Pandemic Playbook - Chapter 3
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Clinical Impact, Infection Control, and Vaccination

Chapter Contents

Insights and Issues: The 2020-21 Pandemic
Management and Policy on Approaching Clinical Issues
Testing
Infection Control
Personal Protective Equipment (PPE)
Protecting the Workforce
COVID-19 Vaccination
Design for Infection Control and Future Safety
Lessons Learned

Infections are common in long-term care facilities. Staff are trained to respond to outbreaks of respiratory tract infections, influenza A, and gastrointestinal infections. In 2020, we dealt with the outbreak of a global pandemic that stressed all systems. We were little prepared with experience, guidance, testing or personal protective equipment (PPE). LTSS providers needed to learn how to prevent, prepare, mitigate, test, isolate, and care for COVID-19-positive cases among both residents and staff with little direction or support.

As we struggled to obtain very limited PPE, residents were fearful, family members were anxious about their loved ones, staff were either “all in” or “all out” in response to stress and fear, and hospitals were preparing to transfer COVID-positive older adults to our communities. Though seemingly insurmountable at the onset, LTSS providers stepped up amid the worst of circumstances to do their best for those they serve, with quality, respect, and compassion.

Insights and Issues: The 2020-21 Pandemic

LeadingAge LTSS Center at UMass Boston research reports:

Management and Policy on Approaching Clinical Issues

What hit the U.S. in early March 2020 was not a rampant, unvaccinated strain of the flu or a natural disaster or a recession. It was worse than all of these; it had a beginning, but it does not have a predictable end.

What was needed to manage older adult housing, care and services in 2020 isn’t in an existing textbook and you can’t Google ideas or a template. It required “rethinking the wheel” in terms of management, policy development, infection control protocols, staff coverage, communications, and more. Providers in long-term services and supports created their own textbooks by quick thinking and complex problem-solving—one day at a time.

Leadership Strategies

Overall Policy for Suspected or Confirmed Positives

  • COVID-19 Interim Policy for Suspected or Confirmed Coronavirus (Pathway Health): This template serves as an overall policy for an organization, outlining the key procedures performed by the provider for preparation, mitigation, and response to COVID-19. It is a comprehensive policy that incorporates the processes necessary to minimize exposure to respiratory pathogens, promptly identify residents or health care personnel with signs or symptoms of COVID-19, manage residents confirmed with COVID-19, and implement interventions based upon federal and state/local recommendations (to include admissions, visitation, standard and transmission-based precautions, hand hygiene, universal source control, PPE use, resident placement, and more).

Testing

Testing is a complex and ever-changing activity in pandemic identification and control. Early on, the Centers for Disease Control (CDC) began issuing guidance on testing in response to an outbreak. “Outbreak” was defined as one positive case of COVID-19 among either residents or staff. The CDC recommended that all residents and staff be tested upon identification of an outbreak. Week-to-week, and sometimes day-to-day, the guidance shifted as scientists learned more about the virus.

Among the main barriers to responsible and reliable testing are the cost, the significant staff time required to complete testing, the access to tests, and the need for rapid turn-around of results. In older adult care, routine staff testing can be overwhelming, logistically and financially.

Infection Control

There are many essential aspects to the prevention of the spread of COVID-19, as well as other pathogens, in long-term care settings. The environment plays a crucial role in the prevention of spread of infection. It is important to identify exactly how this virus spreads in order to find every way possible to prevent transmission in the facility.

Cleaning, Disinfection, and Hand Hygiene

Cleaning and disinfection practices will be essential. All departments must follow cleaning and disinfection policies and procedures.

