Part of being prepared for COVID-19 (coronavirus disease 2019) is knowing whom to test for infection with the coronavirus that causes it, SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). Contact your local or state health department to find out their recommendations and protocols for screening and testing. But in the absence of clear direction, how should healthcare providers proceed?
As long as tests remain in short supply, prioritize testing for those at highest risk of infection and severe disease: patients who have fever and dry cough and who have (1) had contact with a person known be infected with SARS-CoV-2 or (2) traveled to one of the affected countries where there’s been a COVID-19 outbreak.
SARS-CoV-2 can infect both the upper and lower respiratory tracts. Upper respiratory tract symptoms include fever, dry cough, rhinitis, and sore throat. Lower respiratory tract symptoms include fever, dry cough, and shortness of breath. But some patients have no symptoms at all.
Assessing Epidemiologic Factors
In determining epidemiologic risk, please review CDC’s travel advisories. As I write this, countries with level 3 travel health notices due to high levels of SARS-CoV-2 transmission include China, Iran, Italy, and South Korea.
In addition, if a patient is older (older than age 50, but especially older than age 70) and/or has a chronic medical illness (lung disease, heart disease, liver disease, kidney disease, cancer, autoimmune disease, or immunosuppression), he or she is at much greater risk for severe disease and death. You should have a higher index of suspicion among such patients and prioritize them for testing.
How to Test
One of the biggest challenges remains testing. I have been getting emails and Twitter messages from healthcare providers all over the country saying that even the commercial labs like LabCorp and Quest won’t be able to provide them with testing until a few weeks from now. Stay tuned.
Given that test kits remain in short supply, you should consider a tiered approach to testing symptomatic patients.
Start by testing for influenza A and B and respiratory syncytial virus. If those are negative, then perform a multiplex PCR for other common respiratory viruses as a second-line test. And if that’s negative, then test for SARS-CoV-2. This allows us to target testing to those at highest risk for COVID-19.
The turnaround time on testing will vary. Patients who are younger than 50 years of age and who do not have chronic medical conditions should be counseled to quarantine themselves at home while awaiting test results. Patients who have symptoms concerning for COVID-19—if they are older than 50 years or have chronic medical conditions—should present to an inpatient facility for testing and treatment.
Studies have shown that patients with coronavirus often decompensate approximately 1 week into illness and may become critically ill. Anyone who is at high risk for severe disease should be in a monitored setting.
Setting Up Your Practice for COVID-19
A lot of the questions from clinicians on the frontlines center on: “How do I deal with this myself?” What do we do with a patient who comes to see us in the outpatient setting? COVID-19 can masquerade not just as pneumonia but also as the common cold. Do we have to assume that it will come to our practices, offices, emergency departments, etc? How do we prepare?
To me, we can learn from the concept of universal precautions, which arose during the era of HIV.
What does this look like in terms of setting up your waiting room? Ideally, you wouldn’t have people sitting in a waiting room. You’d put them in exam rooms as quickly as possible, and you’d want to disinfect all the surfaces in those rooms—you need to wipe down surfaces after every patient visit. Your favorite brand of household cleaner is effective.
Another way to reduce risk is to keep windows open if you have them. That makes a big difference in terms of ventilation. It’s cheap and highly effective.
Let’s say you have somebody in your office or in the emergency department and you’re concerned that they may have COVID-19. What’s your plan for isolating them? Ideally, you’d place them in a negative pressure room, but it’s unlikely you can do that in your outpatient clinic.
The protocols for persons under investigation are also shifting. Check the CDC Web site for the most up-to-date infection control recommendations for handling patients who may have COVID-19.
The Right Tools
Making sure you have the necessary supplies on hand, and knowing how to use them, is going to be paramount.
For example, get training on the correct way to don and doff personal protective equipment. Doffing is a particularly high-risk procedure when many healthcare providers may inadvertently contaminate themselves.
With COVID-19, few healthcare providers received guidance from their employers on how to use personal protective gear. We, as healthcare workers, need to demand this of hospital administrations and outpatient office administrators.
What will you do if a patient who may have COVID-19 comes to see you in the outpatient or inpatient setting? Is your practice prepared? I invite you to share your thoughts below.