COVID-19: How to Protect Yourself & OthersPPE and Infection Control in Schools

August 25, 2020

Paula Conrad, MSN, RN, CNL, CCRN, CPNInfection Preventionist

Renee LeHane, BSN, RNInfection Preventionist

2

Disclosures / Disclaimer

 I have no financial disclosure or conflict of interest concerning the material discussed in this presentation.

 The COVID-19 pandemic is a rapidly evolving incident: please refer to the Centers for Disease Control and Prevention’s COVID-19 website for the most up-to-date information and resources.

 The information in “The School Nurse & COVID-19” series are recommendations at this point in time on August 20, 2020, based on CDC and DESE guidance.

3

DESE Guidelines

 Health and safety/PPE supplies: Per the initial supply guidance issued by DESE, schools should have an inventory of standard healthcare supplies (e.g., masks and gloves). Use of additional supplies may be optional based on type of tasks performed (e.g., teachers do not need to wear gloves while teaching but may need to during necessary contact with students, such as when providing physical support to students with disabilities). All districts are eligible for federal CARES Act funds to support these purchases.

 Additional safety precautions are required for school nurses and/or any staff supporting students with disabilities in close proximity, when distance is not possible: These precautions must include eye protection (e.g., face shield or goggles) and a mask/face covering. Precautions may also include gloves and disposable gowns or washable outer layer of clothing depending on duration of contact and especially if the individual may come into close contact with bodily fluids

per DESE guidelines 6/25/20

4

What is PPE?

 Personal Protective Equipment (PPE) protects you (the nurse, teacher or staff) from COVID-19 (or other potentially infectious patients or materials) when interacting with others (students or other staff)

 Worn to minimize/eliminate exposure

 Cloth face coverings are NOT PPE and should not be worn for the care of people with suspected or confirmed COVID-19

 For COVID-19 it includes:

 Ear-loop or surgical mask

 NIOSH-approved Respirator (N95)

 Eye protection

 Gown

 Gloves

5

PPE Recommendations for Direct Service Providers

per DESE guidelines 6/25/20

Classifications N95 or KN95 Face ShieldDisposable

GownDisposable

GlovesGowns/

CoverallsCloth Face Covering

Surgical Mask

In care areas of students with suspected COVID-19

X X X X XX

(w/ face shield if N95 not available)

In the same facility but not in the care areas for students with suspected COVID-19

X

Providing personal care to students without suspected COVID-19 but who may potentially be exposed to bodily fluids

X(preferred)

X X

Performing or present during aerosol generating procedures such as nebulizer treatments, chest PT, suctioning, trach care

X X X X

Transportation personnel/monitors who must come in direct physical contact with passengers (e.g. buckling/unbuckling, performing wheelchair safety services)

X X

6

Disposable Gloves

 Clean, non-sterile gloves are to be used to protect your hands

 Gloves do not replace hand hygiene

 Can have micro-perforations

 Change gloves when going from dirty to clean

 Change gloves if they become torn or heavily contaminated

 Change gloves between children

7

Disposable Gowns

 Gowns protect your clothes from contamination

 Gowns should be worn as part of standard precautions if there is anticipated spray or splash

 Gowns are to be worn for an suspected or confirmed person with COVID-19

 Gowns should be change between patients:

 If disposable, discard after each use

 If reusable, launder after each use

8

Eye Protection

 Eye protection protects your eyes from splashes and sprays of infectious matter

 Creates a barrier so droplets cannot spray/land in the eyes

 Eye protection includes goggles or a face shield that covers the front and sides of the face

 Eye protection does not include safety glasses, trauma glasses or eyeglasses with gaps between the glasses and the face

 If a child is not wearing their mask for > 15 minutes and someone is within 6 feet of the child, then eye protection should be worn

9

Surgical Mask

 Barrier

 Protects against large droplets, splashes or sprays of bodily fluids

 Need to be fluid resistant

 Do hand hygiene prior to donning/doffing

 Discard when visibly soiled or wet

 Follow extended use policy on CDC if necessary

10

Respirator (N95)

 Offer a higher level of protection than ear-loop/surgical masks

 It covers the nose and mouth and reduces the person’s risk of inhaling hazardous airborne particles, gases or vapors

