Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease (2019-nCoV or COVID-19), is spreading rapidly in nursing homes across the country. On March 23, the Centers for Medicare & Medicaid Services (CMS) announced that 147 nursing homes across 27 states have at least one resident with COVID-19, according to data from the Centers for Disease Control and Prevention (CDC). The number of providers with internal spread is increasing as well. For example, on March 25, news reports indicated that at least 16 residents and four staff members tested positive for COVID-19 in a West Virginia nursing home. Nursing homes that do not yet have COVID-19 in their facility should be actively working to mitigate the risk to residents and staff. Implementing the following strategies can assist in this effort:
Constantly monitor key infection prevention practices
Infection prevention auditing should highlight two areas:
* Hand hygiene. “From a self-inoculation perspective, the hands are the key,” stresses Michael Bell, MD, deputy director of the Division of Healthcare Quality Promotion at the CDC. “If you were to touch a soiled surface, you could end up with infectious material on your hands. If you then touch your eyes, nose, or mouth without washing your hands first, then you could deliver the infectious materials to yourself. Hand hygiene either in the form of alcohol-based hand gel or soap and water is the key to breaking that transmission. Simply walking into a room that might have something on the surface is not associated with any recognized risk of transmission.”
Consequently, infection prevention audits should start with hand hygiene, says Steven Schweon, RN, MPH, MSN, CIC, FSHEA, FAPIC, an infection preventionist based in Saylorsburg, PA. “Hand-hygiene audits should be conducted on all shifts (i.e., 24 hours a day, seven days a week, 365 days a year), and you should encourage staff to help each other, using friendly feedback, to ensure adherence with good hand hygiene before and after resident care. You should also regularly remind staff not to touch their face and to give a friendly prompt when they view a colleague touching their face.”
Avoiding face touching also is a critical step in extending the life of personal protective equipment (PPE). When caring for residents with confirmed or suspected COVID-19, staff can use the same face mask “for an entire shift and for the care of multiple residents provided that healthcare personnel is able to avoid touching the facemask, and the facemask isn’t getting damp or soiled,” says Lieutenant Commander Kara M. Jacobs Slifka, MD, MPH (USPHS), a medical officer from the CDC’s COVID-19 Response Infection Prevention and Control Team. “Eye protection should also be worn with the face mask, and whenever the face mask and eye protection are removed, healthcare personnel should make sure they are performing hand hygiene before removing it and then again afterward. To further extend the use of eye protection, eye protection can be reprocessed and used again.”
Note: Module 7 of the Nursing Home Infection Preventionist Training developed by the CDC and CMS covers hand hygiene, and section F, Hand Hygiene, of the Long-term Care Infection Control Worksheet offers an audit tool. Also see the Hand Hygiene section of the COVID-19 Focused Survey for Nursing Homes.
* Environmental cleaning and disinfecting. The CDC now has preliminary information about persistence on surfaces, says Bell. SARS-CoV-2 is “stable for several hours to days in aerosols and on surfaces,” according to a March 17 study from the National Institutes of Health and others in The New England Journal of Medicine. Under laboratory conditions, it was detectable for up to three hours in aerosols; up to four hours on copper; up to 24 hours on cardboard; and as long as two to three days on plastic and stainless steel.
“It’s important to remember that those numbers don’t translate directly to the normal environment, but they do serve as a way to frame how we think about viral persistence,” says Bell. “The bottom line, though, is that it is certainly on the order of hours, and this underscores the importance of environmental cleaning and disinfection. Cleaning is necessary to remove the protein and other organic material that can get in the way of a disinfectant working chemically if it is not cleaned first.”
Note: “A Public Health Responses to COVID-19 Outbreaks on Cruise Ships — Worldwide, February–March 2020” in the March 23 Morbidity and Mortality Weekly Report additionally states, “SARS-CoV-2 RNA [ribonucleic acid] was identified on a variety of surfaces in cabins of both symptomatic and asymptomatic infected passengers up to 17 days after cabins were vacated on the Diamond Princess but before disinfection procedures had been conducted (Takuya Yamagishi, National Institute of Infectious Diseases, personal communication, 2020). Although these data cannot be used to determine whether transmission occurred from contaminated surfaces, further study of fomite transmission of SARS-CoV-2 aboard cruise ships is warranted.”
Given the potential role of surface contamination in COVID-19 spread, “environmental hygiene audits using adenosine triphosphate (ATP) or fluorescent monitoring should be considered,” suggests Schweon. Note: Section P, Cleaning and Disinfection of Environmental Surfaces and Reusable Equipment, of the Long-Term Care Infection Control Worksheet offers a corresponding process audit tool. Also see the Transmission-Based Precautions section of the COVID-19 Focused Survey for Nursing Homes.
