COVID-19 and LTC April 2, 2020 Questions and Answer Session Use - - PowerPoint PPT Presentation

COVID-19 and LTC

April 2, 2020

Guidance and responses were provided based on information known on 4/2/2020 and may become out of date. Guidance is being updated rapidly, so users should look to CDC and NE DHHS guidance for updates.

Questions and Answer Session

Use the QA box in the webinar platform to type a question. Questions will be read aloud by the moderator If your question is not answered during the webinar, please either e-mail it to NE ICAP or call during our office hours to speak with one of our IPs A transcript of the discussion will be made available on the ICAP website Panelists today are:

• Dr. Salman Ashraf, MBBS

salman.ashraf@unmc.edu.

• Dr. Maureen Tierney, MD, MSc Maureen.Tierney@Nebraska.gov.

Kate Tyner, RN, BSN, CIC ltyner@nebraskamed.com. Margaret Drake, MT(ASCP),CIC Margaret.Drake@Nebraska.gov. Teri Fitzgerald RN, BSN, CIC tfitzgerald@nebraskamed.com.

https://icap.nebraskamed.com/covid-19-webinars-and-tools

Lessons learned

• Healthcare worker screening matters
• Healthcare workers with even 1 symptom consistent

with COVID-19 should not work

• Basic infection control matters. Continue to push

hand hygiene. Gloves never replace the need to clean hands.

• Dedicating HCW staff to symptomatic residents may

help limit spread

Initially admitted for non-COVID-19 illness and Still No COVID concerns: Can be admitted back to the Nursing Home (consider a transition unit/holding area for 14 days within the facility) with contact/droplet precautions during observation period (AMDA) A COVID test is not required for acceptance back into facility. However, if a COVID test has been performed, transfer should wait until results are back Had COVID-19 concerns/ symptoms but now ruled out: Can be admitted back to the Nursing Home (consider a transition unit/holding area for 14 days within the facility and keep them in contact/droplet precaution until respiratory symptoms resolves and 14 days have passed) Was COVID-19 positive and are recovering: Will either remain in the acute care hospital or be admitted to designated COVID-19 treatment/recovery centers until no longer infectious and then will be transferred back to the nursing home

Accepting Hospitalized Residents Back to the Nursing Home

https://paltc.org/sites/default/files/COVID%2019%20QA%20Community%20Spread%20 March%2023.pdf

What are the recommendations for nursing homes that are not able to clear a hall or area to be designated as a transition area because they do not have available rooms?

Dedication of a unit or wing is not a requirement to admit a resident back who does not have any reason to be suspected for COVID 19 or has already been ruled out for COVID 19. Those facilities without the capacity of creating such a unit can still admit the resident and actively monitor them daily for fever and respiratory symptoms. However, if the facility has the capacity to implement this additional steps and they want to be extra cautious they can consider it. The exact wording from the CMS guidance is as follows: "Note: Nursing homes should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was/is present. Also, if possible, dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where they remain for 14 days with no symptoms (instead of integrating as usual on short-term rehab floor, or returning to long-stay original room)."

https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf.

If there is a positive COVID19 resident that does not require hospitalization, should full PPE be worn for direct care provided to all residents because some may be infected but still asymptomatic. Is that the recommendation?

• 1. If a resident has tested positive for COVID-19 in a nursing home, the current plan is

to have discussion with that nursing home and resident and the resident may be transferred out of the nursing home to a designated COVID-19 care center.

