Last Updated 3/26/2020
What to Tell Patients
The CDC has created a handout for medical practice to make available for concerned patients. Click here to download the pdf, or visit the CDC’s web page of printable handouts and posters.
Practice Protocols & Preparedness
Pre-Screening: When scheduling appointments, instruct patients and persons who accompany them to call ahead or inform staff upon arrival if they have symptoms of any respiratory infection (e.g., cough, runny nose, fever) and to take appropriate preventive actions (e.g., wear a facemask upon entry to contain cough, follow triage procedures).
Promote Respiratory Hygiene: Take steps to ensure all persons with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough) adhere to respiratory hygiene and cough etiquette, hand hygiene, and triage procedures throughout the duration of the visit. Consider posting visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide patients and health care personnel with instructions (in appropriate languages) about hand hygiene, respiratory hygiene, and cough etiquette. Instructions should include how to use facemasks or tissues to cover nose and mouth when coughing or sneezing, to dispose of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene.
Provide supplies for respiratory hygiene and cough etiquette, including 60%-95% alcohol-based hand sanitizer (ABHS), tissues, no touch receptacles for disposal, and facemasks at healthcare facility entrances, waiting rooms, patient check-ins, etc.
Limit Exposure: Ensure that patients with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough) are not allowed to wait among other patients seeking care. Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies. In some settings, medically-stable patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated.
Rapid Triage: Ensure rapid triage and isolation of patients with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough):
- Identify patients at risk for having COVID-19 infection before or immediately upon arrival to the healthcare facility.
- Implement respiratory hygiene and cough etiquette (i.e., placing a facemask over the patient’s nose and mouth if that has not already been done) and isolate the PUI for COVID-19 in an Airborne Infection Isolation Room (AIIR), if available. See recommendations for “Patient Placement” below. Additional guidance for evaluating patients in U.S. for COVID-19 infection can be found on the CDC COVID-19 website.
- Inform infection prevention and control services, local and state public health authorities, and other healthcare facility staff as appropriate about the presence of a person under investigation for COVID-19.
The above is summary guidance for practices. Please visit the CDC’s protocol for full details; it is being updated on a rolling basis. MCMS encourages practices to utilize the CDC’s preparedness checklist for COVID-19 and the CDC’s interim guidance for community transmission preparation in various facility and practice modalities.
What to Look For
The CDC’s clinical criteria for a “patient under investigation” (PUI) for possible COVID-19 infection are based on what is known about the Middle Eastern respiratory syndrome coronavirus (MERS-CoV) and the severe acute respiratory syndrome coronavirus (SARS-CoV). The key is to look for both clinical features and epidemiologic risks before calling our local or state public health department to sound the alarm.
Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Decisions on which patients receive testing should be based on the local epidemiology of COVID-19, as well as the clinical course of illness. Most patients with confirmed COVID-19 have developed fever1 and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing). Clinicians are strongly encouraged to test for other causes of respiratory illness, including infections such as influenza.
Epidemiologic factors that may help guide decisions on whether to test include: any persons, including healthcare workers2, who have had close contact3 with a laboratory-confirmed4 COVID-19 patient within 14 days of symptom onset, or a history of travel from affected geographic areas5 (see below) within 14 days of symptom onset.
Additionally, the CDC’s guidance notes that “fever may not be present in some patients, such as those who are very young, elderly, immunosuppressed, or taking certain fever-lowering medications” and urges physicians to use their clinical judgement in such cases.
This clinical criteria is from the CDC as of March 12, 2020. Check their clinical criteria page for the most up to date information.
When & How to Report
If you have a patient under investigation for COVID-19, immediately let your facility’s infection control department know and report it to our local or state public health department.
All reports in Maryland should be sent directly to the county health department, not to the Maryland Department of Health. Telephonic reporting is preferred in Maryland.
How to Test
The agency’s interim guidelines say to collect multiple clinical specimens and all three specimen types—upper respiratory (nasopharyngeal AND oropharyngeal swabs), and lower respiratory (sputum, if possible) for those patients with productive coughs. Induction of sputum is not recommended. Specimens should be collected as soon as possible once a PUI is identified, regardless of the time of symptom onset. Maintain proper infection control when collecting specimens.
It’s important to test for other respiratory pathogens at the time of the initial evaluation. Don’t let such testing delay your shipping the specimen to the CDC, the agency says.
Also, the CDC recommends—for biosafety reasons—against performing virus isolation in cell culture or initial characterization of viral agents recovered in cultures of specimens that come from patients under investigation for 2019-nCoV.
The Maryland and Montgomery County health department will assist clinicians to collect, store, and ship specimens appropriately, including during afterhours or on weekends/holidays. Use the contact information above to get in touch with them. The Maryland Department of Health has also published a web page on specimen collection and shipping.
LabCorp and Quest Diagnostics are also providing testing. They have each posted web pages (1, 2) that they are updating on a rolling basis.
What Precautions to Take
Health care personnel should use standard precaution, contact precautions, airborne precautions and eye protection such as goggles or a face shield before entering the room. Please note that, in situations where fit-tested NIOSH-approved N95 or higher level respirator for healthcare personnel are in a shortage, surgical masks may be used. Eye protection, gown, and gloves continue to be recommended, but if there are shortages of gowns, they should be prioritized for aerosol-generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP.
Section 2 of this CDC web page emphasizes important PPE compliance. For full precaution guidance, refer to the CDC’s isolation precautions guideline.