Evaluation & Testing

Emergency Department Triage

  1. All personnel should be wearing appropriate PPE (Appendix A)
  2. Patients arriving in the Emergency Department (ED) for care are sorted into designated zones according to presence or absence of respiratory complaints and acuity (refer to ED surge diagram below).
  3. Patients with suspected COVID-19 should be evaluated for presence and content of Advance Directives, particularly regarding intubation and mechanical ventilation.
    1. If no documented Advanced Directive/DNR/DNI is available, an attempt to obtain this should be made as soon as possible. Education regarding disease course balanced with patient choice is of utmost importance.





Suggested Emergency Department Workup for Suspected/Confirmed COVID-19 Patients Requiring Admission

Labs

  • CBC
  • CMP
  • Lactate
  • CRP
  • Procalcitonin
  • D-Dimer
  • Ferritin
  • Type and screen

CLUES TO COVID-19: leukopenia, lymphocytopenia and other inflammatory markers

Micro

  • Refer to COVID-19 Testing Algorithm

CONSIDERATIONS:

Consider: Rapid Flu, RSV, RVP, blood cultures, sputum

Co-infection rate is unknown; bacterial co-infection might increase with severity of illness

Imaging

  • Portable CXR
  • CT should be reserved for hypoxic patients or those where there is clear clinical indication in order to reduce contamination of CT scanner and conserve PPE. CT should only be performed if the results would change clinical management. 

CONSIDERATIONS:

Limited role in diagnosis of COVID-19 as laboratory testing is preferred diagnostic tool. Primary role of CT is the evaluation of superimposed processes such as pulmonary embolism or aortic dissection.

Supportive TX

  • Refer to COVID-19 Order Set

Unless concern for septic shock, recommend intermittent 500 mL boluses as needed based on clinical targets






Priorities For COVID-19 Testing


  1. Nucleic Acid or Antigen

High Priority

  • Hospitalized patients with symptoms
  • Healthcare facility workers, workers in congregate living settings, and first responders with symptoms
  • Residents in long-term care facilities or other congregate living settings, including prisons and shelters, with symptoms

Priority

  • Persons with symptoms of potential COVID-19 infection, including: fever, cough, shortness of breath, chills, muscle pain, new loss of taste or smell, vomiting or diarrhea, and/or sore throat.
  • Persons without symptoms who are prioritized by health departments or clinicians, for any reason, including but not limited to: public health monitoring, sentinel surveillance, or screening of other asymptomatic individuals according to state and local plans.

https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html Accessed May 8, 2020

Testing in asymptomatic patients before certain elective procedures (Appendix D) or at the time of an admission for obstetrical care also falls into the priority group.

There is a specific COVID-19 test order available in CareConnect One.

  1. Serologic (antibody) testing
  • CDC does not currently recommend using antibody testing as the sole basis for diagnosis of acute infection.
  • In certain situations, serologic assays may be used to support clinical assessment of persons who present late in their illnesses when used in conjunction with viral detection tests. 
  • In addition, if a person is suspected to have post-infectious syndrome (e.g., Multisystem Inflammatory Syndrome in Children) caused by SARS-CoV-2 infection, serologic assays may be used.
  • It is currently not clear whether a positive serologic test indicates immunity against SARS-CoV-2; serologic tests should not be used at this time to determine if an individual is immune.
  • These tests can help determine the proportion of a population previously infected with SARS-CoV-2. Thus, demographic and geographic patterns of serologic test results can help determine which communities may have experienced a higher infection rate.

    An order for SARS-COV-2 IgG is available in CareConnect One.





COVID-19 Testing to Inform Classification for Symptomatic patients on Admission or During Admission





COVID-19 Testing for Non-Urgent/Elective Procedures





COVID-19 Testing to Inform Classification for Asymptomatic Obstetrical Patients and Urgent InPatient Populations





COVID-19 Classification for Patients Admitted Who Do Not Meet Criteria for Testing





Isolation of COVID-19 Positive Patient on Readmission





Screening Criteria for Resolution of COVID (excluding NICU, refer to NICU section):

  • 24 hours afebrile without the use of fever-reducing medications, AND
  • Improving symptoms, AND
    • 10 days since onset symptoms or date of positive test (if asymptomatic) for mild to moderate illness

OR

  • 20 days since onset symptoms or date of positive test (if asymptomatic) for severe/critical illness (see below) or severely immunocompromised (see below)

Criteria for Severe/Critical Illness:

  • ICU admission
  • Greater than 3 LPM oxygen
  • On COVID therapy (Remdesivir, plasma, Tocilizumab, steroids)

Criteria for Severely Immunosuppressed:

  • Cancer/on chemotherapy
  • Bone marrow transplant
  • Solid organ transplant
  • Stem cells for cancer treatment
  • Genetic immune deficiencies (ex: common variable immune deficiency, selective IgA deficiency, severe combined immunodeficiency, chronic granulomatous disease, and complement deficiencies.
  • HIV (CD4 Less than 200 and/or not on effective highly active anti-retroviral therapy)
  • Use of oral or intravenous corticosteroids or other medicines called immunosuppressants that lower the body’s ability to fight some infections (e.g., mycophenolate, sirolimus, cyclosporine, tacrolimus, etanercept, rituximab)
  • HIV diagnosis
  • On HIV medications
  • Type 2 Diabetes mellitus on Problem List
  • ESRD on Problem List
  • Receipt of prednisone greater than 20mg/day for greater than 14 days
  • Neutropenia (two separate days with ANC and/or WBC values less than 500)
  • DMARDs (Disease-modifying anti-Rheumatic )

