1
Los Angeles County Department of Public HealthAcute Communicable Disease Control Program
April 30, 2021
COVID-19 Update for Skilled Nursing Facilities
and
Infection Prevention and Control of MDRO’s like Candida auris:
Disclosures
1
There is no commercial support for today’s webinar.
Neither the speakers nor planners for today’s webinar have disclosed any financial interests related
to the content of the meeting.
This webinar is meant for skilled nursing facilities and is off the record. Reporters should log off now.
DISCLAIMER
• This is a rapidly evolving situation so the information being presented is current as of today (4/30/2021), so we highly recommend that if you have questions after today you utilize the resources that we will review at the end of this presentation.
2
Presentation Agenda
• Local COVID trends and dynamic dashboard• Vaccine updates for SNFs
– LTC Pharmacies– CAIR access look up
• Standardization of Emergency Contact Information• Frequently Asked Questions on Recent SNF Guidance Updates• Infection prevention and control of MDROs
– Candida auris
• Q and A
3
4http://publichealth.lacounty.gov/media/Coronavirus/data/index.htm
5
http://publichealth.lacounty.gov/snfdashboard.htm
6http://publichealth.lacounty.gov/media/Coronavirus/vaccine/vaccine-dashboard.htm
COVID Vaccine Updates for SNFs
Vaccine access for SNFs: Long-term care pharmacies
• LA County Health Officer Order (section 13.a) for SNFs mandates that SNFs offer COVID-19 vaccines to staff and residents as soon as the vaccine is made available
• COVID-19 vaccine distribution from LA County Public Health has transitioned to the Federal Retail Pharmacy Partnership (FRPP)– LA County Public Health has been providing either the facility or their contracted long-term care
(LTC) pharmacy with vaccine doses from the LA County allocation
• All LAC SNFs are advised to immediately contact their contracted LTC pharmacy to make arrangements to receive future vaccine doses by today April 30th– The DPH Warehouse will not be delivering vaccine after April 30th
• Most LTC pharmacies supporting SNFs are receiving vaccines directly through FRPP• A few LTC Pharmacies that are enrolling in the FRPP will not have vaccine until May
– For immediate 2nd dose needs before then, please email [email protected].
8
LTC pharmacies participate in FRPP:• Alliance Pharmacy• Del’s Pharmacy• Green Pharmacy• Hygeia LTC Pharmacy• Medicine Shoppe• MedPlus• Omnicare• Owl Western Pharmacy• Pharmerica• Premier Pharmacy/Good Health Inc.• Skilled Nursing Pharmacy (SNP)• Specialist Medical Pharmacy• Star Pharmacy• Verdugo Plaza Pharmacy
• Currently authorized vaccine products have equivalent efficacy with no CDC preferential recommendation
• LA County Health Officer Order (section 13.a) for SNFs mandates that SNFs offer COVID-19 vaccines to staff and residents as soon as the vaccine is made available
• If your LTC Pharmacy is not part of the FRPP and will not have access to any vaccine through their GPO, you can temporarily work with one of these LTC Pharmacies that is willing to offer limited support to non-contracted SNFs in LA County.– Premier (Kim Aksentijevic: [email protected])– Skilled Nursing Pharmacy (Raffaela Meyer:
[email protected])– Star Pharmacy (Fred Iskhakov: [email protected])
• As a last resort, please contact us ([email protected]) for assistance connecting with an LTC Pharmacy that has access to FRPP vaccine supply
9
SNF Vaccine Weekly Progress Survey 4/25-4/29 - 318 respondents
10
Required weekly vaccine progress survey responses requested by Wednesdays each week
Staff Residents TotalTotal 40459 25711 66170Vaccinated - 1st dose 33676 21516 55192
% vaccinated - 1st dose 83% 84%
Vaccinated - 2nd dose 32300 19700 52000
% vaccinated - 2nd dose 80% 77%
California Immunization Registry (CAIR) Look Up
• Most LAC SNFs have no user accounts or had accounts created in December but have never logged in– CAIR has made all of these sites Non-clinical (can request Read-only/QA access)
• If SNFs ever need Clinical access to log doses directly into CAIR, sites can be upgraded• Since most/all are using Prepmod/MyTurn/Mass Vax, clinical access not required• A few SNFs have active regular user accounts and have been logging in – those
remain as clinical sites
11
CAIR Look Up: Brief Instructions to request Read-only/QA user accounts• CAIR Account Update website: http://accountupdate.cairweb.org/• Login to “Account Update” using the site's CAIR Org Code and Zip Code.• Go to the section to add New Users. In the Field named 'User Role Requested'
choose Read-Only or QA user roles for you/your staff that need access– Note: The Read-only role allows staff to look-up patient records and run patient reports (e.g.,
Yellow Card, IZ History). The QA User Role allows staff to look up patient records and run clinic-level reports like the “Doses Administered” report.
