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COVID-19 Updated Guidance for CliniciansMarch 19, 2020
Summary: Please review this health alert for:
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”).
Long Term Care Facilities (LTCF)
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
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.
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:
Snohomish Health District COVID-19 https://www.snohd.org/ncov2019
Washington State Department of Healthhttps://www.doh.wa.gov/Emergencies/Coronavirus
UW COVID-19 Resource Sitehttps://covid-19.uwmedicine.org/Pages/default.aspx
Centers for Disease Control and Preventionhttps://www.cdc.gov/coronavirus/2019-ncov/index.html