COVID-19 (Rev#8,3.12.2020) PDF

UHS HOSPITALS
INTERNAL EMERGENCY PLAN
COVID-19
Table of Contents
Purpose…………………………………….…………………………..………………………..…….Page 2
Clinical Criteria…………………….…………………………………..…………………….……….Page 2
Criteria for Testing……………………………………………………………………………...…..Page 2-3
Criteria for Discontinuation of Isolation………………………………………………………………Page 3
Required Personal Protective Equipment……………………………………………………..……....Page 3
Donning and Doffing of Personal Protective Equipment (PPE)…………...………………..………Page 4-5
Prioritization of Fit Testing…………………………………………………………………..………..Page 6
Room Identification/Signage………………………………………………………………………….Page 6
Local Health Departments……………………………………………………..……………..……….Page 6
Responsibilities…………………………………………………………..………………………Page 7-21
Call Centers for Primary & Specialty Care Practices……………...……..……………..…….Page 7
Walk-In/Primary & Specialty Care Practices….....…………...……………………...…….Page 7-9
Emergency Departments………………..……………………………………….......…..Page 10-12
Inpatient Care Team Caring for Patient…………………………...……………………Page 12-13
Critical Care Task Group……………………………………….………………………..….Page 13
Patient Placement…………………………..……………………………..……………..….Page 14
Dietary………………………………………………………………………….......……….Page 15
Laboratory……………………………...……………………...…….……………….….Page 15-16
Ancillary Services & Testing, including Radiology……………..………………….………Page 16
Pharmacy……………………………………………………………...…………….………Page 16
Environmental Cleaning/Waste Management………………………….………………..….Page 16
Transportation of Patients……………………………………………………….…………..Page 16
Management of Visitors for Suspected/Confirmed COVID-19 Patients……................……Page 17
Visitor and Outpatient Management……………………………………………………..Page 17-18
Virtual Walk-In/Telehealth……………………………………………………….....………Page 18
Occupational Medicine/Employee Health………………………………..……………...Page 18-21
Emergency Operations Plan Activation………………………………..……………...…….Page 21
Key Words Index………………………………………………………...…………………………Page 21
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Up to Date as of: 03/11/2020 1 Version #: 7
Purpose
 This plan will serve as a guideline to assist in management of patients who are suspected or
knowingly infected with Coronavirus 2019 (COVID-19).
Clinical Criteria
(Based on guidance from CDC – For most Up-to-Date Guidance See:
https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html)
Clinicians should use their judgment to determine if a patient has signs and symptoms compatible
with COVID-19 and whether the patient should be tested. Decisions on which patients receive
testing should be based on the local epidemiology of COVID-19, as well as the clinical course of
illness. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute
respiratory illness (e.g., cough, difficulty breathing). Clinicians are strongly encouraged to test for
other causes of respiratory illness, including infections such as influenza.
Epidemiologic factors that may help guide decisions on whether to test include: any persons,
including healthcare workers, who have had close contact with a laboratory-confirmed COVID-19
patient within 14 days of symptom onset, or a history of travel from affected geographic areas (see
below) within 14 days of symptom onset.
Clinicians are strongly encouraged to test for other causes of respiratory illness, including
infections such as influenza.
Epidemiological factors that may help guide decisions on whether to test include; any persons,
including healthcare workers, who have had close contact with a laboratory-confirmed COVID-19
patient within 14 days of symptom onset, or a history of travel from affected geographic areas
within 14 days of symptom onset.
International Areas with Sustained Transmission (as of March 12) include;
China – Level 3
Iran – Level 3
Italy – Level 3
South Korea – Level 3
Japan – Level 2
Hong Kong – Level 1
Criteria for Testing

