The following questions were submitted to and answered by the PHMO SNF COVID-19 Advisory Team, which includes experts in infectious disease, geropsychiatry, palliative care, and case management.
To submit a question to the team on one of these topics, please submit your questions using the link below:
Click any of the questions below to jump to the answer:
April 28, 2020: Can nebulizers increase the spread of COVID?
Can nebulizers increase the spread of COVID?
April 28, 2020
Using a nebulizer can increase the risk of sending virus particles in the air if the patient is sick. To be safe, if patients can use an inhaler instead of a nebulizer, that will reduce the risk of any virus spread. If nebulizers are being used because people have dementia and cannot understand how to use an inhaler with the proper technique, using a spacer can help increase the efficacy of the treatment. If nebulizers need to be used, the number of people in the room should be limited, and they should be wearing masks if possible.
When can we discontinue droplet isolation for patients who have tested positive for COVID?
May 11, 2020
From the CDC:
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). 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 illnesses, it is possible that the duration of viral shedding could be longer or shorter than 10 days after their first positive tests.
- 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 local infectious disease experts when making decisions about discontinuing Transmission-Based Precautions for patients who might remain infectious longer than 10 days (e.g., severely immunocompromised).
In nursing home patients, how often should COVID testing be repeated on patients who have tested negative?
May 11, 2020
You shouldn’t need to repeat COVID tests on negative patients. If they have symptoms or you are suspicious, consider testing for COVID. Or, if there was a possible exposure (such as a resident who lives on the same hallway is positive), you could consider testing. Pages 7 and 12-13 in this guideline document from the Society for Post-Acute and Long-Term Care Medicine provide further guidance: http://paltc.org/sites/default/files/COVID%2019%20QA%20Community%20Spread_5_6_20.pdf
To remain COVID negative and prevent spread, should SNF staff wear face shields over surgical masks? The shields can be cleaned and reused.
May 15, 2020
The current recommendation for PPE in the care of COVID-negative patients is only for surgical mask use. It probably would not hurt to wear face shields for extra protection, although it may be burdensome for staff, and you would need to be sure to disinfect the shields regularly according to manufacturer guidance. You would also need to check to make sure the shields are created for reuse and are not single-use.
It may be more prudent to save new face shields for times when you might need them, such as:
- If a patient develops a respiratory illness, healthcare workers should wear gown, gloves, facemask, and goggles or face shield.
- Staff contact with a patient who needs to be unmasked for a period of time (in a facility this might be something like oral care, or a resident is unable to tolerate wearing a surgical mask). In these situations, the staff should wear a surgical mask and face shield.
- If a patient is hearing impaired despite using amplifier or hearing aid, and relies on reading lips, the patient should wear a surgical mask and face shield, and the staff should wear a face shield, so the patient can read their lips. They should remain 6 feet away from each other.
The second page of this document describes using face shields to help communicate with people with hearing impairment: https://dicon.medicine.duke.edu/sites/dicon.medicine.duke.edu/files/covid_ppe_accommodations-final_5_7_2020.pdf
The information is provided as a consultative resource in response to inquiries from facilities and professionals who remain responsible for determining whether and how to apply it to the circumstance of any facility or individual, and accordingly is not rendered as medical advice or direction for any facility or individual and is not intended to create a physician-patient relationship with any individual.