This document represents a collaborative effort from The Big 8 Plus Health and Safety Coalition and was created in response to the need for a unified approach in planning for the return to schools in the midst of the COVID-19 pandemic. The key details to consider and the resulting recommendations have been developed based on current information from ODH, CDC and NASN, as well as other applicable research data. This is a fairly comprehensive list and the recommendations represent the best practice guidelines for the safe return to schools for both students and staff. While some guidelines are non-negotiable per ODH directives, it will be up to individual districts as to how they implement these best practice protocols. Please note that this is a fluid document and guidelines may change as prescriptive health orders are updated. Created 6/4/20; Rev 9/1/20.

• Protect the health and safety of students and staff

• Assure the ability to meet directives from ODH and the local department of health for social distancing and mitigation of transmission in order for students and staff to return to education in buildings.

• Schools and districts should have the same requirements and detailed specificity as businesses

• School health experts such as a School Nurse, School Board Physician or other school health provider is an essential member of the district planning team
  

• Physical Distancing:
• Create an area and develop guidelines for a supervised space to separate persons with suspected illness from others
• If 6 feet of social distancing is required, this must apply to all areas and settings including but not limited to:
• Transportation
• Classrooms
• Common areas- halls, entry ways, lunch rooms, restrooms
• Office areas
• Playgrounds
• Gymnasiums and auditoriums
• Face Masks:
• Required for all students and staff
• A medical exemption may apply to some students and staff
• Employees who can’t wear masks should not work in congregate settings

• Hand hygiene
• Sanitizer- readily available to students and staff
• Consider health and fire codes regarding accessibility and storage of hand sanitizer
• Assure accessibility to sinks, soap and paper towels
• Hands should be washed
• Upon entry
• Before eating
• Before boarding the bus at end of day
• After restroom use
• Any time hands are soiled
• Do not rely solely on hand sanitizer, use soap and water in between hand sanitizer use
• Gloves are not recommended unless normally worn for other purposes

• Personal Protective Equipment (PPE)
• Follow OSHA standards
• Employer shall provide PPE
• Nurses, special ed staff and bus aids may require other PPE in addition to masks
• Determine what tasks require extra PPE. For example masks for certain student groups during treatment vs. full time wear for educational interventions where distancing is not possible (Appendix A)

• Absenteeism
• Adopt permissive absenteeism procedures to discourage arriving to school ill
• Staff- establish medical leave procedures to ease ill time burdens
• Student- no awards for perfect attendance

• Students and staff share responsibility for building cleanliness

• Provide staff with access to cleaning products and safety data sheets/directions for use

• Provide appropriate protective gear with training

• Pay special attention to common areas

• Door handles, high touch points

• Sinks

• Water fountains

• Printers/Copiers/Shared technology and equipment

• Phones

• Staff only areas (break rooms, mail room etc)

• Shared spaces

• Recommend cleaning at least every two hours

• Buses

• Spray disinfectant between routes (check product instructions and dry times)

• High touch areas- steering wheels, seat backs

• Supplies- no sharing

• Lockers and cubbies

• No sharing
  
• Consider limiting locker use
  

• Space out locker assignments

• Stagger locker access

• Minimize items brought back and forth from school

• Bus entry and exit- load back to front/unload front to back
  
• Install Plexiglas sneeze guard to protect driver
  
• Monitor student movement and maintain 6 feet distance between students
  

• Consider limiting transportation to certain grade levels
  
• Disinfect between routes
  
• Coordinate procedures with other transportation stakeholders such as parochial, public school and daycare transportation staff
  

• Designated entry and exit doors
• Bathrooms
• Post directions on correct hand-washing procedure
• Maintain ample supplies
• Use Plexiglas between sinks
• Limit/stagger student access

• Fire/Tornado drills

• Tornado drills may not be safe due to distancing challenges

• Legislative backing to change requirements (perform drills according to ability to adapt for social distancing)

• First Aid and emergency medical procedure

• Emergency procedures without PPE are at the risk and discretion of the employee and are not required

• Some procedures may not be able to be performed until EMS arrives

• Senior student requirement for First Aid and CPR should be waived or limited to didactic content

• Adapt schedules to limit class size
  
• Move teachers instead of students when changing classrooms

• Stagger class changes

• One-way hallways
  

• Limit permissions for students leaving class (education of teachers on first aid that could be handled in class)

• Plan bathroom breaks

• Limit locker access during class change

• Adapt water fountains to prevent contamination, for example, retrofit fountains to promote no-touch water bottle fillers
• Provide alternate activities for recess to encourage physical distancing

Unified Arts

• Provide outdoor physical education when possible

• Limit class size

• Equipment and instrument sanitation between use
  
• Music/Theater, choir and band- ensemble performances and practices are not recommended

