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      COVID-19 Outbreak Investigation and Management

      COVID-19 Outbreak Investigation and Management

       

      Policy

       

      It is the policy of this facility to recognize and contain COVID-19 outbreaks and outbreak measures will be instituted whenever there is evidence of an outbreak as outlined below.

       

      The Infection Preventionist, or designee, will conduct the COVID-19 outbreak investigation and has the authority to implement and/or direct outbreak measures to control possible transmission. These actions will be carried out in coordination with the Medical Director, administration, and medical staff as well as state and local health agencies. In the absence of the Infection Preventionist, the Director of Nursing or the Assistant Director of Nursing or designee will conduct the investigation.

       

      Appropriate notifications to the Medical Director, Administrator, all departments, attending physicians, state and local agencies, and resident representatives will take place as soon as possible after the outbreak has been identified.

       

      Outbreak monitoring and reporting will continue until the outbreak has resolved. The facility will send all appropriate reports to state, local health department agencies and National Healthcare Safety Network (NHSN) in accordance with State and Federal requirements.

       

      Control measures include:

      • Identifying space in the facility that will be dedicated to care for residents with confirmed COVID-19
      • Identify dedicated, essential staff to work the COVID-19 floor, unit, or wing
      • Single/private room for resident new admissions and readmissions for 14-day quarantine
      • Single/private room for residents exposed to COVID-19 for 14-day quarantine
      • Testing
      • Reporting
      • Active screening of staff, visitors, vendors
      • Resident screening and monitoring
      • Management/restricted of communal areas for dining and activities
      • Physical/Social Distancing
      • Personal Protective Equipment
      • Universal Source Control
      • Hand Hygiene
      • Physical/Social Distancing
      • Visitation restriction during outbreaks
      • Cleaning and Disinfection

       

      An interdisciplinary evaluation of the COVID-19 outbreak will be completed, and findings and recommendations will be presented at the quarterly Quality Assurance Committee meeting.

       

      Definitions

       

      The Centers for Medicare & Medicaid Services indicates, “An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident.”1

       

      **Please check with your State specific guidance for COVID-19 Outbreak in Nursing Facilities

       

      Goal of COVID-19 Outbreak Investigation and Management

      The goal of outbreak investigation and management is to rapidly identify any new cases of COVID-19, prompt resident placement in isolation on the COVID-19 designated unit/area, begin outbreak testing and follow facility systems to stop any further spread of COVID-19 in the facility.

       

      COVID-19 Outbreak Prevention:

       

      All residents and healthcare personnel will be educated on COVID-19 to include:

      • COVID-19 and Signs/Symptoms
      • Personal Protective Equipment (PPE)
      • Resident Placement
      • Universal Source Control
        • Healthcare personnel
        • Residents
      • Physical/Social Distancing
      • Respiratory Hygiene and Cough Etiquette
      • Visitation Policies and Procedures
      • Communal Dining and Activity Areas
      • Hand Hygiene
      • Testing
      • Reporting
      • Screening of Staff, Visitors, Vendors
      • Resident Screening and Monitoring
      • Cleaning and Disinfection

       

       

       

      COVID-19 Outbreak Prevention Measures for Healthcare Personnel

       

      1. Healthcare Personnel must be screened upon entrance to the facility.       Healthcare Personnel with fever and/or signs or symptoms of COVID—19 are restricted from work and will be tested for COVID-19
        • If testing results indicate COVID-19 is confirmed, employee will follow the CDC guidance on “Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection”
      1. Healthcare Personnel routine testing to be completed based upon the Community COVID-19 Activity Level in accordance with CMS Guidance1:
        • See COVID-19 Antigen Testing Policy and Procedure

       

      COVID-19 Outbreak Measures for Residents

       

      In the event of an outbreak or suspected case, the DON, Infection Preventionist, Administrator and Medical Director will be contacted to direct the process:

