ACEP COVID-19 Field Guide

Author: Christopher Sampson, MD, FACEP, Program Director, Emergency Medicine Residency, Assistant Medical Director, MU Emergency Medical Services; Department of Emergency Medicine, Associate Clinical Professor, University of Missouri-Columbia

Criteria

Note: Not all persons under investigation require hospital admission.

If COVID-19 testing is still pending, advise the patient that they need to voluntarily isolate until provided with results. Refer to the CDC guidelines for possible handouts for the patient. Verify contact information for the patient, active phone service, and appropriate language services, if needed.

• Confirm the patient’s ability to manage activities of daily living (ADLs);
• Confirm that the patient has enough resources or support for up to 2 weeks of food and other necessary supplies while in self-isolation;
• Ensure that the patient has an adequate supply of home medications to take during the next 1 to 2 weeks;
• If available, provide a surgical mask to the patient; and 
• Verify the patient has private transportation home.

Special needs populations include homeless patients, prisoners, and nursing-home patients. Refer to local health department guidelines on where these patients can be transported for self-isolation.

For long-term care or assisted-living facilities, the CDC recommends patients “...go to a facility with an ability to adhere to infection prevention and control recommendations for the care of COVID-19 patients. Preferably, the patient would be placed in a location designated to care for COVID-19 residents.”

The following clinical discharge criteria are based on anecdotal reports from Italy. This pathway is based on limited evidence from an interview with Italian emergency medicine physician Andrea Duca and should be used with good clinical judgment. Based on the capacity of the health care system, these criteria may or may not be possible. 

If the following criteria are met with COVID-19 positive results, the patient may be considered safe for discharge. (Lab testing and imaging may not be indicated in mild cases; thus, clinicians must assess the severity of each case and use their own clinical judgment.)

• Normal vital signs (HR <120, RR <20, SBP >100)
• No lab abnormalities
• Negative CXR
• Negative lung US (check for pleural thickening, consolidation, B lines)
• Ambulating pulse ox does not drop >3% points less than resting pulse ox

If the above criteria are met, alternatives can be considered when there are limited hospital beds:

• If there are no findings on CXR or lung US and no pulse ox decline, the patient could be sent home with a pulse oximeter, educated on how to perform a daily walking test, and instructed to return if there is greater than a 3-point drop.

Based on lack of available evidence:

• If the patient is not hypoxic (O₂ saturation <90%) at rest or with exertion and the patient is in no respiratory distress, then the patient could be given explicit discharge instructions on concerning signs and symptoms that warrant return to the emergency department, including worsening shortness of breath, altered mental status, and an inability to tolerate oral intake.

Smart phrase

Authors: William Weber, MD, MPH; Kimberly A. Collins, MD, MPH, FACEP; Wendy L. Macias-Konstantopoulos, MD, MPH, FACEP; John Westhoff, MD, MPH, FACEP; reviewed by the ACEP Public Health and Injury Prevention Committee

Coronavirus concern — confirmed or suspected

You were evaluated in the emergency department with symptoms concerning for infection with coronavirus COVID-19. COVID-19 is a new strain of a common viral illness. While a diagnosis of coronavirus may feel scary, most cases of coronavirus are mild and resolve on their own without hospitalization. At this time, we feel that you are safe to go home.

Steps to take at home to care for yourself:

• Get lots of rest and stay hydrated by drinking plenty of fluids.
• You can take acetaminophen (eg, Tylenol) for fevers or body aches.
• If you have questions, call your primary care doctor, contact your local health department, or visit the CDC’s website at cdc.gov/coronavirus.
• Speak with your primary care doctor within 2 weeks to discuss a plan to follow up.

How to avoid spreading the virus to others:

• Stay at home, except if seeking medical care.
• Cover your coughs (with a tissue or in your elbow), and avoid touching your face unnecessarily.
• Wash your hands often (using soap and water for 20 seconds) to decrease your risk of infecting others.
• Try to avoid close contact with others in your home, including pets. If possible, use a different bathroom, and sleep in a separate room. If you must be near others, be sure to wear a face mask and wash your hands before interacting with them. Disinfect and avoid sharing commonly used items like phones, towels, and dishes with others.
• If a test was sent and is positive, your local health department will contact you. Follow their directions about when to go back to work or school.
• If you were not tested, you may stop quarantine 10 days after the start of your symptoms as long as your symptoms have been completely gone (without using medications) for at least 72 hours (3 days).

If you or those around you are concerned about COVID-19, call your primary care doctor for advice about steps to take. Your health system may have specific locations to go for testing if you are not extremely sick. This lowers the risk that you could catch a virus or pass it on in the emergency department waiting room. If you are extremely sick and going to the emergency department, call ahead, so they can prepare for your visit.

Speak to your doctor or come back to the emergency department for new or worsening symptoms, such as severe headache, confusion, chest pain, difficulty breathing, or vomiting to the point that you cannot drink fluids. Review medication inserts for side effects, and call the emergency department if you have any questions about the medications or care you received.