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COVID‐19 – FIGHTING A SUPER SPREADER

A Summary of a Recent GHCA Webinar

 

Understanding how to prevent infections:

To prevent infections, you must understand the life cycle of infection. There are Six stages of a Super Spreader like COVID-19 or any infectious pathogen.

    1. It becomes an infectious pathogen (a bacterium, virus, or another microorganism that can cause disease)
    2. It then looks for a place to multiple
    3. It looks for a way to leave the host
    4. It looks for a mechanism to travel
    5. It looks for a way to enter a new host
    6. It then creates a new infected victim

To break any of the above mention stages is to stop the infection from spreading. The CDC has developed Core Prevention Strategies in stopping the spread:

    1. Hand hygiene
    2. Standard and Transmission-based precautions
    3. Environmental Cleaning and disinfection

 

– Hand Hygiene –

Alcohol-Based Hand Rub is the CDCs Preferred way to clean your hands, except if your hands are visibly soiled and contaminated with C. difficile or another infectious diarrhea.

Every SNF/ALF Needs to:

    • Have Hand Hygiene Policy and Procedure.
    • A Process and tracking mechanism for Educating and training staff
    • A competency check-off/return demonstration
    • Have observation and feedback to staff
    • Reinforce Compliance
For more information on any of these please refer to: https://www.cdc.gov/handhygiene/

 

– Standard Precautions –

Three Main Components to Preventing the Spread:

      1. Hand Hygiene
      2. Personal Protective Equipment (PPE)
      3. Respiratory Hygiene i.e. cough etiquette

Other Special Components:

      • Injection Safety
      • Medication Storage and Handling
      • Cleaning and Disinfection of Devices and Environmental Surfaces

 

– Person Protective Equipment –

PPE is used to protect from exposure to blood or body fluids. Protection is needed for the Hands, Skin and Clothing, Mouth and Nose and Eyes. This is done by appropriate use of:

 

  • Gloves – to protect hands from body fluids as well as contaminated equipment
  • Gowns – to protect skin and clothing from splashes or sprays of body fluids
  • Masks – to protect the mouth or nose from respiratory secretions, sprays of body fluids
  • Eye Wear – to protect the eyes from splashes, spray and respiratory secretions

 

Gloves alone are not enough. Your hands can get contaminated while wearing or removing gloves. Cleaning your hands after removing your gloves is essential to preventing the spread.

Gown application and removal require a special process to avoid contamination and spread. Remember to review the CDC step by step process for gowning (donning) and ungowning (doffing) and when is or is not the time to use them.

Masks come in a variety of forms but when it comes to prevention the most commonly used are either Facemasks or N95 Respirators. They are not the same. Here are the differences:

Facemask –

    • Are loose fitting. They can be made of a variety of materials.
    • They are designed to contain and prevent large droplets from leaving or entering the mask.

Respirator –

    • Are individually fitted
    • FIT tested and effectiveness is highly dependent on the fit and proper use
    • It has a filter in it to catch small particles from leaving or entering the mask
    • There are several types with the most commonly known as N95

Eye Wear protection also has unique requirements and come in a variety of different styles as Goggles or Face Shields. They should provide:

Goggles –

    • Should fit snuggle over and around the eyes
    • Personal glasses are not a substitute for goggles.

Face Shields –

    • Should cover the forehead, extend below the chin and wrap around the side of the face

 

Appropriate Donning and Doffing Order

Donning Order:

            1. Hand hygiene
            2. Gown
            3. Respirator/mask
            4. Eye protection
            5. Gloves

Doffing Order:

            1. Hand hygiene on gloves
            2. Gown
            3. Gloves – hand hygiene
            4. Eye protection (may keep on for extended wear)
            5. Hand hygiene
            6. Mask (may keep on for extended wear)
            7. Hand hygiene

 

– Respiratory Hygiene – Cough Etiquette –

  • Cover your mouth and nose with a tissue when you cough or sneeze. Put your used tissue in the wastebasket.
  • If you don’t have a tissue, cough or sneeze into your upper sleeve or elbow, not your hands.
  • You may be asked to put on a facemask to protect others.
  • Wash hands often with soap and warm water for 20 seconds. If soap and water are not available, use an alcohol-based hand rub.