– No training is required for either of these user roles.
• Once the Account Update request is submitted, the CAIR Help Desk will process it within a few days. The new users will get an email with their CAIR login information including a link to review the Read-only User Guide.
• For questions on how to submit the Account Update request, go to "instructions" on the Account Update login page to help guide you through the Account Update system. You can also contact the CAIR Help Desk [email protected], Phone: 800-578-7889 12
Standardization of Emergency Contact Information
Update facility emergency contacts with standardized email addresses• If you have not done so already, please create standard email addresses and update
Public Health by sending them to: [email protected]• Purpose is to maintain communication between Public Health and SNFs in the event
of staff turnover so we can continue to provide timely updates for emergencies• Good examples:
– [email protected]– [email protected]– [email protected]– [email protected]
• Avoid: [email protected]
• CDPH will also ask for this in an upcoming AFL15
FAQs on Recent SNF Guidance Updates
Visitation, Communal Dining, Group Activities• If a resident is within 90 days of last infection and has not yet received a vaccine, can
they receive indoor visitation and participate in communal dining/group activities as "fully vaccinated" residents?– No, they’re not considered the same as a fully vaccinated resident. They should be
treated as an unvaccinated person in regard to visitation, communal dining, group activities, cohort status (Green vs Yellow) etc. Vaccination still provides significantly more protection than natural immunity*. For that reason, persons who are <90 days of last infection are also recommended to get vaccinated against COVID-19 as long as criteria for discontinuing isolation has been met.
– “The risk for poor outcomes among unvaccinated SNF residents is highlighted by the hospitalization of four of the six unvaccinated, infected residents, and two subsequent deaths, including in one previously infected resident. This underscores the importance of the Advisory Committee on Immunization Practices’ recommendation that all persons, including those who have recovered from COVID-19, be vaccinated.” - MMWR report April 30, 2021 / 70(17);639-643
17
Cohorting• Can we prevent residents who are unvaccinated from leaving a facility to go out on
pass (e.g., to go to the grocery story, go to the bank, spend time with loved ones)? What about if we feel like their activity will put them at high risk for exposure even if they’re fully vaccinated?– From public health perspective, there are no requirements or recommendations to
prevent residents from leaving. Fully vaccinated asymptomatic residents without known prolonged close contact to confirmed case can return to Green Cohort.
– Consider reviewing possible cohort/zone changes ahead of time with all residents and their loved ones (e.g., for non-fully vaccinated residents)
18
Cohorting• Can a fully vaccinated dialysis resident be cohorted with other non-dialysis fully
vaccinated residents now that the dialysis residents are allowed to be in the Green cohort?– Yes
http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/prevention/#cohorting
19
Inter-facility Transfers• How do you recommend SNFs to confirm that there was no known close contact with
a case for a new admission to determine which zone they will be placed in? – For non-fully vaccinated residents, the quarantine period of 14 days starts on day 1
of admission to the SNF. Their hospitalization days do not count towards their quarantine.
– For fully vaccinated residents, given the currently low community transmission and the rare occurrence of outbreaks in the hospital/ED setting, they can be placed in the Green Cohort on admission to the SNF (unless it’s made known to the facility that there was a concern for close contact).
20
Inter-facility Transfers• If we do place a new admission who is not fully vaccinated in the Yellow Cohort, what
are the testing requirements? Do we still need to test upon admission and at the end of the 14-day quarantine?– Non-fully vaccinated new admissions and re-admissions should be quarantined in
Yellow Cohort for 14 days, no testing upon admission or at 14 days unless they become symptomatic in which case they need to be managed as such.