Dealing With COVID-Positive Residents

  • Leadership Checklist for Potential COVID-19 Admissions (Pathway Health): The Leadership T.H.I.N.K. Ahead Strategies Guide can help an organization’s leaders think strategically about issues related to admitting individuals who are positive for COVID-19. T.H.I.N.K. refers to an organization’s “T-team,” or task force related to COVID-19; Human resource issues; Infection prevention and control issues; Notification issues; and Knowledge issues.
  • Confirmed COVID-19 Resident Protocol Checklist (Pathway Health): This checklist, designed for facility leadership, outlines steps related to a confirmed COVID-19 resident. It was designed to highlight leadership, clinical, and staff actions in accordance with organizational policy and procedures, federal requirements, and state/local public health department requirements.
  • Panel on non-invasive ventilation seeks to simplify ‘maze’ of regulation for device coverage (American College of Chest Physicians): A technical expert panel has published recommendations that could help expedite national coverage determinations for optimal noninvasive ventilation and inform related policies for respiratory care and Medicare access.

Other Infection Control Resources

Transfers and Admissions

Long-term care facilities, like all health care facilities, should prepare for potential shortages in clinical and non-clinical staff and have a plan and processes in place to mitigate such shortages. Part of the emergency planning process is to identify contingency and crisis capacity strategies to be considered.

Personal Protective Equipment (PPE)


Protecting the Workforce

Maintaining appropriate staffing in facilities is essential to providing a safe work environment for our staff and to foster safe resident care. Long-term care facilities, like all health care facilities, should prepare for potential shortages in clinical and non-clinical staff and have a plan and processes in place to mitigate such shortages. Part of the emergency planning process is to identify contingency and crisis capacity strategies to be considered.

COVID-19 Vaccination

Emergency Use Authorization (EUA) authority allows the U.S. Food and Drug Administration (FDA) to facilitate the availability and use of medical countermeasures needed during public health emergencies.

On Dec. 11, 2020, the FDA issued the first EUA for a vaccine for the prevention of COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in individuals 16 and older. This EUA allows the Pfizer-BioNTech COVID-19 vaccine to be distributed in the U.S.

On Dec. 18, 2020, the FDA issued an EUA for the second vaccine for the prevention of COVID-19, the Moderna COVID-19 vaccine, for individuals 18 and older.

The unprecedented speed of the clinical trials and approval of 2 vaccine options provided Americans with the first, albeit cautious, sense of optimism regarding COVID-19 mitigation. As expected, the extraordinary challenges associated with the distribution and administration of these vaccines to all receptive Americans over the age of 16 are daunting and unpredictable; consequently, information and guidelines are frequently modified based upon a wide range of field experiences.

Due to the volatility of guidance, accessibility, and overall detail associated with the vaccines and vaccination process, this Playbook features only vaccine-related content and resources that are more broad and less susceptible to frequent modification. Up-to-date, significantly more detailed information can be accessed on the LeadingAge website.

LeadingAge resources: 

CDC educational resources:

 LeadingAge audio interviews:

Other resources:

Resources to Support Discussions about Vaccine Hesitancy in Nursing Homes:

Design for Infection Control and Future Safety

Among the many necessary changes to post-pandemic senior living will be the need to modify existing floor plans and develop new architectural designs to mitigate the spread of infection. Whether it’s as simple as designing common areas to be more spacious, or as complex as constructing an entrance area that accommodates several employee/visitor screening methodologies, we must design defensively to combat this and possible future viral outbreaks. Several LeadingAge business members have generously offered to share their approaches to infection control via design for our Playbook.

Lessons Learned

In the midst of an emergency as impactful as a pandemic, we must often act first and reflect later. It’s common for leaders to ask themselves retrospective questions, such as:

  • Did I act too quickly or too slowly?
  • What could I have done differently?
  • Did my approach of choice work as well as I anticipated it would?
  • How can I improve my responses if a pandemic recurs?
  • And then, of course, there are a lengthy series of “What ifs” that we ponder.

LeadingAge has received numerous “lessons learned” tips from members during the COVID-19 pandemic, which we are sharing at the conclusion of each related Playbook Section. In addition, a compilation of shared Lessons Learned may be referenced in the Playbook Appendix.

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