Clinical Care

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The medical team at our juvenile detention center is looking for guidance about continuing to do routine physical exams on youth admitted to our facility. Should we still perform initial health assessments within one week of admission per NCCHC standards? Or should we hold off on routine physicals until this crisis has passed?

Because these are new patients, it’s important to get an assessment of their health status. That being said, your local medical authority should determine the details of this assessment according to the level of risk for COVID-19 or other disease transmission to and among you and your patients. Always follow recommended levels of personal protective equipment (PPE) and high-quality infection control procedures, and please see Standard Y-B-01 Infection Prevention and Control Program as a reference.

 
 

What are some things to remember as we provide urgent and essential care to our patients during the pandemic?

Clinicians should screen, diagnose, and treat COVID-19 infections as they would in the local community. Local guidance and practices change frequently so check with your local health department regularly. All staff should follow universal precautions. Clinically ill patients should be treated appropriately. Staff should be ready to transport them to a hospital for more advanced treatment if the patient’s respiratory status is compromised. If relationships with community hospitals and physicians are not already established, start this right away.

 
 

What are the symptoms that should trigger a COVID-19 test and isolation?

This is a clinical decision that the treatment team should make and depends on local testing capabilities. COVID symptoms are nonspecific respiratory infection symptoms—fever, cough, sore throat, shortness of breath. Patients with no confirmed diagnosis but for whom the physician has a high index of suspicion (e.g.,contacts with confirmed cases, patient with symptoms) are candidates for medical isolation. Put a mask on the patient immediately and put them in a closed room.

 
 

If I can’t test a patient with symptoms (because we don’t have any tests), how long should they stay in isolation?

In the absence of laboratory confirmation, the decision to isolate is based on history and symptoms. More tests kits are becoming available; the turnaround for the Roche test is 3.5 hours. Isolate and then test the person. Please consult local authorities and the CDC for the latest information.

 
 

What would change in our practice if we tested vs. didn’t test?

You should be gearing up a plan to have your patients tested. If you have medical services, your staff should be prepared to test on-site. While wearing the recommended personal protective equipment, your staff should test patients who appear to have symptomatic COVID but do not need hospitalization. If there are no medical services on-site, the jail should work out a management plan with the local health department. You do not want to isolate a patient with suspected COVID for a prolonged period of time without testing them.

 
 

Should we continue with chronic care appointments? We are concerned that these appointments may add more risk to our patients.

If you have determined that there is risk of COVID-19 in your population, or you prefer to proactively reduce risk of disease spread during the pandemic, your medical authority should consider that routine, scheduled, face-to-face care on a stable, nonacute patient can be delayed for a brief period until more detailed risk is known. There are some things you can do to monitor the patient’s health status such as review his or her chart, monitor for any needed medication refills, etc. It’s not ideal, but this will reduce your exposure risk and also help you maintain a level of care.

Other things that limit direct contact can be considered on a case-by-case basis; for example, speaking to the patient to gather an interval history. You could even draw and check labs or have a focused exam for those you are worried about (vital signs, direct visualization of the patient, etc.). Another way to view this is as an effort to shift toward “telemedicine” inside your facility, physically seeing only those patients you are concerned about. Please speak with your responsible physician or medical director for guidance as these are clinical decisions to be made on a patient-by-patient basis.