COVID-19: Clinical Guidance for Primary Care Providers

Last Updated: July 6, 2020

No Results Found 0/0
The COVID-19 Clinical Guidance for Primary Care Providers resource is revised often and new content is added regularly to guarantee that the latest evidence and regulatory recommendations are included. The CEP is committed to ensuring this information is accurate and up to date.

Jump to the COVID-19 Resource Centre
Your one-stop shop for all of your COVID-19 related needs, including clinical guidance, maintaining regular primary care practice in the COVID-19 context, Ontario assessment centres, social care guidance, local services and more.

Use this resource to help provide the best possible COVID-19 care for your patients. It pulls together and tangibly interprets the latest recommendations surrounding COVID-19 including assessment and testing, management, provider mental health, infection prevention and more.

Check back daily for the latest updates.

Click on the sections below to get started:
Primary care assessment and testing for COVID-19
Last reviewed: July 6, 2020
Last updated: July 6, 2020
Screening

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.

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.

Active screening

If a patient presents with symptoms and/or exposure to COVID-19:

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.

Assessment

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.

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
  • Chills
  • Headaches
  • 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).

In addition to the symptoms most commonly associated with COVID-19, other atypical symptoms/signs should be considered in children (MOH, May 25, 2020). These symptoms/signs include:

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
Next steps based on symptoms and exposure:
  • Send patient to emergency department. Phone ahead and arrange safe transfer of patient to minimize contact/spread.
  • Tell patient to self-isolate immediately.

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.

Tell patient to self-isolate and self-monitor for 14 days, and to call back for re-assessment if they develop symptoms.

Provide reassurance and advise patient to practice physical distancing and hand hygiene.

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:

  1. All people with at least one symptom of COVID-19, even for mild symptoms.
  2. 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.
  3. 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.

Symptomatic patients

  • A single positive result is sufficient to confirm COVID-19.
  • A single negative result is sufficient to exclude COVID-19.

Asymptomatic patients

  • 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).

Click here for a list of testing devices authorized by Health Canada.

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).
Top resources

These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

Emerging evidence: Asymptomatic shedding, paediatric symptoms and Rx research
Last reviewed: June 30, 2020
Last updated: June 30, 2020

There is only low-quality evidence available on COVID-19, as it is an emerging virus. Many studies being released have not been peer-reviewed. Among those that have been peer-reviewed, many are small, retrospective observational studies and thus have serious limitations and risks of bias. While the findings of emerging COVID-19 studies can be useful in helping to broaden our understanding about how the virus might operate, the results of COVID-19 studies should not be considered validated.

Asymptomatic shedding

Due to community spread of COVID-19 within Ontario, and evidence for asymptomatic and pre-symptomatic transmission, it is recommended that (MOH, May 22, 2020):

  • Surgical/procedural masks be worn for the full duration of shifts for HCWs who are providing direct patient care.
  • Eye protection (e.g., goggles, facemasks) be considered for the full duration of shifts for HCWs who are providing direct patient care.
  • For the purpose of source control, surgical/procedural masks be worn for the full duration of shifts by HCWs who are working outside of direct patient care areas, if physical distancing from other HCWs cannot be maintained.

For more information on PPE, see Primary Care Operations in the COVID-19 Context > Personal protective equipment (PPE).

Frequently asked questions (FAQs)

Data suggest that people can test positive for COVID-19 one to three days before developing symptoms (MMWR, April 10, 2020). A review of evidence on asymptomatic transmission found that transmission in people who are currently asymptomatic occurs in approximately 6-13% of cases, although modelling suggests this might be higher (ACFP, April 14, 2020). Presymptomatic transmission occurs through droplets and contaminated surfaces. A recent study estimates that 44% of secondary cases are infected during the primary case’s presymptomatic period (Nat Med, April 15, 2020).

According to the WHO (April 2, 2020), the time between virus exposure and symptoms (incubation period) is five to six days on average, and may be as long as 14 days. Asymptomatic shedding may occur during this time (Nat Med, April 15, 2020).

There is epidemiologic, virologic and modeling evidence that asymptomatic and presymptomatic transmission can occur (Emerg Inf Dis., May 4, 2020). According to the CDC (May 29, 2020), there have been a number of reports of presumed asymptomatic transmission and viable virus has been cultured in patients with asymptomatic infection. The exact amount of viral shedding required for transmission is not yet clear.

A literature search (CEBM, April 6, 2020) found that between 5% and 80% of people testing positive for SARS-CoV-2 may be asymptomatic. In reviewing 21 reports, authors noted:

  • Symptom-based screening will likely miss cases.
  • Some asymptomatic cases are known as ‘pre-symptomatic’ and will become symptomatic over the course of approximately a week.

Evidence reviewed by the ACFP (April 14, 2020) reported similar results. When testing all individuals in closed environments (e.g. cruise ship, long-term care home), approximately 50% of patients testing positive were asymptomatic at the time of testing. The CDC (May 20, 2020) estimates that 35% of infections are asymptomatic.

In a recent study, the highest viral load (by throat swab) was observed at the time of symptom onset, suggesting the infectiousness peaks on or before symptom onset (Nat Med, April 15, 2020).

In an analysis of the relative transmissibility of asymptomatic cases among close contacts, it was found that symptomatic cases were more likely to transmit COVID-19 (Int J Infect Dis, April 15, 2020). The R for symptomatic groups was 0.78 vs. 0.20 for asymptomatic groups, for a risk ratio (RR) of infectivity of 3.9 for symptomatic vs. asymptomatic.

A case-control study which found that asymptomatic patients shed the virus for a median of 8 days, compared to 19 days in symptomatic patients (virus shedding was measured with NP swabs). However, it is unknown if this difference in length of shedding translates into any differences in infectivity (JAMA Netw Open, May 27, 2020).

WHO (June 5, 2020) reports that the available evidence from contact tracing in their member states suggests that asymptomatic individuals are much less likely to transmit the virus than symptomatic individuals.

The exact duration is unknown. The CDC (June 28, 2020) reports that the virus may be detectable for several days to weeks after illness onset, but it is unknown how infectious it may be.

  • A study of 56 recovered COVID-19 patients who had mild-moderate disease found that virus was detectable by PCR in 100% at week one, 89.3% at week two, 66.1% at week three, 32.1% at week four, 5.4% at week five, and 0% at week six. Patients with prolonged viral shedding tended to be older and were more likely to have comorbidities such as diabetes and hypertension (Clin Infect Dis, April 19, 2020).
  • Another study in 41 recovered COVID-19 patients with severe disease found a median duration of viral shedding of 31 days from illness onset (shortest 18 days, longest 48 days) (Clin Infect Dis, April 17, 2020).
  • A serial investigation in 21 COVID-19 patients (11 non-severe, five severe and five asymptomatic carriers) found that the respiratory swab remained positive for a median of ten days (range two to 21) from symptom onset in non-severe patients, 14 days (range nine to 33) in severe patients, and 18 days (range five to 28) in asymptomatic cases. The differences between groups were not statistically significant (Emerg Microbes Infect, April 20, 2020). For current guidance on when to consider a patient recovering from COVID-19 non-infectious, see Managing COVID-19: Outpatient management and resolution.
  • A retrospective cross-sectional study of 90 COVID-positive samples found that samples were only infective in the first 8 days after symptom onset. This suggests that COVID infectivity may be highest in the first 8 days after symptom onset and low afterwards (Clin Infect Dis, May 22, 2020).

According to the CDC (June 28, 2020), the immune response to COVID-19 is not yet known, including duration of immunity and if people can be reinfected.

An analysis of COVID-19 patients testing positive after recovery found that the positive test results were related to detection of non-viable virus rather than reinfection or reactivation (Korean CDC, May 19, 2020).

