What is the protocol for testing and treating COVID-19 in nursing home residents?

COVID-19 Testing and Treatment Protocol for Nursing Homes

Implement regular surveillance testing of all residents and staff at least weekly (or every 3 days during outbreaks), immediately cohort positive residents in separate areas with dedicated staff, ensure universal PPE use, and promptly treat eligible residents with antiviral therapy (such as Paxlovid) within 10 days of symptom onset to reduce mortality and transmission. 1

Testing Strategy

Surveillance Testing Schedule

• Conduct weekly testing of all residents and staff in facilities without active outbreaks using rapid antigen tests or PCR testing 1
• Increase testing frequency to every 3 days or daily once a single COVID-19 case is identified in the facility, as this represents an outbreak situation 1, 2
• Daily antigen testing can reduce cumulative incidence by 49% compared to no testing, making it the most effective testing strategy 3
• Do not rely on symptom-based screening alone - approximately 43-57% of infected residents are asymptomatic at the time of testing, and symptom screening fails to identify about half of COVID-19 cases 4, 5

Testing Methodology

• Use nasopharyngeal swabs for SARS-CoV-2 testing via RT-PCR or rapid antigen tests 1, 4, 5
• Rapid antigen tests are preferred when available due to immediate results enabling faster cohorting, though PCR remains acceptable 1
• Test ALL residents and staff simultaneously when an outbreak is detected - do not test only symptomatic individuals 1, 4
• Continue weekly retesting of all previously negative residents and staff until no new cases are identified for at least one testing cycle 5

Common Pitfall to Avoid

The early pandemic recommendation to test only symptomatic residents proved inadequate because successful cohorting depends on fast, reliable, and early testing before the virus spreads 1. Testing after symptom onset is too late to prevent transmission 1.

Isolation and Cohorting Protocols

Immediate Actions Upon Positive Test

• Isolate COVID-19 positive residents in well-ventilated single rooms when possible, or maintain at least 1 meter bed distance if single rooms are unavailable 1, 6, 7
• Physically separate COVID-19-positive residents from others in a separate area of the facility - ideally an entire floor or wing designated for temporary housing of infected residents 1
• Implement isolation immediately upon positive test result, not waiting for symptom development 6, 4

Staffing for Cohorted Areas

• Assign dedicated staff to work exclusively in the COVID-19 cohort to prevent cross-contamination 1
• Staff who have recovered from COVID-19 and have protective immunity should be preferentially assigned to work in the non-COVID-19 cohort, while susceptible staff work in the COVID-19 cohort with high-level PPE protection 3
• This immunity-based staffing strategy can reduce outbreak size among residents by 19% even without testing 3

Duration of Isolation

• Maintain isolation until body temperature has returned to normal for more than 3 days, respiratory symptoms have significantly improved, and two consecutive RT-PCR tests are negative with at least one-day sampling interval 1, 6, 7
• Typically this requires at least 5 days from symptom onset or positive test 7

Personal Protective Equipment (PPE) Requirements

Staff PPE

• All staff must wear masks, gowns, gloves, and eye protection when caring for COVID-19 positive residents 1
• Staff should wear N95 masks (preferred) or surgical masks when in the same room as infected residents 1, 6, 8
• Wear double-layer disposable gloves when providing oral/respiratory care, handling patient secretions, or cleaning patient rooms 1, 8

Resident Masking

• COVID-19 positive residents should wear medical masks when in the presence of others, though enforcement can be difficult, particularly in residents with dementia 1, 6

Critical Supply Management

• Maintain adequate PPE supplies as shortages significantly compromise infection control - more than one in five nursing homes reported severe PPE shortages during early pandemic phases 1

Environmental Infection Control

Daily Cleaning Protocols

• Clean and disinfect all high-touch surfaces using 500 mg/L chlorine-containing disinfectant frequently every day 1, 6, 8
• Promptly remove soiled items and implement proper medical waste management with closed garbage bags replaced frequently 1, 6
• Open windows for ventilation in shared areas such as toilets and kitchens 1, 8

