Q&A Inspira’s Virtual Town Hall for School Administrators and Nurses

1. Our district is working on our reopening plan. Is there any new guidance or suggestions on when to keep kids home or send kids home from school? We are assuming that the criteria may be more strict this year in light of COVID-19.

Symptoms of COVID-19 include fever, chills, shortness of breath, fatigue, body aches, sensory loss, diarrhea, congestion and runny nose. Any one of these symptoms would be a reason to keep your child home or send them home. Additionally, anyone with a fever 100.4 or above should be sent home or kept home. School districts should amend their policies according to the CDC’s guideline’s and communicate those changes to parents.

2. Do you think schools need N95 masks? If so, can Inspira help with fit testing?

This is a droplet-transmitted virus so surgical masks in combination with social distancing are going to protect you from droplets, sneezing and coughing. Per CDC guidance, N95 masks would only need to be used during an aerosol generating procedure such as administering a nebulizing treatment. Inspira is able to offer fit testing where needed. Please contact Joe Kauffman at kauffmanj@ihn.org.

3. Do you have any suggestions for families in the event that they need to quarantine a loved one?

Every home is different. You certainly want to limit the individual to one room if possible. Try to create circulation in that room by opening the windows. For meals, try to avoid having the person prepare their own food in the kitchen. Make sure that they use paper or plastic utensils, and that they dispose of them in the same room they are quarantining in. Always have disinfecting wipes available in the bathroom so the quarantined individual can wipe down surfaces as they exit the room. Promote air circulation in that bathroom by running the exhaust fan or opening the window, and try to allow at least a half hour or more before others enter the room. Try to assign one caretaker who is the most healthy- you don't want to assign someone who is high risk. There should be a plastic bag in the room to collect soiled laundry, and the person cleaning it should take the bag immediately to the washer using the proper cleaning solutions and very hot water. As difficult as it may be, everyone in the household must use masks, proper hand washing, hand sanitizing and social distancing to protect themselves and protect their loved ones.

4. How can Inspira help with testing for employees and students?

This varies by situation. The goal would be to utilize a telehealth exam to have our physician evaluate them over a virtual video visit. We would then determine the need to test. If it is determined a test is needed, Inspira offers testing sites across the region that we can refer you to and the order would be given. We would wait for the results prior to releasing the patient to return to school.

5. Will the recording of todays’ presentation be available?

Yes. Recording is available here.

6. Where can we find a list of chemicals or the disinfectants that are effective on COVID-19?

Click here EPA.gov, look for list “N.”

7. Could you please clarify when a nebulizer should not be administered to students in the Nurse's office?

Per CDC guidelines, administration of a nebulizer treatment may be considered an aerosol generating procedure. This would require the use of an N95 mask and proper ventilation. These procedures should be done outside or at the student’s home, and not in the nurse’s office.

8. If a child is sent home with symptoms such as diarrhea, should the school require a physician's note upon return?

Diarrhea could be one of the symptoms for COVID-19. That doesn't mean that a child with diarrhea necessarily has COVID-19, however in this environment right now if a child or a staff member has any of those symptoms it's best that they seek care through their provider. They should get very clear direction from that provider based on their set of symptoms whether they need to be tested or if they are cleared to return to school safely.

9. Our district is suggesting that children have their temperature checks conducted in the classroom. Would this be the appropriate place, or would that put others at risk?

At that point, you have to consider that those children have already entered the building, likely touched multiple surfaces and have been around other people. Our recommendation would be to perform those checks at the building’s point of entry.

10. We plan to do temperature checks immediately when students enter the classroom within 15 minutes of entering the building. For safety reasons, we cannot take temperatures and exclude students from entering the building without an adult to take custody of that child.

New Jersey Department of Education guidance as well as the CDC guidance recommend that temperature screenings be done upon entry into the building. That being said, this comment brings to mind the importance of communication with parents, students and staff members. Try to start with an at home process. If they're self-screening and completing the self-assessment at home, you will have fewer people presenting on site with symptoms. This can be a helpful addition to temperature screenings onsite.

11. If there are no other risk factors present, should the age of the staff member be considered for their safe return to school?

In terms of risk for COVID-19, age alone is not a defining factor. It really is age and a comorbidity or underlying medical condition.

12. If nebulizer treatments need to be performed in the nurse's office, will the office need to be closed for a period of time during and after?

That depends on the amount of air circulation in that office. At Inspira, we shut down the exam room for two hours. Clean the entire surface and let those surfaces stay wet for the appropriate contact time. Whether it’s 2 minutes or 10 minutes, it has to stay wet before you can wipe it.

13. Do you think schools should have isolation rooms to house sick children if feasible?

It is important that once a child has been identified with symptoms of concern, they be removed from other children who may be in the nurse's office. An isolation room may not always be possible, but whenever possible we should further isolate them until they can be picked up by a parent and taken to a provider for further assessment. In any case, wearing a facemask can assist in isolating any potential droplet infection from others.

