CORONAVIRUS 19 (COVID 19) Update

March 12, 2020

SUMMARIZED INFORMATION REGARDING CORONAVIRUS 19 (COVID 19)

Updated 3/15/2020

 

HISTORY

Coronaviruses are a large family of viruses that are common in people as well as animals Animal viruses, at times, are transmitted to humans resulting in serious illness.  Some examples include MERS-CoV, SARS-CoV and now this new virus SARS-CoV-2; the illness it causes is called COVID-19. Most recently, there has been confirmed person-to-person spread of COVID-19. Any outbreak of a novel virus infection between people is always of public health concern. The fact this disease has caused illness resulting in death, and achieved person-to-person spread, is concerning but together we can reduce disease transmission.

 

ILLNESS SEVERITY

The complete clinical picture of COVID-19 is not fully understood but there is a rapidly evolving effort to better understand the disease and, as information becomes available, it will be updated. Illnesses have ranged from mild to severe and can appear as soon as two (2) days after exposure to fourteen (14) days after exposure. Typical symptoms include fever, cough, myalgias and shortness of breath which can progressively worsen to pneumonia. Less common symptoms include nasal congestion, runny nose or sore throat. It is not like Influenza, which has a classical sudden onset, and the most consistent radiographic finding was bilateral interstitial and ground glass infiltrates. Co-infection rates with other respiratory viruses like Influenza or RSV is also very low. To date, illness in less than 4% of those infected has resulted in death in the US, but death rates are as high as 15% in those who are older and frailer.

 

TRANSMISSION

COVID-19 is spread by respiratory droplets produced when an infected person coughs or sneezes. Consequently, people who are in close contact (6 feet) can inhale these microscopic droplets and become infected. Another possible source of transmission occurs when an infected person touches or shakes the hands of a non-infected person. The non-infected person then unintentionally touches their face in such a way they contaminate themselves. It is currently unclear if transmission can occur from contaminated surfaces but this is a likely possibility.

 

HOW IS COVID-19 DIAGNOSED

The CDC has developed a new protocol after the original test was found to have issues affecting accuracy and has been working with FDA to test for the virus. The CDC, who is now working with commercial labs, should be able to start mass testing in the coming week.

 

HOW IS COVID-19 TREATED

Treatment for this coronavirus is similar to  treatment for other respiratory illnesses. There is no current vaccine or cure so the goal of treatment is supportive and for symptoms. Currently, up to 80% of infected people recover without any need to seek care.

 

PROTECTING YOURSELF AND OTHERS FROM COVID-19

Everyone can do their part in helping to respond to this emerging public health threat. A few common sense practices include:

  • Wash your hands thoroughly and often. Make sure you are cleaning between your fingers and under your nails. Use a clean unused paper towel to dry your hands. If an alcohol-based hand rub is used, it should contain at least 60% ethyl alcohol and individuals should rub their hands until completely dry.
  • Avoid shaking hands, especially with those who appear to be ill.
  • Avoid touching your eyes, nose, and mouth as much as possible.
  • Maintain a social distance (usually 6 feet) from individuals with respiratory symptoms.
  • Avoid large gatherings with other people.
  • Practice respiratory hygiene
  • by coughing or sneezing into a bent elbow or tissue and then immediately dispose of the tissue.
  • Disinfect shared surfaces.
  • DO NOT work while ill

 

Note, none of these recommendations are new! Recommendations of this kind have been with us for some time.

 

POST-ACUTE AND LONG-TERM CARE (PALTC) RECOMMENDATIONS

At present the CDC and WHO recommend that health care workers who care for persons suspected of having COVID-19 infection use Standard Precautions, Contact Precautions, Droplet Precautions, and Eye Protection. This means wearing a gown, gloves, facemask, and goggles or a face shield if patients are actively coughing. Designated staff should be responsible for caring for those suspected or known to have COVID-19. These should be trained personnel on infection prevention and control recommendations for COVID-19 with knowledge about the  proper use of personal protective equipment.

