Performing Facility-wide SARS-CoV-2 Testing in Nursing Homes

Purpose

CDC has recommendations for when nursing homes should test all residents and healthcare personnel (HCP) in nursing homes. This document describes considerations for performing facility-wide testing among nursing home residents and HCP. Facility-wide testing involves testing all residents and HCP for detection of SARS-CoV-2, the virus that causes COVID-19, and can be used to inform infection prevention and control (IPC) practices in nursing homes. This document is intended for health departments and nursing homes conducting viral testing for current infection, such as reverse-transcriptase polymerase chain reaction (RT-PCR).

For additional information about test-based strategies and the public health response to COVID-19 in nursing homes, please refer to:

• Interim Testing Guidance in Response to Suspected or Confirmed COVID-19 in Nursing Home Residents and Healthcare Personnel
• Considerations for the Public Health Response to COVID-19 in Nursing Homes

Preparing to perform facility-wide testing in nursing homes

• Health departments should develop a strategy for prioritizing testing among nursing home residents and healthcare personnel (HCP), depending on resources and goals.
  • Prioritize facilities based on the number of cases in the facility, community prevalence, or number of residents with recent healthcare exposures (e.g., recent hospitalization or receiving outpatient dialysis).
  • Plan for serial testing after the initial facility-wide testing to facilitate cohorting and identify new transmission events early.
    • Considerations for time intervals between testing include concern for ongoing transmission and logistics of repeat large scale testing.
  • Determine the type of Emergency Use Authorization or Food and Drug Administration approved viral test and the specimen source (e.g., nasopharyngeal, anterior nares) that will be used. Ensure availability of the required number of specimen collection kits and of personal protective equipment (PPE) needed for specimen collection.
  • If an infection control assessment has not already been performed, include an evaluation of IPC practices while conducting facility-wide testing. Testing should not supersede implementation of recommended IPC practices.
  • Consider other factors prior to testing, such as identifying a clinician who will order testing and how testing for HCP and residents will be funded.
  • Review relevant local, state and federal guidance and regulationspdf iconexternal icon on testing in nursing homes.
  • See Interim Testing Guidance in Response to Suspected or Confirmed COVID-19 in Nursing Home Residents and Healthcare Personnel for further details.
• Health departments and nursing homes should have a plan to respond to results of the testing prior to initiating testing.
  • Ensure results of initial testing inform cohorting approaches in nursing homes.
    • If a nursing home identifies positive residents and is unable to cohort, health departments and nursing homes should decide whether it is feasible to move residents to another designated facility. If a facility is uncertain about their ability to cohort, then the facility should work with local authorities to identify infection prevention and control solutions based on test results.
  • Ensure plan to exclude positive HCP from work. Establish policies to mitigate possible HCP staff shortages as a result of testing.
  • Determine how testing might be used to inform discontinuation of Transmission-Based Precautions for residents and when positive HCP will be allowed to return to work.

Planning for specimen collection and data management

• Health departments and nursing homes should establish who is responsible for performing specimen collection from residents and HCP and a process for specimen collection and transport.
  • Ensure all HCP can be tested, not just those on duty at time of facility-wide testing.
  • Consider whether a nursing home facility’s HCP can collect specimens from both residents and HCP or whether additional support is needed for specimen collection. The facility’s HCP may need to be trained to collect specimens correctly. Training should include IPC requirements and correct PPE use.
  • Determine whether HCP can be tested at the nursing home or whether they will be tested offsite and how results will be shared with the facility and health department.
  • Determine a process that captures which residents and HCP were tested or were unable to be tested.

Coordinating reporting of testing results

• Laboratories that can quickly process large numbers of tests with rapid reporting of results (e.g., within 48 hours) should be selected for facility-wide testing intended to inform infection prevention initiatives to prevent and limit transmission.
  • Ideally, one laboratory should be selected to process specimens from both HCP and residents to facilitate data collection and analysis.
• If the designated laboratory sends results directly to the nursing home, the nursing home and health department should coordinate how all results will be shared with the health department.
• Ensure results are shared between facilities and health departments, even if multiple laboratories perform testing (e.g., state lab performs testing for residents and commercial laboratory performs testing for HCP).
• Health departments should develop a systematic method to receive testing results from laboratories and nursing homes.
• Health departments that receive results directly from surveillance systems or laboratories should ensure the results include date of testing, facility name, and the role of the individual tested (i.e., resident, HCP).
• Nursing homes should maintain records of HCP and residents who have positive tests; those records can facilitate reporting aggregate data into the National Healthcare Safety Network (NHSN) COVID-19 Module for LTCF.
• Data collection tools, which may include baseline epidemiologic information, developed by health departments should be shared with a responsible point of contact at each nursing home. The facility point of contact should be trained on how to collect and submit such data to ensure consistency across nursing homes.
• Testing should be carried out in a way that protects confidentiality to the extent possible and is consistent with applicable laws and regulations.
• Federal regulationspdf iconexternal icon require informing patients, staff, and families of the number of cases in the facility; facilities must have plans for meeting these regulations.
• When employers become aware of cases, the Recordkeeping and Reporting Occupational Injuries and Illness standard (29 CFR 1904external icon), requires certain employers to keep a record of serious work-related injuries and illnesses including work related COVID-19.

