02/28/2020

The below article is the AMDA Guidance on COVID-19 in PALTC Setting. See the original PDF released at: http://paltc.org/COVID-19-guidance.pdf

AMDA is closely monitoring the COVID-19 (novel coronavirus) outbreak.

The CDC has publicly deemed the health risk of COVID-19 for the general American public to be low at this time. The health, safety and well-being of the community is our highest priority.

BACKGROUND

COVID-19 is the abbreviated name for novel Coronavirus Disease 2019 that first emerged in Wuhan, Hubei Province, China. Coronavirus disease 2019 (COVID-19) is a respiratory illness that can spread from person to person.

The situation with this outbreak is evolving rapidly with new information being learned daily. The CDC is monitoring the outbreak and working closely with federal, state, and local health departments. Because of this, healthcare personnel working in post-acute and long-term care (PALTC) settings should refer to the CDC website for the latest updates: https://www.cdc.gov/coronavirus/2019- nCoV/index.html

Illness:

COVID-19 illness may be mild to severe. Symptoms may appear as soon as 2 days and as long as 14 days after exposure. Symptoms include fever, dry cough, and shortness of breath. Other symptoms include nasal congestion, runny nose, sore throat or diarrhea. These symptoms are usually mild and begin gradually. Some people who are infected may remain asymptomatic. Up to 80% of infected people recover without any need to seek care. Some will develop severe illness (typically in the second week of illness) and at present it is estimated that around 2% will die. Just as with influenza and other viral infections, older adults and patients with comorbid conditions are at increased risk for more severe illness.

Transmission:

COVID-19 is spread from person-to-person by respiratory droplets between people who are in close contact with one another (about 6 feet). While there is not yet evidence for spread from surfaces or objects (fomites), this may also be a possible mechanism of transmission. At present, COVID-19 is not felt to be spread through airborne transmission such as seen with tuberculosis or measles.

INTERIM RECOMMENDATIONS FOR POST-ACUTE & LONG-TERM CARE FACILITIES

Who Should Be Evaluated As A Suspected Case:

Currently, people returning from sites where there is ongoing person-to-person transmission of COVID-19, or who have been in close contact with individuals known to be infected with COVID-19 are at greatest risk for COVID-19. Such individuals have been part of the CDC’s case definition used to determine when to evaluate individuals for COVID- 19. On February 26, 2020, the CDC updated its guidance to also consider COVID-19 in individuals with fever and severe lower respiratory failure requiring hospitalization without an alternative diagnosis. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html.

The CDC may further expand guidance on who to test and under what circumstances.

  • We recommend healthcare personnel use the CDC definitions to guide whether an individual should be evaluated for COVID-19.
  • We recommend healthcare personnel regularly monitor the CDC website for updates to the case definition.

How Should Post-Acute & Long-Term Care Facilities Manage Individuals with Suspected COVID-19:

At present, given the rare presence of COVID-19 in the community, healthcare personnel suspecting a case of COVID-19 should contact their local and/or state public health department for guidance on management.

  • At present and under an abundance of caution, the CDC is recommending that healthcare facilities use Standard Precautions, Contact Precautions, Airborne Precautions, and Eye Protection. This means wearing a gown, gloves, facemask, and goggles or a face shield.
  • We also recommend frequent hand hygiene with alcohol-based hand rub or soap and water, washing for at least 20 seconds.
  • We recommend frequent daily cleaning with an EPA-registered, hospital-grade disinfectant of commonly touched environmental surfaces to decrease environmental contamination. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

Most PALTC facilities will not have airborne isolation rooms (often called negative pressure rooms).

If an individual meets the CDC case definition of a suspected case and an airborne isolation room is not immediately available, we recommend facilities place the individual in a single room with a closed door pending consultation with their local health department.

Reducing The Risk Of Introducing COVID-19 In Your Post-Acute & Long-Term Care Facility:

Surveillance:

Active monitoring and surveillance are important to early detection and recognition of potential outbreaks of all infectious illnesses in long-term care settings.* Facilities should already have an active surveillance program in place capable of identifying cases, clusters and outbreaks of disease.

o We recommend facilities, at the present time, reassess their surveillance program and take any necessary steps to optimize its performance.

