Patient Assessment

Screening and TriagingCopy Link!

The screening and triaging process involves three parts:

  1. A quick symptom and exposure screen to determine which patients are at risk for COVID
  2. An acuity triage to determine how quickly and where patients need to be seen
  3. Categorization by likelihood (case definitions) to help sort patients who might have COVID by their likelihood of having it, and to help reduce transmission from likely cases to unlikely cases.

Screening QuestionsCopy Link!

Updated Date: December 20, 2020

Goal of screening: To quickly identify patients with possible COVID infections and prevent transmission of infection to other patients and healthcare workers.

Where to screen: At the point of entry. Most healthcare facilities reduce the number of available entrances and set up screening stations with trained staff at every entrance.

Whom to screen: All people entering a healthcare facility should be screened (patients, visitors, staff). Patients who are coming in for routine care should be screened prior to patient arrival if possible (typically via telephone 24 hours before the appointment) and again at the designated point of entry (whether or not the patient was already screened).

Sample Screening Questions:

  1. Do you have any of the following new symptoms?
  • Fever
  • Cough
  • Shortness of breath
  • Muscle aches
  • Sore throat
  • Runny nose
  • Loss of smell or taste
  1. Have you been tested for or had COVID-19 in the last 14 days?
  2. In the last 14 days have you spent at least 10 minutes within 6 feet of anyone with COVID-19 or symptoms of COVID?
  3. Are you, or a household member, currently on home isolation or quarantine, or have you traveled to a place that requires quarantine?

If the patient answers “No” to all of the above, continue routine check in. People who screen negative should be separated from those who screen positive

If the patient answers “Yes” to any of the above, give the patient additional PPE (a surgical mask) if screening in person and go to Acuity Triage below

Acuity TriageCopy Link!

Updated Date: December 20, 2020

Facility Acuity TriageCopy Link!

Isolation: If the patient is positive during screening, they should be treated as a possible COVID-19 case, also called a “Person Under Investigation' (PUI) and be separated from patients who screen negative.

Acuity triage: After screening positive, patients should next undergo an acuity assessment to determine how urgently they need to be seen by a medical provider. For urgent care or emergency visits, this should be done with a standardized triage system. One triage system designed for LMICs is the WHO/ICRC/MSF Interagency Triage tool (see below). Patients who are designated as higher acuity by a triage system should be seen first.. Triage should be conducted in a dedicated space with equipment to measure vital signs, and there should be clear pathways from triage to a resuscitation area for patients who are identified as critical.

Tool: WHO/ICRC/MSF Interagency Triage Tool (Pages 11-15)

Home and Virtual Acuity TriageCopy Link!

When patients screen positive over the phone prior to a visit, a provider can assess symptoms over the phone or at a home visit to determine the urgency and best location of evaluation: at home via virtual visit (telephone or video), in person (outpatient), or in an emergency unit.

Below is suggested guidance, but individualized provider assessments should always take precedent. If a provider feels that evaluation in an outpatient clinic or emergency unit is necessary,, they should ensure that the specific location recommended has appropriate IPC and PPE to safely care for PUIs as not all facilities are equipped for this purpose.

Tool: PIH Home Visit Tool
Tool: BWH Telephone and Video Visit Tips
Literature Review (Virtual Care):
Gallery View, Grid View

Lower risk for complications

High risk for complications Age ≥ 65; residence in care facility/correctional facility/dormitory/homeless; underlying conditions: chronic lung/heart/kidney/liver disease, mod-severe asthma, immunocompromised, obesity, diabetes, immunocompromise, psychiatric or substance use disorder

Mild Symptoms (No Dyspnea or Chest Pain)

Telephone/Video/Home

Outpatient Visit

Mild Chest Tightness/Pain

Outpatient Visit

Outpatient Visit or

Emergency Unit

Moderate or Severe Chest Tightness/Pain

Emergency Unit

Emergency Unit

Mild Dyspnea Dyspnea that does not interfere with daily activities (e.g. just mild dyspnea with activities such as climbing 1-2 flights of stairs or walking briskly

Outpatient Visit

Outpatient Visit or

Emergency Unit

Moderate Dyspnea Dyspnea that limits daily activities (e.g. dyspnea that limits the ability to walk up 1 flight of stairs without needing to rest or that interferes with meal preparation or light housekeeping

