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Coronavirus Disease 2019 (COVID-19)

1 Contact Hour
This peer reviewed 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), 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 Sunday, May 28, 2023
BOC
Outcomes

≥92% 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 the clinical evaluation of a patient suspected of COVID-19 infection.
  2. Identify modes of transmission.
  3. Discuss methods to prevent transmission.
  4. Identify the treatment of COVID-19.
  5. Discuss preparedness recommendations for Healthcare facilities.
  6. Identify ways to recognize and address mental health concerns related to the pandemic.
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.

Last Updated:
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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.)
Authors:    Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ) , Renee Warmbrodt (RN, MSN, CPNP)

Introduction

On 1/31/20, President Trump activated emergency powers as a response to the novel (new) coronavirus, SARS-CoV-2, also known as COVID-19. Through the following months several national emergency declarations were invoked to try to prevent the spread of COVID-19, activate necessary supports to manage those with COVID-19, and to help protect the economic implications of the pandemic. (National Conference of State Legislatures, 2020). These measures, now led by President Biden and other national forces, continue to evolve as we learn more about COVID-19.

Update 8/18/20

Cases of COVID-19 in the USS are updated daily and found here. The CDC is closely monitoring the outbreak of the novel coronavirus first discovered in China. Current quarantines will not be enough to stop the spread (Western Journal, 2020). The unknown nature of the virus implies that it is only a matter of time before the virus becomes established in the US.

Update 5/21/21

To help develop a plan for managing the Coronavirus disease (COVID-19), the government's Operation Warp Speed funded the development and distribution of three million vaccines by January 2021 (USS Department of Defense, 2021). Since January, over 300,000,000 have been distributed, and 240,000,000 vaccines administered across the United States. Updated vaccine tracking is updated frequently and found here. The Center for Disease Control (CDC) recommends vaccination with the COVID-19 vaccine for persons 12 years of age and older. With the development and distribution of vaccines, new guidelines are being released. Persons infected with COVID-19 must continue to follow the current quarantine recommendations. Those fully vaccinated may be allowed to relax some of the previous quarantine recommendations.

Clinical Evaluation

The following are the most recent recommended testing for individuals with signs or symptoms consistent with COVID-19 (CDC, 2021):

  • The CDC recommends using authorized nucleic acid or antigen detection assays that have received an FDA EUA to test persons with symptoms when there is a concern of potential COVID-19. Tests should be used in accordance with the authorized labeling; providers should be familiar with the tests' performance characteristics and limitations.
  • Clinicians should use their judgment to determine if a patient has signs or symptoms compatible with COVID-19 and whether they should be tested. Most patients with confirmed COVID-19 have developed fever or symptoms of acute respiratory illness (e.g., cough), but some infected patients may present with other symptoms (e.g., altered smell or taste) as well. Clinicians are encouraged to consider testing for other causes of respiratory illness, for example, influenza, in addition to testing for SARS-CoV-2 depending on patient age, season, or clinical setting; detection of one respiratory pathogen (e.g., influenza) does not exclude the potential for co-infection with SARS-CoV-2. Because symptoms and presentations may differ in children, consider referencing the CDC guidelines for COVID-19 in neonates and Multisystem Inflammatory Syndrome in Children (MIS-C).
  • The severity of symptomatic illness due to infection with SARS-CoV-2 may vary from person to person. Among persons with extensive and close contact to vulnerable populations (e.g., healthcare personnel [HCP]), even mild signs and symptoms (e.g., sore throat) of a possible SARS-CoV-2 infection should prompt consideration for testing. Additional information is available in the CDC's Interim Guidance on Testing Healthcare Personnel for SARS-CoV-2.

Recommended testing for asymptomatic individuals with known or suspected exposure to SARS-CoV-2 to control transmission (CDC, 2021e):

  • Testing is recommended for all close contacts of persons with SARS-CoV-2 infection. Close contact is defined as being in the presence of someone within 6 feet for greater than 15 minutes within 24 hours. Because of the potential for asymptomatic and pre-symptomatic transmission, it is important that contacts of individuals with SARS-CoV-2 infection be quickly identified and tested.
  • In areas where testing is limited, the CDC has established a testing hierarchy; refer to the Interim Guidance on Developing a COVID-19 Case Investigation and Contact Tracing Plan for more information.
  • An exception to this recommendation exists for those who are fully vaccinated and those previously infected and recovered within three months of re-exposure. If either of these parties develops symptoms of COVID-19, however, testing is recommended at that time.

