Primary care assessment and testing for COVID-19
If a patient thinks they have symptoms, or is worried they have been exposed to COVID-19, they should complete an online self-assessment tool. Some regions in Ontario have developed self-assessment tools that connect patients with a primary care provider and local resources in their area:
Patients outside these regions should complete the provincial COVID-19 Self-Assessment, which gives guidance tailored to self-reported symptoms and exposure. If responses indicate possible COVID-19, patients will be directed to contact you as their family physician/primary care nurse practitioner, or Telehealth Ontario.
Putting it into practice
Patients with possible COVID-19 should be screened by video or phone, not in person. If an in-person visit is necessary and feasible, patients should be advised to wear their own mask (cloth or other) to the office/clinic, if available, and the primary care setting should undertake the following active and passive screening.
- Post information on clinic website and or send an email to all patients advising them to call prior to coming to the office/clinic. Where possible, post signage outside the office/clinic asking patients to call before entry for appropriate screening and direction.
- Post signage at the office/clinic entrance and at reception requesting patients with symptoms put on a mask (if available and tolerated), perform hand hygiene, then self-identify to reception. If office/clinic is in a shared building, post signage at building entrance.
- Before scheduling appointments, patients should be screened over the phone using the COVID-19 Patient Screening Guidance Document (MOH, June 11, 2020).
- If patients present in-person without phone screening, screen upon entry with the following precautions:
- To protect from contact/spread, staff conduction screening should be behind a plexiglass barrier, if available, or maintain a 2-metre distance from the patient.
- If a barrier or 2-metre distance is not possible, use contact/droplet precautions. This includes the following PPE: gloves, gown, a surgical/procedure mask, and eye protection (goggles, face shield). See Primary Care Operations in the COVID-19 Context > Personal protective equipment (PPE) for details.
Patients with severe symptoms should be directed to the emergency department. Otherwise, patients should be instructed to self-isolate until further discussion with their primary care provider.
Patients should be offered an assessment by video or phone, ideally on the same day. This discussion should include a thorough history-taking and assessment of symptoms and managing them, even if COVID-19 testing is being considered as part of the diagnostic plan.
Patients should be provided with a surgical/procedure mask and be advised to perform hand hygiene. Ensure patients do not leave their masks in waiting areas.
Patients should be immediately placed in an exam room alone with the door closed to avoid contact with other patients the office/clinic. If the is not possible, instruct patients to return outside (e.g. vehicle or parking lot, if available and appropriate) and inform them they will be texted or called when a room becomes available.
Patients should be provided with hand sanitizer (if available), access to tissue and a hands-free waste receptacle for their used tissues and used masks.
Instruct patients to cover their nose and mouth with a tissue when coughing and sneezing, dispose of the tissue in the receptacle and to use the hand sanitizer right afterwards. Patients may also be instructed to take their surgical/procedure mask home with them with instructions for doffing masks.
Patients with possible COVID-19 should be assessed by video or phone, not in person. If patients screen positive in-person, you may offer clinical assessment and examination only if you can follow Droplet and Contact precautions and know how to properly don and doff PPE, including gloves, gown, a surgical/procedure mask, and eye protection (goggles, face shield). See Primary Care Operations in the COVID-19 Context > Personal protective equipment (PPE) for details.
When assessing patients by video or phone, use the COVID-19 remote consultations: A quick guide to assessing patients by video or voice call (BMJ, March 25, 2020).
Any persons experiencing one of the following should be told to self-isolate and tested as soon as possible:
- Fever (temperature of 37.8°C or greater)
- New/worsening cough
- Shortness of breath (dyspnea)
- Sore throat
- Difficulty swallowing
- New olfactory or taste disorder(s)
- Nausea/vomiting, diarrhea, abdominal pain
- Runny nose, or nasal congestion (in absence of underlying reason for these symptoms such as seasonal allergies, post nasal drip, etc.)
- Unexplained fatigue/malaise/myalgias
- Delirium (acutely altered mental status and inattention)
- Unexplained or increased number of falls
- Acute functional decline
- Exacerbation of chronic conditions
- Croup (barking cough, making a whistling noise when breathing)
- Conjunctivitis (pink eye)
- Contact with a confirmed case in the last 14 days
See COVID-19 Reference Document for Symptoms (MOH, May 25, 2020) for a full list of common and atypical signs and symptoms.
Keep in mind
A systematic review of 38 studies on the clinical manifestation of children with COVID-19 found that most cases were mild or moderate, and approximately 14% of cases were asymptomatic. The most prevalent symptoms were fever and cough, followed by nasal symptoms, diarrhea, and nausea/vomiting (Pediatric Pulmonology, June 3, 2020).
