2019 Novel Coronavirus: Orange County Update for Long Term Care Facilities (LTCF)
July 08, 2020
Orange County Health Care Agency (OCHCA) has updated guidance on management of COVID-19-positive and COVID-19-exposed residents of long term care facilities (LTCFs). These guidance updates address the set up and staffing of different units, PPE use on each unit, and recommendations for response-driven and surveillance testing. The guidance can be found using the button below; please read full document for details. Some highlights of this guidance are summarized below.
Testing Residents and Staff
OCHCA agrees with CDPH’s recommendations for:
  • Response-driven testing for a positive resident (with minor modifications);
  • Surveillance testing of 25% of staff; and
  • Testing and quarantine of new resident admissions (both from the hospital and the community)

OCHCA recommendations differ from CDPH’s for:
  • Response-driven testing for positive staff case: testing of close contacts (residents and staff), rather than all residents and staff.
  • Surveillance testing of residents: previous OCHCA recommendation to test 25% of residents on a weekly basis is modified to test only high risk residents on an ongoing basis (see guidance above for details).
Levels of PPE recommended for each unit (minimal recommendations; may use more protective levels):
  • Red Unit: extended use droplet and contact precautions
  • Yellow unit: contact and droplet precautions
  • Green: standard or enhanced standard precautions (depends on situation; see guidance)
  • Observation unit: enhanced standard precautions

  • Surgical masks or N95s acceptable. N95 use necessary for all aerosol-generating procedures (AGPs).
  • Respiratory protection program and fit testing not mandatory if using N95s, but advisable if resources allow and for facilities in which frequent AGPs performed (e.g. vSNFs).
  •  At a minimum, fit check for every staff member using N95, and education on proper donning/doffing, how to perform seal check and importance of hand hygiene after touching/adjusting mask.

  • Encourage procurement of long sleeved cloth washable gowns due to continuing shortage of disposable gowns.
  • May practice extended use of gowns on red unit; single use preferable on all other units (see guidance above for more details).
Other Guidance Updates
 Due to high risk nature of patient population in SNFs and very rapid spread of COVID in these facilities, consider extending isolation period of symptomatic COVID+ health care workers from minimum of 10 days to 14 days, or until symptoms substantially improved. 
General Updates on Outbreaks in LTCF
  • Thirty-nine outbreaks of COVID-19 have occurred in LTCF in Orange County since April, infecting almost 1300 residents and about 860 staff.  Of the infected residents, 194 have died to date, for an overall case fatality rate of about 15%. Additionally, there have been 4 infected staff members who died of COVID-related complications·        
  • High volumes of testing are leading to delayed turn-around times. Facilities are encouraged to have contracts with more than 1 commercial lab in order to increase options for testing (click below for updated lab options). The Orange County Public Health Lab (OCPHL) continues to offer rapid testing of PUIs, both residents and staff; call 714-834-8180 to arrange testing or specimen pick-up. Additionally, OCPHL may be able to offer limited testing support in the event of an outbreak, but cannot assist with routine surveillance testing.
  • Higher lab volumes have led to an increasing number of reported false positive test results. In some instances, this is due to the imperfect specificity of the test (not 100% specific), and in other instances, lab error or cross contamination has been suspected. These results have been more common in lower prevalence populations, such as assisted living facilities, but have also occurred in LTCFs. In a non-outbreak setting, if a positive result in an asymptomatic resident is in doubt (due to lack of exposure to confirmed case or PUI), it may be prudent to isolate the patient and repeat the test before transferring the patient into a COVID unit. Positive results in a symptomatic patient (PUI) or in the setting of an outbreak (regardless of symptoms) are more likely to be true positives and do not require repeating. 

 Criteria for Closure and Reopening to Admissions
Closure to Admissions :
  1. One resident infected: closed until screening of all residents in facility and staff who had contact with patient completed. Can reopen after initial screening if no additional resident cases are identified and source of transmission is identified, but need to repeat screening of residents and close staff contacts at 7* and 14 days (and will be closed if further resident cases identified). Also recommended to test all staff within 14 days.
  2. Two or more residents infected: closed until reopening criteria (described below) are met.
  3. Staff member(s): 
  • Single infected staff member: not closed to admissions. At a minimum, test residents cared for by staff member and close staff contacts at baseline, 7* and 14 days after last contact 
  • Two or more staff infected: facilities may be instructed to close to admissions if a cluster (2 or more within 7 days) of infected staff are identified, especially if those staff have significant patient contact. This closure would continue until at least one round of testing of all residents is completed and no evidence of transmission to residents; also test close staff contacts immediately. Second round of testing of all residents and close staff contacts at 7* and 14 days after last contact recommended as above.
*If baseline testing is performed near 7 days since last contact, then 14 day re-test alone is sufficient
Criteria for reopening to new admissions (must meet all 3):
  1. At least three (baseline, 7 days and 14 days) or more rounds of weekly screening of all COVID-negative residents/patients in the facility have been completed, and last two rounds have identified no new cases.
  2. It has been at least two weeks since last resident/patient case was identified,
  3. Staff have been tested within 14 days prior to reopening
Contact Information
Please contact Communicable Disease Control Division at 714-834-8180 with questions or concerns. Please note that this number is now operational 24/7 for medical providers. Please do not share this number with patients.

Case Numbers are updated daily on our website at: www.ochealthinfo.com/novelcoronavirus
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