5/4/2020

1

CORONAVIRUS : NOVEL CORONAVIRUS

(COV ID-19 ) INFECT ION

K AT Y N G U Y E N , M S N , R NC RY S TA L P L A N K , B S N , R N

CLINICAL CLARIFICATION

• COVID-19 (coronavirus disease 2019) is a respiratory tract infection to have originated as a zoonotic virus that has mutated or otherwise adapted in ways that allow human pathogenicity

• It was officially declared by WHO to be a pandemic on March 11, 2020 DUE to outbreak began in China and spread to many other countries

• COVID 19 disease ranges from asymptomatic or mild to severe symptoms

• Pathogen is a betacoronavirus, 3 similar to the agents of SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome)

• Coronaviruses are known to mutate and recombine often, cause an ongoing challenge to our understanding and to clinical management

• Designated as SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2)

5/4/2020

2

CLINICAL PRESENTATION• In symptomatic patients, illness may evolve over the course of a week or

longer to the point of respiratory distress and shock

• Most common complaints are fever, cough, loss of taste/smell, myalgia, and fatigue

• Patients with moderate to severe disease may complaint of

– Dyspnea

– Pleuritic chest pain

– Upper respiratory tract symptoms (eg, rhinorrhea, sneezing, sore throat)

– Headache and gastrointestinal symptoms (eg, nausea, vomiting, diarrhea)

MODE OF TRANSMISSION

• Via respiratory droplets

• COVID-19 is a respiratory illness spread through droplets when an infected person coughs or sneezes. These droplets can land in the mouths or noses of nearby people or possibly inhaled into lungs(standing within 6 feet)

• It is possible to spread from contact with surfaces or objects that have the virus on it and then by touching mouth, nose and/or eyes

• Close contact with an infected person; outside of an identified outbreak area, a history of recent travel (within 14 days) to an area with widespread infection

• The virus may be transmitted before symptoms develop (incubation from 14-21 days)

• Other transmissions are from contact with infected environmental surfaces, fecal, oral

5/4/2020

3

COMPLICATIONS AND PROGNOSIS

COMPLICATIONS

Most common complication is acute respiratory distress syndrome; other reported complications include:

-Septic shock

– Acute kidney injury

– Myocardial injury

– Secondary bacterial and fungal infections

– Multi-organ failure

PROGNOSIS

• Patients who require hospital admission often require prolonged inpatient stay (more than 20 days), although duration of stay may be inflated by need for isolation until documentation of sustained absence of fever and serial negative results on polymerase chain reaction test

• Otherwise, short-term and long-term prognosis (eg, recovery of pulmonary function) remains to be seen with time

• Mortality rate of diagnosed cases is generally about 2% to 3% but varies by country

SCREENING• Triage screening is recommended at points of medical care to identify patients with symptoms and exposure

history that suggest the possibility of COVID-19, so that prompt isolation measures can be instituted

• Screening tests include:

• Presence of respiratory symptoms (cough, dyspnea) and fever

• Recent (within 14 days) travel to or residence in any geographic areas with widespread COVID-19

• Close contact with a person with known or suspected COVID-19 while that person was ill

• Work in a health care setting in which patients with severe respiratory illnesses are managed, without regard to place of residence or history of travel

• Unusual or unexpected deterioration of an acute illness despite appropriate treatment, without regard to place of residence or history of travel, even if another cause has been identified that fully explains the clinical presentation

5/4/2020

4

PHYSICAL ASSESSMENT

• Fever is usual, often exceeding 39 °C (100.4 F)

• Patient appear quite ill, with tachypnea and labored respirations

• Hypotension, tachycardia, and cool/clammy extremities suggest shock

• Altered mental status

• Prolonged capillary refill (more than 2 seconds) or warm vasodilation and bounding pulses

• Hyperthermia or hypothermia

CDC DIAGNOSTIC TOOLS

The CDC recommends that clinicians use their judgment, informed by knowledge of the patient's travel and/or exposure history, local COVID-19 activity, and other risk factors, to determine the need for testing in persons with a clinically compatible illness

Priority levels for testing:

• Level 1, to ensure optimal care for hospitalized patients, lessen the risk of nosocomial transmission, and maintain the integrity of the health care system; Hospitalized patients; Symptomatic health care workers

