>> Good afternoon.
I'm Commander Ibad Khan
And I'm representing the Clinician Outreach
and Communication Activity,
COCA with the Emergency Risk Communication Branch
of the Centers for Disease Control and Prevention.
I'd like to welcome you
to today's COCA call Coronavirus Disease 2019 COVID-19 Update
Information for Long-term Care Facilities.
For participants using the Zoom platform
to access today's webinar.
If you are unable to gain or maintain access,
or if you experience technical difficulties,
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at www.facebook.com/cdcclinicianoutreach
andcommunicationactivity.
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outreachandcommunication activity.
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at emergency.cdc.gov/coca a few hours after the call ends.
Again, that web address is emergency.cdc.gov/coca.
Continuing education is not provided for this COCA call.
After the presentation, there will be a Q&A session.
You may submit questions at any time during the presentation,
through the Zoom webinar system by clicking the Q&A button
at the bottom of your screen and then typing your question.
If we are unable to ask the presenters your question,
please visit CDC's COVID-19 website
at www.cdc.gov/covid-19 for more information.
You may also email your question to coca@cdc.gov.
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or send an email to media@cdc.gov.
If you're a patient, please refer your questions
to your healthcare provider.
Also, please continue to visit emergency.cdc.gov/coca
over the next several days as we intend to host COCA calls
to keep you informed of the latest guidance
and updates on COVID-19.
In addition to our webpage, COCA call announcements
for upcoming COCA calls will also be sent via email.
So please subscribe to coca@cdc.gov
to receive these notifications.
Please share the invitations with your clinical colleagues.
For instance, we intend to hold a COCA call this coming Monday,
March 23 at 2 PM Eastern.
Where the topic will be COVID-19 and guidance
on underlying medical conditions.
Additional information will be shared via email call
announcements and should be posted shortly
on the COCA call webpage at emergency.cdc.gov/coca.
I would now like to welcome our two presenters
to today's COCA call.
Our first presenter is Dr. Brendan Jackson,
a medical epidemiologist
from the COVID-19 response clinical team at CDC.
Our second presenter is Lieutenant Commander Kara Jacobs
Slifka, a medical officer
from the COVID-19 response clinical team.
Now, our first presenter, Dr. Jackson, please proceed.
>> Thank you and good afternoon.
And thanks everyone for joining.
So, over the next hour, we'd like to share what we know
about preparing for and managing COVID-19
in long-term care settings.
And as our country faces this unprecedented pandemic,
we know that you're on the frontlines of protecting some
of the most vulnerable people in society.
So, our goal this afternoon is to summarize the best
and most up-to-date information we have available
to inform your decisions.
I'm going to discuss clinical aspects of COVID-19,
relevant to long-term care settings.
My colleague Dr. Jacobs Slifka will then discuss how facilities
should be preparing, including actions to prevent spread.
So, over the next 15 minutes I'm going to cover a brief update
on COVID-19, provide an overview
on COVID-19 clinical presentation and course,
including mortality and risk factors.
Focusing specifically on long-term care.
And discuss management and treatment.
I should point out this next slide is my only slide,
so please do not be concerned that the slides do not advance.
So, if you could go to the next slide, that would be great.
So, onto the brief update on COVID-19 in the US.
As you all know, the coronavirus is now spreading
in communities in many states.
To date, thousands of cases have been reported
in the United States, including from nearly every state.
Although we know that many cases are probably going undiagnosed.
We expect many more cases to occur
in the coming days and weeks.
Social distancing is now essential
to reduce spread and save lives.
For life example, the federal government now recommends
that everyone avoid social gatherings in groups of more
than 10 people and avoid discretionary travel.
CDC has more guidance on community mitigation strategies
and other topics including clinical management
on the CDC website at www.cdc.gov/covid19.
Please also consult your local
and state health departments for more information.
All right, well our experiences with long-term care facilities
in Seattle and elsewhere suggests
that the virus can spread rapidly
in long-term care facilities
and have a relatively higher mortality
than among the general population.
So, first I'm going to talk
about recognizing possible COVID-19
to help protect residents and staff.
So, in the clinical presentation,
most of our information about how it presents,
and progresses is based on reports from Asia
and the early US experiences.
So, first, how long does it take from someone coming in contact
with the virus to getting symptoms,
which is also known as incubation period.
Typically, 4 to 5 days.
But it can be as short as 2 days in some people
and up to 14 in others.
We don't yet know much spread happens
from the asymptomatic people.
But we do think that most transmission happens
when people are having symptoms.
All right.
So, what about signs and symptoms?
Some people, we don't exactly know what proportion never get
symptoms and are asymptomatic.
Others might have nonspecific symptoms,
just not feel quite right.
But for those who develop symptoms,
COVID-19 is often a flu-like illness
with over 3/4 having fever, over 1/2 having cough,
and a smaller proportion having things like muscle aches,
fatigue, and sore throat.
A small percentage of people have experienced GI symptoms.
Things like diarrhea and nausea before getting fever
and respiratory symptoms.
Now, based on what we know so far, most, or about 80%
of people have mild symptoms.
It's important to know the COVID-19 seems to progress
to severe disease much more often than seasonal influenza.
