Nebraska DHHS HAI Team, Nebraska Medicine, and The University of - - PowerPoint PPT Presentation
Presented in collaboration with Nebraska ICAP, Nebraska DHHS HAI Team, Nebraska Medicine, and The University of Nebraska Medical Center Moderated by Mounica Soma Guidance and responses were provided based on information known on 8/25/2020 and
Presented in collaboration with Nebraska ICAP, Nebraska DHHS HAI Team, Nebraska Medicine, and The University of Nebraska Medical Center Moderated by Mounica Soma Guidance and responses were provided based
become out of date. Guidance is being updated rapidly, so users should look to CDC and jurisdictional guidance for updates.
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:
nada.Fadul@unmc.edu 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 Sarah Stream, MPH, CDA sstream@nebraskamed.com
https://icap.nebraskamed.com/coronavirus/ https://icap.nebraskamed.com/covid-19-webinars/
and Ne Hospital Association as a tool to help with post acute-care facility transfer of patients during Covid-19
symptoms and discontinuation of isolation guidance
the Covid-19 Resources
Scenario: A primary care patient is a resident in a LTCF. The facility reports that the resident was exposed to COVID-19 by a positive staff member. Today is Tues. and the reported exposure occurred the previous Wed. and Thurs. The patient is asymptomatic. The facility would like to know next steps.
Scenario: A primary care patient is a resident in a LTCF. The facility reports that the resident was exposed to COVID-19 by a positive staff member. Today is Tues. and the reported exposure occurred the previous Wed. and Thurs. The patient is asymptomatic. Testing is indicated. Choose the method--
Symptoms Hospitalized Chinese (N=140) US HCW (N=9282) Fever, cough, or SOB NA 92% Cough 80% 78% Fever 87% 68% SOB 38% 41% Myalgia 21% 66% Headache 8% 65% Sore Throat 5% 38% Diarrhea, Nausea/vomiting 2%/1% 32%/20% Loss of Smell or Taste NA 16% Runny Nose 4% 12%
Huang, C, et al. Lancet. 2020;395:497. Chen, N, et al. Lancet. 2020;395:507-13.
CXR insensitive for diagnosis Typical CT findings should prompt testing CT changes occur within 0-4 days after symptoms and peak around day 6-13 with improvement around day 14 CT progression: – Initial phase bilateral multilobar ground-glass opacification (GGO) with peripheral or posterior distribution, mainly in the lower lobes – Progression GGO into multifocal consolidative opacities, septal thickening, and development of a crazy paving pattern
Salehi S, et al. AJR. 2020;215:1-7 Simpson S, et al. Radiology: CT Imaging, 2020;2 https://doi.org/10.1148/ryct.2020200152
– Amplify RNA of the virus – Use Case = Diagnosis of acute infection
– Detect viral antigens – Don’t amplify – Use Case = Rapid diagnosis
– Detect antibodies made by the immune system – Detected after acute infection develops – Use Case = defining previous infection, population prevalence
– Grow the virus – Slow and not widely available – Use Case = Defining infectivity period
What we know – Robust and rapid serologic response
– IgM rises within 5-7 days symptom
– Seropositivity at 14 days: IgM (88- 94%), IgG (94-100%) NM Serology Performance (IgG assay) – 0-5 days illness onset – 25% agreement – 6-14 days – 90% agreement – >15 days – 94.5% agreement – Specificity 99.3% – 16/214 positive (7.8%)
To, K, et al. Lancet. 2020 https://doi.org/10.1016/S1473-3099(20)30196-1
Serologic Response in Severe and Mild COVID-19 Infection (N=23)
What we don’t know Utility in diagnosing acute infection?
– IgG poor early – IgM assay cross-reactivity
Performance in mild disease? Performance in asymptomatic? The false positive question Is a positive serology protective against subsequent infection and for how long?