Recommendations for conducting swabbing

General considerations

• Follow CDC’s Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19)
• The number of people present during specimen collection should be limited to only those essential for care and procedure support.
  • Visitors or other bystanders should not be present for specimen collection.
• Swabbing of multiple individuals should not be performed in the same room at the same time, unless appropriate separation between swabbing stations can be maintained (see below).

Consider if self-collection is appropriate

• PPE use can be minimized through self-collection while HCP remain at least 6 feet away of the individual being swabbed.
• The individual must be able to correctly self-swab and place the swab in transport media or sterile transport device and seal.
  • If the individual needs assistance, assistance can be provided by placing the swab into transport media or a sterile transport device and sealing it for them.
• If bulk-packaged swabs are used for sample collection, care must be exercised to avoid contamination of any of the swabs in the bulk-packaged container.

Location of specimen collection for nursing home residents

• Specimen collection should be performed one at a time in each resident’s room with the door closed. An airborne infection isolation room is not required. Ideally for rooms with multiple residents, specimen collection should be performed one individual at a time in a room with the door closed and no other individuals present.

Location of specimen collection for HCP

• Ideally, specimen collection should be performed one individual at a time in a room with the door closed and no other individuals present. If individual rooms are not available, other options include:
  • Large spaces (e.g., gymnasiums) where sufficient space can be maintained between swabbing stations (e.g., greater than 6 feet apart).
  • An outdoor location, weather permitting, where other individuals will not come near the specimen collection activity.
• Considerations for multiple HCP being swabbed in succession in a single room:
  • Consider the use of portable HEPA filters to increase air exchanges and to expedite removing infectious particles.
  • Minimize the amount of time the HCP will spend in the room. HCP awaiting swabbing should not wait in the room where swabbing is being done. Those swabbed should have a face mask or cloth cover in place for source control throughout the process, only removing it during swabbing.
• Minimize the equipment kept in the specimen collection area. Consider having each person bring their own prefilled specimen bag containing a swab and labeled sterile viral transport media container into the testing area from the check-in area.

PPE for swabbing

• HCP in the room or specimen collection area should wear an N95 or higher-level respirator (or facemask if a respirator is not available) and eye protection. A single pair of gloves and a gown should also be worn for specimen collection or if contact with contaminated surfaces is anticipated.
  • If respirators are not readily available, they should be prioritized for other procedures at higher risk for producing infectious aerosols (e.g., intubation), instead of for collecting nasopharyngeal specimens.
• Extended use of respirators (or facemasks) and eye protection is permitted. However, care must be taken to avoid touching the necessary face and eye protection. If extended use equipment becomes damaged, soiled, or hard to breathe or see through, it should be replaced. Hand hygiene should be performed before and after manipulating PPE.
• Gloves should be changed and hand hygiene performed between each person being swabbed.
• Gowns should be changed when there is more than minimal contact with the person or their environment. The same gown may be worn for swabbing more than one person provided the HCP collecting the test minimizes contact with the person being swabbed. Gowns should be changed if they become soiled.
• Consider having an observer who does not engage in specimen collection but monitors for breaches in PPE use throughout the specimen collection process.
• HCP who are handling specimens, but are not directly involved in collection (e.g., self-collection) and not working within 6 feet of the individual being tested, should follow Standard Precautions; gloves are recommended, as well as a facemask for source control. 

Cleaning and disinfection between individuals

• Surfaces within 6 feet of where specimen collection was performed should be cleaned and disinfected using an Environmental Protection Agency-registered disinfectant from List Nexternal icon if visibly soiled and at least hourly.
• Terminal cleaning and disinfection of all surfaces and equipment in the specimen collection area should take place at the end of each day. Resident rooms should be cleaned and disinfected in accordance with Implementing Environmental Infection Control in the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.

Definitions

• Healthcare personnel (HCP): HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, volunteer personnel).