INTRODUCTION — At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, China. Subsequently, the infection has spread throughout the world, resulting in a global pandemic. The coronavirus is designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the illness it causes is coronavirus disease 2019 (COVID-19).
This topic will present issues relevant to care in nursing homes (NHs), most of which are licensed and serve as both long-term care and skilled nursing facilities (SNFs). In this topic, we refer to “patients and residents” as “residents,” while acknowledging the heterogeneity of the typical population in a NH that serves as both a long-term care facility and SNF (ie, long-stay “residents” and short-stay “patients”).
The epidemiology and clinical characteristics of COVID-19 are presented elsewhere. (See "COVID-19: Epidemiology, virology, and prevention" and "COVID-19: Clinical features" and "COVID-19: Diagnosis".)
SCOPE OF THE PROBLEM — Nursing homes (NHs) have played a central role in the COVID-19 outbreaks in the United States, a fact first recognized after an outbreak in a NH in Kirkland, Washington resulted in several deaths [1,2]. Since then, further outbreaks have underscored the enormous risk of COVID-19 in the older NH population [3]. Updated case counts and deaths for residents and staff can be found on the Centers for Medicare and Medicare Services (CMS) website.
COVID-19 disproportionately affects NH populations due to the high proportion of frail older adults and those with underlying chronic conditions [4]. These factors increase both the prevalence and severity of infection, resulting in high mortality rates. Clusters of infections have been blind to the quality of the NH; even the best-prepared, highest-quality, and most well-resourced facilities have had tragic clusters of infections with high mortality rates. However, NHs with nurse staffing shortages, and those with more crowding (those with an equal mix of double- and quadruple-occupancy rooms versus an equal mix of single- and double-occupancy rooms), may be more susceptible to the spread of COVID-19 [5-7]. Additionally, there appear to be racial and ethnic disparities in NH COVID-19 cases and deaths [8,9]. In one study, nursing homes that cared for a high number (>30 percent) of residents in underrepresented racial and ethnic groups reported more weekly new COVID-19 cases compared with those who cared for a low number (<2.9 percent; 1.5 versus 0.4 cases per facility) [8].
In addition to the risks inherent in the resident population, NHs are “tinderboxes” for recurrent clusters of infections due to the high resident to health care personnel (HCP) ratios, the closed environment, and use of resident common spaces [5]. Additionally, residents with dementia present unique challenges such as difficulties in maintaining isolation, due to wandering, and the need for high-contact care. Patients with dementia also appear to be at greater risk of severe disease [10]. Although there is an intense regulatory and industry focus on infection control, staff in many NHs were working with inadequate testing capability and shortages of personal protective equipment (PPE) during the first several months of the pandemic, which undermined even the best efforts at infection control. Availability of testing and PPE has now greatly improved in most NHs.
Vaccination (along with other infection control measures) has led to a decrease in the risk of COVID-19 in NHs. However, vaccination appears to be insufficient to completely prevent outbreaks of infection in NH settings. (See 'Vaccination' below.)
PREVENTING INFECTION
General measures — To help reduce the introduction and spread of COVID-19 in nursing homes (NHs), certain general measures should be implemented. These include vaccination of residents and staff, implementing certain visitor restrictions, use of source control (eg, masks), symptom screening, and testing of both residents and health care personnel (HCP). It is important that these general measures be put in place, since asymptomatic and presymptomatic transmission can occur and symptom screening alone may not detect all cases of COVID-19 [11]. As an example, in a multistate study of 182 skilled nursing facilities (SNFs) in 20 states with at least one COVID-19 case as of July 15, 2020, there were 5403 resident cases, of which 2194 (40.6 percent) were asymptomatic, 1033 (19.1 percent) were presymptomatic, and 2176 (40.3 percent) were symptomatic at presentation [12].
Guidelines from the Centers for Disease Control and Prevention (CDC) recommend that each facility designate an individual with infection prevention and control training to provide on-site management [13]. Specific infection control measures are impacted by the degree of community transmission.
During the initial stages of the pandemic, strategies to reduce the risk of COVID-19 infection in NHs also included discontinuing use of common dining areas, canceling all group activities, restricting patient movement within the facility, and eliminating use of volunteers and other nonessential vendors [14-16]. In coordination with federal and state agencies, most facilities have resumed certain activities based upon resident vaccination status and community transmission rates.
In the United States, the CDC has a website that offers other relevant guidelines for NHs during the different phases of the COVID-19 pandemic, as well as an infection prevention and assessment tool.
Visitor restrictions — During the COVID-19 pandemic, NHs restricted visitors in the health care setting. Initially, visitation was primarily limited to end-of-life situations (defined as death estimated in hours to days); however, over time, institutions started to liberalize restrictions (eg, limited socially distanced outdoor visits) given the psychological harm strict visitor restrictions can have on residents, families, and other loved ones [17-19]. (See 'Social isolation' below.)
In the United States, the CDC supports relaxing restrictions on indoor visitation for residents unless the resident is recovering from COVID-19 or is in quarantine after an exposure [13]. There may be additional restrictions during an outbreak setting or when there is substantial or high community transmission. The approach to liberalizing visits within a facility should be made in conjunction with local departments of public health. More detailed information on visitation in NHs can be found on the CDC website and the Centers for Medicare and Medicaid services memorandum on reopening.
Certain precautions should still be taken regardless of resident or visitor vaccination status. These include:
●Visitors and residents (if tolerated) should wear a well-fitting facemask.
●Visitors should not be allowed to enter the facility if they have a fever or symptoms of COVID-19, were diagnosed with COVID-19 in the prior 10 days, or have had prolonged close contact (within six feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period) with someone with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the prior 10 days. These criteria differ from community criteria for discontinuing isolation or quarantine. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Testing and masking precautions' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'In the community setting'.)
