Please Note: On June 4, 2021, this article was updated to reflect recent changes to the Indiana Department of Health’s (IDH) Infection Control Standard Operating Procedure based on the National Institute for Occupational Safety and Health’s (NIOSH) new guidance that health care providers should only use N-95 respirators, rather than K-95 respirators (when N-95 respirators are required), and should not be using crisis standards, as availability of N-95 respirators is sufficient. Accordingly, IDH’s Infection Control Standard Operating Procedure was updated to state:
- Facilities should transition away from the use of K-95s; and
- When possible, by supply and lower transmission in the facility, mask use can return to conventional usage and NIOSH-approved N-95 respirators.
IDH has verbally clarified that facilities do not have to return to conventional N-95 use immediately and may use up any remaining K-95 supply, but going forward, facilities should start only obtaining N-95 respirators (and not K-95 respirators) and transition to that supply. As a reminder, N-95 respirators should be worn in Red and Yellow units, and the NIOSH Certified Equipment List may be utilized to identify all NIOSH-approved respirators. IHCA/INCAL’s PPE Conservation Toolkit is also a helpful tool to track inventory and transition between conservation and conventional PPE use, including a Burn Rate Calculator.
IDH has updated its COVID-19 LTC Infection Control Guidance Standard Operating Procedure, which can be found here. The Infection Control Guidance applies to all long-term care facilities, including nursing facilities and residential care facilities (licensed assisted living communities). Based on the updated Infection Control Guidance, IDH’s LTC Toolkit, Eye Protection Guidance, and Visitation Guidelines have been updated accordingly.
Highlights of the updated Infection Control Guidance are as follows:
- Return to Work: The Guidance underscores staff should not report to work with any symptoms of COVID-19 (i.e., a sore throat even if a fever is not present), even if they are vaccinated or recently received a negative COVID-19 test, as the incubation period can be up to 14 days. All staff should adhere to the CDC’s Return to Work Criteria if any symptoms are present or the staff member is confirmed COVID-19 positive. IDH also released the following Return to Work letter further detailing the criteria, depending on whether a staff member tested positive or was exposed. We encourage facilities to review IDH’s letter closely. Please note, those long-term facilities with active COVID-19 cases can continue to employ COVID-positive staff who are asymptomatic in the Red Unit of the facility.
- Staff Masks: Direct care providers should wear a surgical mask for the duration of their shift, unless an N95 is required. N95 masks should be worn with any resident who is symptomatic or awaiting test results in transmission-based precautions (Red and Yellow Units). Facilities should transition away from K95s, and when supply and lower transmission in the facility allow, facemask use can return to conventional usage. Indirect care providers should continue to wear a mask during their shifts (does not have to be surgical). Masks should be changed when visibly soiled or wet. Notably, fully vaccinated staff may remove their masks in a breakroom or private meeting room, unless there are residents or unvaccinated staff present. Fully vaccinated health care personnel may also remove their mask during outdoor activities with residents.
- Resident Masks: Generally, all residents should wear a mask (does not have to be surgical) when within six (6) of health care personnel (HCP), no matter what unit the resident is on. Residents who are fully vaccinated are not required to wear masks or physically distance during communal dining, social activities, therapy services and/or an excursion, if all persons in the area or on the excursion are also fully vaccinated. If the attending health care personnel and/or a resident involved in the service or activity is unvaccinated, the residents should remain masked, even if vaccinated, and the unvaccinated individual(s) should continue to socially distance. The vaccinated individuals are therefore not required to socially distance from each other if an unvaccinated individual is present but should continue to wear masks. Rule of Thumb: If there is any mixing of vaccinated and unvaccinated individuals in a certain area or on an excursion, then all residents should be wearing a mask (unless they are eating) and the unvaccinated individual(s) should continue physically distancing.
- Eye Protection: Eye protection (i.e., googles or face shield) is required in Green Units when the county in which the facility is located is above 5% in its positivity rate or the facility is in an outbreak, although eye protection is still required when within six (6) feet of a resident in a Yellow or Red Unit at all times. Accordingly, if the county in which a long-term care facility is located is below 5% in its positivity rate and the facility is not in an outbreak, then eye protection is not required in the Green Unit. IDH’s specific Eye Protection Guidance can be found here, and IDH’s updated “Stop Sign” resource can be found here. Eye protection should be disinfected when removed or visibly soiled.
