Hello, and welcome to the second annual inpatient rehab member community event entitled Hot Beds of Infection, Preventing Outbreaks on the Rehab Unit. This is Lauren Shapiro. I'm the chair of the inpatient rehab member community and an associate professor of clinical in the Department of PM&R at the University of Miami, where I also have an inpatient rehabilitation service at the Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis at uHealth slash Jackson Memorial Hospital. For those who are not already members of our community, please join us. We are on Fizz Forum, and please, in particular, share any topics you would like to see addressed in future events. And if you're interested in any leadership roles within this member community, please let me know. My email address is here, or you can message me on Fizz Forum. We currently have a vice chair, but we are interested in expanding our leaders in our group so that we can bring more events to our membership. The objectives for today's event include to improve our ability to provide rehabilitation care for COVID-positive patients while preventing transmission to staff as well as other patients, to describe methods of containing an outbreak in an inpatient rehabilitation facility or IRF, and to review potentially dangerous communicable diseases that have caused outbreaks in IRFs using a case-based approach. And for each case, I'll also highlight the CDC recommendations for infection control in healthcare settings. Our agenda for today, we'll start with some polling of the audience so everyone can share what they're currently doing with regards to their infection control practices and the IRFs in which they work. Then, Dr. Susan Maltzer from Northwell Health will be giving a presentation on containing COVID. Following that, Dr. Leslie Rydberg from the Shirley Ryan Ability Lab will be speaking about building a COVID-19 rehabilitation unit. We'll then be joined by our two additional panelists who will introduce themselves and provide a brief description of the IRFs in which they provide care. Then we'll review some very complicated infection control cases from IRFs, and then we'll have time at the end to discuss any member community issues or concerns. The session directors and panelists have no relevant financial disclosures, but one important disclosure is when this proposal was first submitted, we had all sort of hoped that this pandemic would be largely behind us and this would be an opportunity for us to reflect on the past year, year and a half. But unfortunately, that is not yet the case, but I think the topics that we'll be reviewing today are even more important given the continued pandemic. So let's get started with some polls. We'd really like to have participation from all the participants today, so you'll see a pop-up here. It'd be nice to know who's joining us today. So please respond. Are you an attending physician, resident physician or fellow medical student, or other health care professional? You can just click on your answer and hit submit. All right. Let's share that poll so we can see who's in our audience today. All right. So great. Primarily attending physicians. Hopefully, we'll have some residents or fellows or students join us later, and other health care professionals as well. Great. Moving on. For those who know, does the IRF you work in require a COVID test prior to admission? Yes or no? All right. Let's see the results of that. Can we share the results of that poll? All right. I don't see it, so I'm going to move on, and hopefully, we'll get that fixed. Does your IRF accept patients with active COVID-19 infections, yes or no? We seem to have some trouble with the polls. Okay. Well, why don't we switch to comments in the chat then? Does your IRF accept patients with persistently positive COVID-19 PCR tests who are cleared by infection control, yes or no? And if you would, try to share in the comment section in the chat the number of days after which your institution clears a patient following a positive test. All right. So I see some responses in the chat. So no, yes, depends on setting, yes, 21 days after initial positive, great. All right. So I will move on to the next poll if we get it working. If not, we'll just go to the chat. Has your IRF restricted visitation at any time during the pandemic, yes or no? Yes. Yes. All right. All right. So it seems like the majority are saying yes, they have restricted, and certainly, you know, we have at my institution as well at times, although we are beginning to loosen that as our case counts go down. When do your team members wear N95 respirators or comparable masks? Lots of answers here. I know there are other possibilities as well. Whenever they're inside the facility for all patient care, when in close contact with a patient demonstrating signs or symptoms of COVID-19, when in close contact with known COVID positive patients or never. If we can get the poll running, if we can show the poll, that would be great. But if not, we'll just go to the chat. All right. I don't see a poll. Okay. So I know here in Miami, okay, great. So N95 for known COVID, great. All right. So here in Miami, we are currently wearing them for all patient care, actually, because of high case counts. And then last but not least, has your IRF had cases of candida auris yet? All right. Dr. Carpenter says yes. Great. And Dr. Carpenter said no. Dr. Ryberg, yes. All right. Well, we'll talk more about candida auris, which is an emerging problem, later during the case-based discussion. So with that, let me introduce our first speaker. Dr. Susan Maltzer is the associate professor and vice chair at Northwell Health Department of rehabilitation medicine at Glen Cove Hospital on Long Island, and she'll be discussing containing COVID. So please welcome Dr. Maltzer. Thank you so much. So before I kind of get into the nitty gritty of containing COVID, I want to just discuss where my experience kind of fits in. So here in New York, as you may know, we were kind of like one of the first places in the country to really get slammed with COVID. And, you know, when I look at this headline and it says that there's an astronomical surge, that's kind of what it felt like. It felt like a tsunami of COVID and disease and death. And we had to improvise very quickly our infection control practices and adapt. And, you know, I always tell the story that on March 30th, when we had not had any COVID patients in our acute rehab unit, I got COVID and was home for a week and a half. And the entire time I was home, I was working up on policies of testing and screening our patients. And by the time I had come back to work, all those policies were completely obsolete because we had gone from needing approval of the medical director of the hospital to do a test to trying to test more. And so some of this is something that has changed so much over time with each increasing surge, with each new improvement in therapeutics, vaccines, cases going up and down. And hopefully as my talk progresses, I'll be able to give you some context to that. Next slide, please. So the reason I put the slide here is I think especially for people that may be medical directors of acute rehab units, you know, this trying to contain COVID is really an exercise in leadership. And Michael Dowling, the CEO of Northwell Health, wrote a book called Leading Through a Pandemic. And these are some of the things that I took away from the book as I was able to reflect on our experience here in New York. One is that we have to plan ahead. And so I'm so glad that Dr. Shapiro has made this community session because COVID, you know, is still persisting, but we have other potential infectious threats to our patients here. So you cannot over plan for these things. The other one is that your employees are your number one priority. I know that we all say that our patients are number one priorities, but as a medical director, you know, the wellness and the health of my employees who I'm putting on the front line every day was important to me. And it really guided how I, you know, both set up our rehab units and what kind of patients I took. Because if we don't have trust of our team, that we're doing the right thing for them and we're protecting them, we're not going to get the best outcomes for our patients. And I think more than anything, you know, this really allowed people to step up to leadership when we didn't have clear answers. There was no right or wrong answer in terms of containing COVID on your rehab unit. And so I really benefited a lot from being able to network with other medical directors in New York and across the country and happy for us to kind of step up into this role. Next slide. So I know that Dr. Ryberg is going to go into building a COVID rehab program. I'm not going to discuss that. But when we're talking about infection control with COVID or if we want to think about the flu, MRSA, all these other things, you know, the key tenets that I kind of ran through in my head were things like space, equipment, personnel, and program. How do we isolate patients into separate spaces so that we don't have co-mingling of COVID patients and non-COVID patients? This was very important to me from the very beginning. A lot of people, a lot of acute rehabs in New York had to close because they had to give their beds over to acute care hospitals. We actually ended up expanding because of the way that we are set up here. But I insisted that we completely separate COVID and non-COVID patients because we had to protect, I think, those patients that were still getting strokes and spinal cord injuries and heart attacks. Equipment, you know, besides just the need for extra