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B73 COVID-19 - Procedural Guidance for DPH Staff



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REPORTING PROCEDURES

Outbreak Definitions:

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

Definition of Outbreak:

1. Two or more laboratory confirmed cases (symptomatic or asymptomatic) of 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 for any duration or having the potential to have been cared for by common Health Care Personnel (HCP) within a 14-day time period of each other).

AND/OR

2. Three or more laboratory confirmed cases (symptomatic or asymptomatic) of 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 15 minutes or longer while working in the facility during the 14 days prior to the onset of symptoms or positive test (e.g., 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 include cases (HCP and patients) that meet the case definition on the epi-curve. (Optional)

CONTROL OF CASE AND CONTACTS

CASE

Isolate suspected or confirmed case of COVID-19

Immediately isolate and initiate standard, contact, droplet precautions, plus N95 respiratory use and eye protection for all suspect or confirmed patients with fever and/or symptoms of COVID-19.

HCP should be excluded from work if symptomatic. For facilities experiencing staffing shortages, consult with Area Medical Director (AMD) or designee if HCP in quarantine area is permitted to return to work during an outbreak in the facility. See Infection Prevention and Guidance for Healthcare Personnel

CONTACTS

A close contact is a person with exposure to a confirmed or suspected case of COVID-19 during the period from 2 days before symptom onset until the case meets criteria for discontinuing isolation (see detailed instructions below for staff and patients). For asymptomatic cases, the date of collection of the specimen positive SARS-CoV-2 can be used in place of symptom onset date to determine period of isolation.

Exposures are defined as follows:

  1. Been within approximately 6 feet of a person with confirmed or suspected COVID-19 for a cumulative total of 15 minutes or more in a 24-hour period of time, without a mask (medical grade or higher level of protection such as N-95);

          OR

  1. Had unprotected direct contact with infectious secretions or excretions of a person with confirmed COVID-19 while they were infectious (e.g., being coughed or sneezed on, or touching used tissues with a bare hand, or sharing of a drink or food utensils, or not wearing eye protection (for HCP) if the case was not wearing a facemask or cloth face covering).

*A patient with COVID-19 is considered to be infectious from 2 days before their symptoms started until their isolation period ends. Asymptomatic patients with a positive SARS-CoV-2 diagnostic (viral) test are considered to be infectious from 2 days before their test was taken until 10 days after their test was taken.

Note: A person is still considered a close contact even if they and/or the case were wearing a facemask at the time of exposure. Exceptions to this are HCP wearing appropriate PPE and employees who were wearing a respirator as per Cal/OSHA regulations.

See CDC Public Health Guidance for Community-Related Exposure

Patients:

Identify any close contacts or exposures to the COVID-19 positive case and place them in quarantine for 14 days, regardless of vaccination status. Continue to monitor patients for fever and respiratory symptoms (i.e., cough, sore throat, shortness of breath). Patients who are considered exposed due to being in the same unit/wing as a case do not need to be moved.

Healthcare Personnel (HCP):

Identify all close contact HCP (includes clinical and ancillary staff), and determine risk status using the guide outlined in Infection Prevention Guidance for Healthcare Personnel and a companion guidance, CDC Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19. Monitor HCP for fever, cough, and shortness of breath. HCP who are not fully vaccinated must quarantine and be excluded from work for 10 days after a work exposure. Exceptions for critical staffing shortages is determined by public health officials during an outbreak. Work restrictions may be implemented for HCP who are asymptomatic and fully vaccinated (i.e., staff refusing COVID-19 testing) when directed by public health authorities during an outbreak. See: CDC Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to SARS-CoV-2.

Visitors:

Contact any visitors that may have been exposed to a suspected or confirmed case and instruct them to self-quarantine for 10 days after last exposure unless they are exempt (see COVID-19 Quarantine and Other Instructions for Close Contacts). Visitors should call their primary care provider to discuss testing options.

Note: CDC does not recommend testing, symptom monitoring or special management for people exposed to asymptomatic people with potential exposures to SARS-CoV-2 (i.e., “contacts of contacts;” these people are not considered exposed to SARS-CoV-2).

 

DIAGNOSTIC TESTING

All healthcare providers should be able to provide staff and patients with timely access to SARS-CoV-2 diagnostic testing when indicated (see LAC DPH Health Officer Order: Access to Diagnostic Testing Through Healthcare Facilities)

As shown in the LAC DPH SARS-CoV-2 Testing Guidelines, diagnostic testing is indicated when infection is suspected, such as when the person:

  • Has signs or symptoms of COVID-19. Individuals who have symptoms consistent with acute COVID-19 should be tested for SARS-CoV-2 infection regardless of vaccination status or recent history of previous infection.
  • Is a close contact to a confirmed case, regardless of vaccination status. Testing is not recommended for asymptomatic close contacts who have recovered from laboratory-confirmed COVID-19 within the past 3 months (90 days).
  • Is part of an outbreak investigation and response and/or case investigation. Testing is recommended regardless of vaccination status. Investigations may include testing of asymptomatic persons with recent history of previous infection as directed by Public Health. Nucleic acid amplification tests (NAATs) or antigen tests can be used for diagnostic testing (See: SARS-CoV-2 Reference Panel Comparative Data). Negative results from less sensitive tests (e.g., antigen tests, some NAATs), should be considered presumptive and confirmation with a standard laboratory-based NAAT test (e.g., RT-PCR) is recommended if important for clinical management or infection control decisions.

