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Discontinuation of isolation precautions for coronavirus disease 2019 (COVID-19) patients

Part of: SARS-CoV-2/COVID-19

Published online by Cambridge University Press:  03 May 2021

Laura Anderson ,
Emily Schmitz ,
Philip M. Polgreen ,
Susan E. Beekmann  and
Nasia Safdar
Laura Anderson
Affiliation:
University of Wisconsin Health, Madison, Wisconsin
Emily Schmitz
Affiliation:
University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
Philip M. Polgreen
Affiliation:
University of Iowa Carver College of Medicine, Emerging Infections Network, Iowa City, Iowa
Susan E. Beekmann
Affiliation:
University of Iowa Carver College of Medicine, Emerging Infections Network, Iowa City, Iowa
Nasia Safdar*
Affiliation:
University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin William S. Middleton Memorial Veterans’ Hospital, Madison, Wisconsin
*
Author for correspondence: Nasia Safdar, E-mail: ns2@medicine.wisc.edu
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Abstract

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Information

Type
Research Brief
Information
Infection Control & Hospital Epidemiology , Volume 43 , Issue 1 , January 2022 , pp. 109 - 113
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Early in the coronavirus disease-19 (COVID-19) pandemic, research showed that hospital-related transmission may be contributing to the spread of the virus. Reference Wang, Hu and Hu1 Appropriate implementation of transmission-based precautions is critical to preventing severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission between patients and healthcare workers. Healthcare workers caring for patients with confirmed or suspected COVID-19 should wear a National Institute for Occupational Safety and Health (NIOSH)–approved N95 (or equivalent or higher-level respirator), gown, gloves, and eye protection. Given uncertainty regarding how long patients with COVID-19 remain infectious, it remains unclear when the discontinuation of transmission-based precautions is appropriate.

The Centers for Disease Control and Prevention (CDC) outlines 3 strategies for discontinuing transmission-based precautions for patients with confirmed COVID-19. 2 The CDC initially recommended a symptom- or test-based strategy for symptomatic patients and a time- or test-based strategy for asymptomatic patients. On July 17, 2020, the CDC updated these strategies. 3 The test-based strategy is no longer recommended because many individuals may have a positive polymerase chain reaction (PCR) test without being infectious. The symptoms-based approach now recommends at least 24-hours since the last fever without use of fever-reducing medications. Finally, the CDC recommends that patients with severe disease or who are immunocompromised continue precautions until 20 days since first symptoms, compared to 10 days for less severe illness.

We undertook a survey to assess variation in and approach to discontinuing transmission-based COVID-19 precautions.

Methods

The Infectious Disease Society of America (IDSA) Emerging Infections Network (EIN) is a sentinel network of infectious disease physicians that assists the CDC and public health agencies with surveillance of emerging infectious diseases. Reference Pillai, Beekmann, Santibanez and Polgreen4 During July–August 2020, the EIN sent an online 11-question survey (Appendix 1 online) to 696 physicians with infection prevention and/or hospital epidemiology responsibilities or interests to understand practices regarding the discontinuation of transmission-based precautions for COVID-19 patients. Two reminder e-mails were sent ˜10 days apart. No incentive for participation was provided. Data were analyzed using descriptive statistics (Excel, Microsoft, Redmond, WA). As an EIN query, this survey was exempt from institutional review board review.

Table 1.

Summary Results of Survey on Discontinuation of Transmission-Based Precautions for COVID-19 Patients Among a Network of Infectious Disease Physicians, North America, July–August, 2020 a

Note. ID, infectious diseases; LTCF, long-term care facility; VA, Veterans’ Affairs; DOD, Department of Defense.

a N values indicate number of participants who responded.

Results

The timing of the survey coincided with release of CDC updated guidance. Overall, 320 physicians (46%) responded. Of these, 44 respondents (14%) were not aware of precautions used for COVID-19 patients and opted out of the remaining questions. Among 276 responding physicians, 208 (75%) worked in adult infectious diseases and 109 (39%) practiced in a university hospital. Considerable variability was reported for the length of time inpatients remained in COVID-19–level precautions; 14–20 days was the most common response. Respondents most frequently reported using a combination of all 3 strategies (ie, symptom, test, and time-based) to determine when COVID-19–level precautions could be discontinued in inpatients. In the outpatient setting, a combination of symptom and time-based strategies was the most common (44%). In total, 207 respondents (75%) reported that clearance of COVID-19–level precautions in inpatients was authorized by infection control personnel with infectious disease physician input.

Respondents whose facilities used the symptoms-based approach to discontinuing precautions reported that once symptoms improved, discontinuation occurred at 10 days (38%), 11–30 days (20%), >30 days (1%), or “it depends on the population” (21%). The most common applications of the test-based approach were among immunocompromised patients (50%) and patients with a planned discharge to a nursing home (48%). Respondents whose facilities used the time-based strategy discontinued precautions at 10 days (27%), 11–30 days (22%), >30 days (4%), or “it depends on the population (21%). The most common factors influencing the decision to discontinue COVID-19–level precautions were length of time from initial positive test (80%), improvement in symptoms (74%), and patient characteristics (66%).

