Please Note: On August 13, 2021, this article was updated to reflect recent changes to the Indiana Department of Health’s (IDH) Infection Control Standard Operating Procedure, as follows:
- Masks: In light of the rise of COVID-19 cases and the Delta variant in Indiana, masks must be worn indoors at all times by health care personnel, residents, and visitors, even if the county positivity rate is below 5%. This updated guidance supersedes the guidance from July 30 that required masks at all times if the county positivity rate was above 5%. Fully vaccinated staff and residents may choose not to wear masks in small outdoor activities. Generally, all activities should follow the core principles of infection control with everyone wearing a well-fitting facemask when indoors, social distancing, and practicing frequent hand hygiene.
Further 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. 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.
- Resident Screening: Unvaccinated residents should continue to be assessed for COVID-19 on a daily basis. Vaccinated residents are no longer required to undergo a daily COVID-19 assessment, except for the following circumstances:
- Any resident who exhibits COVID-19 symptoms should be assessed three times a day, whether they are vaccinated or not.
- Fully vaccinated residents in nursing facilities and licensed assisted living who have dementia or who are not fully functional should still be assessed once a day.
- Fully vaccinated residents in licensed assisted living who are fully functional should still be assessed once a week. The COVID-19 assessment may be conducted via phone or in-person,
- 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.
- 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. 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.
- Resident Masks: Residents should resume wearing masks while indoors at all times. Fully vaccinated staff and residents may choose not to wear masks in small outdoor activities.
- Eye Protection: Fully vaccinated staff may choose to not wear eye protection in Green Units or in Yellow Units when caring for residents who are being monitored during the new admission quarantine, regardless of the county positivity rate or outbreak testing. Fully vaccinated staff should continue to wear eye protection in Red Units and in Yellow Units when caring for residents who are symptomatic or positive for COVID-19. Unvaccinated staff should continue to wear eye protection in Green Units when within six (6) feet of a resident when the county positivity rate is above 5% and/or the facility is in outbreak testing. Unvaccinated staff should also wear eye protection in the Yellow and Red Units at all times.
- 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 (fully vaccinated staff do not have to wear eye protection for new admission quaratine). 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 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.