• Level 2, to ensure identification and triage of those at highest risk of complications from COVID-19

– Symptomatic patients in long-term care facilities

– Symptomatic patients aged 65 years or older

– Symptomatic patients with underlying medical conditions

– Symptomatic first responders

5/4/2020

5

CDC DIAGNOSTIC TOOLS

• Level 3, in communities experiencing rapidly increasing numbers of hospitalized cases and if resources allow, to

– decrease community spread and ensure healthy workforce for providing essential services

– Symptomatic workers in critical infrastructure jobs

– Health care workers and first responders

– Other symptomatic persons

DIAGNOSTIC TESTING

• Collection of specimens from upper respiratory tract, lower respiratory tract

• Upper respiratory tract: Nasopharyngeal swab is preferred; oropharyngeal swab may be submitted in addition, if obtained.

• Lower respiratory tract: Broncho alveolar lavage or tracheal aspirate are suitable lower respiratory tract specimens; A deep cough sputum specimen

• Serum: Blood should be collected in a serum separator tube and centrifuged after upright storage for 30 minutes

• Imaging: Chest imaging

5/4/2020

6

RESPIRATORY ASSESSMENT• A respiratory assessment is an external assessment of ventilation that includes observations of the rate,

depth and pattern of respirations, normal thoracic and abdominal movements. The assessments are:

– Complaints of shortness of breath (dyspnea)

– Bluish or cyanotic appearance of the nail beds, lips, mucous membranes and skin

– Restlessness, irritability, confusion, decreased level of consciousness

– Pain during inspiration and expiration

– Labored or difficult breathing

– Orthopnea with the use of accessory muscles

– Abnormal breath sounds such as wheezes, rhonchi or rales

– Inability to breathe spontaneously

– Thick, frothy, blood-tinged or copious sputum production

– Paradoxical chest wall movement

– Tachypnea and labored respirations

PREVENTION• There is no vaccine against COVID-19. Prevention depends on standard infection control

measures, including isolation of infected patients. Quarantine may be imposed on asymptomatic exposed persons deemed by public health authorities to be at high risk

• For the general public, avoidance of ill persons and diligent hand and cough hygiene are recommended. Wash hands often and thoroughly. Soap and water are best. High-alcohol hand sanitizers are acceptable. Social distancing: stay home as much as possible, remain 6 feet away from individuals, no groups larger than 10

• Cover coughs. Use tissue and throw it away; second choice is sleeve/elbow, not hand

• Avoid touching face, eyes, nose and mouth

• Stay home if you are sick

• Clean and disinfect frequently touched surfaces: phone, TV remote, computer keyboard

• Healthcare Professionals: perform frequent hand hygiene with alcohol-based hand rub (ABHR) or soap and water

5/4/2020

7

PREVENTION IN FACILITY

• Preparedness checklists from CDC to identify the resources and plans

• Provide PPEs for residents and staff if needed

• Persons entering the room should follow standard, contact, and airborne precautions: Gloves, gowns, eye protection, and respirator (N95 or better) with adherence to hospital donning and doffing protocols

• In circumstances in which supplies of N95 respirators and other protective equipment are short, their use should be prioritized for aerosol-generating procedures; standard surgical face masks should be used for other situations

• Equipment used for resident care should be single-use (disposable) or should be disinfected between residents;

CRITERIA FOR DISCONTINUATION OF ISOLATION PRECAUTIONS• CDC offers 2 strategies based on test-based or non–test-based criteria. A test-based approach is

recommended for residents who are hospitalized, are severely immunocompromised, or are being transferred to a long-term care or assisted living facility ○

• Test-based

– Demonstration of negative results of molecular assays for SARS-CoV-2 RNA on nasopharyngeal swabs obtained at least 24 hours apart (a single specimen suffices for each test), and

– Subjective and objective evidence of clinical improvement, including absence of fever without use of antipyretic

medication

• Non–test-based

• Subjective and objective evidence of improvement in respiratory symptoms and absence of fever without use of antipyretic medication for 72 hours, and

• At least 7 days since onset of symptoms

5/4/2020

8

COVID-19RESPIRATORY

CARED E B B I E P O O L , B S N , R N , L N H A

RESPIRATORY SURVEILLANCE

• Respiratory Surveillance Line List is a template for data collection and active monitoring of residents and staff during a suspected respiratory illness cluster, e.g. COVID-19

• The information may be used to identify those affected by the illness (residents/staff), duration of the outbreak (beginning/end point), rapid identification of new illnesses and assist with the implementation of infection control practices.