Based on available evidence, reinfection is unlikely in the short term, and the duration of likely immunity is not clear (Alberta Health Services, May 12, 2020).

A study comparing immune responses to COVID-19 found that asymptomatic patients had a weaker antibody response with a shorter duration compared to patients with severe symptoms. Asymptomatic patients had significantly lower levels of COVID-specific IgG antibodies compared to those with severe symptoms, and after 8 weeks, 40% of asymptomatic patients were seronegative versus 12.9% of those who had severe symptoms (Nat Med, June 18, 2020).

A systematic review of 504 patients with an asymptomatic course of COVID-19 found that 62.2% of cases had CT abnormalities, with ground glass opacities being the most frequent abnormality (43.09%). Most studies (61.74%) reported normal laboratory findings (Int J Infect Dis, June 13, 2020).

Multisystem Inflammatory Syndrome in Children (MIS-C)

Also called paediatric inflammatory multisystem syndrome (PIMS), multisystem inflammatory vasculitis, hyperinflammatory syndrome, Kawasaki-like disease or toxic shock-like syndrome.

As reports of children experiencing a multi-system inflammatory syndrome multiply, the Canadian Paediatric Surveillance Program issued a Public Health Alert (CPSP, May 12, 2020) encouraging those providing paediatric care to familiarize themselves with the presentations of this emerging syndrome. It has now been included in the case definition and is reportable to public health.

While rare, clinicians should be aware of this potential syndrome and maintain a high index of suspicion to identify cases. Some patients have deteriorated quickly and have required intensive care unit admission for vasopressors and mechanical ventilation.

Clinical presentations include:

  • Persistent fever and features suggestive of Kawasaki disease (complete or incomplete).
  • Toxic shock-like syndrome.
  • Euvolemic shock states.
  • Severe gastrointestinal illness.
  • Severe myocardial dysfunction and multiple organ failure have also been reported.

If these symptoms present:

  • Take a comprehensive history to identify confirmed or potential COVID-19 contacts.
  • Order laboratory testing. Laboratory signs of systemic inflammation include:
    • raised C-reactive protein (CRP), serum ferritin, ESR, or procalcitonin levels
    • neutrophilia
    • lymphopenia
  • Consider antibody testing (including on convalescent serum) and stool polymerase chain reaction (PCR) testing. Recognizing that these tests are not easily available to all, paediatricians may want to contact their local laboratories to discuss storing serum for future testing.

 
Note: Serology may be positive or negative for SARS-CoV-2. While the WHO cites positive serology or possible contact as a criteria for the case definition, a recent study found that not all children with the syndrome had positive serology at time of testing (The Lancet, May 13, 2020).

WHO Preliminary case definition:

  • Children and adolescents 0–19 years of age with fever > 3 days.
  • AND two of the following:
    • Rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs (oral, hands or feet)
    • Hypotension or shock
    • Features of myocardial dysfunction, pericarditis, valvulitis, or coronary abnormalities (including ECHO findings or elevated Troponin/NT-proBNP)
    • Evidence of coagulopathy (by PT, PTT, elevated d-Dimers)
    • Acute gastrointestinal problems (diarrhoea, vomiting, or abdominal pain)
  • AND elevated markers of inflammation such as ESR, C-reactive protein, or procalcitonin.
  • AND no other obvious microbial cause of inflammation, including bacterial sepsis, staphylococcal or streptococcal shock syndromes.
  • AND evidence of COVID-19 (RT-PCR, antigen test or serology positive), or likely contact with patients with COVID-19 (Note: not all children with the syndrome will have positive serology).

See: Scientific Brief: Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19 (WHO, May 15, 2020)

Current evidence
  • New An American case series (The Journal of Pediatrics, June 14, 2020) of 33 children with MIS-C treated at Cohen Children’s Medical Center (CCMC) reported that the onset/peak occurrence of cases followed the peak in the number of children with COVID-19 admitted to the same hospital by approximately 3 and 5.5 weeks, respectively (onset/peak), suggesting a post-infectious and possibly immunologically mediated pathology. Prominent findings included hemodynamic instability and cardiac dysfunction, which resolved rapidly after anti-inflammatory therapy.
  • New A multi-institutional study (The Journal of Pediatrics, June 14, 2020), also of 33 children, reported the following data about presentation: the median age was 10 years; 84.5% were hispanic or Black; 45% had comorbidities; and the median duration of symptoms prior to presentation was 4.5 (IQR 3, 6) days. Fever (93%) and vomiting(69%) were the most common presenting symptoms. Other common symptoms included abdominal pain (63%), nausea/emesis (69%), and hypotension (63%). Data gathered from Children’s Hospital at Montefiore (CHAM), Mount Sinai Kravis Children’s Hospital (KCH), and Jacobi Medical Center (JMC).
  • An observational study from France (Eurosurveillance, June 4, 2020) identified 156 potential cases of MIS-C and noted that incidence in France peaked several weeks after the national outbreak, suggesting it may be a post-infectious manifestation of COVID-19. The authors estimated the risk of MIS-C to be less than 2 cases per 10,000 children.
  • A second French observational study of 21 MIS-C patients (BMJ, June 3, 2020) reported a mean duration of 45 days between viral-like symptoms (e.g., fever, headache) and the onset of MIS-C, with 90% of patients testing positive for COVID-19 antibodies, 81% requiring intensive care and 52% requiring mechanical ventilation.
  • A recent small observational cohort study from Italy (The Lancet, May 13, 2020) compared a cohort of 10 children recently diagnosed with the syndrome to a cohort of children diagnosed before COVID-19, and found a 30-fold increase in incidence of “Kawasaki-like disease.” Those children diagnosed after the start of the epidemic were older, showed evidence of immune response to the virus, had a higher rate of cardiac involvement, and features of MAS.
Medication cautions in children
Current evidence

Antibiotics are not recommended to treat cases of COVID-19 without clinical suspicion of bacterial co-infection. When there is evidence of a secondary infection, appropriate antibiotics should be administered pre-emptively without waiting for confirmatory test results (CPS, April 20, 2020).

According to the NIH COVID-19 Treatment Guidelines (June 11, 2020) there are insufficient data to recommend for or against the use of specific antivirals or immunomodulatory agents for the treatment of COVID-19 in paediatric patients.

Chloroquine or hydroxychloroquine should not be used for treatment of suspected or confirmed COVID-19 in children unless under the direction of infectious disease specialists. Children and youth already receiving chloroquine or hydroxychloroquine for therapy of chronic conditions such as lupus should continue medication therapy (CPS, March 27, 2020).

Both Health Canada and the U.S. FDA recommend against the use of ibuprofen in children less than 6 months of age (CPS, March 24, 2020).

Medication cautions
COVID-19 and Nonsteroidal anti-inflammatory drugs (NSAIDs)

The World Health Organization issued a scientific brief (April 19, 2020) stating that there is currently no evidence of severe adverse events, acute health care utilization, long-term survival, or quality of life in patients with COVID-19, as a result of the use of NSAIDs.

The NICE rapid guidelines (April 30, 2020) have advised patients to take paracetamol or ibuprofen if they have fever and other symptoms that antipyretics would help treat, and to continue only while the symptoms of fever and the other symptoms are present. If using an NSAID they should take the lowest effective dose for the shortest period needed to control symptoms.

Acute respiratory infections and NSAIDs

Caution should be taken when using NSAIDs in the context of acute respiratory infections (ARI) and patients with the following conditions.

Scroll (left-right) for details
  • Acute myocardial infarction (MI)

    NSAIDs increase the risk of acute MI, even with short term-use (odds ratio = 1.5) (BMJ, 2017).

