Clinical and Public Health Guidance for Managing COVID-19
Interim Guidance (subject to change); March 18, 2020
The number of persons diagnosed with COVID-19 in Illinois continues to increase
Community-wide transmission has been documented in multiple areas of the state
Several commercial laboratories and hospital-based COVID-19 testing options are now available
IDPH laboratories will now only accept nasopharyngeal (NP) swabs; lower respiratory tract specimens (sputum) can also be submitted
Priority testing at IDPH laboratory is for hospitalized individuals with pneumonia not attributable to another etiology
- Immediately report to the Local Health Department:
Persons who are part of a cluster of 2 or more possible or confirmed cases in a residential congregate setting that serves more vulnerable populations such as an assisted living facility, group home, homeless shelter, or correctional setting and
- Persons hospitalized with unexplained pneumonia who are from a residential congregate setting that serves more vulnerable populations such as an assisted living facility, group home, homeless shelter, or correctional settings.
MINIMIZE EXPOSURES TO THE PUBLIC, VULNERABLE PATIENTS AND HEALTHCARE WORKERS
- Advise patients with mild respiratory illness to STAY HOME; testing is not indicated for mildly ill or asymptomatic persons
- This will minimize possible exposures to healthcare workers, patients and the public and reduce the demand for personal protective equipment
PRESERVE PERSONAL PROTECTIVE EQUIPMENT SUPPLIES
- Use standard, contact, droplet precautions, and eye protection when caring for patients who are confirmed or suspected to have COVID-19
Plan now for enhanced surge capacity at healthcare facilities
The World Health Organization (WHO) has announced that the current coronavirus disease 2019 (COVID-19) outbreak is now a pandemic. Community transmission of SARS-CoV-2, the virus that causes COVID-19, is occurring in multiple locations in Illinois.
Widespread transmission of SARS-CoV-2 will likely result in large numbers of people needing medical care in the coming weeks. Syndromic surveillance data show an increase in the number of persons visiting emergency departments who report influenza-like illness. At this time, providers and healthcare facilities are therefore urged to implement mitigation strategies to lessen the impact that COVID-19 may have on staff and patients and to ensure continuing operations. Resources are available on the CDC website. Providers should manage any persons with acute febrile or respiratory illness that cannot be attributed to other causes as being potentially infected with SARS-CoV-2.
COVID-19-like illness is described as new onset of subjective or measured (≥100.4oF or 38.0oC) fever OR cough OR shortness of breath OR sore throat that cannot be attributed to an underlying or previously recognized condition. In children, fever with sore throat may be attributable to conditions other than COVID-19 (e.g., strep throat) and the parent/guardian should be instructed to consult a healthcare provider to rule out other etiologies. A confirmed case of COVID-19 is defined as a person with COVID-19-like illness and a positive laboratory test. A possible case of COVID-19 is defined as a person with COVID-19-like illness for whom testing was not performed.
To date, factors associated with severe illness include age ≥50 years (children and young adults appear to be less affected) and chronic medical conditions, such as chronic lung disease (e.g., asthma, emphysema), hypertension or diabetes. At this time, it is unknown if pregnant women are at higher risk of severe illness.
TESTING FOR COVID-19:
Several commercial and hospital-based laboratories are now offering COVID-19 testing using a molecular assay. However, at this time, IDPH recommends against testing persons with mild illness who can be safely managed at home, unless a diagnosis may impact patient management. This will minimize possible exposures to healthcare workers, patients and the public, and reduce the demand for personal protective equipment. Providers should keep in mind that a negative result in the context of a person who is symptomatic and who is not improving and in whom there is a high index of suspicion for COVID-19 might represent a false negative. If there is reason to suspect a person has COVID-19 despite a negative test result, consider re-testing and continuing infection control practices appropriate for COVID-19.
Because of test kit and supply constraints, IDPH will only allow specimens from hospitalized patients with severe acute lower respiratory illness (e.g., pneumonia) to receive automatic pre-approval after entry of the relevant information in a REDCap (online) request. To obtain approval for other testing (including clusters in a congregate setting), submit a request in REDCap or contact the local health department. Testing for other individuals should generally be performed at non-IDPH laboratories until further notice. A list of commercial laboratories providing testing is on the IDPH website.
Specimens required for COVID-19 testing include 1 nasopharyngeal (NP) swab (used to swab both nostrils) packaged in the SAME viral transport medium (VTM) collection tube. One lower respiratory tract specimen (e.g., sputum) can also be submitted if it can be easily collected (e.g., bronchial or tracheal aspirate in patients who are on ventilator support).
REPORTING PERSONS WITH SUSPECTED OR CONFIRMED COVID-19 TO PUBLIC HEALTH:
Local health departments and IDPH receive positive test results directly from laboratories performing testing. However, providers should immediately report to the Local Health Department:
- Persons who are part of a cluster of 2 or more possible or confirmed cases in a residential congregate setting that serves more vulnerable populations such as an assisted living facility, group home, homeless shelter, or correctional settings.