Clinicians are now free to order COVID-19 testing as needed, without approval by the local Health
Department, in the following situations:
- Close contact with confirmed case of COVID-19, irrespective of symptoms.
- Travelled to Level 2 or Level 3 countries within the last 14 days and showing fever or
respiratory symptoms.
- In mandatory or precautionary quarantine and has developed symptoms of illness.
_____________________________________________________________________________
- Symptoms consistent with COVID-19, with negative molecular viral respiratory pathogen
panel.
*Other cases where facts and circumstance warrant as determined by the treating clinician in
consultation with State or local Health Department.
Criteria for Discontinuation of Isolation
The discontinuation of mandatory isolation of persons with confirmed COVID-19 includes the
minimum criteria of;
- It has been at least seven days since the initial positive test for COVID-19.
- Resolution of fever without use of antipyretic medication.
- Improvement is signs and symptoms of illness.
- Negative results for a molecular assay for COVID-19 from two consecutive sets of
nasopharyngeal (NP) and oropharyngeal (OP) swabs at least 24 hours apart. This means a
total of (4) negative specimens, (2) NP and (2) OP.
Required Personal Protective Equipment (PPE)
_____________________________________________________________________________
Donning and Doffing of Personal Protective Equipment (PPE)
_____________________________________________________________________________
_____________________________________________________________________________
Prioritization of Fit Testing
UHS has prioritized areas and roles that are in need of Fit Testing. High risk roles include RN’s,
Providers, and Respiratory Therapists. High risk areas are areas in which patients are likely to be
treated for respiratory symptoms and/or have negative pressure rooms.
Room Identification/Signage
Local Health Departments

Broome County: (607)778-2804, After Hours: (607)778-1911
Chenango County: (607)337-1660, After Hours: (607)337-1654
Cortland County: (607)753-5028
Delaware County: (607)832-5200
Madison County: (315)366-2327
Otsego County: (607)547-4343
Tioga County: (607)687-8609, After Hours: (607)687-1010
Susquehanna, PA: (570)278-3880
Wyoming, PA: (570)836-2662
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Responsibilities
1. Call Centers for Primary & Specialty Care Practices
A. Call Center personnel will screen patients for symptoms. All patients reporting a
fever will be screened for exposure, this will include:
- Travel History
- Symptoms (fever or influenza/respiratory symptoms)
- Potential for Direct Contact/Exposure to an Infected Person
B. If the patient phoning in meets the criteria for suspected COVID-19, the patient
should be placed on hold and the Physician Practice RN notified.
C. The RN will gather all pertinent information regarding travel history, symptoms
and exposure.
D. The RN will consult with a provider.
E. The RN will notify UHS Infection Prevention of any suspect patient presenting for
care. Notify (607)201-8908 at all times, Alternate numbers (607)763-6194,
(607)763-5073, After hours call the Hospital Operator to assist with contact.
F. Notifications to local Health Department will be based on the above criteria.
G. Whenever medically appropriate, individuals suspected or known to be
infected with COVID-19 will be referred to the UHS Virtual
Walk-In/Telehealth System for initial screening.
2. Walk-In (WI)/Primary & Specialty Care Practices