• 2. We did discuss that there can be a situation where while we are considering

transfer of the COVID -19 positive resident, we may simultaneously be trying to rule

• ut active transmission of COVID-19 within that facility. In that specific situation,

temporarily, healthcare workers may have to use PPE while taking care of everyone in a particular unit, wing or facility. However the key is that it will only happen if there is confirmed case of COVID -19 in a nursing home and an investigation is taking place to make sure there is no evidence of active transmission in the nursing home. In this particular scenario, nursing home will be working together with the local health department in making those decisions. In all other scenarios, PPE use should be in accordance with standard guidance that we are currently using in every day practice.

https://icap.nebraskamed.com/wp-content/uploads/sites/2/2020/03/CDC-NH-COVID- 19-Assessment-Tool-3.19.2020.pdf

NE DHHS: All HCW in LTC should wear a mask for clinical care

http://dhhs.ne.gov/Documents/COVID-19%20Long-Term%20Care%20Facilities.pdf.

PPE Steps you must take

Conduct a physical inventory - every neighborhood, common area, supply closet Immediately take control – under lock and key – of PPE supplies, no matter how well-sourced you feel you are Immediately explain why – – In order to ensure that supplies are available when needed Initiate a system for responsible dispensing – who is on isolation, why; use Omnicell/Pyxis or manual log sheets for record of where inventory goes

Adapted from The NETEC COVID-19 PPE Webinar - Extended use, reuse, and innovative decontamination strategies https://repository.netecweb.org/items/show/861

PPE Steps you must take

Consider a PPE calculator, example: 4 masks per resident bed (if reused per staff member one day only) 8 disposable isolation gowns/floor patient/day Make estimates for the largest number of beds you could possibly have

• ccupied with COVID-19

Plan now for the next phase, communicate what might come next Extended Use Reuse for multiple days Equipment disinfection Cloth and patient gowns as PPE Educate:We are a creative lot, but we do not want people putting themselves in danger (no wiping or soaking masks, do not microwave or bleach them)

Adapted from The NETEC COVID-19 PPE Webinar - Extended use, reuse, and innovative decontamination strategies https://repository.netecweb.org/items/show/861

PPE Steps you must take

Strategize for minimizing entry into resident rooms Telemedicine Tele-everything! Food and nutrition, social work, discharge planning Cluster tasks and meal-times Limit specimen collection times Reduce hospitality and housekeeping events, weekly and PRN linen change Consultant Pharmacist to review MAR’s to cluster meds in sequence (single access)

Adapted from The NETEC COVID-19 PPE Webinar - Extended use, reuse, and innovative decontamination strategies https://repository.netecweb.org/items/show/861

• to assist nursing homes with preparing to care for residents with

COVID-19

• Elements should be assessed through a combination of interviews

with staff and direct observation of practices in the facility

• Per CMS “We expect facilities to use this…to perform voluntary

self- assessment of their ability to prevent the transmission of COVID-19.”

• This document may be requested by surveyors, if an onsite

investigation takes place.

Nursing Home Infection Prevention Assessment Tool for COVID-19 (3/19/2020)

https://icap.nebraskamed.com/wp-content/uploads/sites/2/2020/03/CDC-NH- COVID-19-Assessment-Tool-3.19.2020.pdf And https://www.cms.gov/files/document/qso-20-20-allpdf.pdf-0 Prioritization of Survey Activities, CMS 3/23/2020

Frequently Asked Questions Regarding COVID-19 and PALTC

When COVID-19 Is Currently In Your Regional Community (i.e., Community Spread) https://paltc.org/sites/default/files/COVID%2019%20 QA%20Community%20Spread%20March%2023.pdf.

This is the source document for guidance on slides 14-22, 26 & 27

We have the first positive COVID-19 case in

• PALTC. How do we approach this?

• Minimize spread of infection to other residents and staff:
• All residents on the unit should be carefully screened for common and

uncommon symptoms of COVID-19.

• If a resident is diagnosed with COVID-19 on a unit, do testing of other

symptomatic residents on the affected unit.

• If there are multiple cases positive on the unit for COVID-19, cohort patients

to one unit, hall or wing.

• No movement of staff between units.
• No sharing of equipment, including medicine carts and wound care supplies,

between the units.