In some settings, broader testing beyond close contacts is recommended as a part of a strategy to control the transmission of SARS-CoV-2. This testing includes high-risk settings with the potential for rapid and widespread dissemination of SARS-CoV-2 or in which populations at risk for severe disease could become exposed. Expanded testing might include testing individuals on the same unit or shift as someone with SARS-CoV-2 infection or even testing all individuals within a shared setting (e.g., facility-wide testing).

Health care professionals (HCP) should obtain a detailed travel history for patients being evaluated with fever and acute respiratory illness (CDC, 2020a). The CDC reasons that symptoms may appear between 2 and 14 days after exposure (CDC, 2020b). In confirmed COVID-19 infections, symptoms range from mild flu-like symptoms to death. Symptoms can include:

  • Fever or chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea (CDC, 2020b)

This list does not include all possible symptoms. The CDC will continue to update this list as we learn more about COVID-19.

Look for emergency warning signs for COVID-19. If someone is showing any of these signs, seek emergency medical care immediately:

  • Trouble breathing
  • Persistent pain or pressure in the chest
  • New confusion
  • Inability to wake or stay awake
  • Bluish lips or face (CDC, 2020b)

Symptoms differ with the severity of the disease. For example, fever, cough, and shortness of breath are more commonly reported among hospitalized people with COVID-19 than among those with milder disease (non-hospitalized patients). Atypical presentations occur often, and older adults and persons with medical comorbidities may have delayed presentation of fever and respiratory symptoms. In one study of 1,099 hospitalized patients, fever was present in only 44% at hospital admission but eventually developed in 89% during hospitalization. Fatigue, headache, and muscle aches (myalgia) are among the most commonly reported symptoms in people not hospitalized. A sore throat and nasal congestion or runny nose (rhinorrhea) may also be prominent symptoms. Many people with COVID-19 experience gastrointestinal symptoms such as nausea, vomiting, or diarrhea, sometimes before developing fever and lower respiratory tract signs and symptoms. Loss of smell (anosmia) or taste (ageusia) preceding the onset of respiratory symptoms has been commonly reported in COVID-19, especially among women and young or middle-aged patients who do not require hospitalization. While many of the symptoms of COVID-19 are common to other respiratory or viral illnesses, anosmia appears to be more specific to COVID-19 (CDC, 2020c).

The illness severity can range from mild to critical:

  • Mild to moderate (mild symptoms up to mild pneumonia): 81%
  • Severe (dyspnea, hypoxia, or >50% lung involvement on imaging): 14%
  • Critical (respiratory failure, shock, or multiorgan system dysfunction): 5% (CDC, 2020c)

Laboratory Findings

Lymphopenia is the most common laboratory finding in COVID-19 and is found in as many as 83% of hospitalized patients. Lymphopenia, neutrophilia, elevated serum alanine aminotransferase and aspartate aminotransferase levels, elevated lactate dehydrogenase, high CRP, and high ferritin levels may be associated with greater illness severity. Elevated D-dimer and lymphopenia have been associated with mortality. Procalcitonin is typically normal on admission but may increase among those admitted to an ICU. Patients with critical illness had high plasma levels of inflammatory markers, suggesting potential immune dysregulation (CDC, 2020c).

Radiographic Findings

Chest radiographs of patients with COVID-19 typically demonstrate bilateral air-space consolidation, though patients may have unremarkable chest radiographs early in the disease. Chest CT images from patients with COVID-19 typically demonstrate bilateral, peripheral ground-glass opacities. Because this chest CTT imaging pattern is non-specific and overlaps with other infections, the diagnostic value of chest CTT imaging for COVID-19 may be low and dependent upon radiographic interpretation.

Transmission(CDC, 2020a)

The virus is thought to spread mainly from person to person.

  • Between people who are in close contact with one another (within about 6 feet)
  • Through respiratory droplets produced when an infected person coughs, sneezes, or talks
  • These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs
  • COVID-19 may be spread by people who are not showing symptoms

How easily a virus spreads from person to person can vary. Some viruses are highly contagious, like measles, while other viruses do not spread as easily. Another factor is whether the spread is sustained, which means it goes from person to person without stopping.