Cleaning and disinfecting should have clear accountability, adds Swati Gaur, MD, MBA, CMD, AGSF, the CEO of Care Advances Thru Technology; the medical director for a Georgia healthcare system’s nursing home; and the chair of the Infection Advisory Subcommittee at AMDA, the Society for Post-Acute and Long-Term Care Medicine.
“Our environmental services (EVS) staff clean high-touch surfaces twice a day, but we’re also asking other staff to clean PRN. For example, at each nurse’s station, the unit secretary is responsible for making sure that they have the right kind of cleaning equipment on hand and that they clean whenever someone coughs at the station,” she says. “In addition, our EVS staff are required to check off that they have ensured that all of the alcohol-based hand sanitizer stations in the entire facility are more than halfway full. We can’t run out while providing patient care.”
Train staff on donning and doffing techniques
Donning and doffing applies to gloves, gowns, and other protective equipment—not just masks, notes Bell. “One thing that we have seen in previous outbreaks is that people are really prone to self-contamination when they are removing their protective equipment. Part of safe doffing is ensuring that you do so in a way that doesn’t lead to contaminating your hands, which could then contaminate your eyes, nose, or mouth, and also making sure that you don’t generate splashes. If you have wet gunk on your gloves, you don’t want to sling them off in a messy way. You want to do so in a controlled way.”
Doing the removal process in a slow, thoughtful, deliberate manner is probably the best general advice, adds Bell. “When things are done chaotically and in a rush, the risk to both the person who has been using the equipment and the people around them goes up. So having sufficient space and an easily accessed waste receptacle, and again slowly and deliberately making sure that you take your equipment off, gloves, gowns, face shields, masks, respirators—all of the above—in a way that doesn’t self-contaminate is very important, not just for this infectious disease but for all use of PPE.”
Note: The CDC offers a three-page document with graphics to illustrate the sequence for putting on (i.e., donning) PPE and methods for safely removing (i.e., doffing) PPE using two different sequences (example 1 and example 2). The National Ebola Training and Education Center (NETEC) offers an almost 18-minute video that provides guidance for donning and doffing PPE for following the CDC guidelines for standard, contact, and airborne precautions, as well as a COVID-19 PPE Competency Validation Checklist and Instructor Guide. In addition, Nebraska Medicine and the University of Nebraska Medical Center, which started early providing care for COVID-19 quarantined cruise ship passengers, offer guidance for donning and doffing based on CMS’s example 2:
“Having a PPE buddy to assist with donning and doffing might reduce the self-contamination risk,” points out Schweon. Note: section G, Standard Precautions, and section H, Contact Precautions, of the Long-Term Care Infection Control Worksheet offer auditing assistance, as do the PPE and Transmission-Based Precautions sections of the COVID-19 Focused Survey for Nursing Homes.
Protect your staff re: exposures and symptoms
“Our goal is to keep COVID-19 out of the building. That is the first goal, and everything develops from that goal,” says Gaur. “COVID-19 can come into the building in three ways: through visitors and volunteers, through staff, and through patients. Consequently, we need to risk-mitigate very systematically in all three areas. Your staff—the nurses, the certified nursing assistants (CNAs), and all other clinical staff—will be your most critical asset in a facility outbreak.”
Preventing staff from bringing COVID-19 into the building is a three-step process:
* Monitor staff exposures. “If there is any question of a staff member being exposed to COVID-19, they should report to the infection preventionist. I would strongly recommend that every infection preventionist brush up on the somewhat complex algorithm that CDC has developed for staff exposure so they understand who can come to work and who cannot come to work,” says Gaur. “If a staff member has had an exposure, the infection preventionist will need to assess the staff member’s level of exposure and apply the algorithm based on that level.”
Another critical piece is that staff members often work in different facilities—and spread the SARS-CoV-2 virus among facilities, says Gaur. “This was observed in the Seattle facilities’ outbreak. This loop should be closed. We have asked our DNS to create a spreadsheet for all personnel who go to other post-acute and long-term care facilities.” That spreadsheet will allow the facility to immediately notify other employers in order to limit spread among facilities in the event that any staff member has suspected COVID-19, she adds.
Note: When can staff with confirmed or suspected COVID-19 return to work? See Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim Guidance).
* Ask staff to call in sick to protect residents and co-workers. “Staff members who are sick with symptoms shouldn’t even come into the facility to show up for work,” says Gaur. “If they have a fever or respiratory symptoms, they should call both the DNS and the infection preventionist and not step foot into the building.”