• Practice strict adherence to infection control practices-contact, droplet and

eye protection

• Rehabilitation services should be suspended for the COVID-19 unit.
• Facilities should only cohort COVID-19 confirmed residents and not cohort

suspected cases on respiratory isolation pending testing results (but se contact and droplet with eye protection pending results)

• Patients who are COVID-19 positive (and both negative for flu or other

respiratory viruses) can be in the same room.

Facility-specific goal:

• Close monitoring and supportive care
• Nursing home residents who are COVID-19 positive can deteriorate very
• quickly. These patients need a higher level of nursing and clinical care than

typical nursing home residents.

• Goals of care should be reestablished, including the decision to hospitalize

and placement on ventilator/life support, in an informed discussion in light of COVID 19.

• Decision to treat in place should be based on care goals and medical

necessity.

• COVID 19 patients should be frequently monitored with pulse oximetry.
• Staff should be vigilant for signs that signal quick deterioration; this

includes respiratory distress. This could present as a drop in the patient’s

• xygen saturation being the only clue.
• Palliative care should be considered as appropriate.

COVID-19 patient-specific goal:

If there is a new diagnosis of COVID-19 in the LTC facility:

• Immediately notify your local and state health department for further

guidance.

• We recommend that facilities follow standard practices during a respiratory

illness outbreak as they would for an influenza outbreak.

• A decision to stop new admissions to the facility should be made in

conjunction with the local and state health department.

• Facilities should have a communication plan with families. Communications

may be provided through a variety of means such as phone call, letter, email, website postings, etc.

COVID-19 facility actions:

These symptoms could be caused by several different respiratory viral illnesses including influenza, respiratory syncytial virus (RSV), and COVID-19.

• Isolate the resident and initiate testing for influenza and other potential

respiratory viruses but these are not required any longer. If initial tests are negative or if the provider has a high suspicion, evaluate the need for SARS- CoV-2 testing in consultation with your local and/or state public health department.. The decision to test for COVID-19 is based on clinician’s judgment as per the Criteria for evaluating and testing persons for COVID-19 updated on March 4, 2020.

• Use the COVID-19 Persons under Investigation and Care Report Form to

collect information requested by the CDC aRefer to the CDC guidance for reporting a person under investigation (PUI) or confirmed case: Reporting a PUI or Confirmed Case. Call the LHD, they can help.

• Assess the resident carefully for severity of illness and need for hospitalization

in conjunction with goals of care.

• Implement standard, contact, droplet precaution and eye protection. Use an

N-95 or higher-level respirator for aerosol generating procedures.

One of our residents has a fever, cough, and shortness of breath. What should we do?

• If the ill resident is confirmed to have COVID-19,

any roommates or other contacts should be placed under surveillance for development of respiratory illness. If moved, the roommate should be placed in a private room to minimize

• ngoing exposure to other residents and staff.

Management of other contacts should be coordinated with the local or state health department. What about the roommate and other contacts?

http://dhhs.ne.gov/CHPM%20Documents/contacts.pdf

If the ill resident is confirmed to have COVID-19, the exposed and be referred to occupational health for assessment of the degree of exposure and the need to furlough. In many nursing homes, the function of occupational health is performed by infection

• preventionist. We recommend that nursing facilities create interim

small teams who perform the occupational health function. This is in anticipation of increased need for such function, to cover all shifts and to allow IP to perform other functions related to Infection control and prevention. LHD staff and DHHS will j help advise on who might need to be quarantined or monitored. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk- assesment-hcp.html.

What about the healthcare workers?

If two or more residents have acute respiratory symptoms suggestive of influenza, RSV or COVID-19, we suggest implementing facility-wide precautions… Until there is a confirmed diagnosis for the involved residents, they should not be cohorted. Once it is known that there are two individuals with the same infection, then those individuals may be cohorted if necessary. We recommend, if possible, dedicating one hallway or unit to the care of individuals with respiratory viral syndromes. There should be consistent staffing

• f this unit as well (i.e., the same staff members work in this area, including staff

that works on evening and night shift). If other staff need to come into this area to perform specialized care, such as hospice care, this should be the last group of residents to receive care before that person goes home. Prioritize the use of PPE in this area of the building. If possible several nursing functions (e.g., wound care) should be performed by the assigned staff to limit staff caring across the facility. If this is done consideration should be given to the increased intensity of work during staff assignments

We have two residents with new onset respiratory

• symptoms. Should they be in the same room?