 Certified by CDC/NIOSH (National Institute for Occupational Safety) and cleared by the FDA

 They are not all the same or created equal

 https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/n95list1.html

 People wearing an N95 (nurse) need to be medically cleared and fit tested prior to using this device

11https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508.pdf?fbclid=IwAR2I4JUGxc4DMmKk-yU4lmTVOqU7UQajjFMGsI04GE8B7yPpodDCSs3DbUE

Counterfeit Respirators

 Respirators falsely marked and sold as being NIOSH approved and may not provide the same level of protection

 Signs that it may be counterfeit:

 No markings at all on the filtering facepiecerespirator

 No approval TC number on the respirator or headband

 No NIOSH markings

 NIOSH spelled incorrectly

 Presence of decorative fabric or add-ons (e.g. sequins)

 Claims for approval for children

 Earloops instead of headbands

12

N95 versus KN95

N95 KN95

Made in the US or overseas Made in China

Tested and certified by NIOSH NOT tested and certified by NIOSH

Approved by the FDA Approved by FDA Emergency Use Authorization

Filter 95% of particles Filter 95% of particles

Headstrap method Earloop method

Continue to achieve > 95% filtration after disinfection Have failed to achieve 95% filtration after disinfection

Take Home Message – NIOSH certified respirators are recommended.If an organization is not able to obtain NIOSH respiratory protection, a KN95 could

be used for suspected or confirmed COVID-19 patients if it meets regulatory requirements under the EUA

13

PPE for Aerosol Generating Procedures (AGP)

 Aerosol generating procedures (open suctioning, nebs) create infectious aerosols that can travel in the air

 PPE for AGPs

 N95 respirator

 Eye protection

 Gown

 Gloves

 The number of people should be limited in the room

 AGPs should be done in an isolation room with the door closed

 Surfaces should be cleaned and disinfected following an AGP

14

Aerosol Generating Procedures AGP Procedures include:

 Bronchoscopy

 Resuscitation involving emergency intubation or CPR (including mask bag ventilation)

 Endotracheal intubation or extubation

 Open suctioning of airway secretions or cough assist

 Sputum induction

 HFNC

 CPAP/BiPAP

 High-frequency oscillatory ventilation

 Nebulized treatments

 Upper airway surgeries (including tracheostomy replacement)

 Upper and lower endoscopy

 Transesophageal echocardiography (only during insertion or removal of the probe)

 Aerosol-generating dental procedures

 Autopsy

15

NOT Aerosol Generating Procedures AGP Procedures do not include:

 Regular (i.e. not high flow) nasal cannula oxygen delivery

 Face mask oxygen delivery

 Humidified air/face tent/cool mist

 Chest physiotherapy without open suctioning

 Chest physiotherapy vest without open suctioning

 Collection of nasopharyngeal or oropharyngeal specimens (if collected on a PUI, an N95 respirator would be used as this is part of routine care for a suspected COVID-19 case)

 Patient talking, coughing, or sneezing

 Routine oral care or oral suctioning

 Uncuffed ETT/trach with leaks

 Hand ventilation via endotracheal tube or tracheostomy tube

 Mechanical ventilation using ventilator without a filtered exhalation limb

 Ventilator circuit disconnections, including opening installation ports for in-line suctioning

 In-line suctioning (closed suctioning)

 Nebulized treatment in a closed ventilator circuit including an artificial airway without a leak

16

Donning & Doffing

 Reminders:

 Riskiest activity is doffing

 Store PPE in a clean location

 Hand hygiene is part of the donning/doffing process

Putting it on (donning) and taking it off (doffing)

17

Donning a Surgical Mask

Perform hand hygiene

Perform hand hygiene

Hold mask with colored side facing out, pleats going down

Open pleats

Pull ear loops over ears

Press the metal nose piece to the bridge

of your nose to ensure a secure fit

18

Doffing a Surgical Mask

Perform hand hygiene

Perform hand hygiene

Avoid touching the front of the mask as it is the most contaminated.

