New Guidance on COVID-19 Issued to Long-Term Care Facilities

New guidelines on COVID-19 for long-term care facilities (LTCFs) have been issued by the World Health Organization, as well as by organizations in the US including the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS), that provide best practices to protect the elderly, vulnerable populations and staff.

In the CMS investigation of the outbreak in a skilled nursing facility in February in Kirkland, Washington, inspectors found 3 failings principally responsible for patients being in "imminent danger". These included failure to rapidly identify and manage ill residents, failure to notify the state department of health about the increasing rate of respiratory infection among residents, and failure to possess a sufficient backup plan following the absence of the facility's primary clinician who fell ill.

The demonstrated vulnerability of this population is not unique to the state of Washington, as the CMS relates in the investigation report that the CDC had notified them of 147 facilities across 27 states reporting at least 1 resident with COVID-19. Similar circumstances occurring across the globe prompted the WHO to issue an interim guidance on infection prevention and control for LTCFs.

The guidance from the WHO specifies that LTCFs should ensure that there is an infection prevention and control (IPC) focal point, "to lead and coordinate IPC activities, ideally supported by an IPC team with delegated responsibilities and advised by a multidisciplinary committee."

The guidance cautions that imposition of IPC activities may affect the mental health and well-being of residents and staff, especially regarding the use of personal protective equipment, restriction of visitors and group activities.

The guidance indicates that the IPC focal point should undertake several actions—at a minimum—including: provide COVID-19 IMPC training to all employees; provide information sessions for residents; regularly audit IPC practice compliance; emphasize hand hygiene and respiratory etiquette. Other sections of the guidance include staff conducting prospective surveillance of patient status and timely, appropriate response, and implementing measures to prevent onward transmission.

In a press release announcing new guidance, CMS Administrator Seema Verma stated, "As we learn more about the coronavirus from experts on the ground, we've learned that seniors with multiple conditions are at highest risk for infection and complications, so CMS is using every tool at our disposal to keep nursing homes free from infection."

A communiqué to State Survey Agency Directors in the US from the Director of Quality, Safety & Oversight Group for CMS indicates that the guidance is being provided in addition to "overarching regulations".

The CMS guidance on limiting the transmission of COVID-19 prohibits all visitors and non-essential health care personnel, "except for certain compassionate care situations, such as an end-of-life situation". In those circumstances, visitors are to be required to perform hand hygiene and use personal protective equipment (PPE).

The CMS guidance includes considerations on transferring a resident with suspected or confirmed infection with COVID-19 to an acute-care hospital and accepting a resident who has been diagnosed with COVID-19 from a hospital.

The CDC has updated its previous guidelines with additional information on infection prevention and control for patients with suspected or confirmed COVID-19. The changes include restrictions on visitations, volunteers, group activities and communal dining, and implementing active screening of residents and staff for fever and respiratory symptoms.

In addition, the CDC offers a "COVID-19 Preparedness Checklist" for LTCFs that includes rapid identification and management of ill residents; managing visitors and consultant staff; maintaining sufficient supplies and resources; providing staff with sick leave, education and training; and having surge capacity for staffing, equipment and supplies, as well as for postmortem care.

"It is important to understand transmission dynamics in your community to inform strategies to prevent introduction of spread of COVID-19 in your facility," the CDC guidance advises LTCFs.