Please Note: On November 24, 2020, this article was updated to reflect recent changes to the Infection Control Guidance Standard Operating Procedure to allow gown conservation in Yellow Units when necessary. If gown conservation is necessary in Yellow Units, 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 in a Yellow Unit if a resident is awaiting test results and becomes symptomatic. Further, the updated Infection Control Guidance Standard Operating Procedure clarifies that if gowns are needed in a Green Unit for particular resident care activities, when in gown crisis capacity, gowns should be prioritized for care activities where splashes and sprays are anticipated, which typically includes aerosol-generating procedures.
On October 20, 2020, the Indiana Department of Health (IDH) 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.
Although published on October 20th, the effective date of the updated Infection Control Guidance is October 26, 2020, per IDH’s recent LTC Newsletter. It is also important to note that while PPE conservation is referenced throughout the Infection Control Guidance, conservation strategies should be utilized as a last resort. Long-term care facilities should document PPE supply levels in EMResources, as IDH is prepared to help direct resources but must be notified of PPE levels through EMResources. Further, the Infection Control Guidance requires N95 masks to be utilized in Red and Yellow Units, but FDA-approved K95 masks can also be utilized in place of N95 masks.
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 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 (or approved K95 masks) should be worn with any resident who is symptomatic or awaiting test results in transmission-based precautions (Red and Yellow Units). Indirect care providers should continue to wear a mask during their shifts (does not have to be surgical). When supplies are limited, masks should be conserved, and only a single mask should be worn by each staff member each shift. However, masks should be changed when visibly soiled or wet.
- Resident Masks: 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. A surgical mask should be used for residents when in the salon and for any PUI or COVID-positive residents who are being transferred to a new room or facility.
- Eye Protection: IDH is now recommending the use of eye protection (goggles or face shields) as a standard safety measure for all HCP who provide essential direct care within six (6) feet of a resident, no matter what unit the resident is on. IDH’s specific Eye Protection Guidance can be found here.
- Red Units: PPE use is based on conventional or conservation PPE strategies, depending on PPE supply. Under conventional PPE use, 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 (or K95 mask) and eye protection may be used for the entire shift if not wet or visibly soiled. 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).
- 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. . 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 (or approved K95 mask) and eye protection may be used for the entire shift if not wet or visibly soiled. 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. 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.