COVID-19

Coronavirus Protocol

March 26, 2020

Updated 7/2/20

*(subject to change with new developments)

Updated July 2, 2021 

*(subject to change with new developments) 

1. UPDATE on COVID-19 Protocols 

  • We are updating our COVID-19 quarantine and testing protocols to be more aligned with the processes that other large healthcare organizations within our community are following at this time. 

2. What is considered “exposure”? 

  • What is considered “exposure” to the COVID-19 virus in the healthcare industry is slightly different from what is considered “exposure” in the community. 
    • One is considered to be “exposed” to the virus if they have close contact with someone who has the virus without either person wearing face covering.  
    • Close contact is defined as spending at least 15 consecutive minutes within six (6) feet of a confirmed COVID-19 case. 
    • In a healthcare setting, it is not considered exposure to the virus if both the nurse and the patient were wearing masks during the encounter. 

3. Quarantine and Testing 

  • Fully vaccinated HCP (Health Care Personnel) with higher-risk exposures who are asymptomatic do not need to be restricted from work for 14 days following their exposure.
  • People with SARS-CoV-2 infection in the last 90 days do not need to be tested if they remain asymptomatic, including those with a known contact.
  • Asymptomatic HCP with a higher-risk exposure and patients or residents with prolonged close contact with someone with SARS-CoV-2 infection, regardless of vaccination status, should have a series of two viral tests for SARS-CoV-2 infection. In these situations, testing is recommended immediately and 5–7 days after exposure.
  • Anyone with symptoms of COVID-19, regardless of vaccination status, should receive a viral test immediately.
  • Fully vaccinated HCP may be exempt from expanded screening testing. However, per recommendations above, vaccinated HCP should have a viral test if the HCP is symptomatic, has a higher-risk exposure or is working in a facility experiencing an outbreak.
  • If fully vaccinated, you will not be required to get tested for COVID-19 unless you become symptomatic.  If you choose to get tested, you must get tested on Day #6 and not sooner, as premature testing tends to result in false negative results. Day #1 is the day you visit the patient; you will need to wait 5 days and then get tested on day #6.
  • If you develop any COVID-19 symptoms, you will then need to call your MD, quarantine, and be tested based on your physician’s orders. 

4. Updated PPE Protocol 

  • Effective immediately, our Agency’s standard protocol is that all clinicians must wear a mask (and potentially a face shield/goggles) for all patient visits. 
    • If the patient is a confirmed COVID-19 positive case, clinicians will need to wear a respirator (N95, KN95) and a face shield/goggles. 
    • For all other patients who are presumed to be negative for COVID-19, clinicians will need to wear a surgical mask. Clinicians will need to wear a face shield/goggles for treating patients in settings/areas where moderate to substantial community transmission is occurring. Eye protection is optional for fully vaccinated clinicians when treating patients in settings/areas where minimal community transmission is occurring. 

5. Rapid Antigen Testing 

  • The most reliable method of testing for COVID-19 is the PCR test that is conducted at most  physician offices, testing centers and clinics, and free county testing sites. 
  • As a back-up, people can get tested using rapid antigen testing kits, results of which can be available within 15 minutes. These tests do have some limitations and should be used as a second option to the PCR assay test. 
  • We have purchased rapid antigen testing kits and will be able to conduct COVID-19 tests on employees only for the following situations: 
    • Routine/weekly testing for our staff who are not fully vaccinated. 
    • PRN testing for our staff who are concerned about possible exposure and have to wait long  periods of time to either get tested or get their test results.
    • Immediate testing for anyone with symptoms of COVID-19, regardless of vaccination status.