●During visits, visitors should physically distance from other residents and HCP in the facility. For residents who share a room, visits should be conducted outside of the room, whenever possible.
●Visitors should inform nursing staff if they develop symptoms of or are diagnosed with COVID-19 within 10 days of visiting with a resident.
Universal use of masks — During the COVID-19 pandemic, all visitors, residents, and HCP should wear masks when in the NH setting. All masks should fit snugly over the face without gaps. Strategies to improve mask fit are discussed elsewhere. (See "COVID-19: General approach to infection prevention in the health care setting", section on 'Health care personnel' and "COVID-19: Epidemiology, virology, and prevention", section on 'Type of masks'.)
The goal of universal masking is to reduce transmission of SARS-CoV-2 from unsuspected virus carriers [20,21]. However, masks or respirators with exhalation valves or vents are not considered sufficient for source control (ie, containing respiratory secretions) [22,23].
●Visitors – All visitors should bring or be given well-fitting masks to wear upon entry into the facility. A more detailed discussion of visitor restrictions is found above. (See 'Visitor restrictions' above.)
●Residents – When possible, residents should wear a well-fitting mask when leaving their room or when they are within six feet of any other individual [13]. However, this can be challenging in dementia units where residents may not have the cognitive capacity to wear a mask and where social distancing can also be difficult to maintain. When such residents do not adhere to wearing a mask, the use of enhanced infection control precautions (eg, eye and face protection) by HCP provides additional protection, even when interacting with those who are not suspected of having COVID-19. (See 'Personal protective equipment' below.)
●Health care personnel – HCP should also wear well-fitting masks at all times while in the NH to reduce the risk of transmitting SARS-CoV-2 from asymptomatic staff to patients and coworkers [24].
A medical mask (eg, surgical mask) or respirator must be used when caring for patients. However, if the respirator has an exhalation valve or vent, a medical mask should be placed on top of it since these types of respirators are not sufficient for source control. More detailed discussions of which types of mask to use when caring for patients in the NH setting are discussed below. (See 'Personal protective equipment' below.)
Data supporting the universal use of masks in the health care setting and as source control in community settings are presented elsewhere. (See "COVID-19: General approach to infection prevention in the health care setting", section on 'Universal use of masks' and "COVID-19: Epidemiology, virology, and prevention", section on 'Personal preventive measures'.)
Vaccination
●Indications – Staff and residents of long-term care facilities, including those who have had prior COVID-19 infection, should be vaccinated against SARS-CoV-2 unless there is a contraindication (eg, allergic reactions to the vaccines or their components) [25]. In addition to completing their primary vaccine series, booster doses should be administered to those who are eligible, as described in the table (table 1) [26]. Detailed information on the available vaccines, including vaccine schedules for immunocompetent and immunocompromised persons, the use of booster doses, and the management of adverse reactions, is presented in a separate topic review. (See "COVID-19: Vaccines".)
In long-term care facilities in the United States, vaccination coverage has been relatively high among residents, but it has been lower among staff. In a report that evaluated vaccine uptake in 11,460 facilities during the first month of a vaccine rollout program, a median of 78 percent of residents received one of the available COVID-19 vaccines, whereas only 38 percent of staff members were vaccinated [27]. Updated vaccination rates for staff and residents by state can be found on the Centers for Medicare and Medicare Services (CMS) website.
Improving vaccination in HCP in the NH setting is important since low staff vaccination rates have been associated with an increase in COVID-19 cases and deaths among residents. In a study of over 12,000 United States NHs comparing facilities with low and high staff vaccination coverage, staff vaccination had the most effect on resident outcomes in counties with the highest prevalence of COVID-19. In such counties, there was an estimated 1.56 additional COVID-19 cases per 100 beds, and an additional 0.19 COVID-19–related deaths per 100 beds among residents in facilities with the lowest versus highest staff vaccination coverage [28].
The CDC and the Society for Post-Acute and Long-Term Care Medicine have developed resources that may be helpful in combating vaccine hesitancy in the long-term care setting. VitalTalk has also produced a communication tool for discussing the vaccine with patients and families. Additional information is also provided in a separate topic review. (See "COVID-19: Vaccines", section on 'Combating vaccine hesitancy'.)
●Considerations after vaccination – After receiving the vaccine, residents may experience common side effects (eg, fever, fatigue, headache, chills, myalgia, arthralgia), which may be similar to some of the clinical features of COVID-19. (See "COVID-19: Clinical features".)
In the United States, the CDC has provided guidance to help providers when this situation occurs [29]. As an example, there are certain signs and symptoms that are consistent with infection rather than vaccination, such as cough, shortness of breath, and/or loss of taste or smell. If these are present, patients should be evaluated for SARS-CoV-2 and other infectious etiologies, and clinicians should use infection control precautions for those with suspected COVID-19 pending the evaluation. (See 'Infection control precautions' below.)
For patients with clinical findings that could be consistent with either vaccination or infection, the CDC states the following approach is reasonable [29]:
•Patients should be restricted to their room and providers should ideally use PPE required for caring for a patient with suspected COVID-19. (See 'When caring for residents with suspected or confirmed COVID-19' below.)
•Testing for SARS-CoV-2 should be performed if the resident is in a facility with active transmission, had prolonged close contact with someone with COVID-19 in the prior 14 days, or has symptoms that have persisted for at least two days.
•If the symptoms resolve within 48 hours, the patient has been afebrile for at least 24 hours, and testing (if performed) is negative, then isolation precautions can be discontinued and standard PPE can be used. (See 'When caring for residents NOT suspected of having COVID-19' below.)