 

– Transmission-based Precautions –

In addition to Standard Precautions, there are Transmission-based Precautions which are implemented when a patient/resident is suspected of or known to be colonized or infected with an epidemiologically important organism, novel or targeted Multiple Drug Resistant Organism or highly infectious microorganism. The purpose is one of containment and spread prevention of infectious microorganisms traveling Airborne, by Contact, or in the form of Droplet from an infected patient/residents body fluid.

In long-term care, this may also be considered Enhanced Barrier Precautions

The CDC has very specific guidelines that pertain to this type of Isolation. Please see the below resources for more information:

CDC/HICPAC Guidelines for Isolation Precautions and MDROs: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings – http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
Appendix A – https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/index.html

– Required Transmission-based Barriers –

  • Airborne – negative pressure airborne isolation room, N95 mask or powered air-purifying respirator (PAPR)
  • Contact – gowns, and gloves
  • Droplet – mask
  • Enhanced barrier precautions – gowns and gloves for high contact care activities

– Respiratory Hygiene – Cough Etiquette –

  • Cover your mouth and nose with a tissue when you cough or sneeze. Put your used tissue in the wastebasket.
  • If you don’t have a tissue, cough or sneeze into your upper sleeve or elbow, not your hands.
  • You may be asked to put on a facemask to protect others.
  • Wash hands often with soap and warm water for 20 seconds. If soap and water are not available, use an alcohol-based hand rub.

– Environmental Cleaning and Disinfection –

Healthcare grade disinfectant products are a necessity for environmental cleaning and disinfecting in our centers. They must be used by the manufacturer’s instructions. The main focus should be on:

  • High‐touch surfaces
  • Daily and terminal cleaning
  • Equipment cleaning
  • Assigning responsibility
  • Policy, procedure, staff training, and competency validation

 

Disinfection surfaces

COVID‐19 is very susceptible to disinfectants because Coronaviruses are enveloped viruses that are the easiest to kill. No so much for Non‐enveloped viruses, Mycobacteria, Spores, which are the hardest to kill.

Use products that are EPA list N, for emerging viral pathogens labeled claim as of 1 small or 1 large non-enveloped virus.

Room Cleaning for COVID Patient

CDC recommends

    • If the patient is in the room. Must wear PPE that is required for healthcare workers
    • Consider having nursing staff perform daily cleaning to limit staff in room and PPE use
    • For terminal cleaning
      • Reference CDC guidance for airborne contaminant removal based on air changes per hour to determine how long to keep the door closed and the room empty before entry when only using PPE for standard precautions

 

– Epidemiology of COVID‐19 – Understanding the Coronavirus –

The most commonly reported conditions for those infected with COVID-19 was Diabetes (10.9%), Chronic lung disease (9.2%), and Cardiovascular disease (9.0%). 29% of all cases have been hospitalized with 73% having an underlying condition with 30.6% requiring admission to an ICU. Greater than 80% of fatalities have been in persons 60 years old or over. When evaluating those with clinical presentation, the following was mostly observed:

                  • Fever 83-99%
                  • Cough 59-82%
                  • Fatigue 44-70%
                  • Anorexia 40-84%
                  • Shortness of breath 31-40%
                  • Sputum production 28-33%
                  • Myalgias 11-35%

Symptoms present at the onset of illness vary. Atypical symptoms commonly seen were sore throat, headache, cough with sputum production and/or hemoptysis, diarrhea and nausea/vomiting. Older adults may have delayed onset of fever or respiratory symptoms or atypical symptoms.

Asymptomatic and Pre‐symptomatic

A healthcare worker introduced COVID- 19 into an LTC facility and within 10 days seven residents were symptoms and were positive for COVID- 19. Almost all (93%) of the residents were tested 16 days after the introduction of COVID 19 into the facility and 30% of the residents had positive results despite early adoption of infection prevention and control practices. Of the residents who were positive, 57% were asymptomatic. Using symptom‐based screening alone in a SNF could fail to identify approximately half of the residents with COVID 19.

