Guidance to UConn Health Providers in Caring for Patients with COVID-19 Returning to Ambulatory Settings
As the COVID-19 outbreak evolves this document provides updated guidance to health care providers in order to protect our patients, health care personnel, and community at large. It is essential that our health care teams continue to provide quality care, at the appropriate level for all patients, in order to preserve a functioning health care system. Robust public health measures will be required to reduce transmission of COVID-19, protect health care personnel and ensure patient safety.
Published data suggests that SARS-2-CoV viral shedding, and thus the period of suspected contagiousness, is highest during periods of acute illness and then subsequently declines over time1. Although patients may continue to remain PCR positive for weeks after initial diagnosis, more recently published data suggests that most patients with COVID-19 shed live virus for 1-2 weeks following the onset of symptoms2,3.
Patients Diagnosed with COVID-19 Returning to the Community from Home Isolation
Patients with newly diagnosed COVID-19 in the outpatient setting or those individuals recently admitted and discharged home should be provided with detailed isolation recommendations. See detailed guidance from the CDC. Patients with confirmed COVID-19 should be advised to continue home isolation until they are no longer contagious.
Using the symptom-based strategy home isolation may be discontinued under the following conditions:
- Patient has been afebrile for at least 72 hours (without the use of fever reducing medications) AND
- other respiratory symptoms have improved AND
- at least 10 days have passed since symptoms first appeared
Patients with COVID-19 Presenting for Care in UConn Health Ambulatory Care Settings
For patients recently diagnosed with COVID-19 either in the inpatient or outpatient setting, recommendations regarding scheduling/coordinating their future health care visits at UConn Health are detailed below:
At this time, it is recommended to delay non-urgent health care visits for 21 days from date of diagnosis of COVID-19. In particular, this guidance should pertain to following:
- Non-urgent ambulatory care visits, including outpatient Radiology
- Non-urgent admissions
- Non-urgent surgical and procedural cases
- Routine dental and eye care visits
If a patient has recently been diagnosed with COVID-19 and requires urgent outpatient evaluation within 21 days of their diagnosis, the health care provider should contact Infection Control for guidance on the anticipated encounter, including determining the optimal environment of care and the appropriate personal protective equipment needed for the encounter. Individuals who are highly immunocompromised (medical treatment with immunosuppressive drugs, bone marrow or solid organ transplant recipients, inherited immunodeficiency, poorly controlled HIV) may warrant special infection control measures in recovery after COVID-19. Please call Infection Control for additional guidance for these patients.
Patients with COVID-19 and residual symptoms after 21 days of diagnosis may be able to return to ambulatory care settings, though this should be discussed with the provider scheduled to see the patient prior to their return and handled on a case-by-case basis.
Personal Protective Equipment in Ambulatory Care Settings
- All patients, visitors, clinicians and staff will wear face masks at all times when in any health care facility. This will consist of a hospital-issued procedure or surgical mask. A cloth mask covering the nose and mouth is acceptable for patients and visitors. Patients with open tracheostomies should be given a mask to cover the tracheostomy in addition to the mask to cover their nose and mouth.
- Eye protection consisting of a face shield or protective goggles will be worn by all providers in direct patient care within 6 feet of patients. This is recommended to be worn at all times when within 6 feet of others, including staff.
- When performing an aerosol-generating procedure, the required PPE will consist of eye protection, a gown, an N95 respirator and gloves. These procedures will be performed in a negative pressure environment, when available. See Appendix for examples of aerosol-generating procedures.
Environmental Cleaning in Ambulatory Settings
Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for SARS-CoV-2 in health care settings, including those patient-care areas in which aerosol generating procedures are performed.
- The primary disinfectant used in ambulatory care settings are the PDI Super Sani-Cloth (Purple Top) wipes
- This product consists of Quaternary ammonium and isopropyl alcohol and meets EPA standards for use against SARS-CoV-2
- The overall wet time is 2 minutes
Management of laundry and medical waste should also be performed in accordance with routine procedures.
Additional Infection Prevention Measures
Social distancing (> 6 feet between patients and providers) is recommended, when feasible, during patient encounters in exam rooms as well as when interacting with colleagues in patient care and non-patient care areas.
