Guidance and responses were provided based on information known on 4/2/2020 and may become out of date. Guidance is being updated rapidly, so users should look to CDC and NE DHHS guidance for updates. COVID-19 and LTC April 2, 2020
Questions and Answer Session 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 https://icap.nebraskamed.com/covid-19-webinars-and-tools Panelists today are: Dr. Salman Ashraf, MBBS salman.ashraf@unmc.edu. Dr. Maureen Tierney, MD, MSc Maureen.Tierney@Nebraska.gov. 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.
Lessons learned • Healthcare worker screening matters • Healthcare workers with even 1 symptom consistent with COVID-19 should not work • Basic infection control matters. Continue to push hand hygiene. Gloves never replace the need to clean hands. • Dedicating HCW staff to symptomatic residents may help limit spread
Accepting Hospitalized Residents Back to the Nursing Home Initially admitted for non-COVID-19 illness and Still No COVID concerns: Can be admitted back to the Nursing Home (consider a transition unit/holding area for 14 days within the facility) with contact/droplet precautions during observation period (AMDA) A COVID test is not required for acceptance back into facility. However, if a COVID test has been performed, transfer should wait until results are back Had COVID-19 concerns/ symptoms but now ruled out: Can be admitted back to the Nursing Home (consider a transition unit/holding area for 14 days within the facility and keep them in contact/droplet precaution until respiratory symptoms resolves and 14 days have passed) Was COVID-19 positive and are recovering: Will either remain in the acute care hospital or be admitted to designated COVID-19 treatment/recovery centers until no longer infectious and then will be transferred back to the nursing home https://paltc.org/sites/default/files/COVID%2019%20QA%20Community%20Spread%20 March%2023.pdf
What are the recommendations for nursing homes that are not able to clear a hall or area to be designated as a transition area because they do not have available rooms? Dedication of a unit or wing is not a requirement to admit a resident back who does not have any reason to be suspected for COVID 19 or has already been ruled out for COVID 19. Those facilities without the capacity of creating such a unit can still admit the resident and actively monitor them daily for fever and respiratory symptoms. However, if the facility has the capacity to implement this additional steps and they want to be extra cautious they can consider it. The exact wording from the CMS guidance is as follows: " Note: Nursing homes should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was/is present. Also, if possible, dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where they remain for 14 days with no symptoms (instead of integrating as usual on short-term rehab floor, or returning to long-stay original room)." https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf.
If there is a positive COVID19 resident that does not require hospitalization, should full PPE be worn for direct care provided to all residents because some may be infected but still asymptomatic. Is that the recommendation? 1. If a resident has tested positive for COVID-19 in a nursing home, the current plan is to have discussion with that nursing home and resident and the resident may be transferred out of the nursing home to a designated COVID-19 care center. 2. We did discuss that there can be a situation where while we are considering transfer of the COVID -19 positive resident, we may simultaneously be trying to rule out active transmission of COVID-19 within that facility. In that specific situation, temporarily , healthcare workers may have to use PPE while taking care of everyone in a particular unit, wing or facility. However the key is that it will only happen if there is confirmed case of COVID -19 in a nursing home and an investigation is taking place to make sure there is no evidence of active transmission in the nursing home. In this particular scenario, nursing home will be working together with the local health department in making those decisions. In all other scenarios, PPE use should be in accordance with standard guidance that we are currently using in every day practice. https://icap.nebraskamed.com/wp-content/uploads/sites/2/2020/03/CDC-NH-COVID- 19-Assessment-Tool-3.19.2020.pdf
NE DHHS: All HCW in LTC should wear a mask for clinical care http://dhhs.ne.gov/Documents/COVID-19%20Long-Term%20Care%20Facilities.pdf.
PPE Steps you must take Conduct a physical inventory - every neighborhood, common area, supply closet Immediately take control – under lock and key – of PPE supplies, no matter how well-sourced you feel you are Immediately explain why – – In order to ensure that supplies are available when needed Initiate a system for responsible dispensing – who is on isolation, why; use Omnicell/Pyxis or manual log sheets for record of where inventory goes Adapted from The NETEC COVID-19 PPE Webinar - Extended use, reuse, and innovative decontamination strategies https://repository.netecweb.org/items/show/861
PPE Steps you must take Consider a PPE calculator, example: 4 masks per resident bed (if reused per staff member one day only) 8 disposable isolation gowns/floor patient/day Make estimates for the largest number of beds you could possibly have occupied with COVID-19 Plan now for the next phase, communicate what might come next Extended Use Reuse for multiple days Equipment disinfection Cloth and patient gowns as PPE Educate:We are a creative lot, but we do not want people putting themselves in danger (no wiping or soaking masks, do not microwave or bleach them) Adapted from The NETEC COVID-19 PPE Webinar - Extended use, reuse, and innovative decontamination strategies https://repository.netecweb.org/items/show/861
PPE Steps you must take Strategize for minimizing entry into resident rooms Telemedicine Tele-everything! Food and nutrition, social work, discharge planning Cluster tasks and meal-times Limit specimen collection times Reduce hospitality and housekeeping events, weekly and PRN linen change Consultant Pharmacist to review MAR’s to cluster meds in sequence (single access) Adapted from The NETEC COVID-19 PPE Webinar - Extended use, reuse, and innovative decontamination strategies https://repository.netecweb.org/items/show/861
Nursing Home Infection Prevention Assessment Tool for COVID-19 (3/19/2020) https://icap.nebraskamed.com/wp-content/uploads/sites/2/2020/03/CDC-NH- COVID-19-Assessment-Tool-3.19.2020.pdf And https://www.cms.gov/files/document/qso-20-20-allpdf.pdf-0 Prioritization of Survey Activities, CMS 3/23/2020 • to assist nursing homes with preparing to care for residents with COVID-19 • Elements should be assessed through a combination of interviews with staff and direct observation of practices in the facility • Per CMS “We expect facilities to use this…to perform voluntary self- assessment of their ability to prevent the transmission of COVID- 19.” • This document may be requested by surveyors, if an onsite investigation takes place.
Frequently Asked Questions Regarding COVID-19 and PALTC When COVID-19 Is Currently In Your Regional Community (i.e., Community Spread) https://paltc.org/sites/default/files/COVID%2019%20 QA%20Community%20Spread%20March%2023.pdf . This is the source document for guidance on slides 14-22, 26 & 27
We have the first positive COVID-19 case in PALTC. How do we approach this?
Facility-specific goal: • Minimize spread of infection to other residents and staff: • All residents on the unit should be carefully screened for common and uncommon symptoms of COVID-19. • If a resident is diagnosed with COVID-19 on a unit, do testing of other symptomatic residents on the affected unit. • If there are multiple cases positive on the unit for COVID-19, cohort patients to one unit, hall or wing. • No movement of staff between units. • No sharing of equipment, including medicine carts and wound care supplies, between the units. • Practice strict adherence to infection control practices-contact, droplet and eye protection • Rehabilitation services should be suspended for the COVID-19 unit. • Facilities should only cohort COVID-19 confirmed residents and not cohort suspected cases on respiratory isolation pending testing results (but se contact and droplet with eye protection pending results) • Patients who are COVID-19 positive (and both negative for flu or other respiratory viruses) can be in the same room.
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