(Note: These answers are current as of the course dates: September 26-28, 2020)
Click on a topic below to access that section of the Q&A:
INJECTION SAFETY and WOUND CARE
ISOLATION PRECAUTIONS
Patients that have tested positive, how long do they need to be on COVID isolation prior to returning to a regular room?
Criteria for discontinuing isolation or precautions is as follows:
If the resident is symptomatic and with mild to moderate illness and not severely immunocompromised:
- At least 10 days have passed since symptoms first appeared and
- At least 24 hours have passed since last fever without the use of fever-reducing medications and
- Symptoms (e.g., cough, shortness of breath) have improved
For residents, not severely immunocompromised, who were not symptomatic precautions can be discontinued when at least 10 days has passed since the date of their first positive viral diagnostic test
In both of the above criteria, if the resident is with severe to critical illness or is severely immunocompromised extend time to 10-20 days.
If you go out of state on vacation do you have to remain quarantined at home or do you have to wear full PPE when you return.
Employees traveling should be screened for signs and symptoms and potential exposure history when they return.
Do we need to have a separate unit/area for newly admitted residents?
You should create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19 for 14 days. Staff should wear all recommended PPE (N 95s when available, otherwise surgical facemask, eye protection, gown and gloves) when caring for these residents.
For new admissions with a negative COVID test 24 hours prior to admission do you recommend them being placed on enhanced droplet precautions for 14 days ?
You are required to put them on Enhanced TBP. CDC states, “Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic SARS-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home.”
On a COVID only hall can residents come out of their room? If so do they need to wear face coverings?
Ideally residents that are positive for COVID-19 should be in a private room, with the door closed, and movement outside of the room be limited to medically essential procedures. ALL residents should be wearing a face cover when outside of their room.
Where do we find the information on the resident that go to Dialysis or a doctor office, they DO NOT need to be quarantined?
There is not a CDC guidance document or recommendation to place residents leaving the facility, for medical appointments or dialysis, on quarantine when they return.
CDC (in response to a question) states, “The resident does not require quarantine unless either i). there is a suspicion the resident has signs/symptoms of COVID19 or ii). there was known close contact with a confirmed or probable COVID-19 case while outside the facility.
What constitutes a medically necessary procedure?
A tooth extraction, a chemo treatment, a MRI, etc
For short term rehab residents, would they be able to utilize the rehab gym if used individually and sanitized between sessions?
Yes, and residents should be wearing face coverings.
PPE
If you do not have active COVID cases in your facility but are still considered in an outbreak, should the whole facility remain in full PPE? Or should just the quarantine unit remain in full PPE?
All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown.
If we do not have COVID in the building do you have to wear eye protection at all time even if not in direct patient care?
CDC recommends use of eye protection in areas with moderate to substantial community transmission as healthcare personnel are more likely to encounter asymptomatic or pre-symptomatic persons with SARS-CoV-2 infection. If SARS-CoV-2 is not suspected, based on person’s symptoms and exposure history, HCP should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient encounters. CMS community positivity data can be used to determine level of community transmission. For areas with minimal to no community transmissions, eye protection is considered optional, unless otherwise indicated as part of standard precautions.
Is it acceptable for staff that wear glasses to wear the eyeglass side safety shields?
CDC notes that eye protection should cover the front and sides of the face and if there are gaps between glasses and the face it will likely not protect eyes from all splashes and sprays. Prescription glasses with side shields would not meet this recommendation
Can you clarify when and where face shields/goggles should be worn? Do they need to be worn in all patient care areas, or just in quarantine/COVID units?
CDC recommends staff wear all recommended PPE including N95 respiratory (if available and if not facemask), eye protection, gown and gloves AT ALL TIMES when caring for residents on the quarantine/observation unit AND COVID-19 + designated hall.
In addition CDC recommends use of eye protection in areas with moderate to substantial community transmission as healthcare personnel are more likely to encounter asymptomatic or pre-symptomatic persons with SARS-CoV-2 infection. If SARS-CoV-2 is not suspected, based on person’s symptoms and exposure history, HCP should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient encounters. CMS community positivity data can be used to determine level of community transmission
Are staff required to keep faceshields or goggles on all the time when on the COVID unit or only when they are entering a resident’s room?
CDC states “healthcare personnel (HCP)must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms.
Does PPE change after aerosol treatment on negative COVID patient go into biohazard bags?
No, PPE can be disposed of per routine procedures.