- Any person hospitalized with pneumonia of unknown etiology who are from a residential congregate setting that serves more vulnerable populations such as an assisted living facility, group home, homeless shelter, or correctional settings
PROTECTING PATIENTS AND STAFF:
Providers should strongly discourage persons who have a mild disease consistent with COVID-19- like illness and who do not require medical care from visiting a healthcare facility. Message patients who are at higher risk for more severe disease (e.g., older adults, persons with a compromised immune system or who have chronic health conditions such as heart disease, diabetes and lung disease) to limit the amount of time they spend with other people, especially outside the home, to reduce the possibility of being infected with the virus. Consider placing signage and greeters at entry points to screen persons seeking care and visitors for symptoms of COVID-19-like illness. This will help avoid unnecessary exposures within the healthcare facility. As an alternative to in-person evaluation, communicate with patients by telephone, electronic messaging or video conferencing. Evaluation for patients with severe illness, which might include worsening symptoms or difficulty breathing, should be done in an acute care facility. If a patient with COVID-19-like illness needs to be evaluated in person, instruct them to minimize contact with other persons, travel by private car if possible and, when available, to use a face mask while traveling to the healthcare facility.
INFECTION CONTROL UPDATES:
Healthcare facilities should implement and adhere to policies and practices that minimize exposures to respiratory pathogens including SARS-CoV-2. A continuum of infection control measures should be implemented before patient arrival, upon arrival, throughout the patient’s visit, and until the patient’s room is cleaned and disinfected. It is particularly important to protect individuals at increased risk for adverse outcomes from COVID-19 (e.g., older persons with comorbid conditions). Triage personnel should have a supply of facemasks and tissues for patients with COVID-19-like illness that can be provided to them upon arrival. Source control (putting a facemask over the mouth and nose of a symptomatic patient) can help to prevent transmission to others.
Additionally, in the setting of a pandemic with widespread community transmission in Illinois, all healthcare workers are at some risk for exposure to COVID-19, whether in the workplace or in the community. Therefore, IDPH is asking ALL healthcare workers, regardless of whether they have had a known SARS-CoV-2 exposure, to self-monitor by taking their temperature twice daily and assessing for COVID-19-like illness. If healthcare workers develop any signs or symptoms of a COVID-19-like illness (for healthcare workers, fever cutoff is 100.0oF), they should NOT report to work. If any signs or symptoms occur while working, healthcare workers should immediately leave the patient care area, inform their supervisor per facility protocol, and isolate themselves from other people
PERSONAL PROTECTIVE EQUIPMENT (PPE) UPDATE:
As per the newest CDC guidance, patients can be managed with droplet precautions along with gown, gloves, and eye protection. This means that patients can be evaluated in a private examination room with the door closed. An airborne infection isolation room (AIIR) is no longer required by the CDC unless the patient will be undergoing an aerosol generating procedure (the CDC does NOT consider the collection of a NP or OP swab an aerosol generating procedure).
If a private exam room is not readily available in the healthcare facility, ensure that the patient is not allowed to wait among other patients seeking care. Identify a separate space that allows the patient to be separated from others by ≥6 feet, with easy access to respiratory hygiene supplies. In some settings, 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.
The safety of healthcare workers is a top priority for IDPH. As we gain more understanding of COVID-19, our guidance will evolve. The use of standard, contact, and droplet precautions with eye protection is appropriate when caring for patients with possible or confirmed COVID-19. Personal protective equipment (PPE) should include facemask (procedure or surgical mask) AND gown AND gloves AND eye protection (goggles or face shield).
IDPH recommends healthcare workers do not need to use a fit tested N95 respirator or Powered Air Purifying Respirator (PAPR) for routine (non-aerosol generating) care of a COVID-19 patient. Patients can be evaluated in a private examination room with the door closed.
Supplies of PPE must be reserved for high risk procedures due to potential supply chain constraints. Ample studies indicate the safety of droplet precautions which may also help prevent the complete exhaustion of fit tested N95 respirators and PAPRs; higher level PPE will continue to be needed to protect HCWs during critical and medically necessary aerosol generating procedures (e.g., intubation, suctioning) throughout the course of this outbreak.
Placing the patient in an AIIR and the use of a fit tested N95 respirator or PAPR is still recommended for aerosol-generating procedures (e.g., intubation, suctioning, nebulizer therapy) and when caring for patients with severe illness requiring intensive care. These recommendations are based on our current knowledge of COVID-19 and other coronaviruses, are endorsed by subject matter experts in the field of infection control, and are aligned with the WHO Infection Control Guidance for COVID-19. According to the new Report on the WHO-China Joint Missions on Coronavirus Disease 2019: “Airborne spread has not been reported for COVID-19 and it is not believed to be a major driver of transmission based on available evidence; however, it can be envisaged if certain aerosol-generating procedures are conducted in health care facilities.” Additionally, several studies, including a recent large randomized control trial, showed no benefit to the use of N95 respirators vs. face masks in preventing influenza and other viral respiratory infections in healthcare workers (Radonovich, 2019).
