This course will expire on Friday 8/26/22 due to outdated material. For an updated course on COVID-19 Practice Guidelines, please visit the following course: ceufast.com/course/covid-19-current-practice-guidelines
In January 2020 the novel coronavirus, SARS-CoV-2, COVID-19, officially entered the United States. Since then, COVID-19 has affected people in every state, causing over 45 million infections and over 700,000 deaths (CDC, 2021a). COVID-19 has been detected on every continent and almost every country in the world. As the COVID-19 pandemic continues to impact the world, healthcare providers must learn how to adapt to the ever-evolving virus and healthcare issues associated with it.
Between researching the viral variants, preventing transmission of the disease, and finding treatments to cure COVID-19, the world is aggressively trying to find a way to resolve COVID-19. Since its first detection in Wuhan, China, in December 2019 and rapid spread through the world, there have been numerous theories, therapies, and prevention strategies to reduce the impact of COVID-19.
Ongoing strategies to prevent the spread of COVID-19 include (CDC, 2021j):
Testing for COVID-19 is still the preferred way to identify whether one has been infected with COVID-19. Ongoing testing recommendations include (CDC, 2021l):
The CDC continues to recommend specific quarantine measures for those exposed to and infected with COVID-19. For unvaccinated people exposed to COVID-19, quarantine should be implemented for 14 days following the last exposure. Quarantine is not indicated for fully vaccinated people only exposed to COVID-19; however, they should wear a mask in all indoor and public spaces for 14 days following the last known exposure with a person with confirmed COVID-19 (CDC, 2021e).
For people infected with COVID-19, vaccinated or unvaccinated, quarantine should be implemented for at least ten days following the onset of symptoms. Positive persons should also be 24 hours without fever and with other COVID-19 symptoms improving before breaking quarantine (CDC, 2021e).
Since the identification of the SARS-CoV-2 (COVID-19) virus, the CDC and worldwide laboratories have been closely tracking mutations and variants of the virus. Variants are not to be unexpected in viruses. Viruses are known to mutate as they spread. As more infections occur, new opportunities for viral mutation also occur. As the virus mutates, it potentially becomes more difficult to stop (CDC, 2021k). As of September 2021, eleven COVID-19 variants have been identified and are being followed closely. The variants identified include (CDC, 2021c):
Of these variants, the one of most concern is the Delta (B.1.616.2 and AY.1 sublineages) variant which was first identified in India (CDC, 2021d). In July 2021, healthcare systems suddenly noticed an uptick in new COVID-19 cases. Prior to July, the cases had been steadily declining due to the introduction of the COVID-19 vaccination since January 2021 (CDC, 2021i). The CDC reported the difference in rolling 7-day average went from 12,000 cases in June to greater than 60,000 cases in July (CDC, 2021i).
On July 27, 2021, the CDC acknowledged the increased number of COVID-19 cases by increasing previously reduced isolation recommendations and pushing harder for people to seek vaccination against COVID-19. Delta became and continues to be the predominant variant of COVID-19 in the United States (CDC, 2021i; CDC, 2021k).
As more data has emerged, the Delta variant has been identified to be more infectious than the other COVID-19 variants. The CDC (2021i) reports that the Delta variant is more than twice as contagious as the other COVID-19 variants. With increasing numbers of people infected with the Delta variant of COVID-19, the healthcare systems are, once again, becoming saturated with people sick with COVID-19 (CDC, 2021i).
Unvaccinated people are the most likely to be infected with COVID-19, especially the Delta variant. Unvaccinated people also make up the majority of patients hospitalized with effects from COVID-19 (CDC, 2021d). Not only did the Delta variant cause infection in non-vaccinated people, but vaccinated people more commonly have become infected with the variant as well. However, it is important to note that those fully vaccinated and infected with the Delta COVID-19 variant were less sick and less likely to be hospitalized than those infected and not vaccinated.
As with all the variants of COVID-19, prevention of contracting the Delta variant begins with masking, handwashing, and social distancing. Vaccinations are the next, and equally important, step in helping to prevent the spread of COVID-19.
