Clinical Pathway for Screening for COVID-19 Disease
in an Ambulatory Setting

Evaluation and Testing Guidance for Possible COVID-19 Disease in an Ambulatory Setting
Symptoms
  • Clinical features of COVID-19
    • Cough or shortness of breath (lower respiratory tract infection)*
    • With or without fever (T ≥ 100.4°F)
  • *Isolated nasal congestion or rhinorrhea do not meet criteria
Expedite to exam room, isolation precautions
  • Apply surgical masks to patient, family, escorting staff
  • Escort patient, family immediately from waiting area/public spaces
  • Place in private room with closed door if negative pressure room unavailable
Clinical evaluation
  • Patients and family members can remove masks once provider has donned PPE
    • Hold for reuse on room exit
  • PPE recommendations for providers:
    • Patients with mild/moderate symptoms use Modified Expanded Precautions
      • Gown + Gloves + Surgical Mask + EYE PROTECTION
  • Patients requiring nebulized treatments, possible transfer via 911 use Expanded Precautions
    • Gown + Glove + N95 Mask + EYE PROTECTION
  • Don personal protective equipment (PPE)  
  • History and physical exam
    • Review presence of high risk conditions in patient or family
    • Review need for critical health care services in the next 14 days
TESTING CONSIDERATIONS FOR PATIENTS STABLE FOR CARE AT HOME
Symptoms Patient Factors Testing Comments
Asymptomatic
  • Regardless of high-risk medical conditions or presence of high-risk household contacts
No
  • If there was an exposure, follow self-isolation procedure for 14 days after exposure with symptom monitoring
  • Exceptions:
    • Patient scheduled for aerosol-generating procedure within next 7 days
    • Reside in congregate living facilities
Yes
  • Examples: shelters, residential facilities
Symptomatic
  • Healthy pts with no high-risk or healthcare/ first responder household members
No
  • Treat patient as presumed positive in home isolation*
  • With the any of the following:
    • Unavoidable contact with high-risk household members
    • Unavoidable contact with critical health care worker/first responder
      household members
    • Patients with high-risk medical conditions and/or will require critical
      health services within 14 days
      after symptom onset
    • Reside in congregate living facilities
Yes
Stable for Outpatient Testing, Care
Patient too Ill for
Outpatient Testing, Care
  • COVID-19 Testing as indicated
    • Labcorp® or Quest Diagnositcs, likely 2-4 day turn around
    • CHOP 1-2 day turn around
  • Clean room with hospital-approved disinfectant while still in PPE, close room 1 hour only if AGP, such as nebulization treatment
  • Limit outpatient labs and CXR if COVID-19 testing is pending
  • Transfer to appropriate hospital
    • Pre-notification of patient with
      COVID-19 concern
  • CHOP
    • Notify Transport Team of incoming patient 800-590-2160
    • Call IP&C with questions only if needed
Discharge
  • Supportive care, hydration and antipyretics
  • Give patient under investigation (PUI) form, to local DOH, same day
  • Self-isolation instructions from CDC.gov  
  • Instruct need to call ahead prior to returning to medical care while awaiting test results
Posted: January 2020
Revised: February 2020, March 2, 9, 13, 17, 18, 20, 23, 30, 31; April 1, 2020
Authors: K. Cohn, MD; L. Handy, MD; J. Sammons, MD; V. Kampalath MD; J. Lavelle MD