One thing to note is that most adults do not get a runny nose,
known as rhinorrhea.
That said, people might have a runny nose if they have COVID
if they also have an infection with a virus
that causes something like the common cold.
Now for many, symptoms run their course in about a week,
and then start getting better.
But in others, things can get worse,
leading to severe shortness of breath, pneumonia,
and something called acute respiratory distress syndrome,
known as ARDS, where the lungs fill with fluid.
We want clinicians to know that people may not develop shortness
of breath, until they've already been sick for several days.
We've seen this on numerous occasions,
where even into their second week of illness.
In one report in China,
the average patient wasn't hospitalized
until day seven of their illness.
And sometimes people may be fairly stable for about a week
and more quickly develop respiratory failure.
So be on the lookout for that.
Now, people who have been in acute care hospitals,
about 20 to 30% have required intensive care
for respiratory support.
Ranging from high-flow oxygen to noninvasive ventilation,
like BiPAP, or even mechanical ventilation
with a breathing tube.
One thing to note is that noninvasive ventilation
like BiPAP requires close monitoring,
as some patients will eventually progress
to needing mechanical ventilation or like intubation.
So, moving onto mortality and risk factors,
I think it's widely known that older people and those
with serious chronic medical conditions are
at a higher risk of death.
Which is one of the reasons that long-term care facilities need
to take COVID-19 so seriously.
Now, among hospitalized patients in China,
about 1 in 500 people in their 30s died.
Versus about 1 in 12 people in their 60s,
and about 1 in 7 people in their 80s.
So, you can see that change with age.
We need more information on which conditions,
chronic conditions place people at the highest risk.
But the following conditions here probably increase
that risk.
Things like chronic lung disease, heart failure,
diabetes, certain neurologic conditions,
weakened immune systems like including from certain drugs
with biologics or from chemotherapy,
cirrhosis of the liver, kidney disease, requiring dialysis,
and potentially extreme obesity or a body mass index of over 40.
But we're still learning more about these things.
People who die from COVID-19 often have respiratory failure
from pneumonia, ARDS as I was talking about.
We're also seeing that some patients in addition
to that may develop septic shock and damage to the liver, kidney,
heart, and other organs.
A few items on laboratory findings.
There's nothing that's really clear early in the disease
that says for sure whether this is COVID-19 or not.
We do see that a low lymphocyte count is common
in critically ill patients.
But it might not always be present.
Patients often, later in the illness,
will have an elevated white blood cell count.
But early on, they may be low, high, or normal.
Again, later they might have things
like elevated liver enzymes or lactate dehydrogenase, LDH.
Those are maybe predictors of worse outcomes,
but early on again, it's not as obvious.
It's also important to know when it comes to laboratory testing
that some studies have found that SARS-CoV2 infections,
that's the virus that causes COVID-19 has been seen together
with other respiratory viruses, including influenza.
So, just because you have one doesn't mean you can't
have another.
Now, on imaging, patients often will have a normal chest x-ray
early in their illness.
If they're getting shortness of breath,
they may develop other findings on x-ray like infiltrates,
bilateral lung infiltrates, or even consolidation
and ground-glass opacity on chest CT,
although that's not universally seen.
Okay, now here's a few special considerations
when it comes to long-term care.
First both residents and older visitors have had mortality
rates substantially higher than the general population,
making infection prevention and control all the more important.
Second, when it comes to signs and symptoms,
please educate your staff on what those signs
and symptoms are and their critical role
in protecting residents.
And I mean not everyone with COVID-19 will have a fever.
We all know that older adults, especially those
with severe medical conditions don't always display typical
responses to infection.
So that said, the early symptoms of COVID-19
in these patients may be a little bit vague.
Things like confusion, or just general malaise
and not feeling that well.
So, here's a couple of things that you can do.
If the virus that causes COVID-19 is spreading
in your community, consider checking
on residents more frequently than you otherwise would.
You can ask residents if they feel feverish or have symptoms
of respiratory infection on admission.
And then at least daily.
In skilled nursing units,
facilities could consider adding pulse oximetry to vital signs
if they don't use it already.
And even on long stay units,
residents should be closely monitored.
At least daily for signs and symptoms of illness.
Including checking their vital signs and pulse oximetry.
And the assisted living facilities should also increase
their vigilance for symptoms among their residents
and create a process for monitoring temperature
and pulse oximetry, at least daily if possible.
If a resident develops even mild temp,
we suggest you monitor more frequently.
Pay particular attention to increases in temperature,
even if not being the true criteria for a fever.
And in their heart rate,
or declining oxygen levels by pulse oximetry.
Now, if a case of COVID-19 is found in your facility,
we recommend instituting at least twice daily vital signs
and clinical evaluation.
At a minimum being, temperature, heart rate, and pulse ox to see
if there's anyone else who's getting sick.
Also consider COVID-19 nesting and hospitalization
for older adults with concerning changes,
even if they lack typical fever or respiratory symptoms.
So, enhanced monitoring can be critical
because nursing homes have reported
that residents have developed respiratory failure quickly
after seeming pretty well during an initial mild illness.
