Testing Guidelines for Nursing Homes


  • Reorganized recommendations to address:
    • Viral testing of healthcare personnel (HCP)
    • Viral testing of residents
    • Viral testing in response to an outbreak
  • Changed “baseline” testing to “initial” testing, although these terms are interchangeable
  • Added the following recommendations:
    • Testing the same individual more than once in a 24-hour period is not recommended.
    • Clinicians are encouraged to consider testing symptomatic residents for other causes of respiratory illness, for example influenza, in addition to testing for SARS-CoV-2.

Note:  This document is intended to provide guidance on the appropriate use of testing among nursing home residents and healthcare personnel and does not dictate the determination of payment decisions or insurance coverage of such testing, except as may be otherwise referenced (or prescribed) by another entity or federal or state agency.

Interim SARS-CoV-2 Testing Guidelines for Nursing Home Residents and Healthcare Personnel (HCP)

Nursing home residents are at high risk for infection, serious illness, and death from COVID-19. Testing for SARS-CoV-2, the virus that causes COVID-19, in respiratory specimens can detect current infections (referred to here as viral testing) among residents and HCP in nursing homes. Viral testing in nursing homes, with authorized nucleic acid or antigen detection assays, is an important addition to other infection prevention and control (IPC) recommendations aimed at preventing SARS-CoV-2 from entering nursing homes, detecting cases quickly, and stopping transmission.  This guideline is based on currently available information about COVID-19 and will be refined and updated as more information becomes available.

Testing conducted at nursing homes should be implemented in addition to recommended IPC measures.  Facilities should have a plan for testing residents and HCP for SARS-CoV-2.  Additional information about the components of the testing plan are available in the CDC guidance addressing Preparing for COVID-19 in Nursing Homes.

Testing practices should aim for rapid turnaround times (e.g., less than 48 hours) in order to facilitate effective interventions. Testing the same individual more than once in a 24-hour period is not recommended.  Antibody (serologic) test results should generally not be used as the sole basis to diagnose an active SARS-CoV-2 infection and should not be used to inform IPC action.

While this guidance focuses on testing in nursing homes, it can also be applied to other long-term care facilities (e.g., assisted living facilities, intermediate care facilities for individuals with intellectual disabilities, institutions for mental disease, and psychiatric residential treatment facilities).

Viral Testing of Healthcare Personnel for SARS-CoV-2

  • At the start of each shift, take the temperature of all HCP and ask about the presence of COVID-19 symptoms; perform viral testing of any HCP who have signs or symptoms of COVID-19.
    • HCP who have fever or symptoms should be excluded from work pending results of the test.
  • Perform initial viral testing of all HCP, along with weekly viral testing thereafter, as part of the recommended reopening processpdf icon
  • HCP who test positive for SARS-CoV-2 should be excluded from work until they meet return to work criteria.
    • Facility leadership and local and state health departments should have a plan for performing contact tracing for close contacts of HCP with SARS-CoV-2 infection and meeting staffing needs to provide safe care to residents when HCP who test positive are excluded from work. CDC has created strategies to assist facilities with mitigating HCP shortages.

Viral Testing of Residents for SARS-CoV-2

  • Perform initial viral testing of each resident in a nursing home, as part of the recommended reopening processpdf icon
  • At least daily, take the temperature of all residents and ask them about presence of COVID-19 symptoms; perform viral testing of any residents who have signs or symptoms of COVID-19.
    • Clinicians should use their judgment to determine if a resident has signs or symptoms consistent with COVID-19 and whether the resident should be tested. Most people with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough). Some people may present with only mild symptoms or other symptoms as well.
    • Clinicians are encouraged to consider testing for other causes of respiratory illness, such as influenza, in addition to testing for SARS-CoV-2.
    • Facility leadership and local and state health departments should have a plan for performing contact tracing for close contacts of residents with SARS-CoV-2 infection