• The form may be modified for utilization for other forms of illnesses/outbreaks

• Completed by the Infection Preventionist/designee

• https://www.cdc.gov.longtermcare/training.html

5/4/2020

9

5/4/2020

10

PREVENTING OR LIMITING TRANSMISSION• Practice Standard/Universal precautions with blood, body fluids, secretions, excretions except sweat, non-intact skin and mucous

membranes

• Because the corona virus is transmitted though droplets, transmission-based precautions must be put in place. Dropletprecautions are designed to reduce the risk of droplet transmission of infectious agents and apply to anyone with known or suspected to be infected with COVID-19.

• Droplets may be generated through coughing, sneezing, talking or during the performance of the following aerosol-generating procedures:

• Bronchoscopy

• Intubation

• Heated high flow N/C with machine (NOT green cannula) or Bipap

• High flow nebulizer

• Sputum induction

• Open airway suctioning

• CPR

5/4/2020

11

F695 RESPIRATORY CARE

GUIDANCE

5/4/2020

12

RESPIRATORY INFECTIONS• Respiratory infections are the most common infections in LTC setting and may spread rapidly

• Residents are at an increased risk due to age, co-morbidities, vaccine status, compromised immune system and/or immobility

• Respiratory infections may be compounded in individuals with chronic respiratory diseases: COPD, emphysema, bronchitis or obstructive sleep apnea requiring CPAP use.

• Respiratory infections are among the leading causes of mortality, morbidity and transfers to acute care facilities. Residents are at a greater risk for functional decline, delirium and pressure injuries during hospitalization

• Antibiotic overuse continues to be a concern including for viral upper respiratory infections. It is important to obtain a medication history where possible to identify potential or actual antibiotic resistance and to assist with treatment expectations when managing a viral or bacterial respiratory infection.

MONITOR/DOCUMENT

5/4/2020

13

RESIDENT ASSESSMENT

• Vital signs: pulse ox Q 2 hours, monitor for subtle changes, keep above 92%

• Attitude/Pain

• Respiratory status

– Cough: dry, wet productive, non-productive

– Lung Sounds: Rhonchi, wheezing, fine/coarse crackles

(video refresher) https://www.youtube.com/watch?v=xdSmc0010To

– Sore throat

– Runny nose

– Congestion (clearing throat)

• *Note: refer to Documentation Guidelines for Residents with Positive or Suspected Cases of COVID-19 www.nursinghomehelp.org

RESIDENT ASSESSMENT

• Cognition: may develop delirium/confusion

• Psychosocial addressing depression and/or anxiety

• Communication needs

• Oral hygiene and condition of eyes(reporting of red eyes or redness around eyes)

• Skin integrity (monitor frequently due to immobility)

• Bowel and bladder functioning

• Nutritional status (reporting of loss of sense of smell and taste) including hydration

5/4/2020

14

DOCUMENTATION OF RESPIRATORY ASSESSMENT• Skin color: pallor, waxy look, cyanotic lips, capillary refill delayed

• Oxygen status: room air/oxygen with # liter flow

• Breath sounds: anterior, posterior

• Cough: wet/dry, (non)-productive

• Head of bed elevated # degrees

• Delivery, tolerance of metered-dose inhalers and/or nebulizer treatments (performing an assessment pre/post). Consider switching to a mask for nebulizer treatments to limit the spread of aerosol-based droplets

• **Note: Consult with the resident’s healthcare provider to determine if a metered-dose inhaler with spacer chambers are a viable option for therapy instead of nebulizers

5/4/2020

15

RESIDENT WITH A TRACHEOSTOMY

• Tracheostomy with tracheal suctioning is an aerosol-generating procedure due to the inability of the resident to control his/her secretions requiring suctioning

• Assessment of the resident should include:

• Condition of the tracheostomy site; cleanliness, signs of infection/inflammation (redness, swelling, bleeding or purulent discharge, odor and character of secretions) and condition of the dressing

• Signs of an obstructed airway or the need for suctioning: secretions draining from mouth or trach, inability to cough to clear, audible crackles or wheezes, dyspnea, restlessness or agitation

