COVID-19 Updated Guidance for Clinicians
March 19, 2020
Summary: Please review this health alert for:
- Situation update
- Future projections and care standards planning
- Testing guidelines update
- Personal protective equipment (PPE)
- Long term care facilities
- Kidney centers
- Elective surgery
- Dental services
Situation Update
- Through March 18, 2020, COVID-19 cases in Snohomish County now total 362, with seven deaths (1.9%). Cases have occurred throughout the county (see Figure 1).
- Among the 212 reported cases for whom investigation had been completed, 28% are hospitalized, 3% remain isolated in long term care settings, 21% are isolated at home, and 45% have recovered.
- Age of decedents: 43, 43, 58, 76, 81, 84. All but the 76 year-old had underlying medical conditions predisposing to severe disease (e.g., diabetes; lung, heart, or kidney disease).
- Statewide, 1,177 cases and 66 deaths (5.6%) have been reported from 18 counties (King 597, Pierce 53), with a similar age distribution as that presented above.
- Note that age distribution of reported cases is biased upward due to both severity and care-seeking being higher in older populations.
- The statewide death rate is elevated by a King County long-term care outbreak that has resulted in 129 cases and 23 deaths. Absent that outbreak, the statewide death rate among reported cases is 4.1%. Recall that reported cases represent only a small minority of total cases. The true mortality rate among all infected individuals is probably closer to 1% or less.
Figure 1. Heat Map, Coronavirus Intensity, Snohomish County
Future Projections and Care Standards Planning
Modeling studies of the current regional outbreak suggest that several thousand infections have occurred already and that without intervention incidence will continue to double every 5-7 days, with an estimated cumulative 25,000 total infections occurring by April 7. Although lower in absolute magnitude, the escalation in cumulative cases from 60 to 328 since March 11 parallels and tentatively validates these estimates (see Figure 2).
Furthermore, hospital discharge data analyzed by the Washington State Department of Health show a steep rise in COVID-like illness ED visits and hospitalizations over the past two weeks in all age groups >18 years (see Figure 3). Given that hospitalization for COVID-19 tends to occur around day 7 of illness, all this information combined suggests a substantial surge in demand for ambulatory, emergency and acute inpatient care services in the coming weeks. In addition, needs for transitional post-hospital care and returns to long-term care will increase.
The social distancing measures recently augmented by the Governor and the Health District are primarily an attempt to blunt the slope of the increase and stretch out the course of the outbreak in order to mitigate impacts on the already stressed healthcare system. If not already underway, health care facilities should be reviewing their plans for adapting standards of care for contingency and crisis situations. Now is also a good time to discuss goals of care with elderly and chronically ill patients.
Figure 3. Weekly Percentage of Total Hospitalizations due to COVID-19 Like Illness
Source: Washington State Department of Health
Testing Guidelines Update
Testing capacity is limited by bottlenecks in collection (i.e., patient evaluation capacity) and laboratory analysis (e.g., swab and viral transport availability, throughput capacity). Self-limited mild illnesses and asymptomatic infections that do not lead to health care seeking also limit the number of documented (i.e., diagnosed and counted) cases. Federal, state, and local partners are working together to increase specimen collection and analytic capacity in Snohomish County, but even this likely still will be insufficient to diagnose a majority of cases that will occur due to COVID-19. Our current system simply lacks the capacity to evaluate all these patients and pursuing such would displace limited capacity that should be preserved for vulnerable adults and the severely ill.
For an update on indications for testing and laboratory logistics, please visit: https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/Interim-2019NovelCoronavirusQuicksheetProviders.pdf
For guidance on specimen collection itself and relevant PPE conservation in that context, please visit: https://covid-19.uwmedicine.org/Pages/default.aspx (download “1a-Sample Collection for COVID19 Testing Nasopharyngeal”).
PPE
- Shortages in personal protective equipment (PPE) are being reported throughout the county and statewide, particularly surgical facemasks. Distributions to-date from the strategic national stockpile have addressed only a minority of the demand. Conservation of PPE is an essential component of system-wide care planning going forward.
- Current methods for conserving and extending the life of PPE include the following:
- Facemasks: extended and re-use unless soiled
- Gowns: limit use to when droplets are likely to be generated or direct contact with the patient or bed cannot be avoided.
- For more information on PPE conservation, visit:
Long Term Care Facilities (LTCF)
- LTCF residents with COVID-19 do not need to remain hospitalized until transmission-based precautions (TBP—standard/contact/droplet) are discontinued.
- Prompt and smooth discharge from acute inpatient care facilities to long term care is essential for maintaining bed space and mitigating the impacts of a COVID-19 surge on the healthcare system.
- LTCF residents with COVID-19 should remain on TBP until at least 14 days after illness onset or 72 hours after resolution of fever, without use of antipyretic medication, and improvement in symptoms, whichever is longer.
- For interim COVID-19 guidance for long term care facilities, see: https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/LTCFresidentDiscontinueTBPandDischarge.pdf
Kidney Centers
Hemodialysis patients with viral respiratory tract infections or COVID-19 do not need to be admitted to the hospital solely for the purpose of dialysis unless their overall clinical condition otherwise would merit admission. See interim COVID-19 guidelines for hemodialysis centers at: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/dialysis.html
Elective Surgery
Surgery for which delay would not be harmful to the patient should be deferred or re-scheduled until such a time as the procedure will not compromise PPE, staffing or bed space.
Dental Services
The Washington State Department of Health and the American Dental Association are recommending that dental care providers postpone all elective and non-essential dental procedures to minimize potential for healthcare transmission of COVID-19, and to mitigate limitations on availability of PPE for healthcare personnel caring for those with COVID-19. Dentists should prioritize seeing only patients with dental emergencies defined as care related to the relief of pain and management of infection. For more information, visit:
Additional Resources
Snohomish Health District COVID-19
https://www.snohd.org/ncov2019
Washington State Department of Health
https://www.doh.wa.gov/Emergencies/Coronavirus
UW COVID-19 Resource Site
https://covid-19.uwmedicine.org/Pages/default.aspx
Centers for Disease Control and Prevention
https://www.cdc.gov/coronavirus/2019-ncov/index.html