The CDC has also issued similar guidelines for management of HCP after vaccination. Management of HCP is discussed elsewhere. (See "COVID-19: Occupational health issues for health care personnel", section on 'Post-vaccination considerations'.)
●Efficacy – Vaccination (along with other infection control measures) has contributed to a decrease in the risk of COVID-19 in NHs [30-34]. In a comparison of NHs based on vaccination status, there was a greater decrease in COVID-19 cases among both residents and staff in 797 NHs that had administered the first dose of vaccine within the preceding three weeks compared with 1709 facilities that had not yet initiated vaccination (48 versus 21 percent decline in resident cases, 33 versus 18 percent decline in staff cases) [30].
However, vaccination appears to be insufficient to completely prevent outbreaks of infection in NH settings [35-37]. In a study of 627 SARS-CoV-2 infections occurring in 75 skilled nursing facilities (SNFs) in the Chicago area, 22 were identified as breakthrough infections (occurring in fully vaccinated persons) between December 2020 and March 2021 [36]. Of the 12 residents and 10 staff members with breakthrough infections, 14 (64 percent) were asymptomatic.
The risk of infection in those who are vaccinated appears to vary with the prevalent variant. As an example, the infection rate in persons who were vaccinated was higher in the setting of the Omicron and Delta variants compared with earlier strains [38]. Waning immunity also contributed to the decreased efficacy of vaccines, supporting the need for booster doses. The benefit of a fourth dose (second booster) of the monovalent Pfizer vaccine was demonstrated in a cohort study of over 50,000 nursing home residents in Israel [39]. Compared with those who only had three doses, residents who received a fourth dose had 34 percent greater protection against infection, 64 to 67 percent greater protection against hospitalization, and 72 percent greater protection against death during the Omicron surge. The approach to booster doses depends in part upon availability. (See "COVID-19: Vaccines", section on 'Booster dose'.)
Routine screening and testing
General approach — The CDC and WHO recommend that NHs employ a strategy of symptom screening and viral testing to preempt and identify outbreaks [13,40]. If access to accurate viral testing is limited, priorities for universal testing should include facilities that have a known infection in one or more residents or HCP and facilities in communities with a high prevalence of SARS-CoV-2 infection.
Early identification of cases of COVID-19 is particularly important in long-term care facilities since rapid spread of infections associated with high case fatality rates has been repeatedly reported [1]. Repeated point prevalence testing can identify asymptomatic residents and help guide efforts to reduce transmission [3,41,42].
In addition, both contact tracing and facility-wide testing should be performed when residents or HCP with COVID-19 are identified [43]:
●Contact tracing typically involves determining if staff members and residents interacted using appropriate PPE (eg, mask on the resident and appropriate PPE for the staff member); which units the staff members or residents were on; if residents were outside of their room without appropriate PPE, and whether residents or staff members were potentially exposed outside of the building. Based upon this information, the approach to quarantine can be determined.
●The approach to testing in residents and HCP, including which test to use, is described below and depends in part on vaccination status, degree of community transmission, and presence of an outbreak. (See 'Residents' below and 'Health care personnel' below and 'Which test to use' below.)
Studies demonstrating the benefit of universal testing prior to widespread vaccination include:
•In West Virginia, among 123 NHs, there were seven outbreaks (defined as two or more cases within 14 days) of COVID-19 reported in 2020 from mid-March to mid-April that included 307 cases and 32 deaths; however, universal testing of residents and staff for SARS-CoV-2 (ie, testing irrespective of symptoms) and implementation of appropriate infection control precautions/quarantine for those who tested positive greatly reduced the magnitude of subsequent outbreaks [41]. Although eight outbreaks of COVID-19 were reported in the three weeks following the introduction of these policies, there were only 22 outbreak-associated cases and no deaths.
•In a study of 11 Maryland long-term care facilities, 153 cases of COVID-19 were identified based upon targeted symptom-based testing, universal testing of the remaining residents identified an additional 354 cases (39.6 percent of those tested), of which more than half were asymptomatic [44].
These findings are particularly relevant to settings where vaccination is not readily available.
Residents — The following symptom screening and testing protocols apply to all residents regardless of vaccination status.
●All residents in the NH setting should be screened daily for symptoms of COVID-19 [13] and, if possible, have vital signs (including oxygen saturation) performed; more frequent monitoring may be indicated in the setting of outbreak or in some areas based upon recommendations from local departments of health. Since older adults with COVID-19 may not show typical symptoms (eg, fever or respiratory symptoms, loss of smell), the CDC recommends that more than two temperatures >99.0°F, as well as the presence of atypical symptoms, such as worsening malaise, new dizziness, or diarrhea, prompt isolation and further evaluation for COVID-19 [13].
●Viral testing is required for most new/returning residents, including those who have left the facility for more than 24 hours, as discussed below. (See 'Approach to new/returning residents' below.)
After that, practices vary. In some facilities, surveillance testing of asymptomatic residents for SARS-CoV-2 is only performed if a new SARS-CoV-2 infection is identified in a health care worker or resident, whereas other facilities are doing regular weekly testing in asymptomatic residents who have not had COVID in the last 90 days. (See 'Management during an outbreak' below.)
●For residents who leave the facility for less than 24 hours (eg, for medical appointments, visits with family or friends), routine testing and quarantine is not usually required as long as they have not had close contact with someone with SARS-CoV-2.
The management of residents after an exposure to someone with COVID-19 is discussed below. (See 'Quarantine for residents with possible exposure' below.)
