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Contact Isolation & Cohorting Guidance for COVID-19 in LTCH/RH/Congregate Living Setting

 

Effective February 4, 2022, HNHU will use the following direction when managing contacts in LTC/RH/CLS.

1. A risk assessment will be conducted on contacts to determine if their contact was high-risk, lower-risk, or negligible risk (because they were previously infected with COVID-19 since December 20, 2021).

  • LTCH/RH/Congregate settings will need to provide detailed information in order to make an individual-level risk-based assessment. When detailed information is not available to make a reliable risk assessment, residents and staff should be treated as high-risk close contacts.
  • See Table 1. Contact Management for residents based on exposure type and vaccination status and Table 2. Contact Management for staff based on exposure type and vaccination status.

 

2. For contacts that must isolate, cohorting principles may be applied at the discretion of HNHU and where operationally feasible for the LTC/RH/CLS. Specifically, exposed persons may be cohorted rather than isolating

  • Cohorting = the process of grouping residents based on their COVID-19 status or risk of COVID-19 during an outbreak. Cohorting is a way to help prevent spread of infection within the facility.
  • Cohorting principles may be applied to contact management and during suspect and confirmed outbreaks using a risk-based approach. The principles and ideas outlined below may not be applicable, appropriate or possible in some outbreaks and facilities. As much as possible LTC/RH/CLS should take into account residents’ beliefs and values when making cohort decisions.
  • A Public Health Nurse from HNHU will work with the LTC/RH/CLS to assess the risk of using a cohort- based approach and provide direction for isolation.
  • The priority in cohorting is to:
    • Separate the outbreak area from the non-outbreak area (if there is a non-outbreak area).
    • Within the outbreak area, separate the:
      • exposed, well, and not known to have COVID-19 cohort,
      • exposed, ill but not known to have COVID-19 cohort, and
      • COVID-19 positive and infectious
    • Cohort isolation will be discontinued if evidence of ongoing transmission or symptomology is identified.
    • See Table Cohorting principles for COVID-19 Outbreak Management below.

Notes

  • LTCH, RH and Congregate Living Settings are still responsible for following all applicable Ministry directives
  • Using a cohort strategy when managing outbreaks uses a risk-based approach. Advantages for residents of using a cohort strategy may include access to dining and some access to group activities/gatherings with other residents in their cohort. The risk of using a cohort approach is that COVID-19 may spread within a cohort infecting residents who may not have been infected if an individual isolation strategy was used.
  • HNHU highly recommends that operators communicate with residents and families when a cohort strategy is used including the benefits and risks so that residents and/or families can opt-out of cohort isolation and choose individual isolation.

Table 1. Contact Management for LTC/RH/CLS residents based on exposure type and vaccination status

 

Exposure Residents who are fully vaccinated and boosted (3rd or 4th dose) Residents who are NOT fully vaccinated and/or have not been boosted (3rd or 4th dose) Resident previously positive for Omicron since

December 20, 2021

Lower-Risk
  • Received direct care* from a staff
    positive with COVID-19 who had
    consistent and appropriate
    masking (a well-fitted medical
    mask or fit-tested N95 respirator
    used for source control)
  • Was in a shared indoor space with
    a case or in a setting where close
    interactions occur (e.g., dining
    room) but with public health
    measures (e.g., masking, physical
    distancing) in place
  • Monitor for symptoms for
    10 days
  • PCR and rapid molecular test taken on or after day 5
  • Isolation not required unless symptoms develop or positive test result
  • Isolate for 10 days
  • PCR or rapid
    molecular test on or
    after day 5

 

  • Not required to isolate if they remain asymptomatic

 

High-risk
  • Received direct care* from case
    who did not have appropriate
    masking
  • Close prolonged contacts (<2m) asymptomatic
    with a symptomatic person (e.g.,
    roommates, essential caregivers,
    visitors) or bodily fluid of a
    positive case (e.g., cough, sneeze)
    without the consistent and
    appropriate use of PPE (a fit-tested N95 respirator and eye
    protection)

 

  • Isolated until PCR or rapid molecular test results taken on or after day 5 are received OR for a minimum of 10 days from last contact with the case (without testing)
  • Monitor for symptoms for 10 days
  • PCR or rapid molecular test on day 5
  • If negative: isolation may be discontinued
  • If positive: treat as a case
  • Isolate for 10 days
  • PCR or rapid molecular test on or after day 5
  • If negative, continue isolating for 10 days
  • If positive, continue isolating for 10 days after specimen collection or symptom onset, whichever is earlier
  • Not required to isolate if they remain asymptomatic

 

*Examples of direct contact include: assistance with activities of daily living – eating, drinking, showering, bathing,
wound care, etc.

NOTE: HNHU may deem an exposure high-risk in other factors increased the risk of transmission (e.g., accumulated
contact time with the positive case)

NOTE: In the absence of access to timely PCR or rapid molecular testing, 2 consecutive negative RATs taken at least 24
hours apart (i.e., day 5 and day 6 from date of last exposure) may be used.