• In blended online/in-person learning models, consider federal lunch program waiver in order to provide access to food on non-attendance days

• Provide meals in classroom as an alternative to lunch room gatherings

• Contracted services/personnel coming into buildings other than school staff should follow all health and safety measures
  

• Health assessments
• Implement a symptom check and surveillance form
• Temperatures - not recommended as a screening tool for well students/staff
• Evidence does not support fever alone as a good indicator of COVID-19
• Asymptomatic people can spread disease
• Risk of exposure to those measuring temperature
• Inaccuracy of temperature in uncontrolled setting (device used, environmental temperature fluctuation.
• Employees shall self-assess for symptoms before entering buildings
• Parents/Guardians should assess students at home and not send to school with symptoms

• Students and staff who exhibit illness symptoms during the day
• Students/staff with COVID-19 symptoms must go home
• Check temperature at school when exhibiting signs of illness
• Mask and isolate students under supervision to avoid exposing others
• Parents/guardians should pick up ill students within 30 minutes of being notified
• Identify a space to separate those exhibiting symptoms from others (Appendix B)
• Students/staff excluded for virus symptoms will follow state and local health department guidelines and may be out for 10 days or more
• Use surveillance form to keep a record of ill students and staff and to determine when they may return to work or school
• Check with local health department regarding procedures for reporting COVID-19 illness

• Recommend parents report diagnosis to school or district
  
• Local health department must notify schools of students and staff testing positive for COVID-19 (Category A)
  
• Notify local public health of any reported positive cases
• Local health department performs contact tracing
  
• Collaborate with local health department for surveillance tracking (surveillance form available- contact OASN.org)
  
• Returning to school/work after above
• Follow CDC/ODH Local Health Department guidance for system based, test-based and time based re-entry

• Physical distancing procedures to mitigate transmission

• Stagger medication administration times

• Limit volume of students- one student at a time in the health office

• Routine procedures should be performed in the well area of the health office (sick children should be in a separate space)

• Procedures that aerosolize the virus cannot be performed safely in schools, for example

• Nebulizers

• Suctioning- oral and tracheal

• High flow oxygen

• Specialized PPE is required for procedures that require less than 6 foot distance e.g.

• School Nurse assessment of ill and injured students

• CPI holds

• Hand over hand instruction

• Diapering and toileting

• Medical procedure- catheterizations, tube feed, ostomy care, diabetes care

• PT/OT/Speech/Adaptive PE

• Vulnerable student populations: foster care, homeless, mental illness, ACES, Special Education, Medically complex and medically fragile, chronic disease

• Staff with chronic illness or age- contributing health factors
  
• Accommodations for high risk students/staff should be considered on an individual basis in collaboration with the IEP team.
  

• Symptoms of COVID-19
  
• Preventing cross contamination
  
• When to stay home
  
• Social distancing
  
• PPE (how to use, clean, and minimize cross contamination, Appendix C)
  
• Cloth masks
  
• Disposable masks
• Glove use
  
• Other
  
• Safety protocols
  
• Procedures for reporting illness
  
• Building specific mitigation processes
  
• Social Emotional Health for self and for students: assistance and resources
  

• Symptoms of COVID-19
  
• Preventing cross contamination
  
• When to stay home
  
• Social distancing
  
• PPE (how to use, clean, and minimize cross contamination, Appendix C)
  
• Cloth Masks
  
• Disposable masks
  
• Other PPE
• Safety protocols
  
• Building specific mitigation processes
  
• Social Emotional Health for self: assistance and resources
  

• Symptoms of COVID-19
  
• School Processes and Procedures
  
• When to keep your child home
  
• Fever
  
• COVID-19 symptoms
  
• What to do when your child is sick at school
  
• Reporting illnesses
  
• Mask use, cleaning and care
  

ODH consider waivers for

• CPR/AED requirements for students-suspend hands on requirement
• Health Screening deadlines
• Suspend/Extend October deadline for Kindergarten and “New to District Students”
• Suspend/Extend routine screening of other grade levels
• Allow Nursing discretion for screening priorities
• Special Education/504 considerations
• ETR-schedule individual appointments for health screening if schools are closed
• Re-evaluation-consider referral to health care provider for health evaluation

PPE worn prior to COVID: You may see people wearing more PPE than you are wearing to deal with the same student. This depends on the activity they are doing and their risk of exposure to body fluids or to keep an item clean.

Any PPE that was required BEFORE COVID is still required for the reasons you used it before COVID. It is not because of COVID.

PPE required now (because of COVID): Additional PPE required due to COVID is based on risk of exposure to respiratory droplets (the way COVID spreads). So if the activity places the person at increased risk of exposure to “respiratory droplets”, more PPE may be required.

Example:

Before COVID you wore gloves for a clean urinary catheterization for a student to protect your hands from body fluids.