Employees:

Because healthcare personnel reside in the community and work in facilities, they have the potential to introduce infections into PALTC populations. As with all situations, healthcare personnel who are ill should stay home and seek healthcare advice through their regular provider. Those with mild symptoms are encouraged to call, rather than going in person, for medical advice.

o We strongly recommend healthcare providers avoid working while ill.

o We strongly recommend healthcare facilities develop staff policies to allow and account for potential absenteeism during community-wide outbreaks.

o If there is evidence of community-wide COVID-19 illness, we recommend facilities screen staff at entry into the facility for respiratory signs and symptoms and fever.

Visitors:

Like healthcare personnel, visitors may also inadvertently foster spread of infections in the PALTC setting. Given the unique nature of the PALTC setting, it will not likely be possible to prohibit all visitors in the event of community-wide COVID-19 illness. For example, individuals on hospice should be able to visit with family members who are not ill.

o Consistent with good routine practice, we recommend posting signs requesting that people with acute respiratory illness to refrain from entering the PALTC facility. This applies whether or not there is COVID-19 activity in the community.

o We recommend individuals (regardless of illness presence) who have a known exposure to someone with a COVID-19, or who have recently traveled to areas with COVID-19 transmission, refrain from entering the nursing home.

o If there is community-wide transmission of COVID-19, we recommend facilities consider screening visitors at entry to the facility.

Planning:

As part of a facility’s regular risk assessment, PALTC facilities should develop plans to prepare for and respond to potential outbreaks and/or pandemics. Plans developed for pandemic influenza are reasonable models to use in addressing the prevention and management of COVID-19.** Key measures for this include:

  • Call your State and/or Local Health Department (for testing and guidance)
  • Social distancing, including suspending group activities including dining and other social events
  • Consistent staff, in which staff are assigned to the same unit or hallway on a consistent basis
  • Daily temperature checks and symptom monitoring for residents and staff
  • Furlough for staff with respiratory symptoms
  • Having a plan to bring in temporary staff, perhaps through an agency, when there is insufficient staffing due to illness or increased burden of care

Admitting New Residents with COVID-19:

Current recommendations for the care of individuals with severe illness caused by COVID-19 includes Standard Precautions, Contact Precautions, Airborne Precautions and using eye protection. They also call for placing the person in an airborne infection isolation room (commonly termed a negative pressure room). As noted, few nursing homes have a negative pressure room. Settings without a negative pressure room may consider placing an individual with COVID-19 in a single room with a closed door. Such decisions should be made in consultation with the local public health department.

The length of time during which infected individuals shed virus is not yet known. As symptoms improve, the amount of virus shed by infected individuals should decrease. Based on experience with similar viruses, people with severe illness will shed more virus and for a longer period of time than those with mild COVID-19 infection. People with severe illness may continue to shed virus even 12 days after symptom onset. The decision of when people no longer require isolation precautions should be made on a case-by-case basis and in consultation with public health officials. Such a decision will need to take into account the severity of the illness, comorbid conditions, resolution of fever, and clinical status of the individual.

  • We recommend that nursing homes accept patients recovering from COVID-19 only after consultation with the local and/or state health department and referring facility.
  • If limited resources make this impracticable, we recommend that nursing homes should accept residents with a known COVID-19 infection when that individual can be placed in a single room with a closed door and when there is sufficient and adequately trained staff to care for that individual.
  • We recommend that facilities be familiar with current CDC recommendations regarding cessation of transmission based precautions for individuals with COVID-19.
  • We recommend facilities re-educate all staff, clinical and non-clinical on proper use of personal protective equipment (PPE). https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf

COVID-19 is an evolving situation. Clinicians should use their judgment and consult with public health authorities. Please check websites from the CDC and State/Local Health Departments frequently for updated information.
https://www.cdc.gov/coronavirus/2019-nCoV/index.html

*Long Term Care Respiratory Surveillance Line List (accessed 2/28/20) https://www.cdc.gov/longtermcare/pdfs/LTC-Resp-OutbreakResources-P.pdf

Parent site for the above pdf: https://www.cdc.gov/longtermcare/training.html

**Pandemic Influenza Planning Checklist for Long-Term Care and Other Residential Facilities (accessed 2/28/20)