Alternative Care Sites | CDC

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Key Concepts

  • Establishing alternative care sites will help address surge in the response to COVID-19.
  • Since care will be provided in a non-traditional environment, it is critical to ensure the ACS can support implementation of recommended infection prevention and control practices.

A local surge in the need for medical care may require jurisdictions to establish alternative (or alternate) care sites (ACS), which are intended to allow healthcare providers to provide care in non-traditional environments, such as converted public buildings or mobile field medical units.1

This guidance provides critical infection prevention and control (IPC) considerations for ACS and is intended to supplement existing ACS plans (created by jurisdictions as part of pandemic planning).

The following information is for ACS providing care to adult patients with confirmed COVID-19, but the patient:

  • Still needs Transmission-Based Precautions
  • Does not require the level of care available at an acute care hospital, and
  • Cannot remain in or return to their place of residence

This could apply to:

  • Nursing home residents who have COVID-19 and need to be moved out of the facility
  • People with COVID-19 in the general population who cannot return to their place of residence for social reasons (e.g., there are elderly relatives in the home)
  • Patients with COVID-19 who are currently hospitalized but can be discharged to a lower level of care
  • People with COVID-19 who are currently experiencing homelessness and cannot be discharged to a congregate setting

The expected duration of care for patients in ACS would be based on their clinical needs and the timeline for discontinuation of Transmission-Based Precautions

Tiers of Alternative Care Sites

This guidance proposes two tiers of ACS:

  • Tier one: ACS houses a cohort of patients who need limited monitoring and can care for themselves (e.g., do not need assistance with medications or activities of daily living (ADLs)). These patients could be housed in a dedicated hotel or dormitory meant for this purpose (in their own rooms with their own bathroom).
  • Tier two: ACS houses a cohort of patients who require some level of assistance (e.g., help with ADLs or medications) and who need a closer level of monitoring than patients in tier one. These patients may be better suited in a facility that has an open layout (e.g., school gymnasium) to allow limited numbers of healthcare personnel to more easily monitor their status.

This guidance does not address a third tier of ACS that would provide more advanced care to patients (e.g., continuous IV therapy) or care for both confirmed and suspected COVID-19 patients. These scenarios would require additional IPC and staffing considerations.  For example, if the ACS provided care to both confirmed and suspected COVID-19 patients planning would need to address  maintaining physical separation between the different patient cohorts and assigning dedicate personnel to work in each area.

This guidance identifies some key considerations for IPC in ACS. However, it does not address other important aspects of ACS, including patient transportation to and from nearby healthcare facilities. Jurisdictions should consider how close the ACS is to nearby healthcare facilities, including acute care hospitals, and may need to have agreements in place with surrounding healthcare facilities regarding patient transfer.

Physical Infrastructure

  • Layout plan for all areas of the ACS
  • Layout should include the following areas:
    • Patient triage
    • Staff respite area separate from patient care area with a bathroom for staff use only: staff can store personal belongings, take breaks, and eat
    • Area for staff to put on and remove personal protective equipment (PPE)
    • Patient care area or rooms with access to patient bathrooms/shower areas
    • Designated area in patient care area where staff can document and monitor patients
    • Clean supply area
    • Medication storage/preparation area
    • Dirty utility area

Air conditioning and heating

  • Functional HVAC (heating and cooling) system
  • Tier one: ideally a facility whose HVAC units are mounted on an external wall and able to accommodate some outdoor air dilution as opposed to internal, 100% recirculation units
  • Tier two: care is provided in a large open space; ideally the HVAC has air supply at one end of the space and air return at the other end of the space
    • Staff respite area would ideally be in a room separate from the patient care area; at a minimum it should not be in a location near the air return
    • Facilities with generator support are optimal
  • Determine maximum number of patients who can safely receive care in the ACS
  • Plan for safe spacing between patients
  • Tier one (e.g., hotel rooms): each patient should have a separate room with a separate bathroom
  • Tier two: there should be:
    • At least 6 feet of space between beds
    • Physical barrier between beds, if possible
    • Bed placement alternating in a head-to-toe configuration; ideally beds and barriers should be oriented parallel to directional airflow (if applicable)
  • Space for clean storage
  • Space for dirty storage
  • Clean storage would ideally have a refrigerated section for medications and a room temperature section for other clean supplies (e.g., linen, PPE)
  • Dirty storage would have space for medical and non-medical waste and dirty equipment waiting to be reprocessed
  • Facility is functional for patient movement, including doors that are wide enough for wheelchairs and stretchers
  • No visitors or pets to avoid unnecessary risks to patients and staff; post signage at entrances to the facility indicating this policy

