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Clinical Care of the COVID-19 Patient

by James W. Grigg, MD, Ross MacDonald, MD, and Rachael Bedard, MD.

A significant amount of national attention has focused on the risks of coronavirus in correctional settings. Coverage in the media, public health guidelines, and academic writing have emphasized mitigation strategies to prevent the virus’s spread, such as testing procedures, isolation strategies, quarantine protocols, and decarceration efforts.

The “how-to’s,” however, have been given less attention thus far – specifically, how to safely and effectively provide clinical monitoring and medical care for people who develop COVID-19 while in jail or prison.

Monitor
Actively monitor confirmed or suspected COVID-19 patients for worsening symptoms during the course of their illness. In some individuals, symptoms that start off mild can worsen over the first week, and shortness of breath, low oxygen saturation, weakness, or confusion may develop. Screen patients at least daily for worsening symptoms and monitor vital signs, including oxygen saturation level and heart rate.

The oxygen level is especially important as COVID-19 has been known to present with “silent hypoxia,” wherein patients have low oxygen levels but do not feel or look as sick as would be normally expected, so hypoxia is not suspected. Hypoxia is considered a key measure for severe disease. Given the various challenges inherent in working with incarcerated patients – language barriers, serious mental illness or cognitive impairment, lack of trust, logistical hurdles, and more – a pulse ox of ≤ 94% is a reasonable level at which to consider escalation of care.

Symptom surveys and observation should also always be considered. Ask patients specifically about worsening shortness of breath and confusion, and look for symptoms or signs of other potential complications such as stroke, heart attack, or pulmonary embolism.

Those patients with risk factors for severe disease, including advanced age and relevant chronic conditions, require even closer monitoring.

Incarcerated individuals should be considered at risk for serious disease at an earlier age than the general population due to premature aging and higher rates of mortality from COVID-19 in this population. People of color, significantly overrepresented in jails and prisons, are also generally at higher risk for hospitalization and death due to the disease.

The CDC lists specific chronic conditions that are known to increase risk for severe disease: diabetes, heart disease, kidney disease, severe obesity, lung disease, cancer, and other weakened immune system problems. Those higher-risk patients may need to be monitored in a setting with an increased level of skilled nursing and receive monitoring more frequently than daily, as well as chest X-rays early in the course of illness. They should also be given greater consideration for therapies beyond supportive care, depending on current treatment guidelines.

Manage
Currently, no medications are proven to improve outcomes in COVID-19 patients who are not hospitalized. As with many other viral illnesses, supportive care is the goal in COVID-19 treatment in correctional settings. That includes hydration and symptom management for cough, body aches, fever, and other symptoms.

Generally, acetaminophen may be preferred for fevers and body aches. NSAIDs may be used for COVID-19 symptoms, however, especially if acetaminophen fails. When using those medications, remember they may mask fevers when applying protocols that include fever resolution to help decide when to end a patient’s quarantine.

When caring for patients suspected to have COVID-19, remember that diseases that may be treated with other medications, such as influenza, bacterial pneumonia, and strep pharyngitis, should still be considered. For asthma and COPD patients, nebulizers should generally be replaced with inhalers due to the potential for nebulizers to spread the coronavirus. Similarly, BiPAP and CPAP machines may also spread the virus. A case-by-case review of their use and possible temporary suspension should be considered or used with protocols in place for infection control.

Transfer
To ensure adequate capacity for a potential surge of patients, have a predetermined partner hospital ready to accommodate transfers from your facility if necessary. Given the course of this disease, patients should typically be identifiable before becoming critically ill and should be transferred to the hospital early if showing signs of instability or worsening.

If your partner hospital is a small community hospital that may not be equipped to care for an influx of incarcerated patients, work together to create a plan of action in the event of an outbreak at your facility or in the community.

Develop protocols that take into account the many considerations and challenges of caring for people with COVID-19 in a correctional setting. Protocols should include guidance on monitoring symptoms and vital signs for the development of severe disease, when to escalate the level of care, and which high-risk populations will receive closer monitoring and additional care. Evolving community guidelines should be incorporated and adapted to the incarcerated setting and population as they are updated.

Protocols for minimizing coronavirus transmission in correctional settings remains a very high priority; monitoring and clinical care are also essential to ensuring that patients receive appropriate treatment and decrease their risk of developing critical illness.

The authors are affiliated with New York City Health + Hospitals Division of Correctional Health Services. James W. Grigg, MD, is director of clinical education and a clinical assistant professor in the department of medicine at NYU Grossman School of Medicine; Ross MacDonald, MD, is chief medical officer and senior assistant vice president; Rachael Bedard, MD, is director of geriatrics and complex care services and an assistant professor at the Icahn School of Medicine at Mount Sinai.

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