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Acute Psychiatric Hospitals

B73 COVID-19 - Procedural Guidance for DPH Staff



REPORTING PROCEDURES

Outbreak Definitions:

Under Title 17, Section 2500, California Code of Regulations all suspected outbreaks are reportable.

Definition of Outbreak:

≥2 cases of confirmed COVID-19 in a patient 7 or more days after admission for a non-COVID condition, with epi-linkage. (Epi-linkage among patients is defined as overlap on the same unit or ward, or having the potential to have been cared for by common HCP within a 14-day time period of each other.)

≥2 cases of confirmed COVID-19 in HCP with epi-linkage who do not share a household, and are not listed as a close contact of each other outside of the workplace during standard case investigation or contact tracing. (Epi-linkage among HCP is defined as having the potential to have been within 6 feet for a total of 15 minutes or more within a 24-hour period while working in the facility during the 14 days prior to prior to the onset of symptoms; for example, worked on the same unit during the same shift.)

Epidemiologic Data for Outbreaks

  1. Establish a case definition (i.e., fever [measured or reported] and either cough, sore throat, or stuffy nose): include pertinent clinical symptoms and laboratory data.
  2. Confirm etiology of outbreak using laboratory data.
  3. Create a line list and contact information following the COVID-19 template above.
  4. Maintain surveillance for new cases until no new cases for at least 2 weeks.
  5. Create an epi-curve, by date of onset (see CDC Quick Learn Lesson: Create an Epi Curve for guidance). Only put those that meet the case definition on the epi-curve. (Optional)

CONTROL OF CASE, CONTACTS & CARRIERS

Case

See detailed instructions below for single cases and multiple cases in incarcerated/detained persons, as well as cases in facility staff.

CONTACTS

Contacts are defined as HCWs or patients who have:

  1. Been within approximately 6 feet of a person with COVID-19 for a prolonged period (greater than 2 minutes) per CDC criteria; OR
  2. Had unprotected direct contact with infectious secretions or excretions of the resident (e.g., coughed on, touched used tissues with a bare hand).

Healthcare Personnel (HCP):

Facility to identify all close contact HCP (includes clinical and ancillary staff), and determine risk status using the guide outlined in LAC DPH Guidance for Monitoring Healthcare Personnel and a companion guidance, CDC Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim Guidance).

Document the contacts on the COVID-19 Contact Information Form (see Report Forms section) and submit it to DPH as requested by DPH

  1. Monitor and follow-up for symptoms with HCP contacts during or at the end of monitoring period to check-in and respond to concerns.

Visitors:

Facility to identify any close contact visitors that may have been exposed to a confirmed case and instruct to self-quarantine and self-monitor for symptoms for 14 days after last exposure.

Visitors should call their primary care provider to discuss testing options and guidance.

Facilities should be encouraged to maintain daily visitor log with date and time of visit as a regular practice.

Steps Acute Psychiatric Hospitals should take to reduce the spread of COVID-19

The recommendations have been added to align with the Health Officer Order: Prevention of COVID-19 Transmission in Licensed Congregate Health Care Facilities

Key changes include the following recommendations:

  1. The facility must conduct COVID-19 diagnostic testing for patients and staff, which may include those with and without symptoms, as requested or per DPH. The facility should be prepared to implement mass testing of staff and patients at the request of DPH.
  2. Facilities may choose to do testing on their own, but should contact DPH for post-testing guidance.
  3. The facility must report all confirmed or suspected COVID-19 cases and deaths to LAC DPH immediately by phone: (888) 397- 3993 or (213) 240-7821 (after business hours).
  4. The facility must keep records of all daily staff and patient temperature checks.
  5. All HCP that work in an established COVID- 19 area are not to work or enter into any other facility until 14 days have passed from their last exposure to COVID-19 patients.
  6. Only essential visitors are permitted to enter the facility.
  7. The facility will comply with state and local guidelines for interfacility transfers.

Visit the LAC DPH COVID-19 website frequently for updated information on COVID-19 testing, infection control, FAQs, and guidance for facilities.