6. Post-Travel Quarantine and Testing 

  • People who are fully vaccinated with an FDA-authorized vaccine or a vaccine authorized for emergency use by the World Health Organization can travel safely within the United States.
  • For fully vaccinated individuals:  self-monitor for COVID-19 symptoms; isolate and get tested if you develop symptoms.  You do NOT need to get tested or self-quarantine if you are fully vaccinated or have recovered from COVID-19 in the past 3 months.
  • If you are not fully vaccinated, you will need to quarantine for 7 full days upon returning home.  
  • You will be required to get tested on Day #6. Here is how you calculate the days: 
    • You get back into town on a Thursday, your Day #1 is Friday. 
    • You will quarantine for 5 days – Fri, Sat, Sun, Mon, Tue. 
    • You will get tested on Wednesday, Day #6. Once the test results come back negative you can start doing visits again. 
    • If your test is positive, isolate yourself to protect others from getting infected.
    • If you don’t get tested, stay home and self-quarantine for 10 days after travel.
    • Avoid being around people who are at increased risk for severe illness for 14 days, whether you get tested or not.
    • Self-monitor for COVID-19 symptoms; isolate and get tested if you develop symptoms.
  • For compliance with CDC guidelines and for the safety of all of our staff and patients, we appreciate your compliance in providing us with information regarding your travel plans so we can plan accordingly. 

PRE-VISIT SCREENING 

All clinicians must conduct a screening call immediately before driving to the patient’s house for each visit. 

Ask your patients the following 3 screening questions: 

  1. Travel: In the past 14 days have you or anyone in your home/facility returned from travel outside the United States? {yes/no}
  2. Exposure: In the past 14 days, have you or anyone in your home/facility had close contact with anyone diagnosed with or suspected to have COVID-19? {yes/no}
  3. Symptoms: Do you or anyone in your home/facility have raspy/itchy throat, cough, fever, or shortness of breath, or any of the following symptoms? {yes/no}
Symptom Patient Caregiver
Fever (temperature of 100.4⁰F or higher)
Cough
Shortness of breath/difficulty breathing (new or worsening over baseline)
New loss of smell or taste
Chills/rigors (shivering/shaking with chills, accompanied by sweating)
Myalgias/muscle pain
Rhinorrhea (runny nose, could be thin clear fluid to thick mucous)
Nausea, vomiting, diarrhea or other GI issues
Raspy, itchy or sore throat
Fatigue
Confusion
Headache
Purple or blue lesions on feet and toes, most commonly seen in children  and young adults

Employees, please also check yourself every morning and periodically during the day for temperature elevation and monitor for any s/s of COVID-19 using the above screening tool. Notify Paige Pier with any changes immediately. Paige is our administrator and will direct you per our protocol. 

PRE-VISIT SCREENING 

Educate your patients on the following 3 visit protocols they must follow: 

  1. Physical Distancing: Inform patients that anyone else living in the home must leave the room while you are there for your visit, preferably 15 minutes prior to your arrival so the air can be cleared. If patients require translation and need a caregiver in the room, ask that they stand 6 feet away from you and the patient, if space permits. If caregivers need teaching, try to do so over the phone after your visit. 
  2. Covering Face: Ask your patient to cover their mouth with a mask, bandana, t-shirt or tea towel during your entire visit, whether or not they have any respiratory symptoms.
  3. Daily Temperature Checks: Educate your patients and their caregivers to check their temperature on a daily basis and keep a log. 

Screen your patients on the morning of your visit, prior to driving out to them. And don’t forget to ask the  screening questions about anyone else who is living in the home or has visited in the last couple of days. This is  another vital part of the screening process. 

Once these questions have been answered, include the response in your visit note to document that you  conducted the pre-visit screening.  

If the responses indicate a potential risk or exposure, immediately notify the management team and:  

  1. Continue to do the visit if you have full PPE. 
  2. Ask for the patient to be reassigned to a member of the COVID Response Team if you don’t have full PPE. 

Also, if your patient does not answer your pre-visit call and you decide to drive to your patient’s home to see if  you can do your visit, ask the required screening questions at the door BEFORE entering the home. 

Latest Update from CDC to educate and screen your patients on: 

If you have any of these emergency warning signs* for COVID-19, get medical attention immediately: 

  • Trouble breathing 
  • Persistent pain or pressure in the chest 
  • New confusion or inability to arouse 
  • Bluish lips or face 

* This list is not all inclusive. Please consult your medical provider for any other symptoms that are severe or  concerning to you. 

Call 911 if you have a medical emergency: Notify the operator that you have, or think you might have, COVID 19. If possible, put on a cloth face covering before medical help arrives.