Viral Testing in Response to an Outbreak

Initial Viral Testing in Response to an Outbreak

  • Perform expanded viral testing of all residents and HCP in the nursing home if there is an outbreak in the facility (i.e., a new SARS-CoV-2 infection in any HCP, or any nursing home-onsetSARS-CoV-2 infection in a resident).
    • A single new case of SARS-CoV-2 infection in any HCP or a nursing home-onsetSARS-CoV-2 infection in a resident should be considered an outbreak. When one case is detected in a nursing home, there are often other residents and HCP who are infected with SARS-CoV-2 who can continue to spread the infection, even if they are asymptomatic. Performing viral testing of all residents and HCP as soon as there is a new confirmed case in the facility will identify infected individuals quickly to assist in their clinical management and allow rapid implementation of IPC interventions (e.g., isolation, cohorting, use of personal protective equipment) to prevent SARS-CoV-2 transmission. When undertaking facility-wide viral testing, facility leadership should expect to identify multiple asymptomatic and pre-symptomatic residents and HCP with SARS-CoV-2 infection and be prepared to cohort residents and mitigate potential staffing shortages. See Public Health Response to COVID-19 in Nursing Homes and Strategies to Mitigate Healthcare Personnel Staffing Shortages for more detail.
    • If viral testing capacity is limited, CDC suggests first directing testing to residents and HCP who are close contacts (e.g., on the same unit or floor of a new confirmed case).
    • See Considerations for Performing Facility-wide SARS-CoV-2 Testing in Nursing Homes for additional details.

Repeat Viral Testing in Response to an Outbreak

  • After initially performing viral testing of all residents and HCP in response to a new case, CDC recommends repeat testing to ensure there are no new infections among residents and HCP, and that transmission has been terminated as described below.  Repeat testing should be coordinated with the local, territorial, or State health department.
  • Immediately perform viral testing of any resident or HCP who subsequently develops signs or symptoms consistent with COVID-19.
  • Continue repeat viral testing of all previously negative residents, generally between every 3 days to 7 days, until the testing identifies no new cases of SARS-CoV-2 infection among residents or HCP for a period of at least 14 days since the most recent positive result. This follow-up viral testing can assist in the clinical management of infected individuals and in the implementation of infection control interventions to prevent SARS-CoV-2 transmission.
    • If viral test capacity is limited, CDC suggests directing repeat rounds of testing to residents who leave and return to the facility (e.g., for outpatient dialysis) or have known exposure to a case (e.g., roommates of cases or those cared for by a HCP with confirmed SARS-CoV-2 infection). For large facilities with limited viral test capacity, testing all residents on affected units could be considered, especially if facility-wide repeat viral testing demonstrates no transmission beyond a limited number of units.
  • Continue repeat viral testing of all previously negative HCP, generally between every 3 to 7 days, until the testing identifies no new cases of SARS-CoV-2 infection among residents or HCP for a period of at least 14 days since the most recent positive result.
    • If testing capacity is limited, CDC suggests directing repeat HCP testing to HCP who work at the current facility and also work at other facilities where there are known cases of SARS-CoV-2 infection.

Definitions

  • Healthcare Personnel (HCP): HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, feeding assistants, students and trainees, contractual HCP 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, and volunteer personnel).
  • Nursing home onset SARS-CoV-2 infections refers to SARS-CoV-2 infections that originated in the nursing home. It does not refer to the following:
    • Residents who were known to have COVID-19 on admission to the facility and were placed into appropriate Transmission-Based Precautions to prevent transmission to others in the facility.
    • Residents who were placed into Transmission-Based Precautions on admission and developed SARS-CoV-2 infection within 14 days after admission.
  • Substantial community transmission: Large scale community transmission, including communal settings (e.g., schools, workplaces)
  • Minimal to moderate community transmission: Sustained transmission with high likelihood or confirmed exposure within communal settings and potential for rapid increase in cases
  • No to minimal community transmission: Evidence of isolated cases or limited community transmission, case investigations underway; no evidence of exposure in large communal setting



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