We don't know if this is because the disease came on suddenly
in them, or whether illness had been present for a little while
but it's hard to detect.
It's also important for healthcare providers
to have discussions with residents and families
about their goals of care.
This is true any time and including about the end of life.
If a resident has expressed a desire to avoid hospitalization
or intensive care,
that information should be clearly reported.
So, now onto management and treatment.
Currently, there's no licensed antiviral drugs
for the treatment of patients with COVID-19.
And so, management and care is, generally supportive.
One thing to note in an older population or those
with comorbidities is to use caution with intravenous fluids.
If patients are having respiratory distress,
since older patients are more susceptible
to having volume overload and pulmonary edema or some
of that fluid ending up in their lungs,
which can worsen their breathing.
Another note is that although secondary infection,
you know infection on top of the COVID-19 like bacteria or fungus
or something like that have not been seen that widely,
they do happen in COVID-19.
So, be on the lookout for those,
including for drug-resistant infections.
Another management issue is that based on available data CDC,
is recommending
that corticosteroids be avoided unless indicated
for other reasons.
So, you know you might give it for instance
if a patient is having a COPD exacerbation, or if they're
in the hospital and having septic shock,
under the guidelines for surviving sepsis.
But the reason for avoiding corticosteroids
in most people is the potential
for prolonging viral replication,
or how long the virus stays in the body.
And this is been observed with MERS.
With the MERS coronavirus.
So that's part of what's setting that recommendation.
So, as you all know and you're probably reading online,
there are a number
of investigational therapies out there.
Intravenous Remdesivir,
it's a nucleotide analog is being studied
in the United States for treatment of COVID-19.
At this point, the efficacy of Remdesivir remains unknown.
There are trials ongoing.
Specifically, an adaptive NIH trial
and two open-label investigational new drug trials
of Remdesivir.
It's also available on a limited basis from the manufacturer
for compassionate use.
For more information about these trials
and compassionate use can be found online
at clinicaltrials.gov, or CDC's clinical care guidance webpage.
Now, we're also aware that some physicians are using drugs
like chloroquine, hydroxychloroquine, Lopinavir,
Darunavir and other drugs for COVID-19.
But we're not able to make a recommendation
on those given limited data and no data
from randomized controlled trials.
Investigators are starting new studies
and this situation is evolving very rapidly.
So, it's important to note that CDC does not recommend for
or against the use of any of these investigational
or off label therapies at this time.
I should point out we've also been getting questions
about the use of ACE inhibitors, angiotensin receptor blockers,
and nonsteroidal inflammatory drugs, NSAIDs like ibuprofen.
At this point, there's not enough data for us
to make recommendations about these medications.
So, to summarize, I'd like to emphasize that our understanding
of the nature of the clinical presentation and course
of COVID-19 is still evolving,
especially in this long-term care population.
The CDC will continue to share additional information
as we have it.
Thanks, and I'll now pass it
over to my colleague Dr. Jacobs Slifka.
>> Thank you.
And as Dr. Jackson described, older adults and people
who have severe underlying chronic medical conditions,
things like heart or lung disease, diabetes,
or obesity seem to be at higher risk
for developing more serious complications
from COVID-19 illness.
And given their congregate nature,
frail and older adults residing in nursing homes
and assisted living facilities are
at the highest risk from COVID-19.
If infected with Sars-cov-2, the virus that causes COVID-19,
this population is more likely to experience severe illness,
require hospitalization, and is at increased risk of death.
Ill visitors and healthcare personnel are the most likely
sources of introduction of COVID-19 into the facility.
I want to share a little bit
about our recent public health responses to COVID-19 outbreaks
in nursing homes and assisted living facilities
over the past few weeks as these have helped inform our current
guidance for these settings.
We've discovered clusters of symptomatic residents
at not just one facility, but at multiple facilities
in the same geographic area.
And during those investigations have identified ill healthcare
personnel as being among the earliest identified cases
of COVID-19 in facilities.
We've also seen visitors
of long-term care facilities developing COVID-19
and have seen movement of both ill healthcare personnel
who may work at more than one facility,
and residents being associated with outbreaks.
We have observed challenges with identifying residents
at high risk for progression
to severe illness and hospitalization.
And seen those residents move very quickly from what appears
to be a milder illness to a much more serious infection.
COVID-19 is already circulating in many communities
across the United States.
We expect that COVID-19 will continue to be identified
in more communities, including areas
where cases have not yet been reported.
To protect our vulnerable residents, nursing homes,
assisted living, and other residential care facilities
should assumed that COVID-19 is already in their community
and take aggressive efforts to keep residents, visitors,
and healthcare personnel healthy.
Over the next few minutes,
I will be describing specific strategies that nursing homes,
assisted living facilities,
and other residential care facilities can use
to decrease the risk that COVID-19 enters
and spreads in the facility,
inform and educate residents, staff, and visitors,
and rapidly identify residents, ill residents,
and healthcare personnel so that the appropriate infection
prevention and control practices can be implemented.
We will also talk about strategies
for social distancing among residents
and for preserving PPE supply.
One of the most important things that you can do
to prevent the entry of COVID-19 into you're your nursing home
or assisted living facility is to restrict visitation.