TREATMENT OF COVID-19 PATIENTS 

The following “COVID-19 Protocol” shall be used for ALL

  • Patients known to have COVID-19 
  • Persons Under Investigation (PUI), and 
  • Patients living in Assisted Living Facilities (ALFs) & Board and Care Facilities (B&C) 

DEVICE USE FOR KNOWN COVID-19 PATIENTS 

Ask patient/caregiver to purchase BP machine, as you will not be taking yours in. If they are unable to provide  their own, BP reading will not be done until a BP machine can be provided. 

If they have their own thermometer and pulse-ox machine, please use theirs. If they don’t have a  thermometer, we can provide you with a no-touch thermometer or sticker thermometers to use. 

MASK USE FOR KNOWN COVID-19 PATIENTS 

  1. All clinicians must wear an N95 mask when treating patients with known COVID-19 infection. • After putting on your N95 mask, cover it with a face shield. Once you are done with your treatment, you can keep the N95 for re-use. 
  2. Give 1 surgical mask to patient if they don’t already have one; and 
  3. Give 1 surgical mask to the patient’s caregiver or family member only if they must be in the room. If they can  wait in another room while you finish your visit, please ask them to do so.
  4. Educate your patient (and caregiver, if they too were given a mask) to store their masks in the paper bag  we are providing as they will need to reuse it for our subsequent visits. At this point in time, we cannot  provide them with a new mask for each visit or each week. 

HAND HYGIENE FOR KNOWN COVID-19 PATIENTS 

  1. Hand hygiene is required before entering your clinician bag, after touching the patient’s skin and items in  the patient’s vicinity, in between glove changes and after the final removal of gloves. 
  2. Jewelry can trip microorganisms – either don’t wear them during home visits or remove and clean them  thoroughly each time you perform hand hygiene. 
  3. All clinicians and their COVID-19 patient must wash their hands using soap and water for 20 seconds at the start of the visit and end of every visit.  
  4. When washing hands, please thoroughly scrub the palms, the top of the hand, each individual finger,  under the nails and around the cuticles; similar to how surgeons wash their hands in preparation for  surgery. Demonstrate this to your patient and educate/train them to do the same for each visit. 
  5. All clinicians should perform hand hygiene in between glove changes. Washing hands is preferred over  using alcohol based hand sanitizer. 
  6. When using alcohol hand sanitizer, please rub all surfaces of your hands for 20 seconds in the same  manner (described above) as you would if washing your hands. 

GOGGLE / FACE SHIELD USE FOR KNOWN COVID-19 PATIENTS 

Eye protection is required when treating COVID-19 patients.  

  • Please re-use your goggle/face shield and do not throw it away.  
  • Use clean hands to carefully remove them and clean thoroughly with soap and water. Then, wipe down  with Cavi-Wipe and store properly for re-use in a well-ventilated bag or box. 

DOCUMENTATION FOR KNOWN COVID-19 PATIENTS 

1. Do not take your laptop/tablet into a patient’s homes for charting. Limit the amount of time you are in a  patient’s home to only hands-on care and head-to-toe assessment.  

2. During your pre-visit screening calls, ask questions that will allow you to complete documentation in  advance of your visit. Complete documentation in your car before visiting your next patient while you  remember everything. 

3. Prepare the Patient Handbook in your car before going into the patient’s home so you don’t spend time in the  patient’s house filling it out.  

  • Complete the Consent and other pages as much as possible with generic patient data;  
  • Fill out the plan of care portions and other items that require patient involvement when you are inside; 
  • Tear out the Home Safety Checklist and Patient Emergency Management Plan in your car before taking the Patient Handbook inside with you; you can complete those 2 documents after completing the visit.  

4. All Admission Consents for known COVID-19 patients will be obtained VERBALLY through the 

     Agency’s Virtual Visit platform. This verbal consent will also serve as an electronic visit 

     verification. 

5. All follow-up visits will be initiated with a verbal consent using the Agency’s Virtual Visit platform to 

     serve as an electronic visit verification

WHAT TO TAKE INSIDE A KNOWN COVID-19 PATIENT’S HOME 

  • A plastic “outer” bag that you can place on any surface and discard once you are done with it, filled with: 
  • PPE – Booties, Hair Covering, Mask, Gown, Goggle / Face Shield; and 
  • A plastic “inner” bag that you can take back with you to your car since it hasn’t touched any surfaces,  filled with the following items that can be kept in small, individual Ziploc bags:  

❒ Cell phone, car keys 

❒ Lots of gloves, hand sanitizer, hand soap, paper towel 

❒ A few sheets of CAVI-Wipes 

❒ Medical supplies (for wound care, Foley care, hands-on care, etc.) 