Are all patient cohorts required to wear masks if they have been tested and are COVID 19 negative?
It is recommended that all residents wear a face covering when outside their room, including if leaving the facility for a medical appointment. All facility staff should use universal source control and wear a face mask while in the facility.
With the COVID 19 pandemic and a shortage with fit testing supplies what is an alternative method for testing with N95s?
When supplies are severely limited, while not ideal there may not be an opportunity for the employee to be fit tested. In this case, select a respirator with the best fit, i.e, should fit over the nose and under the chin and achieve a good face seal. Manufacturer’s instructions should be followed for donning and doffing the N95 and conducting a user seal check.
Aerosolizing generating procedures, as in providing nebulizer for COPD exacerbation, can we use a KN95 mask with face shield, if we are unable to adequately perform fit testing for N95 masks?
CDC recommends use of a N95 respirator (fit testing required) when performing an aerosol generating procedure
Regarding med evaluation and fit testing for n95s: given the shortage and constantly changing types of N95s available, is fit testing recommended for each type of mask?
Fit-testing should take place with different brands of N95 respirators; however, if that is not feasible a “user seal check or fit check” should be performed.
VISITATION
If you are in outbreak status, can you still do outdoor visits and Compassion Care visits.
Yes
If family members visit outside without entering a gated courtyard (more than 6 feet distance), do we have to schedule visits or screen the family member?
You have to screen visitors, it doesn’t matter that they are in the same community, they have to wear face masks and you have to schedule visits so you don’t have too many people in the area at one time
Do you have to stop compassionate care visits during an outbreak?
No
Due to staffing, on an 11-7 shift, is a nurse allowed to work on a regular hall and a quarantine hall?
Yes, but she has to have a full PPE change each time she moves from hall to hall.
COVID TESTING
Can we use the rapid testing for staff and residents instead of the lab?
The most recent (October 8th) NC Department of Health and Human Services (NCDHHS) guidance on Antigen testing for serial use in congregate settings, interpretation of results, and reporting of antigen test results can be found at the following link: https://files.nc.gov/covid/documents/guidance/healthcare/Antigen-Provider-Update.pdf
With the rapid swab tests and machine, is there a specific form CMS has for documenting these tests and results? Our facility made our own form due to not being able to find a standard one and that’s what we’ve been using to send these results to the health department.
The QSO 20-38 states the facility can decide how they want to document it they just need to be able to show the surveyor how the tests and results are utilized.
When testing residents, are we to complete a progress note in the residents chart that resident was tested/results? You mentioned document-we have been scanning the results into resident’s electronic chart.
You have to document. If scanning it allows the surveyor to look at the documentation.
What is the testing protocol for outside providers such as hospice nurses, psych NP, etc. when they come into the facility?
In the CMS QSO dated August 26th they state: “We note that the facility may have a provision under its arrangement with a vendor or volunteer that requires them to be tested from another source (e.g., their employer or on their own). However, the facility is still required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility’s testing frequency, as described in Table 2 below (included in the QSO).
What PPE is required for person testing staff/residents? Should it be changed between each person even if they have no suspected signs or symptoms?
For healthcare personnel collecting specimens or within 6 feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. More information can be found at:https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html
Do facilities have to test agency staff? I have noticed that they are not testing agency nursing staff and they are not asking for proof of COVID test.
Yes, CMS notes all staff must be tested according to the facilities testing procedures. In the CMS QSO dated August 26th they state: “We note that the facility may have a provision under its arrangement with a vendor or volunteer that requires them to be tested from another source (e.g., their employer or on their own). However, the facility is still required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility’s testing frequency, as described in Table 2 below (included in the QSO).
NC’s original definition of healthcare worker added some criteria about direct/indirect contact with body fluids. Does CMS expect us to test vendors that do not go into patient care areas such as IT and delivery drivers?
In their August 26th QSO CMS defines facility staff as “Facility staff” includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility’s nurse aide training programs or from affiliated academic institutions. For the purpose of testing “individuals providing services under arrangement and volunteers,” facilities should prioritize those individuals who are regularly in the facility (e.g., weekly) and have contact with residents or staff. We note that the facility may have a provision under its arrangement with a vendor or volunteer that requires them to be tested from another source (e.g., their employer or on their own). However, the facility is still required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility’s testing frequency…”
Federally, isn’t it required to be tested biweekly regardless of the positivity rate?