Only touch the loops/ties/bands for doffing Grasp loops around ears and gently

lift and pull mask away from face

Discard into waste basket

19

Donning/Doffing an N95 Respirator

Video: Easy Technique for Doffing Gown

Video: Donning PPE for Aerosol Generating Procedures

Video: Doffing PPE for Aerosol Generating Procedures

20

Additional Resources

 CDC Website: Using Personal Protective Equipment

 CDC PDF: Guidance for the Proper Use of Protective Equipment

 CDC PDF: Sequence for Putting On or Removing PPE

 BU Shields Video: PPE for COVID-19material developed by MA DPH Bureau of Infectious Disease & Laboratory Sciences

Donning Personal Protective Equipment (PPE):Reusing Respirator and Eye Protection with Wrap-Around Gown

Perform Hand Hygiene1.

Alcohol-based hand sanitizer

7. Perform Hand Hygiene

Ensure gloves go over cuff of gown

9. Perform Hand Hygiene

6. Remove Gloves

8. Put on Eye Protection

10. Put on Gloves

Don PPE outside of patient’s room. Ensure hair is pulled back away from face.

2. Put on Gown

4. Remove Respirator from Storage Container

3. Put on Gloves

5. Put on Respirator

or soap and water for 20 seconds

Face shield or goggles

Ensure gown fully covers entire body when closed or tied

Ensure gloves go over cuff of gown

Alcohol-based hand sanitizer

Alcohol-based hand sanitizer

Hold respirator in one hand

Pinch nose clip to ensuretight seal of mask

Close eyes, bring lower elastic band over head and below ears

Open eyes, grab upper elastic band, close eyes and pull upper elastic band over head and above ears

Bring to face, grab lower elastic band

Grasp glove in palm of hand and pull glove off

Dispose of glove or hold in other hand

Slowly and gently, slide finger under otherglove, between glove and cuff of gown.

Dispose of glove(s) in waste container

April 5, 2020

9. Perform Hand Hygiene

7. Perform Hand Hygiene

Remove Gloves 1.

8. Remove Respirator and Place in Storage Container

5. Perform Hand Hygiene

Grasp glove in palm of hand and pull glove off

Doffing Personal Protective Equipment (PPE):Reusing Respirator and Eye Protection with Wrap-Around GownDoff gown and gloves in patient’s room. Respirator and Eye Protection will be doffed outside the patient'sroom. Remember gloves, face shield, front of gown and sleeves are CONTAMINATED. Clean handsimmediately if you touch any of these surfaces with your bare hands.

2. Remove Gown

Dispose of glove or hold in other hand

Slowly and gently, slide finger under other glove,between glove and cuff of gown.

Dispose of glove(s) in waste container

In p

atie

nt's

room

3. Perform Hand Hygiene

6. Remove Eye Protection – Avoid touching front, contaminated surface of eye protection

Place face shield or goggles on paper towel

Tilt head forward, grasp strap and gently pull strap over head, pulling face shield away from face

Grasp ear pieces behind ears and pull goggles away from face

Alcohol-based hand sanitizer

Pull lower elastic band over head

Gently pull upper elastic band over head and pull

mask away from face

Close storage container and ensure your first initial, last name,

BCH ID#, and unit is written on it

or soap and water for 20 secondsAlcohol-based hand sanitizer

Place respirator in storage container with outside surface down

4. Set-up for Reusing Eye Protection and Respirator

Place storage container and paper towel on countertop

Alcohol-based hand sanitizer

Alcohol-based hand sanitizer

April 5, 2020

Out

side

pat

ient

's ro

om

With respirator and Eye Protection in place, leave patient’s room and enter anteroom or hallway.

soiled linen

Disinfection and Storage of Eye Protection

Disinfect Reusable Eye Protection

Put on Gloves1.

2. Disinfect Reusable Eye Protection

3. Dispose of of wipe and contaminated paper towel in trash

5. Perform Hand Hygiene

6. Store Resuable Eye Protection for Later Use

Wipe eye protection thoroughlywith an alcohol wipe, cleaning theinside first, and then the outside

Place on a clean surface to dry

Grasp glove in palm of hand and pull glove off

Dispose of glove or hold in other hand

Slowly and gently, slide finger under otherglove, between glove and arm.

Dispose of glove(s) in waste container

or soap and water for 20 secondsAlcohol-based hand sanitizer

At end of your shift, store the eye protection in a clean location. Each healthcare worker will keep theireye protection for repeated use.