http://www.publichealth.lacounty.gov/acd/NCorona2019/InterfacilityTransferRules.htmhttp://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/prevention/#cohorting
21
Upcoming Updates• Routine testing
– Until further notice, Los Angeles County SNFs should continue to test 100% of staff weekly regardless of vaccination status
22
23
What remains the same: core infection prevention & control• Core infection prevention & control guidance regardless of county tier status, facility
outbreak status, vaccination status of staff, visitor, or resident– Entry screening for fever, symptoms, recent close contact– Universal masking– 6 ft distancing– Frequent hand hygiene (5 moments of hand hygiene)– Frequent disinfection of high touch surfaces– PPE use for each cohort: including eye protection (face shield/goggles) when providing patient care
<6 ft for Green Cohort residents– Isolation guidance for confirmed COVID-19 infections (positive viral test result) for both staff and
residents regardless of vaccination status
24
Infection Prevention and Control of MDRO’s: Candida auris
Epidemiology of C. auris
26
Why is Candida auris important? NASTY--it can cause significant morbidity & mortality in high-
risk patients– Up to 45% mortality in some regions– 5-10% of colonized cases will become infected
HARDY--it can survive in the environment and can spread quickly and establish residency in healthcare facilities if proper environmental cleaning practices are not followed.
– Can survive quaternary ammonium cleaners.
DIFFICULT TO TREAT--it can be resistant to most of the commonly used antifungal treatments available.
– Echinocandin, azole resistance and amphotericin resistance has been seen in some regions.
https://phil.cdc.gov/Details.aspx?pid=23239 27
LA County C. auris Cases, May 2020- April 2021 (n=489)
28
0
10
20
30
40
50
60
70
80
90
100
May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr
2020 2021
Clinical Surveillance Surveillance-to-clinical
Clinical= id’d via clinical specimen Surveillance= id’d via skin swab (colonized only) Surveillance-to-clinical= case who was colonized and later was positive in a clinical specimen
Affected facilities (n=489)
29
0 50 100 150 200 250 300 350 400 450
Other
Skilled Nursing Facility (SNF)
Subacute unit of SNF
Acute Care Hospital
Long Term Acute Care Hospital
Patient-level risk factors
• Presence of feeding tube (76%)• Presence of tracheostomy (57%)• Presence of wounds (55%)• Require mechanical ventilation (44%)
Photo Credit: CDC 30
Antifungal susceptibility testing results (n= 38)
Antifungal % Susceptible* Amphotercin B 100%Anidulafungin 100%Caspofungin 100%Fluconazole 0%Micafungin 100%Voriconazole (and other second gen triazoles)
N/A
*Per CDC-provided breakpoints: https://www.cdc.gov/fungal/candida-auris/c-auris-antifungal.html 31
Current LACDPH Recommendations for SNFs
32
DO NOT PANICDO NOT REFUSE
33
C. auris+MDRO Prevention Strategies: Back to Basics
Hand Hygiene Personal Protective Equipment & Precautions
Environmental Cleaning &
DisinfectionSlide Credit: Nimalie Stone, CDC
Disinfectants effective against C. auris
1. EPA- registered for claims against C. auris: https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants#candida-auris
2. CDC List of agents effective against C. auris: https://www.cdc.gov/fungal/candida-auris/pdf/section-18-public-health-exemption-508.pdf
If none of these available, then3. EPA- registered for claims against C. difficile: https://www.epa.gov/pesticide-
registration/list-k-epas-registered-antimicrobial-products-effective-against-clostridium
Consider using one now, even with no C. auris in-houseConsider using unit-wide when you have only a few positives/suspects in-house
35
Environmental Cleaning: General Principles Establish a standard process that
ensures consistency and prevents cross-contamination– Working around the room in same
direction every time – Always moving from clean areas
to dirty Adhere to contact time
– Clear labeling is helpful EVS vs Nursing Responsibilities are
clearly outlined
Slide Credit: Nimalie Stone, CDC
Cohorting
• Ideally, residents in Contact Precautions are placed into private rooms• If not possible, can cohort “like with like”
– Positives with positives, suspect with suspect, etc.– Consider other MDROs, COVID-19– Beds should be at least 3 feet apart
• Length of C. auris precautions: duration of admission– No clear CDC guidance for discontinuation of isolation– HCFs can work with ACDC directly for assessment/guidance
37
Inter-Facility Communication
• Use an inter-facility transfer form– LAC template ->– Lab reports should be attached
• For C. auris, call the IP at the receiving facility
http://publichealth.lacounty.gov/acd/docs/FacilityTransferForm.pdf 38
Some myths, de-mystified
39
What to expect from LACDPH
What we will do:• Reach out to provide guidance, resources,
sample policies & templates• Be available to answer any questions or
concerns• Call you to confirm you are aware of a
patient’s suspect or confirmed C. auris status
• Report facilities to licensing for refusing patients simply due to C. auris status alone
What we will NOT do:• Close facilities to admissions• Conduct point prevalence surveys solely
for the reason that you have C. aurispatients admitted
40
Individual Screening Recommendations
General Screening Guidance• Not currently mandated by LACDPH nor
CDPH• Known positives should not be re-swabbed• Screening of healthcare workers generally
not recommended
Screening Criteria– Persons discharged from all long-term acute
care hospitals (LTACHs)– Persons discharged from sites with ongoing
transmission– Epidemiologically-linked contacts (i.e.,
exposed roommates)– Persons with recent international
healthcare exposure– Persons with rare/emerging MDROs
CAHAN 3/8/21: http://publichealth.lacounty.gov/acd/docs/Cauris_Surveillance_CAHAN_March2021.pdfLACDPH under “who is at highest risk”: http://publichealth.lacounty.gov/acd/Diseases/CandidaAuris.htm 41
Colonization vs. contamination vs. infection
Colonization is when microorganisms live on us without causing disease.– Does not require treatment– May or may not be eradicable.– Ex. Skin swab grows Coagulase negative staph, Staph aureus, Candida, etc.
