Preparing for COVID-19: Long-term Care Facilities, Nursing Homes

Background

Given their congregate nature and resident inhabitants served (e.g., older adults typically with underlying continual medical circumstances), nursing residence populations are at excessive threat of being affected by respiratory pathogens like COVID-19 and different pathogens, together with multidrug-resistant organisms (e.g., Carbapenemase-producing organisms, Candida auris ).  As demonstrated by the COVID-19 pandemic, a powerful an infection prevention and management (IPC) program is crucial to guard each residents and healthcare personnel (HCP).

Facilities ought to assign at the very least one particular person with coaching in IPC to offer on-site administration of their COVID-19 prevention and response actions due to the breadth of actions for which an IPC program is accountable, together with creating IPC insurance policies and procedures, performing an infection surveillance, offering competency-based coaching of HCP, and auditing adherence to beneficial IPC practices.

The Centers for Medicare and Medicaid Services (CMS) not too long ago issued Nursing Home Reopening Guidance for State and Local Officialspdf iconexternal icon that outlines standards that might be used to find out when nursing properties might loosen up restrictions on visitation and group actions and when such restrictions ought to be reimplemented.  Nursing properties ought to think about the present scenario of their facility and group and check with that steerage in addition to course from state and native officers when making selections about stress-free restrictions.  When stress-free any restrictions, nursing properties should stay vigilant for COVID-19 amongst residents and HCP with a purpose to stop unfold and shield residents and HCP from extreme infections, hospitalizations, and demise.

This steerage has been up to date and reorganized in keeping with core IPC practices that ought to stay in place whilst nursing properties resume regular practices, plus extra methods  relying on the phases described within the CMS Reopening Guidancepdf iconexternal icon or on the course of state and native officers.  This steerage is predicated on presently accessible details about COVID-19 and might be refined and up to date as extra data turns into accessible.

These suggestions complement the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19)  in Healthcare Settings and are particular for nursing properties, together with expert nursing services.

Additional Key Resources:

Core Practices

These practices ought to stay in place whilst nursing properties resume regular actions.

Assign One or More Individuals with Training in Infection Control to Provide On-Site Management of the IPC Program.

  • This ought to be a full-time position for at the very least one individual in services which have greater than 100 residents or that present on-site ventilator or hemodialysis companies. Smaller services ought to think about staffing the IPC program primarily based on the resident inhabitants and facility service wants recognized within the facility risk assessment.
  • CDC has created an online training courseexternal icon that can be utilized to orient people to this position in nursing properties.

Report COVID-19 circumstances, facility staffing, and provide data to the National Healthcare Safety Network (NHSN) Long-term Care Facility  (LTCF) COVID-19 Module weekly.

  • CDC’s NHSN supplies long-term care services with a personalized system to trace infections and prevention course of measures in a scientific manner. Nursing properties can report into the 4 pathways of the LTCF COVID-19 Module together with:
    • Resident impression and facility capability
    • Staff and personnel impression
    • Supplies and private protecting gear
    • Ventilator capability and provides
  • Weekly information submission to NHSN will meet the CMS COVID-19 reporting requirements.pdf iconexternal icon

Educate Residents, Healthcare Personnel, and Visitors about COVID-19, Current Precautions Being Taken within the Facility, and Actions They Should Take to Protect Themselves.

  • Provide details about COVID-19 (together with details about indicators and signs) and techniques for managing stress and anxiety.
  • Regularly assessment CDC’s Infection Control Guidance for Healthcare Professionals about COVID-19 for present data and guarantee workers and residents are up to date when this steerage adjustments.
  • Educate and practice HCP, together with facility-based and guide personnel (e.g., wound care, podiatry, barber) and volunteers who present care or companies within the facility. Including consultants is essential, since they generally present care in a number of services the place they are often uncovered to and function a supply of COVID-19.
    • Reinforce sick depart insurance policies, and remind HCP to not report back to work when in poor health.
    • Reinforce adherence to straightforward IPC measures together with hand hygiene and selection and correct use of personal protective equipment (PPE). Have HCP show competency with placing on and eradicating PPE and monitor adherence by observing their resident care actions.
      • CDC has created coaching modules for front-line workers that can be utilized to strengthen beneficial practices for stopping transmission of SARS-CoV-2 and different pathogens.
    • Educate HCP about any new insurance policies or procedures.
  • Educate residents and households on subjects together with details about COVID-19, actions the power is taking to guard them and/or their family members, any customer restrictions which can be in place, and actions residents and households ought to take to guard themselves within the facility, emphasizing the significance of hand hygiene and supply management.
  • Have a plan and mechanism to recurrently talk with residents, households and HCP, including if cases of COVID-19 are identified among residents or HCP.