Discussion

Our survey results reveal that most healthcare facilities discontinue COVID-19–level precautions on inpatients with COVID-19 prior to discharge using a combination of the symptom, test, and time-based strategies. Length of time from initial positive test, improvement in symptoms, and patient characteristics influenced respondents’ decisions to discontinue precautions. Although the CDC no longer recommends using the test-based strategy in most cases, 68% respondents reported using this strategy (eg, for immunocompromised patients and patients planning discharge to a nursing home). The symptoms-based approach was popular, but there was considerable variability in when precautions were discontinued following symptom improvement.

These findings highlight the need for more specific research and guidance regarding how to discontinue transmission-based precautions for inpatients with COVID-19 who are transferring to congregate living facilities. Because the spread of COVID-19 in these settings has shown devastating consequences, it is understandable that facilities would desire reassurance that patients are no longer infectious. Increasing the availability of personal protection equipment (PPE) and infection prevention resources at these locations could decrease test-based strategy usage. Another issue requiring clarity is how to discontinue isolation precautions for patients who are recovering but remain critically ill or those who require ongoing aerosol-generating procedures. Although evidence regarding the period of infectivity based on RT-PCR testing of the upper airways is available, less is known about whether this accurately represents the lower airways.

This study has several limitations. The CDC updated their guidance around the time of survey deployment. Some respondents commented that their approach has changed in response to CDC guidance or due to seeing patients consistently test positive. The complexity of case-by-case decisions (eg, requiring negative tracheal aspirate specimens for intubated patients) was not captured by our survey questions. The survey did not address healthcare worker return-to-work practices. It is possible to have multiple EIN respondents at 1 center. However, no more than 5 respondents were from the same city, suggesting center and geographic diversity among respondents.

Overall, we found that discontinuation practices vary widely, and decision making is complicated by many factors. Research is needed to understand how long different COVID-19 patient populations remain infectious to determine when to safely discontinue transmission-based precautions.

Acknowledgments

The contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

Financial support

This work was funded by the Centers for Disease Control and Prevention (Cooperative Agreement no. 1 U50 CK000477).

Conflicts of interest

All authors report no conflicts of interest relevant to this article.

Appendix 1

Survey

Inpatient

  1. 1. Approximately how many inpatients with lab-confirmed COVID-19 has your facility admitted in the past 6 months?

    1. a. None

    2. b. 1–99

    3. c. 100–199

    4. d. 200–299

    5. e. ≥300

  2. 2. For inpatients with COVID-19, what is the approximate length of time they remain in transmission-based precautions for COVID-19 in your facility?

    1. a. <1 week

    2. b. 1–2 weeks

    3. c. 2–3 weeks

    4. d. >3 weeks

    5. e. Until discharge in all cases

  3. 3. What strategy does your facility use to determine when inpatients with COVID-19 can discontinue transmission-based precautions? (Check all that apply)

    1. a. Symptom-based

    2. b. Test-based

    3. c. Time-based

  4. 4. Is clearance of transmission-based precautions in inpatients authorized by (check all that apply):

    1. a. Infection control personnel

    2. b. Infection control personnel with Infectious Diseases physician input

    3. c. Only Command center personnel

Outpatient

  1. 5. Approximately how many outpatients with lab-confirmed COVID-19 has your institution seen in the past 6 months?

    1. a. None

    2. b. 1–99

    3. c. 100–199

    4. d. 200–299

    5. e. ≥300

  2. 6. What strategy is being used to determine when outpatients with COVID-19 can discontinue transmission-based precautions? (Check all that apply.)

    1. a. Symptom-based

    2. b. Test-based

    3. c. Time-based

All Settings

  1. 7. If you selected your facility uses a test-based approach to discontinue transmission-based precautions, what populations is this done for?

    1. a. Adult

    2. b. Pediatric

    3. c. Immunocompromised patients

    4. d. Planned discharge to nursing home

  2. 8. If you selected your facility uses a time-based approach to discontinue transmission-based precautions, what time point is specified?

    1. a. 10 days

    2. b. 11–30 days

    3. c. > 30 days

  3. 9. What factors influence the decision to remove patients with COVID-19 from transmission-based precautions?

    1. a. RNA test availability

    2. b. Illness severity

    3. c. Improvement in symptoms

    4. d. Asymptomatic vs symptomatic

    5. e. Length of time from initial positive test

    6. f. Patient characteristics (eg, immunocompromised)

    7. g. Discharge to home

    8. h. Discharge to congregate living facility (eg, nursing home, jail, shelter)

    9. i. Other (specify): (Free text)

  4. 10. Additional comments about discontinuation of transmission-based precautions for patients with COVID-19? (Free text)

References

Wang, D, Hu, B, Hu, C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061–1069.CrossRefGoogle ScholarPubMed
Discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings (interim guidance). Centers for Disease Control and Prevention website. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html. Published May 2, 2020. Accessed June 25, 2020.Google Scholar
Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. Centers for Disease Control and Prevention website. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.htm. Published July 15, 2020. Accessed August 6, 2020.Google Scholar
Pillai, SK, Beekmann, SE, Santibanez, S, Polgreen, PM. The Infectious Diseases Society of America Emerging Infections Network—bridging the gap between clinical infectious diseases and public health. Clin Infect Dis 2014;58:991–996.CrossRefGoogle Scholar
Figure 0

Table 1. Summary Results of Survey on Discontinuation of Transmission-Based Precautions for COVID-19 Patients Among a Network of Infectious Disease Physicians, North America, July–August, 2020a