A. NYSDOH approved signs are posted at all entrances alerting patients to notify staff
in the event that they have traveled, are experiencing influenza/respiratory
symptoms, or have knowingly had an exposure.
B. All patients reporting a fever will be screened for exposure, this will include:
- Travel History
C. If the patient meets the criteria for suspected COVID-19, the person will be
requested to don a surgical mask. The RN will be immediately notified.
D. The patient will be immediately placed in a private room, preferably negative
pressure. The patient will be asked to clean their hands using alcohol-based hand
sanitizer. The door to the room will be closed. Preferred rooms have been
identified as;
UHS Vestal Walk-In – Room 1
UHS Chenango Bridge Walk-In – Room 2
UHS Endicott Walk-In – Room 1
_____________________________________________________________________________
UHS Robinson Street Walk-In – Room 1
UHS Binghamton Primary Care – Rooms 6, 9
Other Locations – Closest Available Private Exam Room
E. Once placed in a room, the patient will remain masked.
F. All attempts will be made to have the patient remain in the room with door closed,
except where medically necessary.
G. A restroom will be delegated for use by the patient and any visitors. Once the
restroom has been used by a suspected or confirmed COVI-19 infected individual,
the restroom will not be used by uninfected individuals until appropriately cleaned.
H. The patient’s room will be restricted to appropriately trained staff only.
I. Whenever possible, staff entering the patient’s room will be kept to a
minimum. Only critical staff will interact with the patient.
J. Contact, Standard and Airborne precautions, with eye protection will be
implemented and followed until the local Health Department deems that the patient
is no longer a risk or laboratory testing confirms that the patient is not infected with
COVID-19.
K. The Physician will be immediately notified of a suspect patient and will don
appropriate PPE prior to examination. A NP or PA may perform the medical
evaluation and initiate treatment.
L. The RN will notify UHS Infection Prevention of any suspect patient presenting for
care. Notify (607)201-8908 at all times, Alternate numbers (607)763-6194,
(607)763-5073, After hours call the Hospital Operator to assist with contact.
M. Notifications to local Health Department will be based on the above criteria.
N. The RN will notify the Physician Practice Director, Clinical Services of any suspect
patient presenting for care. (607)763-1805 until 5pm Monday-Friday, after 5pm
and on weekends (607)237-6470.
O. A log of all employees who have interacted with the patient will be maintained by
the RN or designee. This will include the names of employees assigned to treat the
patient. The log will be sent to Occupational Medicine when completed. (See:
https://intranet.nyuhs.org/app/files/public/14549/covid-sign-in.pdf)
P. Visitors to rooms of confirmed or suspected COVID-19 patients will be restricted
to parents of minor children and significant others, or those that are required for
medical decision making or the well-being of the patient. Considerations may be
made for end-of-life cases. Where visitors are permitted, staff will conduct training
on appropriate PPE usage prior to allowing visitation.
Q. Routes of travel for visitors, to/from rooms of confirmed or suspected COVID-19
patients will be developed by Security or designee. These routes will be developed
to ensure the shortest travel path to or from the area. Visitors will be escorted
to/from rooms in an effort to ensure that they are not remaining in common spaces,
such as cafeterias, waiting areas and lobbies.
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R. Family members or friends who have been exposed to the patient will not be
permitted to remain in the common Waiting Area. Whenever possible, they will be
placed in another private area or asked to leave site until screened by the local
Health Department.
S. Whenever possible, all testing will be conducted within the patient’s exam room.
Specimen collection must occur under negative pressure. If the practice does not
have a negative pressure room and testing is recommended, the patient will be
relocated to Vestal Walk-In or Binghamton Primary Care for testing. (Refer to
Section on Laboratory)
T. The Sending Provider will document care provided at point of entry and will place
an order for testing in the Electronic Medical Record (EHR). The Sending
Provider/RN will contact the testing location to notify of the patient impending
arrival.
U. The Sending Provider will provide the patient with instructions to proceed directly