* Monitor symptoms. Providers should actively monitor staff for fever and respiratory symptoms at the start of every shift, per CMS and CDC guidance. “It’s essential to create a tiered accountability chart that shows who is accountable for ensuring that a sick staff member doesn’t show up to work. Long-term care employees don’t necessarily have paid sick leave, and they want to come to work. However, you cannot afford that in this pandemic,” says Gaur. “While we are screening, due to unreliability of symptoms, we are asking all staff who will be within six feet to wear a mask to minimize staff transmission.”
“Of course, the DNS is ultimately accountable,” says Gaur. “However, breaking down that accountability into tiers can help make sure that no staff member is accidentally skipped.”
One person on each shift should be assigned responsibility for each staff category: environmental services personnel, CNAs, nurses, rehabilitation therapists, activities, social work, dietary staff, consultants such as hospice nurses, etc., she suggests. “Every single staff member needs to be accounted for and checked off as not having fever or respiratory symptoms when they report to duty. For example, you may want to have the nurse managers on each unit be responsible for ensuring the CNAs are free of symptoms.”
Take a hard look at admissions
“COVID-19 can come in the building via admissions from acute care,” says Gaur. “We initially developed a small questionnaire for our admissions coordinator to use to find out whether potential admissions have fever or respiratory symptoms prior to them coming in, and the nurse who takes the report from the hospital would ask the same questions. However, we realized we needed to make the process robust and now have two independent reviewers. One screens for symptoms in the patient’s hospital chart, and then the nurse who takes the report from the hospital screens as well.” Note: Providers can screen potential admissions with the same tool they use to actively monitor residents for symptoms. The tool used by Gaur’s team, available via AMDA’s COVID-19 resource page, is here.
If any of the screening questions raise the suspicion of COVID-19, staff from Gaur’s nursing home will request a COVID-19 test, she adds. “We are now bringing our new admissions in isolation using standard, contact, and droplet precautions, and we are leaving our admission in isolation for observation.”
In addition, AMDA now recommends that COVID-19-naïve facilities accept only patients with no COVID-19 disease, stresses Gaur. “This is because we are observing long-term care facilities with reasonably good survey ratings that are unable to stem the spread of illness. Therefore, bringing in a COVID-19 patient is very risky to others in the facility.”
Note: Depending on the local situation as the pandemic progresses, some nursing homes may be required to accept COVID-19 patients. For example, on March 20, the California Department of Public Health issued an all-facilities letter stating that skilled nursing facilities (SNFs) should “prepare to receive residents with suspected or confirmed COVID-19 infection.”
Watch out for residents who have outside appointments
Other than admissions, providers also have to be vigilant about residents going out of the building, says Gaur. “We have called all outside specialists and rescheduled all nonurgent visits. We have been sending out our dialysis patients with masks on, but as of today, we are placing them in single rooms and increasing precautions and surveillance. This past week, we have seen several index cases of long-term care outbreak related to dialysis.” Note: To keep track of new developments, providers may want to review AMDA’s FAQ: When COVID-19 Is Currently in Your Regional Community on a routine basis. The organization updates it once or twice a week with feedback from medical directors across the country, CMS, and the CDC.
Check your laundry
The Interim Infection Prevention and Control Recommendations for Patients With Suspected or Confirmed COVID-19 in Healthcare Settings state that COVID-19 doesn’t require special laundry procedures: “Management of laundry, food service utensils, and medical waste should … be performed in accordance with routine procedures.”
However, the improper handling of linens is a key reason that F880 (Infection Prevention and Control) remains the top-cited F-tag in nursing homes across the nation. “Therefore, providers need to review all laundry procedures to ensure adherence with policy,” says Schweon.
Note: Section S, Linen Management, of the Long-Term Care Infection Control Worksheet offers a good starting point.
Review resident and staff vaccination status
“Providers should offer influenza and pneumococcal vaccines to all the residents that originally declined, as well as offering the influenza vaccine to all staff that originally declined,” suggests Schweon. The most recent CDC data indicates that influenza activity remains widespread in 48 states and Puerto Rico, and CDC officials have noted that people can have influenza and COVID-19 at the same time.
Prepare for PPE worst-case scenarios
“Basically, CMS and the CDC say that the decision for patient transfer to the acute-care hospital needs to be made per the patient’s goals of care, as well as their clinical status,” points out Gaur. “They don’t want you to just say, ‘I have a COVID-19 case, therefore I can’t afford to keep them in the building.’ The first question when determining whether to transfer a COVID-19 patient to the hospital needs to be: Is the patient sick enough to go to the hospital? If the answer is yes, then the second question is: What are the goals of care?”
