then I expect patients to start increasingly ask about evidence of your safety. They want to know how they’re going to be treated safely. And now more than I’ve ever seen in my decade plus with AAAASF. So throughout this presentation, I also want to let you know that you’ll be seeing graphics and images in a few links. When you have this information to download from the Cybersight website, all of those are clickable to go directly to the resources that we’re talking about, so you’ll be able to access pretty much most of the items that we reference throughout this presentation.
In the next few slides, we’ll talk generally about accreditation just to give a basic understanding to anybody who’s not familiar with accreditation, so that we all are building from the same foundation. So we’ll briefly discuss what is accreditation, generally quickly talk about the accreditation programs we have, and the value of accreditation in general.
Accreditation uses an impartial third party process to assess the safety of a facility. Impartiality is the critical aspect as defined by the OECD. And so there we don’t want to see, the OECD and many patients don’t want to see, societies regulating their own members or the health regulator. They want to see somebody who’s apart and separate coming in as an impartial third party. It represents the attentions to details that promote a culture of safety within the healthcare center.
Accreditation of a facility is a process. It involves strict testing of several hundred recognized standards, which in our case we’ve developed and evolved over decades. Our goal is to establish standardized practices across the globe to ensure that a patient’s safety is never compromised, while limited bureaucracy. So the facility processes, the physical plants, the documentation, how the employees work through their day to care for a patient, is what we are testing when we talk about accreditation and accreditation surveys. Our surveyors observe staff delivering care, they interview staff and patients, and then they review documentation to support the things that they’ve seen with their own eyes and heard with their ears. They look at logs, records, protocols, policies, et cetera.
The point of accreditation is to drive continuous improvement and we’ve seen this through data analysis. We collect a tremendous amount of data, since 2001, and have published papers showing that accreditation leads to the safest possible care. Accredited facilities and their staff are encouraged throughout the process to engage in ongoing improvement for the facility and their own practices.
And then we require completed corrections. So whenever there is an issue in a facility, we actually want to see that the corrective action was taken. Which means that it’s there and it’s set up and they are in the best possible situation to continue their compliance on an ongoing basis and not just on a single day.
Just generally speaking, we’ve been around since 1980, so that’s where all of our experience and expertise in what we’re talking about comes from. AAAASF currently has 10 programs, three of them are international programs that have been certified by ISQua, if you’re familiar with ISQua. We are approved currently through 2024. We have three programs that are approved by the U.S. federal government, meaning that our surveys allow facilities to participate in federal programs in the United States. And then our remaining programs are each individually approved by the various states in the U.S., based on their legal requirements. But they’re a little bit separate.
The whole point of showing this is to say that we put ourselves through the same process. And so the rigor and the certifications that we go through are an indicator of our willingness to put ourselves through the paces and be tested, and to prove out the value and the rigor of our program.
Accreditation stands on three pillars. Safety is the core of the principal of everything that we do, but the three pillars are the quality of the practitioner, meaning appropriate speciality training, limiting the procedures that that procedure list, that specialist, that medical professional is doing. To what is within their scope and speciality training, and ensuring there’s appropriate anesthesia personnel and monitoring, and that there is safe care all the way through discharge. The second pillar is the appropriateness of the patient. To ensure that facilities have established processes, including quantifiable metrics to assess patients and whether they’re fit. So this might mean patient assessment for comorbidities, smoking, other medications, risk for malignant hyperthermia, or deep vein thromboembolism, all of these processes to establish the appropriateness for care in that center.
And then last but not least, is the safety of the facility. We want to ensure that the safety is clean, maintained well, well-lit, well-equipped, has proper security. A patient deserves a demonstration of the quality of their provider and in many cases, the patient’s aren’t well enough equipped to be able to ask the detailed questions. Through accreditation we want to show and prove out through the data that care in an accredited clinic is safe whether it’s in Beverly Hills, Athens, Beirut, Mumbai, it doesn’t matter.
Safety is universal and is based on our human physiology, so an airway rescue is the same no matter where you are in the globe, and we want to make sure that that standard is applied accordingly. And the accreditation process really is a dialogue between the accreditor and the facility because we’re not a ministry of health that’s there to levy fines or penalties. We’re there to educate. So a facility can feel confident to open up its books to us to show us where it struggles and to allow us to help them improve.
Specifically, now that we understand the generalities of accreditation, we like to talk about the current crisis and use it as a case study. We’re all living in the middle of a public health emergency trying to run our businesses, provide health care, protect ourselves, our staff, and our patients. Emergency preparedness in infection control are critical, they’re critical all throughout every year, but this past year has really shown the importance and put an emphasis on those aspects.
During any outbreak, infection control might require adjusting normal practices and policies to the specific contagion. And an in-depth knowledge of infection control principles and preparedness allows the facility to adapt those protocols much quicker. Even more than infection control, however, the pandemic has brought to light the integrated emergency preparedness and how important that is. We recognize that importance all the time and we’ve experienced firsthand that it can help facilities prepare for all of the what ifs. The 2020 pandemic has forced the health care sector to navigate all stages of a crisis depending on where they are and what stage the infection is carrying out in their location. And they’ve had to have new ways to shift their guidance to their staff and their practices to adapt the ongoing guidance that we receive.
So it’s important that emergency preparedness is integrated in all of the program and all of the facility’s plans. It has to assess its own risk, refine them, test them, use them in a real situation like we are now. Take back some lessons learned and then use those as well.
As we get into emergency preparedness, we just want to ask our second poll question. And that is, do you have an emergency preparedness plan?” Select A if you’ve never conducted a risk assessment or plan. B, if you have conducted these things but you don’t fit into your broader community response. Yes, if your plan hasn’t been updated however, or yes, if you are really on top of things and have a plan that considers your whole community risk and includes updates including COVID-19.