    • Dose-response with increasing risk for acute MI with increasing dose.


    The risk of acute MI is increased in ARI and influenza (odds ratio = 2.7), and NSAIDs increase the risk of acute MI in ARI further (odds ratio = 3.4) (J. Infect. Dis, 2017Pharmacoepidemiol Drug Saf, 2017).

  • Stroke

    NSAIDs use during ARI episodes increases risk of stroke (ischemic odds ratio = 2.27; hemorrhagic odds ratio = 2.28) (Pharmacoepidemiol Drug Saf, 2018).

    Parenteral NSAIDs increase risk of stroke in patients with ARI (Pharmacoepidemiol Drug Saf, 2018).

  • Bacterial infection complication

    NSAIDs may worsen the course of a bacterial community-acquired pneumonia (pleuropulmonary complications odds ratio = 5.7 – 8.1; pleuroparenchymal complications odds ratio = 2.57).

    However, this may be due to symptom masking as studies show patients taking NSAIDs have a longer time to antibiotic initiation (Lung, 2017Chest, 2011Respir Med, 2017J Crit Care, 2014).

  • Hypertension

    NSAIDs can worsen hypertension (odds ratio = 1.4) (UpToDate, 2020Aging Dis, 2018).

  • Heart failure

    NSAIDs can worsen heart failure (odds ratio = 1.19) (UpToDate, 2020BMJ, 2016).

NSAIDs for symptom control

Fever: A recent literature review found that while health professionals viewed fever as deleterious, outcomes with use of antipyretics were mixed and included several studies finding increased mortality risk associated with their use. In administering antipyretics, physicians should consider individual patients’ comorbidities and symptoms of their underlying illness (Br J Nurs, 2019). The NICE rapid guidelines (April 30, 2020) recommend not using antipyretics with the sole aim of reducing body temperature.

Total symptoms and duration: NSAIDs do not significantly reduce total symptoms or duration of respiratory infections (BMJ, 2013).

Acetaminophen: Primary care studies show acetaminophen is just as effective for symptom relief in viral illness (BMJ, 2013).

Medication misconceptions
COVID-19 and ACE inhibitors or ARBs

There has been speculation that patients receiving these medications may be more susceptible to COVID-19 and are at increased risk for adverse outcomes:

• Angiotensin-converting enzyme 2 (ACE2) is a receptor for SARS-CoV-2.
• ACE inhibitors and ARBs may upregulate ACE2, which could facilitate virus entry into cells.

There is currently no clinical evidence to support that taking an ACE inhibitor or ARB will make a patient more susceptible to COVID-19 or worsen outcomes (UpToDate, May 16, 2020; Therapeutic Research Centre, April 2020; NEJM, May 1, 2020).

An observational study has found that patients admitted to hospital with COVID-19 who had a history of hypertension but were not receiving blood pressure medications had a significantly higher risk of mortality compared to patients receiving hypertension treatment. No harm was detected in patients with COVID-19 taking Renin-Angiotensin-Aldosterone System Inhibitors (RAAS) (Eur Heart J, June 4, 2020).

See the HFAM resource COVID and ACEi’s ARBs: Helpful or Harmful? (March 31, 2020) for more information.

Unproven therapies
Medications

Though research is underway, there are currently no medications recommended in the prophylaxis or treatment of COVID-19, because there is insufficient evidence (CMAJ, April 29, 2020).

As with any medication, these drugs are also associated with potentially serious harms.

Off-label prescriptions and the stockpiling of these drugs based on limited evidence to treat COVID-19 has led to drug shortages and compromised care for patients who need these medications for their intended use.

Professional organizations and institutes cautioning against the use of unproven medications for COVID-19 patients

Physician Resources – Treatment of COVID-19 with chloroquine or hydroxychloroquine (The College of Family Physicians of Canada): Statement in support of the Canadian Pharmacists Association’s advice to refrain from prescribing hydroxychloroquine or azithromycin at this moment.

Treatment of COVID-19 with chloroquine or hydroxychloroquine (Canadian Pharmacists Association): Statement on dispensing chloroquine or hydroxychloroquine outside of their usual clinical indications.

NIH COVID 19 Treatment Guidelines (April 21, 2020): NIH does not recommend the use of any agents for pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP) of COVID-19. They state that “no drug has been proven to be safe and effective for treating COVID-19. There are insufficient data to recommend either for or against the use of any antiviral or immunomodulatory therapy in patients with COVID-19 who have mild, moderate, severe, or critical illness”.

The Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19 (April 11, 2020) recommends that hydroxychloroquine/chloroquine +/- azithromycin, lopinavir-ritonavir, tocilizumab, and corticosteroids (for ARDS) only be used in hospitalized patients in the context of a clinical trial.

Current evidence

Azithromycin Prophylaxis: Azithromycin is not currently recommended in the prophylaxis of COVID-19, because there is insufficient evidence that it will prevent COVID-19 (CEBM, April 14, 2020).

Treatment: As with any viral pneumonia, COVID-19 itself is not an indication for antibiotics. If co-infection with a bacterial pathogen is suspected, antibiotics should be initiated based on institutional antibiograms and sensitivities (BC Centre for Disease Control, June 8, 2020).

Antiviral drugs are not currently recommended in the prophylaxis or treatment of COVID-19, because there is insufficient evidence that they will prevent or inhibit COVID-19 (CMAJ, April 29, 2020). The likelihood of death from COVID-19 in patients with mild to moderate disease is extremely low, therefore antiviral drugs will have little or no effect on mortality in such patients (CMAJ, April 29, 2020).

There is some evidence of appreciable harm with hydroxychloroquine, chloroquine, ribavirin and lopinavir-ritonavir and high uncertainty regarding adverse effects in other antivirals drugs (CMAJ, April 29, 2020).

Chloroquine and hydroxychloroquine: The BC Centre for Disease Control (June 8, 2020) recommends against the use of hydroxychloroquine and chloroquine for treatment outside of a randomized controlled trial, and against the use of hydroxychloroquine and chloroquine for prophylaxis. Hydroxychloroquine may cause diarrhea and may increase headache, rash, nausea, vomiting and blurred vision, but the evidence is low-quality (CMAJ, April 29, 2020). Chloroquine and hydroxychloroquine may cause prolongation of the QTc interval (especially in patients with preexisting cardiac disease or if co-prescribed with azithromycin), hypoglycemia, neuropsychiatric effects, drug interactions and idiosyncratic hypersensitivity reactions, and they are highly toxic in overdose. They also cause numerous drug interactions including enhancing the response to direct-acting oral anticoagulants (DOACs), colchicine, cyclosporine, digoxin, and various chemotherapy agents; inhibiting the metabolism of metoprolol, carvedilol, and donepezil; and reducing the effectiveness of codeine and tramadol (CMAJ, April 29, 2020).

The hydroxychloroquine arm of the Recovery trial (June 5, 2020) in the UK has been stopped because there is no evidence of a clinical benefit. A systematic review of evidence (Ann. Intern. Med, May 27, 2020) for hydroxychloroquine or chloroquine for treatment or prophylaxis of COVID-19 found that evidence on the benefits and harms is very weak and conflicting.

Favipiravir: In comparison with umifenovir and lopinavir-ritonavir, favipiravir may have a possible higher incidence of recovery and viral clearance respectively, but the evidence is only very low-quality (CMAJ, April 29, 2020). However, the BC Centre for Disease Control (June 8, 2020) recommends against favipiravir due to lack of data.

Lopinavir-ritonavir and umifenovir: While initial results show that umifenovir and lopinavir-ritonavir may reduce cough, fever and progression to severe disease in patients with mild to moderate COVID-19, the initial evidence available is low-quality (CMAJ, April 29, 2020). Lopinavir-ritonavir may increase diarrhea, nausea and vomiting but the evidence is low-quality (CMAJ, April 29, 2020).