4. Remove Gloves

April 5, 2020

COVID-19 School Nurse Training for the Return to School

How to Protect Yourself and Others:PPE and Infection Control in Schools

Presenters:Arlene Swan-Mahony, DNP, MHA, BSN, RNSharon L. D. Harrison, MSN, MEd, BSN, RNVelma Glover, MEd, BSN, RN, RYT 200 hrMary Jane O’Brien, PhD, RN, CPNP, NCSN Boston Public Schools

August 25, 2020

Disclosures / Disclaimer

We have no financial disclosure or conflict of interest concerning the material discussed in this presentation.

The COVID‐19 pandemic is a rapidly evolving incident: please refer to the Centers for Disease Control and Prevention’s COVID‐19 website for the most up‐to‐date information and resources.

The information in “The School Nurse & COVID‐19” series are recommendations at this point in time on August 25, 2020, based on CDC and DESE guidance.

Overview❏ Risk task classifications: Low-Moderate-High❏ PPE use for school nursing activities❏ Don & Doff Considerations❏ Protective wear for caring for students with special health care

needs: feeding, diapering❏ Infection Control Considerations

▪ Health Room▪ Classroom

❏ Medical Waiting Area/Isolation Room❏ Nursing assessment: Student with COVID-19 symptoms &

Return to School protocol

COVID-19 will not be the only health concern addressed by school nurses– state mandated screenings; flu, pertussis, asthma, diabetes, severe

allergies, behavioral health, medication administration & management,education, & care coordination.

School nurses are called upon to lead, educate, and practice following the tenets of Framework for the 21st Century School Nursing PracticeTM through the principles of Leadership, Standards of Practice, Quality Improvement,

Care Coordination, and Community/Public Health.

The School Nurse will play an essential role in the mitigation of COVID-19and requires every tool available to practice with confidence and safety.

.

THE VALUABLE ROLE OF SCHOOL NURSES DURING THE COVID-19 PANDEMIC

Unique challenges arise when implementing recommended infection control measures for

students and staff in one building.NASN, 2020

PPE: Guidelines for Use in the School Health Room

PPE is determined by Task Classification

Low Risk School personnel and students must interact, and physical distancing cannot always be maintained.

Moderate Risk Tasks include those that require close/direct contact with (i.e., within 6 feet of) people who are not known or suspected to have COVID-19.

High Risk Tasks include the physical assessment of any individual suspected of having COVID-19 & Aerosol generating procedures.

NASN 2020

Low Risk

Activities include:

❏ Conversation with student or staff❏ General interactions❏ Receiving notes, letters from student❏ Handing/receiving supplies, medications

Reccomended PPE:

❏ Surgical face mask OR❏ Cloth face mask

Activities include:

❏ Medication administration: oral, MDI, parenteral

❏ Procedural care: catheterization, g-tube care/feeds

❏ Diabetes care-blood glucose checks, site assessment

❏ General nursing care for illness and injury

❏ Population screening-vision, hearing, ht/wt, postural

Recommended PPE❏ Surgical face mask❏ Disposable Gloves

▪ Situation dependent❏ Eye protection (Goggles OR Face

Shield) with surgical mask▪ Situation dependent▪ Procedures that may cause fluid

entry into eyes, ▪ Caring for students who are

unable to control secretions▪ Developmental level of student

Moderate Risk

Activities include:❏ Physical assessment of any individual

suspected of having COVID-19❏ Duration/Spatial considerations ❏ Aerosol generating procedures:

nebulizer treatments, oral or tracheal suctioning

❏ Trach care❏ Manual ventilation❏ BIPAP, CPAP, Mechanical ventilation

Recommended PPE❏ Disposable gloves ❏ Disposable gown, OR❏ Long sleeved washable covering

▪ Lab Coat▪ Scrub coat

❏ N-95 mask OR ❏ Surgical mask & face shield ❏ Kn95 Face Mask & face shield

High Risk

Recommended PPE by Risk Level and School Nurse Activity NASN, 2020

Risk Level School Nursing Activities PPE Type

LOW RISK Conversation & general interaction with student/staff:● administering/receiving notes/letters/provider’s

orders● receiving supplies, medications

Cloth Face Covering (Not PPE)

MODERATE RISK

● Medication administration: oral, MDI, parenteral● Procedural care: catheterization, g-tube care/feeds● Diabetes care: blood glucose checks, site assessment● General nursing care for illness and injury ● Screenings: Vision, Hearing, etc.

