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Coronavirus Disease 2019 (COVID-19)

1 Contact Hour
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Athletic Trainer (AT/AL), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Respiratory Therapist (RT)
This course will be updated or discontinued on or before Friday, February 18, 2022
BOC
Course Description
The Center for Disease Control (CDC) is closely monitoring the outbreak of the novel (new) coronavirus first found in China. Current quarantines will not be enough to stop the spread. This course will provide Healthcare Professionals with the knowledge to prevent, identify and treat COVID-19
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Outcomes

≥90% of participants will know how to prevent, identify and treat COVID-19.

Objectives

After completing this continuing education course, the participant will be able to meet the following objectives:

  1. Discuss clinical evaluation of a patient suspected of COVID-19 infection.
  2. Identify modes of transmission.
  3. Discuss methods to prevent transmission.
  4. Identify treatment of COVID-19.
  5. Discuss preparedness recommendations for Healthcare facilities.

Introduction

The Center for Disease Control (CDC) is closely monitoring the outbreak of the novel (new) coronavirus first found in China. Current quarantines will not be enough to stop the spread.1 The unknown nature of the virus implies that it is only a matter of time before the virus becomes established in the US.

On 1/31/20, President Trump signed a proclamation to suspend entry to those persons who pose a risk of transmitting the 2019 novel coronavirus.2 At this time, that is defined as people who were physically present within the People’s Republic of China, excluding the Special Administrative Regions of Hong Kong and Macau, during the 14-day period preceding their entry or attempted entry into the United States. In addition, medical screening and quarantine may be implemented.

Clinical Evaluation

The CDC developed the following flow chart as a clinical guide3

flowchart_coronavirus_cdc

Health care professionals (HCP) should obtain a detailed travel history for patients being evaluated with fever, and acute respiratory illness.4 CDC reasons that symptoms may appear between 2 and 14 days after exposure.5 In confirmed COVID-19 infections, symptoms range from mild to death. Symptoms can include:5

  • Fever
  • Cough
  • Shortness of breath

Based on the limited available information, respiratory distress develops about day 8. Acute respiratory distress syndrome (ARDS) developed in 17–29% of hospitalized patients, and a secondary infection developed in 10%.6

CDC has developed a new Real-Time Reverse Transcriptase (RT)-PCR Diagnostic Panel laboratory test kit for use in testing patient specimens for COVID-19. These kits require the use of specialized equipment and software.5

At this time, CDC is recommending the following criteria to identify a Person Under Investigation (PUI)4:
Clinical Features Epidemiologic Risk
Fever or signs/symptoms of lower respiratory illness (e.g., cough or shortness of breath)andAny person, including health care workers, who have had close contact with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset
Fever or signs/symptoms of lower respiratory illness (e.g., cough or shortness of breath)andA history of travel from Hubei Province, China within 14 days of symptom onset
Fever and signs/symptoms of a lower respiratory illness (e.g., cough or shortness of breath) requiring hospitalizationandA history of travel from mainland China within 14 days of symptom onset

Any patient meeting criteria for evaluation for COVID-19, clinicians are encouraged to contact and collaborate with their state or local health department. For patients that are severely ill, evaluation for COVID-19 may be considered even if a known source of exposure has not been identified.

Transmission

Current transmission knowledge is largely based on what is known about similar coronaviruses.

Coronaviruses are a large family of viruses that are common in many different species of animals, including camels, cattle, cats, and bats. Rarely, animal coronaviruses can infect people and then spread between people such as with MERS, SARS, and now with COVID-19.5

Transmission between people usually happens with respiratory droplets in close contacts. Contact transmission is unknown.5

Prevention

There is no vaccine to prevent COVID-19. The best way to prevent infection is to avoid being exposed to this virus. The CDC always recommends everyday preventive actions to help prevent the spread of respiratory viruses, including5:

  • Avoid close contact with people who are sick.
  • Avoid touching your eyes, nose, and mouth with unwashed hands.
  • Stay home when you are sick.
  • Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
  • Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe.
  • Follow CDC’s recommendations for using a facemask.
    • CDC does not recommend that people who are well to wear a facemask to protect themselves from respiratory viruses, including COVID-19.
    • A facemask should be used by people who show symptoms of 2019 novel coronavirus, in order to protect others from the risk of getting infected. The use of facemasks is also crucial for health workers and people who are taking care of someone in close settings.
  • Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing.
    • If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty.