The CDC has guidelines for the collection of clinical specimens.

• https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-

clinical-specimens.html. There are short videos for nasopharyngeal specimen collection on the AMDA website (under Other Resources). Contact your state or local health department to determine where to send the test. The CDC has contact information and further details: https://www.cdc.gov/coronavirus/2019- ncov/php/reporting-pui.html. Some local labs may be able to perform Flu/RSV testing and then send the same material off to testing for COVID-19. Contact your lab to develop strategies to conserve swabs and viral transport media.

How do we collect a sample to test for COVID-19, and where do we send it?

N-95 Respirator Strategy: identify 3-5 people for wear

• 1. Does the long term care already have some staff fit tested (such as, from

previous positions/experiences)? If so compile a list of those HCW to use for collection of nasopharyngeal specimens (for COVID testing and rule out) and aerosolized treatments (such as nebulizers).

• 2. If no HCW identified by #1, contact community resource (partner hospital,

contractor, or local health department) to identify a way to fit test 4-5 HCW/LTC facility. Use these HCW for collection of nasopharyngeal specimens (for COVID testing and rule out) and aerosolized treatments (such as nebulizers). Most likely, your staff will have to report to an alternate location to do this, as it is not likely that the service will come to the LTC facility (due to increased demand).

• 3. If cannot do 1 or 2 above, once supply becomes available (through local

health department?) identify several HCW to attempt the seal check using the N95 that have been provided. Use the HCW that successfully get a seal check for collection of nasopharyngeal specimens (for COVID testing and rule

• ut) and aerosolized treatments (such as nebulizers).
• 4. If no N95 are available, use surgical face mask and a face shield or goggles

(face shield is preferred). *in all instances, the staff identified for use of N95 should be those with licensure/ credentials appropriate for nasopharyngeal specimen collection and administration of nebulizer therapies.

https://www.youtube.com/watch?v=pGXiUyAoEd8.

User seal check for N95 respirators

https://www.utmb.edu/covid-19/health-care- workers/collection-of-nasopharyngeal-specimens-with-the- swab-technique.

Collecting a nasopharyngeal specimen

• If a staff member was exposed to individuals with known or

suspected COVID-19, the staff member needs to immediately alert the DON or designated staff, regularly monitor themselves for fever and symptoms of respiratory infection, and not report to work when ill. These individuals should not continue to participate in direct resident care until further details about the exposure are known. Asymptomatic staff members with a COVID-19 exposure should be assessed by a designated employee, either the DON or the infection preventionist (IP), and the LHD as per CDC guidance. And Based on these guidelines, if the exposed staff is allowed to work they should wear a facemask while at work and practice hand hygiene and monitor for respiratory symptoms and fever prior to coming to work.

What should we do when a staff member is exposed to a resident with possible COVID-19.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

Any ill staff should not be allowed to provide patient care. Sick leave policies should be nonpunitive, flexible and consist with public health

• guidance. Encourage the Human Resources Department to review and

consider revising policies given current circumstances. Any staff that develops signs and symptoms of a respiratory infection while

• n the job should:
• Immediately stop work, put on a facemask, and self-isolate at home
• Inform the facility’s infection preventionist of contacts with

individuals, equipment, and locations

• Contact and follow the local health department recommendations

for next steps (e.g., testing). Refer to the CDC guidance for exposures that might warrant restricting asymptomatic healthcare personnel from reporting to work.

What if a staff member develops respiratory symptoms?

