In this section, we'll talk about testing strategies in assisted living. Many of the recommendations for responding to COVID-19 come from recommendations made for nursing homes. In nursing homes, a medical director can issue standing orders for testing residents, and the administration can develop policies that apply to all staff members. A key difference, of course, in assisted living is that there is not an ability to make standing orders. Residents often have their own clinicians, staff may be limited, and this can make things challenging in assisted living. One way for assisted living communities to address this problem is to adapt their testing strategies to what they may have previously developed for influenza. Regulations from local county, and state health departments also can influence how assisted living facilities may choose to address testing for their residents and for their staff. Let's talk now about recognizing an outbreak in assisted living, and then we'll move on to talking about testing strategies. An outbreak indicates that there is a potential for extensive transmission of SARS-CoV-2 throughout the setting. For COVID-19, any confirmed SARS-CoV-2 infection in an assisted living community means that there's an outbreak, and this includes a new case among residents or among staff. This is one way to recognize an outbreak and it's one of the criteria that we use for influenza. The other way that we define an outbreak is three or more cases of a respiratory infection or an influenza-like illness within 72 hours in the same area of the assisted living community. Again, this can also include residents or staff members. The strategies that we're going to use for testing are different from when there is and when there is not an outbreak. Let's talk about testing during an outbreak. Once there is an outbreak, all residents need to be tested for SARS-CoV-2 and expect at this point to identify people that are pre-symptomatic as well as asymptomatic. The reason why it's so important to do testing for all residents in an outbreak is that we can get other infected residents identified quickly. This means we could do rapid implementation of infection control and prevention measures for residents in all stages of infection. It also means that residents with signs and symptoms of infection can be offered supportive care measures more quickly. Also, once there's an outbreak, all staff need to be tested for SARS-CoV-2. Some facilities only have a limited number or a limited access to testing. Under those circumstances, prioritize of resident who have signs and symptoms of COVID-19 infection. Because we're mainly dealing with older adults, we call that some of the signs and symptoms of COVID-19 maybe atypical. The next group of individuals to prioritize are residents who have had close contact with a known case. For residents, this means being on the same unit or floor as an infected resident, or having been cared for by an infected staff member. For staff, it means prioritizing those who cared for residents who have already tested positive, especially for the index case. It also means prioritizing staff that work in the same unit or floor or on the same shift as the index case, if the index case was a staff member. Staff who are found to have active signs or symptoms of COVID-19 infection should be instructed to put on a mask immediately, and then to leave the building and seek health care through their healthcare provider. Once that first round of testing has been concluded, the residents who tested negative previously should continue to be tested on a regular interval until there's a 14-day period without new cases among residents or staff. This might involve many rounds of testing. The testing should be repeated every three to seven days, and this is based on what the centers for Medicare and Medicaid, or CMS has told nursing homes to do. Continue to test until there is a 14-day period without a new case among residents or staff. Residents that have already tested positive do not need to be retested because they will continue to shed an active virus for weeks. Once 90 days has passed since their first positive test, however, there may be a risk for reinfection, at which point those residents should be retested. This is an evolving area, so as you're reviewing the content for this course, you may want to check in with what is happening at your state or local health department and see what regulations they are offering and recommendations they're offering at this point. The picture on this slide shows an individual dressed in full PPE performing a nasopharyngeal swab on a woman who's seated in a chair. Let's talk now about Ope rationalizing Resident Testing in Assisted Living. As mentioned above, most assisted living used to not have a medical director to issue standing orders. Many assisted living communities do have policies and procedures for administering influenza vaccines. The same approach may need to be adapted to enable widespread testing for residents for COVID-19 infection. Another possibility is to get a standing order from each residence prescribing clinician, to permit COVID-19 testing. This is more cumbersome, as staff will have to get those orders and then keep them organized, in order to have facilities flow with their subsequent rounds of testing. One way to minimize the burden for all involved will be to send the prescribing clinician a template, standardized language that already includes the resident's name and relevant information. Then, the condition could just sign that order and fax it back to the assisted living community. This should also be done in accordance with state or local health guidelines. The box on the right side of your screen shows an example of a standing order as well as documentation for what might happen with the COVID-19 test. It begins with the name and address the assisted living community, patient information, and then allows the prescribing clinician to just check a box that says there can be a standing order is valid from one year for COVID-19 testing. The bottom part of this box then shows what happens when there's a COVID test administered, including indicating the type of test that was given, the date the sample was collected, the site the sample was collected from, as well as the test results. There's also an option to show that there was a COVID-19 tests that was not administered. For that, we should indicate why it didn't happen, so that we have the documentation. It's important to keep this documentation. In the resources section for this lecture, there is a link to a standing order document that you may take and adapt. That document is actually designed for influenza standing orders, but you can certainly make it into one that works for COVID-19. Let's talk now about resident testing when there is not an outbreak. For assisted living communities that have not yet had an outbreak or the outbreak has resolved, we recommend that residents continue to undergo daily screening for signs and symptoms of a COVID-19 infection. Residents do not need to keep getting tested for COVID-19 unless they leave the building on a regular basis, like for hemodialysis from social reasons. They have been exposed to someone with COVID-19, or the develop signs and symptoms of a possible COVID-19 infection has detected by the daily screening. Let's turn our attention now to testing staff members. For nursing homes, CMS recommends routine testing of staff members based on the prevalence of COVID-19 infections in the surrounding community. We feel these recommendations are reasonable to apply to assisted living communities as well. CMS recommends checking the level of activity in the county about twice a month, such as in the first, and third Monday of the month, and then adjusting the frequency of screening accordingly. The rate of COVID-19 infections in neighboring counties can also be used to justify an increase in the frequency of screening. They cannot be used to justify a decrease in the frequency of screening. As shown in the table here, monthly testing of staff is acceptable for communities in counties with a low level of COVID-19 infections in that county. Low level in this case means a less than five percent positivity rate in the previous week. For communities and counties with a higher rate of COVID-19 positivity, more frequent testing is indicated. So, if the rate is 5-10 percent, then testing should be at once a week, and if the community COVID-19 activity is high, greater than 10 percent, then testing of staff needs to be done twice a week. Let's review the testing strategies for assisted living communities. Any case of COVID-19, whether isn't a resident or a staff member is an outbreak. During an outbreak, all residents and staff member should be tested every three to seven days until there had been no new cases identified for at least 14 days. When there is not an outbreak, asymptomatic do not need to be tested. However, staff members need to be tested at least once a month. Then you be testing more frequently if the rates of positive COVID-19 cases in the community are greater than five percent. We recommend using standing orders to facilitate widespread testing of residents.
