Medications not yet evaluated by P&T are considered NON-FORMULARY . . . . . Always check 2 unique patient identifiers - NAME and DATE OF BIRTH - at every step! . . . . . Please be sure to document all clinical activities daily.

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04/20/20 js Universal Masking - Effective Wednesday April 22, 2020
April 20, 2020

From: "Jeff Samz" Sent: Monday, April 20, 2020 11:27:23 AM Subject: Universal Masking - Effective Wednesay April 22, 2020 Effective Wednesday April 22, 2020, all employees, medical staff members, and contractors will be required to wear a surgical, procedural or cloth face mask while working across any of the Huntsville Hospital Health System facilities. Masks should be worn anytime you are in a clinical area or common area of the hospital. We recognize that this is a departure from standard infection prevention guidance. However, we find ourselves in extraordinary times, and, given current circumstances, we believe this guidance will help many employees feel more comfortable. In addition, doing so may reduce the likelihood of viral transmission from asymptomatic and minimally symptomatic employees. This practice will be continually monitored and re-evaluated. Madison Hospital, Decatur Morgan Hospital, Athens Limestone Hospital, Helen Keller Hospital, and Lawrence Medical Center are already requiring masks and nothing changes for them. Rationale for Masking Guidance Our knowledge regarding COVID-19 is rapidly expanding, and the situation and degree of community transmission are also rapidly evolving. This prompts us to update our policies to reflect the current situation regarding issues such as mask reuse and viral transmission. Given what we have learned about COVID-19, this masking approach will serve to protect our patients and other staff members, should the health care worker have early COVID-19 infection or develop symptoms at work (a mask achieves source control and decreases the risk of spreading infection to others). Although our personal protective equipment (PPE) supplies are presently sufficient, we MUST remain good stewards of the existing PPE. To be successful, this approach will require support from each of us across the enterprise. That means we must practice the following behaviors: Good stewardship of preserving PPE supplies, so they last through the peak of the pandemic. Continued focus on social or physical distancing, to decrease viral transmission. Meticulous adherence to hand hygiene (including before and after removing masks). Proper mask use (e.g., wear the mask as directed to cover the mouth and nose, and do not wear the mask on your forehead, chin or around the neck or the arm). Strict avoidance of manipulation/touching the mask, to reduce the risk of touching one’s face, leading to possible contamination and self-inoculation. Process for Obtaining, Reusing and Discarding Procedure/Surgical and Cloth Masks to Preserve Our Supply Health System Supply Chain allocates PPE supplies to each department based on usage needs and product availability. Surgical or Procedural Masks are not publicly available due to concerns of theft. They are available within departments and we will provide a limited supply at entrances for visitors or medical staff members who need one. Please keep and reuse the surgical mask — if it is intact and not visibly soiled or damaged. Masks must not be diverted to persons outside of the HH Health System. Cloth Masks: Cloth masks may be worn for nonpatient care activities; however, cloth masks must not be used in isolation precaution rooms or for clinical patient care activities where PPE is required. Cloth masks are being distributed to each department by Supply Chain and we will have a limited supply available at entrances for staff who do not have one. Staff are responsible for laundering the masks each night at home. We are encouraging the use of cloth masks to preserve our supply of PPE. Process for Patients and Visitors Patients: While we are not requiring all patients to wear procedure masks, inpatients and outpatients who exhibit flu like symptoms should be asked to wear a mask and we are encouraging all patients to do so. Patients who request a mask should be provided one, unless the mask could interfere with their treatment or condition. Visitors: The limited number of visitors in the hospital are being screened at entrances and are asked to leave if they have a fever or flu like symptoms. Visitors who are permitted in the hospital are not required to wear a mask but should be provided one upon request Thank you for your help with this important policy that protects one another and our patients.






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