CMS guidance for routine testing of staff is based on community positivity rate. For more information refer to: https://www.cms.gov/files/document/qso-20-38-nh.pdf
What is recommendation for retesting resident that has tested positive?
For residents who have tested positive, who remain asymptomatic after recovery, retesting is not recommended within 3 months after the date of symptom onset for the initial COVID-19 infection. If the resident was asymptomatic, retesting is not recommended within 3 months from the date of the first positive test.
Our facilities policy is we do not re test for at least 90 days. IF we test a staff member during our routine testing after that 90 day period and the staff member comes back positive does that count as a second infection?
Not necessarily, but the person may warrant evaluation for SARS-CoV-2 reinfection in consultation with an infectious disease or infection control expert. Isolation precautions should be implemented until evaluation is complete.
Should we be retesting positive residents after they test positive. if not how long should we wait until we restest a positive?
Current evidence supports NOT retesting persons who remain asymptomatic for 90 days after the positive test result. If such a person becomes symptomatic during this 90-day period and an evaluation fails to identify a diagnosis other than SARS-CoV-2 infection (e.g., influenza), then the person may warrant evaluation for SARS-CoV-2 reinfection in consultation with an infectious disease or infection control expert and precautions should be implemented during this evaluation.
Can you clarify if we should test all residents if we have an outbreak? The Department of Health instructed that we only test the residents that were exposed to the positive staff.
CDC recommends to expand viral testing to ALL residents in the nursing home if there is an outbreak in the facility (i.e., a new COVID-19 infection in any healthcare personnel or and nursing home onset infection in a resident).
In addition CMS states: Upon identification of a single new case of COVID-19 infection in any staff or residents, 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 COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result.
Link to this guidance is included below and this is also the link referenced in the NCDHHS guidance document “What to Expect: Response to New COVID-19 Cases or Outbreaks in Long-Term Care Settings” https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html
If staff is to be tested weekly, but are out of town, what is to be done?
They should be tested when they return.
Can a facility implement the latest visitation guidance from NCDHHS and CMS EVEN if they are in outbreak status and are a Covid+ facility?
CMS and NCDHHS visitation guidance can be located at the following links. https://files.nc.gov/covid/documents/guidance/Guidance-on-Outdoor-Visitation-for-Larger-Residential-Settings.pdf
https://www.cms.gov/files/document/qso-20-39-nh.pdf
If this resident is to transfer to another facility do they have to have two negative tests? That would be before the 90 day rule or after the 90 days?
There is no requirement for residents to be tested if transferred to another facility.
What if a staff member does not get tested when the facility does the staff testing?
Facility should have policies and procedures in place for addressing this situation. CMS states: “Procedures should ensure that staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the building until the return to work criteria are met. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. The facility should follow its occupational health and local jurisdiction policies with respect to any asymptomatic staff who refuse routine testing.” https://www.cms.gov/files/document/qso-20-38-nh.pdf
Are clinical students to be treated as visitors or staff? Any guidelines for NAI, NAII, PN, or ADN students?
You should have a plan with the clinical site that they are tested in accordance with your facilities testing policies for other staff.
COVID GENERAL
With the outbreak is it just one resident, or could it be one staff member too?
Both CDC and CMS define an outbreak as “A single new case of SARS-CoV-2 infection in any HCP or a nursing home-onset SARS-CoV-2 infection in a resident should be considered an outbreak.”
Is there research with herd immunity that states it will work with covid-19 when its never worked before?
Herd immunity (or community immunity) occurs when a high percentage of the community is immune to a disease (through vaccination and/or prior illness), making the spread of this disease from person to person unlikely. Even individuals not vaccinated (such as newborns and the immunocompromised) are offered some protection because the disease has little opportunity to spread within the community. Herd immunity depends on the contagiousness of the disease. Diseases that spread easily, such as measles, require a higher number of immune individuals in a community to reach herd immunity. Herd immunity protects the most vulnerable members of our population. If enough people are vaccinated against dangerous diseases, those who are susceptible and cannot get vaccinated are protected because the germ will not be able to “find” those susceptible individuals.
What is the source of the “death from COVID19 data?” Is it the State Health Dept data?
For the U.S. it comes from CDC COVID data tracking and from NC it comes from the NC dashboard found at: https://covid19.ncdhhs.gov/dashboard/cases
Should COVID be recorded in facility infection rates?
