Facial Masking Policy

Notice of Facial Masking Policy

To ensure the safety of our patients, visitors, and care team members masks will be required under special circumstances, such as risk for infectious disease transmission.  This policy applied to team members, visitors and patients, two years of age and older.

PPE recommendations will be reassessed in accordance with national and state recommendations if there is a community or regional outbreak.   TGH may also implement additional PPE recommendations if the Infection Prevention Department identifies an increase in occurrence of illness in a specific location over a particular period of time.   These events would be managed by Infection Prevention, in conjunction with medical and hospital leadership.

This policy does not include PPE (particulate or chemical cartridge elastomeric respirators) worn for chemical or physical hazards.

 

Definitions 

• PATIENTS: Any person receiving treatment, care or other services at a TGH location
• VISITORS: Any person visiting any of the TGH locations that is not a patient or team member
• TEAM MEMBERS: Any person that is TGH employee, provider, volunteer, student, resident, independent contractor, vendor, or any other person who provides care, treatment or other services, to TGH patients at a TGH location.
• MASK: A facial covering that covers the mouth and nose that meets TGH and ASTM F3502 standards including procedural masks, surgical masks or NIOSH approved respirators. Facial coverings that do not meet these standards (examples include cloth masks, bandanas, masks with exhalation valves, etc…) are not acceptable.
• COMMON AREA: an area where patients are not treated, diagnosed, or examined.  Open bay settings may be classified as a common area.

 

Procedure

A. Patients:

Patients are required to wear a mask if they are in a common area and:

• Are experiencing signs or symptoms of an infectious disease that may be transmitted through droplets or aerosols (upper respiratory infections, chicken pox, meningitis, TB, etc…). Symptoms include but are not limited to coughing, runny nose, fever, stiff neck, new rash, etc…

      OR

• have a diagnosis of an infectious disease transmitted through droplets or aerosols.

 

B. Visitors:

Visitors should avoid entering the clinical facility if they are sick, unless absolutely necessary.  If entering the facility visitors will be required to wear a mask if they:

• Are experiencing signs or symptoms of an infectious disease that may be transmitted through droplets or aerosols (upper respiratory infections, chicken pox, meningitis, TB, etc…). Symptoms include but are not limited to coughing, runny nose, fever, stiff neck, new rash, etc…)

• Have a diagnosis of a confirmed or suspected infectious disease that is transmitted through droplets or aerosol.

• Are accompanying a patient in a sterile area or where sterile procedures are being performed.
• Are visiting a patient that is experiencing signs or symptoms of an infectious disease that may be transmitted through droplets or aerosols.
• Are visiting a patient with a suspected or confirmed infectious disease that is transmitted through droplet or aerosols. Are visiting a patient whose treating health care practitioner has diagnosed the patient with or confirmed a condition affecting the immune system in a manner which is known to increase risk of transmission of an infection from employees without signs or symptoms of infection to a patient and whose treating practitioner has determined that the use of facial coverings is necessary for the patient’s safety.

 

C. Team Members:

Team members should avoid entering the facility if they are sick.

1. Team members will be required to wear a mask or NIOSH approved respirator if they are:

• With a patient on droplet or airborne isolation;
• Engaging in non-clinical potentially hazardous activities that require facial coverings to prevent physical injury or harm in accordance with industry standards;
• Entering a designated sterile location;
• Caring for a patient or present while a sterile procedure (including aseptic procedures and surgeries) is being performed;
• Are caring for a patient, whose treating health care practitioner has diagnosed the patient with or confirmed a condition affecting the immune system in a manner which is known to increase risk of transmission of an infection from employees without signs or symptoms of infection to a patient and whose treating practitioner has determined that the use of facial coverings is necessary for the patient’s safety;
• Caring for a patient with an infectious disease deemed transmissible, you may be asked to wear a mask, gown and/or gloves;
• Experiencing signs or symptoms of an infectious disease that may be transmitted through droplets or aerosols (upper respiratory infections, chicken pox, meningitis, TB, etc…). Symptoms include but are not limited to coughing, runny nose, fever, stiff neck, new rash, etc…);
• Suspected or confirmed to have a diagnosis of an infectious disease transmitted through droplets or aerosols. Team members may be asked to return to work at a later date, as advised by Team Member Health. Masks may be required following return to work after improvement of symptoms to minimize risk of transmission when it is not possible for laboratory confirmation of resolution of infectivity;
• Working in or on a unit or department where an outbreak of a respiratory pathogen has been identified, team members may be asked to wear a mask to protect our patients, visitors and fellow team members until the outbreak has ended (as managed by Infection Prevention);
• Experiencing a significant exposure risk as advised by Team Member Health, team members may be asked to wear a mask NIOSH approved respirator;
• At higher risk of experiencing and transmitting seasonal respiratory viruses due to being unvaccinated with annual vaccine.

