COVID-19: Clinical Guidance for Primary Care Providers

Last Updated: September 25, 2020

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This 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.

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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 regularly for the latest updates.

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Primary care assessment and testing for COVID-19
Last reviewed: September 24, 2020
Last updated: September 24, 2020
Screening

If a patient thinks they have symptoms, or is worried they have been exposed to COVID-19, they 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 or send an email to all patients on screening requirements and advise them to call prior to coming to the office/clinic. Consider mailing by post for those patients without email and/or internet.
  • 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 reminding patients that, regardless of symptoms, they are expected to wear a mask for the entirety of their visit and perform hand hygiene before reporting 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. When assessing for the symptoms below, focus on evaluating if they are new, worsening, or different from an individual’s baseline health status. Symptoms should not be chronic or related to other known causes or conditions:

  • Fever (temperature of 37.8°C or greater)
  • Cough, including croup (barking cough, making a whistling noise when breathing)
  • Shortness of breath (dyspnea, out of breath, unable to breathe deeply, wheeze)
  • Sore throat (painful or difficulty swallowing)
  • Rhinorrhea (runny nose)
  • Nasal congestion (stuffy nose)
  • New olfactory or taste disorder (decrease or loss of smell or taste)
  • Nausea and/or vomiting, diarrhea, persistent/ongoing abdominal pain
  • Chills
  • Headaches (new and persistent, unusual, unexplained, or long-lasting)
  • Conjunctivitis (pink eye)
  • Fatigue, lethargy, or malaise (general feeling of being unwell, lack of energy, extreme tiredness)
  • Myalgias (muscle aches and pain)
  • Decreased or lack of appetite (for young children); difficulty feeding in infants
  • New or unusual exacerbation of chronic conditions
  • Tachycardia (fast heart rate; including age specific tachycardia for children)
  • Low blood pressure for age
  • Hypoxia (i.e. oxygen saturation less than 92%)
  • Delirium (acutely altered mental status and inattention)
  • Increased number of falls in older persons
  • Acute functional decline
  • Contact with a confirmed case in the last 14 days without proper PPE

 

See COVID-19 Reference Document for Symptoms (MOH, September 21, 2020) for a full list of signs and symptoms and examples of when symptoms may be related to other causes or conditions.

Keep in mind

A systematic review of 131 studies found that fever and cough were the most common symptoms, followed by nasal congestion, fatigue and sore throat, while approximately 19% of children were asymptomatic (EClinicalMedicine, June 26, 2020).

In addition to the symptoms most commonly associated with COVID-19, other atypical symptoms/signs should be considered in children (MOH, September 21, 2020). These symptoms/signs include:

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).

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, September 21, 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

When assessing patients by telephone or video, use the COVID-19 remote consultations infographic (BMJ, March 25, 2020) for guidance on setting up, connecting, taking a history and examination.

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).

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.
Testing
Frequently asked questions (FAQs)

In addition to the COVID-19 Provincial Testing Guidance Update (MOH, August 14, 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 (September 4, 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 (September 16, 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 ‘COVID-19 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.

In a patient who tested positive for COVID-19 AND was cleared, retesting should generally not be done due to persistent shedding (viral detection has been identified in some cases well beyond 4 weeks (>70 days) in some cases).

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, July 29, 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).

Testing for COVID-19 involves sending a respiratory tract specimen – nasopharyngeal swab (NPS) or viral throat swab; NPS is preferred– to a PHO laboratory or other suitable laboratory with capacity for 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 infection, that tests for the presence of viral RNA during active infection (Health Canada, September 22, 2020).

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

The turnaround time for COVID-19 testing at a PHO Laboratory is for 60% of results to be completed within 24 hours and 80% to be completed within 48, but will vary depending on what laboratory performs the testing (PHO, September 16, 2020).

As of September 10, 2020, PHO Laboratory implemented a validated pooling approach to testing, which will allow an increase in testing throughput without greatly compromising sensitivity (PHO, September 16, 2020) . For pooled testing, a portion of three individual specimens are combined into a single pool and run on the SARS-CoV-2 PCR assay as a single test.

  • If the pool result is NOT DETECTED, all three specimens are individually reported as NOT DETECTED.
  • If the pool result is DETECTED, INDETERMINATE or INVALD, each individual specimen is tested individually and reported based on individual result obtained. ­­­­

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. Spartan Bioscience has developed a fix to their COVID-19 test and are preparing for re-submissions to Health Canada, with a target of approval for mid-fall.

Serology testing is only available for clinical use under specific clinical indications listed below. Serology testing should not be used for screening and diagnosis of acute COVID-19 infection, and a positive serology test does not mean a patient is immune to COVID-19 (MOH, August 14, 2020).

Clinical indications:

  • Patients presenting with symptoms compatible with Multisystem Inflammatory Syndrome in Children (MIS-C) who do not have laboratory confirmation of COVID-19 by PCR.
  • Patients with severe illness who have tested negative for COVID-19 by PCR and where serology testing would help inform clinical management and/or public health action. Serology testing for these patients requires consultation and approval by the testing laboratory.

