Recent guidance offered on preparing to treat COVID-19

Several recent articles offered guidance on preparing for the spread of the novel coronavirus disease (COVID-19) in the U.S., and ACP has released a new practice management resource.

On March 11, the FDA put out a letter on surgical mask and gown conservation. The letter offers differing strategies based on whether the supply of masks and gowns is adequate, limited, running low, or totally depleted. On March 13, the World Health Organization issued interim guidance on clinical management of severe acute respiratory infection when COVID-19 is suspected. It describes best practices for infection prevention and control, triage, and optimized supportive care.

Advice on preparing hospitals for COVID-19 was offered by an Ideas and Opinions article published by Annals of Internal Medicine on March 11. It urged hospitals to develop strategies for patient volume and complexity and allocation of health care resources. Patients with COVID-19 should be geographically cohorted as much as possible. High volume may require innovative strategies, “such as converting single rooms to double occupancy; expediting discharges; slowing admission rates; and converting spaces like catheterization laboratories, lobbies, postoperative care units, or waiting rooms into patient care venues,” the paper said. A protocol should guide triage to admission, observation, early discharge, and quarantine.

“Hospitals should anticipate that normal staffing ratios and some standards of care are unlikely to be maintained,” the paper said, adding that “clinical guidelines for use (or denial) of scarce services, such as mechanical ventilation and critical care, should be outlined, in consultation with ethics and medical staff.” The paper also called for development of plans to protect and support health care workers and robust, transparent, and open communication policies.

A clinical update published by JAMA on March 11 offered an overview of the existing data on critical care for patients with COVID-19. It provided some factors associated with need for critical care, including older age (median age of approximately 60 years) and comorbid conditions (most commonly diabetes and cardiac disease). The few pregnant women who have had the disease so far have had a mild course, “but limited cases make predictions about disease course uncertain,” the article said. It offered guidance on differentiating COVID-19 from other diseases, clinical management and outcomes, and avoidance of transmission.

Another article published by Annals of Internal Medicine on March 11 focused on protecting hospitals from the effects of COVID-19 by bolstering their approach to routine respiratory viruses and placing more restrictions on patients, visitors, or health care workers with symptoms of these viruses.

A study published by The Lancet on March 9 described the clinical course and risk factors of adult inpatients with COVID-19 who by Jan. 31 had been discharged from or had died in two hospitals in China. Of the 191 patients, 48% patients had a comorbidity. Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio [OR], 1.10 per year increase; 95% CI, 1.03 to 1.17; P=0.0043), higher Sequential Organ Failure Assessment score (OR, 5.65; 95% CI, 2.61 to 12.23; P<0.0001), and D-dimer greater than 1 μg/mL (OR, 18.42; 95% CI, 2.64 to 128.55; P=0.0033) on admission. The results “could help clinicians to identify patients with poor prognosis at an early stage,” the study authors said. They also found that the median duration of viral shedding was 20 days, with the longest observed duration of 37 days. “The prolonged viral shedding provides the rationale for testing novel coronavirus antiviral interventions in efforts to improve outcomes,” they said.

ACP continued to press the U.S. government to do more to address COVID-19 and on March 11 issued recommendations with 11 different steps that could be taken to expand coverage of and access to testing and treatment, remove barriers to care, and keep our nation's frontline physicians and other health care professionals safe.

ACP has also developed a new practice management resource on telehealth care in response to COVID-19. The use of online digital or telehealth services whenever possible is encouraged in order to mitigate exposure of patients, health care workers, and the community to the virus, and practices should consider establishing related protocols and procedures. “COVID-19 Management Tips for Practices: Telehealth, Coding, and Messaging for Patients” includes online digital and telehealth billing codes to help practices make adjustments due to COVID-19.

ACP is collaborating with the Infectious Diseases Society of America and the CDC to obtain the most accurate and up-to-date information and has gathered COVID-19 resources for internists, including educational activities, on a regularly updated webpage. Last week, ACP also made the necessary and responsible decision to cancel Internal Medicine Meeting 2020, originally scheduled to take place in Los Angeles from April 23 to 25. More details about the cancellation are online.