14. Should physical barriers be placed in the nurse's office?

Without knowing the layout of the room, that is a difficult question. As a general rule, whenever possible, yes. If you have the ability to put physical barriers in between beds it is beneficial.

15. Our district is currently recommending students wear masks on the bus, in the bathrooms and in the hallways. Do you believe this is feasible?

Absolutely. As you saw in the presentation, this cuts back on exposure by at least 50%. It's very important to wear masks throughout the hallways, in the bathrooms and even in the classrooms.

16. Do you feel that staff who are at risk and have multiple risk factors (for example, over 65 with diabetes or heart concerns) should have medical clearance in order to return to work in the fall?

A specific clearance is not necessary. However, we do have more concerns for persons who have comorbidity. It would be pertinent for anyone that has a concern or knows that they have those comorbidities to start a conversation with their health care provider before the start of the school year. Make sure to have a process for continual general management with your provider. It is more important to make sure that you have established that relationship and that he/she understands your needs and has a process in place for periodic checks throughout the school year. We recommend this for anyone of a certain age who has those comorbidities to start with.

17. Is a curtain considered to be a physical barrier?

It can be. Plexiglass is preferred, but a curtain is acceptable in many cases.

18. They're planning to start practices next week. Students will be social distancing in ten-person pods. If there is a positive in a pod, will the entire pod be required to quarantine? What about the coach?

That really depends on the amount of contact between the student who has tested positive and the rest of the players and coach. If it is a sport where there is significant contact, we certainly recommend the other members have a conversation with their providers. They don't necessarily need to quarantine if they're not symptomatic, but I would recommend having a screening process in place daily. That is not to say the entire team needs to quarantine for 14 days for each episode, but we suggest that their providers should be aware of the exposure and provide further instruction.

19. For a school nurse to avoid quarantine with positive contact, is an N95 mask recommended (assuming they're unable to social distance and it's going to be less than ten minutes of contact)?

Unless you're doing an aerosol generating procedure (i.e. nebulizer treatment), a surgical mask should be sufficient. Of course, N95 is always be preferred, but it depends on what you have available to you. Additionally, a full face shield to cover the mask is also recommended.

20. How can our school district request PPE?

Joseph Kauffman or Joe Derella  

21. If it is determined a student or family member or staff are positive, what should the school do about notification of other people and any quarantine issues?

The Department of Education suggests that you have one staff member, preferably the school nurse, dedicated to doing contact tracing within your school. There's an online Johns Hopkins contract tracing course that may be helpful to give you a background with that. NJ Department of Health will be largely doing a lot of the contact tracing outside of the school. Your role in doing contact tracing and notifying will be to identify the close contact of the child who is within six feet of that child for ten minutes or more and identifying the areas of the school that the child was in during the infectious period (48 hours prior to symptom onset). It would be advisable to create a line list including student name, their symptoms, their room number, whether they tested and the test results. As far as notifications, you’ll need some kind of policy in place regarding notification of other students’ families. They should be notified that they may have been exposed to a student who tested positive, but you should NOT give the name of the positive student. DOH needs to be notified of any notices that are sent from the school and of any positive students and staff members. Department of Health has been doing contact tracing throughout this entire pandemic, so they are always a good resource.

22. If a student shows any symptoms should they be sent home?

Certain students have medical conditions that can certainly present symptoms that are on the list that we have referenced for COVID-19. For example, a student with allergies may come to school with nasal congestion or stuffiness. It's really important to take an approach of caution, assuming that it could be COVID-19 and then ruling it out as opposed to the other way around. That is how we’ve managed patients through our Urgent Care and Occupational Health departments at Inspira.

23. Should students be able to use water fountains this year?

We recommend keeping the water fountains off, unless you are able to disinfect after every single use.

24. Will testing be available for uninsured or undocumented students? Do testing sites test young children?

Please reach out to Inspira if you need help testing uninsured or undocumented students. Yes, young children may be tested. The process is no different for an adult than for a child, other than some additional coaching that may be needed during the collection process.

25. I have students in pre-k through sixth grade, approximately 370 students with only one nurse. What would your recommendation be for daily screening?

At Inspira, we have been able to get people from various departments to help where they can. It has worked for us for the past 4 months, and we will continue this way.

26. What would you do if you need to send a sick child home but the parent refuses to pick up or is unable to pick up?

An isolation area is preferred for these situations.

27. We would like to have the parents and staff do a temperature check and symptom check at home prior to attending and send in a report to the school daily. Is that an acceptable way to handle the temperature check?

This can be a second level of protection in addition to screening upon entry, but cannot replace temperature screening upon entry. There is too much room for error, i.e. access to thermometers in the home, faulty temperature reads, etc. It is important to have a screening point upon entry into the school as well.