Oseltamivir: Not recommended for COVID-19 as neuraminidase inhibitors do not appear to have activity against the virus. Initial empiric therapy with oseltamivir might be reasonable during influenza season in critically ill patients if the patient is suspected to have influenza pneumonia; patients can have confirmatory NP swabs for influenza (BC Centre for Disease Control, June 8, 2020).

Remdesivir: The BC Centre for Disease Control (June 8, 2020) recommends against remdesivir outside of a clinical trial. As a preliminary study has shown viral load reduction in vitro (Antivir. Res, April 3, 2020), there have been trials underway to study this drug with early data analyses demonstrating some improvements in clinical outcomes, such as a 31% faster time to recovery (median time to recovery was 11 days with remdesevir and 15 days with placebo, p<0.001) (NIH, April 29, 2020; NEJM, April 10, 2020) and a numerically shorter duration of mechanical ventilation (7 days vs. 15.5 days; not statistically significant); adverse events leading to medication discontinuation were 12% with remdesevir vs. 5% in placebo; number needed to harm = 15 (Lancet, April 29, 2020).

Ribavirin: The BC Centre for Disease Control (June 8, 2020) recommends strongly against ribavirin due to the risk of harm. Ribavirin may increase anemia and bradycardia but the evidence is low-quality (CMAJ, April 29, 2020).

A systematic review (Stem Cells Transl Med, 2020) of cell therapy with mesenchymal stromal cells (MSCs) for COVID-19 acute respiratory distress syndrome (ARDS) found a favourable but not statistically significant trend towards reduced mortality, improved radiographic findings, pulmonary function and inflammatory biomarker levels with no related serious adverse events.

Not recommended for treatment or prophylaxis outside of a randomized controlled trial due to insufficient evidence (BC Centre for Disease Control, June 8, 2020). Clinical trials are ongoing.

Convalescent plasma is not currently recommended in the treatment of COVID-19, because there is insufficient evidence that it will inhibit COVID-19 (CMAJ, April 29, 2020).

Initial low-quality evidence suggests that convalescent plasma may have little to no effect on mortality, may have a small benefit in hastening recovery, may reduce length of hospital stay and duration of mechanical ventilation and may result in little or no difference in rate of serious adverse events (CMAJ, April 29, 2020).

Some groups suggest that corticosteroids may be used in patients with severe COVID-19 and acute respiratory distress syndrome (ARDS), however the research community is currently divided on this recommendation (BC Centre for Disease Control, June 8, 2020; CMAJ, April 29, 2020). Corticosteroids are not recommended in patients with severe COVID-19 who do not have ARDS (CMAJ, April 29, 2020). However, steroids may be used if the patient has another compelling indication, such as an asthma exacerbation, refractory septic shock, or for fetal lung maturation in obstetric patients (BC Centre for Disease Control, June 8, 2020).

Preliminary results from the dexamethasone arm of the RECOVERY Trial (June 16, 2020), where patients receiving 6 mg dexamethasone once daily (orally or by intravenous injection) were compared to patients receiving usual care, showed a reduction of deaths by one third in ventilated patients (rate ratio 0.65 [95% confidence interval 0.48 to 0.88]; p=0.0003) and by one fifth in other patients receiving oxygen only (0.80 [0.67 to 0.96]; p=0.0021). No mortality benefits were seen in patients who did not require respiratory support (1.22 [0.86 to 1.75]; p=0.14). Trial results are pending publication.

Anakinra: There are insufficient data to recommend either for or against use (NIH, May 12, 2020). Clinical trials are ongoing.

Interferon-α: With respect to interferon-α, there is very low-quality evidence that the addition of interferon-α to umifenovir therapy may not affect time to viral clearance or length of hospital stay relative to umifenovir alone (CMAJ, April 29, 2020). There is no evidence available on the harms.

Interferon-β: There is no published evidence regarding benefit or harm of interferon-β in patients with mild to moderate COVID-19 (CMAJ, April 29, 2020).

Interferon-λ: There is no published evidence on the benefits and harms in COVID-19. Clinical trials are ongoing.

Tocilizumab: Not recommended outside of a randomized controlled trial due to insufficient evidence (BC Centre for Disease Control, June 8, 2020). If considered on an individual basis in patients with cytokine storm, it should only be done with expert consultation (Infectious Diseases and Hematology/Rheumatology). Clinical trials are ongoing.

Information is limited due to lack of data. Detailed assessment will be provided when credible scientific literature becomes available. (BC Centre for Disease Control, June 8, 2020). Clinical trials are ongoing.

Information on these therapies is limited due to lack of data. Detailed assessment on these therapies will be provided when credible scientific literature becomes available. (BC Centre for Disease Control, June 8, 2020). Clinical trials are ongoing.

A systematic review (J Clin Med, May 23, 2020) of herbal medicine for COVID-19 examined 7 randomized controlled trials in a total of 855 patients. When herbal medicine plus conventional medicine was compared with conventional medicine alone, the combined therapy significantly improved the total effective rate, cough disappearance rate, sputum production symptom disappearance rate and TCM (traditional Chinese medicine) syndrome score (which includes cough, fever, dry and sore throat, and fatigue).

COVID-19 Vaccine research

There is currently no approved vaccine for COVID-19, but researchers around the world are working to develop and test vaccine candidates. Health Canada is working to fast-track applications for vaccine development. The Canadian Center for Vaccinology at Dalhousie University in Halifax has been approved to begin human trials of COVID vaccine candidates, with Phase 1 trials expected to start in August 2020 and Phase 2 trials in September 2020.

Managing COVID-19: Outpatient management and resolution
Last reviewed: July 3, 2020
Last updated: July 6, 2020
Who can be managed at home?
  • Have mild to moderate, uncomplicated COVID-19.
  • Have an O2 saturation > 93% (if pulse oximeter is available).
  • Have a respiratory rate < 30.
  • Show no signs of respiratory distress.
  • Show no signs of confusion.
  • Are able to stay well hydrated.
  • Have the appropriate resources and social supports to manage any comorbidities at home, self-isolate and carry out regular activities of daily living.
Who should be hospitalized?

There is no reliable scoring system currently available for deciding which COVID-19 patients should be hospitalized (CEBM, April 20, 2020).

Patients should be instructed to seek an urgent follow-up assessment with their family physician or hospitalization if they experience any of the following red flag symptoms (PHAC, April 9, 2020; BMJ, March 25, 2020; WCH):

  • Severe shortness of breath at rest.
  • Difficulty breathing.
  • Increasing significant fatigue (reported in some patients as a marker for hypoxemia without dyspnea).
  • Reduced level of consciousness or new confusion.
  • Cold, clammy or pale and mottled skin.
  • Blue lips or face.
  • Little to no urine output.
  • Pain or pressure in the chest.
  • Neck stiffness.
  • Non-blanching rash.
  • Syncope.
  • Coughing up blood.
Managing patients at home

Counsel all patients about self-monitoring for red flag symptoms of worsening disease (see Who should be hospitalized?) and provide them with an on-call (or your) number. Encourage them to seek an urgent follow-up assessment with a family physician (by calling the on-call/your number) or hospitalization if they experience any of these symptoms (PHAC, April 9, 2020).

Assess patients for pre-existing conditions that may put them at a higher risk of deterioration (older age, asthma, COPD, cardiovascular disease and immunocompromising conditions are particularly relevant). Monitor these patients closely (CEBM, April 20, 2020BCCDC, April 14, 2020NICE, April 20, 2020UpToDate, May 11, 2020). See Symptom management and comorbid considerations.

