What Hospitalists Need to Know About COVID-19

Kranthi Sitammagari, MD, Amith Skandhan, MD, FHM, and Arielle Dahlin, MD

March 11, 2020

This article last updated 3/18/20. (Disclaimer: The information in this article may not be updated regularly. The editors of The Hospitalist encourage clinicians to also review information on the CDC website and on the AHA website.)

An infectious disease outbreak that began in December 2019 in Wuhan (Hubei Province), China, was found to be caused by the seventh strain of coronavirus, initially called the novel (new) coronavirus. The virus was later labeled as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease caused by SARS-CoV-2 is named COVID-19. Until 2019, only six strains of human coronaviruses had previously been identified.

As of March 18, 2020, according to the U.S. Centers for Disease Control and Prevention, COVID-19 has been detected in at least 144 countries and has spread to every continent except Antarctica. More than 201,000 people have become infected globally, and at least 8,204 have died. Based on the cases detected and tested in the United States through the U.S. public health surveillance systems, we have had 5,881 confirmed cases and 107 deaths.

On March 11, 2020, the World Health Organization formally declared the COVID-19 outbreak to be a pandemic.

Dr Kranthi Sitammagari

As the number of cases increases in the United States, we hope to provide answers about some common questions regarding COVID-19. The information summarized in this article is obtained and modified from the CDC.

What Are the Clinical Features of COVID-19?

Ranges from asymptomatic infection, a mild disease with nonspecific signs and symptoms of acute respiratory illness, to severe pneumonia with respiratory failure and septic shock.

Who Is At Risk for COVID-19?

Persons who have had prolonged, unprotected close contact with a patient with symptomatic, confirmed COVID-19, and those with recent travel to China, especially Hubei Province.

Who Is At Risk for Severe Disease From COVID-19?

Older adults and persons who have underlying chronic medical conditions, such as immunocompromising conditions.

How Is COVID-19 Spread?

Person-to-person, mainly through respiratory droplets. SARS-CoV-2 has been isolated from upper respiratory tract specimens and bronchoalveolar lavage fluid.

When Is Someone Infectious?

Incubation period may range from 2 to 14 days. Detection of viral RNA does not necessarily mean that infectious virus is present, as it may be detectable in the upper or lower respiratory tract for weeks after illness onset.

 

 

Can Someone Who Has Been Quarantined for COVID-19 Spread the Illness to Others?

For COVID-19, the period of quarantine is 14 days from the last date of exposure, because 14 days is the longest incubation period seen for similar coronaviruses. Someone who has been released from COVID-19 quarantine is not considered a risk for spreading the virus to others because they have not developed illness during the incubation period.

Can a Person Test Negative and Later Test Positive for COVID-19?

Yes. In the early stages of infection, it is possible the virus will not be detected.

Do Patients With Confirmed or Suspected COVID-19 Need To Be Admitted to the Hospital?

Not all patients with COVID-19 require hospital admission. Patients whose clinical presentation warrants inpatient clinical management for supportive medical care should be admitted to the hospital under appropriate isolation precautions. The decision to monitor these patients in the inpatient or outpatient setting should be made on a case-by-case basis.

What Should You Do If You Suspect a Patient for COVID-19?

Immediately notify both infection control personnel at your health care facility and your local or state health department. State health departments that have identified a person under investigation (PUI) should immediately contact CDC's Emergency Operations Center (EOC) at 770-488-7100 and complete a COVID-19 PUI case investigation form.

CDC's EOC will assist local/state health departments to collect, store, and ship specimens appropriately to CDC, including during after-hours or on weekends/holidays.

What Type of Isolation is Needed for COVID-19?

Airborne Infection Isolation Room (AIIR) using Standard, Contact, and Airborne Precautions with eye protection.

How Should Health Care Personnel Protect Themselves When Evaluating a Patient Who May Have COVID-19?

Standard Precautions, Contact Precautions, Airborne Precautions, and use eye protection (eg, goggles or a face shield).

What Face Mask Do Health Care Workers Wear for Respiratory Protection?

