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ARCHIVE - COVID-19 Clinical Assessment Centre (CAC)

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Introduction

As a response to the Omicron surge in December 2021 and the availability of COVID-19 therapeutics in early 2022, Ontario Health worked with many COVID-19 assessment centres (ACs) to expand their scope to include clinical services to support people with known or suspected COVID-19 infection. These expanded sites – COVID-19 clinical assessment centres (CACs) – were intended to augment the existing assessment centre system, and were modeled on the COVID-19, cough and flu clinics and other influenza-like illness clinics established in the fall of 2021.  

Presently, as Ontario moves through the fall of 2022, we are experiencing a significant increase in COVID-19 and other respiratory illnesses including influenza and respiratory syncytial virus (RSV). Consequently, emergency department visits and hospitalizations for these respiratory illnesses, hereafter referred to as influenza like illnesses (ILIs) are on the rise, particularly in children.  

Prioritizing the community-based care of patients with ILIs, will be crucial to mitigate the strain on emergency departments and prevent hospitalizations. In response October 2022 OH gave direction to the CACs to include the assessment of ILIs in their clinical services, to care for pediatric patients and to expand after hours coverage. In addition, there was a recommendation for CACs to partner with primary care practices and teams in the expansion of the CAC locations and hours. 

Role of Community Assessment Centres in the care of Ontarians with COVID-19 and ILI 

The clinical assessment centres (CACs) are intended to provide timely clinical services to support Ontarians with known or suspected infection with COVID-19 and/or influenza like illness (ILI) while conserving needed capacity in Ontario’s emergency departments and hospitals. The CACs are an additional point of access for Ontarians in the community to receive care of COVID and ILI given the burden of illness and the backlogs of care and health and human resource capacity issues in existing primary and community care sectors.   

This updated guidance outlines the target patient population, a set of planning recommendations to support equity in access, and the common elements of CACs that care for COVID-19 and other ILIs. Each CAC should incorporate strategies to support equity in access for populations with the greatest need, as well as the four key elements in their processes (as outlined below). A list of resources to support disposition planning is provided in Appendix A. 

Target patient population 

The CACs are intended for patients (including pediatric) with known or suspected COVID-19 and/or other ILIs, particularly those who have moderate or worsening symptoms, or those with mild symptoms who are at higher risk of severe disease and require access to COVID-19 PCR testing or therapeutics that are not otherwise available through their primary care clinician. The CAC is not intended to replace the health care provided through existing avenues in primary and community care including the patient’s primary care clinician, walk-in clinics and Health Connect Ontario.  

Patients can either self-refer or be referred by a health care professional (i.e. primary care clinician, pharmacist, public health staff, Health Connect Ontario nurse) who has determined that a clinical assessment at the CAC is required. Patients who require COVID-19 PCR testing or therapeutics which cannot be provided in a timely manner via their primary care clinician should be directed to these CACs. 

The CACs are not intended for patients with mild COVIDDI-19 and/or ILI symptoms who are self-isolating and self-monitoring at home and/or who can be monitored safely in the community with support by their primary care clinician. 

The CACs are also not intended for patients with severe COVID-19 and/or ILI symptoms, who must be directed to call 911 or go directly to the emergency department. 

Mild symptoms of COVID-19 and/or ILI* – patients are able to self-isolate and self-monitor at home. 
  • Fever and/or chills lasting < 5 days (in adults and infants > 3 months)*** 
  • Cough (not related to other causes) 
  • Mild shortness of breath 
  • Decrease or loss of taste or smell 
  • Muscle aches/joint pain 
  • Extreme tiredness  
  • Sore throat 
  • Runny or stuffy/congested nose 
  • Headache 
  • Nausea, vomiting and/or diarrhea​ 
  • Abdominal pain (not related to other causes) 
  • Pink eye (not related to other causes) 
  • Decreased appetite (young children only) 
  • ***Fevers in children:
    • Infants <1 month with a fever need to be assessed in the Emergency Department, those 1-3 months require a timely clinical assessment
    • A fever lasting 5-7 days in an otherwise well child is being observed in the current environment and is not itself a cause for concern
    • A biphasic fever, where a fever returns after being gone more than 24 hours, requires clinical assessment as it may be an idication of worsening viral condition or a new bacterial infection
Worsening symptoms or as advised by a health care professional – direct patient to CAC **​

AND/OR 

Requires access to outpatient assessment or therapeutics for patients at higher risk of severe disease, that are not otherwise available through their primary care clinician – direct patient to CAC**  