to the testing location while wearing a surgical mask.
V. The testing location will meet the patient at the point of entry and escort them
directly to the negative pressure room for administration of testing.
W. If hospital care is required, Superior Ambulance will be contacted to transfer the
patient. Early notification for preparation to transport is required. Patients will be
requested to don a surgical mask and will be covered with a clean sheet during
transport.
X. In the event of a positive test result, exposure risk for all employees interacting with
the patient will be determined by Occupational Medicine.
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3. Emergency Departments (ED)
_____________________________________________________________________________
A. NYSDOH approved signs are posted at all entrances alerting patients to notify ED
staff in the event that they have traveled, are experiencing influenza/respiratory
B. Visitor Management staff will immediately meet patients upon their entering the
ED and start the screening process. This helps to avoid an ill patient sitting in the
waiting room.
C. All patients reporting a fever will be screened for exposure, this will include:
- Travel History
D. If the patient meets the criteria for suspected COVID-19, the person will be
requested to don a surgical mask and clean their hands using alcohol-based hand
sanitizer. The ED Charge RN will be immediately notified.
E. The patient will be immediately placed in a private room, preferably with negative
pressure. The door to the room will be closed. Preferred rooms have been
identified as;
UHS Binghamton General Hospital (BGH) - Room 13
UHS Wilson Medical Center (WMC) - Room 6A or 8
F. Once placed in a room, the patient will be encouraged to leave their mask on.
G. All attempts will be made to have the patient remain in the room with door closed,
except where medically necessary. If the patient is removed from the room for any
reason, they will be requested to don a surgical mask before opening the door to the
room.
H. Commodes will be used for patients. A restroom will be delegated for use by any
visitors. Once the restroom has been used by a suspected or confirmed COVID-19
infected individual, the restroom will not be used by uninfected individuals until
appropriately cleaned.
I. The patient’s room will be restricted to appropriately trained staff only.
J. Whenever possible, staff entering the patient’s room will be kept to a
minimum. Only critical staff will interact with the patient.
K. Contact, Standard and Airborne precautions, with eye protection will be
implemented and followed until the local Health Department deems that the patient
is no longer a risk or laboratory testing confirms that the patient is not infected with
COVID-19.
L. The ED Physician will be immediately notified of a suspect patient and will don
appropriate PPE prior to examination. A NP or PA may perform the medical
evaluation and initiate treatment.
M. The ED Charge RN will notify the Nursing Supervisor (or Manager, Emergency
Department) of any suspect patient presenting for care.
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N. The ED Charge RN will notify UHS Infection Prevention of any suspect patient
presenting for care. Notify (607)201-8908 at all times, Alternate numbers
(607)763-6194, (607)763-5073, After hours call the Hospital Operator to assist
with contact.
O. Notifications to local Health Department will be based on the above criteria.
P. A log of all employees who have interacted with the patient will be maintained by
Q. Visitors to rooms of confirmed or suspected COVID-19 patients will be restricted
R. Routes of travel for visitors, to/from rooms of confirmed or suspected COVID-19
S. Family members or friends who have been exposed to the patient will not be
permitted to remain in the common Waiting Area. Whenever possible, they will be
placed in another private area or asked to leave site until screened by the local
Health Department.
T. Whenever possible, all testing will be conducted at bedside. Specimen collection
must occur under negative pressure. (Refer to Section on Laboratory)
U. During patient transfers for the purpose of testing or admission, patients will be
requested to don a surgical mask and will be covered with a clean sheet.
V. If patients do not meet standard criteria for admission, they should be discharged to
home with follow-up by the local Health Department.
W. In the event of a positive test result, exposure risk for all employees interacting with
the patient will be determined by Occupational Medicine and UHS Infection
Control.
4. Inpatient Care Team Caring for Patient