28. If a student is unable to wear a mask due to a medical condition, would you suggest that student wear a shield?

A shield is meant to protect your eyes and should be used as a supplement to a mask. It is open on the bottom and on the sides, so it is not sufficient protection by itself.

29. Is viral conjunctivitis considered a possible symptom of COVID-19? Should students and staff be excluded from school for 72 hours from any symptom of COVID-19? Or only for fever?

There have been cases where patients that have subsequently been tested positive for COVID-19 have presented with symptoms that were presumed to be viral conjunctivitis. The two are not necessarily synonymous. If a staff member or student presents with that symptom, and we’re not certain that it is viral conjunctivitis and/or if there are other symptoms that may be suggestive of COVID-19, then yes they should be sent through the process for further evaluation.

30. Do you have any resources for families who do not have access to thermometers?

KinsaFluency program offers free thermometers to families of elementary school students within a district that has applied and been accepted. If you are unsuccessful with that resource, please contact Joe Kauffman to see if Inspira can assist at kauffmanj@ihn.org.

31. If a child or staff member is determined to be COVID-19 positive who within the school must be quarantined?

The student who is positive will be required to quarantine. The Department of Health will be getting in contact with that student and their family. The Department of Health will then want to know who was in close contact with that student (those within 6ft for more than 10 minutes). This is where having a line list will be helpful. The Department of Health will want to know that information and will give guidance regarding any kind of quarantine and symptoms. Anyone who has come in contact with this child will want to monitor for symptoms.

32. If a school sends a suspected student home, is there any notification required to the Department of Health at that point?

I do not believe so. Not unless they test positive.

33. Are air purifiers recommended for the nurse's office?

I don't necessarily know if an air purifier is recommended. I haven't read anything about that. What we're looking at is the air exchanges in that room, which will depend on the building.

34. Should we require a doctor's note prior to return from school from a child sent home with presumptive COVID-19 symptoms before they return? Or do we automatically exclude them for 72 hours? Are we able to request a negative test result documentation prior to reentry?

Each individual District will need to set their own requirements for the return to school process. At a minimum, if the student is sent home with suspected Covid-19 symptoms a doctor’s note should be presented as evidence the child is safe to return to school.

35. What defines an exposure?

Within six feet for more than ten minutes with or without a mask.

36. If a staff member is with a student who is special needs, and they will not be able to maintain a 6 ft distance, should they use an N95 mask? They may be in each other’s close space for 4 hours or more.

Per CDC guidelines, this virus is transmitted via droplets, which would require a surgical mask. The addition of a full face shield can provide additional protection.

37. Are temperature checks on arrival proven to have real reliability?

Inspira is currently checking temperatures on arrival at all facilities. Surface temperature screening is not as accurate as an oral temperature, but it has proven to be an effective screening tool. In our facilities, anyone who scans a surface temperature above 100 degrees F is verified with an oral temperature. If still found to be above 100 degrees F that individual is not permitted entry. With the summer heat, we are allowing someone who screens high to sit for a few minutes and acclimate to the indoor climate before being re-screened.

38. Do you have sterilization for N95 masks?

No. We do not have an internal means to sterilize or otherwise decontaminate N95 respirators.

39. How should a school handle a difference between evaluating physicians vs the school physician and policy? There is often no standardization in the community.

You should follow your school physician’s policy. Doing this takes into consideration your district’s requirements as you want them understood. If you are having difficulty with getting consensus between an evaluating physician and the school physician, we are offering to help facilitate that conversation with those key stakeholders.

40. The Health Department stated temperature checks are not required to be performed at school. If a yes & no questionnaire is filled out daily by parents and staff prior to entering school, would this be acceptable as a screening along with visual assessment of student/staff upon entry?

As a district you will set the policy as to what your requirements are for entering the school. We once again would like to remind you that a requirement is the bar you have to exceed to meet compliance. We are suggesting you exceed compliance and require temperature checks and follow other procedures which have had efficiency in keeping us safe.

41. Screening prior to coming into the building will be a tedious task. Who do you recommend will do this task? We are talking about hundreds of kids and employees. We have 12 + buildings and it will be costly for the infrared screeners. Any suggestions?

This is a challenge. At present we use a combination of staff including security officers, guest services desk staff and other staff who have been reassigned temporarily to assist in that role. We have also limited the number of entrances into our buildings to help focus the screening to specific entry points. In our smaller facilities such as physician practices, the office staff have determined the most effective process to screen people upon entry. We continue to assess how to best employ technology along with actual screeners. Our screeners have identified many ill individuals while entering the building simply by questioning their symptoms that day.