Target patient population for CACs

Severe symptoms* – direct patient to call 911 or go directly to nearest emergency department​ 

In adults: 

  • Severe difficulty breathing ​ 
  • Severe chest pain ​ 
  • Feeling confused ​ 
  • Losing consciousness

In children: 

  • Severe chest wall indrawing 
  • Grunting, nostril flaring 
  • Central cyanosis 
  • Presence of any other danger signs (e.g., inability to breastfeed or drink, lethargy, reduced level of consciousness, convulsions) 
  • Reduced urinary output, fewer than 5 wet diapers per day 
  • Concerning vitals 
  • Fever with rash  
  • Seizure  
  • Increasing parent concern 
  • Fever in an infant < 1 month 

**Where Clinical Assessment Centres are available

Planning recommendations to support equity in access to clinical assessment centres 

These recommendations are strongly encouraged as a starting point in the planning for clinical assessment centres to support equity in access for populations with the greatest need: 

  • Work with community partners (including community agencies and local ambassadors) to address barriers to access (e.g., appointment types – walk-in vs. scheduled, hours of operation, considerations for people living with disabilities) 
  • Connect patients with available wraparound supports (e.g., consider CHCs/FHTs offering “virtual team support”, access to PPE or community supports) 
  • Consider how you will monitor whether populations with the greatest need in your community are accessing CACs and modify your approach as needed 

Elements of clinical assessment centres 

Each clinical assessment centre should include these four elements in their processes. 

Element
Description
  1. Patient identification 

Criteria are as follows:  

The CACs are intended for patients with known or suspected COVID-19 or other ILIs with a focus on moderate or worsening symptoms who self-refer or are advised by a health care professional that they require an assessment for their symptoms. This is because their symptoms cannot be safely self-monitored at home, but they are also not experiencing severe symptoms that would require emergency care. The CAC is also intended for patients at higher risk of severe disease who may require access to outpatient therapies that are not otherwise available through their primary care clinician.  

Patients who meet criteria are directed to the CAC. Patients may be directed to the CAC by: 

  • Self/walk-in (walk-ins may be limited based on local context) 
  • Health Connect Ontario (formerly Telehealth) 
  • Primary care clinician or other health care professional 
  • Urgent care clinic/Walk-in clinic  
  • Emergency department 
  • Assessment centres that offer testing only 
  • Public Health/Occupational Heath  
  1. Assessment

 and appropriate  testing 

Patients are assessed by an appropriate health professional (e.g., physician, nurse practitioner, registered nurse, registered practical nurse, paramedic). The assessment may include oxygen saturation, vital signs, and identifying relevant risk factors/comorbidities. 

 Patients may be tested for COVID-19 using a molecular or antigen test, if appropriate, following the provincial testing guidance. Rapid molecular testing instruments (ID Now) for COVID only are available to the CACs through XXX.  

Eligibility for PCR testing for influenza in Ontario using the Multiplex Respiratory Virus PCR (MRVP) is very limited and includes: symptomatic children (<18 years) seen in the Emergency Department, symptomatic hospitalized patients (ward and ICU/CCU), Symptomatic health care workers/staff in institutional settings (non-outbreak), specimens from the first four symptomatic individuals (including healthcare workers/staff) in an outbreak that request respiratory virus testing. See here for PHO non-COVID respiratory testing eligibility. 

Additional onsite testing may be considered and could include rapid strep testing and/or direction for patients to obtain blood tests or chest xrays.  

CAC should use existing laboratory pathways either in the affiliated hospitals or the community.    

Appropriate follow up of testing needs to be ensured.

3. Diagnosis 

Patients are diagnosed by an appropriate health professional (e.g., physician or nurse practitioner). 

The patient’s disposition is determined by the clinical assessment and diagnosis. 

4. Disposition planning (including treatment) 

Disposition planning and treatment will require clinical expertise and judgement of the CAC health professional(s) involved in the assessment of the patient.  

Disposition Planning  

The CAC is responsible for handover of the patient and/or creation of a follow-up plan for patients at higher risk either with their primary care clinician or back to the CAC. 

Depending on the patient’s condition and risk of clinical deterioration, disposition options may include: 

  • Home with self-monitoring (Who can be managed at home?) 
  • Home with remote care monitoring, as available in your region (e.g., programs offered through home and community care, programs offered through primary care clinicians such as COVID@Home Monitoring for Primary Care) 
  • Direct to emergency department for further investigation 
  • Where possible, direct to inpatient COVID-19 unit if available (Who should be hospitalized?) 