Surgical face mask, disposable gloves. Eye protection (not eyeglasses) for procedures that may cause fluid entry into eyes, or when caring for students unable to control secretions – consider developmental level and situation (goggles or face shield).

HIGH RISK ● Physical assessment of any individual suspected of having COVID-19

● Aerosol generating procedures: nebulizer treatments, oral or tracheal suctioning, trach care, manual ventilation, BIPAP, CPA, mechanical ventilation

Disposable gown OR long sleeved washable covering such as a lab coat, scrub coat or smock. IN ADDITION:N-95 respirator mask AND eye protection/face shield (not eyeglasses) OR surgical mask & face shield OR Kn-95 face mask & face shield

Envision Your Practice as a School Nurses & COVID-19

❏ Steps prior to entering/leaving isolation room❏ Job Aides❏ How to better fit a surgical mask❏ Suggested storage of N95 ❏ Suggested placement of mask

during mask breaks ❏ Share a video, COVID-19 &

Schools Fear Out-Learning In

Envision Your Practice as a School Nurses & COVID-19

❏ Envision your steps prior to entering/leaving PPE donned area:■ Make a schedule of nursing intervention■ Ready your supplies■ Bundle activities (meds, feeding…) to effectively

use face-to-face time & cut down on repeated donning/doffing

■ Share your schedule with school staff–Job Aid

Envision Your Practice as a School Nurses & COVID-19

❏ Job Aides are visuals to help remind people■ They are often posted to communicate

● Salient safety concern● Prevent mistakes ● Support compliance with a standard of practice

Envision Your Practice as a School Nurses & COVID-19

❏ How to better fit a surgical mask–Demonstrate■ Fold face mask in half■ Take one of the elastic ear loops, make a knot as close and

tight as possible to the mask■ Repeat on the other elastic ear loop■ Tuck/fold the mask opening inward face side

The mask will now better fit a child’s or an adult’s face

Envision Your Practice as a School Nurses & COVID-19

❏ Suggested storage of N95 ■ Tupperware container–Make holes in the lid and container for air

circulation:● N95 on face–don’t touch the mask● Put the tupperware container to your face, mask is inside the

container● Secure the lower elastic, pull it over your head and onto the back

of the container● Repeat the upper elastic, pull it over your head and onto the

back of the container● Reverse steps to put back on N95

Envision Your Practice as a School Nurses & COVID-19

❏ Suggested placement of mask during mask breaks

Envision Your Practice as a School Nurses & COVID-19

I am going to show you another version of donning and doffing. As you look at it, please start imagining and personalizing, when, where, how, and why, you would perform donning and doffing in your school.

CDC’s Don Video

CDC’s Doff Video

Envision Your Practice Children with Special Healthcare Needs❏ PPE considerations for:

▪ Feeding ▪ Diapering

❏ Reinforcement of universal precautions

❏ Reinforcement of universal control measures by staff

Gown

Envision Your Practice as a School Nurses & COVID-19

❏ Share a video, COVID-19 & Schools: Fear Out-Learning InA Training Module for Boston Public Schools Staff Caring for Students with Special Health Needs

"https://drive.google.com/file/d/1FLv4kIF71sEI-bMX2DRyWO7mtkyR19g9/preview"

Infection Control: Empowering Nurses with Best Practice

on cleaning considerationsGoals:

❏ Understand the basics & guidelines❏ Develop a plan❏ Implement the plan

Health room:

❏ Daily❏ Between student interactions

School Nurse Experience ❏ Form a committee to ensuring proper cleaning & disinfecting

■ Establish regular meeting times.■ Look at the current needs, policy and talk about realistic plans.■ Develop plan – what, who, when■ The principal and custodial staff implement the plan; school

nurse, teachers, and other personnel support the plan.❏ Include: Custodian, Principal or representative, teachers and

paraprofessionals, community representatives, i.e. Asthma Coalition, Mass COSH, Children’s Hospital

❏ OSHA – Occupational Safety & Health Administration❏ CDC- Center for Disease Control❏ Public Health Department ❏ DESE – Dept of Education and Secondary Education❏ -responsible for all services in the school❏ Superintendent Circulars – district policy guidelines❏ Each School

■ Facilities Department – determines the cleaners used in our school and will provide the training on how to use the cleaning materials

Understand the system and who sets the guidelines

Occupational Safety & Health Administration (OSHA) is an agency of the US Department of

Labor

❏ OSHA rules and regulations are designed to protect workers and keep work environments safe and healthy.