Implement Source Control Measures.

  • HCP ought to put on a facemask always whereas they’re within the facility.
    • When accessible, facemasks are typically most popular over fabric face coverings for HCP as facemasks supply each supply management and safety for the wearer towards publicity to splashes and sprays of infectious materials from others. Guidance on extended use and reuse of facemasks is offered. Cloth face coverings ought to NOT be worn by HCP as an alternative of a respirator or facemask if PPE is required.
  • Residents ought to put on a fabric face overlaying or facemask (if tolerated) every time they depart their room, together with for procedures exterior the power. Cloth face coverings shouldn’t be positioned on anybody who has bother respiratory, or anybody who’s unconscious, incapacitated, or in any other case unable to take away the masks with out help.  In addition to the classes described above fabric face coverings shouldn’t be positioned on youngsters underneath 2.
  • Visitors, if permitted into the power, ought to put on a fabric face overlaying whereas within the facility.

Have a Plan for Visitor Restrictions.

  • Post indicators on the entrances to the power advising guests to check-in with the entrance desk to be assessed for signs previous to entry.
    • Screen guests for fever (T≥100.0oF), symptoms consistent with COVID-19, or recognized publicity to somebody with COVID-19. Restrict anybody with fever, signs, or recognized publicity from getting into the power.
  • Ask guests to tell the power in the event that they develop fever or signs in step with COVID-19 inside 14 days of visiting the power.
  • Have a plan for when the power will implement extra restrictions, starting from limiting the variety of guests and permitting visitation solely throughout choose hours or in choose places to proscribing all guests, aside from compassionate care causes (see beneath).

Create a Plan for Testing Residents and Healthcare Personnel for SARS-CoV-2.

  • Testing for SARS-CoV-2, the virus that causes COVID-19, in respiratory specimens can detect present infections (referred to right here as viral testing or check) amongst residents and HCP in nursing properties.
  • The planpdf iconexternal icon ought to align with state and federal necessities for testing residents and HCP for SARS-CoV-2 and deal with:
    • Triggers for performing testing (e.g., a resident or HCP with signs in step with COVID-19, response to a resident or HCP with COVID-19 within the facility, routine surveillance)
    • Access to exams able to detecting the virus (e.g., polymerase chain response) and an association with laboratories to course of exams
      • Antibody check outcomes shouldn’t be used to diagnose somebody with an energetic SARS-CoV-2 an infection and shouldn’t be used to tell IPC motion.
    • Process for and capability to carry out SARS-CoV-2 testing of all residents and HCP
    • A process for addressing residents or HCP who decline or are unable to be examined (e.g., sustaining Transmission-Based Precautions till symptom-based criteria are met for a symptomatic resident who refuses testing)
  • Additional details about testing of residents and HCP is offered:

Evaluate and Manage Healthcare Personnel.

  • Implement sick leave policies which can be non-punitive, versatile, and in step with public well being insurance policies that assist HCP to remain residence when in poor health.
  • Create a list of all volunteers and personnel who present care within the facility. Use that stock to find out which personnel are non-essential and whose companies may be delayed if such restrictions are mandatory to stop or management transmission.
  • As a part of routine follow, ask HCP (together with guide personnel and ancillary workers akin to environmental and dietary companies) to recurrently monitor themselves for fever and signs in step with COVID-19.
    • Remind HCP to remain residence when they’re in poor health.
    • If HCP develop fever (T≥100.0oF) or symptoms consistent with COVID-19 whereas at work they need to inform their supervisor and depart the office. Have a plan for a way to reply to HCP with COVID-19 who labored whereas in poor health (e.g., figuring out and performing a threat evaluation for uncovered residents and associates).
    • HCP with suspected COVID-19 ought to be prioritized for testing.
  • Screen all HCP at first of their shift for fever and signs of COVID-19.
    • Actively take their temperature* and doc absence of symptoms consistent with COVID-19. If they’re in poor health, have them maintain their fabric face overlaying or facemask on and depart the office.
    • *Fever is both measured temperature >100.0oF or subjective fever. Note that fever could also be intermittent or might not be current in some people, akin to those that are aged, immunosuppressed, or taking sure medicines (e.g., NSAIDs). Clinical judgement ought to be used to information testing of people in such conditions.
    • HCP who work in a number of places could pose greater threat and ought to be inspired to inform services if they’ve had publicity to different services with acknowledged COVID-19 circumstances.
  • Develop (or assessment present) plans to mitigate staffing shortages from sickness or absenteeism.

Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices.

