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 should wear their mask at all times during the appointment including while they are in the exam room and hold for reuse after exiting.
  • PPE recommendations for providers:
    • Patients who pose risk for splashing eyes, nose or mouth use Modified Expanded Precautions
      • Gown + Gloves + Surgical Mask + EYE PROTECTION
  • Patients undergoing AGP (aerosol generating procedures) 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
  • Patient Care Considerations
  • Symptoms History
    • 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
  • Chills
  • Myalgias
  • Sore throat
  • New loss of taste or smell
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 24-72 hrs
  • Peri-Operative Guidance
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 w/essential worker household member who has current in-person work requirements
    • Patients with high-risk medical conditions and/or will require critical
      health services within 14 days
      after symptom onset
    • Child returning to camp, daycare or school prior to being cleared from a symptoms-based strategy
Yes
  • **Clearance of home isolation applies to confirmed/suspected and symptomatic/asymptomatic patients and caregivers, but NOT exposed patients and caregivers
  • Clearance of Transmission-Based Precautions for Patients and Caregivers with Confirmed SARS-CoV-2  
    • Asymptomatic/SARS-CoV-2 positive: Home isolation will remain in place for a minimum 10 days from time of diagnosis
    • Symptomatic/SARS-CoV-2 positive or suspected
      • At least 10 days have passed since symptoms first appeared; and
      • At least 3 days have passed since symptom recovery
    • Exposed patients: Home isolation for 14 days after exposure with symptoms monitoring
CDC: Discontinuation of Home Isolation for Persons with COVID-19 (Interim Guidance)  
Stable for Outpatient Testing, Care
Patient too Ill for
Outpatient Testing, Care
  • COVID-19 Testing as indicated
    • 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 and CXR if COVID-19 testing is pending
  • Transfer to appropriate hospital
    • Pre-notification of patient with COVID-19 or living with COVID-19 house member
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
  • COVID Discharge Instructions
  • Peri-Operative Guidance
  • Patients should have pre-procedure screening the
    day prior
  • If unable, testing 72 hrs prior is acceptable if:
    • All household members/patient self-monitor for symptoms and
    • Have no social contact outside of their household
    • Report symptoms immediately
  • CHOP Provider can enter EPIC order:
    • “Consult to drive Through”
    • Testing can be scheduled at Roberts or
      Bucks SCC
Posted: January 2020
Revised:
February 2020;
March 2, 9, 13, 17, 18, 20, 23, 30, 31, 2020;
April 1, 3, 6, 8, 11, 17, 20, 22, 24, 2020;
May 1, 28, 2020;
June 1, 8, 17, 2020
Authors: K. Cohn, MD; L. Handy, MD; J. Sammons, MD; V. Kampalath MD; J. Lavelle MD