❏ The Hazard Communication Standard (HCS) requires chemical manufacturers, distributors, or importers to provide Safety Data Sheets (SDSs) (formerly known as Material Safety Data Sheets or MSDSs) to communicate the hazards of hazardous chemical products.

https://www.osha.gov/Publications/OSHA3493QuickCardSafetyDataSheet.pdf

UNDERSTAND THE RIGHT TO KNOW

Read the label of the product:❏ Is it a cleaner, sanitizer or disinfectant?❏ Note the “dwelling time”❏ Go to the company site and print out the Material Safety Data

Sheet ■ Note the toxic effect on the human body

❏ Start a binder on the cleaning products used at your school■ keep it in your office for reference■ Refer to this information if you needed to call the poison

control center

Developing the Plan for School Cleaning & Disinfecting

DESE Guidance – Facilities Department responsibility:

❏ Update cleaning and disinfecting protocols

❏ Obtain additional supplies,as needed

❏ Train staff appropriately

DESE, 2020

DESE Protocols include cleaning & disinfecting:

❏ At least daily for shared spaces & furniture

❏ Multiple times/day high-touch surfaces like door handles, light switches, handrails

Remember the basics

❏ Germs/ COVID 19

❏ How are germs/microorganisms transmitted?

❏ Who is a carrier?

❏ Germs / microorganisms on various surfaces.

❏ Precautions we take to prevent the transmission in the school setting

❏ CDC guidelines on infection control

Know the Basics: Difference between cleaning, disinfecting, & sanitizingCleaning❏ Removes dirt from surface – soap and water commonly used.

Disinfecting❏ Stronger chemicals used to kill a wider range of organisms

Sanitizing❏ Lowers the amount of organisms to a safe level; requires custodians or a

special cleaning company

Hand sanitizer❏ Reduces organisms on surface of hands; CDC recommends 60% alcohol

content

School Health Room/Classroom

❏ Reduce sharing of common spaces and frequently touched objects.❏ Clean visibly dirty surfaces with soap and water prior to disinfection.❏ Frequently explain cross contamination. People forget.❏ Best practice would be to clean after every student.❏ Do not spray disinfectants while a student is in the room.❏ Keep disinfectant out of the reach of students.

https://www.cdc.gov/coronavirus/2019-ncov/community/cleaning-disinfecting-decision-tool.html

Medical Waiting Room (MWR)

The purpose of the MWR is to minimize transmission of COVID-19 by providing a place for those students who await pick-up because while in school they:

❏ Exhibit symptoms of COVID-19❏ Discover positive COVID-19 test results for themselves or a close contact

Ideally, one student per MWR but if more than one student in MWR:

❏ At least 6 feet apart (spaced as far apart as possible) ❏ Wearing a surgical mask provided by the school (non-N95 and non-cloth)❏ If a student is unable to wear a mask, then no other students in MWR

MWR Staffing

The MWR must be supervised by an adult staff member at all times when students are present. The supervising staff person:

▫ Is trained in CPR/AED▫ Is in close communication with the school nurse▫ Wears appropriate PPE provided by the school

▪ Surgical mask and goggles/face shield if distanced 6 feet from student

▪ If unable to maintain 6 feet distance, then N95 respirator or disposable mask and face shield, gloves, and gowns

Equipment/Supplies for MWR

Outside MWR:

❏ Surgical masks ❏ Gloves❏ Disposable gowns❏ Hand sanitizer❏ Receptacle – storage of nurse’s

N95 mask & face shield ❏ Post job aides

Inside MWR:❏ Hand sanitizer❏ Tissues❏ Several waste baskets

and plastic liner bags

Assessing the Student with COVID-19 Symptoms

When assessing students who have underlying conditions that present as symptoms of COVID-19, use nursing judgement! Treat, and if there is improvement, the student may return to class. Examples include:

❏ Asthma❏ Seasonal allergies❏ Migraine❏ Food sensitivity

Fever OnlyFever of 100.0°F or higher.