COVID surveillance should be tracked, documented and reported but would not need to be included in the facility-acquired rate of infection
TST
Can you review the TST recommendations again? Should they be tested or just take a verbal?
Residents (upon admission) and staff of licensed nursing homes or adult care home (upon employment) shall be tested using a two-step skin test method or a single IGRA test, administered in accordance with recommendations and guidelines published by the Centers for Disease Control and Prevention. HOWEVER, a single TST or IGRA is required in the following situations:
Residents:
- If admitted directly from a hospital or another skilled nursing facility and they have documentation of a 2-step PPD they do not need another PPD OR
- If not admitted directly from another healthcare facility and they have ever had a 2-step PPD they would only need one TST administered at time of admission OR
- If they have had a single negative TST in the past 12 months they would only need one TST administered at time of admission
- Annual screening is required but can be accomplished by verbal elicitation of symptoms (symptom screen)
Employees:
- If they have ever had a 2-step PPD they would only need one TST administered at time of hire.
- If they have had a single negative TST in the past 12 months they would only need one TST administered at time of hire
- Annual screening is required but can be accomplished by verbal elicitation of symptoms (symptom screen)
URINARY TRACT INFECTIONS
What about colonization with intermittent catheterizations that are scheduled on a daily basis?
Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. (Category II) In the non-acute care setting, clean (i.e., non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization. (Category IA)
How often should indwelling catheters be replaced? Some MD offices have replaced them every 30 days while other offices replace them whenever an issue arises.
The CDC recommends, changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. (Category II) (Key Question 2C)
If diabetic and cranberry tabs add sugar but cannot be proved helpful for UTI prophylaxis, should they be prescribed?
Cranberry juice is high is sugar. Studies have not demonstrated a difference in outcome for UTI prevention.
What can I use as a tool for marking catheters?
There are number of commercially available UV blue ink markers that are completely invisible in normal light and glow in UV blacklight.
RESPIRATORY INFECTIONS
How do you determine if COPD exacerbation is viral or bacterial, especially without a chest x-ray?
Protocols for evaluation and treatment of COPD do not require you to identify a cause, because the treatment approach is the same regardless of cause. X-ray helps rule out pneumonia but has no role otherwise in diagnosing the cause or severity of COPD. For specifics, Google the GOLD report (Global Strategy for the Diagnosis, Management, and Prevention of COPD 2020 — a consensus report published periodically since 2001 by an international panel of health professionals).
When residents are having respiratory symptoms, the facility receives flu test results faster than COVID 19 test results? Would the resident need to be tested for both?
That depends on the type of test and the laboratory you are using. Right now there are rapid tests for both Flu and COVID, that can be done on site in 15-30 minutes. There are also more definitive PCR tests for both that can be run in hours but are usually batched by laboratories and come back in a day. Check with your laboratory for what you have available.
What are best practices to prevent flu and COVID?
Both illnesses are spread primarily by respiratory droplets. Best preventive strategies apply to both and are:
- Get everyone immunized for FLU and, when it’s available, COVID.
- Have a formal program to try to keep sick people from entering the building.
- Have an air handling system that exchanges ambient air frequently and, from each room, either passes it through a filter that will catch viral particles or will vent the air out the roof.
- Have policies and procedures to identify ill persons, quarantine them (and immediate contacts), and apply the appropriate precautions
- Have an influenza policy that also involves starting treatment of the ill person(s) and offering prophylaxis to unit staff and residents in the case of an outbreak.
OCCUPATIONAL HEALTH
In regard to vaccinations, what about people who show no immunity after having completed the vaccinations.
This is a broad, complicated question. In a workplace setting, lack of titer-proven immunity is handled on a case-by-case basis but in most cases, documentation of vaccine is a better predictor of immunity than the actual titer as titers wan over time. The CDC’s Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book: Course Textbook – 13th Edition (2015) is a free and a good source of information on vaccines. https://www.cdc.gov/vaccines/pubs/pinkbook/index.html
How long after getting the last HEP B vaccination can you get the titer? I know they recommend 1 month after it.
Best practice is to get the titer one month after completing the series as this is the best chance to get a high titer since titers usually decline over time. The Immunization Action Coalition has a good set of FAQs on healthcare workers and Hep B vaccine. https://www.immunize.org/askexperts/experts_hepb.asp#hcw
I gave someone the first dose on 8/24 and they missed the 9/24 dose, do I have to start the HepB series over?