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. Practice caution when using PCR results—particularly early in the course of infection— as a basis for removing precautions intended to prevent onward transmission. If clinical suspicion is high, infection should not be ruled out on the basis of PCR test alone (Ann Intern Med, August 18, 2020)

  • (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
Emerging evidence: COVID-19 transmission, paediatric symptoms, and Rx research
Last reviewed: September 24, 2020
Last updated: September 25, 2020

There is primarily 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.
Asymptomatic shedding FAQs

The time between virus exposure and symptoms (incubation period) is 5-6 days on average, and may be up to 14 days (WHO, April 2, 2020). Viral shedding may occur before symptoms occur, with SARS-CoV-2 RNA detected 1-3 days before symptom onset and the highest viral loads around the day of symptom onset (WHO, July 9, 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 (September 10, 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.

Estimates vary widely:

  • A systematic review of 63 studies found that for studies with a large sample size (>1000 patients), 1.2-12.9% of patients with COVID-19 were asymptomatic, while studies with a small sample size indicated up to 87.9% of infected individuals could be asymptomatic (Int J Infect Dis, June 29, 2020).
  • 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 (ACFP, April 14, 2020).
  • The CDC (September 10, 2020) estimated that 40% of infections are asymptomatic.
  • A retrospective evaluation found that 36% of patients who tested positive for COVID-19 while under isolation in a Korean community treatment center were asymptomatic; 19.1% of the asymptomatic patients subsequently developed symptoms while in isolation within a median of 15 days (JAMA Intern Med, August 6, 2020).

Contact tracing reports suggest that asymptomatic individuals are much less likely to transmit the virus (WHO, June 5, 2020).

In an analysis of close contacts, symptomatic cases were more likely to transmit COVID-19, with a risk ratio (RR) of infectivity of 3.9 for symptomatic vs. asymptomatic patients (Int J Infect Dis, April 18, 2020).

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

A retrospective cross-sectional study of 90 SARS-CoV-2 positive samples found that samples were only infective in the first 8 days after symptom onset, suggesting infectivity may be highest in the first 8 days after symptom onset and low afterwards (Clin Infect Dis, May 22, 2020).

However, patients with mild to moderate COVID-19 may shed replication-competent virus for up to 10 days following symptom onset, and a small fraction of people with severe COVID-19, including immunocompromised patients, may shed replication-competent virus for up to 20 days (CDC, August 4, 2020).

For current guidance on when to consider a patient recovering from COVID-19 non-infectious, see Managing COVID-19: Outpatient management and resolution.

While we do not yet understand the immune response to SARS-CoV-2 infection, including duration of immunity, patients infected with other betacoronaviruses such as MERS-CoV are unlikely to be reinfected shortly (e.g., 3 months or more) after they recover (CDC, August 4, 2020). Available evidence supports that reinfection is unlikely in the short term and the duration of likely immunity is unclear (Alberta Health Services, May 12, 2020). A 4-month study of 1797 Icelandic COVID patients found that antibody levels reached a peak at 2 months after diagnosis and did not decline within 4 months after diagnosis (NEJM, Sept 1 2020).

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). However, re-infection has been reported; a 33 year old man who recovered from COVID-19 in April tested positive again 4 months later with a strain of SARS-CoV-2 that was genetically distinct from the one causing the initial infection (Clin Inf Dis, Aug 25, 2020).

A study comparing immune response of COVID-19 patients found that asymptomatic patients have a weaker antibody response with a shorter duration compared to patients with severe symptoms. After 8 weeks, 40% of asymptomatic patients were seronegative versus 12.9% of those who had severe symptoms (Nat Med, June 18, 2020).

A retrospective analysis of a COVID-19 outbreak on a fishing vessel with an attack rate of 85.2% (104/122 individuals on board) found that the presence of neutralizing antibodies from prior infection was significantly associated with protection against re-infection (J Clin Microbiol, August 21, 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).

Airborne transmission

In early July, 239 scientists and researchers endorsed a letter urging WHO to strengthen the language on airborne transmission in their guidance on COVID-19, pointing to evidence from airborne transmission of other viral respiratory infections (e.g. SARS, MERS, influenza) as well as a limited number of studies on COVID-19. On July 9, the WHO published a scientific brief summarizing current evidence on COVID-19 transmission (Clin Infect Dis, July 6, 2020;WHO, July 9, 2020).

Key takeaways for primary care
  • The July 6 letter’s recommendations do not represent a change for healthcare settings. Providing sufficient ventilation and avoiding overcrowding are already part of operational requirements for primary care, and ventilation infection control measures are required by the Canadian Standards Association for HVAC systems in health care.
  • In healthcare settings caring for symptomatic COVID patients but not performing aerosol-generating medical procedures, there was no transmission to healthcare workers when they followed droplet and contact precautions (including medical masks as part of PPE).

