centers fOr Disease ., 2 Control ond.Prevenfion,? . - Coronav1rus Disease2019(COVID?19) Interimmfecuon PreventionandConU??Olf: 1 i Recommendations {for i Patientsw1th Con?rmed --.. Coronavirus,.Disease 2019 (COVID719). OrLP?erS?ion?is..Under Inve? tigationif?or in Healthcarej Settings Updated: February 21,2020 Backgrou?d lnfection'contro?l proceduresincluding - administrative rulesandengineering controls, environmental hygiene, correct work practices, and appropriate use?of - personal protective equipmentiPPEiare all necessary to preventinfectionsfrom sprea-dingduring healthcare delivery. Prompt detectiOn andeffectivetriageandisolation ofpotentially infectious patients are essential toprevevnt unnecessary exposures among patients, healthcare perso nel, and visitors atthe facility. All healthcarefacilitiesmust ensure that their personnel are'correctly trained and capable of implementing infection control procedures; individual healthcarepersonnel should'en?sure the'y?uhd?rsta'nd and'can adhe?re'toinfect?iOn control requirements. i This guidance is baSed on the currently limited information-available about coronavirus disease 2019'relate?d to disease 2 severity, transmission efficiency, and sheddingduratlon. This cautious approach will be refined and updated as more information becomes availableandasresponseneeds change in theUnit?d StatesQThis guidance-isapplicableio all US. healthca re settings. This guidance is not intended for nowhealthcare sizh00ls)pRto persons outSide [of 7 heaithcare settingsFor recommendations regarding clinical management, air or ground medical transport?orl?aboratory i settings, refer to the main CDC - De?nition of HealthCarePersonnel ?a For thepurposes of this guidance, HCP referstoall persons, paid and unpaid, workingin healthcaresettings engaged in patient patient asseyssmentfor triage, entering examination rooms orpat?ient rooms to provide care or clean anddisinfect the environment, obtaining clinical . handling sOiled medical supplies or in contact with potentially contaminated environmental surfaces Recommendations Minimize Chance f0]: EXposure3~ Ensure facility policies and practices are in place to minimize exposures to respiratory-pathogens} including the virus that causeSCOVl?D?lQ. Measures should be?implemented before patientarrival, the . duration?ofthe affected patient?slpresence inthe healthcare setting; - BeforeArrival - - . I. . . 0 When scheduling appointments, instruct patients and persons who accompany them tocall ?aheador inform HCP upon arrival if they of any respiratory infection (e.g_..iCough, runny nose, feVerl) andto take appropriate preventive actions a facemask upon entry to contain cough,_follow triageprocedures). if a patient is arriving viatransp?ort by emergency'medical the driver s'hould?c'ontaCt the receiving emergency department (E-D)ior healthcare faCility and folIowprevi?ouslyagreed upon local or regional transport protocols. This willallowthe healthcare facility to patient. - . UponArrlval and During the Visit . 0, Take steps to ensure all-persons of suspected infection fever. couehi adhere to r?soiratorv hvgiene and cough etiouette. hand hveiene. and triage procedures throughout the 1/7 '0 duration of the visit. Consider posting visual alerts signs, posters) at the entrance and in strategic places waiting areas, elevators, cafeterias) to provide patients and HCP with instructions (in appro?priate?languages) about hand hygiene, respiratory hygiene, and cough etiquette. Instructions should include how to use facemasks (See definition of facemask in Appendix) or tissues to cover nose andmouth when coughing or sneezing, to dispoSe of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene. 0 Ensure that patients with of suspected or other respiratory infection fever, cough) are not allowed to wait among other patients seeking care. Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies. In some settings, medically-stable patients might opt to wait in a personal Vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated. ?0 Ensure rapid triage and isolation of patients with of suspected COVID-19 or other respiratory infection fever, cough): I Identify patients at risk for having 9 infection before or immediately upon arrival to the healthcare facility. I Implement triage procedures to detect persons under investigation (PUI) for during or before patient triage or registration at the time of patient check-in) and ensure that all patients are asked about the presence of of a respiratory infection and history of travel to areas experiencing transmission of the virus that causes COVID-19, or contact with possible COVID-19 patients. I Implement respiratory hygiene and cough etiquette placing a facemask over the patient?s nose and mouth ifthat has not already been done) and isolate the PUI for in an Airborne Infection Isolation Room (AIIR), if available. See recommendations for "Patient Placement? below. Additional guidance for evaluating patients in'U.S. for infection can be found on the CDC website. I Inform infection preventiOn and control services, local and state public health authOrities, and other healthcare facility staff as appropriate about the presence ofa person under investigation for 9. 