Nursing home populations are at high risk for infection, serious illness, and death from COVID-19. Reverse transcription polymerase chain reaction (RT-PCR) testing (referred to here as testing or test) for SARS-CoV-2 infection among residents and healthcare personnel (HCP) in nursing homes has become a priority to help inform prevention and control in the facility. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff 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).
Several states have allocated testing resources for nursing homes. Increased availability of testing in nursing homes has the potential to not only describe the scope and magnitude of outbreaks, but also to help inform additional prevention and control efforts designed to further limit transmission among nursing home residents and HCP. See CDC guidance on RT-PCR testing and specimen collection.
Consider the following four key principles when using testing in nursing homes:
1. Testing should not supersede existing infection prevention and control (IPC) interventions.
Testing conducted at nursing homes should be implemented in addition to existing infection prevention and control measures recommended by CDC, including visitor restriction, cessation of communal dining and group activities, monitoring all HCP and residents for signs and symptoms of COVID-19, and universal masking as source control. See CDC guidance on Preparing for COVID-19: Long-Term Care Facilities and Nursing Homes for more details.
2. Testing should be used when results will lead to specific IPC actions.
For example, testing can lead to IPC actions such as
- Cohorting residents to separate those with SARS-CoV-2 infection from those without detectable SARS-CoV-2 infection at the time of testing to reduce the opportunity for further transmission.
- Discontinuing transmission-based precautions for residents diagnosed with SARS-CoV-2 infection.
- Identifying HCP with SARS-CoV-2 infection for work exclusion.
- Enabling HCP to return to work after being excluded for SARS-CoV-2 infection.
- Determining the SARS-CoV-2 burden across different units or facilities and allocating resources.
3. The first step of a test-based prevention strategy should ideally be a point prevalence survey (PPS) of all residents and all HCP in the facility.
Testing of residents
- If testing capacity allows, facility-wide PPS of all residents should be considered in facilities with suspected or confirmed cases of COVID-19. Early experience from nursing homes with COVID-19 cases suggests that when residents with COVID-19 are identified, there are often asymptomatic residents with SARS-CoV-2 present as well. PPS of all residents in the facility can identify infected residents who can be cohorted on a pre-specified unit or transferred to a COVID-specific facility. If undertaking facility-wide PPS, facility leadership should be prepared for the potential to identify multiple asymptomatic residents with SARS-CoV-2 infection and make plans to cohort them.
- If testing capacity is not sufficient for facility-wide PPS, performing PPS on units with symptomatic residents should be prioritized.
- If testing capacity is not sufficient for unit-wide PPS, testing should be prioritized for symptomatic residents and other high-risk residents, such as those who are admitted from a hospital or other facility, roommates of symptomatic residents, or those who leave the facility regularly for dialysis or other services.
Testing of nursing home HCP
- If testing capacity allows, PPS of all HCP should be considered in facilities with suspected or confirmed cases of COVID-19. Early experience suggests that, despite HCP symptom screening, when COVID-19 cases are identified in a nursing home, there are often HCP with asymptomatic SARS-CoV-2 infection present as well. HCP likely contribute to introduction and further spread of SARS-CoV-2 within nursing homes.
- CDC recommends HCP with COVID-19 be excluded from work. Facility leadership and local and state health departments should have a plan for meeting staffing needs to provide safe care to residents while infected HCP are excluded from work. If the facility is in Crisis Capacity and facing staffing shortages, see CDC guidance on Strategies to Mitigate Healthcare Personnel Staffing Shortages for additional considerations.
4. Repeat testing may be warranted in certain circumstances.
After initial PPS has been performed for residents and HCP (baseline) and the results have been used to implement resident cohorting and HCP work exclusions, nursing homes may consider retesting under the following circumstances:
Retesting of residents
- Retest any resident who develops symptoms consistent with COVID-19.
- Retest all residents who previously tested negative at some frequency shortly (e.g., 3 days) after the initial PPS, and then weekly to detect those with newly developed infection; consider continuing retesting until PPSs do not identify new cases.
- If testing capacity is not sufficient for retesting all residents, retest those who frequently leave the facility for dialysis or other services and those with known exposure to infected residents (such as roommates) or HCP.
- Use retesting to inform decisions about when residents with COVID-19 can be moved out of COVID-19 wards. See CDC guidance on Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings for additional information.
Retesting of nursing home HCP
If testing capacity is not sufficient for retesting all HCP, consider retesting HCP who are known to work at other healthcare facilities with cases of COVID-19.