A. Whenever possible, staff entering the patient’s room will be kept to a
minimum. Only critical staff will interact with the patient. Critical staff is
defined as;
Providers
RN’s
Respiratory Therapy
Radiology
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B. Only employees trained in appropriate PPE usage will be allowed to enter the
room.
C. A log of all employees who have interacted with the patient will be maintained by
D. Equipment used on suspected patients or in suspected patient rooms will be cleaned
prior to being used on any other patient or in any other patient’s room. In the event
that the equipment cannot be cleaned appropriately, it will be disposed of.
5. Critical Care Task Group

A. The following statements are applicable to all Phases:
 Staffing plan for critical care and/or surge space will be handled by Nursing
Leadership (DON).
 Communications will not be possible with cell phones due to PPE, especially
gloves. Speaker phones and portable radios will be necessary.
 Visitation will not be possible and other means of communication, such as
telephone and virtual connections between patients and families will need to be
considered.
 Healthcare personnel will do physically and mentally feasible shifts, as wearing
PPE safely will at some point become overbearing. They then must be
relieved.
 Clinical Students, although an important part of the healthcare team, will need
to be limited in their presence, due to the limited supply of PPE.
 Non-critically ill patient placement and care, as well as ancillary department
directions, are covered in other areas of this plan.
B. Phase 1 – (up to 3 patients)
 Uses existing resources.
 Critical Care patients (bipap or ventilator) in negative pressure rooms in ICU or
CVICU.
 Adequate supply of PPE (assumes 50 sets of PPE/day per patient).
 All patients cared for by CDC Recommendation for Standard, Contact, and
Airborne isolation precautions, with eye protection.
C. Phase 2 – See: Surge Plan
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6. Patient Placement
A. Patients shall be placed in available negative pressure rooms.
Negative Pressure Rooms are located;
UHS Wilson Medical Center
Emergency Department Room 6A
Emergency Department Room 8
North Wing 5 NP Suite (will be used as last resort, for Neonatal Care Only)
North Tower 4 Room 454
CVICU Room 392
Intensive Care Unit Room 1
UHS Binghamton General Hospital
Emergency Department Room 13
Memorial 3 Room 335
Memorial 3 Room 336
Memorial 3 Room 337
UHS Vestal Walk-In

Exam Room 1
B. Preferred inpatient room assignments (first choice) for isolated cases (1-2 cases)
are;
UHS Binghamton General Hospital
Critical Care – Intensive Care Unit Room 8
Non-Critical Care – Memorial 3 Rooms 335, 336, 337
UHS Wilson Medical Center
Critical Care – CVICU Room 392, Intensive Care Unit Rooms 1, 2
Non-Critical Care – North Tower 4 Rooms 454, 455, 456
C. In the event that a negative pressure room is not available, notify UHS Infection
Prevention immediately. Notify (607)201-8908 at all times, Alternate numbers
(607)763-6194, (607)763-5073, After hours call the Hospital Operator to assist
with contact.
D. Engineering staff will be assigned to test negative pressure rooms prior to the
admission of any patient suspected or known to be infected with COVID-19. For
negative pressure rooms in the Emergency Departments, Engineering staff will be
assigned to test the room immediately upon a patient being identified.
E. Engineering staff will be assigned to test negative pressure rooms hourly while
suspected or known patient(s) are housed in the room(s).
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7. Dietary
A. No Dietary staff will be allowed to enter the room.
B. Dietary staff will call the patient to retrieve menu order by phone.
C. If a dietary consultation is needed, the Dietitian will interview the patient by phone.
D. All meals will be served on disposable trays, with disposable utensils.
E. All meals will be delivered to Nursing staff, who will present the meal to patients.
F. Disposable trays and utensils will not leave the patient’s room and will not re-enter
the Kitchen area. Nursing will dispose of these items.
8. Laboratory
A. Testing for COVID-19 does not require prior-authorization from the local Health
Department. Testing may occur under the discretion of providers. (See: Criteria
for Testing – above)
B. Nursing staff will be responsible for acquiring all specimens in the Emergency
Department. Respiratory Therapy will be responsible for acquiring all specimens
in on inpatient units.
C. Phlebotomists will not be allowed to enter the room.
D. Specimen collection will occur only in negative pressure rooms.
E. Specimens to be obtained include for COVID-19 testing include;
(2) - Nasopharyngeal (NP) swabs
(1) - Oropharyngeal swab (use influenza swabs)
Sputum, if productive cough (induced sputum is not recommended)
F. Only synthetic fiber swabs with plastic shafts will be used.
G. Communication between Clinical and Laboratory staff is essential to minimize the
risk incurred in handling specimens from patients with suspected COVID-19.
Hand off communication should occur between Clinical staff and Laboratory staff
receiving the specimen.
H. Respiratory specimens should not be sent to the Laboratory via the pneumatic tube
system.
I. Any Laboratory procedure with the potential to generate aerosol or droplets (such
as vortexing) should be performed in a certified Class II Biological Safety Cabinet.
J. While performing routine testing on serum, blood or urine specimens from
suspected or known COVID-19 patients, Laboratory staff will follow Standard
Precautions. This includes disposable gloves, laboratory coat/gown and eye
protection.
K. All packaging and shipping of specimens to the NYS Laboratory at Wadsworth (or
other reference laboratory) will be conducted by WMC Microbiology.
_____________________________________________________________________________
L. Laboratory waste will be handled in accordance with standard procedures for
respiratory pathogens, such as Seasonal Influenza.
M. Work areas and equipment will be decontaminated after specimen processing using
appropriate disinfectants.
9. Ancillary Services & Testing, including Radiology