❒ Surgical mask(s) and paper storage bags for patients and caregivers who do not have their own  mask. 

❒ A “no-touch” temporal thermometer or disposable sticker thermometers (in stock at the      

     agency)  

❒ Pulse-ox machine to check O2 Sat levels at each visit

WHAT NOT TO TAKE INSIDE A KNOWN COVID-19 PATIENT’S HOME  

  • BP machine / Stethoscope / Thermometer that requires contact with patient such as oral, tympanic or  the kind you swipe on the forehead. 
  • The whole nursing bag 
  • A whole box of gloves or a whole container of Cavi-Wipes 
  • Laptop/Tablet 
  • Extra PPE that will not be used during this visit 

PROPER SEQUENCE OF DONNING AND DOFFING FOR KNOWN COVID-19 PATIENTS 

  1. Before conducting your visit, make sure to call your patient and discuss with them or their caregiver/family  the availability of outdoor space for you to don and doff your PPE. You will have to don and doff outside of  the patients home so ask them if they can provide: 
  • a chair / small table / any clean surface for you to put your belongings on while you are donning and  doffing. 
  • accommodations in the garage for you to don and doff. 
  • accommodations in their front / side / back yard for you to don and doff. 
  • a trash receptacle/bin for you to discard PPE in. 
  1. When outside the patient home, prepare the trash receptacle.  
  • If they don’t have an actual trash bin to provide, take a disposable structured paper bag, like a Trader  Joe’s paper bag, and not a collapsible nylon bag with you and place it on a flat surface. 
  • Do not use a red “hazardous waste bag” as a trash bag. 
  1. Don PPE in the following sequence: 
  • Sanitize hands thoroughly with alcohol-based sanitizer. 
  • Put on shoe covers.  
  • Put on gown.  
  • Put on an N95 mask and make sure it has a tight fit.  
  • Put on goggles. If you wear glasses, they can serve as eye protection and you won’t need goggles. 
  • Put on hair covering.  
  • Put on face shield.  
  • Put on gloves – make sure the wrist part of the gloves go under your gown sleeves. 
  1. Ask patient and caregiver to put on their face mask/covering.  
  2. Enter patient’s home. 
  • Coordinate with patient/caregiver if they can open doors for you so you can avoid touching surfaces as  much as possible. 
  1. Ask patient to perform hand hygiene. 
  • If physically possible, ask them wash their hands using soap and water. 
  • If it’s not physically possible, sanitize patient’s hands using sanitizer. 
  1. Put on a second pair of gloves on top of your gloved hands – make sure these gloves cover over the  sleeves of the gown. These will be the gloves that will be considered “dirty”.
  2. Perform care. 
  • Please have extra gloves and hand sanitizer with you in the patient’s home.  
  • If you need to remove your outer gloves in between tasks or in between wound care dressing changes,  you can remove the outer layer gloves, sanitize the inner layer gloves, and then put on a new pair of  outer layer gloves. 
  • Take extra items, such as medical supplies, so you don’t have to stop your visit and go outside to your  car to get things. 
  1. Finish visit and exit patient’s home. 
  2. Return to the spot where you donned your PPE. 
  3. Doff PPE in the following sequence:  
  • Remove shoe covers and discard them in the trash receptacle you have left outside of the house. 
    • Remove gown and outer layer of gloves (as you pull the sleeves of the gown off you will naturally pull  the outer layer of gloves off) and discard them in the trash. Make sure to remove your gown in a  manner that the outside/dirty part of the gown is folded inward to contain microorganisms within it. 
    • Sanitize inner layer of gloves. 
  • Remove face shield; sanitize it thoroughly with a Cavi-Wipe; place it in a clean bag for re-use later.  • Remove hair covering and discard it in the trash. 
  • Remove inner layer of gloves and discard them in the trash.  
  • Sanitize your hands. 
  • Don a new pair of gloves. 
  • Remove goggles (if applicable); sanitize them thoroughly with a Cavi-Wipe; place it in a clean bag for  re-use later.  
  • Sanitize your gloved hands. 
  • Remove the N95 mask; place it in a clean paper bag or shoebox for re-use later, with the outside facing  down. 
  • Remove gloves and discard them in the trash. 
  • Sanitize your hands. 
  1. Arrange for disposal of the trash bag. 
  • Ask patient’s caregiver to discard the trash bag of used PPE in their outside trash bin. 
    • If patient lives alone and has no caregiver, then don’t remove your gloves after removing your N95  mask in the sequencing outlined above. Instead, CLOSE the top of the trash bag before you pick it up  and discard the trash bag in their outside trash bin. 
  • Remove gloves and discard them in the bin. 
  • Sanitize your hands.