The virus that causes COVID-19 is spreading very easily and sustainably between people. Information from the ongoing COVID-19 pandemic suggests that this virus is spreading more efficiently than influenza, but not as efficiently as measles, which is highly contagious. In general, the more closely a person interacts with others, and the longer that interaction, the higher the risk of COVID-19 spread.

It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their mouth, nose, or possibly their eyes. Contact is not thought to be the primary way the virus spreads, but we are still learning more about how this virus spreads.

Spread between animals and people

  • At this time, the risk of COVID-19 spreading from animals to people is considered low risk. Learn more about COVID-19 and pets and other animals here.
  • It appears that the virus that causes COVID-19 can spread from people to animals in some situations. The CDC is aware that a small number of pets worldwide, including cats and dogs, reported being infected with the virus that causes COVID-19, mostly after close contact with people with COVID-19.

Vaccination

Since the beginning of the pandemic, the USS Department of Defense has been working tirelessly to create an avenue to control the novel coronavirus. The development of Operation Warp Speed (OWS) in May 2020 pushed research initiatives to create, test, and distribute safe and effective vaccines by January 2021 (USS Department of Defense, 2021).

In mid-December 2020, the first official COVID-19 vaccinations were distributed to healthcare centers across the United States. The first vaccines to be distributed were the two-dose Pfizer-BioNTech and Moderna mRNA vaccinations. These vaccinations were released under an emergency use authorization (EUA). Complete vaccination with Pfizer-BioNTech COVID-19 vaccination entails two doses separated by 21 days. Complete vaccination with Moderna COVID-19 vaccination entails two doses separated by 28 days. The Pfizer-BioNTech projects a 95% efficacy rate against COVID and Moderna a 94.1% efficacy rate for those with no previous COVID-19 infection (CDC, 2021b).

In late February, a third vaccine, the Johnson and Johnson (Janssen) single-dose viral vector COVID-19 vaccination, was approved under the EUA. The Johnson and Johnson vaccination was briefly paused in April 2021 for concerns of a rare, severe blood clot reaction in several clients. However, as of May 6, 2021, the vaccine was approved to resume distribution. It has been shown to provide a 66.3% efficacy against illness related to COVID-19 (CDC, 2021c).

Several more vaccines are in development. As of May 2021, the CDC recommends all persons 12 years of age and older be vaccinated against COVID-19. The Pfizer-BioNTech vaccination has been approved for persons 12 years of age and older. Moderna and Johnson and Johnson COIVD-19 vaccinations are approved for persons 18 years of age and older. The long-term efficacy of the vaccinations is yet to be determined; however, several prolonged studies are monitoring the vaccination effectiveness closely.

Prevention

Even if fully vaccinated, the best way to prevent infection is to avoid exposure to this virus. The CDC always recommends everyday preventive actions to help prevent the spread of respiratory viruses, including (CDC, 2020a):

  • Avoid close contact with people who are sick.
  • Maintain six feet of social distancing when possible.
  • 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 the CDC's recommendations for using a facemask:
    • The CDC recommends that people wear a face mask to protect themselves from respiratory viruses when social distancing cannot be maintained. This masking is recommended because asymptomatic people may transmit Covid-19.
    • A facemask should be used by people who show symptoms of the 2019 novel coronavirus to protect others from the risk of getting infected. The use of facemasks is also crucial for health workers and people taking care of someone in close settings.
    • As of May 13, 2021, the CDC has released updates regarding the use of masks for those fully vaccinated. Vaccinated persons no longer are required to wear a mask in any setting unless required by federal, state, local, or other laws requiring a face covering to be worn. Masks and social distancing practices should generally be continued in public spaces such as hospitals, schools, and while traveling via public transportation until further notice (CDC, 2021d).
  • 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

Treatment guidelines are evolving so quickly that the CDC is maintaining an electronic guideline available here. As of April 21, 2021, below are the treatment guidelines by the CDC (NIH, 2020).

  • The Coronavirus Disease 2019 (COVID-19) Treatment Guidelines are published in an electronic format that can be updated in step with the rapid pace and growing volume of information regarding the treatment of COVID-19.
  • The COVID-19 Treatment Guidelines Panel (the Panel) is committed to updating this document to ensure that health care providers, patients, and policy experts have the most recent information regarding the optimal management of COVID-19 (see the Panel Roster for a list of Panel members).
  • Working groups of Panel members develop new Guidelines sections and recommendations and updates to existing Guidelines sections. A majority of Panel members endorses all recommendations included in the Guidelines (see the Introduction for additional details on the Guidelines development process).

