DHHEOC Updates: Discontinuation of Transmission-Based Precautions, Disposition of Patients with COVID-19 in Healthcare Settings,

By Sylvia Guidry-Brown, MSN, RN, CSN posted 20 days ago

  

From: DHHEOC@la.gov <DHHEOC@la.gov>
Sent: Tuesday, July 21, 2020 2:31 PM
Subject: Louisiana Health Alert Network (LA HAN)--Discontinuation of Transmission-Based Precautions, Disposition of Patients with COVID-19 in Healthcare Settings, & Updated Return to Work Guidance for Healthcare Workers

 

07/21/2020 02:31:19 PM

Message Urgency: HIGH

 

This is a message from the Louisiana Department of Health Emergency Operations Center (LDH EOC) for the Louisiana Health Alert Network (LA HAN) recipients. This message is from Dr. Frank Welch, Medical Director for the Bureau of Community Preparedness, regarding an interim guidance update: Discontinuation of Transmission-Based Precautions, Disposition of Patients with COVID-19 in Healthcare Settings, and Updated Return to Work Guidance for Healthcare Workers (Interim Guidance). Please share and distribute with relevant stakeholders and partners through your own distribution channels.

 

Discontinuation of Transmission-Based Precautions, Disposition of Patients with COVID-19 in Healthcare Settings, and Updated Return to Work Guidance for Healthcare Workers (Interim Guidance) : Updated July 17, 2020

 

Summary of Changes to the Guidance:

Below are changes to the guidance as of July 17, 2020:

  • Except for rare situations, a test-based strategy is no longer recommended to determine when to discontinue Transmission-Based Precautions.
  • For patients with severe to critical illness or who are severely immunocompromised1 , the recommended duration for Transmission-Based Precautions was extended to 20 days after symptom onset (or, for asymptomatic severely immunocompromised 1 patients, 20 days after their initial positive SARS-CoV-2 diagnostic test).
  • Return to work isolation for Healthcare Workers who were COVID positive has been reduced from 14 days to 10 days if they work in congregate settings to be in line with CDC guidance.
  • Other symptom-based criteria were modified as follows:
    • Changed from “at least 72 hours” to “at least 24 hours” have passed since last fever without the use of fever-reducing medications.
    • Changed from “improvement in respiratory symptoms” to “improvement in symptoms” to address expanding list of symptoms associated with COVID-19.

Discontinuation of Transmission-Based Precautions for patients with COVID-19

The decision to discontinue Transmission-Based Precautions for patients with confirmed SARS-CoV-2 infection should be made using a symptom-based strategy as described below. The time period used depends on the patient’s severity of illness and if they are severely immunocompromised.1 Meeting criteria for discontinuation of Transmission-Based Precautions is not a prerequisite for discharge from a healthcare facility.

 

A test-based strategy is no longer recommended (except as noted below) because, in the majority of cases, it results in prolonged isolation of patients who continue to shed detectable SARS-CoV-2 RNA but are no longer infectious.

 

Symptom-Based Strategy for Discontinuing Transmission-Based Precautions.

Patients with mild to moderate illness who are not severely immunocompromised:

  • At least 10 days have passed since symptoms first appeared and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications and
  • Symptoms (e.g., cough, shortness of breath) have improved

Note: For patients who are not severely immunocompromised1 and who were asymptomatic throughout their infection, Transmission-Based Precautions may be discontinued when at least 10 days have passed since the date of their first positive viral diagnostic test.

Patients with severe to critical illness or who are severely immunocompromised1 :

  • At least 20 days have passed since symptoms first appeared and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications and
  • Symptoms (e.g., cough, shortness of breath) have improved

Note: For severely immunocompromised1 patients who were asymptomatic throughout their infection, Transmission-Based Precautions may be discontinued when at least 20 days have passed since the date of their first positive viral diagnostic test.

 

As described in the Decision Memo , an estimated 95% of severely or critically ill patients, including some with severe immunocompromise, no longer had replication-competent virus 15 days after onset of symptoms; no patients had replication-competent virus more than 20 days after onset of symptoms. Because of the risks for transmission and the number of patients in healthcare settings at risk for severe illness if infected with SARS-CoV-2, a conservative approach was taken when assigning duration of Transmission-Based Precautions. However, because the majority of severely or critically ill patients no longer appear to be infectious 10 to 15 days after onset of symptoms, facilities operating under crisis standards of care might choose to discontinue Transmission-Based Precautions at 10 to 15 days, instead of 20 days, in order to maximize resources for those earlier in their clinical course who are at highest risk for being a source of transmission.