Therapeutics:  

Depending on the patient’s diagnosis, risk for severe disease, and other clinical factors, treatment options may include: 

  • COVID-19 therapeutics including: 
  • Influenza therapeutics including oseltamivir (Tamiflu®) and zanamivir (Relenza) are indicated for outpatient treatment of influenza in select children (over 1 year of age) and adults as per Public Health Ontario guidance (2022) and the Canadian Pediatric Society guidance (2018).  Treatment should be guided by clinical judgement and commenced as soon as possible (ideally within 48 hours). Treatment is indicated for those who:  
    • Are at higher risk of complications of influenza; AND/OR   
    • Have severe, complicated, or progressive illness 
    • OR are hospitalized   
    • Higher Risk:  > 65 years, pregnant women or up to four weeks post-partum, those persons with underlying medical conditions, < 5 years (particularly those 1-2 years old), and residents in congregate settings (any age). (See Figure A-B in AMMI Canada Guidelines).  
    • In children of any age with mild illness and,ho are otherwise healthy, antiviral treatment is not routinely recommended and should not be used if symptoms have been present for > 48 hours (AMMI Canada Guidelines Figure C.1).   
    • Early treatment (ie: before symptoms) may be considered for the very highest risk household contacts of lab-confirmed influenza cases as soon as possible after exposure (AMMI Canada Guidelines Figure D.1).  
    • Occupational exposure to influenza of staff in congregate settings (LTC) would be an .  
    • Dosing based on age and weight are detailed in Table 2 and based on creatinine clearance in Table 3 of the AMMI Canada guidelines. 
  • Antibiotics may be required for the treatment of presumed bacterial infections. See the Cold Standard for the judicious use of antibiotics and the “viral prescription” to share with patients.  
  • Provide advice on antipyretic (i.e. acetaminophen and ibuprofen) treatment/formulations including local identification of compounding pharmacies 
  • Provide direction on preventive care and risk reduction strategies including: the use of masks/isolation within the household, when/where to obtain COVID-19 and/or influenza vaccination and/or how access to RSV prophylaxis program per provincial eligibility criteria.  

 

Tools and resources to support disposition planning are provided the Appendices. 

Appendices: Resources to support disposition planning for Clinical Assessment Centres  

This section is intended to link to existing clinical tools and resources that may assist in assessment, treatment, and disposition planning for patients with suspected or confirmed ILIs visiting a CAC. Assessment, treatment, and disposition planning will require clinical expertise and judgement of a patient’s condition and risk of clinical deterioration. 

  • Appendix A. When to refer to the emergency department or direct transfer to inpatient hospital setting 
    • Adults
    • Children
  • Appendix B. Home with self-monitoring or COVID-19 remote care monitoring 
    • Self-monitoring and Self-Management: Information for patients 
  • Appendix C. Testing for COVID-19, Influenza and RSV 
  • Appendix D. Outpatient treatment 
  • Appendix E. Other local supports available 
Appendix A. When to refer to the emergency department or direct transfer to inpatient hospital setting 
Adults 

The table below describes signs and symptoms in adults that may indicate that direct transfer to the emergency department or to inpatient hospital setting is required. Note that the constellations of signs and symptoms, progression of the patient’s illness over time (if history can be obtained), and additional risk factors are considered together to determine best setting to meet care needs. Use your clinical judgement. 

Signs

Symptoms

  • Heart rate > 110 bpm, respiratory rate > 24 breaths per minute, oxygen saturation (SpO2) consistently ≤ 92% on room air, and/or consistently reducing/downward trend in SpO2 over time. Note: if patient has underly lung disease with documented low normal SpO2 baseline, take this into consideration. Respiratory rate can also be affected by anxiety. 
  • Severe shortness of breath at rest (e.g., breathlessness, respiratory rate > 30 breaths per minute despite normal SpO2) 
  • Blue lips or face 
  • Hemoptysis (coughing up blood) 
  • Cold, clammy, or pale mottled skin 
  • Syncope 
  • Decreased oral intake or urine output (dehydrated and needing intravenous fluids) 
  • New-onset confusion, difficult to rouse, reduced level of consciousness 
  • Pain or pressure in chest 
  • Increasing significant fatigue (can be a marker for hypoxemia with absence of dyspnea) 
  • Severe difficulty breathing 