• Suctioning should be performed following aseptic technique. Risks include hypoxia, infection, tracheal tissues damage and atelectasis

• Follow current CDC PPE guidelines based on availability of PPE

RESIDENT WITH A TRACHEOSTOMY

• Trach care should be completed at least 1 x per shift and PRN, including cleaning of the site, changing of the trach ties, assessment of the skin around the stoma and where the trach ties lie and secretions settle, cleaning of the inner cannula and provision of oral care

• Delivery/tolerance or nebulizer treatments (performing an assessment pre/post)

• Monitoring of equipment functioning, cleanliness

• www.cms.gov Form CMS 20081 Respiratory Care Critical Element Pathway (CEP)

5/4/2020

16

ORAL CARE IN INFECTION PREVENTION• Oral care is an important strategy in the prevention of oral and respiratory infections

• Oral cavity microorganisms, herpes simplex virus or Candida, may develop due to decreased saliva production, medications, debility, chronic diseases or poor oral hygiene.

• Oral bacteria may be associated with cardiovascular disease, stroke, diabetes and pneumonia

• Dental issues can lead to inadequate nutrition, weight loss and increase infection risk

• Strategies for improved oral hygiene include:– Routine assessment at scheduled intervals with creation of a oral healthcare plan

– Access to dental services to include a dentist and dental hygienist

– Staff trained in providing proper oral care to residents in am and pm

• Performance of hand hygiene before/after the provision of care, wearing of gloves during care

EQUIPMENT USE & CLEANING

• Cleaning: physical removal of dirt, body fluids and other organic material accomplished by a combination of detergent, water and applied friction. The number of potential pathogens is reduced to the point their presence is unlikely to cause harm. A clean surface is not considered disinfected or sterile

• Disinfection: destroy the number of potential pathogens on a surface. Disinfection is most commonly done using EPA-approved chemicals or other methods using heat, ultraviolet light or fogging. www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2

• Factors to consider when selecting products:

– “Kill” or “label” claims-what is the effectiveness

– Direct contact time—required time to disinfect (glucometer “wait” time)

– Safety factor for residents, staff and potential to damage equipment/environment

5/4/2020

17

EQUIPMENT USE & CLEANING

• Residents currently under transmission-based (droplet) precautions should have dedicated or disposable non-critical equipment (thermometer, stethoscope, BP cuff and/or gait belt) dedicated to him/her and left in the room

• Resident ‘s personal equipment, walker, wheelchair, should remain in the room and cleaned per facility schedule and according to manufacturers’ recommendations

• Equipment owned by the facility must be thoroughly cleaned and disinfected when it is removed from the isolation room (e.g. nebulizer, concentrator, feeding pump)

• Objects and environmental surfaces that are touched frequently and in close proximity to the resident (e.g. bed rails, over-bed table, nightstands, call lights, BSC, lavatory surfaces in resident bathroom) are cleaned and disinfected at least daily and when soiled according to manufacturers’ instructions using an EPA-registered disinfectant for a healthcare setting. High touch areas (e.g. light switches, door knobs, handrails) several times per day.

EQUIPMENT & SUPPLY STORAGE

• CDC guidelines for storing sterile disposable items:

• Store 8 inches from the floor and 2 inches from an outside wall

• Protect items from direct sun exposure, temperature extremes and excess moisture

• Keep items away from ceiling and sprinkler heads (18” rule)

• Don’t prop open door to clean supply room

• Rotate stock with an expiration date to ensure timely use

• Don’t store items on/around sink or under sink to prevent water damage/contamination

5/4/2020

18

IDPH GUIDANCE FOR NEBULIZER TREATMENTS

IDPH GUIDANCE FOR NEBULIZER TREATMENTS

5/4/2020

19

Palliative & Supportive CareFor Family, Residents, & Staff

Wendy Boren, BSN,RN

“I think the only thing worse than having one of my people die of COVID would be to have them die alone and scared.”—Anonymous

5/4/2020

20

“In this time, palliative care is just as critically needed as fluids, fever reducers, and respirators. We know the strength and extraordinary human kindness and caring that palliative care professionals live every day, in every interaction with patients, with families, with colleagues, and communities. 

Their role in the time of COVID‐19 is to keep the “care” in healthcare, even as systems, patients, and providers are under siege.”