equipment, which we had not planned for before, again, at the time when we did not know that COVID was mostly airborne and not so much contact, we always have to think about what equipment do we need to be able to separate our patients out? So, like, you know, overnight assembling parallel bars and different wheelchairs and really anything we can get. Personnel, right? We always have to think about do we have adequate staffing with people on quarantine, people getting sick, people's family members getting sick? What are we doing to support our team during this process? And, again, how do we invest in our team so that they feel safe? And then program. You know, again, many of our patients had therapy in their room because they tested positive and we had no place to send them. Did they get the best program? How do we modify their program? Do we accept that, you know, we try our best, but in the middle of, you know, a national emergency, we may not be able to do our best. So these are things that I think we should think about for the future. Next slide, please. This is just a little data from a study we published recently in AJPM&R, just looking at length of stay of patients admitted to our COVID rehab unit. So most, you know, most patients stayed around 15 days, which is similar to our regular patients. And that's important because when we're talking about accepting patients that may be COVID positive or may be testing COVID positive, we have to think about are we going to be able to discharge them? Are we going to be able to get home health aides, home health care, nursing, all that stuff if the patient continues to test COVID positive? Are we going to be able to have the family take the patient home? How do you revamp your education to teach the public about, you know, length of quarantine, length of being on infection control precautions? So again, this is something that we kind of had to do overnight. Next slide, please. So in April 2020, once we had a few patients come to us, and then several days later, test positive for COVID, we realized that we needed to wrap our rehab unit in a complete and total bubble. And we separated our COVID and non-COVID patients onto different floors. And so for our non-COVID patients, our stroke unit and our brain injury unit, we insisted on testing every single patient on admission and every seven days. And this was before testing was widespread. And actually, we kind of had to go rogue to do this. If I'm honest, our hospital administration did not really support this because it was very hard to get testing back then. But my infection control nurse and I really insisted that our patients are different from medicine patients, that they commingle in spaces, in dining rooms. They're very close contact between therapists and the patients. And we absolutely had to be sure that our non-COVID patients were really non-COVID patients. So you can kind of see from this slide that we tested 255 patients as part of this COVID surveillance program. Now, I will tell you that these patients did have frequently negative tests before coming to us. But we did not trust anybody else's negative test. We said, we don't care what they have on admission. We're still going to test them. And we're going to test them every seven days. So 255 patients, we were able to identify three patients who were positive despite having had negative tests at the sending facility. So three patients out of 255 does not sound like a lot. But we actually, when we think about the amount of commingling that happens in different gyms and that every patient probably comes into contact with 15 staff members every single day, we felt pretty good about catching these three. And then in July of 2020, this became hospital-wide policy that every patient gets tested on admission and every seven days. So we kind of felt like vindicated a little bit. Next slide, please. So I want to just quickly go over what we do now. What we do now is basically taken from the CDC guidance, which is that for patients that are not immunocompromised, I'll start with that first, after 10 days from the initial positive test, we don't require any negative testing. So as long as they are hemodynamically stable, they're afebrile for 48 hours, and their test was more than 10 days ago, we will take them. If they're immunocompromised, we are usually waiting 20 days since the initial positive or two negative tests if it's less than 20 days. This has been our standard answer, and I have not budged. Ever since we closed our COVID rehab unit, I have said this, I will not make exceptions. I cannot, you know, have more outbreaks here. And so, you know, sometimes ascending facilities do get a little upset when they have a patient admitted with a hip fracture and tested positive for COVID, and they may be asymptomatic, and we don't know if it's because they had COVID three months ago. Now with vaccines, that's changing a little bit. But I've kind of held fast to this rule. Next slide. So just patients who are immunocompromised are those that have had organ transplants, stem cell transplants, patients with HIV, patients on immunomodulators and chemotherapy. This we kind of take case by case. I do work very closely with our referring tertiary hospitals within my own health system, and I see what they are doing as well. So I, you know, with the immunocompromised part, I think there's a little bit more room. I think that's my last slide. Oh, just one more. What do we do now? So ever since we closed our COVID rehab unit, and given that COVID rates are really low in New York right now, thank God, if we have a patient who converts to COVID positive, we transfer them to medicine. Because we essentially are back to normal with our program. And I just feel like it's too much to expose patients and staff and to isolate people. So we send patients to medicine. I try to give them as much therapy over there as I can. And then, of course, we bring them back when they're done. That's it. Thank you so much. Thank you very much. If anyone has any questions, they can place them in the chat, and we will get to them, perhaps after Dr. Ryberg's presentation. So I'm happy to introduce Dr. Leslie Ryberg, who is an assistant professor at Northwestern University Feinberg School of Medicine, attending physician with an inpatient rehabilitation service at the Shirley Ryan Ability Lab. And she'll be speaking about building a COVID-19 rehabilitation unit. Dr. Ryberg. Hi, everyone. Thanks for having me today. I'm Leslie Ryberg, and I'm a physiatrist at the Shirley Ryan Ability Lab in Chicago. I work at a 240-bed rehabilitation hospital. So we have a lot of space and a lot of room and some opportunities for some experimentation and trying different practices here. So when the pandemic started, I was really thinking about how I could help. So it was March of 2020. Thankfully, I didn't get COVID right at the very beginning. And I was a little bit worried that I was going to end up covering in the ICU, intubating people. And I really felt like that was not the best use of my medical background and expertise. I've been focused on medically complex rehabilitation for years. And so working with people with trachs and respiratory issues and prolonged hospitalizations is pretty comfortable for me. So I immediately volunteered to work with the COVID patients, and we opened our unit April 14th of 2020. And what we did at that time, we had three patients come in on day one directly from our sister hospital, Northwestern. And we closed off a wing on one floor, about 12 beds, and we made that our isolation unit. I remember nervously putting on my PPE and heading in to see those first three patients. They were all about 80 years old, had all been intubated, all had dysphagia, but were generally pretty healthy and were recovering pretty well. So it wasn't a very complicated start to it. Okay, go to the next slide, please. So over 250 patients later, we've learned so much about caring for patients during a pandemic. And I think, as Susan said, the most important thing to think about is that everything changes. So in Chicago, we've had several different specific periods where our COVID numbers have been really, really high. So April, May of 2020, and then October, November, December of 2020, things were really high as well. And our isolation unit has therefore grown and shrunk depending on what the need was at that time. So the way we set up originally was that each unit that the isolation unit was all isolation all the time. So every patient was on isolation, every faculty, every staff member was wearing PPE at all times when on the unit. So even walking from one room to another, you had your PPE on even sitting and charting at the nurses station you had your PPE on because it was all considered an isolation unit. And also early on, we didn't have great clearance protocols. So people stayed on isolation for their entire hospitalization. So at one point, we had a full floor 31 bed dedicated as an isolation unit. And currently, we've shrunk down. So we have one patient on isolation as of today. And he's actually a young gentleman with a traumatic brain injury who had an incidental positive on his admission screen. So all of our patients are still getting a COVID test on admission to rehab, and his popped up positive. As a general podiatrist with an interest in medically complex, I try to avoid brain injury. But this is where my overlap comes in. So he's my patient on the isolation unit. We've also been really lucky to have a dedicated infection control team. So we have a Northwestern infectious disease doctor and PhD infection control staff member and so running an entire hospital and