During COVID, you still wear gloves but now also a mask, to catheterize a student (who can wear a mask) to protect your hands from body fluids.

During COVID, you wear gloves, a gown, mask and face shield to catheterize a student who cannot wear a mask or control his oral secretions.

Example:

Before COVID you wore no PPE to give a routine tube feeding.

DURING COVID, you and the student served wear a mask because you are closer than 6 feet for more than 10 minutes.

During COVID, you wear a mask, face shield or goggles, and depending on risk of respiratory secretions from this student perhaps a gown (although other physical barriers are also an option), because the student is unable to wear a mask and you have to be closer than 6 feet for more than 10 minutes.

Schools and N95 masks: Per CDC, NIOSH, and OSHA, in order to be protected by an N95 mask – the wearer must be medically evaluated, fit tested, and trained to properly don and doff the mask annually. Schools are not health care settings, and as such, do NOT have access to the required respiratory programs required for a fit testing program that meets those requirements. Therefore, simply buying an N95 mask and giving it to staff DOES NOT afford them N95 protection. If N95 protection is required for a procedure to be safely performed, it should not be performed in a school.

• Staff or students that present with COVID-19 symptoms while at school should be directed to the designated separation space by the school nurse or person appointed by administration and must wear mask. The nurse/staff should follow infection control guidance from the CDC, Ohio Department of Health, and local public health.
• Parents or guardians of a symptomatic student are to be notified immediately of their child’s status and the student should be picked up as soon as possible.
• The separation space should not be the School Nurse office or health clinic where health services including but not limited to medication administration, diabetes care, evaluation and treatment of ill and injured students are provided for students without COVID-19 symptoms.
• Each school must designate a space to be used to separate staff or students who become ill with a potentially communicable disease.
• At minimum the designated separate space should be clearly labeled and include:
• Limited access so that others do not enter while the ill person is waiting.
• The ability for the ill person to be visually monitored through a window, by cameras or (least desirable) a door cracked open until pick up
• Easy sanitation of room.
• Space to social distance if more than one person is ill with similar symptoms.
• Access to a dedicated bathroom facility, or if not available, use of restroom must be monitored by staff from appropriate social distance, and then immediately sanitized and access denied to others until disinfection procedure is complete.
• Best practice for choosing separate space. All of the above minimum requirements with the addition of any below that you are able to accomplish:
• The separate room is near in proximity to the person who would normally monitor ill students/ staff.
• The door can be closed and still maintain visual monitoring.
• Outside access doors so the person can exit without further contamination of other areas.
• Room has access to dedicated bathroom facility.
• Outside window that can be opened to air room out after use.
• A second separate space, etc., if more than one person is ill with a potentially communicable disease.
• Once the staff/student has vacated the separate space, ventilate well before entering and cleaning.

Deborah Strouse, MEd, MSN, CNP, NCSN, FNP-C

Michele Faehnle, BSN, RN, LSN

Based on limited guidance available from CDC/ NASN/ and collaboration between Columbus City Schools Health Services and Diocese of Columbus. Edited by Big 8 + Health and Safety Coalition.

The Ohio Big 8+ Health and Safety Coalition strongly recommends all Ohio schools

require cloth face coverings (masks) to be worn by everyone who enters the building. Exceptions for individuals can be made per CDC guidance. Face coverings are an additional key step to help slow the spread of COVID-19 when combined with every day preventive actions and social distancing in public settings.

Adapted from Guide to face coverings developed by Cynthia Eghbalnia

To Protect Others

• Wear a face covering that covers your nose and mouth to help protect others in case you’re infected with COVID-19 but don’t have symptoms
• Wear a face covering in public settings when around people who don’t live in your household, especially when it may be difficult for you to stay six feet apart
• Wear a face covering correctly for maximum protection

• In all indoor spaces, including when entering, or waiting outside to enter any school building.
• When riding on public transportation such as buses or ride-sharing in vehicles, or district vehicles
• When working outdoors in situations where social distancing (i.e., maintaining physical distance of at least six feet from other individuals who are not in the same household) cannot be maintained.

