Last Updated February 28, 2020
The following guidance is drawn primarily from the Centers for Disease Control and Prevention’s (CDC) resources for health care professionals on COVID-19. Additional information is provided based on resources from the American Medical Association, the Maryland Department of Health, and Montgomery County Health and Human Services. Every effort is being made by MCMS staff to keep this guidance up to date, but we recommend always referring to both MDH and CDC guidance for the most recent information. Please refer to the resource list at the bottom of this article for reference links.
What to Tell Patients
The Montgomery County Health Department has created a resource page that is a helpful guide on what to say to patients, and to refer them to if they want to learn more. Montgomery County Medical Society used this page as a template to create a handout that physicians may use at their practices, to provide patients with information. Download it as a PDF or Microsoft Word Document.
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 triage procedures to detect persons under investigation (PUI) for COVID-19 during or before patient triage or registration (e.g., at the time of patient check-in) and ensure that all patients are asked about the presence of symptoms of a respiratory infection and history of travel to areas experiencing transmission of SARS-CoV-2, the virus that causes COVID-19, or contact with possible COVID-19 patients.
- 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.
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.
Fever and symptoms of lower respiratory illness such as cough or difficulty breathing are not sufficient. The following is clinical criteria from the CDC as of February 28, 2020. Check their clinical criteria page for the most up to date information.
|Fever1 or signs/symptoms of lower respiratory illness (e.g. cough or shortness of breath)||AND||Any person, including health care workers2, who has had close contact3 with a laboratory-confirmed4 COVID-19 patient within 14 days of symptom onset|
|Fever1 and signs/symptoms of a lower respiratory illness (e.g., cough or shortness of breath) requiring hospitalization||AND||A history of travel from affected geographic areas5 (see below) within 14 days of symptom onset|
|Fever1 with severe acute lower respiratory illness (e.g., pneumonia, ARDS) requiring hospitalization6 and without alternative explanatory diagnosis (e.g., influenza)7||AND||No source of exposure has been identified|
Affected Geographic Areas with Widespread or Sustained Community Transmission, as of February 28, 2020:
- South Korea
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.
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.
- Montgomery County Department of Health and Human Services: M-F Business Hours – 240.777.1755 After Hours & Weekends – 240.777.4000
- District of Columbia Department of Health: 202.727.3616 or report cases using this web portal.
- List of Contact Information for All Maryland Local Health Departments
*Each organization was contacted by MCMS staff to request the correct contact information for reporting. This listing will be updated on a rolling basis. Question? Call MCMS at 301.921.4300.
How to Test
For now, testing for COVID-19 can only be done at the CDC, which has developed a real-time reverse transcription-polymerase chain reaction test that can diagnose COVID-19.
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.
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 airborne precautions specifically require “a fit-tested NIOSH-approved N95 or higher level respirator for healthcare personnel,” and these precautions do require gloves and a gown. Section 2 of this CDC web page emphasizes important PPE compliance. For full precaution guidance, refer to the CDC’s isolation precautions guideline.
Resources for Physicians
From the Centers for Disease Control and Prevention
From the World Health Organization (WHO): WHO Coronavirus Home which is updated on a rolling basis with technical guidelines on a rolling basis.
From the Journal of the American Medical Association (JAMA): Guidance for diagnosis and treatment, updated on a rolling basis.
Local Maryland/Montgomery County Resources
- Maryland Department of Health’s (MDH) web page for the latest updates on the virus
- Montgomery County’s Health Department’s general information page for the public, which practices can refer their patients to.
In the News
- The Washington Post‘s live updates page
- From the AMA Wire, “When global health emergencies strike, how should doctors respond?”
- MedChi, The Maryland State Medical Society’s press release on nCoV
For an up-to-date incidence map, see the Johns Hopkins School of Public Health GIS map.