For suggested criteria for assessing the severity of COVID-19 disease in children, see The acute management of paediatric coronavirus disease 2019 (CPS, April 20, 2020).
- unexplained fatigue/malaise
- multisystem inflammatory vasculitis in children (for more information, see Emerging evidence: Asymptomatic shedding, paediatric symptoms and Rx research > Multisystem Inflammatory Syndrome in Children (MIS-C))
- unexplained tachycardia, including age specific tachycardia for children
- lethargy, difficulty feeding in infants (if no other diagnosis)
It’s important to monitor atypical symptoms because COVID-19 presents itself differently among older adults. For example, an older patient may not experience a fever or may experience unexplained or an increased number of falls (RGP, April 2, 2020; MOH, May 25, 2020).
Refer to the Atypical COVID-19 Presentations in Frail Older Adults (RGP, April 2, 2020) for a summary of what to look for such as:
- Milder symptoms
- Delirium or acute functional decline
- Little or no temperature elevation
- Mild hypoxia (O2S <90%) without respiratory symptoms
- Unexplained or increased number of falls
Although there are no evidence-based methods for assessing shortness of breath (dyspnea) by telephone or video, experts have recommended asking patients 7 key questions (Centre for Evidence-Based Medicine, March 23, 2020).
For information on differentiating between COVID-19 and heart failure exacerbation symptoms in patients with known heart failure, see Is it COVID-19 or Is It Heart Failure? (Canadian Cardiovascular Society, April 1, 2020).
- Send patient to emergency department. Phone ahead and arrange safe transfer of patient to minimize contact/spread.
- Tell patient to self-isolate immediately.
- Refer to COVID-19 assessment centre for testing or test in-office if you are safely able to do so. See Testing section below for additional guidance.
- Tell patient to self-isolate.
- See Managing COVID-19: Outpatient management and resolution for additional guidance.
Asymptomatic patients who are concerned they have been exposed to COVID-19, or who are at risk of exposure to COVID-19 through their employment, are now eligible for testing (MOH, May 24, 2020).
Refer to COVID-19 assessment centre for testing or test in-office if you are safely able to do so. See Testing section below for additional guidance.
If your practice does not have the capacity to perform tests on site, refer the patient to an assessment centre or emergency department for testing.
Frequently asked questions (FAQs)
In addition to the COVID-19 Provincial Testing Guidance Update (MOH, June 2, 2020), a memorandum has been issued that provides direction on testing for asymptomatic individuals (MOH, May 24, 2020) as reflected below.
Testing is now available for the following populations:
- All people with at least one symptom of COVID-19, even for mild symptoms.
- Asymptomatic people who are concerned that they have been exposed to COVID-19, including people who are contacts of or may have been exposed to a confirmed or suspected case.
- Asymptomatic people who are at risk of exposure to COVID-19 through their employment, including essential workers (e.g. health care workers, grocery store employees, food processing plants).
This information may be updated as the situation continues to evolve.
Testing in the primary care office/clinic can only be performed if the primary care provider is able to:
- follow Droplet and Contact precautions outlined by the Ministry of Health (May 22, 2020);
- has the appropriate tools and knowledge of how to test; and
- can ensure coordination of sample delivery to the Public Health Ontario Laboratory or an alternative laboratory providing COVID-19 testing.
A single upper respiratory tract specimen will be accepted for COVID-19 testing, including nasopharyngeal swab (NPS), deep nasal swab, anterior nasal swab or viral throat swab. NPS is the preferred specimen when swabs are available, followed by deep nasal swab. Due to global shortages, Public Health Ontario (June 14, 2020) has provided information on alternative collection kits that are acceptable for COVID-19 testing (see Specimen Collection and Handling).
Nasopharyngeal swab collection is not considered an aerosol generating procedure and can be performed in the office/clinic with appropriate contact/droplet precautions of gloves, gown, surgical/procedure mask, and eye protection (e.g., goggles, face shield). This is important as many people will cough or sneeze when the nasal swab is done. “Links to resources on properly conducting NP swabs are available under ‘In-Person Care’ on OCFP’s Clinical Care- Office Readiness page.
If testing is conducted in the office/clinic, it is important to conduct the nasopharyngeal swab properly to minimize the risk of a false negative sample:
- Pre-label the swab so, once obtained, it can be placed in the bag without further handling.
- Place the specimen in the bag, and place the completed requisition in the attached pouch.
Diagnosing COVID-19 is done by laboratory testing (NAAT result by PCR or nucleic acid sequencing) of a single NP swab. Serological tests are still in development and are currently not approved for the diagnosis of SARS-CoV-2 infection.