Rapid PCR Test Rapid Antigen Test Intended Use Detect Current Infection Detect Current Infection Analyte Detected Viral RNA Viral Protein, Antigen Specimen Types NP swab, Sputum, Saliva Nasal Swab Sensitivity High Moderate Specificity High High Test Complexity Varies Relatively easy use Authorized for Point-of-care testing Most are not Yes Turnaround Time 15 min. > 2 days
Cost per Test Moderate Low
https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests- guidelines.html
– Understand what is being reported at your facility
– E- and ORF1a- not detected = COVID Not Detected – E- and ORF1a- detected = COVID Detected – Only E- detected = Presumptive positive
– Invalid – test didn’t work Repeat swab
– E- not detected = Not Detected – E- detected Will be retested on next run for both E- and N-
https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests- guidelines.html
https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests- guidelines.html
Diagnostic Testing
current infection
person with symptoms or after recent exposure Screening Testing
asymptomatic infections
prevent transmission within an asymptomatic group Surveillance Testing
population level infection
de-identified individuals for data gathering and analysis on a large scale
https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests- guidelines.html
Diagnostic Screening Surveillance Symptomatic or Known Exposure Yes No N/A Asymptomatic w/out Suspected Exposure No Yes N/A Determine Incidence and Prevalence in Community N/A N/A Yes Results Returned to Individual Yes Yes No Results Returned to Requesting Institution No No Yes Results Reported to Public Health Yes Yes If Requested Testing performed in CILA-Certified Lab Yes Yes Yes Testing performed in Non-CILA-Certified Lab No No Yes Test System Must be FDA Authorized Yes Yes NO
https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests- guidelines.html
2020
https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration- isolation.html#:~:text=Recommendations,- Duration%20of%20isolation&text=For%20most%20persons%20with%20COVID,with%20improvem ent%20of%20other%20symptoms.
https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration- isolation.html#:~:text=Recommendations,- Duration%20of%20isolation&text=For%20most%20persons%20with%20COVID,with%20improvement %20of%20other%20symptoms.
https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration- isolation.html#:~:text=Recommendations,- Duration%20of%20isolation&text=For%20most%20persons%20with%20COVID,with%20improvem ent%20of%20other%20symptoms.
Antigen tests are appropriate to be used for screening asymptomatic individuals although a positive result in this population may need to be confirmed by a PCR test while keeping the individual in isolation in the meantime. If antigen test is used on a symptomatic individual then a negative test will have to be confirmed by a PCR test while keeping the individual in isolation in the meantime In an outbreak investigation, PCR tests are preferred. If antigen tests are used then their results may have to be confirmed by PCR tests. (Note: Usually ICAP team and/or local health departments are involved in guiding those decisions)
Use the QA box in the webinar platform to type a question. Questions will be read aloud by the moderator, in the order they are received A transcript of the discussion will be made available on the ICAP website Panelists:
Kate Tyner, RN, BSN, CIC Margaret Drake, MT(ASCP),CIC Teri Fitzgerald, RN, BSN, CIC Sarah Stream, MPH, CDA Moderated by Mounica Soma, MHA Supported by Sue Beach, Marissa Chaney, and Margaret Deacy https://icap.nebraskamed.com/covid-19-webinars/
Responses were provided based on information known on 8/25/2020 and may become out of date. Guidance is being updated rapidly, so users should look to CDC and NE DHHS guidance for updates. NETEC – NICS/Nebraska DHHS HAI-AR/Nebraska ICAP Small and Critical Access Hospitals-Outpatient Region VII Webinar on COVID-19 8/25/2020
what is the use of testing? This question highlights what Dr. Fadul was presenting about the nuances of congregate
that a person who lives in long-term care with other residents, very likely has a roommate, etc., that test is one point in time. So we have to repeat the testing again, most likely, at the end of the quarantine period. But in a congregate setting, the value of knowing if this resident is positive is very high, because we can move the resident into a private room and do different PPE approaches with this resident to make it less likely to spread in the congregate setting. That’s really the idea of calling an antigen test presumptive and being very cautious in doing PCR testing for validation in settings where you are unsure of what the result means because in congregate settings, there is just such high risk. That’s why we wanted to call out that specific example. Teri Fitzgerald added that you would be giving a dedicated staff to anybody who'd be positive. Therefore, it's very important that we find out who is positive up front so that we're dedicating staff to the positives and they're not taking care of both groups. Kate said our approach in long- term care has been incredibly strict, more strict than what we see in the acute care
resource in those situations to help with that.