TREATMENT OF REGULAR / ASYMPTOMATIC PATIENTS 

For all patient visits, please ask your patients and their caregivers/family members to use their own hand  soap, alcohol hand sanitizer, masks, PPE, etc. for themselves and save your supply for your own use. 

GOGGLES 

When caring for patients without any signs/symptoms of COVID-19, in areas with minimal to no community transmission, eye protection is optional for clinicians. Eye protection is recommended for clinicians treating patients in areas with moderate to substantial community transmission.

MASKS 

All clinicians must wear a surgical mask for every single home visit.  

  • Save your N95 masks for patients with symptoms of COVID-19 ONLY. Do not use your N-95 for regular/daily use. 

You may reuse your mask from visit to visit by observing the following protocol: 

  1. Wash/sanitize hands thoroughly as described above before removing your mask. 
  2. Afterwards, remove the mask and place the outside surface face down and the inside part facing upward in a  cardboard/shoe box or a paper bag with a flat bottom so the mask does not roll or tumble around. You may extend the life of your surgical mask by covering it with a cloth mask and washing that in the evening.  

If anyone needs more masks/PPE, submit a request to Paige Pier RN via email at ppier@transitionshp.com. 

HAND HYGIENE  

The number one way to combat the spread of this virus is through hand hygiene, AND hand washing with soap  and water is the best measure to prevent spread of COVID-19.  

All clinicians and their patients must wash their hands using soap and water for 20 seconds twice: once at the start of every visit/before starting treatment and once after finishing treatment/at the end of the visit.  

When washing your hands, please thoroughly scrub the palms, the top, each individual finger, under the nails  and around the cuticles. Similar to how surgeons wash their hands in preparation for surgery. 

If there is no soap & water, or if it is difficult for you or your patient to get to a sink/basin to wash hands, you  and your patient may use alcohol hand sanitizer and rub all surfaces of your hands for 20 seconds in the same  manner (described above) as you would if washing your hands.  

Use a barrier such as dry tissues/paper towel or gloves to touch door handles and faucet handles in patient’s homes and don’t touch any surfaces with your bare hands or with wet paper towels.

PATIENT SIGNATURES 

Electronic signature using patient finger – please observe the following protocols in the sequence listed: 

1. Clinician and patient must wash hands with soap and water for 20 seconds. 

2. Clinician must wipe down cell phone or tablet screen with alcohol wipe thoroughly for 20 seconds. 

3. Request patient to sign on the screen using their finger. 

4. Clinician must wipe down cell phone or tablet screen with alcohol wipe thoroughly for 20 seconds. 

Electronic signature using stylus – please observe the following protocols in the sequence listed: 

1. Clinician and patient must wash hands with soap and water for 20 seconds. 

2. Clinician must wipe down stylus pen with alcohol wipe thoroughly for 20 seconds. 

3. Request patient to sign on the screen using the stylus. 

4. Clinician must wipe down stylus pen with alcohol wipe thoroughly for 20 seconds. 

Regular signature on Paper Route Sheet using a pen – please observe the following protocols in the sequence  listed: 

1. Clinician and patient must wash hands with soap and water for 20 seconds. 

2. Ask your patient to prepare a pen prior to your visit. If they don’t have one, Clinician must wipe down their  own personal pen with alcohol wipe thoroughly for 20 seconds. 