Center to Advance Palliative Care

https://www.capc.org/

Challenges of COVID‐19 in Palliative Care

Sudden, unpredictable onset and worsening of symptoms

Shock to family and friends

No time for ideal decision‐making

Family and friends cannot be at bedside therefore nursing home staff act as liaisons

May be multiple members of the family sick at the same time

https://www.vitaltalk.org/guides/covid‐19‐communication‐

skills/

5/4/2020

21

Challenges of COVID‐19 in Palliative Care Resourcing of equipment, staff

Coping with those Family Questions

What they say What you say, and why

Why can’t my 90 year old grandmother go to the ICU?

This is an extraordinary time. We are trying to use resources in a way that is fair for everyone. Your grandmother’s situation does not meet the criteria for the ICU today. I wish things were different.

Shouldn’t I be in an intensive care unit?

Your situation does not meet criteria for the ICU right now. The hospital is using special rules about the ICU because we are trying to use our resources in a way that is fair for everyone. If this were a year ago, we might be making a different decision. This is an extraordinary time. I wish I had more resources.

Challenges of COVID‐19 in Palliative CareCoping with those Family Questions

My grandmother needs the ICU! Or she is going to die!

I know this is a scary situation, and I am worried for your grandmother myself. This virus is so deadly that even if we could transfer her to the ICU, I am not sure she would make it. So we need to be prepared that she could die. We will do everything we can for her.

Are you just discriminating against her because she is old?

I can see how it might seem like that. No, we are not discriminating. We are using guidelines that were developed by people in this community to prepare for an event like this. The guidelines have been developed over the years, involving health care professionals, ethicists, and lay people to consider all the pros and cons. I can see that you really care about her.

5/4/2020

22

Challenges of COVID‐19 in Palliative CareCoping With Those Family Questions

It sounds like you are rationing.

What we are doing is trying to spread out our resources in the best way possible. This is a time where I wish we had more for every single person in this hospital.

You’re playing God. You can’t do that.

I am sorry. I did not mean to give you that feeling. Across the city, every hospital is working together to try to use resources in a way that is fair for everyone. I realize that we don’t have enough. I wish we had more. Please understand that we are all working as hard as possible.

Challenges of COVID‐19 in Palliative CareCoping With the Resident Questions

Question/Statement Caregiver Answer

I’m scared This is hard. I think anyone would be scared. Can you tell me what you are scared of?

I need some hope. So do I. You tell me what you’re hoping for and I’ll tell you what I’m hoping for. 

You people are incompetent! I can see why you are not happy with things. I am willing to do what is in my power to improve things for you. What could I do that would help?

I want to see your boss.  I can see you are frustrated. I will ask my boss to come by as soon as they can. Please realize that they are juggling many things right now.

Do I need to say my good‐byes? I’m hoping that’s not the case. And I worry time could indeed be short. What is most pressing on your mind?

5/4/2020

23

Coping Strategies for Caregivers 

• How do I tell them I can’t send them to the hospital? How do I say you’re going to die?!

• I’m so darn tired and scared. I don’t know how much more I’ve got in me. 

• I should have been able to save that person! 

• Remember what you can do—you can listen, hug, and just be present. These are gifts.

• You’re doing great. We’re so thankful to have you here. Take a few minutes for you. This is so hard and you’re doing so amazing. Hang in there.

• It’s okay to take time to recognize those feelings—they’re what make a good nurse. Maybe it’s sadness, or frustration, or just fatigue. Those feelings are normal. And these times are distinctly abnormal.

Fears Feedback

Coping Strategies for CaregiversSometimes the easiest way to cope is to remember the fundamentals of nursing communication.

Be honest and clear, use words patients and those close to them will understand

Sit down and take time

Speak in a measured pace and tone

Remember, silences are OKAY. They allow people to process information

And just for you…

Try to find a way to genuinely smile every day. 

Cry if you need to. 

Keep in touch with your family. 

5/4/2020

24

Practical Tips for End‐of‐LifeIf death is inevitable, these are some things that can/should be done.

Pre‐planning funeral questions (with resident and/or family)

Funeral homes are not allowed to hold traditional services right now. Do you want them to keep your loved one until a traditional service can be held or do you want them cremated? (This will greatly help the funeral service at time of pick‐up.)

