To the Bloom Healthcare community,
Bloom Healthcare intends on being your trusted source of information concerning the coronavirus. We will be circulating this publication weekly and/or as we receive new information from the CDC, AMDA, White House, CO Department of Public Health, international medical journals and other sources. Bloom understands that we are all supporting the same vulnerable population and we appreciate your dedication and a solid team approach. We encourage you to reach out to us at 303.993.1330 or directly to your Bloom provider should you have any questions or require clarification.
From the CDC
The decision to discontinue Transmission-Based Precautions for patients with confirmed COVID-19 should be made using either a test-based strategy or a symptom-based (i.e., time-since-illness-onset and time-since-recovery strategy) or time-based strategy as described below. Meeting criteria for discontinuation of Transmission-Based Precautions is not a prerequisite for discharge.
Symptomatic patients with COVID-19 should remain in Transmission-Based Precautions until either:
- Symptom-based strategy
- At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
- At least 10 days have passed since symptoms first appeared
- Test-based strategy
- Resolution of fever without the use of fever-reducing medications and
- Improvement in respiratory symptoms (e.g., cough, shortness of breath), and
- Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) . See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV). Of note, there have been reports of prolonged detection of RNA without direct correlation to viral culture.
Patients with laboratory-confirmed COVID-19 who have not had any symptoms should remain in Transmission-Based Precautions until either:
- Time-based strategy
- 10 days have passed since the date of their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms since their positive test. Note, because symptoms cannot be used to gauge where these individuals are in the course of their illness, it is possible that the duration of viral shedding could be longer or shorter than 10 days after their first positive test.
- Test-based strategy
- Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens). Note, because of the absence of symptoms, it is not possible to gauge where these individuals are in the course of their illness. There have been reports of prolonged detection of RNA without direct correlation to viral culture.
- Note that detecting viral RNA via PCR does not necessarily mean that infectious virus is present.
- Consider consulting with Bloom or another PCP group when making decisions about discontinuing Transmission-Based Precautions for patients who might remain infectious longer than 10 days (e.g., severely immunocompromised).
- Note: isolation protocols could result in a longer isolation period for persons exposed to Covid-19 than for those known to be infected with Covid-19. CDC recommends 14 days of quarantine after exposure based on the time it takes to develop illness if infected. Thus, it is possible that a person known to be infected could leave isolation earlier than a person who is quarantined because of the possibility they are infected.
- This recommendation will prevent most, but cannot prevent all, instances of secondary spread. the risk of transmission after recovery is likely substantially less than that during illness; recovered persons will not be shedding large amounts of virus by this point, if they are shedding at all. Employers and local public health authorities can choose to apply more stringent criteria for certain persons where a higher threshold to prevent transmission is warranted.
The CDC continues to prioritize testing for persons without symptoms who are prioritized by health departments or clinicians, for any reason, including but not limited to: public health monitoring, sentinel surveillance, or screening of other asymptomatic individuals according to state and local plans.
This key imperative to test prioritized asymptomatic patients, coupled with guidance from the CDPHE regarding the importance of protecting staff and residents in congregate care settings, underscores the need to increase testing capabilities.
Select excerpts from the interim guidance on testing & cohorting:
- Why large-scale testing is important:
- Cohorting residents within a facility is difficult without expanded testing. Residents with illness and unknown COVID-19 status should not be cohorted with COVID-19-positive residents. Without expanded testing, LTCFs might implement cohorting strategies that could increase transmission within the facility
- Residents and staff with asymptomatic and presymptomatic SARS-CoV-2 infection, who likely play a significant role in transmission, cannot be identified without testing.
- After conducting large scale testing across residents and staff, residents and staff that tested negative in round 1 should : test weekly; if positive results are received during rounds of testing, consult CDPHE HAI SMEs; consider continuing until two rounds of negative testing
A reminder on Public Health order 2020 published in late April:
- This order requires all CO licensed or certified long term care facilities (including AL) take a number of steps to help prevent and control outbreaks. Requirements include:
- A severe limit on visitors
- At-the-door symptom check for all employees, vendors and visitors before entering the facility
- People with Covid-19 symptoms or positive tests be isolated
- Ensuring all residents have access to necessary medical care
- Facility residents and employees wear a mask or other face covering when in public (not only while working)
- Employees must wear an appropriate mask at all times when in the facility.
- After confirming documentation of positive status and
- Proof of use of one of the CDC’s approved clearance strategies listed above.
Potential residents with no known previous COVID positive test
- A resident without known COVID history should have risk assessed for exposures, including:
- COVID-19 positive caregiver (family, hospice, home health) within last 14 days
- COVID-19 positive person living with patient who has not been cleared formally
- Persons with respiratory symptoms visiting or caregiving for the patient
- ER visit to a facility with known COVID cases in last 14 days
- Hospitalization in last 14 days
- SNF or Rehab visit in last 14 days
- Multiple caregivers necessary for routine care
- Any patient with high risk exposure should be isolated for 14 days prior to move in
- Isolation is defined as having no high-risk exposures
- Have no visitors except for typical caregivers
- All patients, regardless of high-risk exposures, should be tested and receive a negative result prior to move in whenever possible.
- When patients are unable to isolate for a full 14 days, the accepting community should utilize COVID Transmission Based precautions (Full PPE) for 14 days upon move-in.
For any communities needing assistance clearing residents for move-in, please contact Bloom.
Our previous COVID-19 communications and recommendations can be found at: bloomhealthcare.com/news/
We appreciate your partnership and continued diligence.
Thomas Lally, MD