Table 2. Contact Management for LTC/RH/CLS staff based on exposure type and vaccination status

 

Exposure Staff who are fully vaccinated
and boosted (3rd or 4th dose)
Staff who are NOT fully
vaccinated and/or have
not been boosted (3rd or
4th dose)
Staff previously
positive for
Omicron since
December 20, 2021
Lower-Risk
  • Provided direct care* to a
    resident positive with COVID-19
    while using consistent and
    appropriate masking (a well-fitted
    medical mask or fit-tested N95
    respirator used for source control)
  • Was in a shared indoor space with
    a case or in a setting where close
    interactions occur (e.g., break
    room) but with public health
    measures (e.g., masking, physical
    distancing) in place
  • Monitor for symptoms for
    10 days
  • PCR and rapid molecular test taken on or after day 5
  • Isolation not required unless symptoms develop or positive test result
  • Isolate for 10 days
  • PCR or rapid
    molecular test on or
    after day 5

 

  • Not required to isolate if they remain asymptomatic

 

High-risk
  • Provided direct care* to a
    resident positive with COVID-19
    without consistent and
    appropriate masking (a well-fitted
    medical mask or fit-tested N95
    respirator used for source control)
  • Close prolonged contacts (<2m) asymptomatic
    with a symptomatic person (e.g.,
    roommates, essential caregivers,
    visitors) or bodily fluid of a
    positive case (e.g., cough, sneeze)
    without the consistent and
    appropriate use of PPE (a fit-tested N95 respirator and eye
    protection)

 

  • Isolated until PCR or rapid molecular test results taken on or after day 5 are received OR for a minimum of 10 days from last contact with the case (without testing)
  • Monitor for symptoms for 10 days
  • PCR or rapid molecular test on day 5
  • If negative: isolation may be discontinued
  • If positive: treat as a case
  • Isolate for 10 days
  • PCR or rapid molecular test on or after day 5
  • If negative, continue isolating for 10 days
  • If positive, continue isolating for 10 days after specimen collection or symptom onset, whichever is earlier
  • Not required to isolate if they remain asymptomatic

 

*Examples of direct contact include: assistance with activities of daily living – eating, drinking, showering, bathing,
wound care, etc.

NOTE: HNHU may deem an exposure high-risk in other factors increased the risk of transmission (e.g., accumulated
contact time with the positive case)

NOTE: In the absence of access to timely PCR or rapid molecular testing, 2 consecutive negative RATs taken at least 24
hours apart (i.e., day 5 and day 6 from date of last exposure) may be used.

Table 3. Cohorting principles for COVID-19 outbreak management

Topic Principles
Resident Cohorting
  • Separate the Outbreak Area from the Non-Outbreak Area (if there is a non-outbreak area)
  • Cohorts Groups – Positive, Negative, High-Risk Contacts (as long as they are asymptomatic and continue to test negative)
  • Residents are to remain physically separate (i.e., at least 2m or 6ft apart) from one another as much as possible, including those within the same cohort, wear masks for source control if tolerated.
Staff Cohorting
  • All staff should be fully vaccinated against COVID-19
  • Dedicate staff to work with only one cohort of residents during each shift and over the course of the outbreak if possible
  • Avoid staff movement between outbreak and non-outbreak areas of the facility
  • Each staff cohort should remain separate from each other and from staff members in other cohorts (e.g., use staff room at separate times)
  • Workflow should be organized so that care to a cohort is grouped together, to minimize repeated visits to the same cohort.
  • Staff should aim to bundle care for each resident to minimize multiple visits to the resident.
  • If there is a need for staff to work with both positive and negative individuals, wherever possible try to have staff who are COVID-19 recovered fill these roles.
  • If staff need to move between outbreak and non-outbreak units, for example, physiotherapy or wound care who have to see residents in multiple areas of a home, try to have the staff see residents in non-outbreak areas first, followed be negative residents in outbreak areas, and finally, positive residents last. PPE should be changed when moving between cohorts.
Resident Placement
  • Ideally placed in Private/isolation Rooms
  • Symptomatic Positive Omicron Cases
  • Symptomatic High-Risk Contacts
  • Co-infected Residents i.e. COVID-19 and another enteric or respiratory pathogen

Shared Rooms

  • Asymptomatic Positive Omicron cases with asymptomatic positive
  • Asymptomatic High-Risk Contacts with asymptomatic high-risk contacts

In General

  • Residents within a cohort will have their own dedicated bathroom that is not shared with other cohorts.
  • Relocation of residents may be traumatic or disconcerting and consideration should be given to providing additional mental health supports for residents as required.
Dining 
  • Symptomatic Residents should be provided with tray service
  • Dining Rooms can be used within a cohort and with a staggered dining plan
  • Physical distancing should be maintained (i.e., at least 2m or 6ft apart)
  • Enhanced cleaning and disinfection of high touch surfaces in hallways and dining space between each cohort sitting
Activities
  • Group activities should be discontinued for the duration of the outbreak
  • Individual-based programming may continue

 

References