Health care personnel — All health care personnel (HCP), including physicians, nurse practitioners, physician assistants, consultants, administrators, contractors, and vendors who are onsite, should be screened for symptoms and have their temperature taken as they enter the building. Those with symptoms and/or a temperature >100.0°F should not be allowed to enter and should be referred for further evaluation.
In NHs, the CDC recommends that routine viral testing be performed in asymptomatic HCP who are not up to date with their recommended vaccines (table 1), unless they have recovered from SARS-CoV-2 infection in the past three months [13]. Viral testing should be performed in addition to symptom screening.
The frequency of testing should be determined in conjunction with local departments of public health and depends primarily upon the degree of community transmission. As an example, in NHs located in counties with substantial to high community transmission, it is reasonable to test HCP with a viral test twice per week; by contrast, in counties with moderate community transmission, once-weekly testing may be sufficient. The approach to testing in an outbreak setting, which includes testing of all HCP regardless of their vaccine status, is discussed below. (See 'Management during an outbreak' below.)
Additional considerations about testing of HCP can be found on the CDC website. Guidance on testing and work restrictions for asymptomatic HCP after an exposure is discussed in a separate topic review. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)
Which test to use — Several tests are available for detecting infection with SARS-CoV-2 (table 2). The preferred test for detecting SARS-CoV-2 in NH residents and staff is typically a nucleic acid amplification test (NAAT) using a reverse-transcription polymerase chain reaction (RT-PCR) assay. Tests should have a sensitivity of 95 percent and specificity of 90 percent. In the United States, these should be emergency-use tests authorized by the US Food and Drug Administration (FDA). (See "COVID-19: Diagnosis", section on 'NAAT (including RT-PCR)'.)
However, antigen testing may be preferred in certain settings (eg, limited availability of PCR testing or long turnaround times). Although antigen tests are typically less sensitive than RT-PCR, results can be available rapidly (approximately 15 minutes), which is important in implementing effective infection control strategies [45-47]. Antigen testing is also preferred when testing is required for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 90 days, since some people may remain NAAT positive but not be infectious during this period. (See "COVID-19: Diagnosis", section on 'Antigen testing'.)
When an antigen test is used, confirmatory nucleic acid testing (eg, RT-PCR) should generally be performed in asymptomatic HCP and residents whose antigen test is positive, as well as in those who are symptomatic when the antigen test is negative [45]. Some institutions do confirmatory testing for all symptomatic persons (even if the antigen test is positive); this is particularly important when cohorting residents with COVID-19 together.
Confirmatory testing should be performed within 48 hours of the antigen test. Pending the results, HCP should be excluded from work and should quarantine; residents should be placed in a private room and infection control precautions used for patients with COVID-19 should be implemented until the diagnosis is confirmed.
More detailed guidance on how to interpret antigen test results in long-term care facilities, and the need for repeat testing, can be found on the CDC website.
There is no clear role for serologic testing to guide infection control precautions or policies at this time since the level of antibody needed for protection and the duration of protection are not yet known. (See "COVID-19: Diagnosis", section on 'NAAT (including RT-PCR)' and "COVID-19: Diagnosis", section on 'Serology to identify prior/late infection'.)
Management during an outbreak — A single case of SARS-CoV-2 infection identified in HCP or residents should be evaluated as a potential outbreak. To reduce the risk of SARS-CoV-2 transmission in the facility, contact tracing should be implemented in addition to certain changes to routine testing, screening, and infection control precautions. The approach below is consistent with CDC guidelines [13].
Initial management
●Symptomatic residents and HCP – The following approach should be used for symptomatic residents and HCP, regardless of their vaccination status.
•All symptomatic residents should be restricted to their room, and infection control precautions that are required for the care of patients with SARS-CoV-2 infection should be used. (See 'When caring for residents with suspected or confirmed COVID-19' below.)
•Symptomatic HCP should be restricted from work pending evaluation. (See "COVID-19: Occupational health issues for health care personnel", section on 'Symptomatic HCP'.)
●Asymptomatic residents and HCP – Contact tracing should be performed to identify residents who had close contact with the source patient and HCP who had a higher-risk exposure with the source patient. (See "COVID-19: Occupational health issues for health care personnel", section on 'Assessing exposure risk'.)
For those identified as having an exposure, viral testing should be performed in residents who had a close contact to the source and HCP who had a higher risk exposure. Testing should occur as soon as possible (but not earlier than two days after the exposure) and then again five to seven days after the exposure.
In addition, residents who are not up to date with their recommended vaccines (table 1) require quarantine for 10 days (regardless of the result of viral testing). (See 'Quarantine for residents with possible exposure' below.)
•HCP caring for these residents should use infection control precautions required for the care of patients with SARS-CoV-2 infection. (See 'Quarantine for residents with possible exposure' below.)
•Patients who test positive should be evaluated for postexposure prophylaxis. (See 'Other prevention methods' below.)
The approach to quarantine in residents who have received all of their recommended vaccines can vary depending upon the institution, as discussed below. (See 'Quarantine for residents with possible exposure' below.)
If it is not possible to do contact tracing, a reasonable alternative is to investigate the outbreak at a facility-level or group-level. This includes testing for all residents and HCP on the affected unit(s) (regardless of vaccination status); testing should be performed as soon as possible, but not earlier than 24 hours after the exposure and, if negative, again five to seven days later. Residents who are not up to date with their recommended vaccines should quarantine.
Additional information on management of HCP after an exposure is discussed elsewhere. (See "COVID-19: Occupational health issues for health care personnel", section on 'HCP who received all recommended COVID-19 vaccines'.)