Detailed points

From WHO (July 9, 2020)

  • Experimental models show that normal breathing and talking can produce aerosols. The amount varies and may be increased with louder speech volumes. It is not known whether there is enough infectious virus in these aerosols to cause COVID infection. Studies with high-powered jet nebulizers found SARS-CoV RNA in air samples for up to 3-16 hours, but these do not reflect normal human cough conditions and it is not known if there is sufficient virus to be infectious.
  • Outside of healthcare settings, outbreaks related to crowded and poorly ventilated settings such as choir practices, restaurants, and fitness classes suggest the possibility of aerosol transmission. Detailed investigations show that this transmission could also have been explained by droplets or fomites, so the role of aerosol transmission requires further research.

From July 6 letter (Clin Infect Dis)
The authors of the letter argue there is enough supporting evidence to take reasonable precautions:

  • Provide sufficient and effective ventilation (supply clean outdoor air, minimize recirculating air)
  • Supplement general ventilation with airborne infection controls
  • Avoid overcrowding

From July 13 editorial (JAMA Network)

  • People likely produce both droplets and aerosols, transmission may take place along a spectrum, and even medical masks provide some protection against aerosols. It is impossible to conclude that aerosol-based transmission never occurs. However, the balance of evidence suggests that long-range aerosols are not a dominant mode of SARS-CoV2 transmission.
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 multi-system inflammatory syndrome increase, 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.

For more clinical guidance on the investigation and management of this condition, consult the Canadian Paediatric Society’s Paediatric Inflammatory Multisystem Syndrome Temporally Associated with COVID-19 (July 6, 2020). Please refer to the World Health Organization (WHO) Case Definition or the Canadian Paediatric Surveillance Program (CPSP) Case Definition for the diagnostic criteria (MOH, September 21, 2020).

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 screening laboratory tests for hyperinflammation as outlined in the Canadian Paediatric Society’s guidance.  Laboratory features suggestive of MIS-C:
    • C-reactive protein (CRP) ≥50 mg/L and at least one of the following:
    • ferritin >500 mcg/L
    • platelets <150 x109/L
    • lymphopenia <1000/mcL
    • hypoalbuminemia
    • neutrophilia
  • When laboratory evidence of significant hyperinflammation is present, consider additional work-up as available for an evolving picture of CSS (ferritin, LDH, fibrinogen, D-dimers, PTT, INR, triglycerides), and for myocarditis (troponin, NT-proBNP, and ECG).

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 (WHO, May 15, 2020):

  • 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).
Current evidence
  • A systematic review of 39 observational studies in 662 patients found that 90% of children with MIS-C had cardiac involvement, 71% were admitted to ICU, 60% presented with shock, and 1.7% died. Half of patients with MIS-C had an underlying medical condition. Children generally developed MIS-C 3-4 weeks after COVID infection, and 4 studies reported that some children developed MIS-C after an asymptomatic COVID infection (Lancet, September 4, 2020).
  • In a systematic review of 16 reports describing 505 children with MIS-C, clinical findings included fever (100%), gastrointestinal symptoms (88.0%), rash (59.2%), conjunctivitis (50.0%), chelitis/ “strawberry tongue” (55.7%) or extremity edema/erythema (47.5%). Median serum CRP, ferritin, fibrinogen and D dimer concentrations were above the normal range. Myocardial dysfunction requiring ionotropic support (57.4%) plus extracorporeal membrane oxygenation (5.3%), respiratory distress requiring mechanical ventilation (26.1%), and acute kidney injury (11.9%) were the major complications; anticoagulation was used commonly (54.4%) but thrombotic events occurred rarely (3.5%) (Pediatric Infect Dis Soc, September 14, 2020).
  • A systematic review (J Pediatr, Aug 4, 2020) of 8 studies representing 440 cases of MIS-C found a high prevalence of gastrointestinal (87%), dermatologic/mucocutaneous (73%), and cardiovascular (71%) symptoms. The percentage testing positive for COVID-19 ranged from 13-69% for PCR and 75-100% for serology.
  • In a systematic review, 35 documented papers related to MIS-C cases identified 783 individual cases of MIS-C between March-June 2020; with 55% being male (n = 435) and a median age of 8.6 years. Patients with MIS-C were noted to have a high frequency of gastrointestinal symptoms (71%) including abdominal pain (34%) and diarrhea (27%). Cough and respiratory distress were reported in 4.5% and 9.6% cases respectively (Paediatr Respir Rev, August 11, 2020).
Prolonged symptoms of COVID-19
Current evidence

Research on the long-term effects of COVID-19 is still in the early stages. A research letter (JAMA, July 9, 2020) reports that in 143 patients from Italy, 87.4% had at least one symptom that persisted after COVID-19 infection was considered resolved (based on the WHO criteria for discontinuation of quarantine: no fever for 3 consecutive days, improvement in other symptoms, and 2 negative test results).

The most common persistent symptoms, assessed a mean of 60 days after COVID-19 onset, were fatigue (53.1%), dyspnea (43.4%), joint pain, (27.3%) and chest pain (21.7%); and 44.1% of patients reported worsened quality of life. In a study of 109 patients who reported a loss of smell and/or taste due to COVID (Dan Med J, Aug 4, 2020), only 44% had fully recovered their sense of smell and only 50% had fully recovered their sense of taste 30 days later.