Vaccinations play an important role in helping to prevent the spread of disease. Researchers across the world worked to find a vaccine to help prevent transmission and illness with COVID-19. The first mRNA vaccination, Pfizer-BioNTech (COMIRNATY) COVID-19 vaccination, was released under an emergency use authorization in December 2020. A few weeks later, the second mRNA vaccination, Moderna COVID-19 vaccination, was approved. In February 2021, the Johnson & Johnson/Janssen COVID-19 single-dose vaccination also joined the Pfizer-BioNTech (COMIRNATY) and Moderna COVID-19 vaccinations in approval. (CDC, 2021h)
The FDA fully approved the Pfizer-BioNTech (COMIRNATY) COVID-19 vaccination on August 23, 2021, for adolescents and adults 15 years of age and older. For adolescents 12-15 years of age, the Pfizer-BioNTech COVID-19 vaccination can be administered under the continued emergency use authorization. The other two vaccines currently available are expected to gain full FDA approval in later 2021. Vaccines are recommended for all people eligible to receive the vaccination.
Booster vaccinations have been approved for people who received the Pfizer-BioNTech (COMIRNATY) vaccination (CDC, 2021b). Booster COVID-19 vaccinations are recommended for people 65 years and older, those in long-term care settings, and those with underlying health conditions, including immune compromise. Additionally, adults living in or working in high-risk settings may choose to receive a COVID-19 booster vaccination. Booster vaccinations should be administered at least six months after completing the original Pfizer-BioNTech (COMIRNATY) COVID-19 vaccination series (CDC, 2021b).
For people who received the Moderna or Johnson & Johnson/Janssen COVID-19 vaccination, the Pfizer-BioNTech booster is NOT recommended. Moderna and Johnson &Johnson/Janssen are expected to release information regarding a plan for their own boosters soon.
Treatments for COVID-19 are managed by the COVID-19 Treatment Guidelines Panel (the Panel). The Panel works to ensure that the most updated information is disseminated to healthcare providers to support the needs of patients with COVID-19. As of September 15, 2021, the COVID-19 treatment guidelines are outlined below (NIH, 2021b).
From June 25, 2021, to September 2, 2021, the distribution of bamlanivimap plus etesevimab was paused due to the spread of the Gamma (P.1) and Beta (B.1.351) SARS-CoV-2 variants. Bamlanivimab plus etesevimab retains activity against the Delta variant (B.1617.2, non-AY.1/AY.2). This treatment distribution and use have been resumed.
The Panel recommends the use of an anti-SARS-CoV-2 mAb regimen in clients with mild to moderate symptoms and who are at high risk of clinical progression. Monoclonal antibodies should be administered as soon as possible and within ten days of symptom onset and after a positive SARS-CoV-2 antigen or nucleic acid amplification test (NAAT) result (NIH, 2021a). Only one of the therapies should be used. The following Anti-SARS-CoV-2 Monoclonal Antibodies have received emergency use authorizations from the Food and Drug Administration (NIH, 2021a):
The COVID-19 Treatment Guidelines Panel’s Statement on the Prioritization of Anti-SARS-CoV-2 Monoclonal Antibodies for the Treatment or Prevention of SARS-CoV-2 Infection When There Are Logistical Constraints:
The Panel recommends the use of anti-SARS-CoV-2 mAbs for mild to moderate symptoms of COVID-19 as mentioned above and for post-exposure prophylaxis (PEP) in patients with concern for the development of severe COVID-19. Logistical constraints to mAb administration technicalities and staffing availability can impact the ability to administer mAbs to all eligible patients. Recommendations are limited to ensure that those with the highest chance of benefit from the mAbs receive those first.
The Panel recommends that dexamethasone or other corticosteroids be used only in patients with COVID-19 who are hospitalized and require supplemental oxygen. Dexamethasone may be given alone if the combination medication Dexamethasone plus remdesivir is not available or if remdesivir cannot be used. Clients who require high-flow oxygen therapy or noninvasive ventilation may receive either baricitinib or IV tocilizumab along with dexamethasone or dexamethasone plus remdesivir. For clients pending admission to the ICU, dexamethasone plus IV tocilizumab or IV sarilumab (if IV tocilizumab is not available or feasible) should be administered.