 

OUTBREAK RESPONSE MEASURES

Response Testing

  • Close contacts and persons who are part of an outbreak investigation should be tested regardless of vaccination status. Conduct PCR tests during response testing.
  • If testing capacity is limited, testing may be prioritized for the patients and staff in the same area (e.g., nursing station, floor, etc.) as the COVID-19 positive individual. This decision is made in consultation with public health officials. Any close contact and exposed patients of confirmed COVID-19 cases will need to be quarantined. All patients and staff who test negative will need to be included in response testing until there are at least 2 consecutive weeks with no additional infections identified.
  • Facility  and outbreak lead investigator will identify a date to conduct COVID-19 response testing (i.e., PCR) of all relevant staff and patients. Asymptomatic and symptomatic patients who refuse COVID-19 testing must be placed immediately in the quarantine cohort, preferably in a single room. Staff member who refuses COVID-19 testing should immediately be restricted from entering the facility until the outbreak has been closed.
  • Seven (7) days after the initial response testing, facility to conduct a 2nd COVID-19 response testing (i.e., PCR) of all relevant staff and patients who had a COVID-19 negative test result the week prior. Patients who refuse 2nd and subsequent testing must be placed in the quarantine cohort.  Staff member who refuses 2nd and subsequent testing should be restricted from entering the facility until the outbreak has been closed.
  • Facility to continue to track COVID-19 test dates and results for all patients and staff on the EXCEL spread sheet. Tracking results needs to be done in a way so it is available to California Department of Public Health (CDPH) and Los Angeles County Department of Public Health (LAC DPH) upon request.

 Refusal of Testing

  • Staff: The following restrictions only apply to staff directly employed by the facility:
    • Staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the facility until 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 entering the facility until the outbreak has been closed.
    • Note: Facilities are required to follow the public health order and should refer to their own individual employer policies regarding management of employee who do not comply.
  • Patients:
    • Facilities must have procedures in place to address patients who refuse testing. In discussing testing with patients, staff (i.e., psychiatrists, mental health counselors, etc.) should use person-centered approaches when explaining the importance of testing for COVID-19. Patients who have signs or symptoms of COVID-19 and refuse testing must be placed in the quarantine cohort, preferably in a single room, until the criteria for discontinuing transmission-based precautions have been met.
    • If outbreak testing has been triggered and an asymptomatic patient refuses testing, patient must be placed in the quarantine cohort, preferably in a single room.

Environmental Cleaning

Increase environmental cleaning throughout the facility with emphasis on high touch surfaces particularly in the unit where the case(s) was located. Ensure that approved cleaning agent is being used. See EPA About List N: Disinfectants for Coronavirus (COVID-19).

Visitation

Discontinue indoor and outdoor visitation until the outbreak has been closed (see DHHS Visitation at Psychiatric Residential Treatment Facilities and CDPH Visitation Guidance AFL 20-38.7) Visitation may be restricted during an outbreak as directed by public health officials.

Communal Activities and Dining

Discontinue indoor and outdoor communal activities and dining until the outbreak has been closed.  Eating needs to remain supervised due to potential for self-harm with eating utensils and because commonly used psychiatric medications may cause side effects (e.g., tardive dyskinesia, dysphagia, hypo- and hypersalivation) that increase choking risk for patients.  Some options are to position staff in patient’s rooms to monitor their dining or have patients sit in appropriately spaced chairs in the hallway outside their rooms so they can be monitored while they eat.

Interfacility Transfer

Follow COVID-19 interfacility transfer guidelines including:

  • If patients are close contacts to a COVID-19 case, they are to be quarantined for 14 days.
  • If a patient (contact to a positive COVID-19 case) is to be transferred to another facility prior to the 14 days, the receiving facility should be notified of the exposure and quarantine period prior to transfer to ensure that the receiving facility agrees to receive the patient and have the resource to continue patient quarantine upon admission. Facility is to provide information regarding exposure and quarantine status to the healthcare transport personnel.
  • If a patient (contact to a positive COVID-19 case) is to be discharged home prior to the 14 days, family members should be notified of the exposure and quarantine period prior to discharge to ensure continuation of patient quarantine at home.

Reporting Requirements

Instruct the facility to immediately notify District Public Health Nurse (DPHN), assigned to the facility, if any patient or staff report fever or respiratory symptoms and any COVID-19 positive test results. Comply with reporting requirements regarding COVID-19 or SARS-CoV-2 virus testing results. DPHN must be notified of a death and the facility will need to complete and submit a death report to ACDC (see Reporting COVID-19 Associated Deaths).