Outpatient Visit or

Emergency Unit

Emergency Unit

Severe Dyspnea or Home SpO2 94%* regardless of symptoms (or significant decline from baseline) Dyspnea so severe that it renders the patient unable to speak in complete sentences and interferes with basic activities such as toileting and dressing

Emergency Unit

Emergency Unit

Danger signs:

Difficulty breathing/Shortness of breath

Bluish lips or face

Gasping for air when speaking

Coughing up blood

Pain/pressure in chest (NOT associated with coughing)

Altered mental status or severe sleepiness

Inability to eat/drink or walk

Any other significant change in condition

Emergency Unit

Emergency Unit

*If patient has home pulse oximeter, here are instructions. Caution on the reliability of at home pulse oximeters: Trend may be more reliable than the value itself. Dyspnea does not always correlate with oxygen saturation (Shah et al).

Likelihood Categories (Case Definitions)Copy Link!

Updated Date: December 20, 2020

During or after the acuity assessment, a clinical staff member should verify the initial screening assessment classify patients by their risk (likelihood) of having COVID. Patients who are acutely ill or unstable should not have care delayed for this step.

Why Categorize?Copy Link!

Not all patients who screen positive on questionnaires will have COVID and it is important to try to separate patients by how likely they are to have COVID in order to avoid exposing patients who do not have COVID. Patients who have tested negative or who are not suspected to have COVID-19 should never be co-housed with COVID positive or PUI patients. Keep risk categories as separate as possible. See Levels of Isolation.

How to Categorize?Copy Link!

Someone with clinical training should categorize patients by their likelihood of having disease using standard case definitions. This process can be combined with clinical evaluation and can be done in multiple locations (telephone, near facility points of entry, dedicated/ prepared clinics, or COVID-ready acute patient care settings). It is important to note that:

  • Case categorization varies significantly in different hospitals and in different countries. Please follow your local guidance.
  • Clinician judgment is an important part of the decision. If the patient has an obvious alternative explanation for why they have a symptom, their risk could be downgraded. If a patient has significant exposure or classic symptoms, their risk could be upgraded even if they do not meet all criteria.
  • Testing: Test patients in these groups when possible, either before or during this evaluation.

Tool: WHO Case Definitions Handout

Adaptation of the WHO Guidelines for Case Definitions

Case type

Definition

Asymptomatic exposed

An individual who meets the definition of a COVID exposure (described under COVID Exposures but who does not have any symptoms of COVID-19. Treat as described under COVID exposure section.

Minimally symptomatic (sometimes called paucisymptomatic)

Patients not meeting suspected or probable case definitions with one or more new symptoms of fever, cough, shortness of breath, nasal congestion, sore throat, or myalgias. When testing is limited and symptoms mild, these patients may be considered lower priority for testing, but if at all possible they should be tested.

Suspected*Avoid negative terminology such as “COVID suspect”. instead say “person [or patient] with suspected COVID-19”

Anyone who meets both the following criteria:

Clinical Criteria: Acute onset of fever AND cough

OR Acute onset of three or more of fever, cough, generalized weakness and fatigue, headache, myalgia, sore throat, coryza, dyspnea, anorexia/nausea/vomiting diarrhea, altered mental status

Epidemiologic Criteria: Residing in an area with high risk of transmission of virus OR traveling to areas with community transmission OR working in any health care setting within 14 days prior to symptom onset

OR

Anyone with severe acute respiratory illness within the last 10 days who requires hospitalization

Probable*

Any of:

  1. A patient who meets clinical criteria above and has a contact with a probable or confirmed case (or known cluster)
  2. A suspected case with convincing chest imaging consistent with COVID-19 disease
  3. A person with newrecent anosmia (loss of smell) or ageusia (loss of taste) in the absence of any other known cause for these

Confirmed*

A case that has been confirmed with laboratory testing, regardless of signs and symptoms. The exact testing methodology may vary, please see testing. Most places use RT-PCR. Many countries include positive rapid antigen tests with a contact or strong clinical history for COVID-19

*These case definitions are based on the World Health Organization classification system

Algorithm for Case Definitions

Clinical EvaluationCopy Link!

Updated Date: December 20, 2020

HistoryCopy Link!