Both CDC and the Centers for Medicare and Medicaid Services,
CMS, have issued strong recommendations
to immediately restrict all visitation to nursing homes.
There may be some exceptions
for certain compassionate care situations, such as end-of-life.
But no other visitors should be allowed entrance
into these facilities at this time.
Absolutely no ill person should be allowed to enter the facility
for the safety of the residents, visitors, and facility staff.
We recognize the negative impact
that social isolation can have on this population.
But are recommending such extreme measures due to the risk
of serious illness and mortality among older adults.
Communication at this time becomes essential in order
to help residents and families understand the current situation
and maintain connections with loved ones.
CDC has created a template letter for nursing homes
and assisted living facilities to share with residents
and families that explains visitation restrictions,
how healthcare personnel and residents will be monitored
for symptoms of respiratory illness,
the infection prevention and control practices
that they can expect to see in the facility.
Such as the use of personal protective equipment, or PPE.
And the actions that residents can take,
such as how residents may practice social distancing
and clean their hands.
We encourage you during this rapidly changing situation
to incorporate alternative methods for communication
into your routine in order to help ease the anxiety
that your residents and their families may be experiencing due
to COVID-19 and visitation restrictions.
Some ideas for this including using methods such as phone,
or video conferencing to allow residents
and families to connect.
Maintaining contact information for family and friends
of residents, as well as sharing the facility's preferred contact
information with those individuals
so that important messages can continue to be communicated.
And doing things like posting reminder signage outside
of the facility about visitation restrictions.
And who the visitor can contact
for further information is encouraged as well.
In addition to restricting visitors, CDC is recommending
that you restrict any nonessential healthcare
personnel from entering the building.
We recognize that this may not be an easy task.
But the overall goal is to minimize potential exposure
of nursing home and assisted living residents to individuals
that may be able to spread COVID-19.
For those of you that do not yet have COVID-19 in your facility,
now is the time to think about how you might do this.
The first step may be to create a list of staff,
visiting consultants, volunteers,
and any other services that enter your facility.
This will look different for every facility.
But what you may consider doing is engaging each
of those different services and providers in order
to create a plan for how you may limit, or even stop visits.
Consider looking at the services provided and creating a list
of services that absolutely must continue
for the necessary medical care of your residents,
those that may be delayed,
or those that could be stopped, even if temporarily.
Ultimately, the decision
about which personnel should be restricted will need
to be determined locally, at the facility level.
We do have numerous resources available on the CDC webpage
with an abundance of information that can be used
to education both facility-based,
and consultant personnel on COVID-19.
We encourage you to check it out,
and also to create a communication chain
with your staff so that you can rapidly disseminate
any messages.
Social distancing of residents is another challenge,
but very important strategy
for preventing the spread of COVID-19.
Although activities and socialization are so important
for these adults, CDC is recommending
that group activities are cancelled, and residents try
to maintain a distance
of at least 6 feet apart from one another.
Since communal dining involves many residents
and facility staff in the same place, at the same time,
communal dining should be halted.
However, residents must continue to be safely fed.
So, resident needs may dictate exactly how your facility
implements dining for the immediate future.
We encourage you to find creative ways to continue
to keep your residents active and engaged
and share those ideas with one another.
As I've mentioned, we have learned from current outbreaks
that ill healthcare personnel are one of the ways
that COVID-19 can enter a nursing home
and assisted living facilities.
Actively monitoring both residents
and healthcare personnel for fever and symptoms
of respiratory infection is a vital component
of preventing spread of COVID-19.
By rapidly identifying illness
so that appropriate infection prevention practices can
be implemented.
The well-being of your facility staff is essential
to the continued care of your residents.
In order to keep residents and healthcare personnel healthy,
facilities staff must have the ability
to stay home when they are ill.
Staff should regularly monitor themselves,
even when they're not working for fever or symptoms
of respiratory infection.
And when staff come to work at the start of their shift,
they should have their temperature taken,
along with symptoms screening.
Ill staff who are identified throughout the workday should
immediately stop what they're doing, put on a face mask,
notify the facility and go home.
All residents should be assessed at least daily for symptoms
of respiratory infection, including sore throat,
shortness of breath, new or changed cough.
In addition to having their temperature checked.
As soon as an ill resident is identified
that resident should immediately be restricted to their room.
If the facility has a respiratory protection program
with fit tested staff and N95 or higher-level respirators,
a respirator can be used.
Otherwise, healthcare personnel should use gloves, gown,
face mask, and eye protection for the care of any resident
with an undiagnosed respiratory infection,
which includes any resident with suspect, or confirmed COVID-19.
Healthcare personnel should perform frequent hand hygiene,
clean and disinfect environmental surfaces,
especially high touched surfaces and shared equipment.
And the universal use of face masks should be considered.
It is extremely important that nursing homes, assisted living,
and other long-term care facilities notify the Health
Department for residents with severe respiratory infection,
or if they identify a cluster
of residents and/or healthcare personnel
with new onset respiratory systems.
Should a resident require a higher level of care,
such as needing to be transferred
to an acute care hospital, the receiving facility, EMS,
or transport service and the Health Department should
be notified.