General and Administrative Considerations

  1. Identify a mechanism for your facility to obtain SARS CoV-2 samples and to send these specimens from your facility to a commercial clinical laboratory. If the facility does not have a relationship established with a commercial laboratory, the Public Health Lab (PHL) is available for testing.
  2. Be prepared to implement mass testing for all patients and staff, see LAC DPH Mass Testing Strategies for LTCF and Other Congregate Settings. Identify a staff person to coordinate testing and identify staff to perform the testing (if this is not possible, alternative options may be available). Refer to Section C, Testing Logistics, for the information that will be required to prepare for mass testing.
  3. Review and follow the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings and use CDC guidance on conservation of personal protective equipment (PPE). Develop a surge plan for emerging infectious diseases, particularly suspected or confirmed COVID-19 patients.
  4. Plan for ways to continue essential services if on-site operations are reduced temporarily.
  5. Plan for employee absences and create a back-up/on-call system.
  6. Discontinue group activities, field trips, and communal dining.
    1. All meals are to be served within individual rooms unless it is unsafe for patients to eat unsupervised. Patients who may be prone to aspiration or who cannot feed themselves may eat outside their rooms if they follow physical distancing guidelines if staffing is insufficient to support one to one feeding.
    2. Staff may eat together in staff breakrooms or a separate designated area, but physical distancing of six feet or more between persons must be enforced at all times while eating.
  7. Immediately implement symptom screening for all staff, patients, and visitors—including temperature checks. Patients should have their temperature taken every 12 hours if it is a medical facility. If there are no medical staff at the facility, patients should self- monitor their temperature every 12 hours.
    1. Every individual, regardless of reason, entering an acute psychiatric hospital (including patients, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked. An exception to this is Emergency Medical Service (EMS) workers responding to an urgent medical need. They do not have to be screened, as they are typically screened separately.
    2. Records are to be kept of staff and patient temperature checks.
    3. Facilities should limit access points and ensure that all accessible entrances have a screening station.
    4. Anyone with a fever (100.0° F or 37.8° C) or symptoms (fever, chills, sore throat, cough, sneezing, shortness of breath, gastrointestinal symptoms, or not feeling well) may not be admitted.
  8. Prohibit visitors from entering the facility unless compassionate care situations, such as end-of-life.
    1. Those with symptoms of a respiratory infection (fever, cough, shortness of breath, or sore throat) should not be permitted to enter the facility at any time (even in end-of- life situations)
    2. Post signs explaining visitor restrictions.
    3. Set-up alternative methods of visitation such as through videoconferencing through skype or FaceTime
    4. Those visitors that are permitted, should be screened for fever and respiratory symptoms, must wear a face covering while in the building, and should restrict their visit to the patient’s room or other location designated by the facility. They should also be reminded to frequently perform hand hygiene and to practice physical distancing while in the facility.
  9. All facility personnel should wear a surgical mask while they are in the facility.
    1. Staff must wear either an N95 respirator or a surgical mask when in patient care areas or in areas where patients may congregate.
    2. Masks and respirators are not required for staff working alone in closed areas unless they are moving through common spaces where they may interact with other staff or patients.
    3. All staff should follow physical distancing and hand hygiene guidance.
  10. All patients must wear masks when outside their room. Surgical masks are required for any patient that is COVID-19-positive or assumed to be COVID-19-positive.
    1. The facility is required to provide each patient with a clean non- medical face covering daily. Surgical masks should be reserved for staff. Patients who, due to underlying cognitive or medical conditions, cannot wear face coverings outside their room should not be forcibly required to wear face coverings and should not be forcibly kept in their rooms. However, face coverings should be encouraged as much as possible. Patients should additionally be encouraged to follow physical distancing and hand hygiene guidance as much as possible.
  11. When possible, patients should cover their noses and mouths when staff are in their room. Patients can use tissues for this or masks.
  12. Provide education and job-specific training to staff regarding COVID-19, including:
    1. Signs and symptoms
    2. Modes of transmission of infection
    3. Correct infection control practices and personnel protective equipment (PPE) use
    4. Staff sick leave policies and recommended actions for unprotected exposures (e.g., not using recommended PPE, an unrecognized infectious patient contact)
    5. How and to whom COVID-19 cases should be reported
  13. Ensure that your facility has the capacity to isolate patients with COVID-19 and quarantine patients who are close contacts of a COVID-19 case.
  14. Establish a COVID-19 area within the facility:
    1. The COVID-19 area is for patients who have suspected or confirmed COVID-19 and must have a designated bathroom. The area must be physically separated from the area for those who do not have COVID-19.
    2. All staff, equipment and common areas should be kept separate as much as possible.
    3. Designate HCP who will be responsible for caring for suspected or known COVID-19patients. Ensure they are trained on the infection prevention and control recommendations for COVID-19 and the proper use of PPE.
    4. All staff should follow physical distancing and perform frequent hand hygiene.
    5. If staffing scarcity requires staff to work with COVID-19 positive and negative s, staff should be careful to change required PPE between patients, though N95 and face shields may be worn throughout the day consistent with CDC PPE conservation contingency strategies.
    6. LAC DPH does not recommend transferring patients to hospitals unless they require higher level of care. HCP who have a high-risk exposure to a COVID-19 patient (high-hazard aerosol- generating procedure without face mask or eye covering) should be excluded from work for 14 days after exposure. If there was no high-risk exposure, HCP may continue to work and self-monitor for fever and symptoms of COVID-19 twice daily.
  15. Patients with psychiatric conditions may not be easily kept within their rooms. Patients should be encouraged to stay in their room as much as possible and should avoid communal and group activities as much as possible.
  16. Have a family and patient notification process for when a case of COVID-19 is identified.
  17. As much as possible, have employees work at only one facility in order to reduce interfacility spread of COVID-19.