New Sections of the Guidelines as of April 21, 2021

Outpatient Management of Acute COVID-19

  • Patients with concerns for COVID-19 should be triaged via telehealth visits when possible unless the clients have.
  • The Panel recommends using either Bamlanivimab 700mg plus etesevimab 1,400mg (AIIa) or Casirivimab 1,200 mg plus imdevimab 1,200 mg (AIIa) to treat outpatients with COVID-19 who are at risk for clinical progression.
  • The Panel does not recommend chloroquine or hydroxychloroquine with or without azithromycin (AII).
  • The Panel does not recommend dexamethasone or other systemic glucocorticoids in outpatients without infection (AIII).
  • The Panel does not recommend antibacterial therapy in the absence of infection (AIII).

Colchicine

  • The recommendations in this section have been updated to recommend the avoidance of colchicine in hospitalized patients unless the patient is in a clinical trial where colchicine is part of the clinical trial (AIII).

Fluvoxamine

  • Based on current information, there is not enough data to recommend fluvoxamine to treat COVID-19. The Panel does not currently recommend the use of fluvoxamine for the treatment of COVID-19.

Key Updates to the Guidelines Spring 2021

Therapeutic Management of Adults with COVID-19

  • Updates recommendations for using anti-SARS-CoV-2 monoclonal antibodies and tocilizumab (with dexamethasone) in specific patients with COVID-19.

Overview of COVID-19

  • New subsection to discuss new information regarding SARS-CoV-2 variants of concern

Clinical Spectrum of SARS-CoV-2 Infection

  • This section has updates to discuss the reports of SARS-CoV-2 reinfection in patients already known to have COVID-19. It also focuses on updates regarding patients with persistent symptoms or organ dysfunction after acute COVID-19.

Anti-SARS-CoV-2 Monoclonal Antibodies

  • This section has updated information and recommendations regarding the Emergency Use Authorization of Anti-SARS-CoV-2 Monoclonal Antibodies for COVID-19 treatment. It also reports information on the reported SARS-CoV-2 variants and the impact of mutations on in vitro susceptibility to the SARS-CoV-2 monoclonal antibodies.

Convalescent Plasma

  • Before the update, there was an Emergency Use Authorization to treat certain hospitalized patients with COVID-19 with high-titer convalescent plasma. This section provides the newest recommendations regarding the use of convalescent plasma in both hospitalized and non-hospitalized patients with COVID-19.
  • The Panel currently recommends against the use of low-titer COVID-19 convalescent plasma to treat COVID-19 (AIIb). There is insufficient data to recommend using low-titer COVID-19 convalescent plasma to treat hospitalized patients with impaired immunity or for non-hospitalized patients with COVID-19.
  • A new clinical data table is also included in this update.

Interleukin-6 Inhibitors: With Focus on Tocilizumab

  • Updated statements regarding the use of tocilizumab to treat COVID-19 on February 3 and March 5, 2021, are included in this update. The Panel recommends using tocilizumab with dexamethasone in hospitalized patients with rapid respiratory decompensation related to COVID-19. Tocilizumab is not recommended in patients with significant immunosuppression. It should not be given without dexamethasone.

Special Considerations in Children

  • This section provides updates regarding the treatment preferences and options for children with COVID-19.
  • Updated information is also discussed regarding COVID-19 risk factors, vertical transmissions of SARS-CoV-2 infection, and multisystem inflammatory syndrome in children (MIS-C).

Special Considerations in Solid Organ Transplant, Hematopoietic Stem Cell Transplant, and Cellular Therapy Candidates, Donors, and Recipients

  • Solid-organ transplant, hematopoietic stem cell transplant, and cellular therapy donors and recipients are at risk of complications associated with COVID-19. This new section provides recommendations for screening transplant candidates and donors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection before donation and transplant. It is recommended for transplant and cellular therapy candidates, potential donors, and recipients to receive the SARS-CoV-2 vaccination. Clinicians should follow the guidelines for evaluating and managing COVID-19 in nontransplant patients when treating transplant and cellular therapy recipients (AIII). This section also emphasizes the importance of consulting a transplant specialist and reviewing concomitant medications for drug-drug interactions and overlapping toxicities.