We are currently facing serious PPE shortages
across the country.
Assess your inventory now, so that you have an idea
of what PPE you currently have available.
Know your Health Department
and your Health Care Coalition contacts so that you're able
to reach out about the availability
of additional PPE as necessary.
Now is not the time to be expanding your use of PPE.
Now is the time to talk about and educate your staff on ways
to preserve your PPE supply.
More details will be available on the CDC website
as we expect numerous additional resources
to become available in the near future.
But some strategies
for preserving PPE supply include prioritizing gowns only
for certain situations, such as aerosol generating procedures
if they are performed at your facility,
as well as care activities where splashes
and spays are anticipated, and for things
like high-contact resident care activities.
And these high-contact resident care activities are the same
activities that we have talked
about with enhanced barrier precautions.
And these are the activities that are at the highest risk
of transmitting infectious pathogens, and include things
like dressing, bathing or showering, transferring,
providing hygiene, changing linens,
assisting with toileting, device care or use
of a device, and wound care.
Another strategy is to start extended use of eye
and face protection, which depending
on your inventory may mean
that healthcare personnel use the same face mask
and eye protection for their entire shift
and reprocess the eye protection for continued use.
In order to do this, healthcare personnel would only change
their gloves and their gown if it was used
and perform hand hygiene in between providing care
to different residents with confirmed COVID-19,
while continuing to wear the same eye protection,
and the same face mask.
In this situation,
the healthcare personnel must not touch their eye protection
or face mask.
They would then remove the eye protection and face mask,
only if they became damaged or soiled,
or when leaving the unit, or at the end of their shift.
And of course, perform hand hygiene before
and after removal is required.
So, in conclusion, I want to thank you all for being
on this call and for the COVID-19 preparedness efforts
that you're all putting into place
to protect your residents and facility staff.
I want to stress the importance of restricting visitation
to nursing homes and assisted living facilities
and not allowing entrance to any ill person,
including healthcare personnel.
Actively monitoring residents
and healthcare personnel will help identify respiratory
illnesses as early as possible
so that the appropriate infection prevention
and control practices can be implemented immediately,
decreasing the risk of COVID-19 spreading within the facility.
Please closely monitor any ill residents
as they have a high risk of developing serious illness.
And notify the Health Department
when you identify these residents or clusters
of residents or healthcare personnel
with respiratory illness.
Please also refer to our website for additional guidance
and resources, and to your state for local guidance.
Now, I think we are ready to take questions.
>> Presenters, thank you for providing our audience
with such useful information on this rapidly evolving pandemic.
We appreciate your time
and value your clinical insights on this matter.
We will now go into our Q&A session.
Please remember, you may submit questions
through the webinar system by clicking the Q&A button
at the bottom of your screen and then typing your question.
Our first question is one we are seeing routinely from facilities
and the question asks
if our facility does not have an airborne infection isolation
room, is there a need to transfer our residents
who are COVID-19 positive?
>> This is Kara, an airborne infection isolation room,
or AIIR, is not required for the care of residents with suspect
or confirmed COVID-19.
The use of an AIIR, if available should be prioritized
for aerosol generating procedures,
although most long-term care facilities,
we recognize, do not have AIIRs.
Ideally, a resident with COVID-19 is placed
in a single-person room with a private bathroom.
But room sharing and cohorting may be necessary.
We also recognize that many long-term care facilities have
very limited single person rooms.
So, transfer really should be considered only if a resident,
clinically, is requiring a higher
or different level of care.
>> Thank you.
Our next question is sort of a compilation
of a common one we have seen, and that question is asking,
what is your best recommendation for what we should do
if you have a resident that we think might have COVID-19?
>> This is Kara again.
If you're suspecting that a resident may have COVID-19,
you should move that resident to their room and close the door.
The resident should stay in their room, although continue
to be monitored with staff wearing gloves, gown,
face mask, and eye protection.
Notify the Health Department immediately.
And if the resident must leave the room,
they should wear a face mask and perform hand hygiene.
>> And I just wanted to mention, just in terms
of you know we also get asked, do we need to send the person
to the hospital if they've got COVID-19 and I just want
to emphasize that the decision about whether
to hospitalize someone should really be based
on their clinical status.
On a clinical assessment of their need for additional care
and not really based on just whether they have a coronavirus
infection alone.
Because a lot of people are going
to have fairly mild infection.
Again, like we said before, keep in mind
that there are some residents who have mild illness initially
and seem fine, and then they actually will get worse
over time.
So, that's why we're talking
that that monitoring is so important.
Thanks.
>> Thank you.
Our next question is a frequently asked question.
And the inquiries are asking how can they figure out how
to get the test for COVID-19?
>> Yeah, that's a great question.
So, clinicians may be able to access testing through a network
of state and public health labs.
And you can direct those questions
to your State Health Departments.
We know that there's some shortages right now.
An increasing number of clinical labs are receiving FDA
authorization for testing
under this emergency use authorization.
And so, they are and are expected to roll
out even more volume of testing for COVID-19.
So, what facilities can do,
and you may have done this already is contact your existing
laboratory vendor, find out if they have that test available,
or if there's a way to get it through them as well.