Contamination is when colonizing bacteria show-up in cultures but are not causing disease.– Does not require treatment– Can be confused for infection & causes over-treatment.– Ex. Candida in urine culture.
Infection is when microbes invade otherwise sterile sites and cause inflammation.– Needs treatment– Ex. Central line infection
42
Available Resources
43
Weekly C. auris Update
• Lists of SoCal facilities with active transmission shared with all LAC hospitals and SNFs
• Not publicly posted (email only)• Goals are to:
– Allow HCFs to identify ‘suspect C. auris’ -> implement precautions
– Provide updated guidance and resources, including laboratories offering screening guidance
– Offer answers to frequently asked questions
44
MDRO Resources
• CDC C. auris: https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html• LACDPH C. auris : http://publichealth.lacounty.gov/acd/Diseases/CandidaAuris.htm• LACDPH Novel MDRO: http://publichealth.lacounty.gov/acd/Diseases/NMDRO.htm• LACDPH CRE: http://www.publichealth.lacounty.gov/acd/Diseases/CRE.htm• CDPH HAI Program: https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/HAIProgramHome.aspx
– Go here for more guidance on Enhanced Standard Precautions: https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Enhanced-Standard-Precautions.pdf
• AHRQ Antibiotic Stewardship: https://www.ahrq.gov/nhguide/index.html
• Questions? Email us anytime at [email protected]
45
References on SNF Visitation Guideline Updates• Los Angeles County Public Health
– Main SNF COVID-19 Guidance: http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/prevention/– COVID-19 Guidance for Monitoring HCP: http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/HCPMonitoring/– Interfacility Transfer Rules: http://publichealth.lacounty.gov/acd/NCorona2019/InterfacilityTransferRules.htm
• CDPH– AFL 20-22.6: Guidance for Limiting the Transmission of COVID-19 in Long-Term Care Facilities
(https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-22.aspx)
– AFL 21-08.2: Guidance on Quarantine for HCP Exposed to SARS-CoV-2: (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-21-08.aspx)
• CDC– Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes:
https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html
– Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html
– Interim Public Health Recommendations for Fully Vaccinated People: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html
• CMS– QSO 20-39-NH, revised 3/10/2021: Nursing Home Visitation - COVID-19 (https://www.cms.gov/files/document/qso-20-39-
nh-revised.pdf) 46
COVID-19 Vaccine Online Resources for SNFs
• Los Angeles County Public Health– Vaccine Office Hours, Mon-Thu 9:00-9:30am
Microsoft Teams Meeting +1 323-776-6996 United States, Los Angeles (Toll) Conference ID: 973 498 904#
– COVID-19 Immunization Guidance for SNFs: http://ph.lacounty.gov/acd/ncorona2019/healthfacilities/snf/iz/
– Best Practices for Improving COVID-19 Vaccination Coverage in Skilled Nursing Facilities: http://publichealth.lacounty.gov/acd/ncorona2019/docs/SNFVaccinationCoverageBestPractices.pdf
– COVID-19 Vaccine Partner Checklist (including instructions on CalVax (myCAvax), PrepMod (MyTurn), CAIR, etc.): http://publichealth.lacounty.gov/acd/ncorona2019/vaccine/checklist/
• CDPH COVID-19 Vaccination Program: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/COVID-19Vaccine.aspx
• CDC: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html
– Interim Clinical Considerations for mRNA Vaccines: https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html
47
Questions and Answers
48
