COVID-19 Triage

Happy Friday & welcome back to our weekly UC lessons. 

As UC providers, we must know when a patient is a candidate for stay & treat versus which patients are lights & sirens out of our department. Seeing COVID19 patients is no different
 
Lots of you are either new to practicing (yay new grads)/new to UC and/or just like me...the management of COVID19 patients is not something we got formal training on. Plenty of you have reached out and asked, how do I know who I can treat versus who I should send out?
 
Luckily for us, HippoEd had an UC rap podcast all about it. This lesson will summarize their April 2020 COVID19 Triage episode. Tbh, it is a guideline that I rely on heavily everyday. I have added my own information regarding testing as much has changed in terms of availability of testing.

As always, these are small snippets from HippoEd's Urgent Care Rap podcast. If I have provided enough value/you want to buy, use my link for $25 off. I get a small amount of money if you use my link & helps me continue to do what I love--urgent care medical education & sharing with you all. Link: here
 
What's the episode about?
The episode reviews the Risk stratification Guide for Severity Assessment and Triage of suspected/confirmed COVID19 adults in UC, which is was published by two important associations in our specialty: the College of UC Medicine & American College of Emergency Physicians.
 
COVID-19:
First and foremost, the clinical presentation for COVID19 varies. Everyone working in ER/UC knows, we've all had that patient that we were surprised when the lab confirms COVID19. The spectrum of illness associated with COVID-19 is wide, ranging from asymptomatic infection to life-threatening respiratory failure. Symptoms that may be seen in patients with COVID-19

• Cough
• Fever
• Myalgias
• Headache
• Dyspnea (new or worsening over baseline)
• Sore throat
• Diarrhea
• Nausea/vomiting
• Anosmia or other smell abnormalities
• Ageusia or other taste abnormalities
• Rhinorrhea and/or nasal congestion
• Chills/rigors
• Fatigue
• Confusion
• Chest pain or pressure

Should the patient stay or go?

Category 1: consider discharge and home monitoring
Symptomatic patient, PLUS, 

• Clinically well appearing AND 
• Resting O2 Sat >94% on room air and no desaturation with ambulation (have them walk around the pod or walk in place) AND
• No tachypnea, RR <20. 

 
 
Category II: Consider transfer to ED 

Symptomatic patient, PLUS, 

• Patient appears toxic and in distress OR
• Resting O2 sat < 93% on room air, or desaturation on ambulation OR 
• Patients requiring bronchodilator treatment
  • (FYI: most UC do not have the appropriate negative isolation pressure rooms to perform these)

OR….

Any two (or even one criterion based on clinical presentation): 

• Age >60 
• Existing conditions such as Diabetes Mellitus, HTN, CHF, CAD, COPD (or any chronic or severe lung disease), CKD, Cancer, Immunosuppression 
• Change in mentation 
• Respiratory Rate >20/min 
• Pulse >120 bpm 
• Systolic BP<90mmHg, Diastolic BP<60mmHg 

Swabs Galore:
Lots of UC centers now have the capability to perform rapid antigen or PCR tests (results in 15-20 min) or send out COVID19 swabs (results within 1-3 days)—use these tests appropriately. If a patient is unstable, waiting around 20 min for a laboratory confirmation of COVID19  (despite your high clinical suspicion) is not the best option. If you notice, these guidelines do not rely on labs or chest x-ray and instead rely heavily on demographics and clinical appearance. Use your clinical judgement and as always, treat the patient not labs! 

A patient meets the criteria, now what?
remember: these are simply guidelines and your clinical impression is always the most important—do not feel bound by these, even if a patient meets these criteria! I've had plenty of people who check off some of these boxes from a demographic standpoint (age >60 & DM) but appear clinically well, who I've felt comfortable sending home with strict ER precautions. As with any clinical decision tool, these are a guideline and not a strict rule. Your clinical gestalt is everything! 

If you are sending to ER, be sure to notify your ER that patient is suspected or known COVID. Document how patient will transferred: EMS/911 or stable enough to self transfer.

That's all. Let me know if you're liking these lessons below or if there is a topic you'd like me to cover! See you all next week :)