Determine an appropriate follow-up frequency based on patient’s symptom severity, comorbidities, age and social support (WCHBMJ, March 25, 2020; Dufferin/Caledon Community Based COVID Management, 2020).

Ask the patient to self-monitor if patient:

  • Is asymptomatic or has mild symptoms
  • Looks well
  • Has limited comorbidities

Contact patient once/day if patient:

  • Is on days 5-10 from date of symptom onset or positive swab
  • Has mild to moderate symptoms
  • Appears unwell
  • Has limited comorbidities

Contact patient twice/day if patient:*

  • Symptoms are changing rapidly
  • Has moderate symptoms
  • Appears unwell
  • Has comorbidities
  • Is ≥ 80 years of age

* This recommendation is based on the best available guidance at this time. If this frequency of follow-up is not feasible for you and your practice, please use your clinical judgment to determine a more feasible follow-up frequency and leverage community partners and supports (e.g. home care services).

If appropriate, discuss and establish goals-of-care (e.g. supportive care in the ED vs. palliative care in home). See Navigate difficult conversations with patients, families and caregivers and identify the patient’s goals of care for more information (WCH).

Instruct and support patients to self-isolate at home for 14 days (PHAC, April 9, 2020). Support patients to arrange delivery of prescriptions, over-the-counter supplies, household items and groceries where feasible (through delivery services, family members, caregivers, friends/neighbours, etc.) (ECDC, 2020). For pharmacy and grocery store delivery options, see thehealthline.ca. Send patients all required paperwork electronically if feasible (e.g. prescriptions, sick certificates) (BMJ, March 25, 2020).

See the CEP’s Local Services Resource for:

Ask patient to take readings from instruments they have at home if available (e.g. thermometer, Fitbit, smartphone apps, pulse oximeter) while keeping in mind the unknown accuracy of some of these devices (BMJ, March 25, 2020).

See the CEP’s Local Services Resource for:

Establish a safety net. If patients live alone, support them to arrange for someone to check in on them regularly virtually or from a distance (BMJ, March 25, 2020).

If necessary, provide patients with information on symptomatic management, which is consistent with standard treatment for cold-like symptoms and influenza-like illnesses (BCCDC, April 14, 2020). See Symptom management and comorbid considerations.

Symptom management
Common symptoms (MOH, May 14, 2020)

Potential management strategies (NICE, April 3, 2020)

Potential management strategies (NICE, April 3, 2020)

Potential management strategies (NICE, April 3, 2020)

Be aware of and counsel patients on the other symptoms of COVID-19, which can include (MOH, May 25, 2020):

  • 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.)

Atypical symptoms of COVID-19 can include (MOH, May 25, 2020):

  • Unexplained fatigue/malaise/myalgias
  • Delirium (acutely altered mental status and inattention)
  • Unexplained or increased number of falls
  • Acute functional decline
  • Exacerbation of chronic conditions
  • Chills
  • Headaches
  • Croup
  • Conjunctivitis
  • Multisystem inflammatory vasculitis in children
Talking points
Comorbid considerations

It is probable that COVID-19 infection can trigger asthma exacerbation (Canadian Thoracic Society, 2020).

The Canadian Thoracic Society (April 7, 2020) recommends that:

  • Patients with asthma restart or continue to use their prescribed inhaled maintenance therapy, regardless of COVID-19 status.
  • Prednisone can be used to treat severe asthma exacerbations, including those caused by COVID-19 infection.
  • Anti-IgE and anti-IL-5 monoclonal antibodies (biologics) be continued during the COVID-19 pandemic, regardless of COVID-19 status.
  • Patients who are already using nebulizers do so in a separate room from others and implement other infection control recommendations (CTS generally recommends that patients switch from nebulized therapy to metered dose inhalers with spacing devices or dry powder inhalers during the COVID-19 pandemic).

Based on current evidence, patients with CVD do not appear to be more likely to acquire COVID-19 infection, however they do appear to be at a greater risk for developing severe COVID-19 if infected (J Med Virol, May 22; Int J Public Health, May 25, 2020).

It is probable that cardiovascular disease may increase COVID-19 susceptibility and severity (CCSUpToDateUpToDate-CAD).

For patients with known heart failure, see the virtual assessment guide (CCS, April 1, 2020) to differentiate between COVID-19 and heart failure exacerbations.

The Canadian Cardiovascular Society (March 20, 2020) recommends that:

  • Patients with confirmed or suspected COVID-19 should not stop taking an ACEi/ARB/ARNi unless there is a compelling reason to do so, such as symptomatic hypotension or shock, acute kidney injury, or hyperkalemia.
  • Patients with confirmed or suspected COVID-19 should not stop low-dose acetylsalicylic acid.

Based on current evidence, COPD patients do not appear to be more likely to acquire COVID-19 infection, however they do appear to be at a significantly greater risk for developing severe COVID-19 if infected (CTS, April 8, 2020; Int J Public Health, May 25, 2020; PLoS One, May 11, 2020).

It is probable that COVID-19 infection can trigger COPD exacerbation (Canadian Thoracic Society, 2020).

The Canadian Thoracic Society (April 8, 2020) recommends that:

  • Patients who are diagnosed with COVID-19 infection continue their inhaled maintenance therapies.
  • Oral prednisone (or other forms of systemic steroids if clinically warranted) be used to treat acute exacerbations of COPD, including those caused by COVID-19 infection.
  • Patients who are currently on oxygen continue their oxygen use as prescribed, regardless of COVID-19 status, while routinely cleaning their equipment using manufacturer’s instructions. For a list of local respiratory services and equipment, including for home oxygen therapy, see Local Services > Oxygen and respiratory services.
  • Patients who are already using nebulizers do so in a separate room from others and implement other infection control recommendations (CTS generally recommends that patients switch from nebulized therapy to metered dose inhalers with spacing devices, dry powder inhalers, or soft mist inhalers during the COVID-19 pandemic).

Patients with diabetes appear to be at increased risk of having a more severe COVID-19 infection and more likely to suffer poor outcomes (Canadian Healthcare Network, May 9, 2020 [login required]; Aging and Disease, June, 2020).

  • Controlling blood glucose may possibly impact the severity of COVID-19. Previous studies have shown that patients with chronically higher blood glucose levels are more likely to acquire bacterial or some viral infections.
  • Data is not yet available differentiating the impact of Type 1 from Type 2 diabetes in relation to COVID-19.
  • During acute illness, patients may be susceptible to adverse drug events due to comorbidities or medicine use. The following medications (SADMANS) may be of concern in some patients (Can J Diabetes, 2018):
    • Sulfonylureas
    • ACE Inhibitors and angiotensin receptor blockers (ARBs)
    • Diuretics
    • Metformin
    • NSAIDs
    • SGLT2 Inhibitors

Holding diabetes medications

Specific populations

Most children who have COVID-19 can be cared for at home, with supportive care performed by their parents. When considering resolution, note that children have been found to have high viral loads despite mild symptoms, with prolonged shedding in nasal secretions (BCCDC, April 3, 2020).

Fever reduction (CPS, April 20, 2020):

  • Acetaminophen (15 mg/kg every 4 hours, as needed, up to 1 g/dose, to a maximum dose of 75 mg/kg/day or 4 g/day) orally, or
  • Ibuprofen (10 mg/kg every 6 hours, as needed, for children 6 months of age or older, to a maximum dose of 800 mg/dose) orally.