thinking about all the COVID policies that go into that. It's been amazing to have that dedicated staff to really provide in the moment changes. So next slide, thinking about our admission criteria, so who can come into our unit. And so originally, we did not accept patients with a tracheostomy because of the aerosolization. And that was for the first couple months. But now we've been able to accept, we don't accept people on a ventilator, we don't accept people on BiPAP for respiratory failure, but we can accept CPAP, BiPAP, if it's for sleep apnea, we can accept people with tracheostomies, we can accept people as long as they're on stable oxygen, and their oxygen is at four liters at rest or lower. And they must be out of the ICU for five or more days, and they must be fever free. So really thinking about medical stability, medical improvement. Next slide. And then how did we set things up? So we only have one negative airflow room in the hospital. And so we did create the isolation unit around that one room. But we actually were able to create physical barriers to set up where the different aspects of the unit works. So the this picture is an example of a couple of our rooms that we've set up for people with tracheostomies or CPAPs or BiPAPs. So it's an extra layer of protection for people who have aerosolizing procedures or risk factors. And so it's a double doorway, kind of like those restaurants in Chicago where you have to go into the answer room to get into the restaurant. It's kind of the same way with our trach room. And then there's a HEPA filter inside to ensure that we are taking care of the airflow as much as possible. Next slide. And then, as Susan said, we really do need to think about isolation space for therapies. And I know a lot of facilities ended up doing their therapy and their rehab in the patient's room. But we were lucky that we actually were able to create a dedicated treatment space for therapies. So this is kind of a random room, our hospital was built and opened up in 2017. So we actually had some space that had not been built out and was not dedicated for anything. And so we were able to utilize this space and built a COVID rehab gym, which I know is probably not the case for the vast majority of places that you have the resources to do that. But basically, our infection control policy is that patients with confirmed COVID-19 should be treated on a closed access cohort unit with dedicated treatment spaces, and physical barriers. And so this way, we were allowed to have treadmills and parallel bars and motormat and therapy mat and we're able to get our patients out of the gym to work on their dedicated therapy time. Next slide. And most importantly is the people. So this is an article that was in Crane's 2020 for Healthcare Heroes. So our rehabilitation unit was actually named Healthcare Hero. And I'd like to point out that that's me holding the R sign. And this sign was actually, we put this together from our PR team as a thank you to our board of directors and our board as they were doing fundraising. So this was a fundraising effort, actually, but they submitted that for our Healthcare Heroes picture. But basically, the 20th floor rehabilitation unit became the COVID unit. And that was because of our expertise working with patients with medically complex conditions, and thinking about where the negative airflow rooms were and what made the most sense from a hospital. So the nurses were dedicated to the isolation unit. So if they were on the isolation unit, that was the only patients that they cared for. The therapist could treat anywhere in the hospital in the morning or for the first half of the day, and then they would be assigned to do the isolation unit at the end of the day or in the afternoon. So all of our isolation patients tended to have therapies in the afternoon. And then still our dieticians, care managers, and some other staff would actually do a lot of their treatments over the phone or get information over the phone as opposed to going into the isolation unit. And things like delivering meals, the dietary staff would deliver it to the unit, and then the nurses would actually take it into the patient room. So it was a goal to limit the number of people that were in and out of the isolation unit. Next slide. And then of course, nothing would be complete without oodles of personal protective equipment. So we're lucky that we have plenty of supplies. We currently, based on CDC guidelines, have used for the majority of the pandemic used surgical masks and shields or eye covering in patient rooms. But based on the OSHA emergency temporary standards, we're currently using N95s in rooms for all patients who are COVID positive or suspected of having COVID, and obviously N95s for any aerosolizing procedures as well. We had to troubleshoot a little bit to think about how to do family training in our patients who were still persistently positive or testing positive over time. And so we actually did make, obviously there was no visitors on the isolation unit, there still are not, but we will allow families to come in for family training if it's the only way we're going to get a patient safely home. And so we would set that up for the end of the day and make sure that the space was secure and there were not any other positive patients around so that we could limit any spread that way. Next slide. And then clearance from airborne precautions. So our precautions are a little bit more strict than Dr. Maltzer's team in New York. So asymptomatic patients can clear at 10 days, and that's pretty common. Symptomatic patients, which we really defined as people with hypoxia, would clear at 20 days. And in both cases, the symptoms have to be improving, stable to improving. And next slide. But really, we are much more strict about clearing people from isolation if they're immunocompromised. So we do not clear people who are immunocompromised until they have had two negative tests. So we have patients who are immunocompromised who are still testing positive weeks and weeks if not months later, and I am not allowed to clear them from isolation, which becomes a little bit of a hassle. And then we also have really strict criteria for people with tracheostomy. So if you have an open tracheostomy, then you must have two negative COVID tests to clear and one of those must be an endotracheal aspirate. So we're making sure that there's not any risk of that they're not aerosolizing any active virus from lowering their respiratory tract system. So it's been a little bit of a hassle getting people cleared. But we are still actively accepting patients on isolation, we still actively have a unit up and running. And so we still get referrals from all over Chicagoland for people with the effects of COVID, or with active asymptomatic COVID infections. Slide. And so what are the outcomes? What do we think about having set up this unit and kept this unit up and running? So obviously, the best outcome is seeing our patients go home. So this is a picture of Gordon Quinn. He was one of our very first patients in the COVID isolation unit. And so this was, you know, April 2020. And they actually sent in a Chicago Tribune reporter and photographer who came into the unit in their full PPE and followed our patient around and he's a famous filmmaker. And so he's made several documentaries about his experiences with COVID. And it was just really a good first look at what the recovery pathways are looking like for people with COVID. And I think it's also been really fun to see our patients who are discharged from the unit and we're in the news. So there's been a lot of news coverage about rehabilitation and, you know, IRS, and it's really put physiatry in the forefront a little bit, which, obviously, we don't want to have a pandemic to do that. But I have had a lot of interesting conversations with friends, family, people around the country about the role of rehabilitation and physiatry in the pandemic. Next slide. All right, go back to outcomes, sorry. And then looking a little bit at our outcomes. So Dr. Prakash Jayabalan is one of our researchers. And so we've been collecting data on our hospitalized patients. And we've looked at over 400 patients between our alliances. So the Shirley Ryan Ability Lab, Marion Joy Rehab Hospital in Wheaton, the Alexian Brothers Rehab. And so our patients are on average about 64 years old. We've actually seen a lot more women than men. And we've seen kind of a very diverse group in terms of socioeconomic background, racial background, different languages spoken, different areas of the city, the state, and even people from around the country. And in terms of the comorbidities that our patients have had coming in, a lot of high blood pressure, hyperlipidemia, diabetes, and chronic kidney disease for the patients that have made it to our unit. And looking at our rehabilitation outcomes. So we've had about a 72% improvement on their quality indicator from admission to discharge. So our patients really are making a lot of progress and having really good functional recovery in the inpatient rehabilitation unit. All right, I think I'll finish up there. All right, thank you very much. Again, if anyone has any questions for any of our speakers or panelists, please go ahead and put it in the chat. And in the meantime, we're going to move on to our discussion cases. So these are based on real IRF patient scenarios, but non essential details have been changed to protect patient privacy. These are not all from a single institution. And most of the cases don't have a singular correct answer. The panelists decisions will be really based on the training and skills of their