COVID-19 Guidelines

Introduction

  • The Panel has expanded the explanation of the types of recommendation statements used in the guidelines.

General Considerations (Care of Critically Ill Patients with COVID-19)

  • The Goals of Care subsection has included information on advance care planning, emphasizing the importance of identifying surrogate decision-makers for critically ill patients with COVID-19.

Overview of COVID-19: Epidemiology, Clinical Presentation, and Transmission

  • The section has been updated with recent epidemiologic data on COVID-19 in the United States. Emerging evidence suggests that racial and ethnic minorities in the United States experience higher rates of COVID-19 and subsequent hospitalization and death.

Prevention and Prophylaxis of SARS-CoV-2 Infection

  • This section discusses general prevention measures for reducing the risk of acquiring and transmitting SARS-CoV-2, the types of vaccines currently being studied. The drug therapies being investigated for pre-exposure and post-exposure prophylaxis. While the Food and Drug Administration has approved no vaccinations, the FDA has issued Emergency Use Authorizations for vaccines, BNT162b2 (Pfizer-BioNTech), mRNA-1273 (Moderna), and Ad26.COV2.S (Johnson & Johnson/Janssen).

Corticosteroids

  • The recommendations in this section have been updated to allow the use of alternative corticosteroids (i.e., hydrocortisone, methylprednisolone, prednisone) in situations where dexamethasone may not be available. In addition, the results of the RECOVERY trial were updated based on data reported in a recently published paper.

Remdesivir

  • COVID-19 Treatment Guidelines Panel (the Panel) recommended prioritizing the use of remdesivir for hospitalized patients who require oxygen but not on high-flow oxygen, noninvasive ventilation, mechanical ventilation, or ECMO (BII). The course should last five days or until hospital discharge, whichever occurs first. Patients who begun the remdesivir course should complete it, even if additional oxygen requirements develop. There is no specific recommendation for the use of remdesivir for patients requiring high-flow oxygen, noninvasive or invasive mechanical ventilation, or ECMO.

Hydroxychloroquine Plus Azithromycin

  • New clinical data from a large, retrospective, observational study have been added to this section and Table 2B. The Panel does not recommend using chloroquine or hydroxychloroquine with or without azithromycin in the treatment of COIVD-19 patients.

Lopinavir/Ritonavir and Other HIV Protease Inhibitors

  • New data on lopinavir/ritonavir pharmacokinetics in patients with COVID-19 and new data on combination therapy with lopinavir/ritonavir plus interferon beta-1b plus ribavirin for the treatment of COVID-19 have been added to this section and Table 2A. The Panel continues to recommend against lopinavir/ritonavir and other HIV protease inhibitor in treating COVID-19.

Blood-Derived Products Under Evaluation for the Treatment of COVID-19

  • New clinical data have been added to the Convalescent Plasma section. A new section has been created for SARS-CoV-2-specific immunoglobulins. The Panel recommends against the use of low-titer COVID-19 convalescent plasma and mesenchymal stem cells for treating COVID-19.

Immunomodulators Under Evaluation for the Treatment of COVID-19

  • New clinical data for interferon beta-1b were added to the Interferons (Alfa, Beta) section, and the Panel changed the recommendation for interferons: The Panel recommends against the use of interferons for the treatment of severe and critically ill COVID-19 patients, except in a clinical trial (AIII). There are insufficient data to recommend either for or against the use of interferon-beta for the treatment of early (<7 days from symptom onset) mild and moderate COVID-19.
  • The Kinase Inhibitors section was expanded to include additional Janus kinase (JAK) inhibitors and to include Bruton's tyrosine kinase (BTK) inhibitors. The Panel recommends against the use of BTK inhibitors and JAK inhibitors to treat COVID-19, except in a clinical trial (AIII).

Mesenchymal Stem Cells

  • A new subsection on mesenchymal stem cells was added to Immune-Based Therapy in the Blood-Derived Products Under Evaluation for the Treatment of COVID-19 section. The Panel recommends against the use of mesenchymal stem cells to treat COVID-19, except in a clinical trial (AII).