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.

Current evidence
  • 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).

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).

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

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 cautions in children

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 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.

COVID-19 Therapy research
Medications
  • Aside from remdesivir and dexamethasone, there are currently no other medications recommended in the prophylaxis or treatment of COVID-19 (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.
Current evidence

Why has this been in the news?

During the 2009 influenza pandemic, co-infection with bacteria led to the recommendation of empirical antibiotic therapy for patients with suspected influenza pneumonia (Infect Control Hosp Epidemiol, July 30, 2020). This knowledge served as a foundation for initial WHO recommendations to use empirical antibiotics in cases of COVID-19 pneumonia. However, subsequent concerns about inappropriate use of antibiotics has led the WHO to discourage empirical antibiotics in low to moderate suspected or confirmed COVID-19 (WHO, May 27, 2020).

How does this apply to my practice?

Do not prescribe antibiotics to suspected or confirmed COVID-19 patients with low suspicion of a bacterial infection (WHO, May 27, 2020). If co-infection with a bacterial pathogen is suspected, antibiotics should be initiated based on institutional antibiograms and sensitivities (BC Centre for Disease Control, September 11, 2020).

The routine use of antibiotics is not supported in the management of confirmed COVID-19 infection as only a low proportion of patients have been found to have a bacterial co-infection (J Infect, May 27, 2020). This includes azithromycin because there is insufficient evidence that it will prevent COVID-19 (CEBM, April 14, 2020). As with any viral pneumonia, COVID-19 itself is not an indication for antibiotics. Widespread use of antibiotics should be discouraged, as their use may lead to higher bacterial resistance rates.

Why has this been in the news?

Some researchers have suggested that antiviral drugs researched for SARS and MERS, such as hydroxychloroquine, could be applied in the context of COVID-19 treatment (J Med Virol, February 27, 2020). However, current research has indicated that hydroxychloroquine is not effective in reducing deaths or moderate disease in COVID-19 patients (WHO, July 31, 2020). Research has also shown that these medications may also cause harm, and a recent meta-analysis found that evidence is weak and conflicting (Ann Intern Med, August 18, 2020). 

How does this apply to my practice?

  • The only antiviral drug approved for treatment of COVID-19 in Canada is remdesivir, which has been approved for treatment of adults and adolescents with severe symptoms of COVID-19 and pneumonia who require additional oxygen (Health Canada, July 28, 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).
  • Other antiviral drugs, such as hydroxychloroquine or chloroquine, are currently not recommended for treatment of COVID-19 or prophylaxis due to insufficient quality evidence to support their use and the risk of adverse effects for patients (BC Centre for Disease Control, September 11, 2020).

Supporting evidence

Remdesivir

  • Remdesivir is authorized for use in adults and adolescents (aged 12 years and older with a body weight of at least 40 kg). Gilead Sciences Canada, Inc. did not seek authorization for an indication for use of remdesivir to treat children or pregnant women.
  • In the ACTT-1 trial, remdesivir shortened time to recovery but failed to show a mortality benefit (hazard ratio for death was 0.70, 95% CI 0.47 to 1.04) (NEJM, May 22, 2020). In another study, there was a 31% faster time to recovery (median time to recovery was 11 days with remdesivir and 15 days with placebo, p<0.001) and a numerically shorter duration of mechanical ventilation (7 days vs. 15.5 days; not statistically significant) (NIH, April 29, 2020; NEJM, April 10, 2020). Adverse events leading to medication discontinuation were 12% with remdesivir vs. 5% in placebo; number needed to harm = 15 (Lancet, April 29, 2020).
  • In an open-label randomized trial comparing remdesivir to standard care in 596 patients with moderate COVID-19 pneumonia, patients randomized to 10 days of remdesivir treatment did not have a statistically significant difference in change of clinical status (based on a 7-point scale ranging from death to discharge) 11 days after treatment initiation, while patients randomized to 5 days of remdesivir did show a statistically significant difference, but this difference was of uncertain clinical importance (JAMA, August 21, 2020).

Chloroquine and hydroxychloroquine

  • The BC Centre for Disease Control states that hydroxychloroquine or chloroquine are not recommended for treatment or prophylaxis of COVID-19 (September 11, 2020).
  • A multicenter randomized open-label trial in 504 patients with mild to moderate COVID-19 found no improvement in clinical status with hydroxychloroquine, with or without azithromycin, compared to standard care. Patients taking hydroxychloroquine were more likely to have QT prolongation and elevated liver enzyme levels (N Engl J Med, July 23, 2020).

For more information on adverse effects see Treatment of patients with nonsevere and severe coronavirus disease 2019: an evidence-based guideline (CMAJ, April 29, 2020).

Other antivirals

Favipiravir: The BC Centre for Disease Control does not recommend favipiravir due to lack of data (September 11, 2020). Initial low-quality evidence suggests favipiravir may have a higher incidence of recovery and viral clearance compared with umifenovir and lopinavir-ritonavir (respectively) (CMAJ, April 29, 2020).