team members, the resources, equipment and supplies they have available policies of their IRF proximity to an acute care facility, and at times pandemic surge conditions in their communities. So in addition to Dr. Ryberg and Dr. Maltzer, I'm very happy to introduce our other panelists. The first is Dr. Dewan Carpenter, who is the physiatry interim medical director at North Oaks Rehabilitation Hospital in Hammond, Louisiana. And I'll invite her to introduce herself and talk a little bit about her inpatient rehab program. Dr. Carpenter. Yes, thank you so much, Lauren. So yes, I am currently practicing in Hammond, Louisiana, which is situated somewhat in between New Orleans and Baton Rouge. And so our facility, technically, it's considered a standalone rehab. The main hospital is about 10 minutes away from us. So we kind of are very particular about the patient that we do have, making sure that we have the ability to meet all of their needs medically. And we do communicate a lot with our infection control and infectious disease physicians as well. And we actually not quite as fancy as what Shirley Ryan lab has, but we had a little area that was like a solarium for our patients that we actually were able to make a little makeshift gym, we didn't quite have as much. So we had a whole like a three room kind of COVID pod that we were able to do just based on all of the things that kind of have been going on for the last year and a half. So thank you so much. I'm happy to be here. Great, thank you. And we also have Dr. Corrine Velez joining us today. She's the Medical Director of Inpatient Rehabilitation at Advent Health Waterman in Tavares, Florida. So Dr. Velez, please introduce yourself and your program. Hi, thank you, Lauren, for having me. I'm a physician with dual board certification and PMNR and in spinal cord injury medicine. Like Dr. Shapiro said, just newly appointed Medical Director of Inpatient Rehab Unit Services and Advent Health, which is Waterman, which is in Central Florida. Our unit was open in January of 2020. So a little bit before the COVID pandemic started. And it started as an eight bed unit within 300 bed acute care medical facility. So we do have all of the available consulting, imaging and lab services there. Currently, we do have a 12 bed unit and we're expanding to 22 beds in the future. Because it's been a moving target. It's been very difficult to adapt to the time. So I think the advantage of our unit is that it's every room is single bed. So we're able to do isolation within for each particular patient. So it's been an interesting journey so far. Great. Well, thank you both for joining us. So let's move on to our first case. So this is a 38 year old gentleman who sustained a traumatic spinal cord injury with resulting complete paraplegia. While receiving care in the emergency room, he had prolonged close exposure to a patient that was later confirmed as having the measles. This patient was born abroad and he was uncertain if he had been vaccinated as a child. Titers were without detectable antibodies against the measles. So the issues here, unfortunately, at that time, which was a few years back, it was less common to give post exposure prophylaxis. So he did not receive vaccination at that time, nor immunoglobulin. And he was referred to the inpatient rehab facility just one week following his exposure. And of note, it can take about two weeks for the measles rash to develop after an exposure. So we will try to get the polls working again. So first, would you have accepted this patient for admission? Yes or no. So everyone, all the participants and attendees today can select an answer there. And the next question is, would you have empirically placed him on droplet or airborne precautions? So we will put up that poll as well. Yes or no. That does not appear to be working again. So we will throw these questions. Oh, now it's back up. Okay. So everyone can go ahead and answer that. And we'll just wait a few seconds. And then can we share the results of the polls? All right, well, we will start with our panelists. And then hopefully, they'll be able to share the results of the poll. So let's start with Dr. Velez. So I would say that yes, we would have accepted this patient for admission. And we would have placed them both on contact and droplet precautions until cleared by either an infectious disease physician or an infection control team. All right. And next, Dr. Ryberg. I would do the exact same thing. All right. And Dr. Carpenter? Yes, same. We would have empirically placed. And that would not have limited the acceptance to admission. All right. And Dr. Maltzer? I agree. All right. So this was a case from a prior hospital I used to work at. And okay, good. So it looks like everyone would place him empirically on droplet or airborne precautions. And our prior polls showed that about three quarters of people would have accepted the patient for admission. And 25% said no. And I think in this particular case, we did take to our prior rehabilitation hospital. I was the patient's physician. And I had had recent titers showing that I had antibodies, but had to wear an N95 at all times, as did our staff. He received all his therapies in the room. If he had had a diagnosis, perhaps other than spinal cord injury, where we know that our team really provides the highest level of care, I'm not entirely sure he would have been accepted given the need to confine him into the room. You know, certainly brain injury, stroke, and other classic rehab diagnosis, I think we probably still would have taken. But had he been at like a debility case due to pneumonia, I'm not entirely sure the facility would have done that. And his rehabilitation was limited by needing to be in the room. But we still have plenty of goals we were able to work towards, including transfers in bladder and bowel care. So just a brief review of measles, since it's not something we see very often anymore, fortunately. It's a highly contagious disease, up to 90% of those who are not immune will become infected after an exposure. It's spread through droplets in air. And importantly, the virus can live for up to two hours in the air, which is why we did not try to make a satellite gym because it does live in the air for so long. People are infectious for several days before and after the rash appears. These days, post-exposure treatment for the unvaccinated is far more common. The CDC recommends administering the MMR vaccine within 72 hours or giving IV immunoglobulin within six days of exposure. Infection control recommendations include having a single patient room with the door closed, having the patient be masked whenever outside the room, having all staff, including those known to have antibodies, wearing a well-fitting N95 or comparable respirator. The duration of isolation varies depending on the degree of immunocompromise at present. So if someone's immunocompetent and they're known to be infected, they need to be in isolation for four days after the onset of the rash. If they are immunocompromised and known to be infected, it's longer due to prolonged shedding. And it's certainly reasonable to involve your infection control and infectious disease colleagues. But if you have a patient like this one who's exposed, unvaccinated, and asymptomatic, they require isolation for 21 days from exposure or until discharge, depending on which occurs first. So this gentleman remained in his room up until the very end of his rehab admission. So our next case, and I apologize in advance if discussing this case makes anyone itch, I'm definitely prone to starting to scratch whenever I think about lice. So this is a case of head lice infestation. So this is a 36-year-old woman with a history of hypertension who had a hemorrhagic stroke. She was admitted to IRF from an outside hospital in a neighboring county. On admission, she demonstrated left hemiparesis and mild to moderate cognitive impairment. The following morning, the nurse reported seeing moving gray dots on her pillow. And further examination revealed head lice and scalp expirations from scratching. So what precautions would you take? And we'll, oh good, our poll is working. So gown and gloves, surgical cap or bouffant, in-room therapies, or all of the above. So everyone can go ahead and respond to that. And whenever we can show the poll results, we can put those up. All right, good. So everyone said all of the above. All right. So we will throw this case to our panel as well. And feel free to discuss any experience with head lice on the unit or any other reflections as well. First, Dr. Maltzer. So I would, you know, I have not had a head lice case on our unit that we've known about. But having had, you know, multiple children go to sleepaway camps and just having experience with it that way, I'll just say, I feel very comfortable with these patients with, you know, giving them the treatment both with the shampoos and comb outs and ultimately, you know, head lice, you need to have some direct contact from hair to hair. So I think for me, I would do the treatment and try to prevent contact as much as possible. But, you know, I think easier said, much easier said among adults than it is children. And Dr. Velez. I agree with Dr. Mel, sir. I mean, I also have a child, so I know how rapidly it can spread. So I would agree that I would try to implement all of the precautions and thankfully, I have not had that I know of any patients with head lice. And Dr. Ryberg. I have no personal or professional experience with head lice and maybe that's because I have boys at home and I'm not sure it's less of an issue with shorter hair, but I would agree with being aggressive in