- A single positive result is sufficient to confirm COVID-19.
- A single negative result is sufficient to exclude COVID-19.
- A single positive result is sufficient to confirm:
- current COVID-19 infection that is asymptomatic or pre-symptomatic, OR
- prior COVID-19 infection (+/- symptoms) as testing can remain positive for several weeks after infection.
- A single negative result is sufficient to exclude COVID-19 In a patient who tests negative for COVID-19, retesting should be conducted if symptoms develop, change or worsen.
If the patient is within their 14-day self-isolation due to known exposure, the patient should remain in self-isolation for the rest of the 14-day period, regardless of the negative result.
See COVID-19 Quick Reference Public Health Guidance on Testing and Clearance (MOH, June 25, 2020) for more detailed information.
A recent study retroactively compared the results from 353 patients who received both OP and NP simultaneously, and found that 73.1% of NP-positive cases were negative in OP swab. The authors concluded that while use of both swabs slightly increased the positive rate over using NP swab only, NP swabs “may be more suitable” than oropharyngeal swab (Int. J. Infect. Dis., April 22, 2020).
Reverse Transcription Polymerase Chain Reaction (RT-PCR) testing
RT-PCR is a type of nucleic acid amplification testing (NAAT), the gold standard used in Canada and abroad for the diagnosis of active COVID-19 in symptomatic patients. It tests respiratory tract specimens – nasopharyngeal swab (preferred) or viral throat swab – for the presence of viral RNA during active infection, but will not indicate if a person was infected and subsequently recovered (Johns Hopkins Center for Health Security, June 30, 2020).
Testing in patients suspected of having COVID-19 involves sending a respiratory tract specimen – nasopharyngeal swab (NPS) or viral throat swab; NPS is the preferred specimen – to a PHO laboratory for RT-PCR testing. The turnaround time for COVID-19 testing at a PHO Laboratory is up to four days, but will vary according to geographical location and proximity to a PHO Laboratory location (PHO, June 14, 2020).
The Spartan Cube COVID-19 System has been recalled due to concerns raised by National Microbiology Laboratory (NML) regarding the efficacy of the proprietary swab used in the test. No concerns were raised regarding the reagents and portable DNA analyzer device.
This POC test was previously approved by Health Canada, but is now authorized for research use only while these concerns are being investigated.
Serological tests detect the presence of antibodies produced in response to an infection. Due to the variability in time required to produce antibodies after an infection, serological tests are not appropriate for early diagnosis of COVID-19. However, Health Canada has begun authorizing the sale of serological testing devices in Canada for other purposes.
See Serological tests for use against COVID-19 (Health Canada, June 19, 2020) for important information to understand about results from serological testing.
False negative rates of RT-PCR vary between tests, testing platforms and protocols, specimen type, and time of collection (Ann of Intern Med, Apr 13, 2020). When measured in the lab, sensitivity rates as high as 95% (false negative rate of 5%) have been recorded (Euro Surveill., January 23, 2020). In practice, false negative results may be higher due to inadequate sample collection, testing those with asymptomatic or mild disease, or testing early in the course of the disease, when viral levels are below the limit of detection.
- (Int. J. Infect. Dis., April 8, 2020) Sample size: 353 patients. Findings: 73.1% of patients testing positive with nasopharyngeal (NP) swabs were negative with oropharyngeal (OP) swabs.
- (Radiology, Feb. 19, 2020) Sample size: 51 patients. Findings: Sensitivity of chest X-ray was 98% vs. 71% with PCR (45/51 patients had throat swabs and 6/51 patients had sputum samples).
Screening / Assessment resources
- COVID-19 remote consultations: A quick guide to assessing patients by video or voice call (BMJ, March 25, 2020).
- COVID-19 Screening Tools for Electronic Medical Records (EMRs) (eHealth Centre of Excellence, 2020).
- COVID-19 Patient Assessment Tool for Physicians (OMA, March 26, 2020).
- COVID-19 Patient Screening Guidance Document (MOH, June 11, 2020).
- COVID-19 Reference Document for Symptoms (MOH, May 25, 2020).
- Online COVID-19 Self-Assessment tool (Government of Ontario).
- COVID-19 Self-Assessment (Ontario Health West Region).
- Toronto COVID-19 Self-Assessment (Ontario Health Toronto Region).
- How to self-isolate (Public Health Ontario).
- Self-isolation: Guide for caregivers, household members and close contacts (Public Health Ontario).
- How to self-monitor (Public Health Ontario).
- Take care of yourself and each other (Public Health Ontario).
- Physical distancing (Public Health Ontario).
- When and where to wear a mask (Public Health Ontario).
- How to wash your hands (Public Health Ontario).