Services

  • Catering provided with disposable plates/utensils
  • Separate place for staff to eat without wearing PPE
  • Environmental services can be provided regularly and safely by trained staff
  • Environmental services staff have all necessary training and wear appropriate PPE for exposure to disinfectants and patients with COVID-19
  • EPA-registered disinfectants from List N are used according to label instructions
  • Tier one (e.g., hotel rooms): environmental services staff perform terminal cleaning of rooms and patients perform daily cleaning
    • Patients should be provided cleaning materials (i.e., disinfectant wipes, gloves) and instructed to clean high-touch surfaces and any surfaces that may have blood, stool, or body fluids on them daily, according to the label instructions
    • Establish a process for at least daily removal of trash from rooms
  • Tier two (e.g., large open space): environmental services staff would perform both daily and terminal cleaning
    • Wipe-down of all floors and horizontal surfaces at least once daily
    • Immediate clean-up of all spills of blood or body fluids3
    • Regular disinfection of high-touch surfaces (e.g., doorknobs)
    • At least daily cleaning of bathrooms
  • Sanitation and waste services are available for medical waste (if required)
  • Sanitation and waste services are available for routine waste
  • Laundry services are provided in accordance with routine laundering practices using either washer and dryers on site or through a contract with a laundry service
  • Medications are properly labeled and stored
  • The layout has designated a space for medication preparation activities that is not in the immediate patient care area and is away from potential sources of contamination (e.g., sink)
  • Staff who prepare and administer medications have been appropriately trained on methods to prevent medication errors and contamination
  • To the extent possible, patients should arrive with all necessary medications
  • Ensure patients’ medications are properly labeled to prevent use on the wrong patient
  • Tier one: patients should be able to self-administer all medications; medications may be stored in their room
  • On-site glucose monitoring using personal glucometers (no sharing of glucometers)
  • If oxygen is provided, pulse oximeters are required
  • On-site anticoagulation monitoring might also be needed depending on patient characteristics

Patient Care

  • Staffing plan (including medical, IPC, occupational health, administrative, and support staff)
  • Implement sick leave policies for staff/employees that are flexible and non-punitive
  • Ensure at least one individual with IPC training is included in planning and is regularly available to address questions and concerns
    • This individual would ensure that staff receive job-specific IPC training, including educating them on hand hygiene, proper selection and use of PPE and to not report to work when ill
  • Ensure staff have access to occupational health services if they experience a work-place exposure or become ill
  • Staff should be appropriate for the level of care provided
  • Nurse practitioners and physician assistants might be required to conduct activities at limit of their scope of practice
  • If trainees are recruited to assist, IPC training must be provided prior to working
  • Necessary medical supplies are available at or accessible to staff at the facility
  • To the extent possible, patients should arrive with all necessary medications
  • Sharps containers should be located near point of use
  • Examples of additional supplies include alcohol-based hand sanitizer, soap and paper towels, briefs, bedside commodes, urinals, personal hygiene supplies, vital sign machines, thermometers, wheelchairs
  • Adequate sinks for hand hygiene are available
  • Adequate numbers of toilets, including a separate toilet for staff are available
  • Adequate shower facilities are available
  • Based on the population being served, an appropriate supply of bedside commodes, urinals, and personal hygiene supplies (e.g., soap, toothpaste) should be available
  • Tier one: each patient should have a separate room with a separate bathroom
  • Tier two:
    • Minimum of 1 toilet for every 20 persons, or 1 toilet for every 6 persons with disabilities.
    • Approximate ratio of 1 shower for every 25 persons, or 1 shower for every 6 persons with disabilities

Footnotes:

Resources:

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