When assessing a patient with possible COVID-19, ask the following:

  1. Date of Symptom Onset
  1. Patients typically worsen on Day 5-10 after symptom onset and develop acute respiratory distress syndrome (ARDS) at days 7-15 (see time course). Patients with severe symptoms before Day 5, or with any progressive dyspnea, require close monitoring as they are more likely to decompensate.
  1. Ask about any known exposure to SARS-CoV-2 or sick contacts in the past 14 days.
  2. Ask about household members:
  1. Does anyone have increased exposure to SARS-CoV-2 (e.g. working in healthcare, schools, stores, transportation, etc.)?
  2. Is there anyone at home to help monitor the patient?
  1. Dyspnea (difficulty breathing)
  1. Mild: Dyspnea that does not interfere with daily activities (e.g. just mild dyspnea with activities such as climbing 1-2 flights of stairs or walking briskly)
  2. Moderate: Dyspnea that limits daily activities (e.g. dyspnea that limits the ability to walk up 1 flight of stairs without needing to rest or that interferes with meal preparation or light housekeeping)
  3. Severe: Dyspnea so severe that it renders the patient unable to speak in complete sentences and interferes with basic activities such as toileting and dressing
  1. Mental status and function
  1. Has there been a decline or change in alertness, memory, behavior and attention? If so, this should prompt in person evaluation
  2. Patients with recent falls or near falls should be evaluated in person and receive an assessment for traumatic injuries
  1. Chest pain/tightness
  1. Evaluate patients with chest pain or tightness in person. While chest pain is a feature of COVID-19 pneumonia, the high rates of cardiac and thromboembolic complications may necessitate ruling out acute coronary syndrome (ACS) or pulmonary embolism (PE).
  1. Dizziness and hypotension
  1. Assess for orthostatic symptoms, dizziness, mental status changes, or reduced urine output as signs of possible hypotension.
  1. Age and comorbidities
  1. See Patients with Comorbid Diseases below
  2. Geriatric patients: Older adults are at increased risk of adverse outcomes and are more likely to present with atypical symptoms such as altered mental status, decreased appetite, non-focal pain

ExamCopy Link!

In addition to standard physical exam, pay particular attention to:

  1. Vital signs. Patients with COVID manifest significant hypoxemia without any subjective difficulty breathing (Tobin et al). See also pulse oximetry.
  2. Pulmonary exam:
  1. Assess for tachypnea, cyanosis and use of accessory muscles. If present, these suggest a patient is having difficulty breathing and needs close monitoring even if oxygen saturation is normal. Dyspnea does not always correlate with oxygen saturation (Shah et al). Tachypnea can also suggest acidosis and shock.
  2. Assess lung exam: although lung exam is often NORMAL even in patients with COVID-19 pneumonia, always listen to the lungs to evaluate for wheezing or crackles that would indicate other possible or additional cause of illness (e.g. asthma/chronic obstructive pulmonary disease (COPD)/congestive heart failure exacerbation).
  1. Leg and calf swelling:
  1. COVID-19 induces a hypercoagulable state, so always assess for deep venous thrombosis (DVT). Ultrasound with Doppler is the standard modality for diagnosing DVT. D-Dimer is not validated as a tool for stratification of DVT probability in COVID-19, given elevated D-dimers in patients in the absence of thrombosis.
  2. Increased swelling in one leg should prompt consideration of deep venous thrombosis, while increased swelling in both legs more often reflects fluid overload or congestive heart failure

Differential DiagnosisCopy Link!

Keep a broad differential diagnosis, both in patients suspected of having COVID-19 and in patients with confirmed COVID-19, given the many diseases that can mimic features of COVID-19 and the risk of secondary infections or sequelae.

Mimics: Other diseases that can cause symptoms mimicking COVID-19 include tuberculosis, malaria, bacterial pneumonia, congestive heart failure, chronic obstructive pulmonary disease, urinary tract infections, and gastrointestinal illnesses. Any of these diseases can also coexist with COVID-19.

Patients should be evaluated for alternative or coexisting diagnoses based on the local burden of disease, patient risk factors, and clinical presentation. Over the course of their treatment, if a patient’s condition or symptoms change, providers should consider whether the cause is due to COVID-19 or if another process is contributing.