Treatment

There is no specific antiviral treatment recommended for COVID-19 infection.5 Treatment is symptom control and supportive care. There are studies being conducted on the use of medications that have been effective with other viruses.

A patient suspected of having COVID-19 should be placed in Contact and Airborne Precautions.7 People who enter the room of a patient with known or suspected COVID-19 should adhere to Standard, Contact, and Airborne Precautions.

Preparedness Recommendations for Healthcare Facilities

Minimize Chance for Exposures7

Ensure facility policies and practices are in place to minimize exposures to respiratory pathogens, including COVID-19. Measures should be implemented before patient arrival, upon arrival, and throughout the duration of the affected patient’s presence in the healthcare setting.

Instruct patients and persons who accompany them to call ahead or inform HCP upon arrival if they have symptoms of any respiratory infection (e.g., cough, runny nose, fever) and to take appropriate preventive actions (e.g., wear a facemask upon entry to contain cough, follow triage procedures).7

Provide supplies for respiratory hygiene and cough etiquette, including 60%-95% ABHS, tissues, no-touch receptacles for disposal, and facemasks at healthcare facility entrances, waiting rooms, patient check-ins, etc.7 Consider posting visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide patients and HCP with instructions (in appropriate languages) about hand hygiene, respiratory hygiene, and cough etiquette. Instructions should include how to use facemasks or tissues to cover nose and mouth when coughing or sneezing, to dispose of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene.

Ensure that patients with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough) are not allowed to wait among other patients seeking care. Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies.7

Ensure rapid triage and isolation of patients with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough).7 Implement respiratory hygiene and cough etiquette (i.e., placing a facemask over the patient’s nose and mouth if that has not already been done) and isolate a PUI for COVID-19 in an Airborne Infection Isolation Room (AIIR), if available.

Inform infection prevention and control services, local and state public health authorities and other healthcare facility staff as appropriate about the presence of a person under investigation for COVID-19.

Patient Placement

Place a patient with known or suspected COVID-19 in an AIIR that has been constructed and maintained in accordance with current guidelines.7 AIIRs are single-patient rooms at negative pressure relative to the surrounding areas and with a minimum of 6 air changes per hour (12 air changes per hour are recommended for new construction or renovation). Air from these rooms should be exhausted directly to the outside or be filtered through a high-efficiency particulate air (HEPA) filter before recirculation. Room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized. Facilities should monitor and document the proper negative-pressure function of these rooms.

If an AIIR is not available, patients who require hospitalization should be transferred as soon as is feasible to a facility where an AIIR is available.7 If the patient does not require hospitalization they can be discharged to home (in consultation with state or local public health authorities) if deemed medically and socially appropriate. Pending transfer or discharge, place a facemask on the patient and isolate him/her in an examination room with the door closed.7 Ideally, the patient should not be placed in any room where room exhaust is recirculated within the building without HEPA filtration.

Once in an AIIR, the patient’s facemask may be removed. Limit transport and movement of the patient outside of the AIIR to medically-essential purposes. When not in an AIIR (e.g., during transport or if an AIIR is not available), patients should wear a facemask to contain secretions.7

Personnel entering the room should use PPE, including respiratory protection. Only essential personnel should enter the room. Implement staffing policies to minimize the number of HCP who enter the room. Facilities should consider caring for these patients with dedicated HCP to reduce the risk of transmission and exposure to other patients and other HCP.

Use dedicated or disposable noncritical patient-care equipment (e.g., blood pressure cuffs). If equipment will be used for more than one patient, clean and disinfect such equipment before use on another patient according to manufacturer’s instructions.7

HCP entering the room soon after a patient vacates the room should use respiratory protection. Standard practice for pathogens spread by the airborne route (e.g., measles, tuberculosis) is to restrict unprotected individuals, including HCP, from entering a vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles.7

PPE

Follow contact and airborne PPE requirements. Respiratory protection should be, at a minimum, a fit-tested NIOSH-certified disposable N95 filtering facepiece respirator.7

If reusable respirators are used, they must be cleaned and disinfected according to the manufacturer’s reprocessing instructions prior to re-use.