Adjunctive Therapy: Vitamin C, Vitamin D, and Zinc Supplementation

  • Vitamin and mineral supplements have been promoted to treat and prevent respiratory viral infections; however, their roles in treating COVID-19 are yet unproven. Three new sections were added to the guidelines to discuss the proposed rationale for using vitamin C, vitamin D, and zinc supplements.

Preparedness Recommendations for Healthcare Facilities

Minimize Chance for Exposures (CDC, 2020d)

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 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) (CDC, 2020d).

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. (CDC, 2020d) 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 using facemasks or tissues to cover nose and mouth when coughing or sneezing, 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 six or more feet, with easy access to respiratory hygiene supplies (CDC, 2020d).

Ensure rapid triage and isolation of patients with suspected COVID-19 or other respiratory infection (e.g., fever, cough) (CDC, 2020d). 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 airborne infection isolation room (AIIR) constructed and maintained according to current guidelines. (CDC, 2020d) 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 (CDC, 2020d). 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 (CDC, 2020d). 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 (CDC, 2020d).

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 using another patient according to the manufacturer's instructions (CDC, 2020d).

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) restricts unprotected individuals, including HCP, from entering a vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles (CDC, 2020d).

Personal Protective Equipment (PPE)

Follow contact and airborne PPE requirements. Respiratory protection should be, at a minimum, a fit-tested NIOSH-certified disposable N95 filtering facepiece respirator (CDC, 2020d).

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

Use Caution When Performing Aerosol-Generating Procedures (CDC, 2020d)

  • 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 occur 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 (CDC, 2020d). Things to consider include :

  • 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 (CDC, 2020d)

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 (CDC, 2020d).

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 for the following (CDC, 2020d) :
    • The screening of visitors for symptoms of acute respiratory illness before entering the healthcare facility.
    • Facilities should evaluate the risk to the visitor's health (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 for 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 before admission) should be advised to report any signs and symptoms of acute illness to their health care provider for 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 (CDC, 2020d). Examples of engineering controls include :

  • 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 (CDC, 2020d)

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 a job- or task-specific education and training on preventing transmission of infectious agents, including refresher training (CDC, 2020d).

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 using 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 before 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 before 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 (CDC, 2020c). 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 (CDC, 2020d).

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 responsible for communication with public health officials and disseminating information to HCP (CDC, 2020d).

Homecare Guidance

Below is the most recent guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19) (CDC, 2020e).

This interim guidance is for staff at local and state health departments, infection prevention and control professionals, and healthcare personnel who are coordinating the home care and isolation of people with confirmed or suspected COVID-19 infection, including persons under investigation (see Criteria to Guide Evaluation of Persons Under Investigation (PUI) for COVID-19).

This guidance includes patients evaluated in an outpatient setting who do not require hospitalization (i.e., medically stable patients and can receive care at home) or patients who are discharged home following hospitalization with confirmed COVID-19 infection.

In general, people should adhere to home isolation until the risk of secondary transmission is thought to be of low risk. Visit If You Are Sick or Caring for Someone for more information regarding prevention guidelines.

Care for Patients at Home: Interim guidance may help prevent COVID-19 from spreading among people in homes and communities.

For interim healthcare infection prevention and control recommendations, see Interim Infection Prevention and Control Recommendations for Patients with Known or Persons Under Investigation for Coronavirus Disease 2019 (COVID-19) in a Healthcare Setting. The CDC will update this interim guidance as needed and as more information becomes available.

Assess the Suitability of the Residential Setting for Home Care

In consultation with state or local health department staff, a healthcare professional should assess whether the residential setting is appropriate for home care. Considerations for care at home include whether:

  • 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 can adhere to precautions recommended as part of home care or isolation. A caregiver may wear a cloth face covering when caring for a sick person; however, the protective effects (how well the cloth face-covering protects healthy people from breathing in the virus) are unknown. Note: During the COVID-19 pandemic, medical-grade facemasks are reserved for healthcare workers and some first responders. A cloth face covering may need to be improvised using a scarf or bandana. Learn more here.
  • There are household members who may be at increased risk of severe illness from COVID-19 infection. See People Who Are at Increased Risk for Severe Illness to find out who is at increased risk.