About half of you appear to have a plan that considers how the facility fits into the larger community and has been updated regularly to include COVID response. Which, I must say, is very, very good. I do see that about 27% of people have a plan but that doesn’t consider the community in a broader sense. And so I think that’ll be really helpful to go through a little bit. And then I see that about 17% of the people on this call have not conducted a risk assessment. So I think there’s a lot of good information that you’ll all be able to get from this.
When I talk about the integrated plan and how you integrate into the community, I just want to take a second to say each individual private practice, especially if you’re in a smaller center, it’s easy to think of yourself alone. Hospitals may consider themselves part of a national strategy. But the way that we’ve started to look at things is to see the facility as a broader part of the community. And so obviously if you have a fire drill that’s the most common thing that facilities practice, you’re thinking about how a fire might affect your facility, how to evacuate your patients and staff appropriately.
But then there are things that grow from there that might be a water main break on your community, in your block, you might have something that affects the whole city, your whole district, your whole province, or if there’s a huge natural disaster or pandemic, as we see, we’re talking about the entire community. And so we do want to make sure that emergency response is not disjointed. So we want to make sure that these things, that the center, even small centers understand if and how they play a role with their community. And it could take coordinating with community members, other hospitals and other centers, or it could take just a broader evaluation.
And so one of the things that we like to talk about is most private centers didn’t anticipate having to staff or supply large full scale hospitals at the outset of the COVID-19 pandemic. However, that’s exactly where facilities found themselves. I recall in Italy there were calls to get more ventilators into the public hospital system. Here you see an example of a AAAASF accredited clinic who gave his anesthesia machine and ventilator to his hospital so that they could support COVID-19 patients. So instead of just closing his doors and locking up while he wasn’t allowed to practice, he was able to turn those ventilators into something useful for the community during the pandemic. That’s what we talk about when we’re talking about integrating with community.
One of the ways that you can think about national or community response infrastructure, is with these seven different topic areas. And while these apply at the broad national level, it’s helpful for each and every facility, and each and every center, to think through how they achieve these seven platforms in a micro kind of way. And we suggest going through that from a micro way.
The safety and security of your facility. If you’re in an earthquake zone, do you have a plan to make sure that in an earthquake your patients don’t have equipment or debris falling on them? If you’re in an area that’s prone to civil unrest, how does the facility have a proper plan to lock down and secure both patients and information? And not all of these responses or risks will be the same, so I tried to use varied examples because it will depend on your geography, on your society and culture, it will depend on your community.
It will also depend on your neighbors. If you have a plant that uses volatile equipment next to you, that’s going to be very specific for your facility. Taking the time to do the risk assessment is really important to know what you need to respond to.
If we move onto the next level, we’re talking about food, water, and shelter. There’s two things when you think about this. If you’re in an area where the roads become impassable due to flooding, or snow, you might be stuck in the facility for awhile. And especially in an outpatient facility, there’s not the infrastructure set up to provide ongoing nutrition for the patients. And so what is the thought process if you’re in a possibly isolated location? Or if the water supply is easily interrupted, or purification systems are compromised, do you have a system for water?
Really good example here in the U.S. is with the COVID-19 pandemic, most regulators have recommended shutting down drinking fountains, water fountains to provide communal water. So facilities have had to adapt to provide bottled water or to have bottle fill stations as opposed to drinking fountains. Thinks like that, common snacks and things like that, prepackaged snacks. Again, just knowing your risk tolerance, your risk profile, and then having a plan in place to change practices.
From health and medical, it’s a little bit odd to talk about being prepared to provide health and medical care for your patients. But again, if you’re an outpatient center, or specialize in outpatient care, you may not have the infrastructure set up to handle ongoing needs that a patient might have, say managing diabetes or whatever it might be. Making sure that you have a plan in place, either secure needed medications in a situation like that, or to get the patient out of the facility and into a location that can help them manage those conditions. It’s really important because it’s often easy just to think, “We’re a healthcare facility, we can handle the health and safety of our patients.” But it may not be for a prolonged time or a plan to get out of an isolated location.
The next pillar would be energy, so fuel and power. Again, if you’re in an area where there might be a tsunami, how can you stabilize the patient? How can you manage the patient even just if you are evacuating, just long enough while backup power is there? How can you manage, stabilize, close the patient and get the patient out? And again, if you’re having to stay in the location, we often don’t think about having to stay in, we think about evacuation. If you have to stay in, how can you manage without power? Do you have battery backup lights? If you’re in an extremely cold climate, do you have something like thermal blankets? These are just thought processes that need to follow a risk assessment. Obviously thermal blankets are not needed in an extremely hot location.
Communications is another one that’s simply easy, because we think is easy because we all have a cellphone in our pocket, and we all have internet access, or most of us have internet access. But extreme weather can interrupt internet access. And especially as we rely more and more on electronic medical records and logs and cloud-based technologies, we want to make sure that we have some backup for critical things. That’s not to say that you need to manage everything both on the cloud and locally, but how do your staff understand their role in an emergency, and is it on the cloud? And if there’s an interruption, do they have no way to access what they need to know? Those critical information they need for managing chemicals, or managing a patient, or their role in an evacuation? And again, if mobile service is interrupted, either through government, through a commercial, or through a natural disaster, is there a backup plan such as radio, or landline telephones, or whatever else it might be? Just another way to communicate to tell people whether you need help or whether you’re available to help. Again, it’s just a good thing to think through so that you have a backup plan.