Use Caution When Performing Aerosol-Generating Procedures7

  • Some procedures performed on COVID-19 patients could generate infectious aerosols. In particular, procedures that are likely to induce coughing (e.g., sputum induction, open suctioning of airways) should be performed cautiously and avoided if possible.
    • If performed, these procedures should take place in an AIIR, and personnel should use respiratory protection as described above. In addition:
      • Limit the number of HCP present during the procedure to only those essential for patient care and procedural support.
  • Clean and disinfect procedure room surfaces promptly, as described in the section on environmental infection control below.
    • Diagnostic Respiratory Specimen Collection:
      • Collecting diagnostic respiratory specimens (e.g., nasopharyngeal swab) is likely to induce coughing or sneezing. Individuals in the room during the procedure should, ideally, be limited to the patient and the healthcare provider obtaining the specimen.
      • HCP collecting specimens for testing for COVID-19 from patients with known or suspected COVID-19 (i.e., PUI) should adhere to Standard, Contact, and Airborne Precautions, including the use of eye protection.
      • These procedures should take place in an AIIR or in an examination room with the door closed. Ideally, the patient should not be placed in any room where room exhaust is recirculated within the building without HEPA filtration.

Until information is available regarding viral shedding after clinical improvement, discontinuation of isolation precautions should be determined on a case-by-case basis, in conjunction with local, state, and federal health authorities.7 Things to consider include7:

  • presence of symptoms related to COVID-19
  • date symptoms resolved
  • other conditions that would require specific precautions
  • other laboratory information reflecting the clinical status
  • alternatives to inpatient isolation, such as the possibility of safe recovery at home

Manage Visitor Access and Movement Within the Facility

Establish procedures for monitoring, managing, and training visitors. Restrict visitors from entering the room of known or suspected COVID-19 patients.7

Consider alternative mechanisms for patient and visitor interactions, such as video-call applications on cell phones or tablets. Facilities can consider exceptions based on end-of-life situations or when a visitor is essential for the patient’s emotional well-being and care.

  • Visitors to patients with known or suspected COVID-19 (i.e., PUI) should be scheduled and controlled to allow for7:
    • Screening visitors for symptoms of acute respiratory illness before entering the healthcare facility.
    • Facilities should evaluate the risk to the health of the visitor (e.g., a visitor might have an underlying illness, putting them at higher risk for COVID-19).
    • Evaluate the risk of visitors' ability to comply with precautions.
    • Facilities should provide instruction, before visitors enter patients’ rooms, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy while in the patient’s room.
    • Facilities should maintain a record (e.g., logbook) of all visitors who enter patient rooms.
    • Visitors should not be present during aerosol-generating procedures.
    • Visitors should be instructed to limit their movement within the facility.
    • Exposed visitors (e.g., contact with COVID-19 patient prior to admission) should be advised to report any signs and symptoms of acute illness to their health care provider for a period of at least 14 days after the last known exposure to the sick patient.

Implement Engineering Controls

Consider designing and installing engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals.7 Examples of engineering controls include7:

  • physical barriers or partitions to guide patients through triage areas
  • curtains between patients in shared areas
  • closed suctioning systems for airway suctioning for intubated patients
  • appropriate air-handling systems (with appropriate directionality, filtration, exchange rate, etc.) that are installed and properly maintained

Monitor and Manage Ill and Exposed Healthcare Personnel

Facilities and organizations providing healthcare should implement sick leave policies for HCP that are non-punitive, flexible, and consistent with public health guidance.

Train and Educate Healthcare Personnel

Provide HCP with job- or task-specific education and training on preventing transmission of infectious agents, including refresher training.7

HCP must be medically cleared, trained, and fit-tested for respiratory protection device use (e.g., N95 filtering facepiece respirators), or medically cleared and trained in the use of an alternative respiratory protection device (e.g., Powered Air-Purifying Respirator, PAPR) whenever respirators are required.