Coinfection: Patients with confirmed COVID-19 commonly have concurrent secondary infections. Most studies on co-infection and secondary infection are done in high-income or upper-middle income countries; it is unknown if and how co-infection patterns vary in low-income countries

  • Viral coinfection depends on local epidemiology and season
  • Bacterial coinfection is not very common (~3%), secondary bacterial infection is somewhat more common (~7%). See Bacterial Infection)
  • Malaria, dengue and other tropical diseases can co-exist with COVID

Complications:

Patients with confirmed COVID-19 can also present with or develop a number of complications:

Disease Severity and DispositionCopy Link!

Updated Date: December 20, 2020

The decision about severity of illness and where to admit varies considerably depending on the availability of beds, the location, and the patient’s resources to monitor and care at home. This is a general set of suggestions based on BWH, PIH, and WHO criteria, and should be adapted to local needs. In some settings, patients with severe or critical COVID may need to be transferred to facilities with higher-levels of care.

Tool: WHO Classification of Disease Severity (page 13)
Tool: PIH algorithm for initial patient assessment
Tool:
MEWS (The Modified Early Warning Score for Clinical Deterioration) can offer estimates based on vital signs of the probability of ICU admission or death, and has been validated in low-income settings as well (Kruisselbrink et al).

Severity

Mild

Moderate

Severe

Critical

Location

Home

Home or Inpatient

HDU, step-down or ICU

ICU

Oxygen saturation

(If pulse oximetry is unavailable, monitor respiratory rate)

≥ 94% on room air (ambulatory ≥ 92%)

90-94% on room air (or ambulatory < 92%)

< 90% on room air

Meeting criteria for ARDS. Or needs O2 > 6 LPM to maintain SpO2 > 92% (or rapid escalation of oxygen requirement)

Respiratory Rate

12-22

Adults: 22-30

Children:

under 2 months: ≥ 60; 2–11 months: ≥ 50; 1–5 years: ≥ 40 (WHO)

Adults >30

Children: under 2 months: ≥ 60; 2–11 months: ≥ 50; 1–5 years: ≥ 40.

Variable depending on compensation

Blood Pressure and Heart Rate

BP > 90/60 (or not significantly lower than patient’s baseline)

BP > 90/60 (or not significantly lower than patient’s baseline)

Variable (depending on HDU criteria)

Adults: SBP < 90, MAP < 65, tachycardia, other signs of shock

Children: SBP < 5th percentile or >2 SDs below norm for age, HR <90 or >160 in infants, HR < 70 or > 150 in children, capillary refill > 2 sec

Clinical appearance

Reassuring

Variable

Adults: Concerning

Children: cyanosis, fast breathing, grunting, chest indrawing, inability to drink, lethargy, or convulsions

Adults: Concerning

Children: cyanosis fast breathing, grunting, chest indrawing, inability to drink, lethargy, convulsions, mottled or cool skin

Labs

No strict criteria

ABG with pH < 7.3 or PCO2 > 50 or above patient’s baseline, Lactate > 2

Other

Home isolation requirements are met

Need for intensive nursing care

It may not be within the goals of some patients to transfer to be hospitalized, to transfer to the ICU, or to be intubated.

Literature Review (Emergency Department): Gallery View, Grid View

Vitals and MonitoringCopy Link!

Updated Date: December 20, 2020
Tool: Normal vital signs by age.

Pulse Oximetry: Please note that pulse oximeters are less reliable in patients with darker skin tones, and accuracy is improved by trending over time or using both resting and exertional measures. See Home Pulse Oximetry for more details.

We base these recommendations on the assumption of staff and equipment availability. These frequencies may need to be adjusted based on resource availability in different settings.

Severity

Mild

Moderate

Severe

Critical

Temperature Use lower fever criteria in immunocompromised or geriatric patients: one oral temp > 37.8C or two oral temps > 37.2C (IDSA criteria)

On initial assessment

Every 4 hours

At least every 4 hours

At least every 3 hours or continuously

Oxygen Sat, Respiratory and Heart Rate

On initial assessment

Every 4 hours

Continuous or as frequent as possible

Continuous or as frequent as possible

Blood Pressure (BP)

On initial assessment

Every 4 hours

Every 2-4 hours

Continuous, or every 5-15 minutes during resuscitation (30–60 minutes once stable).