Transportation, again, is interesting for a healthcare facility because when we’re talking about evacuation, especially smaller outpatient facilities, may need to have agreements with transport companies or ambulance services. Or again, if you’re having to remain in the location, locked down or sheltered-in-place, is there transportation to bring in things that are needed? Obviously there’s some extreme examples that we can’t think of, but you’re looking for the most likely and how you can manage it reasonably. Can you bring in medicines, can you bring in nutritional items? The transportation component is just as important as securing an agreement to actually get those items. So if the local hospital can provide you medications, great. But if they can’t get them to you, that’s a problem. So you need to make sure you’re thinking through the transportation issues as well.
And then finally, hazardous materials. Most health care facilities are very, very adept at handling hazardous materials on an ongoing basis. But again, if oxygen tanks are secured properly but you’re in an earthquake zone, do you need added precautions to make sure there’s no combustibles that are at risk of falling due to heavy earthquakes?
We all know what happened recently with the explosion of a fertilizer plant. And so this is going to be very community specific, but if you have a neighbor facility, a neighbor business that processes chemicals that are combustible, or has chemicals that might compromise air quality if there’s an accident, are you thinking through that risk? Maybe it would be appropriate if you’re near a chemical plant, to store additional PPE for the patients, just in case there’s a massive spill that compromises air quality. And that’s going to be very specific because not everyone’s going to have that facility in the immediate vicinity.
These are just, again, very broad examples to try to get you thinking creatively. It’s easy to think about a fire, or if you’re in the southeastern United States a hurricane, or if you’re in a tsunami zone, it’s easy to think of those high profile things. But to think of security measures, man-made disasters, pandemics, and other things, requires a creative approach to your risk assessment. And then if you take an approach that goes point by point through these topics, you might come up with a drastically different emergency plan than you’ve been thinking in prior times.
I tried to get through that, it’s a lot of information. I tried to get through it quickly and get you to the more possibly interesting examples of infection control and COVID-19, which Dr. Goldstein will be taking over right now.
[Monte] First of all, thank you to Cybersight and Project Orbis for inviting us today. And thank you to AAAASF for assisting with this presentation. We’re going to talk a bit about emergency preparedness, specifically as it relates to the current public health emergency, the COVID-19 pandemic. And of course, we’re going to make this specific to ophthalmology as best possible because this is Cybersight, after all.
From the national health systems down to individual facilities, who really faced a challenge of responding to a pandemic, while still focusing on routine aspects of practice. Simultaneously, our facilities must remain vigilant during this pandemic to additional disasters, such as recent storms and wildfires in the United States, as an example. Clearly the operating environment has changed. But our goal at providing safe patient care experience before, during, and after these disasters, and in many cases in spite of them, remains the same. And partnerships between the governments, private sectors, and non government organizations or NGOS, is really essential in assisting and supporting our facilities during this disaster.
As the world continues to respond and recover from COVID-19, the framework of a facility-centric, locally executed, and government coordinated approach to the incident stabilization remains the same. What this really means is that coordinated by regulators such as AAAASF to create a cohesive response to each point of care, there must also be feedback and dialogue upward, from the center back to the government. Including data and related to capacity and infrastructure of your facility. The expectation is that government authorities will focus on hospitals and major institutions while local authorities will be able to communicate in both directions about equipment and drugs that small facilities can contribute to the collective effort.
Upon activating for the emergency, the facilities should follow its plan, incorporating any guidance from government authorities and put that into the program. Throughout the public health emergency and after, the facility must evaluate its performance, revise the plan, and incorporate the public health emergency specific information into the plan for future reference. And as your emergency preparedness plan is tested, you should be able to see the changes you have had to implement to continue providing care for your patients. Or describe the operational changes that you had to put into place if you had to cease operations for a period of time and are now in the process of reopening. Discuss the results with your management team and document those results accordingly.
The review and formal discussion that led to the evolution of your emergency preparedness plan is actually an integral part of the plan itself. And in addition, facilities should analyze their response to testing exercises and revise their emergency preparedness plan as required. This analysis and revision in part can be accomplished through completion of after action reports. And at a minimum, after action reports should determine what was supposed to happen, what occurred, what went well, and what the facility can improve upon into the future.
We’re going to dive a little deeper into COVID-19 guidance, resources, and reopening materials. As the public health emergency has evolved, so has the guidance provided by global and national authorities, such as the World Health Organization, the Centers for Disease Control in the United States, and many health ministries throughout the world. AAAASF has responded by providing guidance throughout the public health emergency based upon the most current recommendations from various sources. We have compiled and disseminated numerous resources on infection control and emergency preparedness related to COVID-19 to our accredited facilities, as well as the public at large, through our webpage, on social media, and through direct mail, emails as well. These tools walked the facility through the thought processes of setting visitor policies, screening protocols, human resource policies, and personal protective equipment that’s appropriate for your patient populations and staff. They include infographics, templates, and scripts that facilities can use while interacting with patients and the public at large.
Decisions on reopening eye clinics to routine care, and resuming elective eye surgery need to be made in consideration of numerous factors. Including the proximity of the practitioner to the patient’s face, as recently outlined in the American College of Surgeons. Additionally, facilities must consider the necessity and time sensitivity of the services you provide, local and regional new case rates of COVID-19, and availability of your personal protective equipment and access to COVID-19 testing.