Time-since-illness-onset and time-since-recovery strategy (non-test-based strategy)* Persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions:

• At least 3 days (72 hours) have passed since recovery defined as resolution of

fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,

• At least 7 days have passed since symptoms first appeared.
• (UNMC may recommend longer periods-10/5)
• Test based Strategy
• Negative results of an FDA Emergency Use Authorized molecular assay for

COVID-19 from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart** (total of two negative specimens).

Discontinuation of Home Isolation

Individuals with laboratory-confirmed COVID-19 who have not had any symptoms may discontinue home isolation when at least 7 days have passed since the date of their first positive COVID-19 diagnostic test and have had no subsequent illness. What about family members quarantined with a COVID-+ family member, when does their quarantine end-14 days after their family member is either documented as being COVID-19 – or 14 days from when the loved one wold have been eligible to discontinue isolation Footnote from CDC *This recommendation will prevent most, but may not prevent all instances of secondary spread. The risk of transmission after recovery, is likely very substantially less than that during illness.

Discontinuation of Isolation

• 1. Wear a facemask until all symptoms are resolved or 14

days after symptom onset whichever is longer

• 2. Be restricted from contact with severely

immunocompromised patients

• 3. Adhere to HH and respiratory etiquette as

recommended for control of COVID-19 in the interim guidance

• 4. Self monitor for worsening or recurrence of symptoms

and notify employee health/occupational health/supervisor if occurs

After cleared to return to work

https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/hcp-return- work.html

Assessment Tool for COVID-19 readiness: https://icap.nebraskamed.com/wp-content/uploads/sites/2/2020/03/CDC- NH-COVID-19-Assessment-Tool-3.19.2020.pdf. AMDA Resident screening form https://paltc.org/sites/default/files/Active%20Screeningv1_03.16.20.pdf Facility Exposure Management https://paltc.org/sites/default/files/COVID- 19%20Facility%20Exposure%20Management- %20COVID19%20PositiveV3.pdf. Strategies for optimizing PPE https://www.cdc.gov/coronavirus/2019- ncov/hcp/ppe-strategy/index.html The NETEC COVID-19 PPE Webinar - Extended use, reuse, and innovative decontamination strategies https://repository.netecweb.org/items/show/861

Resources

Infection Prevention and Control Office Hours

Monday – Friday 7:30 AM – 9:30 AM Central Time 2:00 PM -4:00 PM Central Time Call 402-552-2881

Weekly COVID-19 LTC Webinars

DHHS in association with ICAP will continue to host weekly webinars specific to LTCF in the state of Nebraska. The webinars will continue to address situation updates and essential information on COVID-19. Link to weekly COVID-19 LTC webinar invite https://icap.nebraskamed.com/covid-19-webinar-invite-ltcf/ Link to past webinars and recordings https://icap.nebraskamed.com/covid-19-webinars/

CDC: Cleaning and Disinfecting your Facility (including soft surfaces)

CDC Resources and Guidance https://www.cdc.gov/coronavirus/2019- ncov/prepare/disinfecting-building-facility.html

Additional Resources: Universal Mask Use

Universal Mask Policy and FAQ, Nebraska Medicine https://www.nebraskamed.com/sites/default/files/documents/covid-19/surgical-mask- policy-and-faq-nebraska-med.pdf Proper Donning & Doffing of Procedural and Surgical Masks- Nebraska Medicine (Video) https://www.youtube.com/watch?v=z-5RYKLYvaw COVID-19: Conserving PPE Emory University School of Medicine (posters and videos) https://med.emory.edu/departments/medicine/divisions/infectious-diseases/serious- communicable-diseases-program/covid-19-resources/conserving-ppe.html

Responses were provided based on information known on 4/2/2020 and may become out of date. Guidance is being updated rapidly, so users should look to CDC and NE DHHS guidance for updates. Nebraska DHHS HAI-AR and Nebraska ICAP Long-term Care Facility Webinar on COVID-19 4/2/2020

• 1. As a SNF accepting a new admission from a hospital with a negative COVID-19 test, what

precautions do you recommend we take? Keep them isolated from our at risk residents? The recommendations are now that you do and keep them isolated. If it’s possible to create a wing or even part of a hallway, it will be easy to distinguish folks who came back from the hospital, they have been ruled out as they had a negative COVID test and keep them separated from other individuals.