terms of isolation. And then hopefully, as Susan said, the treatment is pretty quick and effective. And so hopefully it can be addressed and get patients back into the community for rehab. And last but not least, Dr. Carpenter. Yes, agree with everyone else. And I guess fortunately enough, we have not had any instances of head lice that I'm aware of. So I'll knock on wood that we continue that way too. Yeah, surprisingly, this was my first one and it was fairly recently. And one of our concerns was she was located on our brain injury unit and many patients in neighboring rooms had had craniotomies or decompressive craniectomies. And we were very worried about them scratching their incision areas. And the patient in the room next to her did in fact have a decompressive craniectomy. Fortunately, there were no further cases and she responded nicely to treatment. So just a brief review, head lice are a pediculous, humanus capitis, doesn't directly cause disease when one's infested, but scratching can result in secondary skin infections, which was our primary control. They're spread by direct contact. They crawl, they don't fly or hop. So you need to have contact with, again, as someone said, hair of the infested person or their combs, brushes, or lying on their bed. It's primarily treated with permethrin lotion, nicks, or some other topical agent. So individuals who are infested do need a private room while in a healthcare setting. Their bedding and towels need to be machine washed on hot cycles and you need to maintain contact precautions for at least 24 hours post-treatment. Although certainly sometimes people require more than one treatment. I did look this up because again, it was our brain injury unit and I had concerns about this. But interestingly, nits can live on helmets for up to 10 days. And there's a National Pediculosis Association that recommends using a surgical cap under a helmet, vacuuming and wiping the helmet, removing and washing foam pads and straps, or you can seal the helmet in a plastic bag for two weeks and it will kill the nits. All right, so let's move on to some COVID cases. So this is a 45-year-old man with no significant past medical history referred from an outside hospital for rehabilitation in the summer of 2021, following multiple lower limb fractures sustained in an ATV crash. His hospitalization was noted for COVID pneumonia with hypoxia, for which he received IV steroids and supplemental oxygen via nasal cannula. 10 days had passed since his first positive test and he was reportedly improving with regards to his cough and shortness of breath. He had been afebrile at time of discharge, but within 24 hours, I'm sorry, within 12 hours after his admission to rehab, he spiked a fever to 102.3 degrees Fahrenheit. He became tachypneic and had an increased need for supplemental oxygen from two liters to five liters. Test X-ray revealed bilateral infiltrates and a repeat COVID test was done stat and returned positive. So we'll try to get our polls running. So if everyone can answer, given that he had been 10 days from his positive test and was improving in terms of symptoms at the time, also considering that it's the summer of 2021 when the Delta variant, at least here locally was the predominant variant, would you have accepted this patient for admission to IRF? Yes or no. We'll give everyone a minute to respond to the poll. And can we share the results of the poll? All right. So a little bit of a split here. So the majority said yes, they would have accepted the patient for admission to IRF and 22% responded no. And then the next question is, given the patient's current clinical scenario, would you now transfer the patient off the rehab unit? Yes or no. And everyone can respond to that. All right. So if we could share the results of that poll. All right. So similar responses where 71% would transfer off and 29% said no. And I think this is a particularly good question to, these are good questions to throw to our panelists because I do think the answer is really gonna vary depending on the resources everyone has available. So let's start off with Dr. Carpenter. So yes, based on the initial information in the screening, I would have admitted this patient to the IRF. Once his condition changed, I would have transferred this patient off the rehab unit. My reasoning would be number one, the increase in oxygen demand. As I mentioned before, we are technically considered a standalone rehab unit and we do not have respiratory therapy readily available. And so any patients that are particularly needing increased oxygenation and things like that, that is my cue that they need to be transferred because if they need any additional things, you know, intubation, things like that, they are not gonna be well-served here. And certainly I don't wanna be having the patient in that predicament where we've got, you know, some time gaps, but also just given the fact that, again, because if this person recovered and now possibly has, you know, reinfection, now I'm also putting, you know, staff and other patients at risk. So multiple issues there for me that would say, is this probably best to be transferred, especially before we get real into therapy and things like that. That would be my, the way I would handle this particular case. And Dr. Malter? So I would have accepted the patient based on the fact that he was 10 days out. And I think, you know, our setup is a little bit different. We are located in a hospital where we have access to hospitalists and, you know, an ICU if we need. I think given that he had this acute change in status, I would have at least tried throwing some antibiotics and fluids at him and seeing if he would improve. And then seeing how he does. So just in my experience, these patients who've had, you know, COVID can develop these COVID pneumonias. They take a really long time to resolve. They are at risk for developing subsequent pneumonia. So I think I would have felt safe in terms of the infection control aspect. And I would have probably, you know, just seen how he would respond to antibiotics and fluids. All right, Dr. Velez? So based on the pre-admission criteria, we would definitely would have admitted the patient. Similar to Dr. Malter, our unit is within an acute care facility. So I would say if you had an option for, it depends, this is where I would apply it. It depends on if the patient is able to manage his secretions, because usually not only the oxygen requirements, but if the patient needs frequent suctioning, meaning more frequent than every two hours, then we would not be able to provide that service within the unit, and we would have to transfer. If they're able to tolerate therapies well, we would just consult with a hospitalist or an infectious disease and continue the therapy. So it all depends on A, suctioning needs and managing their secretions, and then B, are they still able to tolerate therapies with the increased oxygen needs? And Dr. Rydberg? So I would have admitted him to our inpatient rehab facility, but I would have admitted him on isolation because he did have evidence of severe disease because of the initial oxygen requirement. So he would be a 20-day clearance from my standpoint. So we would have admitted him on isolation. However, with new hypoxia in the setting of a very recent COVID infection, I would be worried that this was actually related to his initial COVID diagnosis, especially in the setting of bilateral pneumonia. Obviously, if you can compare current chest X-ray to old chest X-ray and it looks identical, that might be a different story. But I would transfer him back to acute care because of the significant change in oxygen need. So I think that I would be concerned that he would decompensate and require intubation or some sort of a BiPAP because of his respiratory compromise. We absolutely can handle bacterial pneumonia, heart failure. We can do fluids, we can do antibiotics. We have great respiratory therapists, but with that pretty rapid change, I would be uncomfortable keeping him in our unit. And we had based this case on a real case here, although I changed a few little details, and he was transferred off. We had consulted infectious disease and they made that recommendation. And interestingly, following that case and several other kind of similar scenarios, we extended the amount of time to 15 days since the first positive test before bringing to rehab, due in part to this. With the Delta variant, we were seeing that people seem to have kind of slightly unusual courses where we were running into more problems than we had in the summer of 2020. We've actually had a lot of people that crashed at day 10 after diagnosis. Really? So I think most of the participants know this, but as a brief review, the incubation period of SARS-CoV-2 is up to 14 days. Median time from exposure to symptom onset is four to five days. Recommended PPE for healthcare worker caring for a patient with a positive test or suspected infection is gown and gloves, face shield or eyewear, N95 or comparable respirator mask where the patient also wears a mask. And for other patient encounters during periods of high transmission, recommendations vary by locality. And you can actually look up your region on the CDC website and they have additional recommendations for healthcare workers with regards to what they should wear during routine encounters. The duration of need for precautions as has already been reviewed depends on the severity of illness and immunocompromise. For those who are not moderately or severely immunocompromised, and this patient was not, if they're asymptomatic, one needs to wait at least 10 days from their first positive