COVID Testing for Infants born to COVID-positive Moms:

  • Bathe after birth to remove virus potentially present on skin surfaces.
  • Obtain either a single swab of the nasopharynx; or a single swab of the throat followed by the nasopharynx; or two separate swabs from each of these sites and submit for a single test. Refer to Laboratory for Specimen Collection Guidelines.
  • Test at approximately 24 hours of age and again at approximately 48 hours of age.
  • If it is planned that a healthy newborn will be discharged prior to 48 hours of age, clinicians may choose to order a single test at 24-48 hours of age.
  • For infants who are positive on their initial testing, perform follow-up testing every 72 hours intervals until two consecutive negative tests are obtained to establish that the infant has cleared the virus from mucosal sites.
  • For positive infants needing ongoing hospital care, caregivers should continue to use appropriate personal protective equipment until discharge, or until the infant has two consecutive negative tests collected greater than or equal to 24 hours apart. This stringent PCR test-based approach may be optimal for sick and premature newborns as the duration of shedding infectious virus has not been established for such infants.




Specimen Collection Procedure


Collect oropharyngeal or nasopharyngeal specimens within 3 days of symptom onset if possible but no later than 7 days of symptom onset and before the start of antimicrobial therapy. See Appendix C for Specimen Collection Tip Sheet.

  1. Perform hand hygiene and don appropriate personal protective equipment (PPE), Droplet Plus or Airborne Plus, as clinically indicated for the patient.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Assess the patient’s understanding of the purpose of the procedure and his or her ability to cooperate.
  5. Assess the nasal mucosa and sinuses and observe for any drainage.
  6. Determine if the patient experiences postnasal drip, sinus headache or tenderness, nasal congestion, or sore throat or if he or she has been exposed to others with similar symptoms.
  7. Assess the condition of the posterior pharynx.
  8. Assess the patient for systemic signs of infection and for indications for isolation precautions.
  9. Review the practitioner’s orders to determine if a nasal specimen, throat specimen, or both are needed.
  10. Plan to collect the specimen before mealtime to avoid contamination.
  11. Obtain assistance for collecting throat specimens from confused, combative, or unconscious patients.

Collecting a Throat Specimen

  1. Perform hand hygiene and don appropriate personal protective equipment (PPE), Droplet Plus or Airborne Plus, as clinically indicated for the patient.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Instruct the patient to sit erect in bed or in a chair facing the nurse. A patient who is acutely ill or a young child may lie back against the bed with the head of the bed raised.
  6. Have the swab and the sterile tube or culture tube ready for use. If using a prepackaged swab in a tube, loosen the top so the swab can be removed easily.
  7. Instruct the patient to tilt his or her head back. If the patient is in bed, place a pillow behind his or her shoulders.
  8. Ask the patient to open his or her mouth and say “ah.”
  9. Depress the anterior third of the tongue with a tongue blade and observe for any inflamed areas of the pharynx or tonsils. Illuminate the area with a penlight as needed. Do not place the tongue blade along the back of the tongue; doing so is likely to initiate the gag reflex. If the patient gags, remove the tongue blade and allow the patient to relax before reinserting it.
  10. Insert the swab without touching the lips, teeth, tongue, cheeks, or uvula.
  11. Gently but quickly swab the tonsillar area from side to side, contacting any inflamed or purulent sites.
  12. Carefully withdraw the swab without touching the oral structures.
  13. Immediately insert the swab into the sterile tube or culture tube (Figure 2) and push the tip into the liquid medium at the bottom of the tube or follow instructions specific to specimen collection per organizations practice.
  14. Place the top securely on the culture tube.
  15. In the presence of the patient, label the specimen per the organization’s practice.
  16. Prepare the specimen for transport by placing the labeled specimen in a biohazard bag.
    1. Record on the laboratory requisition if the patient is taking an antibiotic or if a specific organism is suspected.
  17. Immediately transport the specimen to the laboratory.
  18. Assess, treat, and reassess pain.
  19. Discard supplies, remove PPE, and perform hand hygiene.
  20. Document the procedure in the patient’s record.

Collecting a Nasopharyngeal Specimen: Swab Method

  1. Perform hand hygiene and don appropriate personal protective equipment (PPE), Droplet Plus or Airborne Plus, as clinically indicated for the patient.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Instruct the patient to sit erect in bed or in a chair facing the nurse. A patient who is acutely ill or a young child may lie back against the bed with the head of the bed raised.
  6. Have the nasopharyngeal swab (on flexible wire) and the sterile tube or culture tube ready for use. If using a prepackaged swab in a tube, loosen the top so the swab can be removed easily.
  7. Gently advance the swab to the nasopharynx until resistance is met.
  8. Roll the swab and allow it to remain in place for several seconds.
  9. Insert the swab into the sterile tube or culture tube and push the tip into the liquid medium at the bottom of the tube or follow instructions specific to specimen collection per organizations practice.
  10. Place the top securely on the tube.
  11. Offer the patient a facial tissue to blow his or her nose if needed.
  12. In the presence of the patient, label the specimen per the organization’s practice.
    1. Prepare the specimen for transport by placing the labeled specimen in a biohazard bag.
    2. Record on the laboratory requisition if the patient is taking an antibiotic or if a specific organism is suspected.
  13. Immediately transport the specimen to the laboratory.
  14. Assess, treat, and reassess pain.
  15. Discard supplies, remove PPE, and perform hand hygiene.
  16. Document the procedure in the patient’s record.