Healthcare Worker Vaccination Requirement

Healthcare worker vaccination requirement mandates employers of health care and home care workers who work in or routinely visit high-risk or residential care settings to document their fully vaccinated status; for those with approved medical or religious exemptions, document weekly or twice weekly regular testing for COVID-19. This mandate reflects the State Health Officer Order and LAC DPH Health Officer Order requiring health care worker vaccination and testing.

Admission and Readmissions

  1. In an outbreak situation, admission of new residents (new admissions) and returning residents (readmissions) should be permitted unless closure is approved by the AMD.
  2. The decision to close admissions, in collaboration with HFID, should be recommended based upon a number of factors.  Consider closing the facility to admissions for the following concerns:
    • Immediate jeopardy for infection prevention and control concerns by licensing
    • Concerning rates of adverse outcomes including hospitalizations and deaths
    • Evidence of concerning viral transmission based on response testing of residents
    • Inability to cohort residents per protocol, inability to effectively quarantine new admissions and readmissions, inability to effectively dedicate COVID-19 and non-COVID-19 areas in the facility
    • Lack of effective infection control practices as evidence by a virtual or on-site infection control visit
    • Inadequate supply of PPE
    • Staffing shortages reported

Closure Criteria

The outbreak can be closed once closure criteria is met:

1. Two consecutive weeks of response testing in a staff and patients have been negative;

OR

2. Upon the discretion of the AMD or MD designee.

Prior to closure, all of the following documents must be completed:

  • PHN uploads all documents into IRIS and completes all required documents in IRIS per protocol
  • PHNS reviews and forwards to AMD
  • 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.

Routine Infection Prevention and Control

View LAC DPH infection prevention guidance and assuring PPE supplies and CDC recommendations for healthcare personnel during the COVID-19 pandemic for additional information.

Due to security and behavioral concerns in behavioral health settings, some infection control guidance may need to be tailored for the safety of the patients (see CDC Clinical Questions about COVID-19: Questions and Answers for further guidance).

  • When possible, use virtual methods for group counseling, therapy, and discussion sessions, or decrease group size so social distancing can be maintained.
  • Patients who due to underlying cognitive or medical conditions cannot wear a mask should not be forcibly required to wear one (and should not be forcibly kept in their rooms). However, facemasks (preferably with short ear-loops rather than longer ties) should be encouraged as much as possible. Ensure that HCP interacting with patients who cannot wear a facemask are wearing eye protection and a facemask (or a respirator if the patient is suspected to have COVID-19).
  • Encourage frequent hand washing with soap and water for patients and HCP. Consider providing personal pocket-sized alcohol-based hand sanitizer (ABHS) dispensers for HCP.
  • Communal dining is generally not recommended to ensure social distancing.  Options for dining is to position staff in patient’s rooms to monitor their dining.  Another option is to allow communal dining in shifts so that staff can monitor patients while ensuring they remain at least 6 feet apart.  A third option is to have patients sit in appropriately spaced chairs in the hallway outside their rooms so they can be monitored while they eat.
  • Limit the number of patients/residents allowed to access smoking spaces at the same time, and position staff to observe and ensure patients are practicing appropriate physical distancing.

Universal Source Control

View CDC recommendations for universal source control.

Recommend COVID-19 PCR testing upon admission for unvaccinated patients, patients whose vaccination status is unknown, patients who are symptomatic, and patients with known exposure as these results can inform the type of infection control precautions used (e.g., room assignment/cohorting, or personal protective equipment used). Recommend antigen or COVID-19 PCR testing upon admission for fully vaccinated patients who are asymptomatic and without known exposure. Continue to monitor all patients for the development of COVID-19 symptoms, and promptly test any newly symptomatic patients and patients who are exposed to a suspected or confirmed case during their hospital stay, regardless of their vaccination status.

Universal Use of PPE for Patient Care

View CDC recommendations for universal use of PPE for patient care.

  • Facilities must demonstrate that they have contracted with suppliers to order a 2-week supply of PPE and other infection prevention and control supplies.
  • PPE and other infection prevention and control supplies (e.g., surgical masks, respirators, gowns, gloves, goggles, hand hygiene supplies) that would be used for both HCP protection and source control for infected patients (e.g., facemask on the patient) should be readily accessible for use.
  • Follow the CDC Guidance on Strategies to Optimize the Supply of PPE and Equipment in the setting of shortages.

For additional information on PPE for patients with suspected or confirmed COVID-19 view CDC recommendations and NIOSH Considerations for Covering N95s to Extend Use.

NOTE: Local public health guidance with respect to outbreak control and management is understood to take precedence of both state and federal guidance.

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  • Public Health has made reasonable efforts to provide accurate translation. However, no computerized translation is perfect and is not intended to replace traditional translation methods. If questions arise concerning the accuracy of the information, please refer to the English edition of the website, which is the official version.

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