  • Hand Hygiene Supplies:
    • Put alcohol-based hand sanitizer with 60-95% alcohol in each resident room (ideally each inside and outdoors of the room) and different resident care and customary areas (e.g., exterior eating corridor, in remedy health club). Unless arms are visibly dirty, an alcohol-based hand sanitizer is most popular over cleaning soap and water in most scientific conditions.
    • Make positive that sinks are well-stocked with cleaning soap and paper towels for handwashing.
  • Respiratory Hygiene and Cough Etiquette:
    • Make tissues and trash cans accessible in widespread areas and resident rooms for respiratory hygiene and cough etiquette and supply management.
  • Personal Protective Equipment (PPE):
    • Perform and keep a list of PPE within the facility.
    • Make mandatory PPE accessible in areas the place resident care is offered.
      • Consider designating workers accountable for stewarding these provides and monitoring and offering just-in-time suggestions selling applicable use by workers.
      • Facilities ought to have provides of facemasks, respirators (if accessible and the power has a respiratory safety program with educated, medically cleared, and fit-tested HCP), robes, gloves, and eye safety (i.e., face defend or goggles).
    • Position a trash can close to the exit contained in the resident room to make it simple for workers to discard PPE previous to exiting the room or earlier than offering care for one more resident in the identical room.
    • Implement strategies to optimize current PPE supply even earlier than shortages happen, together with bundling resident care and remedy actions to attenuate entries into resident rooms. Additional methods may embrace:
      • Extended use of respirators, facemasks, and eye safety, which refers back to the follow of sporting the identical respirator or facemask and eye safety for the care of multiple resident (e.g., for a complete shift).
        • Care have to be taken to keep away from touching the respirator, facemask, or eye safety. If this should happen (e.g., to regulate or reposition PPE), HCP ought to carry out hand hygiene instantly after touching PPE to stop contaminating themselves or others.
      • Prioritizing gowns for actions the place splashes and sprays are anticipated (together with aerosol-generating procedures) and high-contact resident care actions that present alternatives for switch of pathogens to arms and clothes of HCP.
        • If prolonged use of robes is applied as a part of disaster methods, the identical robe shouldn’t be worn when caring for various residents until it’s for the care of residents with confirmed COVID-19 who’re cohorted in the identical space of the power and these residents will not be recognized to have any co-infections (e.g., Clostridioides difficile)
      • Implement a course of for decontamination and reuse of PPE akin to face shields and goggles.
      • Facilities ought to proceed to evaluate PPE provide and present scenario to find out when a return to straightforward practices may be thought-about.
    • Implement a respiratory protection program that’s compliant with the OSHA respiratory safety customary for workers if not already in place. The program ought to embrace medical evaluations, coaching, and match testing.
    • Environmental Cleaning and Disinfection:
      • Develop a schedule for normal cleansing and disinfection of shared gear, steadily touched surfaces in resident rooms and customary areas;
      • Ensure EPA-registered, hospital-grade disinfectants can be found to permit for frequent cleansing of high-touch surfaces and shared resident care gear.
        • Use an EPA-registered disinfectant from List Nexternal icon on the EPA web site to disinfect surfaces that is likely to be contaminated with SARS-CoV-2. Ensure HCP are appropriately educated on its use.

Identify Space within the Facility that Could be Dedicated to Monitor and Care for Residents with COVID-19.

  • Identify area within the facility that might be devoted to look after residents with confirmed COVID-19. This might be a devoted ground, unit, or wing within the facility or a gaggle of rooms on the finish of the unit that might be used to cohort residents with COVID-19.
    • Identify HCP who might be assigned to work solely on the COVID-19 care unit when it’s in use.
  • Have a plan for a way residents within the facility who develop COVID-19 might be dealt with (e.g., switch to single room, implement use of Transmission-Based Precautions, prioritize for testing, switch to COVID-19 unit if constructive).
    • Residents within the facility who develop signs in step with COVID-19 might be moved to a single room pending outcomes of SARS-CoV-2 testing. They shouldn’t be positioned in a room with a brand new admission nor ought to they be moved to the COVID-19 care unit until they’re confirmed to have COVID-19 by testing. While awaiting outcomes of testing, HCP ought to put on an N95 or higher-level respirator (or facemask if a respirator will not be accessible), eye safety (i.e., goggles or a disposable face defend that covers the entrance and sides of the face), gloves, and robe when caring for these residents. Cloth face coverings will not be thought-about PPE and may solely be worn by HCP for supply management, not when PPE is indicated.
  • Have a plan for a way roommates, different residents, and HCP who could have been uncovered to a person with COVID-19 might be dealt with (e.g., monitor carefully, keep away from inserting unexposed residents right into a shared area with them).
  • Additional details about cohorting residents and establishing a chosen COVID-19 care unit is offered within the Considerations for the Public Health Response to COVID-19 in Nursing Homes

Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown.

