Guidance for Inpatient Care During COVID-19

As an increasing proportion of the population becomes infected with the novel coronavirus (COVID-19) and more patients with severe illnesses are hospitalized, it is important for hospitals to remain abreast on how to best care for people with suspected or confirmed disease. To help, researchers from the Mayo Clinic developed a guide for the inpatient care of patients with COVID-19. The full guide is published in the American Journal of Medicine.¹

Hospital planning strategies

To plan for COVID-19 in the hospital system, the guide recommends forming a dedicated unit for patients with suspected or confirmed COVID-19 to help centralize patient care and streamline workload among clinicians and hospital staff. On an individual provider level, healthcare workers should be re-educated on universal precautions, isolation precautions, and the appropriate use of personal protective equipment (PPE). Healthcare workers should also be mindful that unnecessary contact should be avoided and, if possible, the guide recommends the use of telemedicine resources such as video for patient consultations.

Hospitals should prepare for all possible contingencies, notes the guide. Medical staff may get sick themselves and should be educated on the signs of illness in order to appropriately triage for severe acute respiratory coronavirus 2 (SARS-CoV-2) testing. Hospitals should implement contingency planning for instances when staff must take sick leave either for themselves or for family members.

Suspecting COVID-19

All hospital clinicians should be informed of the most common symptoms of COVID-19: fever, dry cough, fatigue, or myalgias. Additional symptoms to monitor include dyspnea, headache, diarrhea, and sore throat. Sneezing is uncommon, notes the guide, and usually indicative on a non-COVID-19 condition. The most common presenting syndrome for COVID-19 is an upper or lower respiratory tract infection, including acute respiratory distress syndrome. However, patients with SARS-CoV-2 may also have gastrointestinal tract symptoms like diarrhea, and viral shedding has been detected in the stool of patients.

The recommendations for SARS-CoV-2 testing have been rapidly changing as the disease spreads, notes the guide. Currently, the Centers for Disease Control and Prevention (CDC) recommend testing hospital patients who have the signs and symptoms of COVID-19.² The guide encourages clinicians to test patients even if they have no known prior exposure to an individual with COVID-19..

Treating patients with suspected COVID-19

Clinicians treating patients with suspected or confirmed COVID-19 should wear a gown, gloves, mask, and eye shield. Airborne precautions are recommended when aerosol-generating procedures (AGPs) are performed. The highest risk category of AGPs currently include:

• Sputum induction
• Bronchoscopy
• Endotracheal intubation and extubation
• Open tracheal and nasotracheal suctioning
• Nasogastric tube placement
• Upper GI endoscopy
• Transesophageal echocardiography
• Upper airway ENT procedures
• Non-invasive ventilation with positive-airway pressure devices and high-flow nasal cannula.

SARS-CoV-2 can be detected from a swab of the nose or mouth, or preferably both, via a polymerase chain reaction-based assay. Due to the shortage of vital testing supplies, the guide recommends the use of nasopharyngeal swabs alone given the comparable characteristics to combined testing. When the SARS-CoV-2 test is pending, clinicians should keep in mind differential diagnoses, including influenza. When medication administration and other necessary cares are required, the guide recommends that they be timed together to minimize potential exposure and conserve PPE.

Caring for patients with COVID-19

Approximately 25% of patients with COVID-19 will be admitted to the intensive care unit (ICU), and the median time from symptom onset to ICU admission is estimated to be 9.5 days.^3,4 Factors associated with severe disease include older age, dyspnea, and presence of comorbidities such as hypertension, diabetes, and coronary artery disease.

Abnormal laboratory findings such as leukopenia, lymphopenia, thrombocytopenia, and elevations in C-reactive protein, D-dimer, lactate dehydrogenase, aspartate aminotransferase,  and alanine aminotransferase are also implicated in severe disease. In addition, abnormal chest radiographs or computed tomography findings such as consolidation, crazy-paving pattern, bronchial wall thickening, lymphadenopathy, and pleural effusion are also associated with severe disease, noted the guide.

If a patient is suitable for care on a general medical floor, proper isolation is required. Supportive care is currently the cornerstone of therapy for COVID-19 patients as they require proper monitoring for signs of renal or cardiac dysfunction, and secondary bacterial infection in patient with lower respiratory involvement. For the use of other medications, the guide note that:

• Corticosteroids be considered in select situations such as refractory shock or severe acute respiratory distress syndrome
• Angiotensin-converting enzyme (ACE) inhibitors should be continued in patients who already take these medications but they should not be initiated in new patients
• Nonsteroidal anti-inflammatory drugs have not been sufficiently studied in COVID-19; however, these medications have been associated with worse outcomes in primary pneumonia.

Current therapies under investigation for use in COVID-19 include chloroquine, hydroxychloroquine, azithromycin, remdesivir, combination lopinavir-ritonavir, convalescent plasma, tocilizumab, and sarilumab. The US Food and Drug Administration recently issued a warning letter regarding the use of chloroquine and hydroxychloroquine. To follow are the highlights for health care professionals⁵:

• FDA recommends initial evaluation and monitoring when using hydroxychloroquine or chloroquine under Emergency Use Authorization or in clinical trials to treat or prevent COVID-19.  Monitoring may include baseline electrocardiogram, electrolytes, renal function and hepatic tests. 
• Be aware that hydroxychloroquine or chloroquine can:
  • cause QT prolongation
  • increase the risk of QT prolongation in patients with renal insufficiency or failure
  • increase insulin levels and insulin action causing increased risk of severe hypoglycemia
  • cause hemolysis in patients with Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency
  • interact with other medicines that cause QT prolongation even after discontinuing the medicines due to their long half-lives of approximately 30-60 days

Hospital discharge

Patients should be instructed to quarantine at home, minimize close social interactions, and wear a mask following hospital discharge, notes the guide. For in-home patients, quarantine should be maintained until 3 days have passed since resolution of fever and improvement of respiratory symptoms, and 7 days have passed since symptoms began. A point of contact for in-home patients should be available to ensure in-home patients have meet these criteria before discontinuing isolation. These contacts should also be tested for SARS-CoV-2 even if they remain asymptomatic.

References

1. Yetmar ZA, Issa M, Munawar S, et al. Inpatient care of patients with COVID-19: a guide for hospitalists [published online April 24, 2020]. Am J Med. doi:10.1016/j.amjmed.2020.03.041.
2. Centers for Disease Control and Prevention. Testing for COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/testing.html. Accessed April 28, 2020.
3. Wu Z, McGoogan JM. Characteristics of and important lessons from the CoronavirusDisease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;2019:17-20.
4. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARSCoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. doi.org/10.1016/S2213-2600(20)30079-5.
5. Food and Drug Administration. Hydroxychloroquine or chloroquine for COVID-19: Drug Safety Communication – FDA cautions against use outside of the hospital setting or a clinical trial due to risk of heart rhythm problems. April 24, 2020. Accessed April 28, 2020.

This article originally appeared on Clinical Advisor