 

Frequent hand hygiene with alcohol-based hand rub or washing for at least 20 seconds (sing happy birthday to yourself) with soap and water is recommended. If an alcohol-based hand rub is used, it should contain at least 60% ethyl alcohol and individuals should rub their hands until completely dry.  Facilities should review and follow contact isolation procedures and make sure staff follow them consistently and correctly. Also, an EPA-registered, hospital-grade disinfectant to clean commonly touched environmental surfaces to decrease environmental contamination is recommended.

 

Since most PALTC facilities will not have airborne isolation rooms (often called negative pressure or AIIR rooms), if an individual meets the CDC case definition of a suspected infection, facility staff should provide the patient a single room with a closed door and consult with the  local health department. Ensure staff, to the extent equipment is available, to follow Standard, Contact, and Airborne or Droplet Precautions, including Eye Protection. Links are provided here

https://www.health.state.mn.us/diseases/coronavirus/index.html

Additionally, remind staff and personnel to stay home if they are sick. It is recommended that healthcare facilities develop staff policies to allow and account for potential absenteeism during community-wide outbreaks.

Facilities should screen all staff at entry into the facility for respiratory signs and symptoms and fever. Click here to download a sample file for screening all staff and visitors. Staff should not be allowed to work if symptoms are present.

 

Finally, due to the ease of spread in a long-term care setting and the severity of illness that occurs in residents with COVID-19, facilities should discourage and/or eliminate visitation of non-essential visitors e.g,  volunteers, vendors and receiving suppliers, some hospice staff, transportation providers . Note, it is reasonable and legal to restrict entry into a facility if a visitor has concerning symptoms however, facilities should have policies addressing when and how visitors might still be allowed to enter the facility (e.g., end of life situations). Also, arrange for equipment to have a dedicated area to be dropped off to minimize exposure to staff and patients.

Additional Guidelines:

  • Cancel communal dining
  • Abstain from all group activities
  • Avoid performing  rehab in the rehabilitation area. Instead perform rehab in and around one’s own room. For rooms that are smaller ensure therapy is one-on-one to avoid communal exposure to therapy
  • Remind residents to practice social distancing and avoid hand-shaking or hugging, and remaining six feet apart.
  • If someone takes ill, have them put on a facemask immediately and self-isolate at home.
  • Advise any individual who entered the facility to monitor for signs and symptoms of fever or respiratory infection for at least 14 days after exiting the facility.  If symptoms occur, advise them to self-isolate at home, contact their healthcare provider, and immediately notify the facility of the date they were in the facility. Facilities should then screen the individuals of reported contact, and take all necessary actions based on findings.

It is recommended that facilities also–

  • Send letters or emails to families advising them to consider using alternative methods for visitation (e.g., video conferencing) during the next several months.
  • Recommend that individuals (regardless of illness presence) who have a known exposure to someone with a COVID-19, or who have traveled to areas with COVID-19 transmission in the last 14 days, or who have traveled to an area defined by the CDC as having a high risk of COVID -19 transmission, should refrain from entering the nursing home.
  • Restrict all non-essential personnel in a community where community-based spread of COVID-19 is occurring.
  • Facilitate remote communication between the resident and visitors (e.g., video-call applications on cell phones or tablets).
  • Increase the availability and accessibility of alcohol-based sanitizers, reinforce strong hand-hygiene practices, use no touch receptacles for disposal, supply facemasks at healthcare facility entrances, etc.
     

EVALUATING AND MANAGING RESIDENTS WITH RESPIRATORY SYMPTOMS

Upon admission, and throughout a patient’s stay, promptly assess any fever and/or signs and  symptoms of a respiratory infection. If a patient has symptoms, or a cluster (e.g., ≥ 3 residents with new-onset respiratory symptoms over 48 hours) of patients have symptoms, or there is an increase in cases reported in the community, begin active monitoring of all residents in the facility for signs and symptoms. It is strongly encouraged to notify the health department about residents with either severe respiratory infection and/or clusters of respiratory infection.