Perform hand hygiene frequently. Wash your hands often with soap and water for at least 20 seconds or use an alcohol-based hand sanitizer that contains 60 to 95% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. Soap and water should be used preferentially if hands are visibly dirty.
The administration of nebulizer treatments in ambulatory settings should be generally avoided. If necessary, the PPE required for administration of nebulizers will consist of eye protection, a gown, an N95 respirator and gloves. These procedures will be performed in a negative pressure environment, when available. Please contact Infection Control to provide guidance on the need for room closure and additional management.
Patients who are undergoing aerosol generating procedures may warrant additional measures, including enhanced PPE and environmental measures and pre-procedural SARS-CoV-2 RNA PCR testing. A partial list of Aerosol Generating Procedures is included in Appendix A. Please contact Infection Control to provide guidance on the need for management of situations in which aerosol-generating procedures are performed.
Testing is available for UConn Health patients who have symptoms consistent with COVID-19 and can be ordered through Epic.
SARS-CoV-2 RNA PCR
The appropriate test for patients with suspected active COVID-19 is a polymerase chain reaction (PCR) test. The current recommended sampling method is through a nasopharyngeal swab. Sample collection is available and performed through the UConn Health collection site, though is dependent on appointment availability.
Testing for UConn Health patients is through Quest diagnostics. The test order is SARS-CoV-2 RNA PCR (Quest).
Testing through JAX Laboratory (SARS-CoV-2 RNA PCR (JAX)) is limited to employee and pre-procedural testing at this time. This test should be ordered by Employee Health or the COVID-19 Call Center providers or designated staff in procedural-based areas. There is additional SARS-CoV-2 RNA PCR testing through other platforms such as Cepheid and Quidel which are for inpatient and employee testing and should not be used for testing patients in ambulatory settings.
At this time SARS-CoV-2 RNA PCR testing is not recommended for patients without symptoms. Planning for testing asymptomatic UConn Health employees is underway and will be done through a centralized process.
SARS-CoV-2 Antibody Testing
SARS-CoV-2 antibody testing is available through Quest Laboratories and will be available through the UConn Health laboratory in the near future. The CDC has issued guidance on SARS-CoV-2 antibody testing4.
Serologic testing should not be used to determine immune status in individuals until the presence, durability, and duration of immunity is established. The results of this test should not be used for guiding decisions regarding work-related and non-work-related activities.
Serologic testing can be offered as a method to support diagnosis of acute COVID-19 illness for persons who present late. For persons who present >14 days after illness onset, serologic testing can be offered in addition to recommended direct detection methods such as PCR. This will maximize sensitivity as the sensitivity of nucleic acid detection is decreasing and serologic testing is increasing during this time period.
Serologic testing should be offered as a method to help establish a diagnosis when patients present with late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children.5
1Xiao AT et al. Profile of RT-PCR for SARS-CoV-2: a preliminary study from 56 COVID-19 patients, Clin Infect Dis. 2020
2Wölfel R et al. Virological assessment of hospitalized patients with COVID-2019, Nature. 2020;581(7809):465‐469.
3Bullard J et al. Predicting infectious SARS-CoV-2 from diagnostic samples, Clin Infect Dis. 2020.
Appendix - Examples of Aerosol Generating Procedures*
Upper and lower endoscopy
Selected laryngoscopy procedures
Electrophysiology procedures requiring general anesthesia
Fluoroscopically guided enteric tube placements
Interventional radiology procedures requiring anesthesia or in patients with a tracheostomy
Dental procedures with aerosol generation
Interventional pulmonary procedures (thoracoscopy, thoracentesis, ablation, etc.)
Non-invasive positive pressure ventilation
High flow oxygen administration
CT guided lung biopsy (interventional radiology)
Nasal endoscopy and laryngoscopy (therapeutic)
Oral cavity/throat biopsy
Tracheotomy tube change
Laser ablation procedures (mouth, nose, face, eyes)
* There may be additional Aerosol Generating Procedures that are performed that are not included on this list. If there are any concerns about an ambulatory procedure that may involve aerosol generation please call Infection Control to discuss whether additional measures that are warranted.