0 Provide supplies for respiratory hygiene and cough etiquette, including60%-95% alcohol-based hand sanitizer (ABHS), tissues, no touch receptacles for disposal, and facemasks waiting rooms, patient check-ins, etc. If It 2. Adherence to Standard, Contact, and Airborne Precautionsl Including 7 the Use of Protection Standard Precautions assume that every person is potentially infected or colonized with that could be transmitted in the healthcare setting. Elements of Standard Precautions that apply to patients with respiratory infections, including those caused by 9, are summarized below. Attention should be paid to training?on correct use, proper donning (putting on) and doffing (taking off), and disposal of any PPE. This document does not emphasize all aspects of Standard Precautions injection safety)?that are required for all patient care; the full description is provided in the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. All HCP (see section 3 for measures for non-HCP visitors) who enter the room ofa patient with known or suspected COVID-19 PUI) should adhere to Standard, Contact, and Airborne Precautions, including the following: - Patient Placement 0 Place a patient with known or suspected PUI) in an AIIR that has been constructed and maintained in accordance with current guidelines. I Alle are single patient rooms at negative pressure relative to the surrounding-areas, and with a minimum of 6 air changes per hour (12 air changesper hour are recommended for new construction or renovation). Air from these rooms should be exhausted directly to the outside or be filtered through a high-efficiency particulate air (HEPA) filter before recirculation. Room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized. Facilities should monitor and document the proper negative- pressure function of these rooms. . I If an AIIR is not available, patients who require hospitalization should be transferredas soon as is feasible to a facility where an AllR is available. Ifthe patient does not require hospitalization they can be discharged to home (in consultation with state or local public health authorities) if deemedmedically andsocially . appropriate. Pending transfer or discharge, place a facemask on the patient and isolate him/her in an examination room with the door closed. Ideally, the patient should notbe placed in any room where room exhaust is recirculated within the building without HEPA filtration. 0 Once in an AllR, the patient's facemask may be removed. Limit transport and movement of the patient outside of Anni II nun Ann. I I 2/7 the to medically?essential purposes. When not In an Alli-t te.g., during transport or IT an IS not available), patients shOuld weara facemask to CentainSecretions. LY 0 Personnel enteringtheroom should use PPE, including respiratory protection, as describedbelow. 0 Only essential personnel should entersthe minimiz?e?the number of HCP who enterthe room. . 4 . 7 I Facilities should consider caring forthese patients with dedicated HCP to minimizerisk of transmission and exposure to other patients and other, HCPFacilities should keep a log of all persons who care for or enter the roomsor care area of these patients. Use dedicated or disposable-noncritical patient-care equipment blood pressurecuffs). lfequipment will be used for more than one patient, clean and disinfect such equipment before use on another p'atient'ac'cording to _manufacturer'sinstructions. ., . HCP entering the room soon after a patient vacates the room should use respiratory protection; (See personal protective equipment section below) Standard practice for pathogens spread bythe'airborneroute measles, tubechlosis) is to restrict unprotected individuals, including HCP, from entering a vacated room until sufficient time has elapsed for enough air changes to remove potentially infectiousparticles (more informationeon clearancerates under differing ventilation conditions is not yet know how long remains infectious in the air. In the interim, it is reasonable toeapplya similar time period before entering the room withoutrespiratory protection as used for pathogens spread by the airborne route measles, tuberculosis). in addition-the room should undergo appropriate cleaning andsurface disinfection before it is returned to routine use. .1 -y - Lo HCP should perform hand hygiene using before and after all patient contact, Contact with potentially infeCtious material,and before putting on