Additional risk factors for adults: 

  • Over 65 years of age
  • Comorbidities
  • Immunocompromised
  • High frailty
  • Lack of support at home to manage own care
  • Increasing maternal age
  • High body mass index
  • Non-white ethnicity
  • Chronic conditions
  • Pregnancy-specific conditions such as gestational diabetes and pre-eclampsia

Sources and additional information: 

Children 

The table below describes signs and symptoms in children that indicate that direct transfer to the emergency department or to inpatient hospital setting is required. Note that the constellations of signs and symptoms, progression of the patient’s illness over time (if history can be obtained), and additional risk factors are considered together to determine best setting to meet the patient’s care needs. Use your clinical judgement. 

Severe symptoms* – direct patient to call 911 or go directly to nearest emergency department​ 

In children: 

  • Severe chest wall indrawing
  • Grunting, nostril flaring
  • Central cyanosis
  • Presence of any other danger signs (e.g., inability to breastfeed or drink, lethargy, reduced level of consciousness, convulsions)
  • Reduced urinary output, fewer than 5 wet diapers per day
  • Concerning vitals
  • Fever with rash
  • Seizure
  • Increasing parent concern
  • Fever in an infant < 1 month

Sources and additional information: 

Appendix B. Home with self-monitoring or COVID-19 remote care monitoring* 

Risk stratification can help to determine if self-monitoring or COVID-19 remote care monitoring program is more appropriate. Patients over 60 years of age, those with medical comorbidities, those with social safety net flags, or patients with symptom deterioration are higher risk and will require frequent monitoring. 

Noting that formal-at home remote monitoring programs are only available for those with COVID1-9. Access to and admission criteria for these COVID-19 remote monitoring will vary regionally and between remote care monitoring programs. CACs will need to be aware of local monitoring programs, including those that are primary care team–based. 

In general patients with the following presentation can be considered for return to home with self-monitoring or a formal COVID monitoring program 

  • Have only mild to moderate uncomplicated COVID-19
  • Have an SpO2 > 93%
  • Adults with a respiratory rate of < 30 breaths per minute
  • Show no signs of respiratory distress
  • Able to stay well hydrated
  • Have access to appropriate resources and social supports to manage at home (including access to food and other necessities, a caregiver, or home care if required; ability to measure own SpO2 with pulse oximeter if required) or these can be arranged

Sources and additional information: 

Self-monitoring and Self-Management: Information for patients 

Pediatric-specific resources for parents:   

  • CHEO: Care for fever at home
  • Sick Kids: Fever
  • Fever/Pain medication: Canadian Pharmacists Association and Children’s hospitals
  • Ontario College of Family Physicians: Caring for kids with respiratory illness at home
  • Confused about covid: My child has covid what should I know?
Appendix C. Provincial testing guidance for COVID-19, Influenza and RSV 

Guidance from the Ministry of Health: 

  • COVID-19 Provincial Testing Guidance (October 2022) 

Public Health Ontario 

Appendix D. Outpatient treatment 

Treatment for COVID-19: 

Treatment for seasonal Influenza: 

Other treatments 

Appendix E. Other local supports available 
  • Ontario Health regions may share additional supports available locally, including:
    • Specialist consult supports (e.g., GIM, palliative care specialist, respirologist etc.) 
    • Additional local supports for patients (home care, food bank or food delivery services through volunteer organizations, palliative care supports, mental health supports)  
  • Through Health Connect Ontario, patients can access non-urgent health advice from registered nurses 24/7 via telephone (811) or online chat at ontario.ca/HealthConnectOntario.  
  • The Centre for Effective Practice has a list of local services, including assistance for isolated people, diagnostic centres, financial services, food, home care, home equipment, mental health services, and pharmacies, broken down further by region where applicable 

Preparing for fall and winter in primary care

Over the past two and a half years, primary care providers in Ontario have continued to provide high levels of care to patients in the challenging environment of a global pandemic. During fall and winter, primary care providers should continue to see patients who are due for care, while taking measures to prevent the spread of COVID-19.

The following is a list of considerations for preparing for fall and winter in primary care. For most practices it may not be feasible to address all these considerations, so practices will need to prioritize what is most important within the time and resources available, while allowing for staff time off and illness.