• Mask breaks pose increased risk for transmission of COVID-19 and are not recommended.
• Outdoor mask breaks are preferable:
• Mask breaks in the classroom should be rare and infrequent
• Everyone must be seated and 6 feet apart
• Should be a quiet time
• No shouting, yelling or singing when mask is off
• Break should be less than 10 minutes
• Everyone must wash or sanitize hands after replacing mask
• Eating or drinking, if you can maintain 6 feet of physical distance from others.
• Participating in an activity in which the face covering will get wet. For example, when swimming.
• Communicating with someone who is deaf or hard of hearing, or who has a medical condition, disability, or mental health condition that makes communication with that individual while wearing a mask difficult, provided that social distancing is maintained to the extent possible. Face shields or clear face masks are encouraged to be used in these situations.
• Receiving a service—including a dental or medical examination or procedure, or personal care service--that cannot be performed or would be difficult to perform when the individual receiving the service is wearing a face covering.
• Alone, such as when working in an office in an enclosed indoor area, or in a vehicle. In such situations, people should still carry face coverings to be prepared to wear when no longer alone.
• Participating in organized sports where the level of exertion makes wearing a face covering difficult.
• Participating in indoor physical exercise—such as in a gym or fitness center—where the level of exertion makes wearing a face covering difficult, as long as social distancing can be maintained at all times.
• During practices or performances in an indoor space when a face covering cannot be used while playing a musical instrument, provided that social distancing is always maintained.
• Playing outdoors if you can maintain 6 feet of physical distance from others.

The following cloth face covering guidance and photos from CDC (CDC.gov) - updated as of 7/28/2020

• Wash your hands before putting on your face covering
• Handle mask by ties or ear loops
• Put it over your nose and mouth and secure it under your chin
• Try to fit it snugly against the sides of your face
• Don’t touch your mask once it’s in place
• Don’t put the face covering around your neck or up on your forehead

• Untie the strings behind your head or stretch the ear loops
• Handle only by the ear loops or ties
• Fold outside corners together to avoid touching inner mask
• If reusing the mask, store safely such as in a paper bag and placed so one can easily grab with the earloops to reuse (avoid touching the part of the mask you breathe through)
• Be careful not to touch your eyes, nose, and mouth when removing and wash hands immediately after removing

Washing machine

• You can include your face covering with your regular laundry.
• Use regular laundry detergent and the warmest appropriate water setting for the cloth used to make the face covering.

Washing by hand

• CDC recommends preparing a bleach solution by mixing:
• 5 tablespoons (1/3rd cup) household bleach per gallon of room temperature water or
• 4 teaspoons household bleach per quart of room temperature water
• Soak the face covering in the bleach solution for 5 minutes.
• Rinse thoroughly with cool or room temperature water.

See More at CDC.gov:

• Stay at least 6 feet away from others
• Avoid contact with people who are sick
• Wash your hands often, with soap and water, for at least 20 seconds each time
• Use hand sanitizer if soap and water are not available

References

CDC: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html

Minnesota Health Department: https://www.health.state.mn.us/diseases/coronavirus/facecover.html

Additional Resources: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html

Video: How to wear a mask - Chicago News: https://www.nbcchicago.com/top-videos-home/how-to-wear-a-face-mask-properly/2262503/

Deb Aloshen, MEd, BSN, RN, LSN; Director, Health and Nursing Services, Cleveland Metropolitan School District

Ann Cipriani, MEd, BA, RN, LSN, NCSN ; Health Services Coordinator, Toledo Public Schools

Cynthia Eghbalnia, MPH, CIH, CSP: Environmental Health and Safety/WC Administrator, Cincinnati Public Schools

Camilla Giallourakis, MSN, APRN, CNP – AC/PC: Nurse Practitioner, Akron Children's Hospital

Amy Hotler, DNP, RN, LSN; Supervisor Health, Family and Community Services, Columbus City Schools

Joan Hlinomaz, MS, BSN, RN, NCSN: Licensed School Nurse, Kettering City School District, Past President OASN

Megan Hussar: School Health Liaison, Canton City Schools

Rhea Jagodzinski, M.Ed., BSN, RN, LSN: ASP Licensed School Nurse, ESC of Lake Erie West, Toledo

Kate King, DNP, RN, LSN: Director, Health, Family and Community Services, Columbus City Schools

Rachel Klaiber, School Nurse, South East OASN Regional President

Angie Lewis, BSN, RN, LSN, NCSN: School Nurse, South East OASN Regional Rep, Rock Hill School

Rhonda McCloskey, MSN, RN, LSN: Schoool Health Liaison, Canton City Schools

Carol Pennington, MSN, RN, LSN: Manager of Nursing and Health Services, Cleveland Metropolitan School District

Susan Ross:Health Services Outreach Coordinator, Canton City Schools

Mary Schatz, MSN, RN, LSN: Nurse Manager School Health Services of Akron Children's Hospital

Kimberly Stanislo, DNP, APRN-CNP, CPNP-PC, LSN: Clinical Assistant Professor, Ashland University

Deborah L. Strouse, MEd, MSN, CNP, NCSN, FNP-C: Emergency Prepareness Nurse Training Coordinator, Columbus City Schools

Michele Wilmoth, MSN, RN, LSN, NCSN: Director, School Health Services, Akron Children's Hospital

Kelly Wagner, MEd, BSN, RN, NCSN: School Nurse, President Ohio Association of School Nurses, Delaware City Schools