Outpatient Specialty Care and Primary Care Clinical Pathway for Screening Children with Suspected 2019 Novel Coronavirus (COVID-19) Disease

Evaluation and Testing Guidance for Possible COVID-19 Disease
Outpatient Specialty Care and Primary Care Settings
Symptoms Concerning
for COVID
  • Cough (sustained), Shortness of breath, difficulty breathing
  • Loss of taste or smell
Expedite to exam room, isolation precautions
  • Ensure family and patient have appropriate masks
  • 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 should remain masked throughout appointment except for physical exam
  • PPE recommendations for concerning symptoms
  • Patients with clinical presentation consistent with COVID-19
    • Modified Expanded: Gown + Gloves + Surgical Mask + EYE PROTECTION
  • Patients undergoing AGP (aerosol generating procedures)
    • Expanded Precautions: Gown + Glove + N95 MASK + EYE PROTECTION if AGP
  • History and physical exam
    • For non-specific symptoms
    • Standard Precautions: Gloves + Surgical Mask + EYE PROTECTION
Symptom Categories
Non-specific to COVID
  • Fever, fatigue, chills/rigors, headache, myalgia
  • Sore throat, congestion/rhinorrhea
  • Nausea, vomiting/diarrhea
  • Review need for critical health care services in the next 14 days
    • Standard Precautions: Gloves + Surgical Mask + EYE PROTECTION
  • COVID Suspected
  • > 1 Concerning symptom or
  • > 2 Non-specific symptoms present
  • Without evidence of another explanatory non-respiratory viral or bacterial illness.
  • Examples:
    • Cellulitis
    • Urinary tract infection
    • Hand-foot-mouth
    • GAS pharyngitis
  • Exceptions:
    • Bronchiolitis, pneumonia (which may be consistent with COVID)
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 hospital admission or aerosol-generating procedure within next 7 days
  • Peri-Operative Guidance
Yes
  • Examples: shelters, residential facilities
Symptomatic
  • Healthy patients with no high-risk or healthcare/ first responder household members
No
  • Treat patient as presumed positive, 14 day quarantine at home from symptom onset
  • 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
  • High-risk medical conditions:
    • Immunocompromise, immunosuppression
    • Significant underlying chronic disease
      • Treat patient as presumed positive, 14 day quarantine at home, until SARS-CoV-2 results available
Stable for Outpatient Testing, Care
Patient too Ill for
Outpatient Testing, Care
  • COVID-19 Testing as above
    • Labcorp® or Quest Diagnostics, 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, CXR if COVID-19 test pending
    • Supportive, 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
  • 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
Posted: January 2020
Revised: February 2020, March 2020, April 2020, May 2020, June 2020, July 2020, September 30, 2020
Authors: K. Cohn, MD; L. Handy, MD; J. Sammons, MD; V. Kampalath MD; J. Lavelle MD