Clinical Guidance: Triaging / Testing

For Hospital and Clinic Caregivers

What should I do if a patient arrives with COVID-19 (novel coronavirus)?

If you encounter a patient who’s been to an area where community spread is occurring (according to the CDC) and who’s developed a fever, cough, or is having difficulty breathing, please ask the individual to put on a mask — and mention the situation to the person’s provider if you aren’t the immediate caregiver. From that point forward, follow appropriate care process guidelines for your job area, located on this site.

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Clinical Assessment Guidelines

COVID-19 (novel coronavirus) testing is now available but remains limited right now. The CDC recommends focusing testing on patients with high epidemiologic risk, a syndrome compatible with COVID-19, and cases with important public and healthcare impact. Here are specific direction to Intermountain clinicians regarding appropriate screening, isolation, and selection of patients for testing for COVID-19.

For Patients at Home 

Patients with mild symptoms are encouraged to avoid healthcare facilities, treat symptomatically, and if needed, access Intermountain Connect Care providers who can evaluate for COVID-19 and give advice about additional care.

For Patients at Intermountain Facilities: Screening for COVID-19

On arrival, all patients should undergo screening to determine if they're at High Risk of COVID-19: 

Isolation, Clinical Evaluation, and COVID-19 Testing

For Patients at High Risk of COVID-19

  • These patients require testing. Follow isolation guidance below and contact the Utah Department of Health.
  • Promptly place patient in a procedure mask and a negative pressure room if available, or a private room if negative pressure is unavailable.
  • Caregivers should use Airborne-Contact protective personal equipment (PPE), including PAPR (preferred), or fit-tested N95 plus eye protection, a gown, and gloves.
  • Take a detailed travel and exposure history and clinical assessment, with consideration for features unique to COVID-19.
  • Contact the UDOH COVID-19 Hotline (1-800-456-7707) to coordinate testing and home isolation.
  • Once the decision to test for COVID-19 has been made, these patients are classified as Persons Under-Investigation (PUI); please fill out the PUI form and confirm isolation instructions from the Utah Department of Health to provide the patient.

Outpatient and Admission Decisions:

For PUI in Outpatient clinics or Emergency Departments who don't require hospital admission, obtain swabs for COVID-19 testing, complete appropriate medical evaluation for other conditions if needed, (for example if they'd qualify for antivirals if influenza positive), and prepare for discharge to home with the following safeguards:

  • Confirm self-isolation instructions from UDOH and
  • Instruct the patient to download the Connect Care app and to check in within 24 hours.

For PUI meeting clinical criteria for hospital admission, please call Transfer Center (855-WE-ADMIT) to coordinate bed placement and inpatient consultation.

  • Admission decisions for PUI should take into account risk factors for poor prognosis: Age 60 or older, dyspnea/hypoxia, and medical comorbidities.

Variable Risk of COVID-19

Patients in this category may have other important clinical and/or epidemiologic features not included in the High Risk category, such as:

  • Travel to or exposure to patients from areas of evolving COVID-19 transmission.
  • Lower respiratory symptoms that overlap with COVID-19, such as fever, cough or dyspnea. Upper respiratory symptoms are uncommon with COVID-19.

Variable Risk patients should be placed in a surgical mask and providers should use DropletContact PPE: surgical mask, eye protection, gloves and gown, unless another diagnosis requires a higher level of precaution.

Providers are encouraged to use their clinical judgment to 1) conduct work-up for other diagnoses, 2) clarify risk for COVID-19, and 3) determine if COVID-19 testing is appropriate.

  • COVID-19 experts are available at 801-50-SCORE, option 3, to help with these decisions.
  • CDC guidelines encourage providers to consider features unique to COVID-19.
  • Flu PCR may now be performed in clinics using strict precautions.
  • If needed, a “COVID CT Protocol” is now available in Imaging Departments.

Decision Making

  • If an alternative diagnosis is identified, or if epidemiologic risk is deemed less likely after a thorough evaluation, proceed with routine clinical care for these patients using appropriate precautions for their diagnosis.
  • If after evaluation, a patient is determined to be at high risk of COVID-19, providers should call UDOH to coordinate testing for COVID-19. Patients undergoing testing are considered PUI.
    • The CDC recommends upgrading to airborne isolation to collect samples for COVID-19 testing.

Low/Minimal Risk

  • Patients with no epidemiologic risk and symptoms consistent with an alternative diagnosis are considered Low/Minimal Risk.
  • Follow appropriate precautions and best-practice clinical management of these patients.

COVID-19 Testing Procedure

  1. Under Airborne-Contact Precautions, collect two (2) specimens from the nasopharynx and (1) from oropharynx or lower respiratory tract:
    • Upper respiratory tract samples:
      • Nasopharyngeal swab - flocked swab (synthetic fiber with plastic shaft- cotton swabs with a wooden shaft are NOT acceptable) into both nasopharyngeal areas with the same swab and place immediately into sterile tube with 2-3 mL of universal transport media (UTM) or M4 Transport medium. These are the same swabs used for RFAPCR and Influenza PCR tests.
      • Oropharyngeal/throat swab: Swab the posterior pharynx, avoiding the tongue (flocked swab + UTM).
    • Lower respiratory tract samples:
      • BAL or tracheal aspirate: Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C and coordinate overnight shipment to CDC on ice pack with UDOH.
      • Sputum: Have the patient rinse the mouth with water and then expectorate deep cough sputum directly into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C and coordinate overnight shipment to CDC on ice pack with UDOH.
    • Send one of the nasopharyngeal specimens for influenza testing (Flu A/B PCR or RFAPCR) to an Intermountain laboratory via standard protocols.
  2. Complete the PUI form available from the UDOH or SCORE line providerss.
  3. Fill out a paper laboratory requisition form.
  4. Place the specimens in a biohazard bag with the requisition form.
  5. Contact Intermountain Central Laboratory and inform them that UDOH has approved COVID-19 testing and inquire about which Intermountain hospital to send the specimen to via confirm courier service. Intermountain Laboratories will then coordinate with UDOH for a second courier to take the specimens to the Utah Public Health Laboratory.
  6. Tests are currently run twice a day at UPHL.

Point-of-Care (in clinic) rapid Influenza testing

For non “High Risk” patients, the rapid point of care Flu PCR test may be performed in the clinic under Droplet Contact precautions (procedural mask, eye shield or goggles, lab coat, and gloves) while preparing the specimen.

For more details, refer to this Clinical Assessment Guidelines document.
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