Additional Panel recommendations under this update include recommending:
As of July 30, 2021, the Food and Drug Administration expanded the emergency use authorization for the anti-SARS-CoV-2 monoclonal antibodies casirivimab plus imdevimab to be used for post-exposure prophylaxis (PEP). Casirivimab plus imdevimab is recommended as PEP for people at high risk for progression to severe COVID-19 if infected with SARS-CoV-2 and who have either been incompletely vaccinated or who are fully vaccinated but may not have amounted an appropriate immune response and who have exposure history to COVID-19. Doses of casirivimab plus imdevimab should be administered as soon as possible within seven days of high-risk exposure.
Dosing of casirivimab plus imdevimab includes 600mg of each medication (casirivimab 600mg plus imdevimab 600mg) as four subcutaneous injections, each 2.5ml, at four different sites or as a single IV infusion. Observation of the patient for one hour after the injections or infusion is required in the case of adverse effects.
At this time, there is insufficient evidence to repeat dosing of casirivimab plus imdevimab every four weeks or for those who have repetitive high-risk exposures.
Prior and additional guidance regarding the treatment of SARS-CoV-2 (COVID-19) can be found within the full NIH COVID-19 Treatment Guidelines.
In some patients with COVID-19, symptoms continue to affect their lives long after their initial infection. Most people with COVID-19 recover completely from the illness within a few weeks. However, those with post-COVID conditions may experience a range of new or ongoing health issues that occur for four or more weeks after the initial COVID-19 infection (CDC, 2021f). It is important to note that even people who initially had no or mild COVID-19 symptoms are at risk for developing post-COVID conditions.
Types of post-COVID conditions can include individual or combinations of the following symptoms (CDC, 2021f):
Patients with severe COVID-19 illness may be at increased risk of multiorgan effects or autoimmune conditions. While rare, children are at increased risk for multisystem inflammatory syndrome (MIS) during or immediately following a COVID-19 infection (CDC, 2021f).
Patients hospitalized with COVID-19 may have difficulty discerning long-term symptoms of COVID-19 versus complications from hospitalization. Symptoms from hospitalization can occur, especially if hospitalization was prolonged and/or illness was severe. Patients may experience severe weakness and exhaustion. Patients with severe illness and requiring intensive care may develop post-intensive care syndrome (PICS) and/or post-traumatic stress disorder (PTSD) (CDC, 2021f).
The incidence of post-COVID conditions is not yet known. The best way to prevent post-COVID conditions is to prevent COVID-19 illness. People eligible for vaccination should be vaccinated as soon as possible. People should continue to practice mask-wearing and social distancing. Frequent hand washing and avoiding crowds and poorly ventilated indoor spaces are also helpful in preventing COVID-19 infection.
The healthcare system continues to be stressed by COVID-19. Healthcare providers are experiencing burnout, short staffing, limited hospital space, and concerns for their own health. COVID-19 has challenged not only the physical well-being of healthcare providers but also everyone’s mental health. Continuing to have resiliency in fighting against COVID-19 is essential to caring for communities and the healthcare systems that support them.
The safest practice to prevent transmission of COVID-19 in healthcare facilities is by wearing source control (i.e., a well-fitting mask, NIOSH-approved N95, approved respirators) when interacting with other people. In facilities in communities where there is low to moderate COVID-19 transmission and individuals are fully vaccinated, wearing source control may be optional unless otherwise specified by specific facility rules. In facilities where everyone is not fully vaccinated, there is frequent contact with suspected or confirmed COVID-19 infection, close contact with high-risk clients, moderate to severe immunocompromise, or if physical distancing cannot be practiced source control is recommended (CDC, 2021g).
Post visual alerts to alert employees and clients in the facilities of infection prevention and control practices expected of all people within the facility. Identify every person entering the facility to ensure proper management of positive viral SARS-CoV-2 test, COVID-19 symptoms, and those meeting criteria for quarantine. If either client or healthcare personnel meets any one of those symptoms, implement appropriate COVID-19 management strategies and work restrictions as outlined in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.
Offer vaccination resources and counseling for those not vaccinated for COVID-19.