The minimal intervals for the 3-dose HepB vaccines are at least 4 weeks between doses #1 and #2, at least 8 weeks between doses #2 and #3, and at least 16 weeks between doses #1 and #3. It is not necessary to restart the series because of an extended interval between doses, no matter how long.
Do you have to be vaccinated w/ the pneumovax q5 years or is once sufficient for >65 years of age?
Please see the CDC updated adult vaccination schedule for the recommendations based on age, medication conditions and special situations. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
What’s the difference in cost between the Zostavx & Shingrix?
Costs vary based on insurer. However, Zostavax is being phased out of the US market and will no longer be available after November 18, 2020. Shingrix is the preferred vaccine for shingles.
Shingrix two doses only after age 50 2-6 months apart?
CDC recommends two doses of Shingrix separated by 2 to 6 months for immunocompetent adults age 50 years and older.
If you get the Shingrix and don’t get the second dose within the suggested time period do you have to get the whole series again?
If more than 6 months have elapsed since the first dose of Shingrix, you should administer the second dose as soon as possible. However, you do not need to restart the vaccine series.
If the second dose is given less than 4 weeks after the first dose, the second dose should be considered invalid. A valid second dose should be administered 2 months after the invalid dose (minimum acceptable interval is 4 weeks following invalid dose).
Will taking the medication change your status from getting HIV with the 7 day course.
Good clarification. The State of New York and the State of California have made a 7-day supply of non-occupational post-exposure HIV prophylaxis available at pharmacies without a prescription with the goal to get patients HIV preventative medications as soon as possible. The patients still need a 28-day course and follow-up with a provider. To restate, a seven-day course of HIV medications is NOT an appropriate length of time for HIV preventions after occupational or non-occupational exposure to HIV.
What are your thoughts of giving residents in the long term care setting the standard dose of the influenza vaccine?
If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season. For persons aged ≥65 years, any age-appropriate IIV formulation (standard-dose or high-dose, trivalent or quadrivalent, unadjuvanted or adjuvanted) or quadrivalent recombinant influenza vaccine are acceptable options. In the majority of seasons, influenza vaccines will become available to long-term care facilities beginning in September, and influenza vaccination should be offered by the end of October. Informed consent is required to implement a standing order for vaccination, but this does not necessarily mean a signed consent must be present. Although vaccination by the end of October is recommended, influenza vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons because the duration of the season is variable, and influenza activity might not occur in certain communities until February or March. https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm
ANTIBIOTIC STEWARDSHIP
My facility providers prescribe abx as “prophylaxis” and are indefinite time frame… I am new to the IP role… recommendations?
This is from the Infectious Disease Society of America. In sum, the evidence isn’t great in favor of probiotics. Most of the studies are done in hospitalized patients, but they are mostly in the 65+ age group and similar to NH residents. I personally have used it for patients who get antibiotic-associated diarrhea, but don’t do so across the board because I don’t believe the evidence is there. : https://www.idsociety.org/practice-guideline/clostridium-difficile/
XXVII. What is the role of probiotics in primary prevention of CDI?
Recommendation
- There are insufficient data at this time to recommend administration of probiotics for primary prevention of CDI outside of clinical trials (no recommendation).
Summary of the Evidence
Several meta-analyses indicate probiotics may be effective at preventing CDI when given to patients on antibiotics who do not have a history of CDI [298–300]. The typical CDI incidence among hospitalized people >65 years of age on antibiotics with a length of stay >2 days is ≤3%, even during outbreaks of CDI [21, 36, 248]. The studies with the greatest influence on the results of the meta-analyses had a CDI incidence 7–20 times higher in the placebo arms than would otherwise be expected based on the patient population studied, potentially biasing the results to benefit of the probiotic [301, 302]. When these studies are excluded, a trend toward a reduction in CDI remains, but it is not as great as when these studies are included. Many limitations remain when the studies with extremely high CDI incidence are excluded, including differences in probiotic formulations studied, duration of probiotic administration, definitions of CDI, duration of study follow-up, and inclusion of patients not typically considered at high risk for CDI. There is also the potential for organisms in probiotic formulations to cause infections in hospitalized patients [303–305]. Due to these issues, there are insufficient data to recommend administration of probiotics for primary prevention of CDI.