Paediatric populations considered at higher risk for severe COVID-19 are those:

  • 1 year old or under (i.e. infants)
  • with heart or lung disease (e.g., asthma, cystic fibrosis)
  • with neurological or neuromuscular condition
  • with other chronic conditions such as diabetes mellitus, sickle cell disease, malignancies, and/or immunosuppressive conditions (e.g., post-organ transplant, chronic steroids)
  • already being ventilated at home

 
See CDC (July 3, 2020)CPS (April 20, 2020).

It is probable that a weakened immune system may reduce a patient’s ability to fight infectious diseases like COVID-19. Immunocompromised patients may be at risk of more severe illness and may remain infectious for longer than other COVID-19 patients (CDC, June 25, 2020).

It is recommended that:

  • Primary care providers consult the patient’s specialist (or a specialist in the same field if the patient’s usual specialist is unavailable) for direction related to the condition they are treating. If immunocompromised patients with COVID-19 are on immunosuppressant therapy, treatment may need to be modified or stopped. Systemic corticosteroids should not be stopped abruptly (NICE, April 3, 2020, 2020NICE, April 23, 2020NICE, April 9, 2020CEBM, March 30, 2020).
  • Do not delay life-saving treatment or emergency care (CDC, June 25, 2020).
  • Apply more stringent requirements to criteria for discontinuation of self-isolation for immunocompromised patient with resolved COVID-19 (CDC, May 3, 2020).
  • An infectious diseases specialist (especially one who has expertise working with patients who are immunocompromised) may also need to be consulted for assistance with COVID-19 management.

See Top resources for condition-specific guidance.

Keep in mind: Older adults ≥ 80 have the highest mortality rate due to COVID-19 in Ontario (Public Health Ontario, June 29, 2020).

Atypical COVID-19 presentations in frail older adults

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, 2020MOH, 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

Discuss and establish goals-of-care (e.g. supportive care in the ED vs. palliative care in home). Involve caregivers and family members. See Navigate difficult conversations with patients, families and caregivers and identify the patient’s goals of care for more information (WCH; PHAC, April 9, 2020).

Hispanic and black pregnant women appear to be disproportionately affected by SARS-CoV-2 infection during pregnancy (CDC, June 26, 2020).

Adverse pregnancy outcomes

  • Data on the impact of COVID-19 on pregnancy is limited to approximately 500 published cases in the latter half of pregnancy (SOGC, May 21, 2020).
    • Preterm birth is the most commonly reported adverse perinatal outcome (estimated rate of 6-15%), with the majority being late preterm. However, most babies born to mothers with COVID-19 are born healthy and at term.
    • Other adverse pregnancy outcomes appear to be proportional with the degree of maternal respiratory illness.
    • Complications of pregnancy such as diabetes, preeclampsia, advanced maternal age, obesity and postpartum hemorrhage are risk factors for maternal sepsis and severe COVID-19 infection.
  • A retrospective cohort study (American Journal of Perinatology, May 19, 2020) found that pregnant women who presented with COVID-19-related symptoms and subsequently tested positive for COVID-19 have a higher rate of preterm delivery and need for respiratory support than asymptomatic pregnant women. The CDC (June 26, 2020) found similar results with a higher risk of hospitalization, ICU admission, and mechanical ventilation, but not death.
  • Researchers in Spain found that pregnant women with severe COVID-19 developed signs and symptoms similar to preeclampsia, and that this could be differentiated from preeclampsia by the lack of high levels of the preeclampsia-associated enzymes sFLT-1/P1GF, LDH and UtAPI (BJOG, June 1 2020).

Prenatal care and hospitalization for COVID-19

Delivery considerations

  • The NIH COVID-19 Treatment Guidelines (May 12, 2020) advise that generally, obstetric indications rather than COVID-19 diagnosis should dictate the timing of delivery. However, if COVID-19 is diagnosed in the third trimester, it is reasonable to try to postpone delivery, assuming no other medical indications occur, until there is a negative test result or quarantine restrictions are limited, to limit transmission to the newborn.
  • See the COVID-19 Guidance: Labour, Delivery and Newborn Care (MOH, May 19, 2020) for recommendations on PPE during delivery, support people during labour, and care of infants born to COVID-19 positive mothers.

Mother-to-child transmission and infant testing

Breastfeeding

Resolution

Patients with mild to moderate COVID-19 (diagnosed as a result of having symptoms compatible with COVID-19 or having tested positive for COVID-19) can be advised to discontinue isolation (MOH, May 2, 2020):

  • At 14 days after symptom onset IF the patient is afebrile and symptoms are improving* (MOH, May 2, 2020).

 
This guidance is applicable to healthcare workers and patients living in congregate settings (e.g. long-term care homes, shelters), however healthcare workers should check with their employer for specific resolution criteria.

Patients with severe COVID-19 who were hospitalized, can be advised to discontinue isolation (MOH, May 2, 2020):

  • After two consecutive negative specimens are collected (at least 24 hours apart) AND the patient has become afebrile and symptoms are improving*. If swab remains positive, test again in approximately 3-4 days (once negative, conduct swab at least 24 hours later) (MOH, May 2, 2020).

 
This guidance is applicable to patients remaining in hospital after symptom improvement and those being discharged to congregate settings (e.g. long-term care homes, shelters) (MOH, May 2, 2020).

* Absence of cough is not required for those known to have chronic cough or those experiencing reactive airways post-infection (MOH, May 2, 2020).

Top resources
Managing COVID-19: Long-term care homes
Last reviewed: July 6, 2020
Last updated: June 29, 2020
Universal masking in long-term care homes

Universal masking measures have been put in place for all staff and essential visitors of long-term care homes (LTCHs) regardless of whether the home is in outbreak or not (MOH, April 10, 2020).

Surgical masks or procedural masks (“masks” in this section) can function either as source control (worn to protect others) or part of personal protective equipment (to protect the wearer) (PHO, April 20, 2020).

With every patient/resident:
What to wear, when
Infection control: healthcare worker and resident cohorting

Long-term care homes must use staff and resident cohorting to prevent the spread of COVID-19 (MOH, June 10, 2020).

In smaller long-term care homes, or homes where it’s not possible to maintain physical distancing of staff or residents, all residents and staff should be managed as if they are potentially infected, and staff should use droplet and contact precautions when in an area affected by COVID-19.

Putting it into practice

Healthcare worker cohorting can include:

  • Designating providers to care for either ill residents or well residents.
  • Limit the number of healthcare facilities and locations each healthcare worker accesses.

Resident cohorting can include:

  • Alternative accommodation in the home to maintain physical distancing.
  • Cohorting of the well and unwell.
  • Utilizing respite, palliative care, and other beds and rooms, as appropriate.
Navigating difficult conversations

When implementing resident cohorting strategies, recognize the emotional impact of moving and/or isolating residents. Use the talking tips below to help address resident stress and anxiety.

“This is your home and we will make every effort to make you comfortable in your new room with all of your belongings.”

“In-room dining is important for you and other residents so that we can protect everyone, including yourself.”

See Managing COVID-19: Palliative care for help with navigating conversations regarding goals of care or palliation.

Screening for COVID-19
Putting it into practice

Passive screening

  • Signage should remind all persons in the LTCH to perform hand hygiene (PHO, March 16, 2020) and follow respiratory etiquette.
  • Signage should also indicate signs and symptoms of COVID-19 and steps (MOH, April 15, 2020) that must be taken if COVID-19 is suspected or confirmed in a staff member or a resident.

Active screening

In the event of a positive screen:

Anyone showing symptoms of COVID-19 is not be allowed to enter the LTCH and must go home immediately to self-isolate.

Residents with symptoms of COVID-19 must be isolated according to droplets and contact precautions (PHO, March 17, 2020), and tested.

Testing for COVID-19
Putting it into practice

LTCH not under outbreak

  • Testing must be conducted on every symptomatic resident and staff member.