Assisting our facilities to reopen safely, by protecting themselves, their patients, and the community at large from the spread of COVID-19, is of prime importance to us. Early in the pandemic, we developed a desk review tool to help prepare facilities for reopening and ensure compliance with COVID-19 related infection control and emergency preparedness program requirements. We recently revised it and it’s now an official COVID-19 surveyor worksheet, complete with the standards to be cited, if deficient practices are discovered during our surveys. Our surveyors have begun utilizing this tool as of the first of February of this year, and we are encouraging our facilities to use this worksheet as a self-assessment tool for survey preparation. This and all other materials we present will be made available to you after the webinar. This tool is intended to prompt the facility and its staff to make adjustments to existing practices and develop new practices as required to best protect patients and staff.
And here’s another poll. Would AAAASF providing more FDA, Centers for Disease Control, or World Health Organization resources help? Answer A, yes, it would be a primary source of information. B, it would supplement what you receive locally. C, somewhat, but you would struggle to implement under the current circumstances. Or D, it would not contribute to what you receive locally. Oh, it’s very interesting. Certainly, AAAASF material and continuing to disseminate that would be very helpful. So that’s very good to know. Thank you.
Until there’s a resolution of the pandemic, facilities should continue to incorporate changes to adjust traffic flow through the facility and mandate social distancing in their waiting room. It is recommended to make doorways and passageways one way whenever possible. You should keep the waiting room as empty as possible. And social distancing markers and barriers present, advising seating patients to remain at least six feet from one another. And in fact, encourage waiting outside of the facility by patients and visitors, until patients can enter directly where they need to be. And even pre-screen your patients outside whenever feasible.
Maintain frequent and meticulous hand hygiene. Facilities should implement policies and procedures for hand hygiene, using alcohol-based hand sanitizer based on recent guidelines. In the United States, the Centers for Disease Control has issued such guidance. International facilities can follow that, their own health ministry, or that provided by the World Health Organization.
Facilities should implement enhanced environmental infection control measures. Such as enhanced cleaning and disinfection procedures between each use of exam rooms, procedure rooms, operating rooms, bathrooms, lobby/reception areas, nursing stations and all high-touch surfaces. Ensure the products used are appropriate for SARS-CoV-2 in a health care setting. And ensure that staff don appropriate personal protective equipment during cleaning activities. They should wear disposable gloves when cleaning and disinfecting surfaces and of course discard the gloves after use. These procedures should be written directly into your policy and procedure manual if you have one.
There should be frequent terminal cleaning of common high-touch areas, such as door handles and elevator buttons. And everywhere in your facility you increase air flow whenever possible. Use of commercially available slit lamp barriers in the ophthalmology world, or breath shields is highly encouraged. And they may provide an extra measure of protection against the virus. These barriers do not, however, prevent contamination of the equipment on the patient’s side. Which then may be touched by staff and other patients leading to transmission. And be aware that homemade barriers may be more difficult to sanitize and could become a future source of contamination.
Items appropriate for disinfection include hospital grade disinfectants that are known to be effective against SARS-CoV-2 virus. You can use diluted household bleach, alcohol solutions with at least 70% alcohol, and common Environmental Protection Agency registered household disinfectants, including certain Clorox brand products, certain Lysol brand products, Purell professional disinfection wipes and more. And in the United States, the Environmental Protection Agency offers a full list of antimicrobial products expected to be effective against the virus.
Manufacturer’s guidance should be followed whenever cleaning diagnostic equipment, such as visual field analyzers. Zeiss updated that guidance on how to treat it’s Humphrey perimeter during visual field examinations. And, of course, other manufacturers may offer similar guidance from their website or in direct instructional materials. For diagnostic eye drops required for ophthalmic examinations, single dose containers are highly recommended whenever possible. However, if multidose eye drops are the only option in your facility, containers should be kept in cabinets or other closed spaces, away from anywhere that could become contaminated during a patient encounter. And extra care must be taken not to touch eyelashes or ocular surfaces with the tip of the eye drop vial.
Of course, examiner’s hands should be disinfected immediately after touching the patient’s face or any other area. And keep high-touch items such as magazines and toys out of your waiting rooms and patient care areas. Disable drinking fountains, remove coffee/snack stations, and anything else that should not be used. Remove items and surfaces that cannot be readily cleaned, such as cloth and fabric items and chairs. And ensure that personal protective equipment is always available for staff and patients as recommended by authorities.
In June of 2020, the American Academy of Ophthalmology posted a study by Dr. Tina Felfeli and colleagues. They conducted a simulation evaluating the potential spread of respiratory droplets during a slit lamp examination. The findings, published in JAMA Ophthalmology, highlight the need for patients to wear a mask during close clinical encounters, including a well-fitted cloth mask if it’s the only option available. And that correct positioning of the mask is critical, because an improperly worn surgical mask is even less effective than a correctly worn cloth mask. And slit lamps must be cleaned between patients to prevent cross contamination.
It is recommended that facilities require personal protective equipment, including face covering worn by patients, caregivers, and ancillary staff at all times. And ensure your staff has had a refresher training course in the appropriate use of personal protective equipment, including proper donning and removal and proper mask fitting. Eye protection for the ophthalmologist is highly recommended. It’s based on the theoretical risk of infection of the ocular surface if it’s exposed. However, we recognize that in certain situations, wearing goggles for an ophthalmologist may be impractical.
For any in office procedures that require a physical proximity to a patient, regardless of the prevalence of COVID-19 in your area, recommendations are for surgeons to wear masks and eye protection, and an N95 mask should be considered. If necessary, follow CDC recommendations on N95 extended use or reuse. And increasingly, ophthalmologists will be asked to examine and perform office space procedures on patients who are recovering, or who have recovered from COVID-19. Currently in the United States, repeat testing for COVID-19 is not recommended for nine weeks following either a positive test or a documented infection. We will be covering some specific recommendations relating to procedure rooms a little bit later in the talk.