A. Whenever possible, all testing will be conducted at bedside.
10. Pharmacy
A. Par levels for frequently used pharmaceutical supplies have been increased.
11. Environmental Cleaning/Waste Management

A. Environmental Cleaning and Waste Management practices are outlined in specific
Environmental Services policies and procedures.
B. All cleaning and waste practices have been developed using guidelines from the
Centers for Disease Control (CDC).
C. PDI wipes and Virex Plus solution is approved for use with COVID-19.
D. Frequency of cleaning for public spaces has been increased.
12. Transportation of Patients
A. During patient transfers for the purpose of testing or admission, patients will be
requested to don a surgical mask and will be covered with a clean sheet.
B. Regarding transportation from UHS location to UHS COVID-19 testing location
(ie, Vestal Walk In or Binghamton IM):
 For suspect patients who are clinically compromised, they will be sent via
ambulance to Emergency Department.
 For suspect patients who are ambulatory, not clinically compromised, and who
have independent transportation, they will be encouraged to transport self to
testing location.
C. Regarding transportation from UHS testing location (ie, Vestal Walk In or
Binghamton IM) to a non-UHS community location:
 For suspect patients who are ambulatory, not clinically compromised, and who
have independent transportation, they will be encouraged to transport
themselves back into the community.
_____________________________________________________________________________
13. Management of Visitors for Suspected/Confirmed COVID-19 Patients
A. Visitors to rooms of confirmed or suspected COVID-19 patients will be restricted
B. Routes of travel for visitors, to/from rooms of confirmed or suspected COVID-19
C. A Patient Liaison may be assigned to the patient by Social Work or Patient
Relations. The Liaison will assist in coordinating communication by the patient,
with family and friends, via telephone or video conferencing, if applicable.
14. Visitor and Outpatient Management

Currently, visitation for all patients is discouraged. This will change on a daily basis.
For the most up-to-date information regarding visitation, consult your Manager or
Supervisor.
A. NYSDOH approved signs are posted at all entrances alerting individuals to notify
staff in the event that they have traveled, are experiencing influenza/respiratory
B. Visitor Management staff is assigned to screen all individuals entering the facility
through public entrances. The screening includes;
- Potential for travel History
- Potential for symptoms (respiratory infection)
C. For the Transitional Care Unit only; Individuals are screened for;
1. Signs or symptoms of a respiratory infection, such as fever, cough,
shortness of breath, or sore throat.
2. In the last 14 days, has had contact with someone with a confirmed
diagnosis of COVID19, or under investigation for COVID-19, or are ill
with respiratory illness.
3. International travel within the last 14 days to countries with sustained
community transmission.
4. Resides in a community where community-based spread of COVID-19 is
occurring.
5. Have taken any recent trips (within the last 14 days) on a cruise ship or other
venues with larges crowds.
_____________________________________________________________________________
D. If the individual meets either of the above criteria, attempts will be made to
dissuade the person from visiting.
E. If the individual requests treatment within the Emergency Department, Security
staff will be contacted and escort the person, using an exterior route, to the
Emergency Department. Suspect persons will be kept at a minimum of 6’ from all
other individuals and will not be placed in a public Reception or Waiting Areas.
15. Virtual Walk-In/Telehealth

A. UHS coordinates a Virtual Walk-In/Telehealth program. Whenever medically
appropriate, this system will be the first choice referral for individuals suspected or
known to be infected with COVID-19. The goal of this process is to eliminate
face-to-face interaction (where medically appropriate) and decrease the potential
for staff exposure.
16. Occupational Medicine/Employee Health

(Based on guidance from CDC – For most Up-to-Date Guidance See:
https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html )
As recommended by the CDC, all employees are required to notify Occupational Medicine in the
event that they have the potential for travel or community-associated exposure.
Recommended Monitoring Work Restrictions