LTCH under outbreak

  • Testing must be conducted on symptomatic, asymptomatic residents and staff members who have been in contact with cases.
  • Asymptomatic contacts of a confirmed case include:
    • All residents living in adjacent room.
    • All staff working on the unit/carehub.
    • All essential visitors that attended at the unit/carehub.
    • Any other contacts deemed appropriate for testing based on a risk assessment by local public health unit.

Specimens from LTCHs and other residents of institutions will be prioritized if “Institution” is clearly marked on the PHO laboratory requisition (May 5, 2020).

See the MOH Provincial Testing Guidance Update (MOH, June 2, 2020) for a list of symptoms, including atypical signs and symptoms.

COVID-19 is likely to present atypically in older adults (nausea, diarrhea, decreased appetite and oral intake, weight loss and others), see Atypical COVID-19 presentation in frail older adults (RGP Toronto, April 7, 2020).

See Primary care assessment and testing for COVID-19 for the Testing Procedure FAQs.

Outbreak management

LTCHs must consider a single, laboratory confirmed case of COVID-19 in a resident or staff member as a confirmed COVID-19 outbreak.

If a resident who was admitted or re-admitted to the home is tested during the 14- day isolation period and the results are positive and the resident has been in isolation under contact and droplet precautions during the entirety of the 14-day period, declaring an outbreak may not be necessary.

When only asymptomatic residents and/or staff with positive results are found as part of the enhanced surveillance testing initiative for all residents and staff, it may not be necessary to declare an outbreak. This should only be assessed and done in consultation with the local public health unit.

Residents, staff or visitors who were in close contact with the infected resident, or those within that resident’s unit/hub of care, should be identified. See COVID-19 Outbreak Guidance for Long-Term Care Homes (MOH, April 15, 2020) for additional guidance.

Contact your local public health unit to report a staff member or resident suspected to have COVID-19 to ensure an outbreak number is provided.

Essential staff must follow self-isolation recommendations (PHO, March 25, 2020) inside and outside of the workplace. At minimum, a mask must be worn at all times in the workplace, including common areas. For healthcare worker symptom resolution and return-to-work guidance, see Primary Care Operations in the COVID-19 Context > Infection monitoring and protocols for healthcare workers.

For guidance on how to de-escalate IPAC measures towards the end of and/or following a COVID-19 outbreak in a long-term care setting, see De-escalation of COVID-19 Outbreak Control Measures in Long-term Care and Retirement Homes (PHO, June 6, 2020).

Readmission and new admission of residents to LTCHs

As per Directive #3 for Long-Term Care Homes under the LongTerm Care Homes Act, 2007 (MOH, June 10 , 2020), hospital transfers to long-term care homes and retirement homes, can occur if:

  1. It is a re-admission to long-term care (the resident is returning to their home).
  2. The home is NOT in a COVID-19 outbreak. Under exceptional circumstances readmissions may take place during an outbreak if:
    • It is approved by the local public health unit, and
    • There is concurrence between the home, public health and hospital.
  3. The resident has been:
    • Tested for COVID-19 at point of discharge, has a negative result and is transferred to the home within 24 hours of receiving the result, or
    • Confirmed infected and cleared of COVID-19. Residents being admitted who have been cleared of COVID-19 do not need to undergo 14-days of self-isolation.
  4. The receiving home has a plan to:
    • Ensure that the resident being re-admitted (except those who have been cleared of COVID-19) can complete 14-days of self-isolation, under Droplet and Contact Precautions and is tested again at the end of self-isolation, with a negative result. If the result is positive, the resident must complete another 14-days of self-isolation, and
    • Continue with other COVID-19 preparedness measures (e.g., cohorting).
  5. The resident is placed in a room with no more than one (1) other resident. That is, there shall be no further placement of residents in 3 or 4 bed ward rooms.

As per Directive #3 for Long-Term Care Homes under the LongTerm Care Homes Act, 2007 (MOH, June 10 , 2020), new admissions from the community or from a hospital (including ALC patients) to a long-term care home or retirement home can occur if:

  1. The receiving home is NOT in a COVID-19 outbreak. Under exceptional circumstances admissions may take place during an outbreak if:
    • It is approved by the local public health unit, and
    • There is concurrence between the home, public health and hospital.
  2. The resident has been:
    • Tested for COVID-19, has a negative result and is transferred to the home within 24 hours of receiving the result, or
    • Confirmed infected and cleared of COVID-19. Residents being admitted who have been cleared of COVID-19 do not need to undergo 14-days of self-isolation.
  3. The receiving home has:
    • Sufficient staffing,
    • A plan to ensure the resident being admitted (except for those who have cleared COVID-19) can complete 14-days of self-isolation, under Droplet and Contact Precautions, and is tested again at the end of self-isolation, with a negative result. If the result is positive, the resident must complete another 14-days of self-isolation, and
    • A plan to continue with other COVID-19 preparedness measures (e.g., cohorting).
  4. The resident is placed in a room with no more than one (1) other resident. That is, there shall be no further placement of residents in 3 or 4 bed ward rooms.
Family physicians/primary care nurse practitioners providing care in LTCHs for the first time

Providing care in a long-term care home may be an unfamiliar experience for some. The information below provides clinical guidance and logistical support to the workflow of LTCHs when providing in-person individual health assessments and hands-on care. It is not limited to COVID-19 specific care.

Please note: All non-essential visits are to be conducted virtually. Primary care providers can use the VirtualCare App (ThinkResearch, 2020) to remotely connect with nursing staff and residents. Providers can also visit LTC+ Virtual Care Support for Long-term Care Homes in Ontario (WCH, 2020) for a virtual care program that connects providers working in LTCHs with 24/7 virtual consultations with medical specialists and services. See Primary Care Operations in the COVID-19 Context > Delivering patient care remotely for more general information on remote/virtual visits.

If you are able to and are interested in being matched to work at long-term care facilities, see the following matching tools for healthcare workers:

For questions about medical-legal protection while working in a different clinical setting, see:

CMPA Physician Advisors are available to provide support throughout the pandemic and can be reached at 1-800-267-6522 Monday to Friday from 8:30 a.m. to 4:30 p.m. ET or through the CMPA member portal.

CNPS beneficiaries with questions about nursing during a pandemic are encouraged to contact CNPS for advice at 1-800-267-3390.

Practical tips and clinical guidance to keep in mind when working in LTCHs
  • Leave all non-essential belongings in the car/in a safe location.
  • Introduce yourself to the administrator and participate in the screening process. If you fail the screening, immediately leave the site, proceed to self-isolate (PHO, April 10, 2020) and conduct virtual visits only.
  • Have a discussion with the care staff to establish understanding of specific protocols and procedures within the LTCH.
    • Ensure you know how to summon assistance for a fire, cardiac arrest, and other emergencies. The colour codes used are the same for all of Ontario. If you do not know the colour code when you hear one, please ask.
  • Determine which HCWs and staff are available to assist with any assessments or hands-on care, if necessary. Can communicate with staff or refer to a schedule, if available.
  • Perform hand hygiene (PHO, March 16, 2020) before and after every resident/patient interaction.
  • Conduct a personal risk assessment (AHS, 2018) and don appropriate PPE before engaging with patients/residents.
  • Review patient’s history and what medications they are currently on.
  • If the patient has dementia and/or other cognitive disorders that impair decision-making ask LTCH staff to engage with Substitute Decision-Maker (SDM) via virtual means or telephone.
  • Ensure the proper storage of the resident’s records according to the protocols of the facility.
  • If more than one site will be visited in a single day, repeat the self-assessment process prior to arrival at the next site.
  • Self-monitor (PHO, May 17, 2020) for 14 days following your last on-site visit.
Top resources

These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

Managing COVID-19: Palliative care
Last reviewed: July 6, 2020
Last updated: June 30, 2020
The role of primary care
Navigate difficult conversations with patients, families and caregivers and identify the patient’s goals of care

Due to COVID-19’s increased strain on the healthcare system, primary care providers will need to engage in difficult conversations regarding restricted treatment options, rapid deterioration and end-of-life planning. Importantly, the provider will need to ensure the patient understands the nature and severity of their illness, and explore their goals of care to support decision-making and enable person-centred care.