Optimize indoor air quality by utilizing engineering controls. Reduce or eliminate unnecessary exposures from patients with suspected or confirmed COVID-19 by setting up specific areas to triage, assess, and direct well and ill patients.
Anyone with symptoms of COVID-19, even if mild, and regardless of vaccination status, should be tested as soon as possible for COVID-19. Asymptomatic healthcare personnel with high-risk exposure should be tested for SARS-CoV-2 infection as soon as possible after two days following exposure and again between days 5-7 after exposure. If the healthcare personnel have had COVID-19 within the past 90 days and remain asymptomatic, testing for COVID-19 in light of a positive high-risk exposure is not indicated.
Facilities should have plans to track and notify people within the facility of a possible high-risk COVID-19 exposure. Established communication paths can help to prevent unnecessary spreading of COVID-19 among healthcare providers and patients. More information can be found in the Healthcare Infection Prevention and Control FAQs for COVID-19.
Patients with suspected COVID-19 infection should not be moved with or in close contact with patients with confirmed COVID-19 until COVID-19 is confirmed. Patients with suspected or confirmed SARS-CoV-2 should be placed in a single-person room with a dedicated bathroom. The door to the room should be closed as long as it is safe to do so.
Facilities should consider designating units for SARS-CoV-2 infection to help prevent the spread of COVID-19 infection among people not originally infected with COVID-19. Only cohabitate patients with the same respiratory pathogens in the same room. Limit transport of patients with suspected or confirmed COVID-19 to only medically necessary purposes (CDC, 2021g).
Personal protective equipment should be worn with any interaction between healthcare personnel and a patient with suspected or confirmed SARS-CoV-2. More information regarding recommendations and use of personal protective equipment can be found in Protecting Healthcare Personnel | HAI | CDC.
Aerosol generating procedures (AGPs) can increase the transmission of COVID-19 among healthcare personnel and other patients. AGPs should be avoided when appropriate. They should occur in airborne infection isolation rooms. Those present during the procedure should be directly involved in the procedure. Those who are not directly involved should avoid the patient and room within safe limits until the AGP is completed. (CDC, 2021g)
Counsel patients and visitors regarding the risk of potential transmission of COVID-19 while hospitalized. Encourage the use of phone calls, tablets, and video calls as appropriate. Visitors should respect one visitor to every patient room rule.
COVID-19 transmission-based precautions should be recommended to all people. After high-risk exposure, clients should have COVID-19 testing performed to help identify any transmission of infection. Monitor closely for symptoms of COVID-19. Transmission-based precautions should be implemented for at least ten days following onset of symptoms and at least 24 hours after last fever. Some transmission-based precautions for clients admitted to a healthcare facility are lifted after symptoms completely resolve, they are fever-free for >20 hours, and other COVID-19 symptoms have resolved. To lift transmission-based precautions, clients who are asymptomatic must have two consecutive respiratory specimens to test for COVID-19 greater than 24 hours apart. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV).
Continue to use dedicated medical equipment when caring for patients with SARS-CoV-2. Routinely clean and disinfect surfaces and hands.
A 48-year-old patient with shortness of breath with suspected SARS-CoV-2 infection is admitted to a designated COVID-19 unit at a local hospital. A SARS-CoV-2 test was obtained, but the results have not yet returned. The charge nurse on the unit must combine client rooms as there are no more open single rooms to admit the patient. The charge nurse prepares to transfer a different patient with positive SARS-CoV-2 into a room with another patient with positive SARS-CoV-2 infection. The clients have no other respiratory pathogens as determined by PCR testing. After housekeeping appropriately disinfects and cleans the transitioned patient’s room, the charge nurse accepts the admission of the 48-year-old into the cleaned room.
The charge nurse takes the appropriate action in consolidating patient rooms when needed. Patients with the same respiratory pathogen can be roomed together if needed. The client with suspected COVID-19 infection should not be roomed with a client with a positive COVID-19 test result unless the suspected client receives positive SARS-CoV-2 test results.
As more information regarding COVID-19 emerges, recommendations are destined to change. The recommendations for the management and prevention of COVID-19 are updated regularly with the CDC. Healthcare providers must continue to be resilient and treat COVID-19 to the best of their abilities.