Lopinavir-ritonavir and umifenovir: Limited low-quality evidence suggests that umifenovir and lopinavir-ritonavir may reduce cough, fever and progression to severe disease in patients with mild to moderate COVID-19, and that Lopinavir-ritonavir may increase diarrhea, nausea and vomiting. (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, September 11, 2020).

Ribavirin: The BC Centre for Disease Control does not recommend ribavirin outside of approved randomized controlled trials (September 11, 2020). Ribavirin may increase anemia and bradycardia but the evidence is low-quality (CMAJ, April 29, 2020).

Why has this been in the news?

A systematic review 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 (Stem Cells Transl Med, 2020). Currently there are only preliminary studies that have illustrated the safety and efficacy of MSCs and exosomes in mitigating symptoms associated with COVID-19, and studies have shown that they can be used on compassionate basis, owing to their ability to repair and decrease the inflammatory reactions involved in the morbidity and mortality of COVID-19.

How does this apply to my practice?

More preclinical and clinical studies are required to understand the mechanism of action and establish the safety and efficacy of cell-based therapy before it can be used in practice (Hum Cell, August 11, 2020).

Why has this been in the news?

Colchicine has been examined by researchers for its properties as an anti-inflammatory drug and for its potential impact on cardiac biomarkers (JAMA, June 24, 2020). Researchers have suggested that it may be an inexpensive oral treatment as an anti-inflammatory and to treat myocardial injury caused by COVID-19 (Eur Heart J Cardiovasc Pharmacother, April 27, 2020).

How does this apply to my practice?

Colchicine is not recommended for treatment or prophylaxis outside of a randomized controlled trial. Some clinical trials are ongoing to investigate the use of Colchicine as a treatment for COVID-19 because of its anti-inflammatory properties (BC Centre for Disease Control, September 11, 2020).

Why has this been in the news?

On March 25, 2020 the U.S. Food and Drug Administration (FDA) approved the use of convalescent plasma as treatment for COVID-19 as an emergency investigational new drug (eIND) (CADTH, August 26, 2020). On August 23, 2020, the FDA issued an emergency use authorization (EUA) for COVID-19 convalescent plasma for the treatment of hospitalized patients with COVID-19 (FDA, September 2, 2020).

How does this apply to my practice?

Convalescent plasma is currently not recommended for treatment of COVID-19 outside of a randomized controlled trial, because there is insufficient evidence that it will inhibit COVID-19 (BC Centre for Disease Control, September 11, 2020; CMAJ, April 29, 2020; CMAJ, July 6, 2020).

In Canada, convalescent plasma therapy for COVID-19 is currently available only as an investigational drug treatment for participants in the CONCOR-1 clinical trial (CADTH, July 23, 2020).

Supporting evidence

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). A systematic review of 7 studies in 5,444 patients found that the use of convalescent plasma reduced mortality (OR 0.44, 95% CI 0.25 to 0.77), increases viral clearance (OR 11.29, 95% CI 4.9 to 25.9) and leads to clinical improvement (OR 2.06, 95% CI 0.8 to 4.9). However, studies included were of very low or low quality (J Med Virol, Aug 10, 2020).

Why has this been in the news?

Corticosteroids have received worldwide attention as a potentially effective treatment for COVID-19 (WHO, September 2, 2020). This recent attention can be attributed to a preliminary report featuring the results of the Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial that was published on June 22, 2020 (it has since been followed by a peer-reviewed manuscript published one month later in the New England Journal of Medicine). The publication reported the effects of dexamethasone on the outcomes of hospitalized patients with COVID-19. The dexamethasone arm of RECOVERY represents the largest trial to-date to not only produce a statistically and clinically significant result, but one that also impacts survival, all by using a well-known, inexpensive treatment. The methodology and results of the dexamethasone arm of RECOVERY have quickly become a topic of debate and critique (BC Centre for Disease Control, September 11, 2020).

How does this apply to my practice?

The BC Centre for Disease Control (September 11, 2020) strongly recommends dexamethasone 6 mg IV/PO q24h for up to 10 days for patients requiring mechanical ventilation and also recommends it for hospitalized patients requiring supplemental oxygen (RECOVERY trial). If dexamethasone is not available, methylprednisolone 30 mg IV q24h or prednisone 40 mg PO q24h are the preferred alternatives. If dexamethasone supplies are limited, they should be reserved for critically ill patients.

Supporting evidence

  • Preliminary results from 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.
  • In a prospective meta-analysis of clinical trials (7 randomized trials that included 1703 patients of whom 647 died) of critically ill patients with COVID-19, the study found that the administration of systemic corticosteroids, compared with usual care or placebo, was associated with lower 28-day all-cause mortality. There was no suggestion of an increased risk of serious adverse events (JAMA, September 2, 2020).
  • Outside of patients requiring mechanical ventilation or supplemental oxygen, steroids may also 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, September 11, 2020).

Why has this been in the news?

