OCHCA Guidance on Discontinuation of Transmission-Based Precautions for Patients Positive for COVID-19 in Hospitals and Facilities*
(*SNF, LTCF, RCFE, assisted/independent living or other senior living facility)
The Orange County Health Care Agency (OCHCA) recommends that senior living facilities develop and maintain standards in preparation for caring for 2019 Novel Coronavirus (COVID-19) in their facilities, so that hospitals will not be overburdened with patients no longer needing acute care.

The CDC gives test-based and non-test-based options for discontinuation of transmission-based precautions for hospitalized patients with confirmed COVID-19 ( https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html ).  Although the CDC states that test-based clearance is preferred for hospitalized patients and patients returning to a long term care facility (LTCF), this approach can be problematic for several reasons:

  1. Viral shedding may continue to occur for several weeks after illness improvement, leading to prolonged hospitalizations waiting to achieve two negatives;
  2. Viral shedding may recur after two consecutive negative tests;
  3. Patients going to LTCF may not be able to practice good respiratory hygiene due to disability or cognitive impairment, and respiratory symptoms may persist for several weeks after recovery;
  4. Senior residential settings are at high risk of COVID-19 outbreaks.

For these reasons, OCHCA advises that hospitals/facilities utilize a step-wise approach for patients being discharged to facilities, using the non-test-based strategy for discontinuation of airborne precautions and preparation for discharge, followed by a minimum 3 week period of droplet and contact precautions in either the hospital or facility setting (see attached clearance guide)

The CDC non-test-based strategy recommends that persons may be considered for discontinuation of transmission-based precautions when at least 3 days (72 hours) have passed since recovery, defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and, at least 7 days have passed since symptoms first appeared. After non-test-based criteria have been met, and patients are becoming stable for discharge but cannot return to a home setting, OCHCA recommends that hospitals and facilities do the following:

  • Consult with OCHCA to assure that the receiving facility has an appropriate setting to care for a confirmed COVID-19 case
  • If facility’s setting is appropriate, patient may be discharged to/accepted in the facility once CDC’s non-test-based clearance criteria (see above) have been met.
  • Maintain patient in universal, contact and droplet precautions (in own room with door closed) until at least 3 weeks after non-test-based criteria met, or until all symptoms have completely resolved, whichever is longer.
  • Cohort COVID-19-confirmed patients together in same room for convalescence if space does not allow for a single room for each patient (DO NOT cohort COVID suspects with COVID-confirmed patients).
  • Cohort staff and equipment for the care of these patients, and prioritize PPE (surgical masks, face shields and sturdy gowns) for their care.
  • If respiratory symptoms do not resolve completely by 3 weeks, but are mild (dry occasional cough) and the patient has no other symptoms, contact and droplet precautions may be discontinued at that point.          
  • If respiratory symptoms remain significant 3 weeks after non-test-based criteria met, the facility may choose to either continue droplet and contact precautions until respiratory symptoms resolve, or use a test-based strategy to discontinue precautions; the CDC’s test-based strategy requires two consecutive negative NP PCR swabs collected at least 24 hours apart.

It is important that facilities ensure that they have adequate PPE to be able to care for confirmed or suspected COVID-19 patients. Recent recommendations for universal masking in SNFs will affect overall PPE supplies, so please plan accordingly. Cloth masks can be used as source control for SNF staff that are not involved in any resident care activities, e.g., staff performing only administrative tasks and not having significant contact with residents. Respirators (if available) or surgical facemasks should be prioritized for staff performing resident care, implementing extended use/limited reuse policies. 

If you have any questions please contact the OCHCA Communicable Disease Control Division at 714-834-8180.