  • Depending on the prevalence of COVID-19 in the neighborhood, this may embrace inserting the resident in a single-person room or in a separate remark space so the resident may be monitored for proof of COVID-19. HCP ought to put on an N95 or higher-level respirator (or facemask if a respirator will not be accessible), eye safety (i.e., goggles or a disposable face defend that covers the entrance and sides of the face), gloves, and robe when caring for these residents. Residents may be transferred out of the remark space to the primary facility if they continue to be afebrile and with out signs for 14 days after their admission. Testing on the finish of this era may be thought-about to extend certainty that the resident will not be contaminated.

Evaluate and Manage Residents with Symptoms of COVID-19.

  • Ask residents to report in the event that they really feel feverish or have signs in step with COVID-19.
  • Actively monitor all residents upon admission and at the very least each day for fever (T≥100.0oF) and symptoms consistent with COVID-19. Ideally, embrace an evaluation of oxygen saturation by way of pulse oximetry. If residents have fever or signs in step with COVID-19, implement Transmission-Based Precautions as described beneath.
    • Older adults with COVID-19 could not present widespread signs akin to fever or respiratory signs. Less widespread signs can embrace new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, lack of style or scent. Additionally, greater than two temperatures >99.0oF may additionally be an indication of fever on this inhabitants. Identification of those signs ought to immediate isolation and additional analysis for COVID-19.
  • The well being division ought to be notified about residents or HCP with suspected or confirmed COVID-19, residents with extreme respiratory an infection leading to hospitalization or demise, or ≥ three residents or HCP with new-onset respiratory signs inside 72 hours of one another.
  • Information in regards to the scientific presentation and course of sufferers with COVID-19 is described within the Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease 2019 (COVID-19). CDC has additionally developed steerage on Evaluating and Reporting Persons Under Investigation (PUI).
  • If COVID-19 is suspected, primarily based on analysis of the resident or prevalence of COVID-19 in the neighborhood, comply with the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This steerage ought to be applied instantly as soon as COVID-19 is suspected
    • Residents with suspected COVID-19 ought to be prioritized for testing.
    • Residents with recognized or suspected COVID-19 don’t have to be positioned into an airborne an infection isolation room (AIIR) however ought to ideally be positioned in a personal room with their very own lavatory.
      • Residents with COVID-19 ought to, ideally, be cared for in a devoted unit or part of the power with devoted HCP (see part on Dedicating Space).
      • As roommates of residents with COVID-19 may already be uncovered, it’s typically not beneficial to put them with one other roommate till 14 days after their publicity, assuming they haven’t developed signs or had a constructive check.
    • Residents with recognized or suspected COVID-19 ought to be cared for utilizing all beneficial PPE, which incorporates use of an N95 or higher-level respirator (or facemask if a respirator will not be accessible), eye safety (i.e., goggles or a disposable face defend that covers the entrance and sides of the face), gloves, and robe. Cloth face coverings will not be thought-about PPE and shouldn’t be worn when PPE is indicated.
    • Increase monitoring of in poor health residents, together with evaluation of signs, important indicators, oxygen saturation by way of pulse oximetry, and respiratory examination, to at the very least three occasions each day to establish and rapidly handle severe an infection.
      • Consider growing monitoring of asymptomatic residents from each day to each shift to extra quickly detect any with new signs.
    • If a resident requires the next degree of care or the power can’t absolutely implement all beneficial an infection management precautions, the resident ought to be transferred to a different facility that’s able to implementation. Transport personnel and the receiving facility ought to be notified in regards to the suspected analysis previous to switch.
      • While awaiting switch, residents ought to be separated from others (e.g., in a personal room with the door closed) and may put on a fabric face overlaying or facemask (if tolerated) when others are within the room and through transport.
      • All recommended PPE ought to be utilized by healthcare personnel when coming involved with the resident.
    • Because of the upper threat of unrecognized an infection amongst residents, common use of all recommended PPE for the care of all residents on the affected unit (or facility-wide relying on the scenario) is beneficial when even a single case amongst residents or HCP is newly recognized within the facility; this may be thought-about when there’s sustained transmission in the neighborhood. The well being division can help with selections about testing of asymptomatic residents.
    • For selections on eradicating residents who’ve had COVID-19 from Transmission-Based Precautions check with the Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients with COVID-19

Additional Strategies Depending on the Facility’s Reopening Status

These methods will rely on the phases described within the CMS Reopening Guidance or the course of state and native officers.

