Policy:

To effectively manage and contain an outbreak when identified in this Center.

To promote an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Outbreak investigation will be organized by the Infection Control Nurse (Infection Preventionist) or designee when an outbreak is suspected.

This team listed below will meet daily to monitor the outbreak and initiate any needed changes. Local and state department of health will be appraised as required.

Section A

Infection Prevention Team:

Infection Preventionist

Administration ( Administrator and Nursing Director)

Unit Nurses

Housekeeping Director

Dietary Director

Maintenance Director

Social Services

Admission Director

Outbreak investigation will be organized by the Infection Control Nurse (Infection Preventionist) or designee when an outbreak is suspected.

1.
This Center will inform the resident and their representative within 12 hours of a single confirmed infection of COVID-19, Influenza or Norovirus. All residents in the facility, as well as their representatives and family members by 5 p.m. the next calendar day

Additionally.

• • • • Notify the primary physician for the resident who has a confirmed case.
      • Notify the local and state health departments with information per local/state reporting requirements.
      • This will be done by letter, website posting, listserv, recorded telephone message, or other means that make the information easily accessible.
      • Designated staffperson(s) number will be posted and email will be posted for resident representatives and guardians as a means of urgent communication.
        

2.
Three (3) or more residents or staff with new onset of respiratory symptoms and/or Gastrointestinal symptoms that occur within 72 hours and,

3.
State health department will be notified about residents with severe respiratory infection or a cluster of respiratory infections (e.g., 3 or more residents or Health Care Professional (HCP) with new-onset respiratory symptoms over 72 hours) and of residents or HCP with symptoms of respiratory infections.

• • • • Notify the resident representative for each resident with new onset respiratory symptoms
             (resident already knows as this is the person experiencing the symptoms).
      • Notify the primary physician for each resident who has new onset respiratory symptoms.
      • Notify all residents in the facility, as well as their representatives and family members, by 5 p.m. the next calendar day.

4.
Updates to residents and their representatives will be provided weekly, or each subsequent time a confirmed infection of COVID-19 is identified and/or whenever three or more residents or staff with new onset of respiratory symptoms occurs within 72 hours the resident and their representatives will be notified of a potential outbreak.

• • • • • Report by 5 p.m. the next day every time there is a new cluster (when there are three or more residents/staff with new onset respiratory symptoms within 72 hours of each other).
        • If one or more of the individuals in the cluster tests positive, report this as an increase in cumulative COVID cases in the building (prompting a report by 5 p.m. the next day).
        • Continue to report-at least weekly or whenever a subsequent occurrence of a positive case or new cluster prompts a new required report by 5 p.m. the next day–the presence of the “cluster” in the building until one or more of the individuals in the cluster is ruled out with a negative laboratory test.
        • If one or more individuals in the cluster tests negative, there is no longer a cluster of 3 or more, no longer required to report it.
        • Report whenever an individual who was in a cluster is ruled out. However, if a new suspected case occurs, it may create a new cluster within a subsequent 72-hour period, report that by 5 p.m. the next day and follow the same process outlined above.

5.
Center’s designee will include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations in the nursing home will be altered. (return to Phase 0)

6.
Immediate steps will be taken to the best of the center’s ability to isolate individuals as per department of health and local department’s guidance.

7.
Testing will be expansive and extensive center wide for COVID-19 and Influenza.

8.
Staff testing will also be underway to stop the introduction and limit exposure and control the spread of these contagious diseases.

Section B

Procedure:

1.
According to defined clinical parameters or state regulations: COVID-19 Two (2) resident/patients and/or staff in three (3) days become sick with these

listed symptoms and at least one (1) of these has a positive test for COVID-19.

2.
Confirm the existence of an outbreak:

• • • • • Define as one (1) LabID SARS-CoV-2 positive (detected), that is an excess over expected (usual) level within the center i.e., normal rate is 0% and is now (1) positive (detected) LabID result.
        • Symptoms:
          Fever, Dry Cough, Shortness of Breath, Fatigue
          Elders’ symptoms may exhibit:
          Increased confusion, worsening chronic conditions of the lungs, loss of appetite, and decrease fluid intake
          Less common: sore throat, headache

3.
This center will implement a center wide testing of residents and all center’s staff.

4.
If resident/patient(s) refuses to undergo COVID-19 testing, those individuals will be treated as Person Under Investigation (PUI).

5.
Nursing will document resident/patient’s refusal and notify responsible representative of refusal to testing.

6.
Resident/patient at any point in time may change their mind to testing, the center will proceed with testing this individual.