Provide Guidance for Precautions to Implement during Home Care

A healthcare professional should:

Mental Health Concerns Regarding the Lockdown and Pandemic

The impact of COVID-19 has affected numerous aspects of life. The abrupt and continued changes to daily life throughout the pandemic have created stressors that can become overwhelming. Many people are struggling to manage their mental health needs because of the effects of the pandemic, the quarantines, and constantly evolving infection guidelines.

Studies have shown that stress and mental health crises have increased since the beginning of the pandemic. Approximately 78% of American adults report that the coronavirus pandemic has created stress for them (American Psychological Association, 2020). Children and adolescents suffer from anxieties regarding schooling, peer interaction, and planning for the future. Feelings of isolation and loneliness exacerbate stress and anxiety. Stress can cause the following:

  • Feelings of fear, sadness, worry, numbness, or frustration
  • Changes in energy, appetite, desires, and interests
  • Difficulty concentrating and making decisions
  • Difficulty sleeping or nightmares
  • Physical reactions, such as headaches, body pains, stomach problems, and skin rashes
  • Worsening of chronic health problems
  • Increased use of tobacco, alcohol, and other substances (CDC, 2021a)

While stress is considered normal and expected in times like the current pandemic, managing stress in appropriate ways works to help prevent long-term health complications and negative effects on one's mental health.

The CDC recommends numerous ways to help manage and cope with the pandemic's stressors (CDC, 2021a). These include:

  • Taking breaks from news updates such as watching, reading, or listening to news stories and social media.
  • Take care of your body by using deep breathing techniques, exercising, eating healthy meals, getting appropriate sleep, and avoiding excessive use of alcohol, tobacco, and other substances.
  • Schedule times for unwinding.
  • Connect with others either virtually or within small groups under the recommendations listed above.

Case Study 1

John enters the ERR with a complaint of cough and fever for four 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 mentions he had been in several airports due to work travel two weeks prior. 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.

Case Study 2

Linda calls her primary care office to discuss what actions to take after experiencing a COVID-19 exposure at work. Linda's coworker tested positive for COVID-19 one day prior. The coworker had symptoms of cough, low-grade fever, and loss of smell. Linda's coworker works in the same office as Linda. Their desks are spaced six feet apart, and masks are worn in the workplace except when eating. Linda is not experiencing symptoms. The nurse triages Linda to a telehealth appointment with the primary healthcare provider.

During the telehealth appointment, it is identified that Linda completed the two-dose Pfizer-BioNTech one month prior. Based on this information and the absence of symptoms, Linda was not required to obtain a COVID-19 test. Information was given to Linda regarding the need to obtain testing if she develops symptoms of COVID-19. Linda was cleared to return to work immediately.

Patients with concerns for COVID-19 without respiratory symptoms should be triaged to telehealth appointments, when possible, to prevent unnecessary exposure of additional persons while seeking medical care for COVID-19. The newest CDC recommendations (May 13, 2021) note that fully vaccinated persons are not required to be tested for COVID-19 despite an exposure, nor are they required to quarantine following exposure to another person with COVID-19. Linda should continue to monitor for symptoms up to 14 days following the date of exposure and with any exposures to COVID-19 in the future.

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References

  • American Psychological Association. (2020, October 20). Stress in America signals a growing national mental health crisis. Visit Source.
  • CDC. (2020a, February 12). Evaluating and reporting persons under investigation (PUI). Visit Source.
  • CDC. (2020b, February 6). Coronavirus Disease 2019 (COVID-19). Visit Source.
  • CDC. (2020c, February 12). Interim clinical guidance for management of patients with confirmed 2019 novel Coronavirus (COVID-19) infection. Visit Source.
  • CDC. (2020d, February 12). 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.Visit Source.
  • CDC. (2020e, June 20) Interim guidance for implementing home care of people not requiring hospitalization for 2019 novel Coronavirus (COVID-19). Visit Source.
  • CDC. (2021a, January 22). Coping with stress. COVID-19. Visit Source.
  • CDC. (2021b). Vaccines for COVID-19. COVID-19. Visit Source.
  • CDC. (2021c, May 6). J&J/Janssen update. COVID-19. Visit Source.
  • CDC. (2021d, May 13). Guidance for fully vaccinated persons. COVID-19. Visit Source.
  • CDC. (2021e, March 17). Testing overview. COVID-19. Visit Source.
  • National Conference of State Legislatures. (2020, March 25). President Trump declares state of emergency for COVID-19. Visit Source.