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
Utilize LOW Prevalence Guidance per IPC
COVID Suspected
  • ≥ 1 Concerning Symptom or
  • ≥ 2 Non-specific Symptom Category without evidence of another explanatory illness. In periods of low prevalence, other explanatory illnesses may include common circulating viral illnesses at the time.
  • Examples of non-COVID explanatory illnesses:
    • Bacterial illnesses: cellulitis, classic Hand-foot-mouth, GAS pharyngitis, UTI, respiratory
    • Viral: classic hand-foot-mouth, gastroenteritis in periods of high community spread, bronchiolitis in a period of high RSV prevalence, or other known high prevalence viruses based on community epidemiology.
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 + Hand Hygiene
    • Eye protection for all patients with respiratory illnesses
    • Eye protection for all patients during periods of high COVID prevalence
    • Don gloves and gown per standard precautions (e.g., concern for exposure to body fluid)
Routine Care Process
Suspected COVID Due to
Concerning Symptoms
or
Exposed
  • Ambulatory Modified Expanded
    • Hand Hygiene
    • 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.
  • If AGP performed in an asymptomatic, unexposed patient, provider should wear surgical mask and eye protection and room closures are not needed.
Aerosol Generating Procedure (AGP) and Suspected COVID or Exposed
Testing Considerations for Patients with Expected Discharge
Assess Symptoms Type of Test Recommended
Symptoms Present
No Symptoms; Regardless of Exposure status; Able to Mask
  • No Testing
  •  
  • Consider if returning to residential or other congregate living settings
No Symptoms and Exposed And
Unable to Mask
  • Consider PCR or Antigen Test Day no earlier than 5 days post exposure to support return to school unmasked
  •  
  • Consider if returning to residential or other congregate living settings
Hospital admission, procedure, AGP scheduled within the next 72 hours
  • PCR or other CHOP approved Test required

Guidance for Quarantine and Isolation for Healthy Children Returning to the Community

CDC Guidelines  
COVID-19 Outlook: A Pandemic in Transition Requires Updated School Guidance, CHOP Policy Lab  

  • Note:
  • Children with severe COVID infection or those with weakened immune systems may require longer periods of isolation of 10-20 days, parents and patients should discuss with their individual provider. Additionally, in CHOP care locations, children require a minimum 10 day period of isolation to guide provider use of PPE.
Exposed
And
NO Symptoms
  • No quarantine if:
    • Age ≥ 18 yrs, received all recommended vaccines     OR
    • Age 5 - 17 yrs, completed primary vaccine series   OR
    • Any age, Confirmed COVID within the last 90 days
  •  
  • Wear a mask for 10 days from the date of last contact
  • Consider test 5 days after last contact, pending test availability
  • If develop symptoms or have a positive test, follow isolation guidance
  •  
  • Quarantine is needed for the following people:
    • Age ≥ 18 yrs, who have not received all recommended vaccines  
    • Received single dose Johnson & Johnson over 2 months ago, and no booster
    • Anyone not vaccinated or not completed primary series
  •  
  • Wear a mask and stay home for 5 days after last contact with COVID + person and monitor symptoms
  • If symptoms develop, get tested and isolate pending test results
  • If no symptoms develop, can leave the house and return to school / daycare and continue to wear a mask for 5 days
  • Consider test 5 days after last contact, pending test availability
  • If develop symptoms or have a positive test, follow isolation guidance
  •  
  • Unable to wear mask
  • Assess ability for all child under 5 to wear a mask; if able follow above guidance
  • If unable, child must stay home 10 days after exposure, or 7 days with a negative test at day 5 or later 
  • If develops symptoms, follow isolation guidance
COVID Positive Test
or
Clinical diagnosis
of COVID
  • Isolate
  • Regardless of vaccination, stay home for 5 days
    • Day 0 is 1st day of symptoms, if no symptoms day of + test
  •  
  • If symptoms are significantly improved after 5 days of isolation, with no fever for 24 hours, child can leave the house and return to school and continue to wear a mask for 5 days
  • No additional testing is required for return to school / daycare
  •  
  • Unable to wear mask
  • Assess ability for all children under 5 to wear a mask; if able follow above guidance
  • If unable child must stay home 10 days for positive test result
Stable for Outpatient Treatment
Transfer for Continued Evaluation
Treatment is Required
Posted: January 2020
Revised: May 2022
Authors: K. Cohn, MD; L. Handy, MD; J. Sammons, MD; V. Kampalath MD; J. Lavelle MD