42. Is it suggested that temperature checks be instituted before entering the bus?

This is preferred (if possible) as it would stop the symptomatic student from entering the bus and diminish potential risk for others. School districts will need to work with their transportation providers to develop a plan for how to handle children who screen high and how to ensure their safe return home.

43. Our school is a "receiving school" and some of our kids come from an hour away. We are concerned about needing to send a sick child home at the risk of parents being unwilling or unable to pick up. What would be your recommendation?

We suggest creating an isolation room for symptomatic students. This would allow parents time to pick up their children while mitigating the potential risk for others.

44. Will the rapid test be available for school-aged children as to avoid them missing school longer than necessary? i.e. awaiting results for 4-7 days.

Inspira is currently reviewing several options for a rapid test.

45. Thank you for the answer about isolating a sick kid for the day, but do we send them home on the same bus as the other students at the end of the day?

Symptomatic children should not ride the bus with other healthy children. We recommend isolating the child and having a parent pick up.

46. Students in early childhood centers, would it be ok for them to play with a 2 - 3 ft barrier in between them wearing masks?

There isn’t any CDC guidance on this topic. This would have to follow your school’s policy.

47. I work in a special needs School. Many of our children require tube feedings. What type of PPE do our nurses need to use?

In this case, we recommend wearing mask, gloves, gown and eye protection.

48. If a student is sent home with a runny nose for example upon screening, what should the instructions be for returning to school?

For any child sent home with symptoms related to COVID (fever, dry cough, GI symptoms, etc.), we would recommend that clearance from their physician be obtained before returning to school.

49. The Gloucester County Health Department stated temperature checking was not necessary/not a good indicator. This presentation is great, but much different than the county health- conflicting information.

Our recommendation as part of an overall assessment plan is that temperatures be taken. While you may not be required to do this, our suggestion as a best practice is to develop an assessment/screening inclusive of temperature checks.

50. Are there currently guidelines in place for high-concentration activities such as gym class, bus riding, lunch time?

Guidance is changing constantly. Currently there isn’t any guidance on these activities.

51. If we cannot position students to be away from one another within a 6-foot radius, then students must wear masks. But if we have them wear masks, what can that radius be? A 5-foot radius? A 4-foot radius?

Best practice to prevent the spread of infection is for everyone to be masked and maintain six feet of distance where possible. There is no specific guidance on lessening the distance when masked. Radius is 6 feet unless there is a physical barrier in place such as plexiglass, even with masks.

52. School Nurse Offices are frequently areas of a great amount of traffic with both students and staff. What is your recommendation to reduce this?

Based on the size of your environment you will want to minimize the number of people in a space. Ideally you would want to maintain the six feet of distance with everyone masked, (realizing that the RN will be in closer contact while interacting with the student). Appropriate signage can be posted to advise others to wait outside the room, at appropriate distances delineated by additional signage. For example, floor decals with feet images to indicate where to stand.

53. Will air purifiers with a HEPA filter effectively catch and contain the virus in a classroom setting?

While this may be effective to keep the air clean of other allergens, unfortunately it will not be effective specifically for the coronavirus.

54. Should chorus/choir/band be temporarily discontinued?

There is currently no guidance on this subject from the CDC. Guidelines are constantly changing.

55. We are currently at 0.93% transmission in Cumberland County. Do you know at what rate schools would be closed?

The mandating of school closing has been by executive order from the Governor’s office. The 0.93 transmission number was the State of New Jersey’s number on July 15, 2020. Currently county by county transmission numbers are not available. A rate that is below 1 indicates that the outbreak is subsiding and a rate of above 1 indicates the virus is spreading.

56. Logistically if we are checking temps when students and staff enter the building (to say we don’t want to wait until they are in the classroom), and we are limiting entry points, would you suggest to keep them on the bus and then check them on the bus? If we try and check everyone in the lobby it will cause a large group to gather and a fear that the students won’t distance themselves, they will be lined up outside with will affect their temp.

It would be ideal to stagger groups and keep them on the bus, perhaps letting out one bus at a time to avoid a line outside the school.

57. What if a child doesn’t consent to having a temperature check or having other checks performed—are these checks enforceable in any way?

This question falls back on the school district policy and the enforcement of the policy. The school district attorney should be involved with these types of decisions. Keep in mind, the Governor is allowing parents to have the option for virtual learning if they elect not to follow policy.

58. If we utilize the Inspira telehealth at school for staff and students, how will billing be processed? We do not always have insurance information for students.

Inspira has the ability to bill personal health insurance, and for employees we can direct the bill to the district if the exposure is thought to be work-related.

59. I understand Inspira has offered to fit test school nurses –will this be community service or charge?

If you have medical personnel requiring a fit test and respirator clearance please contact Joe Kauffman at kauffmanj@ihn.org, and he will coordinate the necessary appointment cost free. Additional personnel may be considered on a case by case basis.