If additional cases identified — If the initial outbreak investigation reveals additional cases and contact tracing does not appear to reduce transmission, facility-wide or group-level (eg, floor or unit) testing should be performed, regardless of vaccination status. The CDC suggests repeat testing every three to seven days, but the ultimate frequency depends upon the availability of resources [13]. Testing should be performed until no new SARS-CoV-2 infections have been identified for at least 14 days.
In the setting of ongoing transmission, quarantine may be required for all residents on a specific floor or unit. More detailed information on management of an outbreak can be found on the CDC website.
Reducing use of aerosol-generating procedures — The use of aerosol-generating procedures should be minimized in all patients to reduce the potential risk of SARS-CoV-2 transmission. As an example, nebulizer treatments should be changed to metered-dose inhalers unless nebulizer treatment is deemed essential for an individual resident. In these instances, HCP should use enhanced infection control precautions when administering the nebulizer treatment (or any other aerosol-generating procedures, such as continuous positive airway pressure [CPAP], bilevel PAP [BPAP], deep suctioning of tracheostomies, high-flow oxygen administration, and cardiopulmonary resuscitation [CPR]). More detailed discussions of infection control precautions used for aerosol generating procedures, including the type of personal protective equipment [PPE], are discussed elsewhere. (See 'Isolation for residents with confirmed or suspected infection' below and 'When caring for residents with suspected or confirmed COVID-19' below and 'When caring for residents NOT suspected of having COVID-19' below.)
Health care personnel who work at multiple facilities — Some HCP work in multiple health care facilities, thus increasing their risk of acquiring SARS-CoV-2 [48]. Although this should be discouraged, there are many areas with critical shortages of HCP and medical providers. Ideally, HCP who do work in multiple facilities should limit work to one single facility on any given day. HCP who work in multiple health care facilities should be a high priority for repeat virologic testing.
Infection control precautions — To reduce the risk of SARS-CoV-2 transmission, enhanced infection control precautions should be used when caring for those with and without COVID-19. The CDC and WHO suggest that most of these same infection control policies and precautions be used for HCP or residents who have received any of the available COVID-19 vaccines [40,49]; however, this may change as new data are collected. The key elements of an infection control program are summarized here and discussed in detail in separate topic reviews. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection" and "COVID-19: General approach to infection prevention in the health care setting".)
Quarantine for residents with possible exposure — The approach to quarantine after an exposure in the nursing home is generally the same as that used in the hospital setting [13]. This is discussed in detail elsewhere. (See "COVID-19: General approach to infection prevention in the health care setting", section on 'Patients who have had an exposure to COVID-19'.)
Residents who are quarantined should be placed in a private room, and such patients should not be cohorted or share a room with patients who have COVID-19. Clinicians should use infection control precautions similar to those used for patients with suspected or confirmed COVID-19. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Patients who have had an exposure to COVID-19'.)
Once quarantine is discontinued, patients should still continue to follow institutional recommendations for wearing masks (eg, when others are in the room or if they are out of the room).
Isolation for residents with confirmed or suspected infection — Residents with suspected or confirmed COVID-19 should be in a private room, when possible. However, when private isolation rooms are not available, residents with confirmed COVID-19 may be roomed together, assuming there are no other contraindications (eg, drug-resistant organism).
Facilities should identify an area to care for residents with suspected or confirmed COVID-19, and dedicated staff should be assigned to work only in that area of the facility. If the facility has airborne infection isolation rooms (ie, single-resident, negative-pressure rooms), they should be prioritized for residents who require aerosol-generating procedures (eg, residents with tracheostomies requiring nebulizer treatments). When this is not possible, a private room should be used and the door kept closed. If available, a portable high-efficiency particulate air (HEPA) filter can be used.
Personal protective equipment — It is important that staff receive intensive and repeated education on infection control procedures, including training on how to properly put on (figure 1) and take off (figure 2) PPE as well as the use of hand hygiene to avoid contamination. Videos demonstrating the proper donning and doffing of PPE are available. It is also helpful to have instructions with illustrations on the doors of patients in isolation. Whenever possible, observers should monitor HCP for proper PPE donning and doffing techniques as part of the infection control program. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Type of PPE'.)
When caring for residents with suspected or confirmed COVID-19 — All HCP who enter the room of a patient with suspected or confirmed COVID-19 should wear a gown, gloves, a respirator or medical mask, and eye or face protection (goggles or face shields).
For respiratory protection, an N95 respirator should be used when caring for all residents with suspected or confirmed COVID-19. If PPE is limited, medical masks are an alternative for non-aerosol-generating procedures. A more detailed discussion of the type of PPE that should be used when caring for residents with confirmed or suspected COVID-19, including the rationale for this approach, is presented in a separate topic review. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the health care setting'.)
When caring for residents NOT suspected of having COVID-19 — When there is ongoing community transmission of SARS-CoV-2, certain enhanced infection control precautions (eg, goggles or face shields) should be used in addition to standard precautions and universal masking, regardless of the individual suspicion for COVID-19. The types of precautions depend on the degree of community transmission and whether the health care worker is providing routine care or is involved with high-risk procedures (eg, aerosol-generating procedures or treatments). This is discussed in detail in a separate topic review. (See "COVID-19: General approach to infection prevention in the health care setting", section on 'Precautions for those NOT suspected of having COVID-19'.)
During patient rounds, we prefer to see those without known COVID-19 before those with confirmed or suspected infection. The availability of PPE in some NH settings is often limited, and this can reduce the need to don and doff PPE and may help reduce the risk of transmission when delivering patient care. More detailed information on strategies to optimize the supply of PPE is presented in a separate topic review. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'When PPE is limited'.)
When precautions can be discontinued
●Residents – Most residents with suspected or known COVID-19 can discontinue precautions using a non-test-based strategy (table 3) [22,50].