In Assisted and Independent Living, 2 residents were hospitalized with COVID- 19 a day later social distancing, no communal dining, no activities, no visits, and staff screening were started with enhanced cleaning and hand hygiene stations installed. Four days later all residents and staff were tested, 3 out of 80 residents were infected, 2 out of 62 staff were.

Unique to COVID Precautions

For COVID-19 specifically, CDC recommends Standard Precautions with contact and droplet with eye protection. The N95 mask is preferred if available; otherwise use a facemask. Eye protection should be with a face shield or goggles or any eye protection that covers around the eyes. Prescription glasses do not provide sufficient protection. Always apply assuming everyone may have the virus.

PPE Training Resources

National Emerging Special Pathogen Training and Education Center (NETEC) – www.netec.org
Putting on a respirator – CDC NIOSH – https://www.cdc.gov/niosh/docs/2010‐133/pdfs/2010‐133.pdf
NIOSH video on FIT testing – https://www.osha.gov/video/respiratory_protection/fittesting.html

– CDC Guidance –

– Optimizing the use of PPE

https://www.cdc.gov/coronavirus/2019‐ncov/hcp/ppe‐strategy/index.html
    • Extended wear of masks and face shields/eye protection during a shift
    • Disinfect eye protection
    • Can wear a gown for multiple patients ONLY if providing care for patients positive for COVID‐19 and no other co‐infections; otherwise, gowns need to be discarded after use

– Reinforced prevention strategies –

    • Essential visitors only with screening including a temperature check
    • No communal dining
    • Screen staff for each shift with temperature check
    • Monitor residents for signs and symptoms daily

– Patients and residents who enter facilities should be screened for COVID‐19 through testing, if available

– All personnel wear a facemask while in the facility

– If transmission occurs, COVID precautions for all residents

– Residents wear facemasks when they leave their room

– Residents to cover their nose and mouth when staff are in the room using tissue, non‐medical masks, or cloth mask/covering

– Cohort staffing to care for COVID positive residents

– Limit staff assignments to the same residents

– Strive for consistent assignment of staff to residents and strive to not have staff work across units or floors

– Ensure staff educated on COVID signs and symptom

– Use of self‐assessment checklist

– Cohort residents

      • Positive or known COVID‐19
      • Unknown COVID‐19 status
      • Non‐COVID‐19

– All admissions/re‐admissions place with unknown COVI‐19 status place on COVID precautions for 14 days

– Educate families to access limitations and placement alternatives for COVID‐19 positive or unknown

– CDC Guidance Staff Exclusion –

  • Identify staff with close contact with a positive resident who was not wearing appropriate PPE and exclude from work for 14 days
  • Risk-based exposures – high, medium, and low
    • Low-risk exposures do not require exclusion
https://www.cdc.gov/coronavirus/2019‐ncov/hcp/guidance‐riskassesment‐hcp.html

– CDC Discontinuing Precautions for Recovering Positive Patients

  • Test‐based strategy
    • Resolution of fever without the use of fever‐reducing medications and
    • Improvement in respiratory symptoms (e.g., cough, shortness of breath), and
    • Negative results of an FDA Emergency Use Authorized COVID‐19 molecular assay for detection of SARS‐CoV‐2 RNA from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart (total of two negative specimens)
  • Non‐test‐based strategy
    • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever‐reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
  • At least 7 days have passed since symptoms first appeared

Additional Resources

CDC Self‐assessment tool/Checklist

https://www.cdc.gov/coronavirus/2019‐ncov/downloads/novelcoronavirus‐2019‐Nursing‐Homes‐Preparedness‐Checklist_3_13.pdf

CMS focused survey tool

https://www.ahcancal.org/facility_operations/disaster_planning/Documents/self‐assessment.pdf

CDC Air Contaminant Removal Table

https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1
References: GHCA: COVID‐19 ALF WEBINAR COMBATING A SUPER‐SPREADER APRIL 14, 2020 A.C. Burke, MA, CIC, VP of Health Care Quality RB Health Partners, Inc.