My Medical Director gives Probiotics with all antibiotics. I need to discuss this and show data, as you stated not recommended. Where is that data?
https://academic.oup.com/cid/article/66/7/e1/4855916
https://www.mayoclinicproceedings.org/action/showPdf?pii=S0025-6196%2819%2930725-6
The IDSA folks feel there is not sufficient evidence to recommend it. Some of the studies show benefit and some don’t and some studies show harms from probiotics (e.g. risk of fungemia). They cost money, they cost nursing time, they add to pill burden, so I think it should be a discussion and maybe in patients who have more diarrhea with antibiotics or a past bout of c. diff, it may make sense, but for every patient it seems likely it likely causes more harm than good.
Facility infection tracking sheet questions:
Information on how to access the tracking sheets can be found at this link: https://nursinghomeinfections.unc.edu/
Is the McGeers purpose to deter unnecessary ABT use? Should it be completed prior to ABT use?
McGeers is surveillance criteria. It can be used to get a general sense of appropriate prescribing. However, there are no gold standards when it comes to ABT use. The Loeb criteria were really developed to guide decision-making at the point of prescribing for UTIs at least, and that’s what I use. I do think it’s reasonable to ask before each ABT- does this really need an abx and meet criteria. I like this article as a way to think about it. https://www.medicine.wisc.edu/sites/default/files/clinical_uncertainties_in_the_approach_crnich.pdf
LTC ENVIRONMENT
Is a medical negative pressure room simply 6 or more air changes per hour?
Airborne precautions are used when you have a lung or throat infection or virus, such as chicken pox or tuberculosis, that can be spread via tiny droplets in the air from your mouth or nose. These germs may stay suspended in the air and can spread to others.
Airborne infection isolation (AII) refers to the isolation of patients infected with organisms spread via airborne droplet nuclei <5 µm in diameter. This isolation area receives numerous air changes per hour (ACH) (>12 ACH for new construction as of 2001; >6 ACH for construction before 2001), and is under negative pressure, such that the direction of the air flow is from the outside adjacent space (e.g., the corridor) into the room. The air in an AII room is preferably exhausted to the outside, but may be recirculated provided that the return air is filtered through a high-efficiency particulate air (HEPA) filter. The use of personal respiratory protection is also indicated for persons entering these rooms when caring for TB or smallpox patients and for staff who lack immunity to airborne viral diseases (e.g., measles or varicella zoster virus [VZV] infection). For more information see CDC Guidelines for Environmental Infection Control in Healthcare Facilities https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm
How often should the ice chest be cleaned that are used on the nursing unit.
The CDC guidelines (Guidelines for Environmental Infection Control in Healthcare Facilities) for ice machines/chests and ice are below. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm
A: Ice Machines and Ice
- Do not handle ice directly by hand, and wash hands before obtaining ice. Category II
- Use a smooth-surface ice scoop to dispense ice. Category II
1. Keep the ice scoop on a chain short enough that the scoop cannot touch the floor or keep the scoop on a clean, hard surface when not in use. Category II
2. Do not store the ice scoop in the ice bin. Category II - Do not store pharmaceuticals or medical solutions on ice intended for consumption; use sterile ice to keep medical solutions cold, or use equipment specifically manufactured for this purpose. Category IB
- Machines that dispense ice are preferred to those that require ice to be removed from bins or chests with a scoop. Category II
- Limit access to ice-storage chests, and keep container doors closed except when removing ice. Category II
- Clean, disinfect, and maintain ice-storage chests on a regular basis. Category II
1. Follow the manufacturer’s instructions for cleaning. Category II
2. Use an EPA-registered disinfectant suitable for use on ice machines, dispensers, or storage chests in accordance with label instructions. Category II
3. If instructions and EPA-registered disinfectants suitable for use on ice machines are not available, use a general cleaning/disinfecting regimen. Category II
4. Flush and clean ice machines and dispensers if they have not been disconnected before anticipated lengthy water disruptions. Category II - Install proper air gaps where the condensate lines meet the waste lines. Category II.
- Conduct microbiologic sampling of ice, ice chests, and ice-making machines and dispensers where indicated during an epidemiologic investigation. Category IB
What temperature should banana’s be stored?
Once ripe, the bananas can be stored in the refrigerator; their skin will turn black but the flesh should be good for a few more days.
Are staff members allowed to warm up food for residents brought from the outside or leftovers? If so should temperature be measured before giving to resident?
