Because clinical manifestations of COVID-19 are so varied, National Institutes of Health (NIH) says management and treatment of patients should correlate with the severity of the illness. New guidance issued by the agency categorizes patients into six levels, based on degree of symptoms ranging from asymptomatic to critical, and summarizes care recommendations for each group. According to NIH, physicians should:
- advise patients who are asymptomatic or presymptomatic, but have tested positive for the virus, to self-isolate. Those who develop symptoms should contact their physicians, while individuals who remain asymptomatic can end isolation after seven days. Healthcare professionals in this category should consult their employer and review the Centers for Disease Control’s COVID-19 Information on returning to work;
- closely monitor those who are mildly ill with various signs and symptoms, including fever, cough, sore throat, malaise, headache and muscle pain but do not have shortness of breath, dyspnea, or abnormal imaging, at an ambulatory care facility or via telehealth visits. Doctors should consider comorbidities and risk factors for severe disease. No lab evaluations are necessary if the patient is otherwise healthy;
- admit moderately ill patients, with evidence of lower respiratory disease by clinical assessment or imaging and an oxygen saturation of (SaO2) >93% on room air, to a healthcare facility for observation and to prevent rapid progression of pulmonary disease. Doctors are encouraged to prescribe antibiotics if the individual has bacterial pneumonia or sepsis. Those with this degree of illness will likely require hospitalization, and employees are advised to use personal protective equipment, including masks, gloves, gowns, face shields and goggles, when administering care. Moderately ill patients should be placed in airborne infection isolation rooms (AIIRs), if available, for any aerosol-generating procedure and care teams should wear N95 respirators or powered, air-purifying respirators in place of a surgical mask.
- evaluate severely ill patients, those with respiratory frequency >30 breaths per minute, SaO2 93% on room air, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300, or lung infiltrates >50%, with pulmonary imaging (chest x-ray, ultrasound, or if indicated, CT), ECG, laboratory tests, including CBC with differential and metabolic profile, including liver and renal function tests. Measuring inflammatory markers, such as CRP, D-dimer and ferritin, can also help to form a prognosis. To prevent clinical deterioration, these patients will likely need to undergo aerosol-generating procedures, be placed in AIIRs, if available, and receive oxygen therapy immediately using nasal cannula or high-flow oxygen. Antibiotics should be administered if the individual has bacterial pneumonia or sepsis;
- care for critically ill patients, those who have respiratory failure, septic shock, and/or multiple organ dysfunction, as they would those with other critical illnesses, while taking measures to prevent environmental contamination by COVID-19. These individuals should be placed in AIIRs, when available, undergo aerosol-generating procedures and receive oxygen therapy immediately using nasal cannula or high-flow oxygen to manage clinical deterioration. Doctors are advised to prescribe antibiotics if secondary bacterial pneumonia or sepsis is suspected and consider all comorbidities and nosocomial complications. Additional instruction is outlined in the Society of Critical Care Medicine’s Surviving Sepsis Campaign.
NIH notes that there is insufficient data to recommend “either for or against any antiviral or immunomodulatory therapy,” including chloroquine and hydroxychloroquine, for all COVID-19 positive patients. Furthermore, the Food and Drug Administration has not approved any drugs for treating the virus, although hundreds of medications are undergoing clinical trials around the globe. Therapeutic Options for COVID-19 Currently Under Investigation summarizes guidance to help inform treatment decisions regarding a number of these medications.
MLMIC encourages all our insured clinicians to stay informed of guidance for the treatment of COVID-19 patients, as recommendations may continue to change as more data regarding treatment options becomes available.
MLMIC continues to keep its policyholders informed of all COVID-19-related developments on the dedicated resource page on our website and via our 24/7 hotline. Our experts are available to help address the challenges that may arise as you continue to care for patients throughout the nationwide response to this pandemic.