Standard Precautions

• Continue hand hygiene, surface disinfection, and antibiotic stewardship, though recognize these practices alone are inadequate against airborne SARS-CoV-2 transmission 1
• Clean and disinfect hands after contact with patients, before leaving patient rooms, before and after eating, and after using the toilet 1, 8

Treatment Protocols

Antiviral Therapy

• Administer Paxlovid or other available antivirals to eligible residents as soon as possible after positive test and within 10 days of symptom onset to reduce probability of death 1
• Despite proven effectiveness, antivirals remain underused in nursing homes and should be prioritized 1

Supportive Care for Mild Cases

• Monitor vital signs regularly including temperature, heart rate, respiratory rate, and oxygen saturation 6, 7, 8
• Provide nasal catheter or mask oxygen therapy if needed, adjusting flow according to patient condition 6, 8
• Ensure adequate hydration (limited to no more than 2 liters per day) and nutritional support with protein-rich foods 8
• Use paracetamol as the preferred antipyretic for fever and symptom relief 8

Criteria for Hospital Transfer

• Transfer to hospital immediately if any of the following develop: 6, 8
  • Respiratory rate ≥30 breaths/min or worsening breathlessness
  • Oxygen saturation <94% on room air (or ≤93% at rest)
  • Persistent chest pain
  • Confusion or inability to stay awake
  • Progressive worsening despite supportive care

What NOT to Do

• Do not use corticosteroids for mild COVID-19 - they may prolong viral clearance and increase mortality in non-severe cases 8
• Avoid blind or inappropriate use of antibiotics unless there is clear evidence of secondary bacterial infection 8
• Do not use hydroxychloroquine - it does not improve outcomes and may increase adverse events 8

Post-Exposure Prophylaxis

Indications for Prophylaxis

• Consider post-exposure prophylaxis for high-risk residents who are not fully vaccinated or immunocompromised and have been exposed to an infected individual or when SARS-CoV-2 infection occurs in other residents in the facility 9
• High-risk factors include age ≥65 years, obesity (BMI >25), cardiovascular disease, chronic lung disease, diabetes, chronic kidney disease, and immunosuppression 9

Prophylaxis Regimen (if available and appropriate for current variants)

• Administer 600 mg casirivimab and 600 mg imdevimab by subcutaneous injection or intravenous infusion as soon as possible following exposure 9
• For ongoing exposure >4 weeks in immunocompromised residents, give initial 600 mg dose followed by 300 mg every 4 weeks 9
• Critical limitation: Monoclonal antibody prophylaxis is only effective against susceptible variants - verify current variant susceptibility before use 9

Special Considerations for Dementia Residents

Communication Strategies

• Provide information using simple reminders and visual instructions to explain the current situation 6
• Interact frequently, ask how they are doing, and take time to listen 6
• Avoid negative language such as "crisis," "pandemic," "lockdown," or "isolation" 6
• Use old photographs, objects, or songs from the past for distraction 6

Maintaining Quality of Life

• Stimulate movement, exercise, and creative or household activities to maintain routine 6
• Reduce social isolation by encouraging families to drop off letters, drawings, or packages 6
• Facilitate use of technology (tablets, smartphones) for online social engagement with relatives 6
• Maintain small group activities when possible while maintaining social distancing 6

Vaccination Strategy

• Ensure all residents receive COVID-19 vaccination as the primary prevention strategy - vaccination dramatically reduced case fatality rates even with highly transmissible variants like Omicron 1
• Post-exposure prophylaxis is not a substitute for vaccination 9

Monitoring and Quality Assurance

Outbreak Surveillance

• Contract with at least a part-time infection control specialist as required by CMS 1
• Track facility infection rates relative to surrounding community levels 1
• Recognize that even high-quality facilities with good infection control are at risk in community hot spots - nearly 100% of facilities experienced outbreaks during the first pandemic year 1

Staff Monitoring

• Test staff at the same frequency as residents - asymptomatic staff can develop antibodies and transmit infection despite repeated negative tests 5
• Monitor staff for symptoms and implement standard infection control for all healthcare personnel 5