- Red Units: HCP should use one gown and one set of gloves per resident in the Red Unit and should change after every resident encounter followed by hand hygiene. Gowns should be doffed prior to leaving the Red Unit or resident room. A HCP’s N95 mask and eye protection may be used for the entire shift if not wet or visibly soiled. Facilities should transition away from using K95 masks. While conventional use is preferred, if gown conservation is necessary, then extended gown use may be used in the Red Unit for all resident care, although single gown use during gown conservation times should be prioritized for aerosol-generating procedures, care activities where splashes and sprays are anticipated, and high-contact resident care activities that provide opportunities for transfer of pathogens (i.e., wound care, bathing). When PPE supply and lower transmission in a facility allow, PPE usage can return to conventional use.
- Yellow Units: HCP should use one gown and one set of gloves per resident in the Yellow Unit and should change after every resident encounter followed by hand hygiene. While conventional use if preferred, if gown conservation is necessary, then gowns may be hung on the inside of a resident’s door and used for one shift by the same health care personnel for the same resident, unless the gown becomes visibly soiled or wet. It is suggested to use a re-washable cloth gown for this type of extended wear when possible. Gown conservation should not be utilized if a resident is awaiting test results and becomes symptomatic. A HCP’s N95 mask and eye protection may be used for the entire shift if not wet or visibly soiled. Facilities should transition away from using K95 masks. When PPE supply and lower transmission in a facility allow, PPE usage can return to conventional use. If an asymptomatic resident tests positive via an antigen test, the resident is to be placed in TBP but should not be moved to a Red Unit unless they have a confirmatory positive on a PCR test. This includes when a facility is in outbreak testing, or the resident is a close contact. If the PCR test is negative, then the resident should remain in TBP for 14 days if the facility is in outbreak testing or the resident is a close contact and continue to monitor for symptoms. If the PCR test is positive, then the resident should be moved to the Red Unit.
- Green Units: HCP should wear a surgical mask and eye protection as a standard safety measure. These may be used for the entire shift if not wet or visibly soiled. Additional PPE may be needed depending on resident care needs, and when in gown crisis capacity, gowns should be prioritized for care activities where splashes and sprays are anticipated, which typically includes aerosol-generating procedures. When PPE supply and lower transmission in a facility allow, PPE usage can return to conventional use. During testing of symptomatic Green Unit residents, the resident can shelter in place if there is no roommate so long as the resident is placed in TBP when awaiting results. If the resident has a roommate, then they need to be moved to the Yellow Unit while awaiting results. Roommates of those that test positive, once the positive residents is moved to the Red Unit, may shelter in place under TBP for the full 14 day quarantine period due to exposure.
- Glove Hygiene: Hand hygiene should be performed before the use of non-sterile gloves upon entry into a resident room for direct care, in addition to upon removal the gloves.
- Isolation Bins: For Red Units, isolation carts or bins should be outside each individual room, or just inside the contained Red Unit for doffing. For Yellow Units, trash cans should be used inside each individual resident room for doffing.
- Aerosol-Generating Procedures: AGPs may occur in Green Units but should be limited in Red and Yellow Units unless medically necessary. During low community spread (the positivity rate is under 5%) and when the facility is not in outbreak testing, fully vaccinated residents with fully vaccinated roommates may leave the door open during an AGP. If the roommate is unvaccinated, then the curtain must be closed. For any AGP that is performed on an unvaccinated resident, during high community spread (the positivity rate is above 5%), during outbreak testing, or on a resident in a Red or Yellow Unit, the AGP should be performed in a private room with full transmission-based precautions with the door closed for duration of procedure and one hour after the procedure ends. The transmission-based precautions should include an N-95 mask, eye protection, gown, and gloves and keeping the door closed throughout the procedure and disinfecting all surfaces following the procedure for all AGPs, no matter the status of the resident or positivity rate. Accordingly, the same transmission-based precautions should be adhered to in Green Units, although the AGP does not need to occur in a private room, although for CPAP/BIPAP/nebulizers, the curtains and doors should be closed if a roommate is present.