These measures are part of an overall infection control package designed to keep healthcare workers safe: rapid identification and source control of symptomatic patients, strict adherence to respiratory and hand hygiene practices, training staff on correct use of PPE, and routine cleaning and disinfection of surfaces and equipment.
HCPs with confirmed or suspected COVID-19: Crisis Strategies to Mitigate Staffing Shortages:
- Healthcare systems, healthcare facilities, and health authorities might determine that the recommended approaches cannot be followed due to the need to mitigate HCP staffing shortages. In such scenarios HCP should be evaluated by occupational health to determine appropriateness of earlier return to work than recommended above
- If HCP return to work earlier than recommended above, they should still adhere to the Return to Work Practices and Work Restrictions recommendations as outlined above.
HEALTHCARE FACILITY PREPAREDNESS:
Healthcare resources in Illinois will become strained in the weeks ahead and healthcare facilities should plan for enhanced surge capacity. Considerations might include closing nonessential services, cohorting patients, using non-patient care spaces for triage of patients suspected to have COVID-19, opening closed units, using ambulatory areas, discharging/transferring patients, and creating designated isolation spaces. Healthcare facilities are also encouraged to implement plans now for canceling elective admissions and procedures. The American College of Surgeons released a statement on March 13, 2020, recommending that health systems “minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures” and “minimize use of essential items needed to care for patients, including but not limited to, ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators.”
Currently, medical care for COVID-19 is supportive. Corticosteroids should be avoided unless they are indicated for other reasons (e.g., COPD exacerbation, septic shock). The antiviral remdesivir is being studied as one experimental treatment. Criteria for compassionate use of the drug as per the manufacturer Gilead include a confirmed SARS-CoV-2 infection, pneumonia, and hypoxia (oxygen saturation ≤94% on room air). Exclusion criteria may include creatinine clearance <30 ml/min and liver function tests >5 times normal.
Clinicians interested in obtaining the drug can directly reach out to the National Institutes of Health or Gilead. In addition, see CDC’s current Clinical Guidance at https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
ISOLATION AND QUARANTINE GUIDANCE FOR MANAGING PERSONS WITH POSSIBLE OR CONFIRMED COVID-19
Isolation and quarantine are different. These two terms are not interchangeable. Isolation refers to the separation of sick people with a contagious disease from people who are not sick. Quarantine refers to the separation of asymptomatic people who were exposed to a contagious disease to see if they become sick.
When preparing to discharge patients with confirmed or possible COVID-19 from the emergency or inpatient department, or sending them home from an outpatient healthcare facility, instruct them to self-isolate and remind their household contacts to self-monitor (see below). IDPH DOES NOT require a negative COVID-19 test to release a patient from a healthcare facility. Providers in Chicago should follow CDPH guidance on release of patients for a healthcare facility.
SELF-ISOLATION AT HOME
As a routine matter, but especially during the current pandemic, persons who are not hospitalized but who have possible or confirmed COVID-19 should be instructed to isolate themselves in a private residence until 10 days following onset of illness and 72 hours after being consistently afebrile without use of antipyretics and with resolving respiratory symptoms. Caregivers should consult a healthcare provider for children with fever and sore throat to determine if testing is indicated for other illnesses such as strep throat. Persons staying at home because of confirmed or presumed COVID-19 infection should not attend work or school and should avoid public settings and other situations that may permit close contact with others. This guidance applies to any person, regardless of whether they have received a laboratory-confirmed COVID-19 diagnosis, including healthcare workers.
Healthcare workers and other staff employed by a facility regulated by the state or should check with their employer before returning to work as the employer may have a different policy regarding COVID-19.
SOCIAL DISTANCING AND SELF-MONITORING:
We are entering a phase of the pandemic where social distancing may have the greatest impact on minimizing transmission. All Illinoisans are asked to practice social distancing, meaning that they should stay at home to the extent possible and only leave home for essential tasks. All Illinoisans should consider themselves as possibly exposed to SARS-CoV-2 and must therefore self-monitor for COVID-19-like illness – especially those who have had close contact with a person with possible or confirmed COVID-19 and those who are healthcare workers. Close contact includes those persons who reside or provide care in the same household of the ill person or are an intimate partner of the ill person. Close contacts should monitor their health at all times but should be particularly vigilant for 14 days starting from the last time there was close contact with the person while they were ill. Persons in whom COVID-19-like illness develops should isolate themselves at home and adhere to guidance on self-isolation at home for persons with confirmed or possible COVID-19 (see above). Such ill persons should only seek healthcare if they have severe or worsening illness.
As a reminder, patients with mild illness do not need COVID-19 testing, unless it may change clinical management.
Emotional reactions to this emerging health crisis are expected. Remind yourself, your staff and your patients that feeling sad, anxious, overwhelmed or having other symptoms of distress such as trouble sleeping is normal. If symptoms become worse, encourage them, and yourself, to reach out for support and help.
Illinois healthcare providers and institutions are reminded to check COVID-19 resources available on the IDPH website, local health department websites, and the CDC website.