Exposure
Epidemiologic risk factors for COVID-19 (until 14 days for Asymptomatic
category
after last potential exposure) HCP
Prolonged close contact with a COVID-19 patient who was wearing a facemask (i.e., source
control)
Exclude from work
HCP PPE: None Medium Active for 14 days after last
exposure
Exclude from work
HCP PPE: Not wearing a
Medium Active for 14 days after last
facemask or respirator
exposure
HCP PPE: Not wearing eye Self with delegated
Low None
protection supervision
HCP PPE: Not wearing gown Self with delegated

Low None
or glovesa supervision
HCP PPE: Wearing all

recommended PPE (except Self with delegated
Low None
wearing a facemask instead of supervision
a respirator)
_____________________________________________________________________________
Recommended Monitoring Work Restrictions
Exposure
Epidemiologic risk factors for COVID-19 (until 14 days for Asymptomatic
category
after last potential exposure) HCP
Prolonged close contact with a COVID-19 patient who was not wearing a facemask (i.e., no
source control)
Exclude from work
HCP PPE: None High Active for 14 days after last
exposure
Exclude from work
HCP PPE: Not wearing a
High Active for 14 days after last
facemask or respirator
exposure
Exclude from work
HCP PPE: Not wearing eye
Medium Active for 14 days after last
protectionb
exposure
HCP PPE: Not wearing gown Self with delegated
Low None
or glovesa,b supervision
HCP PPE: Wearing all

recommended PPE (except Self with delegated
Low None
wearing a facemask instead of supervision
a respirator)b
HCP=healthcare personnel; PPE=personal protective equipment

a
The risk category for these rows would be elevated by one level if HCP had extensive body
contact with the patients (e.g., rolling the patient).
b
The risk category for these rows would be elevated by one level if HCP performed or were present
for a procedure likely to generate higher concentrations of respiratory secretions or aerosols (e.g.,
cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum
induction). For example, HCP who were wearing a gown, gloves, eye protection and a facemask
(instead of a respirator) during an aerosol-generating procedure would be considered to have a
medium-risk exposure.
Additional Scenarios:
 Refer to the footnotes above for scenarios that would elevate the risk level for exposed
HCP. For example, HCP who were wearing a gown, gloves, eye protection and a facemask
(instead of a respirator) during an aerosol-generating procedure would be considered to
have a medium-risk exposure.
 Proper adherence to currently recommended infection control practices, including all
recommended PPE, should protect HCP having prolonged close contact with patients
infected with COVID-19. However, to account for any inconsistencies in use or adherence
that could result in unrecognized exposures, HCP should still perform self-monitoring with
delegated supervision.
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 HCP not using all recommended PPE who have only brief interactions with a patient
regardless of whether patient was wearing a facemask are considered low-risk. Examples
of brief interactions include: brief conversation at a triage desk; briefly entering a patient
room but not having direct contact with the patient or the patient’s secretions/excretions;
entering the patient room immediately after the patient was discharged.
 HCP who walk by a patient or who have no direct contact with the patient or their
secretions/excretions and no entry into the patient room are considered to have no
identifiable risk.
Recommendations for Monitoring Based on COVID-19 Exposure Risk
HCP in any of the risk exposure categories who develop signs or symptoms compatible with
COVID-19 must contact their established point of contact (public health authorities or their
facility’s occupational health program) for medical evaluation prior to returning to work
1. High-and Medium-risk Exposure Category
HCP in the high-or medium-risk category should undergo active monitoring, including
restriction from work in any healthcare setting until 14 days after their last exposure. If
they develop any fever (measured temperature >100.0oF or subjective fever) OR
respiratory symptoms consistent with COVID-19 (e.g., cough, shortness of breath, sore
throat)* they should immediately self-isolate (separate themselves from others) and notify
their local or state public health authority and healthcare facility promptly so that they can
coordinate consultation and referral to a healthcare provider for further evaluation.
2. Low-risk Exposure Category
HCP in the low-risk category should perform self-monitoring with delegated supervision
until 14 days after the last potential exposure. Asymptomatic HCP in this category are not
restricted from work. They should check their temperature twice daily and remain alert for
respiratory symptoms consistent with COVID-19 (e.g., cough, shortness of breath, sore
throat)*. They should ensure they are afebrile and asymptomatic before leaving home and
reporting for work. If they do not have fever or respiratory symptoms they may report to
work. If they develop fever (measured temperature > 100.0 oF or subjective fever) OR
respiratory symptoms they should immediately self-isolate (separate themselves from
others) and notify their local or state public health authority or healthcare facility promptly
so that they can coordinate consultation and referral to a healthcare provider for further
evaluation. On days HCP are scheduled to work, healthcare facilities could consider
measuring temperature and assessing symptoms prior to starting work. Alternatively,
facilities could consider having HCP report temperature and symptoms to occupational
health prior to starting work. Modes of communication may include telephone calls or any
electronic or internet-based means of communication.
3. HCP who Adhere to All Recommended Infection Prevention and Control Practices
Proper adherence to currently recommended infection control practices, including all
recommended PPE, should protect HCP having prolonged close contact with patients
infected with COVID-19. However, to account for any inconsistencies in use or adherence
that could result in unrecognized exposures, HCP should still perform self-monitoring with
delegated supervision as described under the low-risk exposure category.
_____________________________________________________________________________
4. No Identifiable risk Exposure Category
HCP in the no identifiable risk category do not require monitoring or restriction from
work.
5. Community or travel-associated exposures
HCP with potential exposures to COVID-19 in community settings should have their
exposure risk assessed according to CDC guidance. HCP should inform their facility’s
occupational health program that they have had a community or travel-associated
exposure. HCP who have a community or travel-associated exposure should undergo
monitoring as defined by that guidance. Those who fall into the high- or medium- risk
category described there should be excluded from work in a healthcare setting until 14 days
after their exposure. HCP who develop signs or symptoms compatible with COVID-19
should contact their established point of contact (public health authorities or their facility’s
occupational health program) for medical evaluation prior to returning to work.
17. Emergency Operations Plan Activation