Respiratory SymptomsCough, difficulty breathing, SOB.

No fever or other symptoms.

Does the student have asthma?

Yes

Multiple Symptoms

Send HomeNurse advise

parent/guardian to contact student’s PCP for possible

testing for COVID-19.

Nurse assesses symptom for historically known etiology of

symptom: migraines, IBS, lactose intolerance, etc.

Is nurse suspicious that the symptom is COVID-19 related?

If non COVID-19 underlying cause is identified, & nurse is convinced that this is the cause of the symptom, then student may be treated and mayReturn to Class

Send HomeNurse contacts the

parent/guardian, notifies of symptom and the need to pick-up

the student (NO school bus); student is to continue to wear

surgical mask and is monitored in the medical waiting/isolation room until parent/guardian arrives. Nurse advises parent/guardian to consult with student’s PCP & if their student

develops other symptoms of COVID-19 to seek testing. Nurse

reviews symptoms and how to get the student tested/testing sites.If symptoms worsen quickly, call

911

Yes

No

BPS Nurse Screening Guide for COVID-19

Send Home

If nurse is not

convinced that the

symptom is not

COVID-19

Send Home or Call 911

Nurse assesses symptoms deciding if 911 is needed

and discusses with parent guardian.

YesNo

No Yes

Do symptoms improve after taking medication?

Nurse Administer

No

Is rescue medication MDI available?

A student sent to the nurse with any symptom of COVID-19 (possible fever, cough, difficulty breathing, sore throat, congested or runny nose, loss of taste or smell, chills, headache, nausea, vomiting, diarrhea, poor feeding) is masked and

seated in the medical waiting/isolation room.No Fever – One

Non-Respiratory Symptom Only

Terms: Isolation, Quarantine, Close Contact, and COVID-19 related fever

Isolation: Separates people infected with Covid-19 from those not infected. Separates those people with COVID-19 symptoms as well as those who have tested positive for COVID-19 who may be symptomatic or asymptomatic.

COVID-19 related fever: A fever as a COVID-19 symptom is defined as 100.0˚F or higher.

Close Contact – close contacts will be defined as only those who have been within 6 feet of distance of the person testing positive for at least fifteen minutes, while the person was infectious. The infectious period begins 2 days prior to symptom onset. If someone is asymptomatic, the infectious period is considered to begin 2 days prior to the collection of their positive test.

Quarantine is used to keep someone who might have been exposed to COVID-19 but who are not yet feeling symptoms away from others. People in quarantine should stay home, separate themselves from others, monitor their health, and follow directions from their state or local health department.

Protocol for return to school if identified as a close contact

All close contacts should be tested Close contacts (CCs) must self-quarantine for 14 days after their last exposure to the person who tested positive, regardless of the CCs test result. Even with a negative test result, the CC must continue to self-quarantine for the full 14 days as the virus may take up to 14 days to cause illness.

Protocol for return to school for an individual testing positive for COVID-19

Self-isolation for COVID-19 positive cases is a minimum of 10 days

People who test positive may return to school after 10 days isolation and once they have:

a. gone for 3 days without a fever (and without taking fever-reducing medications like Tylenol); and

b. experienced improvement in other symptoms (for example, their cough has gotten much better); and

c. received clearance from public health authority contact tracers (the local board of health or Community Tracing Collaborative).

Repeat testing prior to return is not recommended. Return to school should be based on time and symptom resolution.

Protocol for return to school after experiencing COVID-19 symptoms if there

is an alternative diagnosis

If a provider has documented an alternative diagnosis, the individual may return to school based on the recommendations for that alternative diagnosis (e.g., influenza or strep pharyngitis).

