Immediately:

• Keep the door to the room closed, wear a fit-tested N95 respirator, gloves, gown, and eye protection (face shield), and place a medical mask on the resident when anyone is in the room, unless the resident is unable to tolerate the mask. In a semi-private room, keep the privacy curtain closed and the residents separated as much as possible until one of the residents can be moved.

• Notify the resident and the resident’s representative of the COVID-19 related illness.

Within 24 Hours (confirmed case or presumed case only):

• Review the patient’s history to determine if the patient had COVID-19 in the prior 3 months and may have a persistent positive SARS-CoV2 PCR test.

• If available, place and operate a portable HEPA/UV filtration device in the room unless the room is an Airborne Infection Isolation Room.

• Complete the outbreak investigation & contact tracing and plan to meet testing requirements.

• Relocate the resident with confirmed COVID-19 to a room in a designated COVID-19 area if such an area is already in use, or relocate the roommate.  If a roommate needs to be relocated, do not move the roommate to another semi-private room.

• Offer any available and appropriate testing and treatment for COVID-19 as per the IDSA treatment guidelines: https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/

Ongoing:

• Residents with confirmed COVID-19 may be cohorted in a room or unit with other residents with confirmed COVID-19 as long as no other contraindications to cohorting exist as per usual infection prevention procedures. Avoid cohorting patients with confirmed COVID-19 with patients who have presumed COVID-19 or previously recovered from COVID-19. 

• If there is a confirmed outbreak of COVID-19 on the resident’s unit, newly-ill residents should be managed as presumptive-positive COVID-19 cases and have COVID-19 PCR testing.

• Only staff fitted for an N95 respirator will perform aerosol-generating procedures, including suctioning (if not using an inline catheter), nebulizer administration, manipulation of BiPAP/CPAP mask, chest physiotherapy, and CPR. A portable UV/HEPA filtration device must be used in the room during the aerosol-generating procedure.

• Actively monitor the resident once per shift for at least two weeks.

  • Interview for new symptoms, when the resident is able.

  • Measure and document body temperature and oxygen saturation.

  • Additional observations to consider:  Vital signs, lung auscultation

• Residents with suspected or confirmed COVID-19 should be cared for by the same clinical staff, dedicated to the care of the COVID-19 patients whenever possible.  Minimize the number of persons entering the resident’s room, including clinicians performing non-clinical work or work of other clinicians as long as the work is within their scope of practice.

• The resident should only leave the room for medically-necessary procedures.

  • Resident to perform hand hygiene (with assistance, if needed) & don a medical mask before leaving the room.

An exposure is defined as being within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period to the COVID-19-positive person.

• Actively monitor the resident once per shift.

  • Interview for new symptoms when the resident is able.

  • Measure body temperature and oxygen saturation.

  • Additional observations to consider:  Vital signs, lung auscultation

• Notify a provider if a resident develops symptoms and follow "Resident with Symptoms" above.

• Asymptomatic residents with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Avoid testing residents who were positive for COVID-19 in the prior 30 days. For residents who were positive for COVID-19 in the prior 3 months use an Antigen test instead of a PCR test. If the facility is notified of the exposure more than 6 days after it occurred, contact your medical director or the regional epidemiologist for instructions regarding the frequency and duration of testing.

• Implement Masking (Source Control) for 7 days after the last exposure if all test results are negative, or 10 days if testing is not performed.

  • The resident should wear a mask when people enter the resident’s room, if the resident is able to tolerate a mask.

  • The resident should wear a mask, perform hand hygiene, and maintain physical distancing when out of the room and unable to wear a mask, such as when eating.

Quarantine:

Quarantine Residents with an exposure who have not had a COVID-19 infection in the last 1 month and who:

• • Are unable to tolerate a mask or maintain physical distancing.

  • Are moderately to severely immunocompromised.

Contact the Infection Prevention Nurse for instructions in ongoing outbreaks as additional quarantine may be required.

For residents who are required to quarantine:

• • Resident to remain in his/her room.

  • Staff should wear a gown, gloves, eye protection (face shield), and N95 respirator.

  • The quarantined resident should be placed in a private room. If limited private rooms are available, or if numerous residents are simultaneously identified as having recent exposure, the resident should remain in their current location.

  • Resident should wear a medical mask when staff enters the room, unless the resident is unable to tolerate the mask. The resident should also wear a mask, perform hand hygiene, and maintain physical distancing when out of the room and when out of the building.

  • Continue precautions for at least seven (7) days after the exposure.  If the resident has remained asymptomatic and the results of all required COVID-19 tests were negative, precautions can be discontinued on Day 8 after the exposure.

  • If testing was not performed, precautions may be discontinued in an asymptomatic resident on Day 11 after the exposure.

Identify staff or residents with similar contacts as the new case to investigate potential COVID-19 transmission.

• Screen the identified staff and residents for symptoms of COVID-19. Residents with symptoms of COVID-19 should be managed as described under "Resident with Symptoms" above.

• Test the identified staff and residents once for COVID-19. While PCR testing is preferred, Antigen testing may also be used and is preferred for people who were positive for COVID-19 in the prior 90 days. Do not test staff or residents who resulted positive for COVID-19 in the prior 30 days.

Determine which residents or units may have been exposed to the confirmed or presumed COVID-19 resident or staff member. Manage exposed residents as per "Exposed Resident" above.  Exposed staff should wear a respirator or well-fitting mask at all times for 10 days after their exposure.

Institute universal use of medical masks for all staff, visitors, and residents (if able to tolerate a mask) of the identified units or areas for 14 days after identification of the new case that resulted in exposure(s).

Designated facility staff perform the Outbreak Investigation.

Follow "Residents with Symptoms" above for any resident newly displaying signs and symptoms, even if the resident previously tested negative.

• Confirmed or presumed COVID-19 patients should be cared for following "Residents with Symptoms" above.

• Staff on affected units should wear a respirator (KN95, N95) at all times until 14 days have passed since the onset of the most recent patient case.

• Staff caring for confirmed or presumed COVID-19 patients should avoid caring for other residents or floating to other units. If contact with other units is unavoidable, they should wear a respirator (KN95, N95) at all times.

• If the facility is unable to perform contact tracing for the outbreak:

  • Staff on affected units should wear eye protection (face shield) when within 6 feet of any resident, until 14 days have passed since the identification of the most recent patient case.

  • Follow the "Exposed Resident" section above for all asymptomatic residents on the affected unit.

• See https://www.cdc.gov/covid/hcp/infection-control/ for additional options with ongoing outbreaks.

When 2 cases of laboratory-confirmed influenza are identified within 72 hours of each other in residents on the same unit, outbreak control measures should be implemented as soon as possible.

Refer to this CDC page for guidance about influenza outbreaks in long-term care facilities:

https://www.cdc.gov/flu/hcp/infection-control/index.html

Follow this algorithm for testing and treatment decisions: Influenza Antiviral Treatment Algorithm