Multiple recent clinical studies have evaluated different biological agents (“biologics”) that target specific cytokines. Currently, there is promising data developing around the inhibition of cytokine production by biologics, but these therapeutics come with multiple drawbacks for their use in treating COVID-19. Small molecule therapeutics (such as furosemide) are gaining attention as being a potentially “repurpose-able” known drug that is safe, available in reasonable quantities worldwide, easily synthesized at low cost, and easy to handle and store (Am J Med Sci, July 6, 2020). Since inhaled furosemide has broad-spectrum anti-inflammatory properties, targeting IL-6, IL-8 and TNF-α , it has been proposed as a possible therapeutic agent for COVID-19. (Am J Med Sci, July 6, 2020)

How does this apply to my practice?

As clinical trials have not yet begun, it is currently not recommended to use inhaled furosemide in practice.

Why has this been in the news?

Researchers have questioned whether repurposing already approved drugs offers any effective treatments of COVID-19. One class of drugs that may improve the body’s immune response to illness is immune modulators (Lancet, May 20, 2020). Coronaviruses may induce the production of cytokines that are present in many auto-inflammatory disorders. Some researchers have suggested that immune modulators might help to neutralize the hyperinflammatory state that is caused by COVID-19 and can be a cause of respiratory distress among patients (Lancet Rheumatology, May 29, 2020)

How does this apply to my practice?

Immune modulators are not recommended as treatment or prophylaxis for COVID-19 outside of a clinical trial, due to insufficient evidence to support their use.

Supporting evidence 

Anakinra: Anakinra is currently not  recommended for treatment or prophylaxis for COVID-19 as there is insufficient data  (NIH, May 12, 2020). Clinical trials are ongoing.

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.

Intravenous immunoglobulin (IVIG): The BC Centre for Disease Control states that intravenous immunoglobulin G is not recommended for treatment or prophylaxis outside of a randomized controlled trial (September 11, 2020).

Monoclonal antibodies: There is currently no evidence to support the use of these medications. Clinical trials are underway.

Sarilumab: Not recommended for treatment or prophylaxis outside of a randomized controlled trial (BC Centre for Disease Control, September 11, 2020).

Tocilizumab: In a retrospective observational cohort study, tocilizumab reduced the risk of a composite endpoint of invasive mechanical ventilation or death in adults with severe COVID-19 pneumonia (adjusted hazard ratio 0.61, 95% CI 0.40-0.92; Lancet, June 24, 2020). Another observational study of compassionate use of tocilizumab in patients with COVID-19 pneumonia found that tocilizumab reduced inflammation (measured by C-reactive protein), oxygen requirements, vasopressor support, and mortality. Adverse events and serious adverse events were minimal, but two deaths (7.4%) occurred that were felt unrelated to tocilizumab (Clin Inf Dis, June 23, 2020).

A systematic review found that, based on low-quality evidence, there is no conclusive evidence that tocilizumab would provide any additional benefit to patients with severe COVID-19 (Int J Antimicrob Agents, July 23, 2020).

Why has this been in the news?

Ivermectin is primarily used for the internal and external treatment of parasites (FDA, May 1, 2020; HealthLinkBC, 2018). Despite diverse effects of this medication, many of its underlying mechanisms are not yet known (J Antibiot, September, 2020). A recent in vitro study showed that ivermectin was active against COVID-19-infected cell lines (Antiviral Res, June, 2020).

How does this apply to my practice?

Ivermectin is currently not recommended as a COVID-19 treatment option due to limited information and lack of data. Detailed assessment will be provided when credible scientific literature becomes available (BC Centre for Disease Control, September 11, 2020). Clinical trials are ongoing.

Why has this been in the news?

Researchers have proposed that the MMR vaccine could have a possible role in reducing COVID-19 complications related to lung inflammation and sepsis, which is strongly associated with COVID-related mortality (mBIO, Jun 19 2020). This is due to evidence that live attenuated vaccines can produce nonspecific protection against infections unrelated to the vaccine’s target pathogen by inducing a “trained” nonspecific innate immune response.

How does this apply to my practice?

There is insufficient evidence to support MMR vaccination as treatment or prophylaxis outside of clinical trials. Clinical trials are underway.

Why has this been in the news?

Recent retrospective studies have shown the potential benefit of statin use amidst patients with COVID-19. One retrospective study suggests that those on statins may have immunomodulatory benefits that have been linked to lower risk of death in patients with COVID-19. The study found that the 28-day all-cause mortality rate was 5.2% for COVID-19 patients receiving statins, compared with 9.4% for matched patients not receiving statins. This equates to a 42% relative reduction in the risk of death (adjusted hazard ratio 0.58, 95% confidence interval, 0.43–0.80) (Cell Metab, August 4, 2020). Another retrospective study has identified that statin use during the 30 days prior to admission for COVID-19 was associated with a lower risk of developing severe COVID-19, and a faster time to recovery among patients without severe disease (Am J Cardiol, September 15, 2020). However, in a recent meta-analysis (total of 9 studies with a total of 3449 patients) it showed that statin use did not improve severity outcome nor mortality rate from in-hospital outcomes of patients with COVID-19 infection (Diabetes Metab Syndr, August 26, 2020).

How does this apply to my practice?

