U.S. Department of Health & Human Services

02/23/2021 | Press release | Distributed by Public on 02/23/2021 17:09

Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic

1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic

CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed SARS-CoV-2 infection (See Section 2 for additional practices that should be used when caring for patients with suspected or confirmed SARS-CoV-2 infection). Facilities should develop policies and procedures to ensure recommendations are appropriately applied in their setting (e.g., emergency department, home healthcare delivery).

These additional practices include:

Implement Telehealth and Nurse-Directed Triage Protocols

  • Continue to use telehealth strategies to reduce the risk of SARS-CoV-2 transmission in healthcare settings while maintaining high quality patient care.
  • When scheduling appointments for routine medical care (e.g., annual physical, elective surgery):
    • Advise patients that they should put on their own well-fitting form of source control (see Implement Universal Source Control Measures for more details) before entering the facility.
    • Instruct patients to call ahead and discuss the need to reschedule their appointment if they have symptoms of COVID-19 within the 10 days prior to their appointment, if they have been diagnosed with SARS-CoV-2 infection within the 10 days prior to their appointment, or if they have had close contact with someone with suspected or confirmed SARS-CoV-2 infection within 14 days prior to their scheduled appointment.
  • When scheduling appointments for patients requesting evaluation for possible SARS-CoV-2 infection, use nurse-directed triage protocols to determine if an appointment is necessary or if the patient can be managed from home.
    • If the patient must come in for an appointment, instruct them (or their responsible party if they are unable to communicate) to take appropriate preventive actions (e.g., follow triage procedures, put on their own well-fitting form of source control before entry and throughout their visit or, if a well-fitting form of source control cannot be tolerated, hold a tissue against their mouth and nose to contain respiratory secretions) and immediately inform triage personnel upon arrival (e.g., call from car) so they can be placed in an examination room.

Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19

Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented.

  • Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility
    • Post visual alertspdf icon (e.g., signs, posterspdf icon ) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a well-fitting form of source control and how and when to perform hand hygiene.
    • Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand sanitizer (ABHS) with 60-95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.
  • Limit and monitor points of entry to the facility.
  • Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control.
    • Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days.
      • Fever can be either measured temperature ≥100.0°F or subjective fever. People might not notice symptoms of fever at the lower temperature threshold that is used for those entering a healthcare setting, so they should be encouraged to actively take their temperature at home or have their temperature taken upon arrival.
      • Obtaining reliable temperature readings is affected by multiple factors, including:
        • The ambient environment in which the temperature is measured: If the environment is extremely hot or cold, body temperature readings may be affected, regardless of the temperature-taking device that is used.
        • Proper calibration of the thermometers per manufacturer standards: Improper calibration can lead to incorrect temperature readings.
        • Proper usage and reading of the thermometers: Non-contact infrared thermometers frequently used for health screening must be held at an established distance from the temporal artery in the forehead to take the temperature correctly. Holding the device too far from or too close to the temporal artery affects the reading.
  • Properly manage anyone with suspected or confirmed SARS-CoV-2 infection or who has had contact with someone with suspected or confirmed SARS-CoV-2 infection:
    • Healthcare personnel (HCP) should be excluded from work and should notify occupational health services to arrange for further evaluation.
    • Visitors should be restricted from entering the facility and be referred for proper evaluation.
  • Patients should be isolated in an examination room with the door closed.
  • If an examination room is not immediately available, such patients should not wait among other patients seeking care.
    • Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies.
    • In some settings, patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated.
    • Depending on the level of transmission in the community, facilities might also consider designating a separate area at the facility (e.g., an ancillary building or temporary structure) or nearby location as an evaluation area where patients with symptoms of COVID-19 can seek evaluation and care.

Re-evaluate admitted patients for signs and symptoms of COVID-19

Screening for fever and symptoms should also be incorporated into daily assessments of all admitted patients. All fevers and symptoms consistent with COVID-19 among admitted patients should be properly managed and evaluated (e.g., place any patient with unexplained fever or symptoms of COVID-19 on appropriate Transmission-Based Precautions and evaluate).