However, the approach to discontinuing precautions for moderately or severely immunocompromised residents and those with severe disease can vary. As an example, we generally prefer a symptom-based strategy for such patients, but we extend the duration (eg, 10 to 20 days based upon the resident’s clinical presentation and degree of immunosuppression). However, others prefer a test-based strategy for these populations.
Once isolation is discontinued, patients should still continue to follow institutional recommendations for wearing masks (eg, when others are in their room or if they venture out of their room).
A more detailed discussion of when precautions can be discontinued in the health care setting is found in separate topic review. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Discontinuation of precautions'.)
●Health care personnel – Return-to-work criteria for HCP with SARS-CoV-2 depends on the severity of disease, the patient’s underlying conditions, and the presence of staffing shortages. This is discussed in detail elsewhere. (See "COVID-19: Occupational health issues for health care personnel", section on 'Return to work criteria'.)
Approach to new/returning residents — The approach to new or returning residents can vary. Federal, state, county, and local guidance on strategies for new admissions and readmissions have been variable and sometimes conflicting.
Any patient transferred to a NH or SNF with symptoms of COVID-19 should be isolated, regardless of vaccination status. (See 'Isolation for residents with confirmed or suspected infection' above.)
Our general approach to asymptomatic residents is as follows:
●Residents with recent SARS-CoV-2 infection – Residents with known COVID-19 who are being discharged from the hospital and have met criteria for discontinuing precautions do not require additional isolation precautions upon return to the NH. This includes those who met criteria using a non-test-based strategy (table 3). However, residents who are ready to be discharged prior to meeting these criteria should continue to adhere to the infection prevention and control recommendations described above. (See 'When caring for residents with suspected or confirmed COVID-19' above and 'Isolation for residents with confirmed or suspected infection' above.)
If a test-based strategy was used and the patient has prolonged shedding, there is no specific guidance on when the isolation/quarantine can be discontinued. Thus, the decision to discontinue the isolation/quarantine must take into consideration the duration time since diagnosis, the resident’s underlying conditions, how long the resident has been clinically improved, the psychological effects of prolonged isolation, and the risk of transmission to HCP and other residents (see "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Test-based strategies'). Residents with COVID-19 more than 90 days earlier should be managed the same as those without prior SARS-CoV-2 infection.
●Residents without known SARS-CoV-2 infection – Patients without known COVID-19 who are transferred to a NH or SNF should be tested for SARS-CoV-2 within the 48 hours prior to transfer. Residents should also have a series of two viral tests for SARS-COV-2 infection: immediately and, if negative, again five to seven days after their admission [13]. The clinical status and vital signs of all entering residents should be monitored at least three times per 24-hour period, including daily temperature measurements [14-16]. After this period of time, routine monitoring, as discussed above, should be implemented. (See 'Residents' above.)
Residents who have not received all of their recommended vaccines (table 1) should be quarantined upon arrival. The CDC states that quarantine is not required for asymptomatic residents who have completed all of their recommended vaccines [13]. However, the approach to new or returning residents in individual communities can vary and depends upon guidance from local health officials.
As an example, institutions have varying requirements for the number of tests required prior to entry into the facility (eg, one versus two) and the duration of quarantine once they arrive (eg, 7 versus 10 days). In some states, quarantine is required for all residents who leave the building for more than 24 hours.
Other prevention methods — The use of other prevention methods (eg, pre- and postexposure prophylaxis) may have a role in select settings. These are discussed in detailed elsewhere. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Pre-exposure prophylaxis for selected individuals' and "COVID-19: Epidemiology, virology, and prevention", section on 'Limited role for post-exposure prophylaxis'.)
MANAGEMENT OF ACUTE SARS-COV-2 INFECTION — Patients who develop COVID-19 in the nursing home setting should be evaluated to determine the severity of disease and need for emergency room evaluation or hospitalization. (See "COVID-19: Management in hospitalized adults" and "COVID-19: Evaluation of adults with acute illness in the outpatient setting", section on 'Telephone triage'.)
Many patients with COVID-19 will not require hospitalization and can be managed in the nursing home setting. For such patients, treatment options include supportive care and, if available, antiviral agents or monoclonal antibodies. These treatment strategies and the data supporting their use are discussed in detail in a separate topic review. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Symptom management and recovery expectation' and "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Therapies of limited or uncertain benefit'.)
GENERAL MANAGEMENT CONSIDERATIONS — The pandemic has presented nursing home (NH) staff and clinicians with several opportunities to reinforce and build on resident management strategies in order to both prevent excess COVID-19 cases and improve care. The strategies below are for all residents, regardless of known COVID-19 infection, as all residents are at risk and asymptomatic infections are common.
Minimizing hospital transfers — For the last decade, NHs have been under increasing pressure to reduce hospital transfers due to financial incentives and regulatory guidance. During the pandemic, it is especially important to reduce unnecessary transfers because they expose vulnerable NH residents not only to hospital-acquired conditions but potentially to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
●Several tools and strategies are available for NHs that can help achieve this goal through the Society for Post-Acute and Long-Term Care Medicine (AMDA) and the Interventions to Reduce Acute Care Transfers Program (INTERACT) [51]. These strategies generally include using tools and alerts to identify changes in condition early, structured communication with health care personnel (HCP) in the NH and between the NH and hospital, and the use of decision support tools to identify when a clinician should be notified immediately about a specific change in condition.
●Improved communication and collaborative relationships with local hospitals and health systems are useful to minimize transfers as well as review interfacility transfer policies and efforts to educate nurses, advance practice clinicians, and clinicians.