and upon removal of PPE, including gloves. Hand hygienein healthcare settings also can be performed by washing with soap andwater forat least 20 seconds. if handsare visibly soiled, use Soap and Water before returning LL 0 Healthcare facilities should ensurethat supplies are readily available in everchareLlOCLation. . PersonalProtective EquipmentEmployers should select appropriate PPE and provide it to HCP in accordance with PPE standards (29 CFR 1910 Subpart I) l] .HCP must receive training on and demonstrate an understanding of when to use What PPE is necessary; how to? prOperly don, Use, and doff i L. LPPE in amannerto prevent Lself?ContaminatiOn; hoLwto properly dispose of or disinfect and maintain and the limitations of PPE. Any reusable PPE must be decontaminated, and maintained after?and between Uses. Facilities Should have policies and preceduresdescribinga recommended sequence for safely donning and doffing PPE: Gloves I Perform hand; hygiene, then put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. I Remove and discard gloves when leaVing thepatient-roombr,carearea, and immediately performhand hygiene. Gowns Put on a clean isolation goWn upon entry into the patient room or area. Change the goWn ifLiLt becomes soiled. ?Remove and discard the'gown in'a dedicated container for Waste or linen before le?aving'the patient room or care area. Disposable gowns should be discarded after u5e. Cloth g0wns shoUld be laundered after?each use. 0 Respiratory Protection I Use respiratory protection (Le, a respirator) that is at least-as proteCtLiVe as afit?tested MOSH-certified dispOsable N95 filtering facepiec?e respirator before entry intothe patient room or care area. seeappendix for respirator definition. - - I Disposable respirators should be removed and discarded after exiting the patient?s room or care area and closing thedoor. Perform hand hygiene after discarding the respirator. I if reusable respirators air?purifying reSpirator/LPAPR) are used, they must be cleaned-and disinfected according to prior to re-use.? . I Respirator use must be in the context of a complete respiratory protection program in accordance with. Occupational Safety and Health Administration (OSHA) Respiratory Protection standard (29 l3 Staff should be medically cleared and fit-tested if using respirators with tight-fitting facepieces a NIOSH- certified disposable N95) and trained in the proper Use ofrespirators, safe removal and disposal, and medical Contraindications to respirator use. 0 Protection I Put on protection goggles, a disposable face shield that covers the front and sides of the face) upon- entry to the patient room or care area. Remove protection before leaving the patient room or care area. Reusable protection goggles) must be cleaned and disinfected according to manufacturer?s reprocessing instructions prior to re?use. Disposable protection should be discarded after use. . Use Caution When Performing Aerosol-Generating Procedures 0 Some procedures performed on patients could generate infectious aerosols. In particular, procedures that are likely to induce coughing sputum induction, open suctioning of airways) should be performed cautiously and avoided if possible. 0 If performed, these procedures should take place in an AIIR and personnel should use respiratory protection as described above. In addition: I Limit the number of HCP present during the procedure to only those essential for patient care and procedural support. I Clean and disinfect procedure room surfaces as described in the section on environmental infection control below. - Diagnostic Respiratory Specimen Collection 0 Collecting diagnoStic respiratory specimens nasopharyngeal swab) are likely to induce coughing or sneezing. individuals in the room during the procedure should, ideally, be limited to the patient and the healthcare provider obtaining the specimen. HCP collecting specimens for testing for the virus that causes 9, from patients with known or suspected COVID-19 PUI) should adhere to Standard, Contact, and Airborne Precautions, including the use of protection. 0 These procedures should take place in an AIIR or in an examination room with the door closed. Ideally, the patient should not be placed in any room where room exhaust is recirculated Within the building without HEPA filtration. - Duration of isolation Precautions for PUis and con?rmed 9 patients 0 Until information is available regarding viral shedding after clinical improvement, discontinuation of isolation precautions should be determined on a case-by-case basis, in conjunction with local, state, and federal health authorities. 