Current retrospective studies do not provide enough evidence to suggest using statins to lower mortality in COVID-19. There needs to be more high-quality evidence on statin use for COVID-19 before applying to practice. The aforementioned studies do offer some reassurance that patients already taking a statin for cardiovascular risk can continue, as this is unlikely to increase harms during COVID-19 infection, and may have some benefits.

Why has this been in the news?

Some researchers have hypothesized that supplements may be beneficial in preventing COVID-19 due to their potential to influence immune response (CCMJ, June 10, 2020). A systematic review of herbal medicine for COVID-19 examined 7 randomized controlled trials in a total of 855 patients (J Clin Med, May 23, 2020). 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).

How does this apply to my practice?

Supplements are currently not recommended as treatment or prophylaxis for COVID-19 outside of randomized controlled trials (BC Centre for Disease Control, Septembe 11, 2020). Clinical trials are ongoing.

COVID-19 Vaccine research

Researchers around the world are working to develop and test vaccine candidates. Worldwide, there are 38 vaccine candidates in human trials (WHO, September 17, 2020); for a lay language version see CBC, September 21, 2020, with the most advanced in Phase 3. Health Canada is working to fast-track applications for vaccine development and there are currently at least 7 candidates in development in Canada. Human trials have begun in Quebec City for one vaccine candidate. The Canadian Center for Vaccinology at Dalhousie University in Halifax is expecting to begin human trials of another vaccine candidate in late summer or early fall.

A Phase 2 trial (Lancet, July 20, 2020) of a COVID vaccine candidate in 503 healthy volunteers from China showed that it induced a significant immune response 28 days after injection. Severe adverse reactions occurred in 9% of the low dose group and 1% of the high dose group (fever was the most common reaction). The vaccine was better tolerated but less effective in older adults, and the authors suggest future research to assess the need for a second dose in this population. A COVID vaccine has been approved in Russia, but its safety and efficacy have not yet been examined in Phase 3 trials (Nature, Aug 11, 2020). Trials of an inhaled COVID-19 vaccine are also beginning (Imperial College London, Sept 14, 2020). A Phase 3 trial of a vaccine developed by Johnson & Johnson is also beginning; for more information see the Phase 3 trial protocol.

Managing COVID-19: Outpatient management and resolution
Last reviewed: September 25, 2020
Last updated: September 25, 2020
Who can be managed at home?

Patients can be managed at home if they (BCCDC, April 14, 2020):

  • 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 2, 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

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).

Putting it into practice
Symptom management
Common symptoms (MOH, May 14, 2020)

Fever (≥37.8 °C)

Potential management strategies (NICE, April 30, 2020)

New or worsening cough

Potential management strategies (NICE, April 3, 2020)

Shortness of breath (dyspnea)

Potential management strategies (NICE, April 30, 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

Responding to questions about unproven therapies for COVID-19: “Though research is underway, there are currently no medications recommended for preventing or treating COVID-19 because there is not enough evidence to make any conclusions yet” (CMAJ, April 29, 2020).

See Emerging evidence: COVID-19 transmission, paediatric symptoms, and Rx research > COVID-19 Research therapies for information.

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 (CDC, September 11, 2020; CPS, April 20, 2020):

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

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, August 14, 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, 2020NICE, April 23, 2020NICE, April 9, 2020CEBM, March 30, 2020).
  • Do not delay life-saving treatment or emergency care (CDC, August 14, 2020).
  • Apply more stringent requirements to criteria for discontinuation of self-isolation for immunocompromised patient with resolved COVID-19 (CDC, August 16, 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, September 23, 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, August 17, 2020).

Adverse pregnancy outcomes

  • Based on data from over 750 published cases:
    • Most babies of mothers with COVID-19 are born healthy and at term (SOGC, May 21, 2020).
    • Preterm birth (generally late preterm) is the most common adverse outcome (6-15%) (SOGC, May 21, 2020; Medicina de Familia, June 23, 2020).
    • A systematic review of 790 pregnancies found that adverse pregnancy outcomes were associated with infection acquired at early gestational ages, more symptomatic presentation, myalgia at presentation, and use of oxygen support therapy (EJOG, July 21, 2020).
    • Complication rates are proportional to the degree of maternal illness (SOGC, May 21, 2020).
    • Compared with non-pregnant patients, pregnant patients with COVID-19 had significantly lower incidence of fever (51% vs. 91%, p < 0.00001) and cough (31% vs. 67%, p < 0.0001) (BMC Infect Dis, August 3, 2020)
    • Pregnancy complications such as diabetes, preeclampsia, advanced maternal age, obesity and postpartum hemorrhage increase the risk of maternal sepsis and severe COVID-19 (SOGC, May 21, 2020).
    • COVID-19 may mimic signs and symptoms of preeclampsia, but does not elevate preeclampsia-associated enzymes (BJOG, June 1, 2020).
    • A survey of 1987 pregnant women in Canada found a high prevalence of clinically relevant symptoms of depression (37%) and anxiety (57%), associated with concerns about COVID-19, disruption to prenatal care and delivery, isolation, and relationship strain (Journal of Affective Disorders, July 28, 2020).
    • Pregnant women with COVID infections were more likely to have a Caesarian delivery compared to pregnant women without COVID infection (aRR: 1.31, 95%CI: 1.04, 1.65, p = 0.024; J Travel Med, Sept. 5, 2020).