      1. All facility residents
        • Screening (identify facility policy, i.e.3 times/day) for fever and signs/symptoms of COVID-19 and potential exposure
      2. New Admissions/Readmissions
        • Private/Single room in a separate observation area for 14 days under monitoring and evaluation to identify evidence of COVID-19
        • “Testing at the end of the 14-day observation period can increase certainty that resident is not infected.”3
        • “A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak.” Resident should be placed onto the COVID-19 designated unit/area and placed on isolation.1
      1. Rapid identification that an outbreak exists.
        • Symptomatic resident
        • Testing consistent with CDC and CMS guidance
      2. To implement immediate response:
        • Symptomatic Resident:
      • Prompt testing
        • POC Antigen
        • RT-PCR (with lab able to provide results in less than 48 hours)
      • Place resident in a private room in separate observation area awaiting results
        • Resident Confirmed COVID-19 Positive:
      • Isolation on dedicated COVID-19 wing/unit
      • Full Personal Protective Equipment (PPE) to prevent the spread of the COVID-19 outbreak:
        • Gloves
        • Gown
        • Eye Protection
        • N95 or higher respirator
      • Implement dedicated, essential staffing on COVID-19 wing/unit
        • Roommates of Residents Confirmed COVID-19 Positive:
      • Resident should be tested for COVID-19, placed in a private room and observed under quarantine for 14 days.
        • Full PPE for all employees entering room
          • Gloves
          • Gown
          • Eye Protection
          • N95 or higher respirator
        • All Residents:
      • During a facility outbreak, full PPE for the care of all residents:
        • Gloves
        • Gown
        • Eye Protection
        • N95 or higher respirator

       

      • Outbreak testing of all residents previously tested negative until no new cases identified
        • “For outbreak testing, all staff and residents should be tested, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of 3 COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result.”1
          1. The CDC indicates, “if testing capacity allows and does not divert staff and resources away from performing other critical IPC measures (e.g., ensuring effective implementation of Transmission-Based Precautionsfor infected and potentially exposed residents), the facility should consider testing more frequently (e.g., every 3 days) for the first two weeks of the outbreak, then test less frequently (e.g., every 7 days) thereafter until no new cases are identified for 14 days.”2
          2. When testing of asymptomatic residents is completed as part of an outbreak response, “if an antigen test is positive, no confirmatory test is necessary. Residents should be placed in transmission-based precautions.”4
        • Communal dining and activities will be halted during an outbreak
        • Physical/Social distancing will be practiced by all staff and residents whenever possible
        • Universal source control
          • Residents
          • Employees
        • Visitation restriction during outbreak with exception of compassionate care situations

       

      COVID-19 Outbreak Measures for Healthcare Personnel (Employees)

       

      1. Healthcare Personnel must be screened upon entrance to the facility. Employees with fever and/or signs or symptoms of COVID—19 are restricted from work and will be tested for COVID-19.
      • If testing results indicate COVID-19 is confirmed, employee will be sent home and facility will follow the CDC guidance on “Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection”
      • All healthcare personnel that previously tested negative will be tested followed by retesting every 3-7 days until testing identifies no new cases for at least 14 days since the most recent positive results.1
        • “If testing capacity allows and does not divert staff and resources away from performing other critical IPC measures (e.g., ensuring effective implementation of Transmission-Based Precautionsfor infected and potentially exposed residents), the facility should consider testing more frequently (e.g., every 3 days) for the first two weeks of the outbreak, then test less frequently (e.g., every 7 days) thereafter until no new cases are identified for 14 days.”2

      b.     Dedicated and Essential Staffing

      c.     Education: Orientation of new employees and routine education should include:

      ·      COVID-19 signs and symptoms, description of what a COVID-19 “outbreak” is, their role in an outbreak and methods of prevention