A. A COVID Response Team has been developed using the Hospital Incident
Command System model.
B. Conditions within the facilities and community will be continually monitored by
Senior Management, Infection Control, Nursing Leadership, and Emergency
Management. These conditions will include;
- Number or Patients Presenting
- Severity of Symptoms
- Spread of the Disease within the UHS Service Area
- Availability of Supplies
- Impact on Organizational Operations
At any time, Senior Management may request activation of the Emergency
Operations Plan and Hospital Command Center, for the purpose of coordinating
resources and communication.
C. Emergency Management and Quality Management are responsible for reporting
bed census information and completing regulatory survey, as requested by the State
Health Department.
Key Words Index

Coronavirus Disease 2019 (COVID-19)
Personal Protective Equipment (PPE)
Contact and Droplet Isolation
_____________________________________________________________________________

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UHS HOSPITALS

INTERNAL EMERGENCY PLAN

Criteria for Testing

Required Personal Protective Equipment (PPE)

Local Health Departments

2. Walk-In (WI)/Primary & Specialty Care Practices

4. Inpatient Care Team Caring for Patient

5. Critical Care Task Group

UHS Vestal Walk-In

9. Ancillary Services & Testing, including Radiology

11. Environmental Cleaning/Waste Management

D. Frequency of cleaning for public spaces has been increased.

12. Transportation of Patients

14. Visitor and Outpatient Management

15. Virtual Walk-In/Telehealth

16. Occupational Medicine/Employee Health

Recommended Monitoring Work Restrictions

HCP PPE: Not wearing gown Self with delegated

HCP PPE: Wearing all

HCP PPE: Wearing all

HCP=healthcare personnel; PPE=personal protective equipment

17. Emergency Operations Plan Activation

Key Words Index

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