To further decrease the risk of viral spread, ophthalmologists should inform their patients that they will speak as little as possible during an examination. And in fact, request that their patients also refrain from talking as much as possible. And we encourage all facilities to utilize infection control surveillance tools, such as spot audits, to ensure that you are complying with policies and procedures surrounding infection control. Including the use of personal protective equipment, adherence to hand hygiene requirements, and environmental cleaning and disinfection.
There have been recommendations for changes in patient care processes, including changes in scheduling practices, screening of patients, changes in patient flow, reducing the visits of the most vulnerable patients in response to COVID-19, made by organizations including the American Academy of Ophthalmology. The AAO recommends adjusting scheduling practices with fewer cases to be scheduled in an office or surgery day. And recognize that clinic schedule volumes might need to remain below pre-COVID-19 levels for the foreseeable future.
Additional precaution is required in operating rooms, and may lead to longer turnover times between cases, impacting the number of cases that can be performed in a day. And along with complying with all national and local guidelines, it is recommended that the resumption of clinical activities be undertaken gradually. And this is to accommodate these requirements and other unforeseen issues. The American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery, and the Outpatient Ophthalmic Surgeons Society recently developed a checklist to assist with reopening ophthalmic surgery centers to address these issues. And that too will be made available to you.
The AAO advises that you reduce caseloads, increase time between patients to allow for proper decontamination, and disinfection of both shared space and patient care areas between each patient. Increased use of telehealth wherever that’s available, such as here in the United States, and you can use that for consultation and follow ups. For routine eye care, or urgent promise for healthy patients, with no evidence of COVID-19 and no risk factors, it is recommended that masks or face coverings be on patients at all times. Maintain physical distancing, be in close proximity to a patient only during the examination. Maintain distance while taking a history, or obtain history by phone prior to a visit. Reduce the duration of direct contact with a patient, limit the number of individuals in the examination room. Only one patient, one parent and a patient if the patient is pediatric, or one caregiver with an adult who requires an assistant.
Clinicians should wear at least surgical masks as described and recognize that N95 masks may provide additional protection, but we also understand that they may not be available in all facilities. Eye protections such as face shields and goggles should be worn to the extent practical. Although it may be necessary to remove such protection during some examination procedures. Thorough hand washing before and each patient contact is essential. And instruct patients not to touch anything unless they are absolutely required to do so. Patients should refrain from placing their own personal objects on environmental surfaces in the room. And surfaces and equipment should be cleaned with virucidal disinfectant between all patients.
But routine eye care for patients with symptoms suggested of COVID-19, defer appointments until infection is ruled out and symptoms have resolved. However, for urgent ophthalmic problems in patients with symptoms suggested of COVID, the patient may be seen in your eye clinic. Follow all the precautions taken for routine care of the uninfected patients, in addition, ensure patients are placed in the examination lanes or rooms immediately with the door closed and placed into a surgical mask. And the treating ophthalmologist and health care personnel should wear gowns, gloves, surgical masks, and eye protection. Please consider an N95 whenever a procedure is planned that may result in aerosolization of the virus.
The routine eye care of patients with confirmed diagnosis of COVID-19, patients should quarantine at home as specified by the Centers for Disease Control in the United States, the World Health Organization, your public health authority, or your institutional guidance and policy. Facilities should defer appointments until after quarantine and after symptoms have removed. And understand testing requirements of your local jurisdiction should patients have had COVID-19.
For urgent ophthalmologic problems in patients with documented COVID-19, or those under investigation, all of the precuastions that were described for routine care of the uninfected patients should be done, along with addressing certain exceptions. Patients should be escorted directly to an examining room with no contact from any other but essential staff. And limit the staff to those that are essential to interact with the patient. N95 or their equivalent should be worn by all clinicians, gowns and gloves must be worn. And eye protection should be worn at times and not be removed. Take extra care when doffing protective gear. And examination rooms should be taken out of service after an examination until the room can be thoroughly decontaminated per the CDC, your state or national health, or institutional guides. If practical, it might be much more appropriate for this patient to be seen in a hospital or other acute care setting, which is better equipped to provide both eye care and medical care to patients with COVID-19.
Because testing for SARS-CoV-2 remains incomplete, the true prevalence of SARS-CoV-2 remains mostly unknown in a lot of areas. Therefore, for surgical procedures that may generate aerosolized virus, preoperative testing for all patients, and the use of N95 masks in aerosolizing procedures by operating room is recommended. For cases that require general anesthesia, patients not in N95 masks should remain out of the operating room during intubation and extubation. And for non aerosolizing procedures performed under monitored anesthesia care or sedation, the patient can just remain in a surgical mask.
Recently, the FDA has issued emergency use of authorization for vaccines from Pfizer, Moderma, and now Johnson & Johnson. These vaccines will dramatically reduce the risk of moderate to severe COVID-19 disease in individuals infected with the virus. And may prevent transmission. However, while a vaccinated person who subsequently becomes exposed may not develop clinical disease, there still may be a window in which they may be infectious to others. Current testing and personal protective equipment protocol for surgical patients must continue to remain in place.
Similarly, ophthalmologists and clinical staff who have been vaccinated should continue to wear a mask during all patient encounters and their appropriate PPE. Any patient with a positive test for SARS-CoV-2 should be considered potentially infectious whether they have been vaccinated or not for now. And a history of being vaccinated should not alter the interpretation of COVID-19 testing.