Protocol for return to school after experiencing COVID-19 symptoms and the result of COVID-19 test is negative

If the individual with COVID-19 symptoms has tested negative for COVID-19, then the individual may return when there is:❏ Improvement in symptoms AND❏ No fever (100.0F) for > 24 hours without fever reducing meds

Protocol for return to school after experiencing COVID-19 symptoms and

not tested for COVID-19

Those not tested for COVID-19 may return to school 10 days from start of symptoms as long as:

❏ Symptoms have improved

AND

❏ No fever for > 24 hours without fever reducing medication

BPS School Nurse Flowchart – Protocols for COVID-19 Related Return-to-School Scenarios (from DESE/MDPH Joint statement 8/19/20)

The student is identified as having:Close contact to a person who tests positive for COVID-19

COVID-19 symptoms

diagnosed as an alternative diagnosis

COVID-19 symptoms &

negative COVID-19 test

result

COVID-19 symptoms but not tested for

COVID-19

Must self-quarantine for 14 days after the last exposure to the person who tested positive; even if this CC tests negative, the CC must continue to self- quarantine for the full 14 days as COVID-19 may take up to 14 days to cause CC to be ill.

If a provider has documented an alternative diagnosis, the individual may return to school based on the recommendations for that alternative diagnosis (e.g., influenza or strep pharyngitis).

The individual may return when there is:

● Improvement in symptoms

AND

● No fever for more than 24 hours without fever reducing medications

The individual may return to school 10 days from start of symptoms if:

● Symptoms have improved

AND● No fever for

more than 24 hours without fever reducing medications

Individuals who have tested positive for COVID-19

May return to school after 10 days isolation and:

● Improvement in symptoms

● No fever for 3 days without fever reducing medications

● received clearance from public health authority

Questions

ReferencesBoston Teachers Union, Nurse Faculty Senate (2020). COVID-19 & Schools: Fear Out – Learning In. A Teaching Module for Boston Public Schools Staff Caring for Students with Special Health Care Needs.

htttps://drive.google.com/file/d/1FLv4kIF71sEI-bMX2DRyWO7mtkyR19g9/preview

Centers for Disease Control and Prevention (CDC). (2020). How to Use PPE. Retrieved from:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html

CDC Healthcare Infection Control Practices Advisory Committee (HICPAC). (2017). Core Infection Prevention and Control

Practices for Safe Healthcare Delivery in All Settings –Recommendations of the HICPAC.retrieved from: https://www.cdc.gov/hicpac/recommendations/core-practices.html

CDC (2020). When to Quarantine. Retrieved from:

https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fif-you-are-sick%2Fquarantine-isolation.html

CDC. Understanding and Selecting Respiratory Protection Devices

https://www.cdc.gov/niosh/npptl/pdfs/N95-Infographic-REACH-II-508.pdf /

Comprehensive Personal Protective Equipment (PPE) Guidance

https://www.mass.gov/doc/updated-comprehensive-personal-protective-equipment/download / accessed 8/13/20

Guidance for Healthcare Personnel on the Use of Personal Protective Equipment (PPE) in Schools During COVID-19

https://www.nasn.org/nasn-resources/practice-topics/covid19/ accessed 8/13/20

Jones E, Young A, Clevenger K, Salimifard P, Wu E, et al. (2020). Healthy Schools: Risk Reduction Strategies for Reopening

Schools. Harvard T.H. Chan School of Public Health Healthy Buildings program. Retrieved from:

https://schools.forhealth.org/wp-content/uploads/sites/19/2020/06/Harvard-Healthy-Buildings-Program-Schools-For-Health-Reopening-Covid19-June2020.pdf

Massachusetts Department of Elementary and Secondary Education (DESE). (2020). COVID-19 Information and Resources,Joint Memo

Clarifying Key Health and Safety Requirements for Schools, Protocols for Responding to COVID-19 Scenarios, and, Fall Reopening Facilities and Operations Guidance Retrieved from: http://www.doe.mass.edu/covid19/

National Association of School Nurses. (2020). Guidance for healthcare personnel on PPE use in schools.Retrieved from:

https://higherlogicdownload.s3.amazonaws.com/NASN/3870c72d-fff9-4ed7-833f-215de278d256/UploadedImages/PDFs/Guidance-for-Healthcare-Personnel-on-PPE-Use-in-Schools.pdf

National Association of School Nurses (2016), Framework for 21st Century School Nursing Practice. Retrieved from:

https://www.nasn.org/nasn/nasn-resources/professional-topics/framework

References