 

D. Provisions for Patients Who Opt Out:

If an alternative method of infection prevention is requested, please contact Infection Prevention Department to determine a suitable alternative.  Patients or visitors may request to opt out and may do so if an alternative method of infection control is available. Patients and Visitors may not opt out if no alternative method of infection control is available. Patient may not opt-out of any masking requirements in the following circumstances:

• A Patient has been diagnosed or is exhibiting signs or symptoms of an infectious disease that can be spread through droplet or airborne transmission; or
• Opting out has been identified by a provider as being medically or programmatically contraindicated for medical, safety or programmatic issues; or
• Opting-out would otherwise infringe on the rights and would risk the safety or health of other patients, individuals or staff/employees of Hospital.

 

D. Provisions for Visitors Who Opt Out: 

If there are no alternative methods of infection prevention, a visitor may not opt-out of any masking requirements in the following circumstances:

• The visitor has been diagnosed or is exhibiting signs or symptoms of an infectious disease that can be spread through droplet or airborne transmission;
• Opting-out would otherwise infringe on the rights and would risk the safety or health of other patients, individuals or staff/employees of Hospital.
• There are no alternative methods of infection prevention.

 

E. Provisions for Team Members Who Opt Out:

• Team members may not opt out of masking criteria listed in Section C (a).
• TGH reserves the right to consider other exclusions from the opt-out provisions in order to comply with applicable state and federal laws, rules, requirements and regulations.
• If a team member is electing to opt out, please contact Team Member Health or Infection Prevention to be discussed on a case-by-case basis.

 

References

• Stat. § 408.824 (SB 252)
• Fla. Stat. § 381.026 (Florida Patient Bill of Rights)
• Fla. Admin. Code 59AER23-1 (Definitions Rule)
• Fla. Admin. Code 59AER23-2 (Standards Rule)
• Centers for Disease Control and Prevention, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Setting: Infection Control | CDC
• OSHA Rules
  • Bloodborne Pathogens (29 CFR 1910.1030)
  • Personal Protective Equipment (29 CFR 1910. 132)
  • Respiratory Protection (29 CFR 1910. 134)
• Conditions of Participation Infection Control Worksheet – See tag 1.A.3. – “The Infection Control Officer(s) can provide evidence that the hospital has developed general infection control policies and procedures that are based on nationally recognized guidelines and applicable state and federal law.”
• Joint Commission
  • Hospital Respiratory Protection: Resources and Projects | The Joint Commission
  • Hospital Respiratory Protection Program Toolkit (osha.gov)
• CDC Prevention strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations.
• Barrier Face Covering and Surgical/Medical Mask Standards
  • ASTM F2100-23, Standard Specification for Performance of Materials Used In Medical Face Masks
  • ASTM F3502-23a, Standard Specification for Barrier Face Coverings
• Occupational Respiratory Protection (applicable to employees)
  • Occupational Safety and Health Administration (OSHA), 29 CFR 1910.134

Title: Facial Masking
Original Issue Date:  July 26, 2023
Last Review Date:  July 26, 2023
Last Revision Date:  July 26, 2023
Originating Department: Infection Prevention
Approved by: Laura Haubner, MD, SVP, Chief Quality Officer
133535594.1

 

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