[Tom] Dr. Goldstein, I just wanted to ask a quick, or interrupt you quickly there. You mentioned Johnson & Johnson, Pfizer, Moderna. The same information is available or holds true for the other approved vaccines as far as I know around the world. Whether it’s the, I forget the name of the Chinese approved drug that’s being used in many countries. As well as the AstraZeneca drug that’s being used in South Africa, I know early indications are that vaccinated people limit the spread. But my understanding is that the guidance holds true even if you’re using those other brands that have been approved in other countries so far.
[Monte] That’s correct, Tom, thanks very much for pointing those out. Great.
In July, the American Academy of Ophthalmology posted another study by Tina Felfeli. They conducted a simulation and evaluation of the potential spread of respiratory droplets during ophthalmic surgery. And the findings highlight that a complete seal of the adhesive drape around the surgical field is critical for preventing the spread of respiratory droplets for the patients. A tight surgical mask should be used to minimize the risk of cross contamination for operating room personnel and surgeons should be mindful when removing a surgical drape due to potential spread of droplets underneath the drape. And please consider administration of post operative drops and application of eye patches for the patient should be done prior to removal of the drape whenever possible.
We recognize that every country has its own reporting requirements for COVID-19 diagnosis. We request that you become familiar with yours. Maintain a list of emergency contacts for reporting suspected and confirmed COVID-19 cases. We ask that you have access to local COVID-19 testing sites if they’re available. And create policies and protocols for reporting suspected and confirmed COVID-19 cases to the appropriate health authorities in your area and AAAASF. Have emergency preparedness policies and protocols addressing suspected and confirmed COVID-19 diagnosis in patients, visitors, staff, including processes to address actions to take if COVID-19 infections are suspected in your facility. You must know how you would communicate with staff and other patients that were treated that day that have come in contact with suspected cases. And how would you decontaminate these areas and would your facility provide additional testing to those potentially exposed?
Another poll. Are you able to test for COVID-19? Answer yes if you have a reliable axis to COVID-19 tests and/or administer them or testing sites. B, sometimes we have limited access to COVID-19 tests or testing sites but supplies are frequently interrupted. Or C, no, we do not have reliable access to COVID-19 tests and/or testing sites.
Now let’s…reliable access at 67%, that’s really good to hear, but that still leaves a large portion without reliable access. And I will say, as the medical director of my own facility, we do a lot of ophthalmology, COVID-19 testing has been a major impediment to bringing our patients back into the care area. So clearly there’s a need out there to improve that.
Despite best intentions, things do slip through. At AAAASF, we’ve recently had to cite deficiencies for facilities not ensuring terminal cleaning staff have been trained in appropriate infection control and items for the COVID-19 pandemic. During a recent case tracer, an anesthesiologist, a circulating nurse, the scrub tech, they didn’t perform hand hygiene as required, as they did not sanitize their hands between donning and doffing their gloves. In another recent survey a used anesthesia circuit was left on the anesthesia machine and was present from one case to another.
And a staff member in another instance was cleaning the OR after surgery, the disinfecting wipe was dropped on the floor, it was then picked up and continued to use that dirty wipe to clean the surgical bed and other surfaces. And in the example on the slide, interestingly enough, the facility did not screen everyone who entered their facility for COVID-19, as it was their policy, and that was the surveyors that walked in. Today, more than ever, we really need to ensure that we are following infection control and prevention guidelines with extreme consistency and adherence to accreditation standards. And these accreditation standards will assist in that endeavor.
In conclusion, we have realized that certain values have stood out as critical amongst this pandemic and health crisis. COVID-19 detection and protection efforts emphasize that infection control is paramount and anything other than strict adherence places our patients, staff, and ourselves at risk. And personal protective equipment, it’s not just for surgery anymore. The field of ophthalmology has special concerns given the doctor’s proximity to the patient and that must be considered in your plan. Facilities need to be part of a health system response. And even smaller, private facilities have an essential role to play in the coordinating response and they can contribute much-needed resources.
Finally, we realize that guidance comes in many different forms and from many different professional organizations and government entities from the entire world. Facilities need to ultimately ensure that they are compliant to the requirements of their own national entities for public health, as well as accreditation standards.
And for our last poll, do you have a vaccination plan? Answer A, vaccination is in progress and in process and going according to plan. B, vaccination is planned but it’s not yet begun. C, there is a goal to vaccinate the population but no detailed plan. D, there has been little planning for COVID-19 vaccination. And E, our government will need to rely on international community and NGOs for COVID-19 vaccine distribution.
Interestingly enough, so half have vaccination in progress. But the other half, or 47% really need quite a bit of help and a full 20% will rely on non government authority, so it’s very helpful information to know.
Okay, well, thank you all very much for here in New Jersey, it was the morning. I’m not sure where it is where you are. Again, thank you to Project Orbis, Cybersight, AAAASF for allowing us to present and hopefully we can get to some questions.
[Tom] Yeah, if everyone can hear me. I’ve been doing my best to answer a lot of the questions in text format. There’s a lot of really good questions and they’re pretty detailed. So I have one that I definitely want to ask to Dr. Goldstein to respond to live. And then if you guys have more questions, send them in, and we’ll try to respond to them live. And if not, I have some that I’ve answered in text but we might want Dr. Goldstein to weigh in on to and provide some additional color to.
We’ll start with the one that I haven’t answered yet. And that’s how to manage young pediatric cases that cannot accept wearing a mask during an examination at the clinic? I know this is a problem, pretty much generally across all specialities with pediatrics.