●Engaging all residents and families or other loved ones in advance care planning discussions and updating advance directives as appropriate can guide decision-making on the appropriateness of hospital transfers. This is especially important in situations where intensive care unit beds and respirators are in short supply [16,52]. (See 'Advance care planning' below.)
Medication management — Polypharmacy and prescription of potentially inappropriate medications are common in NHs. The pandemic provides added impetus to address these issues, because reducing medications can not only prevent adverse events and reduce costs but can also reduce the risk of viral transmission and personal protective equipment (PPE) use by limiting nurse-resident interactions, and can save nursing time when many NHs are short-staffed.
●Many evidence-based and expert-recommended tools are available to help reduce polypharmacy, unnecessary medications, adverse events, and nursing time needed to monitor for various parameters (eg, sliding scale insulin, overtreatment of hypertension and hold parameters). The University of Maryland School of Pharmacy has developed a medication management tool specifically designed for use in NHs during the COVID-19 pandemic is available on their website. Deprescribing is also discussed in detail elsewhere. (See "Deprescribing".)
●Reducing contact time between HCP and residents is a cornerstone of infection control and protects both residents and HCP. Medical staff should work with the consulting pharmacist, and residents should have an assessment aimed at reducing the number of medications and the frequency of medication administration. Specific targets for intervention include:
•Eliminating unnecessary medications as described above.
•Optimizing use of long-acting medications rather than multiple dose short-acting medications.
•Considering withholding certain medications for a few weeks or months and restarting when infection risk is lower if needed. Examples include vitamins, PRN (as necessary) medications that have not been used, continuous use of probiotics, and drugs of no proven efficacy in NH residents with advanced illnesses and/or severe dementia, such as lipid-lowering agents and cholinesterase inhibitors [53,54].
●Measures to reduce and/or stop any aerosolizing procedure (eg, continuous positive airway pressure [CPAP]/bilevel PAP [BPAP]/nebulized medications) should be carefully reviewed because of the risk of viral transmission during these procedures. (See 'Reducing use of aerosol-generating procedures' above.)
Reducing nonessential clinical interactions — Some clinical interactions can be safely reduced or placed on hold for several weeks or months to reduce resident contact, particularly when there is an outbreak within the facility and/or limited PPE. However, caution should be exercised in this regard to avoid placing residents at undue risk. There should also be a clear plan for reinstating any such care or treatment after enough vaccinations have been administered to mitigate the risks imposed by the pandemic.
Advance care planning — The pandemic adds impetus to complete and document advance directives in order to continue to improve end-of-life care. Some NH residents have advanced illnesses and many are at the end of life. If they acquire the virus and develop symptoms of COVID-19, they may rapidly deteriorate with respiratory distress. Transfer to hospital and respiratory care in the intensive care unit may be unnecessarily burdensome to these residents and their families.
Further efforts at advance care planning, in particular Do Not Hospitalize Orders for residents in whom the risks and discomforts of hospitalization outweigh the benefits. Many tools are available to assist with this process on the Interventions to Reduce Acute Care Transfers (INTERACT) website.
Other COVID-19 resources and further discussion of advance care planning are available elsewhere. (See "Advance care planning and advance directives".)
Routine vaccinations — In general, there should be no changes to routine vaccination recommendations for NH residents during the COVID-19 pandemic. However, there may be consideration for the timing of routine vaccinations with respect to COVID-19 vaccination. This is discussed in detail elsewhere. (See "COVID-19: Vaccines", section on 'Other administration issues'.)
In particular, NHs should prioritize early vaccination of patients against influenza. (See "Principles of infection control in long-term care facilities", section on 'Residents' and "Seasonal influenza vaccination in adults".)
Staff should also receive influenza vaccination unless they have a clear contraindication. Immunity among the staff is a major factor in preventing the spread of the illness among NH residents, many of whom do not have a robust immune response to the vaccination. (See "Immunizations for health care providers", section on 'Influenza vaccine'.)
However, as is the case with other acute illnesses, in persons with acute COVID-19, vaccination should be delayed until the acute illness has resolved. This approach is supported by the Centers for Disease Control and Prevention (CDC) in their guidance on influenza vaccination [55], and it is reasonable to extrapolate this same principle to other routine vaccinations.
End-of-life care and hospice — NHs should prepare for the likelihood of excess resident deaths. Strategies include:
●Ensuring that adequate supplies of morphine and sedatives are available for residents with anxiety and dyspnea as well as for comfort care for those at the end of life.
●Communicating often with families and other loved ones of residents who are approaching death, in light of the fact that they cannot be present at the bedside. Staff should facilitate telephone or video calls between residents and their loved ones. Families and other loved ones should be aware of whether any end-of-life visitation is allowed.
●Providing palliative care consultations to residents approaching the end of life, or, if available, the services of a hospice agency.
•The hospice care team can provide social service and spiritual support for residents, families, and HCP. Hospice can also be used to support loved ones during the bereavement period. However, the role of hospice agencies may be challenging in light of restrictions on visitation.
•Palliative care consultation can be done virtually and often requires the participation of surrogate decision-makers and loved ones. Palliative care consultants can assist with advance care planning discussions as well as with symptom management. Tools to assist with virtual palliative care end-of-life visits are described elsewhere. (See "Palliative care: The last hours and days of life", section on 'COVID-19 communication resources'.)
End-of-life care, including caring for residents in isolation, is discussed elsewhere. (See "Palliative care: The last hours and days of life", section on 'Patients dying in isolation'.)
Adaptations to hospice care for residents with COVID-19 are discussed elsewhere. (See "Hospice: Philosophy of care and appropriate utilization in the United States", section on 'Adaptations for COVID-19'.)