0 FactOrs that should be considered include: presence of related to COVID-19 infection, date resolved, other conditions that would require specific precautions tuberculosis, Clostrid/oides other laboratory information reflecting clinical status, alternatives to inpatient isolation, such as the possibility of safe recovery at home. 0 For additional information refer to the Interim Considerations for Disposition of Hospitalized Patients with 19. 3. Manage Visitor Access and Movement Within the Facility - Establish procedures for monitoring, managing and training visitors. 0 Restrict visitors from entering the room of known or suspected patients PUI). Alternative mechanisms for patient and visitor interactions, such as video-call applications on cell phones or tablets should be explored. Facilities can consider exceptions based on end?of?life situations or when a visitor is essential for the patient?s emotional well-being and care. . Visitors to patients with known or suspected COVID-19 PUI) should be scheduled and controlled to allow for: 0 Screening visitors for of acute respiratory illness before entering the healthcare facility. 0 Facilities should evaluate risk to the health of the visitor visitor might have underlying illness putting them at higher risk for 9) and ability to comply with precautions. 0 Facilities should provide instruction, before visitors enter patients' rooms, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy while in the patient?s room. 0 Facilities should maintain a record log book) ofall visitors who enter patient rooms. 0 Visitors should not be present during aerosol-generating procedures. 0 Visitors should be instructed to limit their movement within the facility. 0 Exposed visitors contact with COVID-19 patient prior to admission) should be advised to report any signs and of acute illness to their health care provider for a period of at least 14 days after the last known exposure to the sick patient. 0 All visitors should follow respiratorv hvgiene and cough etiquette precautions while in thecommon areas of the facilitv. 4/ 7 1 I I 4. Implement Engineering Consider designing and installing engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals. Examples of engineering controls include physical barriers or partitions to guide patients through triage areas curtains between patients in shared areas, clOsed Suctioning systems for airway suctioning for intubated patients as well as appropriate air-handling systems (with appropriate directionality, filtration, exchange rate, etc.) that are installed and properly maintained. - 5. MonitOr and Manage and Exposed Healthcare Personnel Movement and monitoring decisions for HCP with exposure to 19 should be made In consultation with public health authorities Refer to the Interim Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19) for additional information. Facilities and organizations providing healthcare should implement sick leave p0licies for HCP that are non-punitive, flexible, and consistent with public health guidance. - - 6. Train and Educate Healthcare Personnel Provide HCP with job? or task? specific education and training on preventing tranSmission of infectious agents, including refresher training - I - HCP must be medically cleared, traineol, and fit tested for respiratory proteCtiOn device uSe N95 filtering facepiece respirators), or medically cleared and trained In the use of an alternative respiratory protection device P0wered Air- Purifying Respirator, PAPR) whenever respirators are required. OSHA has a number of respiratOry training Videos E. Ensure that HCP are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment. 7. Implement Env1ronmental Infection ContrOI Dedicated medical equipment should be used for patient care. All non- -dedicated, non- -disposable medical equipment used fOr patient care should be cleaned and disinfected according to manufacturer's instructions and facility policies Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly Routine cleaning and disinfection procedures g. using cleaners and water to pre- c?lean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for 19 In healthcare settings, including those patient- -care areas in which aerosol- generating procedures are performed. Products with EPA- approVed emerging viral pathogens claims are recommended for use against 19. These products can be identi?ed by the following claim: 0 "[Product name] has demonstrated effectiveness against viruses similar to 19 on hard non- porous surfaces. Therefore, this product can be used against COVID- 19 when used in accordance with the directions for use against [name of supporting Virus] on hard, non? porous surfaces." - I This claim or a similar claim, will be made only through the following communications outlets: technical literature distributed exclusively to health care facilities, physicians, nurses and public health officials, "1 -800" consumer information services, Social media Sites and company websites (non- -label related). Specific claims for 19" will not appear on the product or master label 0 See additional information about EPA-approved emerging viral pathogens claims B. 