6.2 Resident placement/assessment of risk

6.2.1 Staff cohorting

6.2.2 Requirements for risk categories

6.2.3 Resident Cohorting

6.2.4 Discontinuing IPC precautions in care homes for residents who are COVID-19 positive

6.2.5 Residents returning from day visit or overnight stay

Defined risk categories have been agreed at UK level to inform resident placement and the precautions required. Any other known or suspected infections must be taken into consideration before resident placement within each of the risk categories.

Examples of risk categories for care homes are described below and staff should familiarise themselves with these. NHS Boards must also undertake risk assessments of clinical areas to help ensure that the high risk pathway is placed appropriately reducing risk to staff, patients and visitors and taking account the hierarchy of controls

Details of the Low Risk Category are not included here however it is expected that all residents in care home settings will fall into the Medium (Amber) or High (Red) risk categories. Guidance beyond this section will only refer to the medium and high risk categories.

1. Known as the High Risk COVID-19 risk category in the UK IPC remobilisation guidance and is more commonly known as the red risk category.

  1. Confirmed COVID-19 residents within the first 14 days of onset (or test date if asymptomatic). Symptomatic or suspected COVID-19 residents (as determined by hospital or community case definition or clinical assessment where there is a suspicion of COVID-19 taking into account atypical and non-specific presentations in older people with frailty those with pre-existing conditions and patients who are immunocompromised).
  2. Those who are known to have had close contact with a confirmed
    COVID-19 individual and are still within the 10-day self-isolation period.
  3. Residents who are symptomatic or suspected COVID-19 but who decline testing or who are unable to be tested for any reason.

2. Known as the Medium Risk COVID-19 risk category in the UK IPC remobilisation guidance and may be commonly known as the amber risk category.

  1. All residents who do not meet the criteria for the pathways above and who do not have any symptoms of COVID-19.
  2. Asymptomatic residents who refuse testing or for whom testing cannot be undertaken for any reason.

6.2.1 Staff cohorting

Efforts should be made as far as reasonably practicable to dedicate assigned teams of staff to care for residents in each of the high and medium risk categories.  There should be as much consistency in staff allocation as possible, reducing movement of staff and the crossover between risk categories.  Rotas should be planned in advance wherever possible, to take account of different risk categories and staff allocation.  For staff groups who need to go between risk categories, efforts should be made to see residents on the medium risk categories, then the high risk category.   Facemasks should be changed between risk categories.

6.2.2 Requirements for risk categories

Any resident on the medium risk category who develops symptoms of COVID-19 should be isolated on the high risk category immediately and tested for COVID-19 and notify your local Health Protection Team (HPT). Any resident who is asymptomatic and tests positive for COVID-19 should be then cared for as per the high-risk category.

Care homes are likely to have residents with dementia and/or cognitive impairment and so staff are advised to conduct a local risk assessment to ascertain appropriate placement. This does not mean resident needs to move their room or be moved to a different area but advises of the relevant risk category precautions that require to be put in place.

6.2.3 Resident Cohorting

Any resident who has a coinfection with COVID-19 and any other known or suspected infectious pathogen must not be cohorted with other COVID-19 residents.

Cohorting in care homes should be undertaken with care. Residents who are shielding (extremely high risk of severe illness) must not be placed in cohorts and should be prioritised for single occupancy rooms.

Where all single room facilities are occupied and cohorting is unavoidable, then cohorting could be considered whilst ensuring that:

6.2.4 Discontinuing IPC precautions in care homes for residents who are COVID-19 positive

Before IPC control measures are stepped down for COVID-19, it is essential to first consider the ongoing need for transmission based precautions (TBPs) necessary for any other alert organisms, e.g. MRSA carriage or C. difficile infection, or patients with ongoing diarrhoea.

Key notes to be referred to in conjunction with table 1;

Table 1 - Discontinuation of IPC requirements for COVID-19 residents in care homes (COVID-19)

Group

Number of isolation days required

COVID-19 Clinical requirement for stepdown

Testing required for stepdown

Transferring between risk  categories on stepdown

Care home current residents (known
COVID-19 positive)

14 days from symptom onset (or first positive test if symptom onset undetermined)

Absence of fever  for 48 hours without use of antipyretics and at least some respiratory recovery.

Not routinely required unless being discharged from hospital

Residents should be managed on the high risk category until criteria described in this table is met and can then transfer to the medium risk category

Care home residents (known COVID-19 positive), being admitted from hospital

(see further guidance)

14 days from symptom onset (or first positive test if symptom onset undetermined)

If they have completed the 14 day isolation in hospital, no further isolation should be required on return/admission to the care home.

 

Absence of fever for 48 hours without use of antipyretics & at least some  respiratory recovery

If COVID recovered patient discharged to care home before 14 day isolation ended 2 negative PCR tests before discharge at least 24 hr apart. In addition, if not completed 14 days isolation, can do so in care home and do not require to start new isolation period, nor require further testing.

Residents should be managed on the high risk category until criteria described in this table is met and can then transfer to the medium risk category

Care home staff

10 days from symptom onset (or first positive test if symptom onset undetermined)

Absence of fever for 48 hours without use of antipyretics and at least some respiratory recovery.

Not routinely required.

 

Staff can return to work as normal once criteria is met

Residents/patients discharged from hospital to care homes (COVID-19 recovered)

Since PCR testing can take several weeks to revert back to negative due to persistence of non-viable viral RNA remnants, repeat PCR testing within 90 days of a COVID diagnosis in preparation for discharge must be considered carefully. COVID recovered patients in hospital can be discharged to the care home after 14 days from symptom onset (or first positive test, if asymptomatic) without further testing. In such instances, discharge at 14 days providing the person is afebrile for 48 hours without anti-pyretics and clinically stable, is based on clinical judgment of fitness for discharge. This decision should be made in collaboration with the receiving care home manager who needs to agree to patient transfer before this occurs. If COVID recovered patients have completed their 14 days of isolation in hospital, no further isolation should be required on return to the care home.

If a COVID recovered patient is to be discharged before their 14 day isolation period has ended, they should have two negative PCR tests before discharge from hospital. Tests should be taken at least 24 hours apart. In addition, if they have not completed their 14 days isolation then they can do so in the care home, and do not require to start a new period of isolation, nor do they require further testing.

Where it is in the clinical interest of the resident and negative testing is not feasible (e.g. resident does not consent, detrimental consequences or it would cause distress) a risk assessment and a care plan for the remaining period of isolation up to 14 days in the care home must be agreed.

Note: an admission to hospital is considered to include only those patients who are admitted to a ward. An attendance at A&E that didn’t result in an admission would not constitute an admission.

Residents/Patients discharged from hospital to care homes (non-COVID-19)

All non-COVID-19 residents being discharged from hospital should be isolated for 14 days from or including the date of discharge from hospital.

Risk assessment prior to hospital discharge for residents with a non-COVID-19 diagnosis should be undertaken in conjunction with the care home. A single negative result should be available preferably within 48 hours prior to discharge from hospital. The exception is where a resident is considered to suffer detrimental clinical consequence or distress if they were not able to be discharged to a care home. In these cases, the resident may be discharged to the care home prior to the test result being available, whether the result is positive or negative, but the 14 days of isolation must be completed regardless in the care home.

For further guidance on admission of COVID-19 recovered and non COVID-19 residents from hospital or from community please refer to PHS COVID-19: Information and Guidance for Care Home Settings (Adults and Older People)

6.2.5 Residents returning from day visit or overnight stay

Residents who leave care home for the day or for an overnight stay should be triaged in advance of their immediate return to the care home and again on arrival at the care home to determine which category they should be placed on.