COVID-19 Long-term Care Office Hour Healthcare-associated Infections & Antibiotic Resistance Program
Louisiana Department of Health Office of Public Health | Infectious Disease Epidemiology Section July 10, 2020 at 10:00 a.m.
Special thanks to our nurses. #YearOfTheNurse HAI/AR Program Long-term Care Office Hours
Fridays from 10:00 – 11:00 a.m. through July 31st
Observations from COVID-19 containment in healthcare settings
Sharing forum for long-term care facilities
Registration (new link!): https://bit.ly/2V1C3vE
Office Hours Moderators Dr. Grace Lee Preventative Medicine Resident, Tulane University Alexa Ramirez HAI Surveillance Epidemiologist Ashley Terry AR Surveillance Epidemiologist Erica Washington HAI/AR Program Coordinator Condensed Recap “Like with Like”
Test-based strategies
Factors that affect exposure
COVID – COVID – COVID + High Exposure Low Exposure Nursing Home Testing Strategy for COVID-19
Initiate point Review test Reassess the Re-conduct Review test results from the prevalence results. percentage of testing. If no second round. If no positives are testing among Consider positives to positives, or a identified among residents and residents and retesting at determine if low number of staff, then cease general resident staff even if an interval re-testing positives, are testing. Continue to test staff there are no that is should occur identified among weekly as well as residents who current COVID shorter than 3-4 days or 7 residents and are immunocompromised and/or cases in the 7 days, e.g. days from staff, retest a have frequent medically- facility. 3-4 days. today. week later. necessary visits.
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Q&A: Does this apply to prior positive COVID cases? No. This scheme is to identify new positives among people who were either untested or who previously tested negative. Should a facility with no cases that has never done point prevalence testing undergo testing? Yes. The testing will identify asymptomatic and pre-symptomatic cases that should be cohorted away from susceptible patients. If all residents have, or have had, COVID, does staff testing need to continue? Yes. Staff can still potentially infect each other. Additionally, we don’t have clear guidance on immunity for COVID cases and for how long such immunity will be so it is best to stay vigilant. How long does testing need to continue? Ending testing is a decision that should be made in conjunction with the Louisiana Office of Public Health. Considerations for community activity and reopening phase for the State of Louisiana should be reviewed.
High number of positives (≥20%) identified on the initial (or longitudinal) testing round. Guidance applies to all conditions (high, low, or no positives identified on point prevalence round.
No Visitation in Nursing Homes
LDH is not approving visitation - whether indoor or outdoor – in long-term care facilities. We’re seeing a statewide spike in cases. Visitation may introduce avoidable risks to our most vulnerable residents Please continue to encourage virtual and
window visits as appropriate. LDH Coronavirus Dashboard | Data updated: 7/2/2020 http://ldh.la.gov/coronavirus/ We have to do everything possible to keep our residents safe. CDC National Healthcare Safety Network Updates CDC National Healthcare Safety Network Updates Patients with Persistent or Recurrent Positive Tests
Some Takeaways Studies that have looked at how long SARS-CoV-2 RNA can be detected in adults have demonstrated that in some persons it can detected for weeks. Cycle threshold (Ct) values cannot be used to assess when a person is no longer infectious. Ct values are not a measure of viral burden Ct values are not standardized by RT-PCR platform If a person who previously tested positive by RT-PCR for SARS-CoV-2 and clinically recovered from COVID-19 is later tested again is positive by RT-PCR, they should be managed as potentially infectious and isolated. The determination of whether a patient with a subsequently positive test is contagious to others should be made on a case-by-case basis, in consultation with infectious diseases specialists and public health authorities, after review of available information If an infected person has clinically recovered using the symptom-based strategy, they do not need a test of cure. The symptom-based strategy is intended to replace the need for repeated testing. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#Patients-with-Persistent-or-Recurrent- Positive-Tests
Auditing Program Key Points
Observation is the only way to directly measure health care worker adherence to hand hygiene guidelines. Adherence rates will vary depending on which indications are measured, by whom, and in which patient populations, as well as by the method used for calculating rates. Spending time and effort in training data collectors and selecting user-friendly forms with clear instructions will greatly enhance the accuracy and credibility of the measurement results. Last Week’s Q&A Case Studies Case #1 The dialysis organization designates positive and negative facilities. Where should this patient go for dialysis (positive or negative facility) and how should they be handled at the nursing home?
Test Date Location Result Notes 4/9/2020 Nursing Home Positive Symptomatic 4/13/2020 Nursing Home Positive Isolation, enrolled into dialysis 4/30/2020 Hospital Positive Enrolled in COVID dialysis center 5/20/2020 Dialysis Negative 5/19/2020 Nursing Home Negative 5/21/2020 Nursing Home Negative 5/24/2020 Dialysis Negative
6/3/2020 Hospital Positive Shunt displacement; rapid test in ER
6/4/2020 Hospital Negative Routine procedure test 6/8/2020 Nursing Home Positive Rapid test Case #1 Answer
Test results, whether full PCR or rapid tests, should inform your actions for handling patients. The latter positive results may or may not indicate infectiousness. In light of this, CDC recommends the most conservative approach for her care.