• 2. What are your recommendations for admissions to long term care facilities if the patient has

been tested and test is negative and no symptoms are present, do they need to be isolated at the long term care facility and if so, for how long? The recommendation is 14 days. If you can, it would be better to have a sort of transition unit for people coming from the hospital who tested negative. Because, for people coming from sort

• f that environment, it is probably better to have them in the transitional area, not absolutely
• necessary. It is prudent to take some extra precautions.
• 3. Did I hear correctly - if any staff person has any symptoms - a cough or runny nose or elevated

temp - ANY symptom at all, they should not work? Yes, if there is any kind of respiratory illness like fever, shortness of breath, sore throat, and

• cough. For healthcare workers there is prioritization of testing. They can call their PCP and get

testing arranged and get the tests done. If the test results are negative, they can continue to work while wearing a mask.

• 4. Can you clarify all HCW that should wear masks are every department including dietary,

maintenance, housekeeping, office staff or just clinical staff such as nursing staff and physicians? Any time when there is clinical interaction. In other words, folks who have exposure to patients. In this kind of setting, it might be useful to have meals delivered outside of the patient’s room and then the person who is carrying for the folks go in, try and pool tasks, so that why you don’t have to have dietary wearing masks necessarily.

• 5. How can we plan for use when we cannot even obtain PPE?

Local health departments have been given the urging right now because of this directive to get more PPE to LTC. Utilizing the PPE request form that your local health department has and contacting them again will be helpful. There should be more PPE for sure coming to LTC.

• 6. What is your recommendation for cleaning a room of an ALF/LTC for a positive COVID

especially with carpet and personal items? You need to clean the room, high touch surfaces especially. We haven’t seen any special directive on carpet. The positive patient is definitely going to have droplets that could be landing

• n surfaces in the room. You will need to use an appropriate disinfecting agent that the CDC has

a link to the EPA list of appropriate disinfectants. You will need to clean it especially adhering to the wet time of the disinfectant and make sure you hit it on all the high touch surfaces. Please follow the guidance on using disinfectant properly. For daily cleaning, the recommendations for COVID positive patients is that the daily high touch surface cleaning actually be done by people who are going to be in the room already, so it’s usually not the role of many other people who are doing that but to not have environmental cleaning coming into COVID positive rooms on a daily basis, but more on a terminal clean basis. There are recommendations for terminal clean and what environmental cleaning people should be wearing for those terminal clean on the slide

• set. Do not vacuum a carpet in a COVID positive room while there are people inside the room to

prevent aerosolization. Link to cleaning and disinfecting your facility—CDC guidance https://www.cdc.gov/coronavirus/2019-ncov/prepare/disinfecting-building-facility.html

• 7. You are saying for all healthcare workers to wear surgical masks; however in writing it only

states when possible - can you come out with a stronger stance in writing? NE-DHHS website says “When possible, employees should wear a mask when working with patients”. If you have the capacity to wear masks that is if you have masks in your facility they need to be worn when seeing patients. If there is any director of any LTCF refusing to support this directive, please let Dr. Maureen Tierney know about it. Nebraska medicine has very good guidance on how to implement universal masking. Link to Nebraska DHHS Guidance for Novel Coronavirus: LTCF (including assisted living, nursing homes, and independent living, etc.) http://dhhs.ne.gov/Documents/COVID-19%20Long-Term%20Care%20Facilities.pdf Universal Mask Policy and FAQ, Nebraska Medicine https://www.nebraskamed.com/sites/default/files/documents/covid-19/surgical-mask-policy- and-faq-nebraska-med.pdf