On-Site Assessments
Each HCP has a N95 to use on a designated day of the week and bag for storage until the next week. While examining the bag, you see a CNA removing and donning her N95 without performing hand hygiene before or after. Additionally you observe the storage bag has 7 marks indicating its been worn at least 7 times.
What are your initial concerns with this strategy, and how do you approach providing feedback to the facility?
Extended use goes up to 5 days
Have hand sanitizer available and accessible around the facility
Retrain and post instructions around facility on how to properly don and doff PPE
Ask about PPE stock (may be the reason for extended use).
After providing recommendations for creation of a separate observation unit for newly admitted or readmitted residents, you discuss PPE use for residents in this unit. The facility is not currently experiencing any PPE shortages. However, in anticipation of caring for residents with COVID-19 the Administrator wants to implement PPE extended use and re-use strategies in the observation unit to conserve supplies.
Do you have any concerns with the Administrator’s PPE strategy for the observation unit?
All recommended COVID-19 PPE should be worn during care of residents under observation due to SARS-CoV-2 exposures, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (I.e. goggles, or a disposable face shield that covers the front and sides of the face) gloves and gown.
As residents under observation may have COVID-19 prior to admission/re-admission, the use of optimization strategies such as extended and/or re-use for certain types of PPE (e.g. gowns) could result in the transfer of infectious materials to residents without COVID-19.
Since this facility has no active COVID-19 cases and is not experiencing a shortage of PPE, the administrator should plan to utilize conventional practices and monitor daily burn rates for each type of PPE.
You can follow up with the administrator on PPE optimization strategies following the tele-ICAR.
What are some considerations that facilities should have if they decide to have vaccination clinics in the setting of an outbreak?
Individuals in LTCF and other congregate settings are at high risk of SARS-CoV-2 infection and residents should be vaccinated at the earliest opportunity. Individuals residing in facilities with active outbreaks (except those isolated due to acute SAR-CoV-2 infection) should receive vaccination as soon as possible to avoid delays and missed opportunities given the high burden of disease in these populations.
Residents or staff with an exposure who are awaiting results of a SARS-CoV-2 test may be vaccinated if the person does not have symptoms consistent with COVID.
While residents and staff who have recovered from COVID-19 during the past 90 days have the option to defer vaccination, this is not a requirement and they may still receive vaccine prior to the end of the 90-day period.
How would you approach an administrator’s concerns about staffing shortages?
Facilities should encourage HCP who are ill to stay at home. Even though serial testing may identify more cases of COVID-19 among staff members, it may ultimately limit transmission within a facility.
Fully vaccinated HCP with higher-risk exposures who are asymptomatic do not need to be restricted from work for 14 days following their exposure though it may still be considered for those who have underlying immunocompromising conditions.
Communicate with local healthcare coalitions, federal, state and local public health partners to identify additional HCP outside of regular staffing channels (e.g. recruiting retired HCP or volunteers)
Liberty has a dedicated COVID-19 care unit. They not only plan to place any COVID-19 positive residents in the unit, but also new admissions/readmitted residents and residents who frequently leave the facility.
What are your thoughts and recommendations on how the facility is placing residents in the COVID-19 unit?
Placement of residents who are not diagnosed with SARS-CoV-2 infection should not be placed on a dedicated COVID-19 unit.
Newly admitted residents diagnosed with SARS-CoV-2 infection who have not yet met criteria for discontinuation of transmission-based precautions should be placed in the COVID-19 unit.
In general, all other new admission and readmissions should be placed in a 14 day quarantine, even if they have a negative test upon admission.
Residents who leave the facility, regardless of vaccination status, should be reminded to follow all recommended IPC practices including source control, physical distancing and hand hygiene.
In most circumstances, quarantine is not recommended for residents who leave the facility for less than 24 hours (e.g. for medical appointments, community outings) and do not have close contact with someone with SARS-CoV-2 infection
Facilities might consider quarantining residents who leave the facility if uncertainty exists about their adherence of those around them to recommended IPC measures.
What are some considerations facilities should have regarding resuming visitation?
Facilities may consider allowing indoor visitation when there is not an ongoing outbreak.
Visitations should not be considered in the following circumstances:
A) Unvaccinated individuals residing in facilities where < 70% of residents are vaccinated and in counties with >10% positive rate.
B) Vaccinated and unvaccinated residents requiring transmission – based precaution for exposure to SARS-CoV- 2.
Facilities should also explain the risk of visitation to all residents regardless of vaccination status to allow for informed decisions
Both visitors and residents should wear mask and social distance through out the visit if possible.
What are some of the considerations when managing resident(s) of a Memory Care Unit who have been diagnosed with COVID-19?
Some memory care units may be secured or provide restricted access (e.g. using a code) to control entry and exits, and have specially trained staff or teams working with residents.
Familiar routines and caregivers are important, sudden changes may result in agitation or aggression.
Social distancing in memory care units is particularly challenging, as residents may not understand the need to avoid close contact and others may need physical redirection from staff to avoid wandering or injury.
During the video Tele-ICAR with Liberty, an ICAR facilitator learns that there are currently no confirmed COVID-19 cases (residents or HCP); however, they are testing all unvaccinated HCP every Monday using their point of care antigen testing platform since they have a >10% county positivity rate. There was no mention of testing via RT-PCR.
Multiple HCP specimens are collected at the same time in a vacant conference room prior to the start of the morning shift. The POC antigen machine and testing supplies are stored in this room so that samples may be processed there after collection.
Do you agree with the facility’s HCP testing strategy? Are there ways the HCP testing strategy could be improved?
Outside of an outbreak, routine testing of unvaccinated HCP is recommended based on SARS-CoV-2 community transmission, As the county positivity rate was >10% the facility should be testing all unvaccinated HCP at least twice per week.
The facility should have a process of confirmatory RT-PCR testing of presumptive negative results for symptomatic HCP and for presumptive positive results in asymptomatic HCP.
HCP specimen collection should be performed one at a time in a closed room with no one else present. Other options include use of a HEPA filter to increase air exchanges in the conference room, performing collection in a large space (e.g. gym) or outdoors, testing different groups at different times to minimize crowding, or implementing self-collection to minimize PPE use.
POC testing machines and supplies should be stored separately from areas where samples are collected to prevent contamination. Delays from sample collection to testing should be minimized.
What guidance would you provide to a HCP who was recently vaccinated but is experiencing systemic sign of symptoms (e.g. headache, fever, muscles aches, chills)?
These signs and symptoms tend to resolve after two days for most people.
In situations whether the recently vaccinated staff member does not have other signs or symptoms that may be due to SARS-CoV-2 infection and otherwise feels well enough to work, the HCP may be allowed to return to work without viral testing.
However, an HCP experiencing signs or symptoms that are unlikely to be related to COVID-19 vaccination but that may be due to SARS-CoV-2 infection (cough, shortness of breath, rhinorrhea (runny nose), sore throat, loss of taste or smell) should be excluded from work.
For HCP who are symptomatic and test negative by POC antigen testing, and a negative confirmatory SARS-CoV-2 RT-PCR test is recommended.