Preparing for COVID-19: Long-term Care Facilities, Nursing Homes
March 19, 2020
Source: Centers for Disease Control and Prevention
A new respiratory disease – coronavirus disease 2019 (COVID-19) – is spreading globally and there have been instances of COVID-19 community spread in the United States. The general strategies CDC recommends to prevent the spread of COVID-19 in LTCF are the same strategies these facilities use every day to detect and prevent the spread of other respiratory viruses like influenza.
Symptoms of respiratory infection, including COVID-19:
- Shortness of breath
Long-term care facilities concerned that a resident, visitor, or employee may be a COVID-2019 patient under investigation should contact their local or state health department immediately for consultation and guidance.
COVID-19 Preparedness Checklist for Nursing Homes and other Long-Term Care Settings
Nursing homes and other long-term care facilities can take steps to assess and improve their preparedness for responding to coronavirus disease 2019 (COVID-19). This checklist should be used as one tool to develop a comprehensive COVID-19 response plan, including plans for:
- Rapid identification and management of ill residents
- Considerations for visitors and consultant staff
- Supplies and resources
- Sick leave policies and other occupational health considerations
- Education and training
- Surge capacity for staffing, equipment, and supplies, and postmortem care
The checklist identiﬁes key areas that long-term care facilities should consider in their COVID-19 planning. Long-term care facilities can use this tool to self-assess the strengths and weaknesses of current preparedness efforts. This checklist does not describe mandatory requirements or standards; rather, it highlights important areas to review to prepare for the possibility of residents with COVID-19.
Interim Additional Guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-19 in Nursing Homes
Summary of Changes to Guidance:
Updated guidance to recommend that nursing homes:
- Restrict all visitation except for certain compassionate care situations, such as the end of life situations
- Restrict all volunteers and non-essential healthcare personnel (HCP), including non-essential healthcare personnel (e.g., barbers)
- Cancel all group activities and communal dining
- Implement active screening of residents and HCP for fever and respiratory symptoms
COVID-19 is being increasingly reported in communities across the United States. It is likely that SARS-CoV-2 will be identified in more communities, including areas where cases have not yet been reported. As such, nursing homes should assume it could already be in their community and move to restrict all visitors and unnecessary HCP from the facility; cancel group activities and communal dining, and implement active screening of residents and HCP for fever and respiratory symptoms.
Given their congregate nature and residents served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at the highest risk of being affected by COVID-19. If infected with SARS-CoV-2, the virus that causes COVID-19, residents are at increased risk of serious illness.
Ill visitors and healthcare personnel (HCP) are the most likely sources of introduction of COVID-19 into a facility. CDC recommends aggressive visitor restrictions and enforcing sick leave policies for ill HCP, even before COVID-19 is identified in a community or facility.
These recommendations supplement CDC’s Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings. These recommendations are specific for nursing homes, including skilled nursing facilities. Much of this information could also be applied to assisted living facilities. This information complements but does not replace, the general infection prevention and control recommendations for COVID-19.
This guidance is based on the currently available information about COVID-19. It will be refined and updated as more information becomes available and as response needs change in the United States. It is important to understand transmission dynamics in your community to inform strategies to prevent the introduction or spread of COVID-19 in your facility. Consultation with public health authorities can help you better understand if transmission of COVID-19 is occurring in your community.
Things facilities should do now
Educate Residents, Healthcare Personnel, and Visitors
- Share the latest information about COVID-2019.
- Review CDC’s Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings.
- Educate and train HCP.
- Reinforce sick leave policies. Remind HCP not to report to work when ill.
- Reinforce adherence to infection prevention and control measures, including hand hygiene and selection and use of personal protective equipment (PPE). Have HCP demonstrate competency with putting on and removing PPE.
- Educate both facility-based and consultant personnel (e.g., wound care, podiatry, barber) and volunteers. Including consultants is important because they often provide care in multiple facilities and can be exposed to or serve as a source of pathogen transmission.
- Educate residents and families including:
- information about COVID-19
- actions the facility is taking to protect them and their loved ones, including visitor restrictions
- actions residents and families can take to protect themselves in the facility
Provide Supplies for Recommended Infection Prevention and Control Practices
- Hand hygiene supplies:
- Put alcohol-based hand sanitizer with 60–95% alcohol in every resident room (ideally both inside and outside of the room) and other resident care and common areas (e.g., outside dining hall, in therapy gym).
- Make sure that sinks are well-stocked with soap and paper towels for handwashing.
- Respiratory hygiene and cough etiquette:
- Make tissues and facemasks available for coughing people.
- Consider designating staff to steward those supplies and encourage appropriate use by residents, visitors, and staff.
- Make necessary Personal Protective Equipment (PPE) available in areas where resident care is provided. Put a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room, or before providing care for another resident in the same room. Facilities should have supplies of:
- respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP)
- eye protection (i.e., face shield or goggles).