[Monte] Yeah, so thanks, Tom, for that question. Pediatrics and other people who can’t wear masks, it’s been a major focus. It has prevented, early on, a lot of these patients receiving proper care. Most of the time it was delayed. But as we move forward, and I think we’ve become a lot more knowledgeable on how to react, we really treat them as COVID positive patients, we try to clear everything out, we minimize the exposure to everybody. Everyone on the clinical side needs to wear the appropriate PPE as if they’re COVID positive patients. And then everything gets delayed and everything cleaned appropriately as if there was exposure to a COVID positive. That’s the best way that we know. Early on as an anesthesiologist, we treated all the early pediatric patients as COVID positive and we were very successful using that approach, it’s a very good question.
Hey, Tom, I’m going to interrupt you, you can unmute yourself. One of the questions that came on earlier is if people who don’t know the different organizations. Maybe briefly we can describe the difference between Joint Commission, AAAHC and AAAASF and their approach to accreditation on the international level?
[Tom] Yeah, I answered in text on this and I didn’t begin with this because I wasn’t quite sure how familiar everybody is from the various locations that are joining today with the various organizations. In the United States there are generally accepted to be three national accrediting organizations for this type of setting, for outpatient settings. And it’s the three that you just mentioned. It’s AAAASF, that’s us, AAAHC and the Joint Commission.
Most people in the United States, and I would venture to say many people internationally, are familiar with the Joint Commission or Joint Commission International, which really focuses primarily on large, full-scale hospitals. I believe they have some smaller programs, but often those are difficult for smaller facilities because they’re taking an approach to a hospital or a hospital system and trying to make it fit into an office. AAAHC in the United States really was made for multiple speciality ambulatory surgery centers and so they also have a large presence in that area. But then again, when you’re talking about smaller facilities, centers, single two-doctor offices, they do a smattering of that as well. AAAASF really grew up mainly with offices. Two doctors, three doctors, four doctors. We have large offices that we accredit, up to 188 doctors, but our main focus is in the smaller practices. And because of that and because we’re a doctor-led organization, our standards are written very specifically to be very focused on the clinical aspects that have the best outcome for the patients.
We also believe that we differentiate for three main reasons. We have very strict requirements around doctor training, to make sure that the doctors are practicing within their scope of speciality and they’re not doing things that are not within their general scope of training. We also have 100% compliance. Other organizations may say you’ve met all of our critical criteria, you’ve met most of our other criteria, you haven’t met five or six criteria, but we’re going to approve you and encourage you to correct these issues. AAAASF actually has a 100% compliance mandate. So we actually don’t confer accreditation until we have proof that every last deficiency has been corrected through document review, through photos, through videos, through things like that.
And then third, is we have mandatory peer review and data reporting. So we actually require all facilities to enter into an online portal certain patient data that allows us to work with our partners at Harvard University to conduct studies on patient safety. That have proven out that care in an accredited location is safer than non-accredited locations. So those are the main differentiators and we take that approach globally as well.
[Monte] Thanks, Tom. I see a couple that I’m going to try to answer. One of the questions is do you think it’s still important to do screening questions for patients and visitors? Because sometimes they lie about their condition. Well, that’s an excellent question. I will say it is essential to continue screening. I’m the medical director of a multispeciality ambulatory surgical center in New Jersey. We continue to aggressively ask screening questions. And yes, we do at times find that patients did not adhere to protocol procedures or have really revised what they said about their health conditions. We really, in this pandemic age, we have no problem delaying procedures and making it clear that this is being done for the patient’s own safety. So I think that’s a very good question.
And really, the next question is would it be considered best practice to revise and update maximum occupancy for the clinic given social distancing requirements during the public health emergency? And again, that is absolutely essential. We very much limit anywhere within our purveyance, who can come in and out of our clinics. We also limit the number of staff in certain areas. So it’s key to pay attention to where staff are taking their breaks. We have very small occupancy limits where our own staff eat and how they can eat together. And they need to use appropriate PPE when they do that. And we have been very successful doing that, Tom.
[Tom] I would add too that depending on your location and the infrastructure in your location, it’s very common in the United States to have really large parking lots for every building. And here one of the common practices is right now is checking in, doing the screening, and then asking the patient to wait in the car. That’s going to be specific on if you have curbside availability, if your patients are walk up, depending on the climate, it’s not so great to be waiting in a car that’s not running when it’s 4 degrees Fahrenheit here in the U.S., in some areas. But that’s an approach that people take to reduce minimum occupancy or maximum occupancy without saying don’t show up for three more hours. To the extent you can use methods like that, it helps you maintain your occupancy and your flow in turning over your rooms, without limiting your physical space. Especially if you have a very constrained waiting room.
[Monte] One other question was about N95 masks and there’s a lot of talk about N95 masks and when they’re used. Early on in the pandemic, everybody was required to use them. As we move forward and learn a lot more about this virus, it really needs to be done selectively. There’s certain exposures I think that warrant using an N95 mask. Which was alluded to in the talk, sometimes using a mask improperly can be worse than using a less effective mask properly. That should be considered as we move on. Some people have kept N95 masks on for months at a time and they’re using the same mask, that’s not effective. So you’d be better off using a new surgical mask than a N95 mask that’s months old.
Run these things, you have to really figure out what’s most effective for your institution, but there are certain situations where, obviously, if you’re going to be in the situation where you have a positive COVID-19 patient and you are going to have aerosolization, then that is certainly the case and N95 mask should be used. And you should limit exposure to that patient by anyone unless they’re absolutely essential.
[Tom] I don’t know if you saw the next question was about an update to central sterilization departments in relation to COVID-19. I think sterilization, at this point, it’s more about attention to detail than it is changing what they do because it’s still sterilization.