Thanks.
>> Thank you.
We have multiple follow-up questions
on the topic of testing.
So, first question asks what clinical samples are best
for testing for COVID-19?
>> So, in terms of which clinical samples to collect.
For initial testing,
CDC recommends a single nasopharyngeal, so an NP swab
up the nose, deep inside the nose for testing.
Clinicians can also choose to swab both the nasopharynx,
deep inside the nose, or the oropharynx,
the back of the mouth.
And combine those swabs in a single tube for testing.
Although given limited supplies, it may just be better
to just stick with the nose.
For patients that develop a productive cough, sputum can be,
in certain cases, submitted for testing immediate
that maybe have higher sensitivity, it's not required.
I want to mention though, and I don't know
if long term care facilities would be doing this,
but we don't recommend inducing sputum
if people aren't producing it already.
Because that can generate more aerosols
and potentially increase risk of infection to others.
For some you I know have ventilator units.
If you have patients that are intubated,
bronchoalveolar lavage, basically, you know putting
down a tube and a wash down the windpipe,
or tracheal aspirates can be collected for testing.
And those may have a little bit
of increased sensitivity in those populations.
And I also want to point
out that patients might have a negative test early
on in illness, and that repeat testing, if that's available
to you, after a day or two, if your symptoms continue
to worsen, that might actually be a little more sensitive
in picking up the virus that causes COVID-19.
>> So, another follow-up question is
so if a resident does test positive
for another respiratory virus, does that exclude COVID-19
as a cause of illness?
Can you elaborate on that please?
>> Sure, it's a great question.
And I know early on when testing was particularly limited,
and it may still be going on in some places, people,
they needed to sort of conserve the number
of tests that were available.
And so, if somebody had a positive test for another virus
that would prompt them not to look for the COVID-19.
What we're seeing from international data
and a little bit now in the US data is
that patients can have more than one virus at the same time,
particularly if there's a large panel being ordered.
Or even have a co-infection between influenza
and the virus that causes COVID-19.
So, unfortunately, a positive test
for another virus just can't by itself, rule out COVID-19.
>> Thank you for your response.
We have more questions more so on the idea
of monitoring patients in these facilities.
And the questions ask how do you decide
which residents should have increased monitoring
and if there is such a thing as that, then are you basing
that on the individual signs and symptoms.
Or is it a comprehensive sort of knowledge of what's going
on in the community as far as spread is concerned?
>> Yeah, that's a good question, it's good to draw down on
that a little bit more.
I think what we're concerned about at this point is
that community spread maybe present nearly everywhere
in the US, or it has the potential to be everywhere,
we don't have a good handle on all of that.
And so, given that it probably makes sense for facilities,
as best they're possible to actively monitor all residents
for these types of symptoms
and check their vital signs on admission.
So, when they arrive to a facility and at least daily.
So, again, checking for fever, respiratory symptoms.
You know, the skilled nursing units and long term stay units
that would be great if they could measure vital signs
as well as pulse oximetry daily after that.
And that may be more of a challenge
for assisted living facilities, but it would be good
to create a process to check those vital signs
and for symptoms daily as well.
Now, if a resident has even mild symptoms, it would be good
to monitor them at least twice daily, to make sure
that any disease isn't getting worse.
Now, we know there's all kinds of illnesses
that can cause mild symptoms, a little bit of confusion,
and a low-grade temperature.
Not all that is of course, COVID-19.
But it's wise given where we are right now,
to monitor people more frequently.
And then, certainly if there has been a case of COVID-19
in your facility, it would be good
to monitor all residents at least twice daily.
Thanks.
>> Thank you for that.
We're getting a lot of questions
about personal protective equipment.
And the first question asks you mentioned updating more supply
and more opportunities for personal protective equipment,
you hinted at some possible changes on the horizon.
If a facility's running short on their supply of PPE,
where can they obtain more supply.
Can you give more information?
>> This is Kara.
PPE supply is running very low in the United States
and so it's important to assess your inventory
so that you have an idea of how much PPE you have,
and if you are unable to obtain more PPE from your suppliers,
or if you're part of a corporate group and you are unable
to obtain additional PPE through that group, you should reach out
and contact your Health Department
and your Health Care Coalition as a next step.
This is also why I was describing and encourage you
to educate your staff about strategies
for preserving the PPE that you do have.
>> Thank you for that.
Next question asks along with PPE and other such measures,
how can I best prepare my facility for COVID-19.
>> This is Kara, and I want to use this question to put a plug
in for a preparedness checklist
that we do have available online.
It's on so, there is an abundance
of information on the CDC website.
But if you go in and navigate to the information
for long-term care facilities, that I believe is
under the healthcare facilities section.
There will be a link to a checklist on the preparing
for COVID-19 long term care facilities nursing home page.
And that's that page that we provide specific guidance
to long-term care settings.
And there's a checklist that's available that you can print
and walk through and will help you develop a preparedness plan
which includes information about communication.
There are places where you can fill in contact information
for people that maybe useful for you to be able to reach quickly.
There is information about education, monitoring residents
and healthcare personnel.