- Consider implementing a respiratory protection program that is compliant with the OSHA respiratory protection standard for employees if not already in place. The program should include medical evaluations, training, and fit testing.
- Environmental cleaning and disinfection:
- Make sure that EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment.
Evaluate and Manage HCP with Symptoms of Respiratory Illness
- Implement sick leave policies that are non-punitive, flexible, and consistent with public health policies that allow ill HCP to stay home.
- As part of routine practice, ask HCP (including consultant personnel) to regularly monitor themselves for fever and symptoms of respiratory infection.
- Remind HCP to stay home when they are ill.
- If HCP develops fever or symptoms of respiratory infection while at work, they should immediately put on a facemask, inform their supervisor, and leave the workplace.
- Consult occupational health on decisions about further evaluation and return to work.
- Screen all HCP at the beginning of their shift for fever and respiratory symptoms.
- Actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. If they are ill, have them put on a facemask and leave the workplace.
- HCP who work in multiple locations may pose a higher risk and should be asked about exposure to facilities with recognized COVID-19 cases.
- Restrict nonessential healthcare personnel (including consultant personnel) and volunteers for entering the building.
- When transmission in the community is identified, nursing homes and assisted living facilities may face staffing shortages. Facilities should develop (or review existing) plans to mitigate staffing shortages.
Policies and Procedures for Visitors
- Because of the ease of spread in a long-term care setting and the severity of illness that occurs in residents with COVID-19, facilities should immediately restrict all visitation to their facilities except certain compassionate care situations, such as the end of life situations.
- Send letters or emails to families advising them that no visitors will be allowed in the facility except for certain compassionate care situations, such as the end of life situations. The use of alternative methods for visitation (e.g., video conferencing) should be facilitated by the facility.
- Post signs at the entrances to the facility advising that no visitors may enter the facility.
- Decisions about visitation during an end of life situation should be made on a case by case basis, which should include careful screening of the visitor for fever or respiratory symptoms. Those with symptoms should not be permitted to enter the facility. Those visitors that are permitted must wear a facemask while in the building and restrict their visit to the resident’s room or other location designated by the facility. They should also be reminded to frequently perform hand hygiene.
Evaluate and Manage Residents with Symptoms of Respiratory Infection
- Ask residents to report if they feel feverish or have symptoms of respiratory infection.
- Actively monitor all residents upon admission and at least daily for fever and respiratory symptoms (shortness of breath, new or change in cough, and sore throat).
- If positive for fever or symptoms, implement recommended IPC practices.
- The health department should be notified about residents with a severe respiratory infection, or a cluster (e.g., >3 residents or HCP with new-onset respiratory symptoms over 72 hours) of residents or HCP with symptoms of respiratory infections.
- In general, when caring for residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless the suspected diagnosis requires Airborne Precautions (e.g., tuberculosis). This includes restricting residents with respiratory infection to their rooms. If they leave the room, residents should wear a facemask (if tolerated) or use tissues to cover their mouth and nose.
- Continue to assess the need for Transmission-Based Precautions as more information about the resident’s suspected diagnosis becomes available.
- If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community,
- Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom.
- Room sharing might be necessary if there are multiple residents with known or suspected COVID-19 in the facility. As roommates of symptomatic residents might already be exposed, it is generally not recommended to separate them in this scenario. Public health authorities can assist with decisions about resident placement.
- Facilities should notify the health department immediately and follow the Interim Infection Prevention and Control Recommendations for Patients with COVID-19 or Persons Under Investigation for COVID-19 in Healthcare Settings, which includes detailed information regarding recommended PPE.
- If a resident requires a higher level of care or the facility cannot fully implement all recommended precautions, the resident should be transferred to another facility that is capable of implementation. Transport personnel and the receiving facility should be notified about the suspected diagnosis prior to transfer.
- While awaiting transfer, symptomatic residents should wear a facemask (if tolerated) and be separated from others (e.g., kept in their room with the door closed). Appropriate PPE should be used by healthcare personnel when coming in contact with the resident.
- Cancel communal dining and all group activities, such as internal and external activities.
- Remind residents to practice social distancing and perform frequent hand hygiene.
- Create a plan for cohorting residents with symptoms of respiratory infection, including dedicating HCP to work only on affected units.
In addition to the actions described above, these are things facilities should do when there are cases in their facility or sustained transmission in the community.
Healthcare Personnel Monitoring and Restrictions:
- Implement universal use of facemask for HCP while in the facility.
- Consider having HCP wear all recommended PPE (gown, gloves, eye protection, N95 respirator or, if not available, a facemask) for the care of all residents, regardless of the presence of symptoms. Implement protocols for extended use of eye protection and facemasks.
Resident Monitoring and Restrictions:
- Encourage residents to remain in their rooms. If there are cases in the facility, restrict residents (to the extent possible) to their rooms except for medically necessary purposes.
- If they leave their room, residents should wear a facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing (stay at least 6 feet away from others).
- Implement protocols for cohorting ill residents with dedicated HCP.