(and doesn’t want to advertise for certain businesses) but for the sake of the audience, asked what are some of those PCR rapid testing machines, or capabilities? What do you call those? She asked for Dr. Fadul’s input so that people might be able to kind of differentiate what's in their facility.
in hospital settings is a Gene Expert. It's a safe machine, and it's actually used for a lot of other infections, most commonly for C Diff and also for tuberculosis and other infections when we use molecular diagnosis. But that same machine can be used for COVID 19 and the turnaround time is pretty quick. Depending on the setting and how often they are running the test, it could be
go to the OR if they need to have an urgent surgery, for example, instead of waiting for the test to come back in less than 24 hours or less we do the rapid testing so we can move to the OR
and we feel like we need to, or we have a problem with the COVID fluoroscope, so then we
might need to do the rapid PCR in that case to move the patient to the regular floor. But most commonly, we're using it in the pre-op setting.
confirmed by send-out PCR testing? The answer is no. In that case, rapid PC tests, just like the lap the other types of PCR tests are pretty sensitive and pretty specific. If you have a rapid PCR test result, you could rely on it as if you had the PCR test, the other types of PCR tests. There's really no decreasing sensitivity or specificity by doing it a rapid PCR rather than just regular PCR.
examples of scenarios where you would use a rapid antigen test? I would probably use it if I had a symptomatic patient come into the clinic. If you think about the rapid COVID test, think about it as the rapid flu test. If you are in an outpatient setting or an urgent care setting, and you have a patient coming in with symptoms adjustable influenza doing it rapid flu test can be very helpful because if it's positive and the patient has symptoms suggestive of the illness, then you can pretty much say, “You do have the flu, go home and do this and take Tamiflu, etc.”. It's very similar with COVID. If you have patients coming in with symptoms suggestive of COVID, and you do a rapid COVID antigen test in the clinic and the an antigen testis positive, then you could pretty much stop there and say, “Yeah, you do have
rapid antigen test is negative, then you would have to send a PCR test in that case. Now, if you think about it, the sensitivity is about 80%. So, meaning one out of five patients who do have COVID are going to come back negative, but that also means four out of five are going to come back positive. So it might actually save you a lot of time and a lot of extra work and waiting for that patient. If you're able to do the rapid antigen test to test symptomatic patients. Dr. Fadul thinks that's really the most useful scenario for the use of these tests.
had a significant exposure for at least 7 days. What are your thoughts? We are concerned with testing too early, on asymptomatic people. They are under isolation during this time.
She agrees that's a very valid point. If you have an outpatient who had an exposure, the incubation period of the virus is anywhere between 2- 14 days. If you test immediately after the exposure, you might actually be before the window off the virus replication. Therefore, a negative test in that case cannot rule out that this patient had COVID 19. So we recommend
cited number, You could wait for five days after exposure and then test them at that time. You don't want to wait too long, because if you wait too long, then especially if you're using an antigen test, the test might come back negative. And that again does not allow the infection If you are using a PCR test then it's okay to wait maybe seven days or so, because that's kind of in the midst of that incubation period. If you can trust your patient to stay under isolation, then you might just monitor in the first few days of COVID or the first few months, we did not just any asymptomatic patients, period, because we just did not have the testing capacity that we have
right now on. Back then, we would just tell these patients, “Yeah, you were exposed. You may have it. Just stay at home and quarantine for 14 days.” So that's also an option, depending with testing capacity. Kate Tyner added that when we're doing contact tracing on COVID exposures, we always use the 48 hours before the first day of symptoms or testing. Kate would say to this person who asked the question, “You just have to be careful to include those two days that proceed the symptoms
during that, that should be considered already in that incubation period, especially in a congregate setting. That's where we have the most experience with. A a husband and wife couple, for example, if the husband tested on Wednesday, did he start exposing the wife to COVID on Wednesday? No, he started exposing the wife to COVID, most likely Monday, 48 hours before testing. By that rationale, by the time you get results on Thursday or Friday, you're already 3 to 4 days in. In congregate settings, we will test that early. It's actually pretty rare, still, that we will have that rapid turnaround of testing since we are using the PCR test. In most places across the state so far, it's more likely that we're kind of late in the game on doing look
these perform? Is it PCR/Antigen? In the long-term care facilities in Nebraska ICAP knows of about 10 facilities that have been provided the anti gin detection units there, either the BD Veritas or the Sofia units, and those are an antigen detection unit. Nationally, this is why CDC has become more instructive about how to use these antigen detection tests because they're going to become much more widely used here within the next couple weeks.
guidance that was just released, as well as the new isolation guidelines, and visit the Nebraska Medicine website; find the “Resources for Providers for COVID 19”. That is inpatient and ambulatory, and there are all kinds of resources available there.