Ensure that HCP are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to the correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment.

Implement Environmental Infection Control

Dedicated medical equipment should be used for patient care. All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to the manufacturer’s instructions and facility policies.

Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are necessary for COVID-19 in healthcare settings. Products with EPA-approved emerging viral pathogens claims are recommended for use against COVID-19.7 If there are no available EPA-registered products that have an approved emerging viral pathogen claim for COVID-19, products with label claims against human coronaviruses should be used according to label instructions.7

Establish Reporting within Healthcare Facilities and to Public Health Authorities

Implement mechanisms and policies that promptly alert key facility staff, including infection control, healthcare epidemiology, facility leadership, occupational health, clinical laboratory, and frontline staff about known or suspected COVID-19 patients.

Promptly notify state or local public health authorities of patients with known or suspected COVID-19. Facilities should designate specific persons within the healthcare facility who are responsible for communication with public health officials and dissemination of information to HCP.7

Homecare Guidance

A healthcare professional should assess whether the residential setting is appropriate for home care. Considerations for care at home include whether8:

  • The patient is stable enough to receive care at home.
  • Appropriate caregivers are available at home.
  • There is a separate bedroom where the patient can recover without sharing immediate space with others.
  • Resources for access to food and other necessities are available.
  • The patient and other household members have access to appropriate, recommended personal protective equipment (at a minimum, gloves, and facemask).
  • The patient and other household members are capable of adhering to precautions recommended as part of home care or isolation (e.g., respiratory hygiene and cough etiquette, hand hygiene).
  • The presence of household members who may be at increased risk of complications from COVID-19 infection:
    • people >65 years old
    • young children
    • pregnant women
    • people who are immunocompromised
    • people with chronic heart, lung, or kidney conditions

Case Study

John enters the ER with a complaint of cough and fever for 4 days. The clerk asks John to put on a mask and set in the waiting room alcove. The clerk notifies the triage nurse, who immediately triages John. John traveled to mainland China last week. The triage nurse puts John in a private room and implements contact and airborne precautions.

Had the clerk not identified John as someone needing a mask and location in the alcove instead of the main waiting room, people in the ER waiting room would have been exposed. Had the triage nurse not immediately triaged and isolated John, more people would have been exposed.

After diagnosis, John was found to have the flu. He was discharged home. The actions to prevent exposure of people and staff were time-consuming but warranted. The actions prevented the spread of the flu and possibly something more serious.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  1. Western Journal. CDC Director Warns Outbreak is Coming to US, Containment only Buying Time. Published February 14, 2020. Retrieved February 15, 2020. Visit Source.
  2. Proclamation by President Trump. 1/31/20. Suspension of Entry as Immigrants and Nonimmigrants of Persons who Pose a Risk of Transmitting 2019 Novel Coronavirus. Published January 31, 2020. Retrieved February 15, 2020. Visit Source.
  3. CDC. Flowchart to Identify and Assess 2019 Novel Coronavirus. Published February 12, 2020. Retrieved February 15, 2020. Visit Source.
  4. CDC. 2/12/20 Evaluating and Reporting Persons Under Investigation (PUI). Published February 12, 2020. Retrieved February 15, 2020. Visit Source.
  5. CDC.Coronavirus Disease 2019 (COVID-19). Published February 6, 2020. Retrieved February 15, 2020. Visit Source.
  6. CDC. Interim Clinical Guidance for Management of Patients with Confirmed 2019 Novel Coronavirus (COVID-19) Infection. Published February 12, 2020. Retrieved February 15, 2020. Visit Source.
  7. CDC. 2/12/20. Interim Infection Prevention and Control Recommendations for Patients with Confirmed 2019 Novel Coronavirus (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings. Published February 12, 2020. Retrieved February 15, 2020. Visit Source.
  8. CDC. 2/12/20. Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for 2019 Novel Coronavirus (COVID-19). Published February 12, 2020. Retrieved February 15, 2020. Visit Source.