Now that the CDC no longer says that an airborne infection isolation room (AIRR) is required to care for patients with suspected or confirmed COVID-19, the biggest problem is N95 respirators, says Gaur. N95 respirators or higher-level respirators, such as powered air purifying respirators (PAPRs), should be used with gown, gloves, and eye protection to care for residents with suspected or confirmed COVID-19 when (1) staff “have been medically cleared, trained, and fit-tested, in the context of a facility’s respiratory protection program” and (2) PPE shortages don’t restrict their use, says the CDC in Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. Note: In mid-March, the Occupational Safety and Health Administration (OSHA) issued temporary enforcement guidance recommending that healthcare employers change to a qualitative fit testing method from a quantitative testing method to preserve the integrity of N95 respirators.
If a facility does not have a respiratory protection program with fit-tested staff, the CDC recommends using a face mask instead of a respirator in conjunction with the gown, gloves, and eye protection to care for residents with suspected or confirmed COVID-19.
“The problem with CMS’s directive to use goals of care and clinical status to determine whether a patient should be transferred is that nursing homes often don’t have that access to N95 respirators or the ability to do fit-testing—and many reportedly are even running low on face masks and other PPE,” acknowledges Gaur.
Depending on the local situation, providers may be required to care for residents with suspected or confirmed COVID-19 using the CDC’s new strategies for optimizing the supply of PPE in both contingency capacity situations (i.e., temporary measures to address expected shortages that may change daily standard practices but may not significantly impact care or staff safety) and crisis capacity situations (i.e., temporary measures to address known shortages that aren’t commensurate with U.S. standards of care). The CDC has provided optimization strategies for eye protection, isolation gowns, face masks, and N95 respirators. Providers should incorporate these strategies in their plan to address PPE supply shortages, says Gaur.
Note: Providers may need to think outside the box to ensure they have adequate supplies of PPE and other necessary supplies. For example, distilleries, breweries, and wineries across the country are now making alcohol-based hand sanitizer, which may be a viable option for providers who can’t obtain it via suppliers, state health coalitions, or state health departments. See a partial listing here.
Review all aerosol-generating procedures
When providers have N95 respirators available as part of a respiratory protection program, the CDC considers them most critical for high-risk procedures. “One example of a high-risk procedure is getting a swab sample from a resident with suspected COVID-19 because of the likelihood of a close-range sneeze or cough. However, they also include other aerosol-generating procedures, such as nebulizer treatments, suctioning, and tracheostomy care,” says Gaur.
“Initially, we generated lists of all current residents who are on breathing treatments and double-checked that PRN nebulizers were still needed. We have since realized that aerosol-generating procedures like nebulizers are the highest risk,” says Gaur. “The particles have the potential to be suspended in air for a considerable amount of time. In addition, the need for a nebulizer may be the only sign that a resident is having difficulty breathing. That should generate a discussion of why the resident needs the breathing treatment: Is it a surrogate for shortness of breath? Therefore, we have completely eliminated PRN nebulizers.”
In fact, some nursing homes in Washington state that have had COVID-19 outbreaks have stopped using nebulizers at all, says Sabine von Preyss-Friedman, president of the Washington State Society for Postacute and Long-term Care Medicine (WA-PALTC) and a medical director at several Seattle-area nursing homes. Note: Von Preyss-Friedman has developed a useful list of exposure management strategies based on the experiences of Washington facilities.
Residents using nebulizers could be switched to metered-dose inhalers for the duration, suggests John Lynch, MD, who is the medical director for infection prevention programs at a Seattle hospital and leader of the University of Washington’s COVID-19 response team.
Another aerosol-generating procedure that nursing homes need to consider is BIPAP, suggests Lynch. Given that many nursing home residents depend on BIPAP to maintain their health, providers should consider mitigation strategies.
Lay out rules for hospital transfers
When a resident with suspected or confirmed COVID-19 does need to be transferred, CMS expects providers to alert both emergency medical services and the receiving facility. “To ensure everyone is informed, staff should state that a patient has suspected or confirmed COVID-19 in the 911 call,” says Gaur. “It’s also good practice to have them give both a verbal and a written report to the accepting emergency department. Using both communication methods helps ensure your staff do everything possible to limit the exposure of other healthcare personnel.”
Editor’s note: Bell spoke at the March 13 CDC clinician outreach and communication activity (COCA) call, COVID-19 Update and Infection Prevention and Control Recommendations. Slifka spoke at the March 17 COCA call, COVID-19 Update and Information for Long-term Care Facilities. Von Preyss-Friedman and Lynch spoke at the March 12 WA-PALTC webinar, COVID-19: What You Can Do Now.
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