For Families—They will need to connect. They can make a photo album for the nursing staff to share with their loved one. Allow family to have face‐time or simply hold the phone up to their loved one’s ear. Allow people to say their good‐byes. 

Follow the guidelines provided for COVID‐specific body preparation, room cleaning, and transport. 

Melody Schrock, BSN, RN

5/4/2020

25

Covid-19 & Staff

With the ever-changing recommendations and increased physical and mental demands on our staff it is up to leaders to balance staffing needs, keep staff educated and boost morale.

Common heard themes-

We do not have enough staff.

Where are we to find staff?

There is SO much and it changes almost daily!

Our staff is doing great, but spirits are low.

We do not have enough staff

CNA- focus on patient care

Housekeeping: making beds

Kitchen: passing water, trays, hydration/snack carts

Cross training for feeding assistants “super aides”

Individuals with choking risk eating at doorway, versus at bedside

Consistent staff on units- include housekeeping, dietary

All: answer call lights, assist with “nests”

1135 Waiver for reduced requirements for CNA, NA still require 16 hour orientation, gauge interest in other departments to be CNA or a feeding assistant- Activities, SW, Office staff, etc

5/4/2020

26

Consistent/unit staffing

COVID-19 Long-Term Care Facility Guidance April 2, 2020

Separate staffing for COVID-19 positive residents to best of ability and work with state and local leaders to designate separate areas to care for those residents

Develop COVID care teams.

Do they need a separate schedule?

12 hour shifts vs. 8 hours?

4 on/ 2 off?- see example:

Different times?

10-10 vs 6-6?

Added reassurance

Staggered lunches/breaks

Separate break area

4 on/ 2 off example

Where are we to Find staff?

We have heard of staff challenges for years and now we are in crisis mode facing many unknown factors. Time to think outside the box!

MANY are laid off now- notify unemployment offices/temp agencies of openings

SCHOOLS/COLLEGES are not in session- email/call/post on websites/Facebook pages

Health Occupations classes

Medical classes

FACEBOOK, TWITTER, INSTAGRAM, TIC-TOC, FLYERS, ROADSIDE SIGNS, BILLBOARDS

5/4/2020

27

Educate staff

Daily tips/updates

Break it down

Keep it simple

Post it large- versus long emails/memos

Staff/unit huddles

Boost morale

Provide meals

Fun scrubs, fun patterned masks (for those who are having to use cloth/sewn masks)

Chocolate/treats

Joke of the day (bad dad jokes)

Air-fives!

Public Postings of KUDOs!

Hall dancing

Singing

SMILES!

5/4/2020

28

Your QIPMO Nurses

Wendy’s email: borenw@missouri.edu

Katy’s email: nguyenk@missouri.edu

Crystal’s email: plankcl@missouri.edu

Debbie’s email: poold@missouri.edu

Melody’s email: schrockm@missouri.edu

Carol’s email: siemc@health.Missouri.edu

RESOURCESREFERENCES:

• WHO: Coronavirus Disease 2019 (COVID-19): Situation Report--51. WHO website. Published March 11, 2020. Accessed March 27, 2020. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf

• CDC: Coronavirus Disease 2019 (COVID-19) Situation Summary. CDC website. Updated March 26, 2020. Reviewed March 26, 2020. Accessed March 27, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/summary.html

• WHO: Clinical Management of Severe Acute Respiratory Infection When Novel Coronavirus (nCoV) Infection Is Suspected: Interim Guidance. WHO website. Updated March 13, 2020. Accessed March 27, 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratoryinfection-when-novel-coronavirus-(ncov)-infection-is-suspected

• CDC: Coronavirus Disease 2019 (COVID-19): Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19). Updated March 24, 2020. Reviewed March 14, 2020. Accessed March 27, 2020. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html

• CDC: Coronavirus Disease 2019 (COVID-19): How COVID-19 Spreads. CDC website. Updated March 17, 2020. Reviewed March 4, 2020. Accessed March 27, 2020. https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html

• www.cms.gov

• www.apic.gov Infection Prevention Guide to Long Term Care

• www.AADNS-LTC.org Resident Surveillance Record for COVID-19

• www.nursinghomehelp.org

• www.idph.state.il.us IDPH Long Term Care Interim Guidance 3/27/2020 Nebulizer Treatments for COVID19 Confirmed Positive or Suspected Cases