test. If they had mild to moderate disease, at least 10 days since symptoms appeared, at least 24 hours since last fever and assuring their symptoms have improved. And then for severe to critical illness, at least 10 days and up to 20 days since the first symptoms. And it's recommended that one consider consultation with infection control experts. And just of note, I know at my institution, we've had some kind of varying discussions as to what constitutes severe disease to help us determine how long we need to wait. And interestingly, the CDC actually has this on their website. So if the respiratory rate is greater than 30 breaths per minute, or the O2 sat was just less than 94%. So if someone was satting like 92, 93, in my mind, I wouldn't have considered that severe disease, but they do. So that I think is an important consideration. If someone has some baseline low oxygen saturations, a decrease in their baseline O2 sat of greater than 3%, a PAO2, FiO2 less than 300, or lung infiltrates greater than 50%. So I think many of the patients who need rehabilitation following severe COVID infection, for COVID infections, as opposed to incidental findings when they're hospitalized for other reasons, most of them would likely qualify as having severe disease. So again, who qualifies as being severely immunocompromised? These were recently updated. So those on chemotherapy, those with hematological malignancies, those with stem cell or solid organ transplants, those with HIV with a CD4 count less than 200, those with combined primary immunodeficiency syndrome. And now for those on immunosuppressive therapy, that includes prednisone 20 milligrams or higher for more than two weeks. And it's noted, I think Dr. Rydberg pointed out earlier, she had a case where someone kept testing positive long after, but the CDC has reported in one case of a severely immunocompromised patient, they had virus capable of replicating for 143 days. So in these severely immunocompromised patients, it is possible that they are truly still infectious. So consultation with ID is recommended consultation with ID is recommended before discontinuing precautions in that patient population. And although a test-based strategy is not usually recommended for clearing patients from precautions, it can be considered in the immunocompromised individuals. So now we have another case of a persistently positive COVID test that's quite different. So this is a 62 year old woman with a history of controlled diabetes mellitus and end stage renal disease on hemodialysis, who was admitted to IRF with debility following hospitalization for COVID pneumonia. She received IV steroids and required supplemental oxygen, but did not require intensive care or mechanical ventilation. She was admitted to IRF 13 days following her first positive test. A PCR was done one day prior to admission and was negative at the time. So she was cleared from airborne precautions and was allowed to use the shared gym while wearing a surgical mask. She made very good progress and discharge was planned. Her outpatient dialysis center requested a COVID PCR test within 48 hours of discharge before accepting the patient back to the dialysis center. And of course her test returns positive, but she has no active signs of infection. So let's get our polls running. And I know there are certainly other responses here and please feel free to use the chat. But first, what would you all do? Have infection control, just call the dialysis center, hold off on discharge, wait a few days and retest, or perhaps send for a cycle threshold CT value test, although I know those can be hard to come by depending on where people are working. So why don't we have everyone respond to the poll? We'll wait a minute there. All right, can we share the results? All right, so very mixed responses. And certainly a combination of all three is probably also very appropriate. So 57% said they'd have infection control, call the dialysis center. 29% said hold off on discharge, wait a few days and retest. And 14% said they would send for cycle threshold value tests to determine if they have virus capable of replicating. All right, and the next question, would you resume airborne precautions? So let's start that poll. Yes, no, or defer to infection control. All right, so if everyone's responded, let's share the results of that poll. All right, so no one said yes. And 50-50, no and defer to infection control. So let's discuss this case. Let's start off with Dr. Rydberg. So I do have access to cycle threshold testing, which can be a good way to test access to cycle threshold testing, which can be a good way to determine if this is basically a higher or lower viral load. So it can give you a sense of acuity and how infectious the person is. In this case, she's already been cleared from isolation and she has a positive test within 90 days, which means this is very unlikely to be a new or separate COVID infection. So I would consider her to be not infectious and to not require isolation at this time. So I know that a lot of dialysis centers, home health agencies, outpatient therapy sites like to have a negative test because it'll make them feel a lot better. But unfortunately, as we know, these tests can stay positive for a long time. So if I can get a cycle threshold value that shows that this is an old infection, that would certainly make me feel better. I don't know if the dialysis center would accept that. So honestly, what I would do is probably just retest because you're gonna probably get a negative one eventually. And otherwise, write a note in the medical chart stating that this patient is no longer infectious based on the CDC clearance guidelines. And I would write it in my note and have the care manager send that over to the dialysis center. And if that wasn't good enough, then I would have the infection control doctor sign off on it because they outrank me when it comes to COVID. All right, and Dr. Carpenter? I actually did have this scenario happen and we don't have access to the CT value test. So that wasn't an option for me. What we actually did was actually just have our infectious disease doctor to call the dialysis center and explain exactly what Dr. Rydberg said that some of these patients can have persistently positive COVID testing, but looking at everything in her clinical presentation, there was absolutely no indication that there was ongoing infection. And therefore we documented that and we ended up not having a problem. But I would say retesting would also be part of my potential answer as well. And obviously we would not have presumed airborne precautions, but I always do confer with infection control before solely making that decision. Dr. Malter? So I'll agree. We've had this happen like more times than I can count between dialysis, assisted living, all kinds of stuff. So in my experience, no amount of reasoning is helpful here. Once somebody has a policy, they like do not want to hear from you. So for us, we would have just kept the patient and retested every single day. Okay, and Dr. Velez? I agree with Dr. Malter here too, that if you're going by policy and guidelines, I probably would have first consulted with ID just to make sure that A, if we are going to call, have them do it. Because like Dr. Rydberg say, they would outrank us in terms of infection, disease issues. But most likely we would have just hold off from discharge and just test until we get a negative result. So yes, this was a colleague's patient and we did just that. We just retested and it came back negative and they went to dialysis. But I think it is an increasingly common scenario that we all have been facing. All right, our next case is a norovirus outbreak. All right. So a 70 year old man was admitted to IRF following an ORIF or a femoral neck fracture on a Friday evening, because all the bad things in rehab happen on a Friday evening. That night, he experienced severe explosive diarrhea and vomiting. Over the course of the weekend, his roommate and the patient in a neighboring room also developed severe diarrhea as did two nurses and one PCT. On Monday, three additional patients on that unit and one other staff member developed symptoms. There are no affected patients on the other units within the IRF to suggest a foodborne outbreak. The first three patients all tested negative for C. diff toxins. Stool samples from the patients then returned positive for norovirus. So the question, and if we can get the poll running, would you close your unit to new admissions? What would you guys do? So if everyone can respond yes or no. All right. And then we'll just wait a few seconds. And can we share the poll? All right, so 78% said yes and 22% say no. So I hope that no one else has had to deal with the norovirus outbreak, but we will open the discussion for the panel. So we'll start off with Dr. Velez. So I would have closed it to new inpatients because if the contamination was so fast, not only with patients, but potential with staff, definitely there's a risk of having this massive outbreak. So consult with ID. I would have held off from new admissions, put them contact precautions. And if we are going to do therapies, just limit them to the room only, and not having them share the equipment in the gym. Dr. Ryberg? I agree with Dr. Velez. All right. Dr. Carpenter? Yes, 100% agree. If you've ever been on a cruise ship or have heard the stories, you know. I would totally agree. All right. And Dr. Maltzer? Totally. All right. Yeah. So this happened at a hospital I used to work at several years back, and we had a huge norovirus outbreak. And we did, in fact, have to close the unit to new admissions and do therapies