3. Request patient to sign on the Route Sheet using the pen. 

4. Clinician must wipe down their own personal pen with alcohol wipe thoroughly for 20 seconds. 

DEVICE USE 

Ask your patient if they have a thermometer, BP machine or pulse-ox machine you can use for them so you  don’t have to use yours.  

If you need to use your own BP cuff, manual or electronic, please observe the following protocol: 

  • Cleanse your BP cuff and device with a Cavi-Wipe before and after use. 
  • Place a paper towel or dental bib on the inside part of your BP cuff that touches the patient’s skin or  clothes. 

If you need to use your own Thermometer, please observe the following protocol: 

  • Wipe down the thermometer with an alcohol wipe before and after use, and always use a  thermometer cover/filter. 

If you need to use your own Pulse-Ox machine, please observe the following protocol: 

  • Ask patient to wash their hands with soap and water for 20 seconds. If that’s not possible, then to  sanitize their hands with alcohol sanitizer. 
  • Wipe down the pulse-ox on the inside and outside surfaces thoroughly with an alcohol wipe before and  after use.

DOCUMENTATION / CONSENT / PATIENT ADMISSION BOOK 

  1. Do not take your laptop/tablet into patients’ homes for charting. Limit the amount of time you are in a  patient’s home to only hands-on care and head-to-toe assessment.  
  2. During your pre-visit screening calls, ask questions that will allow you to complete documentation in  advance of your visit. Complete documentation in your car before visiting your next patient while you  remember everything. 
  3. Complete the Consent in your car before going into the patient’s home so you don’t spend time in the  patient’s house filling it out. Tear out the Home Safety Checklist and Patient Emergency Management Plan in your car before taking the Patient Handbook inside with you, and complete those 2 documents after completing the visit. Leave the Patient Admission Book in the patient’s home and complete it as you normally would. 

NURSING BAG USE 

Only take with you what you need for your visit and not your entire nursing bag. Here are some ideas of  different things you can do to help comply with infection control. 

  • Fanny pack: These wrap around your waist and do not need to be placed on any surface in a patient’s  home. You can put your BP cuff, etc., phone, pen and medical supplies in there.
  • Cross-Body Bag: These can stay in the front of your body to get items that you need; then you can flip it to the back of your body when you are bending over and providing care.
  • Bag-in-a-Bag: Place your BP cuff/equipment and medical supplies in a bag and put that bag inside a  disposable trash bag. When you are done with your visit, you can take the inside bag out and take it  back to the car with you and throw the outside bag away in their trash. 

The following sections, “Bag Hygiene” and “Bag Technique Myths” have been taken from: “COVID-19 Infection Management: Bag Technique in the Home Environment 

Author: Carol Javens, RN, BSN, CHPN, Implementation Manager Date: March 18, 2020 https://www.axxess.com/blog/home-care/covid-19-infection-management-bag-technique-in-the-home environment/ 

Bag Hygiene 

  • When opening the clinician’s bag, do not open a flap in a manner that would allow it to touch surfaces  in the patient’s home.  
  • Wheeled bags should remain on the floor of the patient’s home.  
  • Always ensure the bag is placed on the cleanest surface possible in the patient’s home. Another option is hanging the bag on a door or hanger.  
  • The bag should remain closed when the clinician is not actively obtaining items. 
  • Do not load the bag so that it tips over and touches the surfaces of the patient’s home. 
  • When items are removed from the clinician’s bag, use a barrier between the items removed and the  surface of the patient’s home.  
    • Barriers should be water-resistant and single-use.  
    • Examples are wax paper, chux/disposable pads, or plastic bags.  
    • Newspaper and paper towels should be avoided, as these materials wick water up and may  transmit pathogens to your bag. 
  • Clean the outside of your bag regularly and especially when it is visibly soiled.
  • There are times when you would not want to bring your clinician’s bag into the patient’s home.  
    • One example would be if the patient is on transmission-based precautions or has a multi-drug  resistant organism.  
    • Another would be if there are pests inside the home or there is excrement in the home  environment.  
  • Clinicians should use their judgement if it is best only to bring items they need for the visit into the  patient’s home.  
    • If you decide to carry those items needed during the visit, double bag the items using  disposable plastic bags and leave the outer bag in the patient’s home.

After appropriate disinfection, you can bring items out of the home using the inner bag.