'o If there are no available EPA-registered products that have an approved emerging viral pathogen claim for 19, products with label claims against human coronaviruses should be Used according to label instructions. Management of laUndry, food service utensils, and medical waste should also be performed In accordance with routine procedures. Detailed information on environmental infection control in healthcare settings can be found In Guidelines for Environmental Infection Control In Health? Care Facilities and Guideline for Isolation Precautions: Preventing Transmission of infectious Agents in Healthcare Settings [section IV. F. Care of the environment] 5/7 8. Establish Reporting within Healthcare Facilities and to Public Health Authorities - Implement mechanisms and policies that alert key facility staff including infection control, healthcare epidemiology, facility leadership, occupational health, clinical laboratory, and frontline staff about known or suspected 9 patients PUI). 0 Communicate and collaborate with public health authorities. 0 notify state or local public health authorities of patients with known or suspected PUI). Facilities should designate specific persons within the healthcare facility who are responsible for communication with public health officials and dissemination of information to HCP. Appendix: Additional Information about Respirators and Facemasks: Information about Respirators: - A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer?s risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by the including those'intended for use in healthcare. . Respirator use must be in the context of a complete respiratory protection program in accordance with OSHA Respiratory Protection standard (29 CFR 1910.134 HCP should be medically cleared and fit-tested if using respirators with tight-fitting facepieces a NIOSH-approved N95 respirator) and trained in the proper use of respirators, safe removal and disposal, and medical contraindications to respirator use. - NIOSH information about respirators 9 OSHA Respiratory Protection eTool Filtering Facepiece Respirators (FFR) including N95 Respirators - A commonly used respirator is a filtering facepiece respirator (commonly referred to as an N95). Filtering facepiece respirators are disposable half facepiece respirators that filter out particles. 0 To work properly, FFRs must be worn throughout the period of exposure and be specially fitted for each person who wears one (this is called "fit-testing? and is usually done in a workplace where respirators are used). 0 Three key factors for an N95 respirator to be effective 0 FFR users should also perform a user seal check to ensure proper fit each time an FFR is used. 0 More information on how to perform a user seal check See a list of NIOSH?approved N95 respirators Powered Air-Purifying Respirators (PAPRs) - Powered air-purifying respirators (PAPRs) have a battery-powered blower that pulls air through attached filters, canisters, or cartridges. They provide protection against gases, vapors, or particles, when equipped with the appropriate cartridge, canister, or filter. - Loose?fitting PAPRs do not require fit testing and can be used with facial hair. 0 A list of NlOSH-approved PAPRs is located on the NIOSH Certified Equipment List Information about Facemasks: lfworn properly, a facemask helps block respiratory secretions produced by the wearer from contaminating other persons and surfaces (often called source control). . Facemasks are cleared by the US. Food and Drug Administration (FDA) for use as medical devices. Facemasks should be used once and then thrown away in the trash. Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19) 6/7 CDC has developed interim guidance for staff at local and state health departments, infection prevention and control professionals, healthcare providers, and healthcare workers Who are coordinating the home care and isolation of people who are confirmed to hav,e or being evaluated for corOnavirus disease 2019 ?19) (see Criteria to Guide Evaluation of Persons Under Investigation (PUI) for COVID- -19). - interim Guidance for Implementing Home Care of People Not Requiring Hospitalization fOr Coronavirus Disease 2019 (COVID- 19) Important Links and Additional InfectiOn Control Resources - . World Health Organization (WHO) Coro?navirus DiseaSe2019 (COVID-19) technical guidance Bi 0. Respirator Trusted-SoUrce information - Respirator Fact Sheet FoOtnote 1. Fever may not be present in some patients, such as those Who are very young, elderly, immunosuppressed, or taking certain medications. Clinical judgement should be used to guide testing of patients in such situations. Page last reviewed: February 21, 2020 7/7