and kind of cohort patients and team members. So I unfortunately had to be the outbreak physician, and I was not allowed to see other patients at the time. And I just stayed on the unit all day until the outbreak cleared. It was fun. I had to bleach my body, basically, when I was about to leave the unit every day. So norovirus, in brief review, is a highly contagious virus that causes sudden onset vomiting and diarrhea. It's transmitted via direct contact with infected people, contaminated food or water, and touching contaminated surfaces. Unfortunately, it's resistant to most hand sanitizers. So if you do have a case, the hand gel that we usually use typically is not effective for norovirus, although there are some on the market, including one made by Clorox, that will kill norovirus. And it's resistant to most disinfectants, so you do typically need to use bleach. I know many of us think of it as a cruise ship illness, but half of outbreaks do occur in long-term care facilities. So when you do have a patient with norovirus, they need contact precautions for at least 48 hours after resolution of symptoms. And it's recommended that one uses a face shield or eye protection plus mask when working with vomiting patients. They should be in a single room or cohorted. You need to restrict movement within a unit and off the unit except where medically necessary. So they should not use a gym unless you have an isolation gym ready. You should consider suspending group activities. The CDC does recommend considering closure of the unit to new admissions, and sick personnel should not return to work for at least 48 hours after symptoms resolve. So our next case is a 54-year-old woman who was admitted to IRF from an outside hospital, again late on a Friday night, following an exacerbation of her multiple sclerosis, reportedly due to a urinary tract infection, but the culture was negative. The next morning, the physician noted the patient was persistently coughing while she was trying to perform the HNP. Upon further inquiry, the woman revealed that both her husband and best friend had recently been diagnosed with influenza. A rapid influenza test returns positive. One physician, two nurses, and one therapist had prolonged close contact with the patient without a mask on. All but one team member had received the flu vaccine that season, but there had been reports that the flu vaccine that year hadn't been very protective against the circulating strains. These team members also work with other immunocompromised patients, including those with cancer and transplants. So besides implementing droplet precautions, what would your team members do to avoid exposing other patients? Nothing, quarantine at home, take Tamiflu prophylactically, or wear surgical masks during patient care, if anything at all. So we'll answer the polls here, give everyone a chance to respond. All right, and can we share the results of the poll? All right, so interesting, a good mix here. 22% said they'd quarantine at home, 11% said take Tamiflu prophylactically, and 67% said they would wear surgical masks during patient care. So we can go ahead and discuss this. So we'll start with Dr. Maltzer. So I actually think that my approach would be different now than it had been prior to COVID. So prior to COVID, with just one case of flu and a couple of exposure of staff, I'll be honest, probably maybe the infection control people would have encouraged the staff to take Tamiflu. I don't even know that we would have instituted like a mask mandate for the unit, which we had done when we had outbreaks of flu. Of course, now after COVID, our tolerance for infectious diseases is a lot less. So now post COVID, I would honestly have the staff quarantine at home. And if their doctors or infection control recommend a Tamiflu, they can take that. And then all staff would obviously still be wearing surgical masks. So I just think that my tolerance for like having people exposed to the flu and spreading it around has gone way down. Very interesting. Dr. Velez? It's funny because it was 22%, not sure if it was just us that said quarantine at home, but that's what I had answered as well. And I think, I hate saying it, but yes, I think it's because of the tolerance. Because before I would have said not wear surgical mask during patient care, oh, you got vaccinated, it might not be such a big deal. But I think that not only because of the flu, but with the COVID, you can have one or the other. And then it just complicates the picture, but I think that I would have probably recommended staff to just quarantine at home. Dr. Rydberg? I think it's also interesting because everyone already is wearing surgical masks during patient care at this point. And so would we even, I mean, how much would we consider it an exposure at this point? So, I mean, I would recommend that they continue wearing surgical masks and track it, but I don't think I would do anything beyond that. Great. And Dr. Carpenter? Yeah, I would say my answer pre-COVID, one would be the patient, I mean, the employee who was not already vaccinated would have been wearing a surgical mask anyway. Whereas the other vaccinated one wouldn't, but to Dr. Rydberg's point, if this happened recently, certainly everybody would have been already wearing the surgical mask. So, we would probably recommend, you know, self-monitoring for symptoms, fever, that kind of thing, and continue with the surgical mask during patient care. All right. So, yes, this was a pre-COVID case. I probably should have mentioned that. So, yes, this was a pre-COVID case. I probably should have made that clear. And it was Christmas weekend. So, I was the doctor on call. I did take Tamiflu, but then my infectious disease colleague told me to stop. So, influenza transmitted via large particle droplets, contact with a contaminated surface to the face, or potentially infectious bodily fluids. Droplet precautions include hand hygiene, surgical masks with an N95 reserve for aerosol-generating procedures, private room, and continuing precautions for seven days after onset or 24 hours after symptom resolution, the longer of the two. Prophylaxis with antivirals can be used to control outbreaks in healthcare settings, but should not be used for routine prophylaxis. All right. So, our next case is a case of CRE. So, this is a 43-year-old woman with cerebral palsy who was admitted to the IRF with debility following a hospitalization for Klebsiella pneumonia that was resistant to meropenem. She had been receiving therapies in her room. Two days following her admission, she demonstrated worsening cough and a stat chest x-ray is ordered, but the radiology technician refused the study based on her CRE status. So, the issue here is really a diagnostic study is necessary for the patient's care, but there's some risk of exposing others by moving the patient through the facility. So, we'll open up the poll, and certainly there are other possible answers as well. So, would you just continue the order for chest x-ray and treat empirically for residual versus recurrent pneumonia? Switch order to a portable chest x-ray and review appropriate precautions to take in the room with the technician. Arrange for the patient's x-ray to be done as the last case of the day before a deep cleaning or escalate the issue to the director of the radiology department. So, we'll give everyone a chance to respond to the poll. All right, and can we share the results? All right, so good. No one would just discontinue the order, and it looks about two-thirds would switch to a portable chest x-ray and one-third would make it the last case of the day. So, let's discuss this case briefly. We'll start with Dr. Carpenter. Yes. So, I would try to arrange with radiology to have the x-ray done as the last case of the day to avoid exposure to the technician. That way, the patient is still getting the chest x-ray that obviously is needed to continue patient care appropriately and minimizing any infection risk. Infection risk. All right, and Dr. Malter? I would agree. I would agree with Dr. Carpenter. All right, Dr. Velez? I agree. I probably would have called radiology and told them, I need the imaging, so which one do you prefer? Do you want me to order it portable, or would you like to take it at the end of the day? I'm probably trying advocating for the patient. I probably wouldn't give them the option of no study. Yes, and Dr. Ryberg? For our isolation patients who need a chest x-ray, I often will just order a portable to limit the exposure and transport through the hospital, unless it's something where I really feel like I need better quality images. So, in this case, if I could have gotten the information I needed from a portable, that's probably the safest option. It brings me back to early in the pandemic when our patients with COVID had so much dysphagia, and we couldn't get swallow studies early on, because we had to go through multiple steps with housekeeping and infection prevention and radiology in order to figure out how to get those done as safely as possible. And so, we were limited with the diagnostic tests that we really needed to guide our treatment, but we were very limited. So, there were a lot of us who were rather vocal in pushing to get these through. And thankfully, now, it's just part of the process. So, we do them when we know there's no other swallow studies for the rest of the day, and then have a specific cleaning process after. All right. So, CRE, for quick review, bacteria that produce a carbapenemase and or are resistant to at least one carbapenem antibiotic, those being ertapenem, mirapenem, dorapenem, or imipenem, infection results in mortality rates of