      • Hand hygiene
      • COVID-19 Active Screening
        1. Employees
        2. Residents
      • Visitors
      1. Others
      • Personal Protective Equipment
        1. All residents
        2. Residents on quarantine
      • On COVID-19 designated unit/wing
      • COVID-19 observation and quarantine for new admissions, readmissions and residents exposed to COVID-19
      • Placing residents with confirmed COVID-19 on the COVID-19 designated unit/wing
        1. Assessment for change of condition related to COVID-19
        • Reporting symptoms of COVID-19 to the Infection Preventionist or Nurse Manager promptly.      
      1. Residents
      2. Employees (will need to leave facility immediately upon identification of symptoms and testing directions)
      • Cleaning and Disinfection

      d.     Monitoring/Surveillance

        • Routine daily screening and ongoing monitoring of resident condition with cares for signs and symptoms of COVID-19 will be done by the frontline staff with cares.
        • Surveillance, logging, and mapping by the Infection Preventionist or member of the Infection Control team to determine any trends for action and for future analysis.
        • A system for the Infection Preventionist to monitor COVID-19 outbreaks in the community using the COVID-19 county positivity rate on the COVID-19 Nursing Home Data site ( https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg ) and communicate with public health agencies for pertinent information regarding infections or outbreaks identified in the community or any other significant findings.

      e.     Enforce Compliance

        • It is the responsibility of all employees to comply with facility infection prevention and control policies and procedures:
      1. Hand Hygiene
      2. Standard and Transmission-based Precautions
      • PPE
      1. Respiratory Hygiene and Cough Etiquette
      2. Equipment and Environment
        1. Disinfection and appropriate product use
        • The Infection Preventionist, Supervisors and managers will be accountable for assuring staff, resident, and visitor compliance.
        • If non-compliance is identified through process surveillance, further actions may be taken by the Infection Preventionist or administration.

       

      1. Notify State and Local Health Officials
        • As required by State Law, Public Health Codes or Ordinances, report COVID-19 cases to public health agencies as soon as possible.
      1. CLIA Reporting
      2. State Requirements
      • NHSN Reporting
        • Report measures the facility has taken to prevent further spread within the facility and to (or from) the community.
        • Seek assistance from public health if needed.

      g.     Continue to Monitor

      ·      Identify any new signs, symptoms and/or cases of COVID-19.

      ·      Determine if there are additional lab results or new information that would assist to identify common causes.

      h.     Re-evaluate and Modify

      ·      The Infection Preventionist and facility leadership will identify any additional necessary modifications, or any measures as needed, for example:

                                                     i.     Possible closure of a unit or the facility to new admissions or transfers out (except in a medical emergency)

      i.      Resolve

      ·      When there have been no new cases as a result of testing employees and residents as a response to an outbreak for at least 14 days, discuss with the Medical Director and Public Health to determine if the outbreak resolved.

      ·      Report resolution to appropriate public health agencies.

      j.      Analyze Data and Plan for the Future

        • The Infection Preventionist will compile data gathered during the COVID-19 outbreak and examine for possible improvement opportunities in identification and management of the outbreak.
        • The Infection Preventionist will develop a written report of the COVID-19 outbreak details. The report will identify possible strategies that could be implemented to prevent future outbreaks or improve the process.

      k.     Report

      ·      The Infection Preventionist will outline the report to the Quality Assurance Committee and determine actions to take that may assist prevent or control in the future.

      ·      Develop a plan to implement process improvement activities.

      ·      Report the findings to all department managers and employees. Feedback is a critical factor in staff satisfaction and performance improvement.

       

      References and Resources

       

      1Centers for Medicare & Medicaid Services: QSO-20-38-NH, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID19 Focused Survey Tool. August 26, 2020: https://www.cms.gov/files/document/qso-20-38-nh.pdf

       

      2Centers for Disease Control and Prevention. Clinical Questions about COVID-19: Questions and Answers. Updated October 5, 2020: https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#Testing-in-Nursing-Homes

       

      3Centers for Disease Control and Prevention. Preparing for COVID-19 in Nursing Homes. Updated Nov. 20, 2020: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html

       

      4 Centers for Disease Control and Prevention. Considerations for Use of SARS-CoV-2 Antigen Testing in Nursing Homes. Updated Dec. 28, 2020: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-antigen-testing.html