Dr Amith Skandhan

A fit-tested NIOSH-certified disposable N95 filtering facepiece respirator should be worn before entry into the patient room or care area. Disposable respirators should be removed and discarded after exiting the patient's room or care area and closing the door. Perform hand hygiene after discarding the respirator.

If reusable respirators (eg, powered air purifying respirator/PAPR) are used, they must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to reuse.

What Should You Tell the Patient If COVID-19 Is Suspected or Confirmed?

Patients with suspected or confirmed COVID-19 should be asked to wear a surgical mask as soon as they are identified, to prevent spread to others.

Should Any Diagnostic or Therapeutic Interventions Be Withheld Because of Concerns About the Transmission of COVID-19?

No.

How Do You Test a Patient for SARS-Cov-2, the Virus That Causes COVID-19?

At this time, diagnostic testing for COVID-19 can be conducted only at CDC.

The CDC recommends collecting and testing multiple clinical specimens from different sites, including two specimen types – lower respiratory and upper respiratory (nasopharyngeal and oropharyngeal aspirates or washes, nasopharyngeal and oropharyngeal swabs, bronchioalveolar lavage, tracheal aspirates, sputum, and serum) using a real-time reverse transcription PCR (rRT-PCR) assay for SARS-CoV-2.

Specimens should be collected as soon as possible once a PUI is identified regardless of the time of symptom onset. Turnaround time for the PCR assay testing is about 24-48 hours.

Dr Arielle Dahlin

Testing for other respiratory pathogens should not delay specimen shipping to CDC. If a PUI tests positive for another respiratory pathogen, after clinical evaluation and consultation with public health authorities, they may no longer be considered a PUI.

Will Existing Respiratory Virus Panels Detect SARS-Cov-2, The Virus That Causes COVID-19?

No.

How Is COVID-19 Treated?

Symptomatic management. Corticosteroids are not routinely recommended for viral pneumonia or acute respiratory distress syndrome and should be avoided unless they are indicated for another reason (eg, COPD exacerbation, refractory septic shock following Surviving Sepsis Campaign Guidelines). There are currently no antiviral drugs licensed by the U.S. Food and Drug Administration to treat COVID-19.

What Is Considered 'Close Contact' for Health Care Exposures?

Being within approximately 6 feet (2 meters), of a person with COVID-19 for a prolonged period of time (such as caring for or visiting the patient, or sitting within 6 feet of the patient in a health care waiting area or room); or having unprotected direct contact with infectious secretions or excretions of the patient (eg, being coughed on, touching used tissues with a bare hand).

However, until more is known about transmission risks, it would be reasonable to consider anything longer than a brief (eg, less than 1-2 minutes) exposure as prolonged.

What Happens If the Health Care Personnel (HCP) Are Exposed to Confirmed COVID-19 Patients? What's the Protocol For HCP Exposed To Persons Under Investigation (PUI) If Test Results Are Delayed Beyond 48-72 Hours?

Management is similar in both these scenarios. CDC categorized exposures as high, medium, low, and no identifiable risk. High- and medium-risk exposures are managed similarly with active monitoring for COVID-19 until 14 days after last potential exposure and exclude from work for 14 days after last exposure. 

Active monitoring means that the state or local public health authority assumes responsibility for establishing regular communication with potentially exposed people to assess for the presence of fever or respiratory symptoms (e.g., cough, shortness of breath, sore throat).

For HCP with high- or medium-risk exposures, CDC recommends this communication occurs at least once each day. For full details, please see the CDC's Interim U.S. Guidance

Should Postexposure Prophylaxis Be Used for People Who May Have Been Exposed to COVID-19?

None available.

COVID-19 Test Results Are Negative In a Symptomatic Patient You Suspected of COVID-19? What Does It Mean?

A negative test result for a sample collected while a person has symptoms likely means that the COVID-19 virus is not causing their current illness.

 

 

What If Your Hospital Does Not Have An Airborne Infection Isolation Room (AIIR) for COVID-19 Patients?

Transfer the patient to a facility that has an available AIIR. If a transfer is impractical or not medically appropriate, the patient should be cared for in a single-person room and the door should be kept closed. The room should ideally not have an exhaust that is recirculated within the building without high-efficiency particulate air (HEPA) filtration.