Putting it into practice
  • Prepare yourself and explain the purpose of the meeting to the patient – or their family, power of attorney (POA), and/or substitute decision maker (SDM). Gather the information you need to know in order to have an informed goals of care discussion.
  • Explore your patient’s understanding of COVID-19 to determine what information your patient has and needs.
  • Discuss goals of care that are most aligned with the patient’s values and what is clinically appropriate/available.
  • Recommend and document a plan that summarizes the patient’s values and discuss what you will do first to help the patient before discussing treatments that will be stopped or not offered.
  • Reaffirm and support the patient.
Document decisions regarding do not resuscitate (DNR)
Putting it into practice

Prognostic considerations regarding DNR in the event of COVID-19:

Prognostic factors for complications and worse outcomes

  • In those over age 80, mortality increases to 15-20%.
  • Between five to 10 days after exposure, patients tend to stabilize or decompensate rapidly – e.g. Acute respiratory distress syndrome (ARDS).
  • Age > 65, diabetes, hypertension are all associated with ARDS.
  • Of those who develop ARDS, 52% may go on to a fatal outcome.
  • Anecdotal experience suggests that those who develop ARDS will likely die within eight to 12 hours if not intubated.

Lab markers associated with worse outcomes

  • Worsening lymphopenia
  • Elevated LDH
  • Elevated CRP, ferritin, IL-6
  • Elevated troponin
  • Other factors associated with outcome include their premorbid state and duration of illness
Manage symptoms, and address other palliative care needs for patients with COVID-19

Access to palliative care and hospice services for COVID-19 patients may become limited or unavailable. Family physicians and community palliative care nurse practitioners need to be prepared to address the palliative care needs of their COVID-19 patients.

Provide end-of-life care for COVID-19 patients

When patients with COVID-19 are in their final weeks and days of life, family physicians and community palliative care nurse practitioners need to be prepared to support and provide end-of-life care.

It is important to ensure rapid access to palliative medications that are often at higher doses than seen in standard practice (RCGP).

Dose ranges should be considered to allow for urgent decision-making regarding escalation of dose for distressing symptoms.

The most common terminal symptoms (fever, rigors, severe dyspnea, cough, delirium and agitation) can develop rapidly and be distressing.

Where possible, avoid use of the following as they may generate aerosolized COVID-19 virus particles and increase the risk of infecting healthcare providers, and family members:

  • Oscillatory devices (fans)
  • Oxygen Flow greater than 6L/min
  • High-flow nasal cannula oxygen
  • Continuous positive airway pressure (CPAP) or bilevelpositive airway pressure (BiPAP)
  • All nebulized treatments (bronchodilators, epinephrine, saline solutions, etc.)
  • Oral or airway suctioning (especially deep suctioning)
  • Bronchscopyand tracheostomy

For a small number of patients who have severe, refractory symptoms at the end of life, rapid titration or Continuous Palliative Sedation Therapy (CPST) may be needed. See Continuous Palliative Sedation Therapy Protocol For COVID-19 Pandemic (McMaster University, March 31, 2020).

For strategies for potential shortages in medications relevant to palliative care during COVID-19 see this resource by the Ontario Palliative Care Network (May 26, 2020).

Putting it into practice
Scroll (left-right) for details
  • Pain or dyspnea

    Hydromorphone

    • Dose: 0.25-0.5 mg; may start at lower dose (0.25 mg) if patient is opioid naive, frail or an older adult 
    • Route: Subcut
    • Frequency: q30min PRN; but low threshold to change to scheduled q4h dosing

    Morphine

    • Dose: 1-2.5 mg; may start at lower dose (0.25 mg) if patient is opioid naive, frail or an older adult
    • Route: Subcut
    • Frequency: q30min PRN; but low threshold to change to scheduled q4h dosing
    Click for treatment tips
  • Respiratory secretions / congestion

    Scopolamine (hyoscine HYDRObromide)

    • Dose: 0.4-0.6 mg
    • Route: Subcut
    • Frequency: q4h PRN

    Glycopyrrolate

    • Dose: 0.4 mg
    • Route: Subcut
    • Frequency: q2h-q4h PRN

    Atropine 1% ophthalmic drops

    • Dose: 3-6 drops
    • Route: SL
    • Frequency: q4h PRN

    Furosemide (if fluid overload)

    • Dose: 20 mg
    • Route: Subcut
    • Frequency: q2h PRN and monitor
    Click for treatment tips
  • Nausea or delirium

    Haloperidol

    • Dose: 0.5-1 mg (if patient is frail elderly, may start with 0.25 mg)
    • Route: Subcut
    • Frequency: q6h-q12h PRN
    Click for treatment tips
  • Sedation

    Midazolam

    • Dose: 1-2 mg (higher doses can be used for refractory dyspnea)
    • Route: Subcut
    • Frequency: q30 min PRN
    • Note: Higher doses can be used for refractory dyspnea

    Lorazepam

    • Dose: 0.5 mg (1-2 mg, if severe respiratory distress)
    • Route: SL (subcut, if more suitable for the patient)
    • Frequency: q1h PRN (q4h-q8h, if severe respiratory distress)
    Click for treatment tips
  • Fever and chills

    Acetaminophen 650 mg Suppositories

    • Dose: 650 mg
    • Route: PR
    • Frequency: q6h PRN
  • Agitation/restlessness

    Methotrimeprazine (if more sedation is desirable)

    • Dose: 2.5-12.5 mg
    • Route: PO / Subcut
    • Frequency: q2h PRN (up to three doses in 24 hours)*

    Haloperidol (if less sedation desirable)

    • Dose: 0.5 mg
    • Route: Subcut
    • Frequency: q1h PRN


    * If > 3 PRN in 24h, provider to review and consider scheduled q4h and q2h PRN dosing

    Click for treatment tips
  • Urinary retention

    Foley catheter 16 French

    • Insert catheter PRN
  • Dry mouth

    Mouth swabs

    • Mouth care q.i.d and PRN
Plan for an expected death in the home

In the final weeks and days of life, the focus of care moves towards managing the active dying process, which includes identifying that the patient is near death and ensuring that the patient, their substitute decision maker(s), their family and caregivers understand what to expect as death approaches. For many patients, the preference is to die at home. The processes for planning and managing expected deaths in the home are generally developed at the local or regional level.

Provide grief and bereavement support

For many people, the time following the death of a loved one can be filled with a range of emotions and physical reactions. It is important in the grief journey that people are able to openly talk about these experiences, reactions and feelings. Providers can recommend the following resources for those who have lost a loved one:

Grief and bereavement support for health care providers
New fee codes

Focus practice physicians can bill as specialists using K083 (Ontario MD).

For regular palliative care codes, K081 and K082 could be used depending on the depth of the visit (Ontario MD).

Note: many palliative care physicians are family physicians and they are not immediately eligible for specialist codes unless they have a focused practice designation. If they do, they may bill with the K083 code (Ontario MD).

Top resources
Share your thoughts
["Fingerprint"]
["Fingerprint"]
['50074653']
['50074653']
["Fingerprint"]
["Fingerprint"]
['50074653']
['50074653']