Social isolation — The physical and psychological wellbeing of all residents is impacted by many of the strategies outlined above, designed to limit resident contact with other residents, their families, and HCP. NHs must continue to provide social engagement for residents and rapidly reinitiate, when appropriate, family and friend visitation in order to balance the need to protect residents from infection with that of isolation-related morbidity [19,56]. A more detailed discussion of the psychological impact of being on quarantine is presented elsewhere. (See "COVID-19: Psychiatric illness", section on 'Individuals in quarantine'.)
SUPPORT FOR HEALTH CARE PERSONNEL — Health care personnel (HCP) support is of particular concern in facilities where multiple residents have died. Although hospice can provide support for HCP, facility-wide support should be made available to all staff. Many HCP are at risk for burnout because of understaffing, delaying time off, illness of family members, fear of getting sick themselves, day care and school closures, and reduced income because of loss of work of family members. Facilities need a multipronged approach to support their staff. Examples include HCP education on safe and effective use of personal protective equipment (PPE), supplying meals/snacks, opportunities to relax/meditate, flexibility on time off policies so that accrued time off is not lost, and ongoing financial support during times of illness, especially if COVID-19-related. (See "COVID-19: Psychiatric illness", section on 'Health care workers'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics".)
SUMMARY AND RECOMMENDATIONS
●Impact of COVID-19 in nursing homes – COVID-19 disproportionately affects nursing home (NH) populations due to the high proportion of older adults and those with underlying chronic conditions. In addition, NHs are “tinderboxes” for recurrent clusters of infections due to the high resident to health care personnel (HCP) ratios, the closed environment, the use of resident common spaces, and the unique challenges of residents with dementia who have difficulty adhering to social distancing and universal masking policies. (See 'Scope of the problem' above.)
●Overview of measures to prevent infection – To help reduce the introduction and spread of SARS-CoV-2, certain general measures should be implemented in the NH setting in areas of ongoing transmission. These include vaccination, certain visitor restrictions, universal use of source control (eg, masks), symptom screening, and testing of asymptomatic residents and HCP in certain settings. (See 'Preventing infection' above.)
●Vaccination – Staff and residents of long-term care facilities, including those who have had prior COVID-19 infection, should be vaccinated against SARS-CoV-2. In addition to completing their primary vaccine series, booster doses should be administered to those who are eligible (table 1).
After receiving the vaccine, individuals may experience common side effects (eg, fever, fatigue, headache, chills, myalgia, arthralgia), which may be similar to some of the clinical features of COVID-19. In this setting, management depends upon the types of symptoms that are present, duration of symptoms, and the risk for disease. (See 'Vaccination' above.)
●Infection control precautions for those with suspected or confirmed COVID-19 – In addition to these general measures, the following types of infection control precautions should be used when caring for those with suspected or confirmed COVID-19 in the NH setting, regardless of COVID-19 vaccination status (see 'Infection control precautions' above):
•Residents with suspected or confirmed COVID-19 should be placed in a private room when possible. However, when private isolation rooms are not available, residents with confirmed COVID-19 may be roomed together, assuming there are no other contraindications (eg, drug-resistant organism). (See 'Isolation for residents with confirmed or suspected infection' above.)
•HCP should wear a gown, gloves, a respirator or medical mask, and eye or face protection (goggles or face shields). For respiratory protection, an N95 respirator should be used for all aerosol-generating procedures. We suggest an N95 respirator rather than a medical mask (eg, surgical mask) when caring for all residents with suspected or confirmed COVID-19; however, medical masks are an alternative for routine care when personal protective equipment (PPE) is severely limited. If respirators with exhalation valves or vents are used, a medical mask should be placed on top of it, since these types of respirators are not sufficient for source control. (See 'When caring for residents with suspected or confirmed COVID-19' above and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection" and 'Universal use of masks' above.)
•Most patients can discontinue precautions using a non-test-based strategy (table 3) since data suggest that prolonged viral RNA shedding after symptom resolution is not clearly associated with prolonged infectiousness. However, a test-based strategy is preferred for those who are moderately to severely immunocompromised. (See 'When precautions can be discontinued' above.)
●Precautions for those without COVID-19 – In areas of ongoing transmission, enhanced infection control precautions (eg, face shields), in addition to universal masking, are reasonable to use for all patients regardless of the individual suspicion for COVID-19. (See 'When caring for residents NOT suspected of having COVID-19' above.)
Residents without known COVID-19 who are being admitted to a NH facility should have negative testing for SARS-CoV-2 within the 48 hours prior to transfer regardless of vaccination status. In addition, patients should be tested after arrival. Those who have not received all recommended vaccines should also be quarantined. Institutions have varying requirements for the number of tests required prior to entry into the facility and the duration of quarantine. (See 'Approach to new/returning residents' above.)
●Additional considerations
•General management strategies – In the NH setting, there are certain resident management strategies appropriate for all patients that may further reduce infection risk. These include minimizing hospital transfers, medication management/reduction to limit nurse-resident interactions, and reduction in nonessential clinical interactions. (See 'General management considerations' above.)
•Advance care planning – Advance care planning, in particular Do Not Hospitalize Orders, should be discussed for residents in whom the risks and discomforts of hospitalization outweigh the benefits. Palliative care consultations and hospice can provide support for families and residents who are nearing the end of life. (See 'Advance care planning' above and 'End-of-life care and hospice' above.)
•Addressing the psychological impact – Psychological stress affects both residents and HCP. Residents are impacted by social isolation and efforts to enhance social engagement are essential. HCP are at risk of burnout and will need multipronged support strategies, including flexible time off policies and financial support during personal or family illness. (See 'Social isolation' above and 'Support for health care personnel' above.)