Health care personnel should still use gloves, gown, respiratory and eye protection and follow all other recommended infection prevention and control practices when caring for these patients.

What If Your Hospital Does Not Have Enough Airborne Infection Isolation Rooms (AIIR) For COVID-19 Patients?

Prioritize patients for AIIR who are symptomatic with severe illness (eg, those requiring ventilator support).

When Can Patients With Confirmed COVID-19 Be Discharged From the Hospital?

Patients can be discharged from the health care facility whenever clinically indicated. Isolation should be maintained at home if the patient returns home before the time period recommended for discontinuation of hospital transmission-based precautions.

Considerations to discontinue transmission-based precautions include all of the following:

  • Resolution of fever, without the use of antipyretic medication.

  • Improvement in illness signs and symptoms.

  • Negative rRT-PCR results from at least two consecutive sets of paired nasopharyngeal and throat swabs specimens collected at least 24 hours apart (total of four negative specimens — two nasopharyngeal and two throat) from a patient with COVID-19 are needed before discontinuing transmission-based precautions.

Should People Be Concerned About Pets or Other Animals and COVID-19?

To date, CDC has not received any reports of pets or other animals becoming sick with COVID-19.

Should Patients Avoid Contact With Pets or Other Animals If They Are Sick With COVID-19?

Patients should restrict contact with pets and other animals while they are sick with COVID-19, just like they would around other people.

Does CDC Recommend The Use of Face Masks In the Community to Prevent COVID-19?

CDC does not recommend that people who are well wear a face mask to protect themselves from respiratory illnesses, including COVID-19. A face mask should be used by people who have COVID-19 and are showing symptoms to protect others from the risk of getting infected.

Should Medical Waste or General Waste From Health Care Facilities Treating PUIs and Patients With Confirmed COVID-19 Be Handled Any Differently or Need Any Additional Disinfection?

No. CDC's guidance states that management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures.

Can People Who Recover From COVID-19 Be Infected Again?

Unknown. The immune response to COVID-19 is not yet understood.

What Is The Mortality Rate of COVID-19, and How Does It Compare to The Mortality Rate Of Influenza (Flu)?

The average 10-year mortality rate for flu, using CDC data, is found to be around 0.1%. Even though this percentage appears to be small, influenza is estimated to be responsible for 30,000 to 40,000 deaths annually in the U.S.

According to statistics released by the Chinese Center for Disease Control and Prevention on February 17, the mortality rate of COVID-19 is estimated to be around 2.3%. This calculation was based on cases reported through February 11, and calcuated by dividing the number of coronavirus-related deaths at the time (1,023) by the number of confirmed cases (44,672) of COVID-19 infection. However, this report has its limitations, since Chinese officials have a vague way of defining who has COVID-19 infection.

The World Health Organization (WHO) currently estimates the mortality rate for COVID-19 to be between 2% and 4%.

Kranthi Sitammagari, MD, is a co-medical director for quality and assistant professor of internal medicine at Atrium Health in Charlotte, North Carolina. He is also a physician advisor. Sitammagari currently serves as treasurer for the NC-Triangle Chapter of the Society of Hospital Medicine and as an editorial board member of The Hospitalist.

Amith Skandhan, MD, FHM, is a hospitalist and member of the Core Faculty for the Internal Medicine Residency Program at Southeast Health (SEH) in Dothan Alabama, and an assistant professor at the Alabama College of Osteopathic Medicine. He serves as the medical director/physician liaison for the Clinical Documentation Program at SEH and also as the director for physician integration for Southeast Health Statera Network, an Accountable Care Organization. Skandhan was a cofounder of the Wiregrass chapter of SHM and currently serves on the Advisory board. He is also a member of the editorial board of The Hospitalist.

Arielle Dahlin, MD, is a second-year internal medicine resident at Southeast Health in Dothan, Alabama. She serves as her class representative and is the co-chair/resident liaison for the research committee at SEH. Dahlin also serves as a resident liaison for the Wiregrass chapter of Society of Hospital Medicine.

This article originally appeared on the-hospitalist.org.

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