Implement Universal Source Control Measures

Source control refers to use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. In addition to providing source control, these devices also offer varying levels of protection for the wearer against exposure to infectious droplets and particles produced by infected people. Ensuring a proper fit is important to optimize both the source control and protection offered. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19.

  • Patients and visitors should wear their own well-fitting form of source control upon arrival to and throughout their stay in the facility. If they do not bring their own, they should be offered an option that is equivalent to what is recommended for people in the community
    • Patients may remove their source control when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room.
    • Cloth masks, facemasks and respirators should not be placed on young children under age 2, anyone who cannot wear one safely, such as someone who has a disability or an underlying medical condition that precludes wearing a mask safely, or anyone who is unconscious, incapacitated or otherwise unable to remove their cloth mask, facemask or respirator without assistance.
    • Visitors who are not able to wear source control should be encouraged to use alternatives to on-site visits with patients (e.g., telephone or internet communication), particularly if the patient is at increased risk for severe illness from SARS-CoV-2 infection.
  • For guidance on recommended source control for HCP, refer to Implement Universal Use of Personal Protective Equipment below.
    • HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.
    • To reduce the number of times HCP must touch their face and potential risk for self-contamination, when used for source control, HCP should consider continuing to wear the same respirator or well-fitting facemask (extended use) throughout their entire work shift.
    • HCP should remove their respirator or facemask, perform hand hygiene, and put on their community source control when leaving the facility at the end of their shift.
  • Educate patients, visitors, and HCP about the importance of performing hand hygiene, including immediately before and after any contact with their cloth mask, facemask, or respirator.

Encourage Physical Distancing

Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission.

Examples of how physical distancing can be implemented for patients include:

  • Limiting visitors to the facility to those essential for the patient's physical or emotional well-being and care (e.g., care partner, parent).
    • Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets.
  • Scheduling appointments to limit the number of patients in waiting rooms, or creating a process so that patients can wait outside or in their vehicle while waiting for their appointment.
  • Arranging seating in waiting rooms so patients can sit at least 6 feet apart.
  • Modifying in-person group healthcare activities (e.g., group therapy, recreational activities) by implementing virtual methods (e.g., video format for group therapy) or scheduling smaller in-person group sessions while having patients sit at least 6 feet apart.
    • In some circumstances, such as higher levels of community transmission or numbers of patients with COVID-19 being cared for at the facility, and when healthcare-associated transmission is occurring, facilities might cancel in-person group activities in favor of an exclusively virtual format.

For HCP, the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers in breakrooms or co-workers or visitors in other common areas. Examples of how physical distancing can be implemented for HCP include:

  • Reminding HCP that the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions.
  • Emphasizing the importance of source control and physical distancing in non-patient care areas.
  • Providing family meeting areas where all individuals (e.g., visitors, HCP) can remain at least 6 feet apart from each other.
  • Designating areas and staggered schedules for HCP to take breaks, eat, and drink that allow them to remain at least 6 feet apart from each other, especially when they must be unmasked.

Implement Universal Use of Personal Protective Equipment

Transmission from asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection can occur in healthcare settings, particularly in areas with moderate to substantial community transmission.

The fit of the medical device used to cover the wearer's mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer's exposure to infectious particles. Respirators offer the highest level of both source control and protection against inhalation of infectious particles in the air. Facemasks that conform to the wearer's face so that more air moves through the material of the facemask rather than through gaps at the edges are more effective for source control than facemasks with gaps and can also reduce the wearer's exposure to particles in the air. Improving how a facemask fits can increase the facemask's effectiveness for decreasing particles emitted from the wearer and to which the wearer is exposed.

PPE recommended for the care of patients with suspected or confirmed SARS-CoV-2 infection is described in Section 2.

HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history):

  • HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis; for example, use an N95 respirator or equivalent or higher level respirator if the patient is suspected to have tuberculosis).
  • Additionally, HCP should use PPE as described below:
    • N95 respirators or equivalent or higher-level respirators should be used for
      • All aerosol-generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings? ) AND
      • All surgical procedures that might pose higher risk for transmission if the patient has COVID-19 (e.g., that generate potentially infectious aerosols or involving anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, respiratory tract) (refer to Surgical FAQ During the COVID-19 pandemic, are there special considerations for surgical or other procedural settings, including performance of AGPs?).
    • One of the following should be worn by HCP for source control while in the facility and for protection during patient care encounters:
    • Eye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions.

HCP working in areas with minimal to no community transmission, should continue to adhere to Standard and Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses. This might include use of eye protection, an N95 or equivalent or higher-level respirator, as well as other personal protective equipment (PPE). In addition, universal use of a well-fitting facemask for source control is recommended for HCP if not otherwise wearing a respirator.

Consider Performing Targeted SARS-CoV-2 Testing of Patients Without Signs or Symptoms of COVID-19

In addition to the use of universal PPE and source control in healthcare settings, targeted SARS-CoV-2 testing of patients without signs or symptoms of COVID-19 might be used to identify those with asymptomatic or pre-symptomatic SARS-CoV-2 infection and further reduce risk for exposures in some healthcare settings. Depending on guidance from local and state health departments, testing availability, and how rapidly results are available, facilities can consider implementing pre-admission or pre-procedure screening testing with authorized nucleic acid or antigen detection assays for SARS-CoV-2.
Testing results might inform decisions about rescheduling elective procedures or about the need for additional Transmission-Based Precautions when caring for the patient. Limitations of using this testing strategy include obtaining negative results in patients during their incubation period who later become infectious and false negative test results, depending on the test method used.

Consider if elective procedures, surgeries, and non-urgent outpatient visits should be postponed in certain circumstances.

Facilities must balance the need to provide necessary services while minimizing risk to patients and HCP. Facilities should consider the potential for patient harm if care is deferred when making decisions about providing elective procedures, surgeries, and non-urgent outpatient visits. Refer to the Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic for additional guidance.

Optimize the Use of Engineering Controls and Indoor Air Quality

  • Optimize the use of engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals. Examples of engineering controls include:
    • Physical barriers and dedicated pathways to guide symptomatic patients through triage areas.
    • Remote triage facilities for patient intake areas.
    • If climate permits, outdoor assessment and triage stations for patients with respiratory symptoms.
    • Vacuum shrouds for surgical procedures likely to generate aerosols.
    • Reassess the use of open bay recovery areas.
  • Explore options, in consultation with facility engineers, to improve indoor air quality in all shared spaces.

Create a Process to Respond to SARS-CoV-2 Exposures Among HCP and Others

Healthcare facilities should have a process for notifying the health department about suspected or confirmed cases of SARS-CoV-2 infection, and should establish a plan, in consultation with local public health authorities, for how exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. The plan should address the following:

  • Who is responsible for identifying contacts (e.g., HCP, patients, visitors) and notifying potentially exposed individuals?
  • How will such notifications occur?
  • What actions and follow-up are recommended for those who were exposed?

Contact tracing should be carried out in a way that protects the confidentiality of affected individuals and is consistent with applicable laws and regulations. HCP and patients who are currently admitted to the facility or were transferred to another healthcare facility should be prioritized for notification. These groups, if infected, have the potential to expose a large number of individuals at higher risk for severe disease, or in the situation of admitted patients, are at higher risk for severe illness themselves. Additional guidance on assessing the risk for patients and co-workers exposed to HCP who worked while infected with SARS-CoV-2 infection is available in the Healthcare Infection Prevention and Control FAQs for COVID-19

Information about when HCP with suspected or confirmed SARS-CoV-2 infection may return to work is available in the Interim Guidance on Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19.

Information about risk assessment and work restrictions for HCP exposed to SARS-CoV-2 is available in the Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to Coronavirus Disease 2019 (COVID-19).

Healthcare facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate these, including providing resources to assist HCP with anxiety and stress. Strategies to mitigate staffing shortages are available.