WHAT TO DO IF YOU IDENTIFY TWO OR MORE COVID-19 CASES

A. Two or more unknown respiratory cases within 72 hours

Initial Recommendations:

  1. Define a quarantine area around the suspect patient(s).
    Note: The actual quarantine area will depend on each building but define the area by your local workflow (e.g., the unit the patient is located would be a logical decision).
  2. If it is possible to move roommates into other rooms within the quarantine area, then move them. Otherwise, keep them in place.
    1. Consider moving suspect patients into the quarantine area if suspicion for COVID-19 is high.
  3. Cohort staff (keep the same, limited number of staff caring for the COVID-19 patients and ensure they do not interact with other non-quarantined patients).
  4. For any transfers out of the building, notify EMS and the receiving facility regarding possible COVID-19 exposure to minimize transmission.
  5. Initiate standard, contact, and droplet precautions plus eye protection for all suspect patients with fever and/or respiratory symptoms.
  6. Encourage testing for routine respiratory pathogens if available at the facility.
    1. Test for Influenza and/or other respiratory pathogens to establish an alternative diagnosis.
    2. If COVID-19 testing is available, consider sending tests to commercial laboratories.
  7. Increase environmental cleaning throughout the facility with emphasis on high touch surfaces, particularly in the unit where the patient was located
    1. If you have not already done so, ensure that you are using and EPA approved cleaning agent List N: Disinfectants for Use AgainstSARS-CoV-2.
  8. Restrict all visitation except for certain compassionate care situations, such as end of life.
  9. Restrict all volunteers and non- essential healthcare personnel (e.g., barbers).
  10. Identify all HCP that have been in contact with that patient 48 hours prior to symptom onset.
  11. Discontinue all community and group events and outings.
    1. Serve meals in patient rooms if possible, or stagger dining times to decrease the size of the groups.
    2. If smaller group activities are necessary, keep the same group together to decrease the risk for virus spread.
  12. Limit the number of staff members interacting with the symptomatic patient and try to keep the same individuals caring for the patient as much as possible.
  13. Monitor all HCP (regardless of contact with a case) for fever, cough, and shortness of breath.
    Symptomatic healthcare workers may not work. Recommend checking all HCPs for fever (>100.0° F) and respiratory symptoms at the beginning of the shift.
    1. Notify DPH immediately if any HCP contact tests positive for COVID-19.
    2. For symptomatic HCPs, ensure they are not working. They should follow CDC return to work guidance.
  14. Cancel and re-schedule all upcoming non-essential medical appointments

B. Two or more confirmed COVID-19 cases

Initial Recommendations:

  1. The confirmed cases should be in a single- person room or cohorted in a single room with the door closed and a dedicated restroom.
  2. Lab testing of symptomatic patients should be done through a commercial lab, if possible.
  3. Mass testing is recommended for staff and patients,
  4. If mass testing strategy for early intervention is to be instituted, see Mass Testing Strategies for Long-Term Care Facilities (LTCF) and Other Congregate Settings guidance.
  5. Post a notification letter at the entrance of the facility and community area.
  6. Notify all families and patients of COVID-19 cases. Identify and notify all HCP that have been in contact with that patient 48 hours before the onset date of symptoms.
  7. Instruct the facility to do active monitoring of their patients and staff: monitor for fever and signs/symptoms of cough, sore throat, and shortness of breath twice a day.
  8. Identify facility staff who can monitor sick staff with daily “check-ins” using telephone calls, emails, and/or texts.
  9. Instruct facility to notify LAC DPH immediately if any report fever or respiratory symptoms.
  10. Implement a line listing of all HCW, patients, and visitors with symptoms.
  11. Instruct HCP to notify all other employers of the type and nature of their exposure.
  12. Identify and notify all visitors that have been in contact with the confirmed patient to self- isolate and monitor for fever (>100.0° F) or signs/symptoms of cough, sore throat, and shortness of breath twice a day for 14 days.
  13. HCP assigned to a case should wear full PPE. But if PPE shortage, a mask (surgical mask or higher) and eye protection should be worn for all patient encounters. For conservation of PPE, please refer to CDC guidance.
    Note:
    The rationale for mask and eye protection is to try to prevent HCP exposure. Surgical masks can be worn for an extended period but should be discarded after they become saturated with moisture.
  14. Inform the facility to perform infection control audits and increase environmental cleaning throughout the with emphasis on high touch surfaces particularly in the unit where the patient was located.
  15. Place symptomatic patients on isolation in a private room with droplet/contact precautions or within the COVID-19 designated area if available.
  16. Place asymptomatic patients in the quarantine area.
  17. Post signage of your quarantine area.
  18. Initiate Contact, Droplet, and eye protection precautions in the quarantine area.
  19. Confirmed COVID-19 patients may be cohorted together in the same room, otherwise they should be in a single room if possible.
  20. Cohort staff as much as possible to minimize transmission.
  21. The facility to consult with the DPHN assigned to the facility regarding closure of the facility to new/returning admissions.: Refer to Interfacility Transfer Rules During COVID-19 PANDEMIC.

Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings: For more details, refer to CDC Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings.

  1. If discontinuing isolation for suspect cases, facilities are advised to do the following:
    1. Patients should be tested 2 times at least 24 hours apart given the high false-negative rate of testing. Once the negative test results are received, discontinue isolation unless an alternative diagnosis requires transmission-based precautions.
    2. If testing is not available or not tested:
      1. At least 10 days after symptom onset AND at least 1 day (24 hours) afebrile (< 100.0° F) without the use of antipyretic medications AND improvement of symptoms.
  2. If discontinuing isolation for confirmed symptomatic patients with COVID-19, facilities are advised to do the following:
    1. Symptomatic-based strategy
      1. At least 1 day (24 hours) have passed since recovery defined as resolution of fever without the use of antipyretic medications and improvement in symptoms; and,
      2. At least 10 days have passed since symptoms first appeared
    2. Test-based strategy
      1. Resolution of fever without the use of fever-reducing medications and
      2. Improvement in respiratory symptoms (e.g., cough, shortness of breath), and
      3. Negative results of at least two consecutive respiratory specimens (e.g., nasopharyngeal swab) collected ≥24 hours apart (total of two negative specimens).
  3. If discontinuing isolation for asymptomatic laboratory-confirmed patients with COVID-19, facilities are advised to do the following:
    1. Time-based strategy:
      10 days have passed since the date of their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms since their positive test. (Note: since symptoms cannot be used to determine where these individuals are in the course of their illness, so there is a possibility the duration of viral shedding may be shorter or longer than 10 days after their positive test).
    2. Test-based strategy:
      Negative results of at least two consecutive respiratory specimens (e.g., nasopharyngeal swab) collected ≥24 hours apart (total of two negative specimens).
  4. Transmission-Based Precautions have been discontinued, but the patient has persistent symptoms from COVID-19 (e.g., persistent cough), they should be placed in a single room, be restricted to their room, and wear a facemask (if tolerated) during care activities until all symptoms are completely resolved or at baseline.

Interfacility transfer from hospital to Acute Psychiatric Hospital and Transmission-Based Precautions:-Refer to Interfacility Transfer Rules During COVID-19 PANDEMIC
Interfacility transfers should be limited as much as possible, while still maintaining appropriate levels of care for all patients.
Patients should not be sent to the Emergency Department (ED) to obtain SARS CoV-2 testing.

  1. For patients not needing hospital admission: Refer to Return-to-Facility Discharge Rules for Patients in the Emergency Department.
  2. Patients who developed symptoms of COVID-19 in the acute psychiatric hospital and are transferred to acute care hospital may return to the facility of origin once clinically stable if staffing levels are adequate. They should be placed in COVID-19 dedicated area.
  3. New COVID-negative admissions to the acute psychiatric hospital should be restricted based on the assessment of the AMD or AMD delegated physician and depends upon the layout of the facility and the capacity for the facility to separate COVID positive patients from negative patients and whether there is evidence of ongoing transmission (i.e., new symptomatic cases) in the facility.

Transfers from one acute psychiatric hospital to another acute psychiatric hospital: LAC DPH does not recommend transferring patients to hospitals unless they require higher level of care or is unable to isolate the patient adequately. Refer to InterfacilityTransfer Rules During COVID-19 PANDEMIC. If the facility is a dedicated COVID receiving facility, they may accept transfers of COVID+ patients from other acute psychiatric hospital.

CLOSURE CRITERIA

Outbreak can be closed once closure criteria is met:
14 days have passed since last confirmed or symptomatic case (includes staff and patients) Note: Outbreak can be closed after consultation with AMD.
  1. PHN uploads all documents into IRIS and documents in IRIS per protocol.
  2. PHNS reviews and forwards to AMD.
  3. PHN or PHNS can close COVID-19 outbreak in IRIS after approval by AMD or AMD delegated physician. Closure letter will be signed by AMD or AMD delegate and placed in IRIS under the filing cabinet.

DEATH REPORTING

DPHN must be notified of a death and the facilities will need to complete and submit a death report form to ACDC.


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