She should be placed in isolation at your facility, and
She should attend the COVID+ dialysis facility. Case #2
We have a resident that went to doctor appointment and she did wear mask while out and did have temp taken and all precautions. Do we still have to put her in quarantine for 2 weeks? Case #2 Answer
Yes, we recommend placing this resident in a private room for two weeks. Wearing a mask should help decrease risk to the resident, but it doesn’t eliminate it. In these situations it’s better to be cautious. Case #3
LDH’s guidance is a bit different from CDC’s. Which should I follow? Guidance Hierarchy LDH may make guidance documents, requirements, and materials that are more cautious than those disseminated by federal partners based on local data and feedback from healthcare facilities. Louisiana’s criteria are more conservative than Centers for CDC’sDisease for several reasons: Louisiana Department Control •andSARS -CoV-2 is still a novel of Health Preventionvirus, • the Department’s ultimate desire is to keep our citizens safe by stopping transmission, and • scientific knowledge of the virus is still growing. Case #4
We performed another facility wide test battery on 6-30-2020 and received our results last night. Thankfully, all of our residents are negative. Unfortunately, we did have another employee test positive (one of our dietary staff members). She continues to be asymptomatic and is currently being furloughed as recommended. We will continue weekly testing of staff on Monday and Tuesday. So far out of the four employees who tested positive previously, two have met the return to work criteria and continue to test negative. Case #4 Feedback
Staff who have tested positive in the past and recovered do not need to be included in your regular, weekly testing. Please continue to test all staff who have either never been tested in the past or who have only ever tested negative for COVID. Staff who have persistent positives must proceed with the test-based strategy must continue on that path until recovery criteria have been met (2 consecutive negative tests collected >24h apart). Case #5
Employee headache 6/29 & 6/30; history of allergies; takes 2 meds/ day for allergies. Asking to be screened for concern of taking care of disabled child and grandchildren. Did mention 2 weeks ago had a cough with some head congestion. But not reported until today. Also to note, we do have a symptomatic positive employee within this building (but in separate rooms from each other). There is some panic. The risk of encounter with our positive employee and this particular employee was low. I decided to swab her. Should she be sent home? Case #5 Answer Don’t dismiss symptoms to allergies! Anyone with symptoms should be tested and sent home to self-isolate until the results are back. These are the common symptoms listed by CDC:
• Fever or chills • New loss of taste or smell • Cough • Sore throat • Shortness of breath or difficulty breathing • Congestion or runny nose • Fatigue • Nausea or vomiting • Muscle or body aches • Diarrhea • Headache Both employees have been symptomatic; therefore, both should be sent home. Open Forum Future LTC Office Hours Content
Date Content July 3, 2020 Developing a respiratory protection program July 10, 2020 Case studies July 17, 2020 Dialysis and nursing care July 24, 2020 TBD July 31, 2020 TBD
• Content subject to change • Contact [email protected] if you have a success story you wish to share on a future call CDC COVID-19 Guidance
CDC continues to learn more about Coronavirus Disease 2019 (COVID-19) and the guidance around Healthcare Infection Prevention and Control (IPC) for healthcare settings is constantly changing to reflect developing knowledge. Below is a list of some of the healthcare IPC related guidance documents and resources recently published or updated by CDC: o FAQ on Infection Control (5/29/20) o Monitoring HCP Guidance (5/29/20) o Guidance for Pharmacists and Pharmacy Technicians (5/28/20) o Key Strategies for Long-term Care Facilities (5/21/20) o Ambulatory Care Settings (5/21/20) o Healthcare Facility Guidance (5/21/20) o Testing for Coronavirus in Nursing Homes (5/19/20) o Performing Facility-wide SARS-CoV-2 Testing in Nursing Homes (5/19/20) o Nursing Homes & Long-Term Care Facilities (5/19/20) o Interim IPC Guidance for Dental Settings (5/19/20) o Infection Control Guidance (5/18/20) o COVID-19 Case Investigation and Contact Tracing (5/18/20) o Hand Hygiene (5/17/20) o Supporting Loved Ones in LTC Facilities (Factsheet) (5/15/20) o Preparing Your Dialysis Facility for COVID-19 (Factsheet) (5/15/20) o Patients on Home Dialysis (5/13/20) o Considerations for Memory Care Units in Long-term Care Facilities (5/12/20) Resources
PPE requests: call the State Supply Hotline at 225-325-5900. Region 4 facilities should call the regional office for supplies: 337-262-5311.
EPA products effective against SARS-CoV-2: https://www.epa.gov/pesticide-registration/list-n- disinfectants-use-against-sars-cov-2.
IDEpi Contacts Regional Surveillance http://ldh.la.gov/index.cfm/page/1045 Epidemiologists [email protected] Infection Control Inquiries COVID Quick References http://ldh.la.gov/index.cfm/page/3876 24-h line for providers 1-800-256-2748