Prenatal care, referral to hospital, and delivery

Mother-to-child transmission and infant testing

Breastfeeding

  • It is not known whether COVID-19 can be spread through breast milk, but the limited amount of evidence available suggests this is unlikely (CDC, June 25, 2020).
  • Breastfeeding COVID-19 positive mothers should:
    • Wash hands while holding the baby, bottles, breast pump or other materials
    • Be masked while holding or feeding the baby
    • Cough or sneeze away from the baby when holding or feeding
    • Follow breast and skin cleansing hygiene before holding or feeding
    • Clean breast pumps and bottles and do not share these supplies with other mothers (MOH, May 19, 2020).
  • If a mother is too sick to breastfeed, she can pump milk (CPS, May 6, 2020).
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, June 25, 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, June 25, 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, June 25, 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, June 25, 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: September 22, 2020
Last updated: September 22, 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:

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, August 28, 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.”

For more help managing difficult patient conversations in the context of COVID-19, see:

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

  • LTCHs should instruct all staff to self-monitor (PHO, July 31, 2020) for COVID-19 at home.
  • Screening must occur twice daily (at the beginning and end of the day or shift) to identify symptoms (MOH, September 21, 2020), including temperature checks and atypical symptoms. This excludes emergency first responders who should, in emergency situations, be permitted entry without screening.
  • LTCHs should screen new admissions and re-admissions for symptoms and potential exposure to COVID-19.
  • For residents that leave the home for a short-stay absence (no overnight stay), the home must provide a mask. The resident must wear a mask while out, if tolerated, and be screened upon their return, but does not need to be self-isolated.All procedures and protocols including active screening must be taken as outlined in Directive #3 (MOH, September 9, 2020) and Resuming Visits in Long-Term Care Homes (MOLTC, September 2, 2020).
  • For a LTCH specific screening tool, see COVID-19 Screening Tool for Long-Term Care Homes and Retirement Homes (MOH, May 6, 2020).

In the event of a positive screen:

 

See the Summary of Required Precautions in COVID-19 Guidance: Long-Term Care (MOH, April 15, 2020) for more information.

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

  • In the event an outbreak of COVID-19 is declared in the home, all staff in the entire home AND all residents in the home should be tested including on symptomatic and 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.
Keep in mind
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. 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.

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, August 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, August 28 , 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.

For guidance and policies on resuming visits in LTCHs, see the Resuming Visits in Long-Term Care Homes (MOLTC, September 2, 2020).

Short-stay absences and temporary absences in LTCHs

As per Directive #3 for Long-Term Care Homes under the LongTerm Care Homes Act, 2007 (MOH, September 9, 2020), residents may leave the home’s property for a short stay absence for health care related, social, or other reasons. A short stay absence does not include an overnight stay, with the exception of single-night emergency room visits. Upon return to the home, residents must be actively screened (see Screening section above) but are not required to be tested or self-isolate.

Residents must be provided with a medical mask to be worn at all times when outside of the home (if tolerated) and reminded about the importance of public health measures including physical distancing.

  1. Outpatient medical visits are considered a short stay absence and residents do not require testing or self-isolation upon their return.
  2. Emergency room visits that take place over a single night (e.g., assessment and discharge from the emergency department spans one overnight period) should also be considered equivalent to an outpatient medical visit that does not require testing or self-isolation upon return. If the resident is admitted to the hospital at any point, or the emergency room visit takes place over two or more nights, homes should follow the steps outlined above under Readmissions.

As per Directive #3 for Long-Term Care Homes under the LongTerm Care Homes Act, 2007 (MOH, September 9, 2020), residents may leave the home’s property for a temporary absence (one or more nights) for personal reasons. Upon return to the home the resident will be required to self-isolate for 14 days. For residents who are being discharged from a hospital, please refer to the Readmissions section above.

Homes must review and approve all temporary absences based on a case by case risk assessment considering, but not limited to, the following:

  1. The home’s ability to support self-isolation for 14 days upon the resident’s return
  2. Local disease transmission and activity
  3. The risk associated with the planned activities that will be undertaken by the resident while out of the home
  4. The resident’s ability to comply with local and provincial polices/ bylaws.
  5. Any further direction provided by the MLTC. If the home denies a temporary absence request, the home must communicate this to the resident/substitute decision maker in writing, including the rationale for this decision.

*The requirements in this Directive (MOH, September 9, 2020) related to short-stay absences and temporary absences are not meant to apply to retirement homes. The requirements related to resident absences for retirement homes should continue to be guided by applicable Retirement Home Regulatory Authority and Ministry for Seniors and Accessibility requirements and policies, as amended from time to time.

Family physicians/primary care nurse practitioners providing care in LTCHs

The information below provides clinical guidance and logistical support to redeployed or volunteer primary care providers to 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
  • 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: September 21, 2020
Last updated: September 8, 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
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
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Top resources
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