up to about 50% of hospitalized patients, common modes of transmission in healthcare settings via the hands, contaminated equipment, sink or toilets. Infection control measures include contact precautions. Hand hygiene can be with soap and water or alcohol-based sanitizer. And you need to wear gown and gloves. They need a private room with a private bathroom, dedicated equipment, and caution with movement of patients throughout the facility or system. All right. And our last discussion case is a case of Candida auris colonization. So, this is a 49-year-old man admitted to IRF from an outside hospital in the region following a hospitalization for bacterial meningitis. He had moderate cognitive impairment and required minimal to moderate assistance with mobility and self-care. He had seen pictures of your facility's new gym, and he couldn't wait to use the state-of-the-art equipment. His referring hospital has had a number of cases of C. auris infection. In order to contain the spread, all patients arriving from that hospital undergo surveillance screening cultures. His cultures demonstrate he is colonized with C. auris. So, would you let him use the gym? We'll put up the poll here. Yes, without restrictions. Yes, but only as the last case of the day or no. And if everyone can respond. All right. And if we can share the results of that poll. All right. So, 22% say no, and 78% say yes, but only as the last case of the day. So, we can start the discussion. We'll start with Dr. Breidberg. So, at our facility, we would consider this to be a GI contact precautions. And so, for people in close contact, it would require gown and gloves. And so, we do actually allow those patients to do therapy outside of the room, but there has to be additional special precautions taken in terms of spacing and cleaning protocols. All right. And Dr. Carpenter? Yes, I would agree. Dr. Malter? Yes, I have to agree as well. You know, I have to say, out of all the all the infection control stuff that I worry about, this really worries me. You know, I think it's the unknown and the whole like not being able to get rid of it business. So, but I would agree with the panel. And Dr. Velez? So, at my current facility, we have not had CRS. However, I did work at a VA facility before, and there I did have a patient with CRS, complete quadriplegia on a ventilator, also had CRE. And this was facility number four for him. And I think that in the previous facility, before coming to us, there was several cases of CRS. So, they had done the testing before sending it to our facility, but we did not have the results during the pre-admission screen. We received them. And then after that, they called us and the test was positive. So, at that point, we had infectious control and consulted with ID. And they told us, if you can limit the therapies just to the room, that would be great. However, there are some occasions that if they really do need to use the equipment, you can leave them for the end of the day and just make sure that there's deep cleaning and decontamination. And that's what we did. So, I see a comment and question. Do you, Dr. Velez, you know, when you had that patient, did you have like a private nurse and private therapist who was only like taking care of that one patient or they had usual assignments? Nursing was very difficult because there's three shifts and they rotate, I think at that point, every two to three days. Therapists, yes, we did have an assigned therapist to that patient. And most of the therapies were done in the room. But then at the end of the day, we would allow out of the three hours, just try to do a limited session with the equipment. So, therapy, yes, one assigned, but the nursing, whoever was on shift and just make sure that they had proper precautions. Yeah, this has been a huge challenge for us in South Florida. We've had many cases and the initial recommendation was for us to have one nurse per one patient, which we have been really unable to do. But fortunately, we have not had any spread through our facility. And at one point we had so many cases, we did create an isolation gym just for those who are colonized with Candida auris. So, for those who have not yet been familiar with Candida auris, which I really wasn't until fairly recently, this is an emerging fungus. It's spread person to person and via contact with contaminated surfaces or equipment. It's often multi-drug resistant. So, it can cause fungimia, wound infections and ear infections. And that's how it got its name, auris. Invasive infections are very difficult to treat and one in three die. It has caused multiple outbreaks in healthcare facilities. I know in California, several years ago, there was an outbreak in New York and we have had ongoing problems for the past several months to a year here in South Florida. So, these individuals require enhanced contact precautions for their entire stay. They need to be in a private room or cohorted, including in the gym, unique gown and gloves and dedicated equipment, including Dynamaps. For disinfection, you can use hydrogen peroxide or bleach. Some, but not all fungicidal agents kill it. And they must be the last case of the day for procedures and imaging studies. So, we've had kind of the same issue as Dr. Ryberg had mentioned with the COVID patients, but a lot of difficulty getting our swallow studies done in these individuals because they have to be the last case of the day. And unfortunately, our speech therapists usually start their day quite early because they like to be there for breakfast. So, it's made it very difficult. So, that is our last discussion case. I thank all of our panelists for joining us today. I have a few takeaway points, but if anyone has any questions, please go ahead and put it in the chat. So, takeaway points for today's session. With appropriate precautions, we can safely provide IRF care to COVID positive patients. There are, of course, some unique considerations with regards to infection control in IRFs. Obviously, we have patients originating from multiple referring facilities. We have shared gyms and equipment. And of course, patients' impairments may complicate efforts to keep them distanced, masked, and performing proper hand hygiene. And unfortunately, COVID is far from the only microbe that we need to be concerned about, and C. Auris really seems to be very much an emerging problem. So, with that, all right. So, I see a question in the chat. So, how have people been managing double occupancy rooms and visitors? I think that's a great question. Maybe we could take turns answering that. Dr. Rydberg? Yep, I can go first. So, we are lucky in that we don't have double occupancy rooms at this point, although I'm sure that infection control will have a lot to say about that. And obviously, COVID positive, COVID negative would be cohorting together. We never shut down for visitors except for in the COVID isolation unit. So, for a long time, we were only allowing one designated visitor. And so, they had one person, only one visitor for the entire duration of their stay. And now, we are allowing two visitors at a time, and they may swap out. So, it's changed depending on how prevalent COVID is in our environment. And Dr. Carpenter? Yes, we have single occupancy rooms, which all have dedicated bathrooms. And we, as far as our visitor policy, went from prior to numbers rising with COVID to only two visitors. And then, when our numbers went back up again, it was one visitor that was swapping out, which we are still basically at, even though our numbers have gone down a lot. We haven't gone back to the two visitor policy, and then they could come and go. Dr. Malter? I'm very jealous of your single occupancy rooms. Unfortunately, believe it or not, we still have some triples and quads that we're trying to get rid of. This is a problem, right? So, we have our visitors mask, and we have to remind people to keep masking. But this is something that definitely keeps us up at night a little bit. You know, I think when the test positivity rate goes down, we allow more visitors. When the test positivity rate had gone up in the winter, we restricted visitors. But so far, we've mostly been okay with mask requirements. And Dr. Velez? I'm at a single occupancy facility. So, similar to Dr. Ryberg and Dr. Carpenter, if the rates were up, we would limit. Otherwise, we would loosen the restrictions for visitors. All right. Any other questions? And I can also open it up. Unfortunately, we're not going to be able to have our in-person networking meeting as well. I know a lot of us were really looking forward to meeting up in Nashville. But if anyone has any issues they'd like to raise, we could probably promote you to panelists, if you'd like, if you raise your hand. Otherwise, I'll look out in the chat. And there are a number of discussions going on. Just a reminder, our community is on FIZ Forum. I know a lot of people have been experiencing increasing difficulty getting authorization for IRFs, particularly with a third-party vendor that is partnering with some of the insurance companies, Navahealth. So, there are some running discussions. If you check out the post on FIZ Forum, please share your experiences. It's very helpful to keep track of what's going on at facilities across the country. And I look forward to interacting with everyone on FIZ Forum. And with that, I thank everyone for participating today. I thank our panelists as well. And I very much hope we can meet in person next year. Thank you.

infection control

inpatient rehabilitation facility

IRF

head lice

COVID-19

influenza

CRE

Candida auris

isolation

treatment

bedding

contact precautions

oxygen needs