PUI:

• • • • • Resident/patient will be cohorted accordingly
        • Temperature monitoring will continue every shift
        • Onset of elevated temperature or other related symptoms consistent with COVID-19 will require immediate cohorting with symptomatic residents.

7.
Influenza:

Three (3) or more clinically defined cases or one or more laboratory Identified result for Influenza in a Center within a 10-day period from October through May.

8.
Pneumonia:

Two (2) or more Residents with nosocomial cases of non-aspiration pneumonia within a 10-day period should be reviewed for outbreak potential.

Section C

1.
Develop a case definition based on symptoms, characterized by disease cases

• • • • • What: the pathogen, site, and/or sign/symptoms
        • Who: the population in which cases are occurring?
        • Where: the unit location of cases
        • When: length of time cases has been occurring

2.
Create line listing and search for additional causes and cases

• • • • • Review surveillance and lab reports
        • Obtain appropriate lab specimens as directed by the physician or state/local health department

3.
Use appropriate line listing forms when symptoms are identified for both Resident and staff:

• • • • • Respiratory Line Listing, Gastroenteritis line listing

4.
Organize data according to time, place, and person

• • • • • Time: duration of the outbreak and pattern of occurrence
        • Place: develop location and onset of dates of cases
        • Person: evaluate characteristics that influence susceptibility such as age, sex, underlying disease, immunization history
        • Exposure by nursing staff, or other infected Residents

5.
Formulate likely cause

• • • • • identify (organism) source and possible mode of transmission

 Notify:

• Administrator
• Director of Nursing
• Medical Director
• Attending Physician/Medical Director
• Staff and Department Directors
• Family of the affected Resident(s)
• Local/State Health Department, according to regulations
• Nursing will inform residents and their representatives within 12 hours of the occurrence of a single confirmed infection of Influenza, COVID-19, or Norovirus. Three (3) or more residents or staff with new onset of respiratory symptoms and /or Gastrointestinal symptoms that occur within 72 hours; residents and their representatives will be notified of a potential outbreak.
• Social Services and nursing will notify all residents’ responsible representatives of outbreak either by phone, email and/or written letter weekly or more frequently as needed.
  

Section D

1.
Implement control measures based on sign, symptoms, diagnosis, mode of transmission, and location in the Center.

Measures may include:

• • • • • Transmission-based precautions.
        • Restrict visitors.
        • Screening all employees for elevated temperatures and signs/symptoms.
        • Restriction of affected residents from group activities.
        • Suspending communal dining.
        • Suspend admissions to affected unit.
        • Suspend admissions to center if deemed necessary.
        • Housekeeping, intensive environmental cleaning with frequent cleaning of high touch areas with EPA approved disinfective agent.

• • • • • Staff Coordinator will Implement staffing contingence plan for possible change in staffing levels.

2.
Once all has been reviewed with Administrator, Infection Preventionist, Medical Director and Nursing

• • • • • Conduct mandatory staff education
        • Hand hygiene
        • Outbreak disease symptoms
        • Reporting the occurrence of symptoms of resident/patients and staff.
        • Transmission-Based precautions
        • PPE made available in preparation for an outbreak
        • Advise staff who are exhibiting symptoms to stay at home

3.
Monitor for effectiveness of investigation and control measures until cases cease to occur or return to normal level

4.
Compare group of uninfected Residents with infected Residents

5.
Conduct care practice observation IF cause implies a breakdown in resident care practices.

6.
Complete an Investigative Summary and submit a copy to

• • • • • Nursing Director
        • Administrator
        • Medical Director

*Summarize data/information collected, include case definition, contact tracing, cause and final evaluation of outbreak.

Resources:

NJDOH, Guidance for COVID-19 and/or exposed healthcare personnel https://nj.govhealth/cd/documents/topic/NCOV/Guidance for COVID-19 Diagnososed and/or exposed HCP.pdf.

CDC, Testing for Coronavirus (COVID-19) in nursing homes https://www.cdc.gov/coronovirus/2019-ncov/hcp/nursing-homes-testing.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control­ recommendations.html

CMS, April 19, 2020 (QSO-20-26-NH) Communicable Disease Reporting Requirements/Transparency

CMS, 6-4-2020 Clarification of notification guidelines

AHCA/NCAL – COVID-19 Update #75; revised notification guidelines

New Jersey Department of Health Executive Directive No.20-026 Effective date: August 10, 2020