Interventions to help a health system prepare for patients with COVID-19 include establishing a committee for logistic planning and information dissemination, creating a service dedicated to caring for patients with COVID-19, and building contingency plans for anticipated staffing needs.
Common findings of COVID-19 include fever, cough, dyspnea, lymphopenia, and normal procalcitonin.
Supportive care is the mainstay of therapy, though several medications including hydroxychloroquine and remdesivir are undergoing clinical trials.
Since its emergence in December 2019, the virus known as severe acute respiratory syndrome coronavirus 2 has quickly caused a pandemic. This virus causes a disease now known as coronavirus disease 2019, or COVID-19. As an increasing proportion of the at-risk population becomes infected, and patients with severe illness are hospitalized, it is essential for hospitalists to remain current on how to best care for people with suspected or confirmed disease. Establishing a system for logistical planning, and accurate information sharing is strongly recommended. Infection control remains the ultimate goal. As such, healthcare workers should be educated on universal and isolation precautions, and the appropriate use of personal protective equipment. Social distancing should be encouraged to prevent the spread of infection, and creative and innovative ways to reduce contact may need to be considered. Moreover, it is imperative to prepare for contingencies as medical staff will inevitably get sick or become unavailable. Hospitalists have the difficult task of caring for patients, while also adapting to the many logistical and social elements of a pandemic.
Planning for COVID-19
As more and more of the population become infected, it will be necessary for health care systems and providers to plan and adapt to the rapidly evolving societal and healthcare landscape. New information, and misinformation, manifests daily, and it is important to establish a committee focused on logistical planning and accurate information sharing. It may also be useful to form a dedicated unit for patients with suspected or confirmed COVID-19. At least initially, the hope is that this will help centralize patient care and contribute to infection control. If an institution is equipped to use order sets or note templates specific to COVID-19 patients via their electronic medical record system, this may be helpful to streamline work, and to ensure consistent patient care.
On an individual provider level, the overwhelming goal is to limit exposure to the virus. To that end, hospitalists (and other healthcare workers) should be educated on universal precautions, isolation precautions, and the appropriate use personal protective equipment. Education and fit testing for respiratory protective equipment such as N95 masks, and powered air purifying respirators should be mandatory for anyone with direct patient contact.
Unnecessary contact should be avoided to prevent the spread of infection. For example, while hospital rounds are traditionally conducted as a team, contact should ideally be limited to the provider primarily responsible for the patient. Telemedicine resources, such as video chat services, can also be used by the healthcare staff when direct patient contact is not mandatory. A consideration can be made that some inpatient consultations may be performed entirely by chart review or with the use of video services. Moreover, policies that limit or prohibit hospital visitors should be strongly considered.
It is imperative to prepare for contingencies. Medical staff will inevitably get sick and should be educated on the signs of illness in order to appropriately triage for SARS-CoV-2 testing. Likewise, there should be contingency planning for instances when staff must leave for illness, family illness, or other similar circumstances. While quarantined, and if without symptomatic illness, hospitalists may find innovative ways to continue to work from home such as covering triage calls, providing telemedical care, and logistic planning. Providing different forms of family support, such as childcare, can enable hospitalists to minimize absences and continue to work. Much will be asked of health care staff during this outbreak.
When to suspect COVID-19
Other common symptoms include dyspnea, headache, diarrhea, and sore throat (Figure 1). Cough is usually dry, but not uncommonly will be productive of sputum. Sneezing is infrequent in COVID-19 and usually indicative of other respiratory conditions rather than COVID-19.
Chest X-rays are abnormal in only 59.1% of patients.
Computed tomography (CT) is more sensitive and typically shows bilateral, multifocal, ground-glass opacification.
Cases of myocarditis and heart failure have also been described.
Finally, SARS-CoV-2 may also be capable of neuro-invasive disease given its tropism, and propensity to cause headache. However, the data on this is preliminary, and requires further investigation.
Approach to patients with suspected COVID-19
Once a patient is suspected of having COVID-19, it is important from an infection control standpoint to initiate proper isolation. For most patients, this requires contact, and modified droplet precautions. Typically, this includes adhering to universal precautions while appropriately donning a gown, gloves, mask, and eye shield.
Airborne precautions are recommended when aerosol-generating procedures (AGPs) are performed and deemed as moderate or high risk. The highest risk category of AGPs currently include sputum induction, bronchoscopy, endotracheal intubation and extubation, open tracheal and nasotracheal suctioning, nasogastric tube placement, upper GI endoscopy, transesophageal echocardiography, upper airway ENT procedures, and non-invasive ventilation with positive-airway pressure devices and high-flow nasal cannula. Administering nebulized medications is considered low risk in producing AGPs. However, nebulization is deemed moderate risk in producing AGPs if the patient coughs excessively with administration or it is not known how the patient tolerates the nebulized medication. Collection of nasopharyngeal specimens is considered low risk.
and some patients have required antibiotic treatment for presumed bacterial superinfection.
Often, the same swab can be utilized for Influenza testing, and other investigation or empiric treatment can be considered.
Medication administration and other necessary cares should be timed together as much as possible to minimize potential exposure and conserve personal protective equipment. Providers should consider utilizing electronic forms of communication and monitoring, such as video conferencing, to reduce potential exposure.
Care of patients with confirmed COVID-19
The median time from symptom onset to ICU admission is estimated to be 9.5 days,
and some of these patients may be admitted to the general medical unit with subsequent deterioration. If the patient’s respiratory status is declining or compromised, transfer to an ICU should be considered. Care of patients with COVID-19 in the intensive care unit is not within the scope of this article, and has been discussed elsewhere.
Abnormal chest X-rays, or chest CT findings such as consolidation, crazy-paving pattern, bronchial wall thickening, lymphadenopathy, and pleural effusion are also associated with severe disease.
Table 1Associations with severe COVID-19
While experience with corticosteroids is limited, their routine use is not recommended due to lack of efficacy in other severe coronavirus outbreaks.
Corticosteroid therapy should only be considered in select situations, such as refractory shock or severe ARDS.
Angiotensin-converting enzyme (ACE) 2 appears to be the receptor utilized by SARS-CoV-2, raising debate of competing risks and benefits of angiotensin receptor blocking agents.
It remains unclear if this class of medications is beneficial or harmful. Interim guidelines recommend continuing ACE inhibitors in patients who are on these medications but not start in new patients. Likewise, nonsteroidal anti-inflammatory drugs have not been sufficiently studied in COVID-19; however, these medications have been associated with worse outcomes in community-acquired pneumonia
and some experts warn against their use in COVID-19.
Management of COVID-19 is summarized in Table 2.
Table 2Summary of Management of COVID-19
Treatments under investigation
Hydroxychloroquine and azithromycin is also being studied with early data.
Remdesivir, a broad-spectrum antiviral drug developed to treat Ebola virus, has in vitro activity against SARS-CoV-2, and is currently being used in clinical trials to assess efficacy.
, Combination lopinavir-ritonavir, medications used for human immunodeficiency virus (HIV), is being trialed in select patients as well.
Convalescent plasma is another theorized treatment due to some efficacy in SARS-CoV, without current experience in COVID-19.
Immunomodulatory medications such as tocilizumab and sarilumab are also under investigation. Unfortunately, none of these therapies are yet to be proven efficacious in COVID-19, though enrollment in a clinical trial remains an option for some patients.
Hospital discharge and subsequent quarantine
The key to controlling a pandemic is reducing this rate below 1, primarily through early and effective infection control measures. Hospitalists are in a unique position to treat multiple unseen patients through effective implementation and education on infection control strategies.
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