[Monte] I agree with that, Tom. Sterilization, that has not shown to be a method of transmission. What this all is boiling down to and there was a lot of talk earlier on in the pandemic about air exchanges and waiting hours between cases. There really is not a lot of good documented evidence that that’s been effective. But attention to detail for droplets in these certain parts and protecting ourselves and the staff, that has been shown to be very effective. And using the accreditation principles that have been put out has actually shown very well that we can prevent the spread within our own offices and institutions of COVID-19, now that we’ve learned and have specific recommendations.
[Tom] And then the next question is more about do we envision these practices and protocols in the future or just through the crisis? I have personal thoughts on the emergency preparedness side of it, but if you want to speak at least to some of the protocols that are COVID-specific first, I can talk a little bit more about the emergency preparedness angle.
[Monte] I think some of these things will end up holding on and some won’t. We have a very short memory about these items moving forward in the pandemic. I think we have learned some best practices moving forward, which we’re going to incorporate into our infection control and our emergency preparedness measures. As it relates to a question earlier on about what else do I need in my emergency preparedness plan, what else do I need in my facility? I don’t think we talked a lot about risk assessment, Tom, and that’s a major part of this. So it really depends upon where you are in the world, you need to do a risk assessment as part of that plan. There are very good risk assessment tools out there and I think, Tom, hopefully we can make one of ours, or one that we use, available to the Cybersight community as part of this.
And once you do your risk assessment, there are areas where the pandemic, I think, will stay longer. Those clearly we know are having problems with vaccination or having problems with testing. Your risk assessment in a year will lead to different policies, procedures than other areas which have good vaccination programs today and will be out of the pandemic a little earlier. That’s a good way to approach this.
And then I like to think we have a great waiting room in our ambulatory surgical center. I used to like to go out and see patient’s families and have a chat with them. But I’ve grown so accustomed, actually to have all this vast space, I really wonder if we’re ever going to go back to having patients crammed on top of each other, patient’s families and their patients right next to each other. And truthfully, I don’t think we’re going to do that in the foreseeable future. So that’s one example of something that will take hold and I think will be around with us for some time.
[Tom] The other part and I’ll just off of your talk about the risk assessment. And again, I tried to touch on it a little bit without bogging down too much on it. Most of us are familiar with a risk assessment from a natural disaster standpoint. Again, I’ll just use the U.S. as an example. If you’re in the southeastern United States, you probably want to be worried about, thinking about hurricanes. Here in California, you might want to be thinking about an earthquake plan. If you’re Oklahoma, you want to be thinking about a tornado plan. They’re all very different approaches and very different risk assessments that you have to do for natural disasters. And the same’s going to apply globally. I have family in Italy and they’re worried about earthquakes and other areas of the world may not be quite so worried about that. But the same approach is taken both to man-made disasters, whether you have civil unrest in your area, or things like the pandemic.
And where I think there’s going to be some culture shift, there’s some interesting articles about, especially about the West and the United States, maybe taking a more personal responsibility and tact when you’re feeling ill. And they were using it in comparison to Hong Kong and Taiwan in being that when people in those areas are feeling sick, they’re going to wear a surgical mask out in public anyway. So those masking protocols and screening protocols are more dependent on the patient at the time, and not blankets applied across all patients. But if you have a patient that’s not feeling well they may come in with a mask and you may do some additional screening over time, whereas that’s going to be a culture shift in the U.S. They may be doing a lot of that already in Hong Kong or Korea or Taiwan because of experience with SARS and in some other countries with the experience with MERS. I think those are really important aspects that we might take hold on and might become more permanent.
More broadly speaking, though, I would say what’s going to take hold from the pandemic is more the approach that we need to be really ingrained with the principles of infection control, and of care, and be more adaptable. When you have a plan, chances are the catastrophe’s not going to fit that plan, but it gives you a road map to deviate in slight directions that allows you to be responsive. And what I’ve heard over and over from our facilities around the world that had emergency preparedness plans in place because of accreditation, they had never contemplated COVID. But it allowed them to adapt more quickly, and be reopened, and safer, faster than all of their colleagues because they were ready to adapt and they had a plan in place, and they were able to take principles and apply them to the new environment. I think that’s what we’ll continue.
[Monte] I think that’s a good point, Tom. And as part of the plans, a lot of them had responses to bioterrorism or other infectious agents. Which, truthfully, where it’s in the plan, I don’t know how carefully they reviewed in most places. But when it became obvious that the pandemic was a major issue, we really did go back to those plans and use that as a framework for how to respond. It actually proved, as being accredited, proved quite useful in developing response.
The other one was flu. Flu is a major source of emergency preparedness plans in certain areas in the United States or the world. And those concepts, obviously hyped up or even if you want to say on steroids, built upon. But the basis for how we’re functioning now, a lot of it has to do to our response to regular flu outbreaks. Things like meticulous attention to hand gels, and masking of patients, and having nobody near each other. Well, that really forms around our emergency preparedness plan at flu.
[Tom] Okay, so I don’t see any other questions coming in right now. If you have any last ones, please feel free to enter them. Otherwise, you can, this presentation will be available on Cybersight, you can download it. As I said, all the links are clickable. And you can follow them through to the website to get our guidance, our resources. Right now they’re available in English and Spanish and you can download templates for screenings, signage, various things. I think there are about 40 or 50 pages each. So anything that you can need that will be helpful to you, you’re free to download, all of that stuff is freely available.
And also you can contact us through the organization on the website. My own email is [email protected]. You can feel free to email me with questions, concerns, requests for more information. If you are struggling with something, chances are someone else is. And if you prompt us to do the research, we’ll make it available to as many people as we possibly can.
Once again, I want to thank Dr. Goldstein for presenting, for Cybersight, and Orbis for having us here and for you all for joining us.
[Monte] Okay, great, everybody. Thanks so much, have a great day.
[Tom] Thank you.