The literature/regulations/internet consider this question a “hot topic”. From F813- Food Safety Requirements, the one thing we do know, nursing homes are required to have a policy regarding use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. When foods are brought in, everyone must be accountable to make sure proper food handling practices are followed. This requires ongoing education to all staff as well as residents, visitors and family members. Foods brought in from outside sources must be stored in a way that is either separate of, or easily distinguishable from, facility food. The required Food from Outside Sources policy must ensure that staff assists the resident in accessing and consuming the food, if the resident is not able to do so on his or her own. https://www.licamedman.com/ftag/870/f813-personal-food-policy https://www.bsnsolutions.net/storing-and-reheating-food-from-outside-sources-its-a-hot-topic In regard to temperature, the food safety guidelines recommend to keep hot food, HOT (135oF or above), cold foods, COLD (40oF or below), and have proper reheating processes (e.g., 165oF or above and use food thermometer to confirm proper temperature).
Is the waiting period prior to cleaning the room after the discharge of a positive resident only necessary if they left in their infectious period?
After discharge of a COVID-19 patient, terminal cleaning can be performed by EVS personnel. They should delay entry into the room until time has elapsed (e.g., 46 minutes for 99% reduction with 6 AC/h) for enough air changes to remove potentially infectious particles. After this time has elapsed, EVS personnel can enter the room and should wear a facemask (for source control) along with a gown and gloves when performing terminal cleaning.
What do you think are the biggest differences between infection prevention in acute care and long- term care (LTC)?
Most people who need inpatient hospital services are admitted to an “acute‑care” hospital for a relatively short stay. But some people may need a longer hospital stay. Long‑term care facilities focus on patients who, on average, stay more than 25 days.
The general methods of infection prevention are similar in both healthcare facilities to include: hand hygiene before and after touching a resident (or patient) or contaminated environment; cleaning and disinfecting environmental surfaces and non-critical medical devices; removing soiled items (e.g., linen, adult diapers from the environment), wearing personal protective equipment (such as gloves, a gown, or a mask); respiratory hygiene/cough etiquette; safe injection practices; universal precautions (e.g., OSHA BBP rule); and transmission-based precautions (e.g., contact, droplet, and airborne). Hand hygiene is the single most effective way to prevent the spread of infections in both acute-care and LTC facilities.
INJECTION SAFETY and WOUND CARE
Is it acceptable to reuse scissors if they are disinfected between patients?
Scissors ideally should be dedicated to individual residents when used in wound care. If scissors cannot be dedicated and DO NOT come in contact with blood, body fluids or non-intact skin (non-critical device) they can be disinfected with your EPA registered disinfectant
How long should glucose meter sit after cleaning before using it for next patient?
The manufacturer’s contact time for the EPA registered disinfectant should be followed.
To clarify, if individual glucometers are used and stored in the resident’s rooms, do they still need to be disinfected or cleaned after use?
Dedicated glucometers that are stored in the residents room should be disinfected if visible soiled and on a regular basis (daily for example) CDC recommends that “If meters are dedicated for single-patient use and facilities have taken steps to assure that they are stored in a location to prevent inadvertent use for the wrong patient and/or cross-contamination (stored in the resident’s room) then meters should be cleaned and disinfected according to manufacturer’s instructions and, at a minimum, anytime they are being reassigned to a different patient.
MISCELLANEOUS
We had an example of a resident whose urine came back with ESBL. My facility did not have a policy for isolation on ESBL. We did place her on contact precautions until her antibiotics were discontinued , but we did not retest her urine. Should we have retested her urine or placed her on isolation from the beginning ?
In LTCFs precautions are typically discontinued based on the organism, site of infection, clinical status of the resident and whether the resident is continent OR secretions and/or excretions can be contained. Re-culturing for test of cure is not recommended.
How can you easily tell the difference between viral or bacterial conjunctivitis. Or should one just assume its viral?
Some possible clues to try and help determine viral versus bacterial.
- Viral conjunctivitis is thought to be more common in adults
- Viral conjunctivitis is often times accompanied by a cold or other respiratory symptoms as well (probably the best way to tell the difference)
- Bacterial may be associated with copious amounts of discharge and the eye may appear more inflamed.
What about pregnant staff for residents with shingles?
The risk with shingles is the immune status of the pregnant healthcare worker. If they are immune to chickenpox they should not be at risk for acquisition of shingles.
If you do not have negative pressure rooms and you have a resident w/chickenpox or disseminated shingles, you would have to xfer them to the hospital since they require Airborne Isolation. Is that right?
Yes