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
Definition of Symptoms and COVID Suspected Patients
COVID Symptoms Concerning Symptoms
  • Sustained cough
  • Shortness of breath
  • Difficulty breathing
  • Loss of taste or smell
Symptom Categories non-specific to COVID
  • Fever
  • Fatigue
  • Chills/rigors
  • Headache
  • Myalgia
  • Sore throat
  • Congestion/rhinorrhea
  • Nausea
  • Vomiting/diarrhea
COVID Suspected
  • ≥ 1 Concerning Symptom or
  • ≥ 2 Non-specific Symptom Category
  • Without evidence of another explanatory non-respiratory or viral illness
  • Examples: Cellulitis, classic Hand-foot-mouth, GAS pharyngitis, UTI
  • Exceptions: Bronchiolitis, pneumonia
Exposure
  • Full Exposure Definition with Examples
  • Prolonged (> 15 minutes), close (< 6 feet) contact with a person who is COVID-positive
  • Spent 15 cumulative minutes close (< 6 feet) contact with a person who is COVID-positive
Clinical Evaluation
  • Ensure family, patient have appropriate masks
  • Review visitation job aid and sibling escalation pathway if more than one caregiver is present with patient
  • Patients, family members remain masked throughout care except for PE as needed
PPE Recommendations and Isolation and Don Personal Protective Equipment (PPE) Video
Asymptomatic,
Non-specific symptoms
  • Standard Precautions
    • Surgical Mask + Eye Protection + Hand Hygiene
    • Don gloves when exposed to body fluid
Routine Care Process
Suspected COVID
Concerning Symptoms
or
Exposed
  • Modified Expanded
    • Hand Hygiene
    • Gown + Gloves + Surgical Mask + Eye Protection
  • Expedite to Exam Room.
  • Door closed.
  • Use negative pressure as available. Buerger neg pressure rooms remain closed 30 minutes after AGP.
  • Clean room with hospital-approved disinfectant while still in PPE.
  • All other locations: Close room for 1 hour if AGP performed, such as nebulization treatment, Clean room with hospital-approved disinfectant while still in PPE.
Aerosol Generating Procedure (AGP) and Suspected COVID or Exposed
Testing Considerations for Patients Stable for Care at Home
SYMPTOMATIC Patients
Indications for Testing Test Selection, Interpretation

  • Influenza-like Illness (ILI)
    • Fever > 100.4°F and cough and/or sore throat
  • During influenza season
ASYMPTOMATIC Patients
Indications for Testing Test Selection, Interpretation
  • Results are needed for contact tracing of exposed patient
  • Exposed, unvaccinated patients can be tested on or after day 5-7 and end isolation if negative
  • Required for admission to another facility such as shelters or residential facilities
  • Exposed VACCINATED patients can be tested as early as day 3 after exposure.
  • PCR Test
  • Rapid Antigen or PCR tests may be used at or after day 7.
  • If a test is requested on day 5 or 6, it MAY be performed, but should be a PCR only.
  • Quarantine must continue to day 7 in all circumstances.
  • PCR Test required
  • Rapid Antigen or PCR tests may be used on or after day 7 for any exposure. Prior to day 7, a PCR should be used preferentially. Quarantine is not required but patients should be masked indoors in public places.
PCR test required
Clearance of Transmission-Based Precautions
Asymptomatic/SARS-CoV-2 positive At least 10 days have passed since the date of the first positive test
Symptomatic/SARS-CoV-2 Positive or Suspected
  • At least 10 days has passed since symptoms first appeared and
  • At least 24 hours have passed since last fever w/o use of fever medications and
  • Symptoms are improved
No symptoms, unvaccinated and exposed
  • Exposed patients quarantine for 10 days after last exposure as long as they
    remain asymptomatic
  • This can be reduced to 7 days if they test negative day 7 and remain asymptomatic
  • All patients, regardless of initial clearance date, should monitor for symptoms for 14 days
No symptoms, vaccinated and exposed
  • Vaccinated persons with exposure to suspected/confirmed COVID-19 do not need to quarantine if they:
    • Are 2 weeks past their full vaccination series
    • Have remained asymptomatic since their COVID-19 exposure
    • Mask in all indoor settings, and symptom monitor for 14 days
    • Testing: A COVID-19 PCR test should be performed at day 3 (up to day 7) from exposure, and if negative the exposed patient can revert to usual masking practices while continuing symptom monitoring.
  • This is true for household exposures
No symptoms, vaccinated, with continuous exposure (ie, household member with ongoing contact)
  • Vaccinated persons with exposure to suspected/confirmed COVID-19 do not need to quarantine if they:
    • Are 2 weeks past their full vaccination series
    • Have remained asymptomatic since their COVID-19 exposure
    • Mask in all indoor settings, and symptom monitor for 14 days after end of exposure
    • Testing: Recommend testing every 5 days, with a final test performed 3 days after the last day of the index case (ie, household member with COVID-19) is cleared of transmission-based precautions and isolation.
  • This is true for household exposures
Stable for Outpatient Treatment
Transfer for Continued Evaluation
Treatment is Required
  • Transfer to appropriate hospital
  • Pre-notification if known COVID-19
Posted: January 2020
Revised: February 2020, March 2020, April 2020, May 2020, June 2020, July 2020, September 2020, October 2020,
November 2020, December 2020, January 2021, February 2021, March 2021, April 2021, June 2021, August 2021,
September, 2021
Authors: K. Cohn, MD; L. Handy, MD; J. Sammons, MD; V. Kampalath MD; J. Lavelle MD