Infection prevention, supplies, staffing shortages,
and many other things that will help your facility to work
on different pieces of that preparedness plan
to get you as ready as possible.
>> Thank you for that.
Next question asks what do you suggest should be done
for residents of these facilities if they test positive
for COVID-19, do they need to be hospitalized?
>> Yeah, no that's a good question.
This is Brendan again.
We were talking about that a bit earlier.
I think that you know a recommendation is really,
it's based on the clinical status, almost as you would
for any other disease.
Kara already touched on some of the infection prevention
and control recommendations and interventions
that need to go in place.
Largely related to PPE.
But you know it really comes down to a clinical assessment
of whether that patient needs additional care
that a hospital can provide.
If the patient is clinically stable, has mild illness,
at that point there's really no need for hospitalization,
but increased monitoring is always a good idea.
>> Thank you.
We're getting more follow up questions on PPE
and our inquirer wants to know can you please explain what you
mean by preserving or optimizing PPE.
Some strategies that you could share.
>> Sure, this is Kara again.
So, when we talk about preserving or optimizing PPE,
we're referring to strategies to prolong the limited supply
of PPE and so these strategies may differ depending on the type
of PPE and on the situation.
But they include things like extended use of PPE,
selected use and reuse of PPE.
And there will be more detail coming from CDC specifically
on this and on different types of PPE
and how we can optimize their use
in the face of supply shortages.
And I would expect to see this information soon coming
from CDC and on our website.
>> Sounds like it's going to be really important information,
since this is going to be something new
that any recommendation had been made before.
>> Definitely.
And once we have this information available,
we will definitely be working on reaching out
and sharing this information with partner groups and helping
to disseminate this to all of you.
>> Thank you for that.
We have more questions about monitoring,
but this time the focus seems to be
on the actual healthcare personnel at the facility.
Can you explain what you mean
when you say actively monitor healthcare personnel?
And what are some ways that a facility can do that?
>> Yes, this is Kara again.
When we say that we want you to perform active monitoring
of healthcare personnel,
in addition to healthcare personnel monitoring their own
symptoms, throughout the day, whether they're at home
or at work, we want them to check their temperature each day
at the start of their shift, and report any symptoms
of respiratory infection.
This is something that can be worked out at your facility
in terms of how you will go about doing this,
but we do actually have some resources online,
again that you can access
through the long-term care information.
We have surveillance tools that you can use
for both healthcare personnel as well as residents
that would allow you to check and ensure
that each healthcare provider has checked their temperature
and has checked their symptoms each day
when they are coming in for their shift.
>> Now, I just mentioned,
because we've been getting questions from other companies,
businesses about whether they should be monitoring
their employees.
And the general recommendation is no, but I think the reason
for long term care settings is because they're caring
for such a vulnerable population, is that right?
>> Yes. Yes.
Exactly. We know that this population of older adults
in nursing homes assisted living,
other residential settings are at very high risk
of developing infection and developing severe illness.
And we also know from the outbreaks that we have seen,
so far, that healthcare personnel are one of the ways
that COVID-19 may find its way into facilities.
And we want to prevent that as well as detect any
of those illnesses as soon as possible
so that we can decrease the risk of them spreading
in the facility and decrease the risk
of these vulnerable residents becoming ill.
>> Thank you so much for the clarification.
We have some questions that have come in about treatment
of COVID-19 and they essentially boil down to the use
of empiric antibiotics.
Can you speak to the use of empiric antibiotics
for patients suspected of having COVID-19?
>> Sure. Yeah.
You know when you have a patient with a fever
and respiratory symptoms
and they've got an infiltrate or you know some white stuff
on chest x-ray suggestive of pneumonia, it may be reasonable
to treat with antibiotics, right?
You don't know right away whether they have COVID
or something else.
I think it's important to know though
that COVID-19 can cause a pneumonia that looks just
like a bacterial pneumonia on chest x-ray.
So, when you're making those decisions about whether
to start antibiotics, you just have to keep
in mind your clinical suspicion,
and the overall illness severity.
I'll just point out that you know, in like for instance
in influenza, secondary bacterial infections happen
fairly routinely, when people have severe illness.
We have not seen that as much yet with COVID-19,
but it's certainly a possibility to keep in mind.
>> Thank you for that response.
We have facilities asking generally,
how do you evaluate your cleaning agent, if it will work
against the virus that causes COVID-19
>> This is Kara, I'll comment on that.
So, I think first of all you should be using an EPA
registered hospital grade disinfectant.
And there is additional information online in a couple
of different sections within our infection prevention
and control guidance.
As well as within some of the checklists
and the long term care guidance that we have available
that refers you to the EPA website
for the EPA registered disinfectants
that have qualified under the EPA's emerging viral pathogens
program for use against the SARS-CoV-2.
I also want to comment on the use of cleaning
and disinfecting, both of high touch surfaces throughout your
facility, and ensuring that this is frequently being done,
as well as cleaning shared resident equipment.
And I'm talking about things like blood pressure cuffs.
And things like Hoyer lift.
Any kind of equipment that might be moved from resident
to resident, or possibly
in different locations within your facility.
Those things should be cleaned immediately after they're used
with a resident, and before they are used on another resident.