 

Test-Based Strategy for Discontinuing Transmission-Based Precautions.

In some instances, a test-based strategy could be considered for discontinuing Transmission-based Precautions earlier than if the symptom-based strategy were used. However, as described in the Decision Memo , many individuals will have prolonged viral shedding, limiting the utility of this approach. A test-based strategy could also be considered for some patients (e.g., those who are severely immunocompromised1) in consultation with local infectious diseases experts if concerns exist for the patient being infectious for more than 20 days.

 

The criteria for the test-based strategy are:

 

Patients who are symptomatic:

Patients who are not symptomatic:

Discontinuation of empiric Transmission-Based Precautions for Patients Suspected of Having SARS-CoV-2 Infection

 

The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with suspected SARS-CoV-2 infection can be made based upon having negative results from at least one respiratory specimen tested using an FDA-authorized molecular viral assay to detect SARS-CoV-2 RNA.

  • If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and performing a second test for SARS-CoV-2 RNA.
  • If a patient suspected of having SARS-CoV-2 infection is never tested, the decision to discontinue Transmission-Based Precautions can be made using the symptom-based strategy described above.

Ultimately, clinical judgement and suspicion of SARS-CoV-2 infection determine whether to continue or discontinue empiric Transmission-Based Precautions.

 

Disposition of Patients with SARS-CoV-2 Infection

 

Patients can be discharged from the healthcare facility whenever clinically indicated.

If discharged to home:

If discharged to a nursing home or other long-term care facility (e.g., assisted living facility), AND

  • If Transmission-Based Precautions are still required , the patient should go to a facility with an ability to adhere to infection prevention and control recommendations for the care of residents with SARS-CoV-2 infection. Preferably, the patient would be placed in a location designated to care for residents with SARS-CoV-2 infection.
  • If Transmission-Based Precautions have been discontinued, the patient does not require further restrictions, based upon their history of SARS-CoV-2 infection.

SARS-CoV-2 Illness Severity Criteria (adapted from the NIH COVID-19 Treatment Guidelines)

 

Note: The studies used to inform this guidance did not clearly define “severe” or “critical” illness. This guidance has taken a conservative approach to define these categories. Although not developed to inform decisions about duration of Transmission-Based Precautions, the definitions in the National Institutes of Health (NIH) COVID-19 Treatment Guidelines are one option for defining severity of illness categories. The highest level of illness severity experienced by the patient at any point in their clinical course should be used when determining the duration of Transmission-Based Precautions.

 

Mild Illness : Individuals who have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal chest imaging.

 

Moderate Illness: Individuals who have evidence of lower respiratory disease by clinical assessment or imaging, and a saturation of oxygen (SpO2) ≥94% on room air at sea level.

 

Severe Illness : Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room air at sea level (or, for patients with chronic hypoxemia, a decrease from baseline of >3%), ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50%.

 

Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.

 

In pediatric patients, radiographic abnormalities are common and, for the most part, should not be used as the sole criteria to define COVID-19 illness category. Normal values for respiratory rate also vary with age in children, thus hypoxia should be the primary criterion to define severe illness, especially in younger children.

 

1The studies used to inform this guidance did not clearly define “severely immunocompromised.” For the purposes of this guidance, CDC used the following definition:

  • Some conditions, such as being on chemotherapy for cancer, untreated HIV infection with CD4 T lymphocyte count < 200, combined primary immunodeficiency disorder, and receipt of prednisone >20mg/day for more than 14 days, may cause a higher degree of immunocompromise and inform decisions regarding the duration of Transmission-Based Precautions.
  • Other factors, such as advanced age, diabetes mellitus, or end-stage renal disease, may pose a much lower degree of immunocompromise and not clearly affect decisions about duration of Transmission-Based Precautions.
  • Ultimately, the degree of immunocompromise for the patient is determined by the treating provider, and preventive actions are tailored to each individual and situation.

A summary of current evidence and rationale for these changes is described in a Decision Memo.

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