Publication

April 3, 2020

The Colorado Department of Public Health and Environment (CDPHE) updated perhaps the most comprehensive COVID-19 guidance for Colorado long-term care facilities on March 25, 2020.  The Guidance, titled INTERIM Guidelines for Preparation and Response to Single Cases and Outbreaks of COVID-19 in Long-Term Care Settings, includes useful CDPHE tracking and reporting tools, as well as protocols for responding to suspected and confirmed COVID-19 cases.  The document covers recommendations for addressing cases among residents and healthcare personnel (HCP) in nursing home environments and states that it could also be applied in assisted living facilities. 

The Guidelines cover all stages of preparation, reporting, and monitoring:

1. Preparation:  Twelve steps are recommended to adequately prepare for and prevent introduction of COVID-19 into a facility.  Additional resources include:
   1. Restriction of visitors in accordance with Public Health Order 20-20;
   2. CDPHE Concept of Operations (CONOPS) recommendations for PPE shortages;
   3. CDC Guidelines for COVID-19 Preparation in LTC facilities; and
   4. CDC Healthcare Facility Recommendations for Preparation.
       
2. Reporting: Facilities should securely email the Outbreak Reporting Form for Long-Term Care Facilities to HAIOutbreak@state.co.us or the local public health agency.
    
3. Resident Surveillance and Monitoring: 
   1. Routine monitoring of all residents for designated symptoms is advised, with an increased frequency of monitoring of twice daily if there are suspected or confirmed outbreaks. 
   2. A tracking tool for residents and staff members with signs and symptoms is provided, understanding that additional tracking may be recommended in the setting of a suspected or confirmed outbreak. 
       
4. HCP Surveillance and Monitoring:  Staff should be screened at the beginning of each shift, including taking their temperature and documenting the absence of fever, shortness of breath, cough, sore throat or other symptoms. 
   1. Records of other facilities where staff are working should be kept, with regular inquiries into whether those facilities have recognized COVID-19 cases.
       

Handling Cases within the Community

When a resident with respiratory illness is identified, immediately:

• Implement precautions.  Do not wait for a confirmed diagnosis.
• Use PPE.  If there is a shortage use alternative barriers to cover the mouth and nose (e.g., tissues).
• Place the resident in a private room.  If none are available, ensure six feet of separation.  An airborne infection isolation room (AIIR) is not required.
• Implement staffing policies to minimize the number of essential HCP who enter.

When suspected or confirmed outbreaks are identified:

• Cohort Residents and Staff: Implement protocols for cohorting residents with designated HCP.  See the CDC’s Patient Placement section.
• Resident Activities and Screening:  Residents should remain in their room except for medically necessary purposes, but should wear PPE and perform social distancing if they do leave their room.
• HCP:  Universal use of facemasks should be implemented, using contingency capacity Strategies for Optimizing the Supply of PPE. 
• New admissions: Should be halted until further consultation with public health.

Testing and Specimen Collection:

• Residents with respiratory illness should be tested for COVID-19, as well as influenza, RSV and other respiratory viruses.  However, COVID-19 testing should not wait for the results of other testing due to the risk of coinfection.
• If two or more residents have tested positive, then additional COVID-19 testing may be unnecessary and all residents in the unit should be cared for as if they are positive.
  • Other units should be tested to establish the extent of the spread.
  • Symptomatic HCP should be prioritized for testing. 
  • Postmortem testing should be completed for undiagnosed deaths.
• Specimen collection steps are detailed, with links to CDC and CDPHE resources.
• Cleaning and disinfection of procedure rooms should be done in accordance with CDC Interim Infection Prevention and Control Guidance.

Infection Control:

• Checklist:  A CDPHE Outbreak Investigation Infection Prevention Checklist for Long-Term Care Facilities details measures to implement during suspected or confirmed outbreaks.  The checklist lists certain control measures as needing to be implemented immediately.
• Isolation, Quarantine and Standard and Transmission-Based Precautions: Depending on the level of symptoms and exposure, these precautions should be implemented.
• Aerosol Generating Procedures (AGPs): Follow CDC Guidance.
• Tracking Contacts:  A HCP Tracking Form should be used to log all persons who care for or enter rooms or the care area of residents with COVID-19.
• HCP Exposures:  Utilize CDC guidance on conducting Risk Assessments for HCP.
• Environmental Infection Control:  Measures include cleaning with an EPA-registered, hospital-grade disinfectant of commonly touched surfaces (e.g., EPA List N registered disinfectants). After a patient is discharged, refrain from entering the vacated room until sufficient time has elapsed (e.g., a minimum of 2 hours or in accordance with certain clearance rates for differing ventilation conditions)

Case Management:

• In-Facility Management:  Residents with mild illness may be treated in the facility if medically appropriate.  CDC Clinical Management and Treatment should be followed.
• Acute Care Management:  Transfer residents if a higher level of care is needed or if the recommended precautions to protect other residents cannot be implemented.
• Transport:  Inform the receiving hospital and transport personnel of the COVID-19 suspicion or diagnosis.
   

Community Recovery from COVID-19

Discontinuation of Isolation:

• A CDC test-based strategy for discontinuation of transmission-based precautions should be followed, including:
  • Fever resolution;
  • Improvement in respiratory symptoms; and
  • Negative results of FDA Emergency Use Authorized COVID-19 molecular assays.
• When testing is not available, non-test-based strategies should be used until:
  • At least 3 days after recover (defined as resolution of fever and respiratory improvement); and
  • At least 10 days have passed since symptoms first appeared.
  • Consult public health on a case-by-case basis regarding special populations.
• Residents should remain in their rooms.
• Staff and essential visitors should mask until the outbreak is resolved, defined as 14 days after the onset of symptoms of the last case (in residents and staff).
• The above isolation criteria might be modified by public health in cases where PPE is not in adequate supply.

Return to the Facility after Hospitalization or New Admission to the Facility:

• Facilities should admit any individuals they would normally admit, including individuals from hospitals where a case of COVID-19 was present.  See CMS Guidance.
• If the facility has suspected or confirmed outbreaks, consult public health for admissions recommendations.
• Residents with a COVID-19 history that have not met criteria for discontinuation of precautions should go to a facility with adequate PPE and ability to adhere to infection prevention and control recommendations. 
• Residents with a history of COVID-19 can be admitted. If the symptoms are resolved, no further restrictions are necessary.  If the resident has persistent symptoms, they should be restricted to a single room.

Return of HCP to Work after Confirmed or Suspected COVID-19:

• Follow CDC Return to Work Criteria for HCP.
• If a non-test-based strategy is used, at least 3 days should pass since recover, defined as fever resolution without the use of fever-reducing medications and improvement in respiratory symptoms and at least 10 days have passed since symptoms first appeared.

Outbreak Resolution:

• Defined as 14 days after the onset of symptoms on the last case of both residents and staff, assuming infection and prevention control precautions have been in place.
• Unit-specific outbreak resolution can be considered with public health.

Visit our COVID-19 Hub for ongoing updates.