Implement Social Distancing Measures

  • Implement aggressive social distancing measures (remaining at the very least 6 ft aside from others):
    • Cancel communal eating and group actions, akin to inside and exterior actions.
    • Remind residents to follow social distancing, put on a fabric face overlaying (if tolerated), and carry out hand hygiene.
    • Remind HCP to follow social distancing and put on a facemask (for supply management) when in break rooms or widespread areas.
  • Considerations when restrictions are being relaxed embrace:
    • Allowing communal eating and group actions for residents with out COVID-19, together with those that have absolutely recovered whereas sustaining social distancing, supply management measures, and limiting the numbers of residents who take part.
    • Allowing for secure, socially distanced out of doors excursions for residents with out COVID-19, together with those that have absolutely recovered. Planning for such excursions ought to deal with:
      • Use of material face overlaying for residents and facemask by workers (for supply management) whereas they’re exterior
      • Potential want for added PPE by workers accompanying residents
      • Rotating schedule to make sure all residents can have a chance if desired, however that doesn’t absolutely disrupt different resident care actions by workers
      • Defining occasions for out of doors actions so households might plan across the alternative to see their family members

Implement Visitor Restrictions

  • Restrict all visitation to their services aside from sure compassionate care causes, akin to end-of-life conditions.
    • Send letters or emailspdf icon to households advising them that no guests might be allowed within the facility aside from sure compassionate care conditions, akin to finish of life conditions.
    • Use of different strategies for visitation (e.g., video conferencing) ought to be facilitated by the power.
    • Post indicators on the entrances to the power advising that no guests could enter the power.
    • Decisions about visitation for compassionate care conditions ought to be made on a case-by-case foundation, which ought to embrace cautious screening of the customer for fever or symptoms consistent with COVID-19. Those with signs shouldn’t be permitted to enter the power. Any guests which can be permitted should put on a fabric face overlaying whereas within the constructing and prohibit their go to to the resident’s room or different location designated by the power. They also needs to be reminded to steadily carry out hand hygiene.
  • Considerations for visitation when restrictions are being relaxed embrace:
    • Permit visitation solely throughout choose hours and restrict the variety of guests per resident (e.g., not more than 2 guests at one time).
    • Schedule visitation upfront to allow continued social distancing.
    • Restrict visitation to the resident’s room or one other designated location on the facility (e.g., exterior).

Healthcare Personnel Monitoring and Restrictions:

  • Restrict non-essential healthcare personnel, akin to these offering elective consultations, personnel offering non-essential companies (e.g., barber, hair stylist), and volunteers from getting into the constructing.
    • Consider implementing telehealth to supply distant entry to care actions.

Definitions:

  • Healthcare Personnel (HCP): HCP embrace, however will not be restricted to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, college students and trainees, contractual workers not employed by the healthcare facility, and individuals indirectly concerned in affected person care, however who might be uncovered to infectious brokers that may be transmitted within the healthcare setting (e.g., clerical, dietary, environmental companies, laundry, safety, engineering and services administration, administrative, billing, and volunteer personnel).
  • Source Control: Use of a fabric face overlaying or facemask to cowl an individual’s mouth and nostril to stop unfold of respiratory secretions when they’re speaking, sneezing, or coughing.  Facemasks and fabric face coverings shouldn’t be positioned on youngsters underneath age 2, anybody who has bother respiratory, or anybody who’s unconscious, incapacitated, or in any other case unable to take away the masks with out help.
  • Cloth face overlaying: Textile (fabric) covers which can be supposed to maintain the individual sporting one from spreading respiratory secretions when speaking, sneezing, or coughing. They will not be PPE and it’s unsure whether or not fabric face coverings shield the wearer. Guidance on design, use, and upkeep of material face coverings is available.
  • Facemask: Facemasks are PPE and are also known as surgical masks or process masks. Use facemasks in keeping with product labeling and native, state, and federal necessities. FDA-cleared surgical masks are designed to guard towards splashes and sprays and are prioritized to be used when such exposures are anticipated, together with surgical procedures. Facemasks that aren’t regulated by FDA, akin to some process masks, that are sometimes used for isolation functions, could not present safety towards splashes and sprays.
  • Respirator: A respirator is a private protecting gadget that’s worn on the face, covers at the very least the nostril and mouth, and is used to cut back the wearer’s threat of inhaling hazardous airborne particles (together with mud particles and infectious brokers), gases, or vapors. Respirators are licensed by the CDC/NIOSH, together with these supposed to be used in healthcare.

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