Physical exam

On initial assessment

On admission & once a shift

Once a shift minimum

Every 30–60 minutes during resuscitation.Every 2–4 hours once stable.

Mental Status

On initial assessment

Every 4 hours

Every 2-4 hours

Continuous observation or intermittent, every hour

Intake & Output

Every shift

Every 4 hours

Every 1 hour

Chest X-ray

As needed

As needed

As needed

12-lead ECG

On admission and as needed

As needed

As needed

Telemetry

As needed for clear indication

Ideally continuous for all patients, otherwise as needed for clear indication

Lab MonitoringCopy Link!

Laboratory FrequenciesCopy Link!

Updated Date: December 20, 2020

The table below provides a summary of the laboratory monitoring at a well-resourced academic tertiary institution. Monitoring labs such as IL-6 levels will not be possible in most institutions, and excellent care can still be provided without these specialized labs.

Laboratory

On admission

Trending

De-escalating (non-ICU)

CBC with Differential

Once

Daily

Daily

BMP

Once

Daily

Daily

Magnesium

Once

Daily

Daily

LFTs

Once

QOD*

Discontinue (if stable/improving)

CPK

Once

QOD*

Discontinue (if stable/improving)

Troponin

Once

QOD*

Discontinue (if stable/improving)

Nt pro-BNP

Once

QOD*

Discontinue (if stable/improving)

D-Dimer

Once

QOD*

Discontinue (if stable/improving)

PT/INR

Once

ICU only: QOD*

Discontinue (if stable/improving)

Fibrinogen

Once

ICU only: QOD*

Discontinue (if stable/improving)

CRP

Once

QOD

Discontinue (if stable/improving)

IL-6

Once

QOD

Discontinue

Ferritin

Once

QOD

Discontinue (if stable/improving)

Procalcitonin

Once

Provider discretion

N/A

Soluble IL-2 Receptor

Once

N/A

Discontinue

LDH

Once

N/A

N/A

EKG

Once

Provider discretion

N/A

*Note: Consider discontinuation on day 8 if patient status and lab values are stable or improving

If the patient is acutely worsening

  1. Redraw all admission labs above to assess the cause of the acute change, and include any other workup that may be needed (e.g. blood cultures, urine strep pneumo and legionella, chest x-ray, EKG)
  2. Resume the regular trending lab frequency with the exception of troponin and Nt-Pro BNP which can be discontinued as soon as downtrending

When lab availability is limited, this is an alternate lab schedule:

Laboratory

On admission

During admission

Evaluation of clinical worsening

CBC/FBC with Differential

Once

Every other day or twice a week

Once

Glucose

Once

Daily

Once

Electrolytes (Na, Cl, HCO3, K)

Once

Every other day or twice a week

Once

Magnesium

Once

Once

BUN/Cr

Once

Every other day or twice a week

Once

Liver function tests

Once

Once

LDH

Once

Once

CRP

Once

Once

D-dimer

Once

Once

Common Laboratory FindingsCopy Link!

Updated Date: May, 2020

Laboratory abnormalities are more frequent and significant in patients presenting with severe disease. Many of these are associated with more severe disease or death. (Arentz; Chen; Du et al; Guan et al; Young et al; Zhang et al; Zhou et al). Some common abnormalities in COVID patients include:

  • Lymphopenia
  • Mild hepatocellular injury (AST / ALT ~200s, GGT often elevated, AlkPhos rarely elevated) (Zhang et al)
  • Anemia
  • Elevated D-dimer
  • Elevated creatine kinase
  • Elevated LDH
  • Low/normal procalcitonin, elevated in severe disease and/or superimposed bacterial infection
  • Elevated inflammatory markers: LDH, CRP, ESR, ferritin, IL-6
  • Elevated PTT or INR in COVID-19-related coagulopathy

Interpretation:

  • Coagulopathy:
  • Elevations in PTT and/or INR can be a sign of coagulopathy (i.e. dysfunction in the body’s clotting system which leads to an increased risk of bleeding and increased risk of clotting). Suspect disseminated intravascular coagulation when platelets drop and D-dimer, PTT, and INR increase.
  • D-Dimer:
  • An elevated D-dimer in patients with COVID-19 is not always a sign of thrombosis, though it can be. Consider other signs and symptoms and use available diagnostic methods such as ultrasound and/or CT scan to further evaluate these cases.
  • Inflammation and Cytokine Storm:
  • Inflammatory labs such as D-dimer, LDH, CRP, and ESR are often elevated in patients with severe COVID-19, so if a previously stable patient deteriorates, check these. Cytokine Storm Syndrome, an inflammatory response that can lead to shock and multi-organ failure, should be considered if the following lab parameters are met (though some patients may not meet these cut-offs):
  • CRP >50mg/L
  • And at least two of the following:
  • Ferritin >500 ng/mL
  • LDH >300 U/L
  • D-dimer >1000 ng/mL

ImagingCopy Link!

Updated Date: December 20, 2020
Literature Review (CT and Chest X-Ray):
Gallery View, Grid View
Literature Review (Ultrasound):
Gallery View, Grid View

Chest X-rayCopy Link!

Chest x-ray can help identify alternate causes of shortness of breath. Some chest x-ray findings can suggest a diagnosis of COVID-19. Normal chest x-rays do not rule out COVID: Chest X-rays may be normal in up to ~30% of COVID patients requiring hospitalization, particularly in early disease (Wong). Sensitivity 59% in one study, as compared to 86% for CT scan (Guan).

Low-risk patients with mild symptoms and confirmed PCR testing do not routinely need chest imaging. Most patients with findings of COVID-19 pneumonia can safely be managed at home unless clinically unstable, at high-risk of decompensation, or with pneumonia involving >50% of lung parenchyma. Where possible, portable chest X-rays are usually sufficient and require less personnel.

Consider chest x-ray in these circumstances:

  1. High clinical concern for concomitant lobar pneumonia, CHF, TB, or other etiology that could be discovered on plain film.
  2. Patients with oxygen saturation < 92% on supplemental oxygen, increased work of breathing, or new decompensation to rule out new or secondary causes
  3. High clinical suspicion but negative PCR testing (patient could have a false negative test or have been tested too early in the course).
  4. Sudden clinical change in a known COVID patient
  5. To check critical care interventions (line and endotracheal tube placement)

Tool: BWH Guide on Radiology in COVID and Guidance for Radiologists

CT ScanCopy Link!

CT scan plays no role as a screening test for patients for COVID-19, for either diagnosis or exclusion (Simpson).

CT can be used if there is a concern for other pathology. Consider CT in these circumstances:

  1. High clinical suspicion for pulmonary embolism (angiogram contrast scan)
  2. High clinical concern for concurrent abscess, empyema, loculated effusion, significant hemoptysis, pneumomediastinum, etc or if clinician feels it would substantively change management

Tool: BWH Guide on Radiology in COVID and Guidance for Radiologists

Tool: Radiopedia on COVID

UltrasoundCopy Link!

Serial ultrasound is showing promise as a low-cost method to assess disease progression. Although ultrasound findings in COVID-19 have been shown to correlate with CT scan results, the false negative rate of ultrasound is not currently known (Zani et al). A standardized approach using 12 designated zones has been proposed and is strongly recommended to allow for serial comparison (Kruisselbrink et al; Convissar et al).

Tool: POCUS 101 Complete Guide to Lung Ultrasound

Patients with Comorbid DiseasesCopy Link!

Updated Date: December 20, 2020

Patients with chronic conditions have specific risks and needs related to COVID-19 diagnosis, treatment, and social support (e.g. to allow safe isolation/quarantine if needed.) Patients with diabetes, hypertension, heart disease, and obesity have been shown to have higher rates of hospitalization and severe illness due to COVID-19. (See Prognostic Indicators)

Relevant comorbidities are covered in greater detail in different chapters, and include the following:

  • Immunosuppressed patients may have atypical presentations of COVID-19 (e.g no fever). Patients with HIV who present with respiratory symptoms should be evaluated for TB in addition to COVID-19 as clinically indicated.

Management of existing medications is an important consideration in these patients. These medications are discussed in Treatments for Comorbid Diseases and may include the following.

  • ACE inhibitors
  • Immunosuppressants
  • Nonsteroidal anti-inflammatory drugs
  • Steroids
  • Inhalers