National Nursing Home Training Series: Week 3 Recap

Cohorting: Effective Management of Residents and Staff

Effective cohorting — which separates COVID-19-positive nursing home residents from non-infected residents — is a complex dance in the COVID-19 era of savvy facility maintenance, strategic staffing, unparalleled attention to infection prevention and constant communication. Everyone in your facility has a role to play, said Deb Smith, MLT (ASCP), BSN, CIC, CPHQ, infection preventionist for Health Quality Innovators (HQI), who discussed effective cohorting management of residents and staff during her presentation on June 10, 2020 for the Centers for Medicare & Medicaid Services National Nursing Home Training Series.

Discontinuation Criteria: Begin with the End in Mind

Barring local requirements, you may consider the following criteria when reintegrating COVID-19-positive or formerly symptomatic residents back into the non-infected population of your facility:

Symptomatic Residents:

  • 10 days or more since onset of symptoms
  • No fever for 72 hours
  • Respiratory symptom improvement

Symptomatic Residents with Positive COVID-19 Test: 

  • No fever for 72 hours
  • Respiratory symptom improvement
  • Two negative follow-up COVID-19 test results collected 24 hours or more apart

Asymptomatic Residents with Positive COVID-19 Test:

  • Still asymptomatic 10 days or more after a positive COVID-19 test
  • Still asymptomatic after two negative follow-up COVID-19 test results collected 24 hours or more apart

Effective Cohorting

Pending test results, symptomatic residents should be placed in a single room, if possible. Symptomatic cohorting should be considered only if single rooms are unavailable. Roommates should be considered exposed and potentially infected; transfer them to a single room, if possible, or cohort them with other exposed residents.

The following scenarios will occur with resident admissions and readmissions if you use the above criteria for evaluation:

  • Discontinuation criteria met = admit to regular unit with no restrictions
  • Unknown COVID-19 status = admit to single room or observation area for monitoring. Consider admission testing to identify asymptomatic carriers if you have the access and capacity
  • Discontinuation criteria unmet = admit to COVID-19 unit

Check out Smith’s presentation slides on www.QIOProgram.org for more detail.

Creating your COVID-19 Unit

Based on these discontinuation criteria, COVID-19-positive residents could spend at least 10 days — and probably many more — with a quarantined cohort. Thus, careful facility and staff management are paramount to contain the infection. In addition to a physically separate area and dedicated staffing and equipment for the COVID-19-positive unit, some other aspects of unit management you’ll want to address include:

  • Consider dedicating ancillary staff, such as dietary and housekeeping. At the very least, educate all staff on personal protective equipment (PPE) use and COVID-19 signs and symptoms
  • Provide a separate entrance, break rooms and supplies for staff
  • Set up processes for communications, supplies and meal delivery within the COVID-19-positive unit, as staff cannot leave the unit until the end of their shifts
  • Investigate laundering scrubs onsite
  • Invite local health department staff to tour the unit. They may catch areas of vulnerability that you may have missed.

Infection Prevention: The Role of Environmental Cleaning

Whether staff are working within the COVID-19-positive unit or among the general population, it’s important to get the basics of environmental cleaning right. Confirm your cleaning staff is using an Environmental Protection Agency (EPA)-approved disinfectant. Some facilities are using checklists to confirm that patient rooms, common rooms and other high-touch areas are cleaned at least twice per shift. Another facility that HQIN works with uses an electrostatic sprayer to provide a daily 360-degree application of disinfectant. Check out more of HQIN’s environmental cleaning tips in the National Nursing Home Training section of www.QIOProgram.org.

Define Expectations for Staff

With guidance from CMS, the Centers for Disease Control and Prevention (CDC) and the states changing daily, it’s easy to lose sight of staff roles during the pandemic. Yet defined expectations offer your staff some consistency during this chaotic time. Smith notes that facility leadership should be willing to communicate all updates — multiple times a day if needed — to all staff. Some suggested roles include:

  • Administration and leadership: track local, state and national updates
  • Infection preventionist: conduct surveillance, design precautions and provide education
  • Nursing: manage unit; may take on ancillary responsibilities
  • Dietary staff: enhance infection prevention during food service
  • Central supply: manage and optimize PPE supplies and patient care supplies
  • Maintenance: manage selection and isolation
  • Housekeeping: perform facility-wide enhanced cleaning
  • Laboratory: conduct accurate, timely testing
  • Public health department: recommend and interpret surveillance and testing guidance

Download the HQIN QIN-QIO slides and resources from the National Nursing Home Training Series page, visit www.QIOProgram.org to connect with the QIN-QIO serving your state or territory, and sign up for updates about the CMS National Nursing Home Training Series.