COVID-19 and LTC March 26, 2020 NE COVID Epi Totals and Positives - PowerPoint PPT Presentation

Guidance and responses were provided based on information known on 3/26/2020 and may become out of date.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 March 26, 2020

NE COVID Epi

Totals and Positives by lab Totals by lab NPHL 491 UNMC 504 Lab Corp 135 Quest 132 Mayo 82 ARUP 8

Risk Factors Travel — 50-60% UK, Italy, Singapore, WA, CA, FL, CO, NY Contact-25-35% Community Acquired-4 Selection/Testing Bias Models from other cities likely 15-20 cases for every positive we see.

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.

Important Reminders Keep COVID-19 from entering your facility: • Restrict all visitors except for compassionate care situations (e.g., end of life). • Restrict all volunteers and non-essential healthcare personnel (HCP), including consultant services (e.g., barber). • Actively screen all HCP for fever and respiratory symptoms before starting each shift; send them home if they are ill. • Cancel all field trips outside of the facility. • Have residents who must regularly leave the facility for medically necessary purposes (e.g., residents receiving hemodialysis) wear a facemask whenever they leave their room, including for procedures outside of the facility. https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf

Identify infections early: • Actively screen all residents at least daily for fever and respiratory symptoms; immediately isolate anyone who is symptomatic. • Long-term care residents with COVID-19 may not show typical symptoms such as fever or respiratory symptoms. Atypical symptoms may include: • new or worsening malaise • new dizziness • Diarrhea • sore throat Identification of these symptoms should prompt isolation and further evaluation for COVID-19 if it is circulating in the community.

Resident Screening Resources Notify the health department if: • severe respiratory infection • clusters (≥3 residents and/or HCP) of respiratory infection, or • individuals with known or suspected COVID-19 are identified. https://icap.nebraskamed.com/wp-content/uploads/sites/2/2020/03/AMDA-Resident- Screening-Form.pdf

Prevent spread of COVID-19: • Cancel all group activities and communal dining. • Enforce social distancing among residents. • When COVID-19 is reported in the community, implement universal facemask use by all HCP (source control) when they enter the facility; If facemasks are in short supply, they should be prioritized for direct care personnel. All HCP should be reminded to practice social distancing when in break rooms or common areas. • If COVID-19 is identified in the facility, restrict all residents to their room and have HCP wear all recommended PPE for all resident care, regardless of the presence of symptoms. Refer to strategies for optimizing PPE when shortages exist. This approach is recommended to account for residents who are infected but not manifesting symptoms. Recent experience suggests that a substantial proportion of longterm care residents with COVID-19 do not demonstrate symptoms. • When a case is identified, public health can help inform decisions about testing asymptomatic residents on the unit and in the facility. https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf

Assess supply of personal protective equipment (PPE) and initiate measures to optimize current supply: • For example, extended use of facemasks and eye protection or prioritization of gowns for certain resident care activities https://www.cdc.gov/coronavirus/2019- ncov/hcp/ppe-strategy/index.html. Identify and manage severe illness: • Facility performs appropriate monitoring of ill residents (including documentation of pulse oximetry) at least 3 times daily to quickly identify residents who require transfer to a higher level of care.

See link to complete document at the Nebraska ICAP website: https://icap.nebraskamed.com/wp- content/uploads/sites/2/2020/03/CDC-NH- COVID-19-Assessment-Tool-3.19.2020.pdf Listing of the local health departments and contacts: http://dhhs.ne.gov/CHPM%20Documents/contacts.pdf

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) 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 appropriate transmission based precaution until respiratory symptoms resolves) Was COVID-19 positive and are recovering: Will be admitted to designated COVID-19 treatment/recovery centers until completely recovered and then will be transferred back to the nursing home

Discontinuation from self-quarantine and self-monitoring may cease if after 14 days there has been NO development of respiratory illness symptoms. Symptoms may include: fever, cough, shortness of breath, sore throat, runny nose. CDC guidance (www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when- sick.html)states that an individual can stop self-isolation if: – It has been at least 7 days since symptoms first appeared – AND – No fever for at least 72 hours (fever-free for 3 full days off fever-reducing medicine) AND – All other symptoms have improved (e.g., cough has improved)

Definitions Social distancing: Minimize interactions in crowded spaces by working from home, closing schools/switching to online classes, cancelling/postponing conferences and large meetings, and keeping individuals spaced 6 feet apart. Self-monitor: Monitor yourself for symptoms consistent with COVID-19 infection, including cough, shortness of breath, fever, and fatigue. Persons with known exposure to COVID-19 infection are asked to check for symptoms including fever twice daily (e.g., 8 am and 8 pm). Persons with COVID-19 infection should document symptoms to enable accurate determination of duration of isolation (see above). Self-quarantine: Persons with known exposure to a person with COVID-19 infection should remove themselves from situations where others could be exposed/infected should they develop infection, and self-monitor to identify if COVID-19 infection develops. Self-isolate: Persons with clinical or lab-confirmed for COVID-19 infection should eliminate contact with others as detailed above. Commuters crossing state borders (e.g., Council Bluffs to Omaha, Sioux City to South Sioux City, and Cheyenne to Scotts Bluff), travelers passing through the state/moving within the state, and transportation service workers are not considered special at-risk groups and are not addressed in these our-of-state returning traveler recommendations.

Discontinuation of Isolation Test-based strategy (simplified from initial protocol) Previous recommendations for a test-based strategy remain applicable; however, a test-based strategy is contingent on the availability of ample testing supplies and laboratory capacity as well as convenient access to testing. For jurisdictions that choose to use a test-based strategy, the recommended protocol has been simplified so that only one swab is needed at every sampling .

Discontinuation of Home Isolation Time-since-illness-onset and time-since-recovery strategy (non-test- based strategy)* Persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions: • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and • improvement in respiratory symptoms (e.g., cough, shortness of breath); • and, • At least 7 days have passed since symptoms first appeared . • Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart ** (total of two negative specimens).

Discontinuation of Isolation Individuals with laboratory-confirmed COVID-19 who have not had any symptoms may discontinue home isolation when at least 7 days have passed since the date of their first positive COVID-19 diagnostic test and have had no subsequent illness. Footnote *This recommendation will prevent most, but may not prevent all instances of secondary spread. The risk of transmission after recovery, is likely very substantially less than that during illness.