 

TRANSFERRING RESIDENTS WITH SUSPECTED COVID-19

CMS has made it a point to recommend that facilities without an airborne isolation room should not be required to transfer a patient to the hospital unless the patient needs a higher level of care than the nursing home can provide or the facility is not capable of adhering to infection control practices.

Prior to transfer to a hospital, emergency medical services personnel and the receiving facility should be alerted to the resident’s possible or confirmed diagnosis. Additionally, a facemask should be placed on the resident during transfer.

 

ACCEPTING RESIDENTS WITH SUSPECTED COVID-19

A nursing home should accept a patient diagnosed with COVID-19 as long as it can follow CDC guidance for transmission-based precautions. Cohorting/Room sharing of patients with COVID-19 infection may be necessary if there are multiple residents with known or suspected COVID-19 in a facility.

The timing of discontinuation of transmission-based precautions has not yet been fully established. Interim recommendations have been developed for similar historical coronaviruses but at this time decisions should be made in conjunction with the medical director of the facility and local and state health departments.

 

RECOMMENDATIONS TO DECREASE RISK OF OUTBREAKS

Historical plans that have been developed for influenza are reasonable models to use in addressing prevention and management of COVID-19. Currently, isolation precautions are a must for anyone suspected of being infected. Additional recommendations include:

  • Suspending all group activities
  • Using consistent staff e.g. staff are assigned to the same unit or hallway and not allowed to transfer to a floor or unit that is not infected
  • Daily temperature checks and symptom monitoring for all residents and staff on the infected unit
  • Furlough staff with respiratory symptoms
  • Frequently review CDC recommendations for surveillance and updates

FOR EMERGENCY RESPONDERS

If a call is received that a patient is suspected of having COVID-19, EMS clinicians should wear appropriate Personal Protective Equipment (PPE) before entering the scene. Begin the assessment from a distance of at least 6 feet from the patient, unless it is not possible. Place a facemask on the patient for source control. If a nasal cannula is needed place it under the facemask. Alternatively, an oxygen mask can be used if clinically indicated. All personnel should avoid touching their face while working.

During transport, limit the number of providers in the patient compartment to essential personnel to minimize possible exposures. Make a mental note of those personnel in direct contact with the patient.

If the patient requires transport to a healthcare facility for further evaluation and management the following is recommended:

  • EMS clinicians should notify the receiving healthcare facility of the possibility of COVID-19
  • Keep the patient separated from other people as much as possible.
  • Family members, relatives or friends should not be allowed to ride in the EMS transport if possible. A face mask is recommended if this is not possible.
  • When arriving at the facility, follow routine procedures as directed by the receiving facility.
  • Defer documentation until after patient contact if possible. This will help minimize unintentional self-contamination from particles that may remain on emergency equipment. A necessary part of this documentation should include those EMS personnel, and their level of contact with the patient, since this may need to be shared with local public health officials.

 

WHAT TWIN CITIES PHYSICIANS IS DOING:

Our practice is committed to doing whatever we can to limit risk to our patients and our staff while continuing to provide excellent care to our patients. Each community we visit will determine their own plan for visitors as well as patients, and the information provided here has been made available to them as they work to develop their plans. Please know that these plans are fluid and may change as we learn more about this virus. Given that, please contact the community directly with any questions directly regarding their current protocol.

If you develop a new cough and/or fever, we suggest that you stay home until you are well. Our providers and office staff will follow these same precautions. We have also developed plans to ensure that we are able to continue to care for our patients despite foreseeable obstacles that may arise in the future.

In the event of a quarantine, or if a provider is ill and unable to work, our providers will be able to provide all patient visits via telehealth. Each community who will use telehealth during that time will need to have a smartphone, tablet, or computer with a browser online and ready for use at these visits. That device must have a camera, microphone, and speaker so that the provider is able to see and speak with the patient.

Please contact our operations manager, Meg Petrich, at 763-334-7995 or mpetrich@mytcp.org with any questions or concerns.