So, making sure that you have appropriate cleaning agents,
but also that staff and housekeeping have access
to them, that they are able to use them frequently.
>> Yeah, I just want to add to that for a second if I could.
Which, this is Brendan.
If you know we've been talking
about this more active monitoring of patients
with doing vital signs, and you know if you're going
from patient to patient with the pulse ox,
and the blood pressure cuff, and otherwise,
you know you don't want
to be actually potentially spreading something while you're
doing that.
So, I think what you said is so important about making sure
that mobile equipment gets cleaned.
Because you don't want this monitoring program
to actually be more of a problem than it solves.
>> Thank you for the response.
We have more questions about personal protective equipment.
And our question asks,
should our facility be using N95 respirators or facemasks?
>> This is Kara.
So, if your facility has a respiratory protection program,
fit tested healthcare personnel, and N95
or higher-level respirators then
if you have them, you should use them.
However, most nursing homes
and other long-term care facilities do not.
And given supply shortages that we are currently facing,
face masks are an acceptable alternative.
And as we've discussed, already on this call,
you should also be thinking about how
to preserve the PPE you have.
Whether it is face masks, or N95 respirators, eye protection,
and other PPE, start thinking
about how you may preserve the supply that you have.
>> Thank you for that.
And a follow up question on that is can you further elaborate
and give more information about how
to extend the use of face masks?
>> Sure, this is Kara again.
So, there will be additional material available
through CDC and on our website.
But one strategy for extending the use of face masks is to keep
that face mask, to use that same face mask possibly
for an entire shift.
And for the care of multiple residents.
Provided that that healthcare personnel is able
to avoid touching the face mask,
and the face mask isn't getting damp or soiled.
Eye protection should also be worn with the face mask.
And whenever the face mask and eye protection are removed,
the healthcare personnel should ensure
that they are performing hand hygiene before removing it
and then again afterwards.
And to further extend the sue of eye protection,
that eye protection can be reprocessed and used again.
>> Thank you.
Our next question asks about the hand sanitizer.
If our facility is running out of alcohol-based hand sanitizer,
should we be switching to soap and water?
>> This is Kara, we have definitely heard about shortages
of alcohol-based hand sanitizer.
We've heard reports of this running low
in some parts of the question.
So, if you have it,
we definitely recommend that you use it.
However, make sure that you have soap at your sinks.
That you have paper towels at your sinks,
and that you have a trash can or garbage nearby
so that staff are able to continue
to perform hand hygiene before
and after resident care, using soap and water.
>> Thank you.
Question asks that you had briefly mentioned the use
of investigational therapies.
Can you please talk a little bit more
about investigational therapies
and what other therapies are being tested right now?
>> Sure. Yeah.
So, I mentioned that investigational drug Remdesivir.
Like I said, there is an adaptive NIH trial
that's underway.
There's a couple open label trials,
they're not blinded trials going on as well.
And it's also available
for compassionate use on a limited basis.
There are trials outside of the US studying things
like the HIV medicine lopinavir/ritonavir.
I think others are looking at other HIV medications.
Some are looking at drugs that are inhibiting part
of the immune system in hopes that that would work.
One would be certolizumab an IL 6 inhibitor.
And another is looking at hydroxychloroquine and the way
that it may just modulate the immune system and make it harder
for the virus to enter.
However, I think the issue is,
at this point we don't have solid data on any of these
and so this is why CDC is not able
to make a recommendation one way or the other on their use.
>> Thank you.
We have a question asking
if my facility should be performing COVID testing.
>> This is Kara, I know Dr. Jackson has commented a little
bit on testing already, but I wanted to step in and mention
that although the approach may change by state and local area,
currently if you suspect that a resident
in your facility has COVID-19,
or if you are identifying severe respiratory illnesses,
or clusters of respiratory illness in staff
or healthcare personnel.
Our recommendation is that you immediately contact your Health
Department for further guidance.
And testing will be among the many things
that they discuss with you.
>> Thank you that and we have time for one last question,
and this is sort of a common question that we are seeing.
That if we have residents in our facility that are on hospice
and have requested the presence of their family members,
how do you recommend we handle those family member visits.
>> This is Kara.
And I first want to comment
that we understand how difficult a visitation restriction is
for all who are involved.
And have thought and talked with different facilities
about how this may be implemented.
For individuals who are at end-of-life, this is something
that should be handled on a case by case basis with a facility.
But should a visitor be granted permission,
or considered permission for access
to the building during an end-of-life situation?
The visitor should first be screened for fever and symptoms
of respiratory infection.
Because we really do not want anyone who is ill to be coming
into long term care facilities.
However, if a visitor is entering the building,
they should be provided a face mask.
They should be instructed to frequently perform hand hygiene.
And their visits should be limited
to a specific location in the building.
That may be the resident's room,
or it may be another location that's designated
by the facility.
But this is something, this is the general guidance
that we are providing.
But we encourage facilities to think about this and talk
about this with their residents and family members.
>> Thank you so much.
On behalf of COCA, I would like to thank everyone
for joining us today with a special thank you
to our presenters Dr. Jackson
and Lieutenant Commander Jacobs Slifka.
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