All sectors are encouraged to:  

  • Work with Chief Regional Officers and regional tables to coordinate and support local surge capacity (this includes enhanced Health Human Resource Response/Models of Care tables). 
  • Partner regionally to support timely access to care for patients. 
  • Implement strategies to maximize influenza and bivalent COVID-19 vaccine uptake among health care workers. 
  • Encourage patients to use Health Connect Ontario for non-urgent health advice. Registered nurses are available 24/7 via telephone (811) or online chat at ontario.ca/HealthConnectOntario. 

Within primary care and community support services, it is important to: 

  • Continue delivering timely immunization, early identification, and referral of patients who would benefit from COVID-19 therapies (e.g., Paxlovid). 
  • Support emergency department diversion by prioritizing care for children and adults with COVID-19, influenza, and other respiratory illnesses. 
  • Continue to focus on preventative care (e.g., cancer screening) and the provision of comprehensive primary care. 
  • Ensure community support service organizations continue to participate and collaborate on regional response and recovery efforts. (Ontario Health, November 1, 2022).

Vaccinations

  • We will continue to monitor for emerging information on vaccination in children under 5, booster eligibility and new vaccines
  • See Vaccine rollout in Ontario for information on vaccine eligibility, including 4th doses
  • See Vaccination in primary care for guidance on offering vaccinations in primary care and identifying eligible populations in your practice
  • Multiple vaccinations can be given at the same time, but you must follow Ontario’s immunization schedule.
  • For individuals 5 years of age and older, COVID-19 vaccines may be given concurrently with (i.e., same day), or at any time before or after, non-COVID-19 vaccines (including live and non-live vaccines) (Ontario Health, November 7, 2022).
  • Many local public health units are running catch-up clinics for students who may have missed school-based immunizations and patients can be directed there
  • School-based vaccines can be ordered from local public health units through standard vaccine ordering processes to administer in primary care offices

For more information on where to get your flu shot, please click here. Two enhanced products are specifically indicated for those 65 years and older (a high-dose quadrivalent and an adjuvant trivalent), noting that all products protect against influenza and patients should not delay vaccination to wait for a particular product (Ontario Health, November 3, 2022).

  • If you are vaccinating patients in your practice, provide immunization to patients and their accompanying persons when they are seen for other reasons (including COVID-19 vaccination) and during home care visits.
  • Concerted efforts should be made to vaccinate:
    • Anyone who is at high risk of severe COVID-19 related illness:
      • Older adults, especially over 65. See AVOID frailty (Canadian Frailty Network, 2020) for more information on the importance of vaccines in frail older adults.
      • Those with chronic medical conditions (lung disease, heart disease, diabetes, hypertension, etc.)
      • Those who are immunocompromised, with an underlying medical condition or taking medications that lower the immune system
      • People living with obesity (BMI of 40 or higher)
    • Anyone who is capable of transmitting influenza to those at high risk of severe and critical illness related to COVID-19, such as those with high-risk family members, or caregivers of high-risk individuals
    • Essential workers: health care workers, teachers, bus drivers, retail workers, grocery store clerks, etc.

Infection Prevention and Control (IPAC)

COVID-19 testing, assessment and treatment

Continuity of care

    • Refer to #10 for a list of patient populations to consider prioritizing
  • When running reports in your EMR to identify patients, consider the following:
    • Structured information (birthdate, sex) is typically the most easily queried.
    • You can use your EMR to search for specific health conditions, immunization history, last visit date and other information about your practice. You can generate a report to pull the data from the EMR.
    • Consider creating searches using the patient’s CPP (e.g. Problems/Diagnosis list).
    • Reports particularly useful at this time would include:
      • Specific chronic conditions
      • A combination of last date seen OR last note made OR last date billed within your chosen date range (last 6 months, last 9 months, etc)
      • Preventative Care Queries/Preventative Care Summary Reports for active patients in need of cancer screening
  • The eHealth Centre of Excellence offers free EMR coaching, and a collection of automated solutions that can help clean up, standardize and search through data in your EMR.
  • If you are unsure of how to use your EMR to support proactive panel management, there are free OntarioMD resources to help you:
    • i4C Advisory Service: Free service providing hands-on support from OMD Practice Advisors and Peer Leaders to create an enhancement plan reflecting individual practice priorities.
    • Peer Leaders: Peer Leaders work one-on-one to help providers get more value from their certified EMR.
    • EMR Progress Assessment Tool: Free, evidence-based, online self-assessment for providers to assess their EMR use and make improvements to enhance patient care. The EPA investigates key functional areas: Practice management, information management, and diagnosis/treatment support.

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