Information for Clinicians

 

If providers have questions, call Baltimore City Health Department Acute Communicable Diseases 410-396-4436 (business hours); 410-396-3100 (after-hours, weekends). Fax test results to 410-625-0688.

Key Messages

  • It is imperative that all providers strongly counsel patients to isolate before and immediately after their COVID-19 testing is complete
  • It is imperative that all providers inform patients who are positive for COVID-19 that the health department will be calling them to conduct contact tracing
  • Click here, and see below, for information on how to get patients tested for COVID-19
  • Sign up for Baltimore City Health Department Provider Outreach Updates, which provide local context and resources as they relate to national and state guidance
  • All cases of Multi-System Inflammatory Syndrome in Children (MIS-C) must be immediately reported to the Baltimore City Health Department. See below for details.
  • Urgent Reminder to Register and Report to ImmuNet: Since October 1, 2019, the Maryland Department of Health has mandated that all vaccines provided in Maryland are reported to ImmuNet, regardless of patient opt-out status in ImmuNet (Maryland statute Health General §18-109). Distribution of future COVID-19 vaccines will require healthcare providers to be registered in ImmuNet.We encourage you to register and begin reporting the administration of vaccines through ImmuNet, if you have not already done so. Registration is free, and more information on ImmuNet registration, the process of reporting vaccinations, and the Help Desk contact information can be found here: https://www.mdimmunet.org/.

 

Table of Contents

RECENT UPDATES

TESTING - GENERAL GUIDELINES

TESTING IN THE OUTPATIENT SETTING

ISOLATION AND QUARANTINE INSTRUCTIONS

REMOVING PATIENTS FROM HOME ISOLATION

RISK FACTORS FOR SEVERE DISEASE

MULTI-SYSTEM INFLAMMATORY SYNDROME IN CHILDREN (MIS-C)


INFECTION CONTROL IN HEALTHCARE SETTINGS

PPE RESOURCES

MEDICATION SAFETY AND COVID-19

GENERAL RESOURCES

 ADDITIONAL INFORMATION FOR PROVIDERS 

 

Recent Updates

 

Testing- General Guidelines

Testing Criteria

As per the Health Order from 5/19/2020, healthcare providers should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Clinicians are encouraged to test for other causes of respiratory illness.

Healthcare providers should also consider ordering the testing of patients who are asymptomatic when, based on independent professional judgment, COVID-19 exposure is suspected.

Testing Priorities

Current testing priorities are listed in the Health Order from 5/19/2020 using the most expeditious means available (either a hospital lab, private lab, or the State Laboratory)

  1. Symptomatic hospital patients;
  2. Symptomatic patients and staff in nursing homes, long-term care facilities, or other congregate living facilities housing individuals who are medically fragile, or as directed by the Maryland Department of Health;
  3. Symptomatic emergency medical services personnel, healthcare workers, correctional officers, law enforcement personnel, and other first responders;
  4. Symptomatic high-risk unstable patients whose care would be altered by the diagnosis of COVID-19;
  5. Persons identified through a public health cluster and selected contact investigations; or
  6. Persons without symptoms as determined by a healthcare provider’s independent professional judgment if COVID-19 exposure is suspected or as directed by MDH, an MDH-designated response team, or a local health department. 

 

Reporting Test Results

Providers should notify the Baltimore City Health Department of all confirmed COVID-19 cases immediately, especially those in residents or staff in congregate living facilities, including long term care facilities, nursing homes, and skilled nursing facilities.

  • Fax either a) a lab report or b)  Form 1140  to 410-625-0688.
  • Please include the ordering provider’s contact information for the public health investigation.
  • It is also extremely helpful to include the admission note and other applicable notes (Emergency Department note, Infectious Disease consult, imaging results, etc.) in the fax.

 

TESTING IN THE OUTPATIENT SETTING

COVID-19 Testing Availability in Baltimore

Click here for information about testing availability in Baltimore City.

Conducting Outpatient Testing

  • Providers should make every attempt to use telemedicine or telephonic communications to evaluate patients and avoid unnecessary visits to healthcare facilities and outpatient offices.
  • Local providers can provide testing to their patients if they have access to adequate PPE and NP, OP, or nasal swabs through a commercial laboratory. Swab collection must occur in the provider’s office – LabCorp and Quest are not collecting NP/OP samples at their phlebotomy sites.
  • Physicians who would like to order a COVID test through the Johns Hopkins COVID testing tents may place an order through Johns Hopkins CareLink, a web-based portal that allows physicians outside of the Hopkins network to order labs through Hopkins laboratories. After an order is placed, the patient will be called to schedule an appointment for a test. Information on Johns Hopkins CareLink can be found here. Physicians who would like to sign up for CareLink can find information here.
  • Encourage patients to CALL AHEAD to provider offices to discuss questions regarding testing criteria. If patients are instructed to come to the clinic for testing, appropriate infection control practices should be followed:
    • Patients should call ahead so staff is aware they are coming.
    • Ensure patients wear a mask immediately upon entering the office.
    • Limit contact with other patients. This can include patients not remaining in the waiting room, being placed in a private room with the door closed, or being evaluated and tested outside the clinic building (for example, in their cars). 
    • Encourage patients to come with as few family/friends as possible. 
  • Other resources for clinicians:

Isolation and Quarantine Instructions

  • It is imperative that all providers referring patients to testing at any location or conducting testing at their facility strongly counsel patients to isolate before and immediately after their testing is complete.
    • Providers should also counsel the patient’s household contacts to remain quarantined until testing results are completed (and longer if test results are positive.) See BCHD Isolation and Quarantine instructions for providers and patients. More extensive guidance from CDC is here.
  • Testing is only effective at preventing disease transmission if accompanied by isolation of ill individuals and quarantine of those who are exposed. 
  • Patients who require additional resources to effectively isolate, such as food assistance or social services, should call 2-1-1.  For behavioral health support, please call the Crisis Information and Referral line at (410) 433-5175. 
  • Please inform your patients that the health department will be calling them to conduct contact tracing.
    • Baltimore City Health Department calls all positive cases within Baltimore City and conducts contact tracing. It is very helpful for providers to inform patients to expect a call from the Health Department.

Removing Patients from Home Isolation

For patients with COVID-19 under isolation, including confirmed patients (who were tested) and suspected patients (who were not tested), home isolation can discontinue under the following conditions*:

  • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications
  • And an improvement in respiratory symptoms (e.g., cough, shortness of breath);
  • And at least 10 days have passed since symptoms first appeared.

For patients who have not had COVID-19 symptoms but tested positive and are under isolation, home isolation can discontinue under the following conditions*:

  • At least 10 days have passed since the date of their first positive COVID-19 diagnostic test assuming they have not subsequently developed symptoms since their positive test.

*This recommendation will prevent most, but may not prevent all instances of secondary spread.  The risk of transmission after recovery is likely substantially less than that during illness.

Guidance on Symptom Monitoring

  • Some patients with COVID-19 have presented initially with mild symptoms, and develop worsening at day 5-9 into illness. Counsel patients on monitoring their symptoms especially those with risk factors for severe disease.
  • Patients who have severe symptoms, such as difficulty breathing, should seek care immediately. Older patients and individuals who have underlying medical conditions or are immunocompromised should contact their physician early in the course of mild illness. In most situations, those patients will need to be evaluated in an emergency department.

 

Risk Factors for Severe Disease

Based upon available information to date, those at high risk from severe illness of COVID-19 include:

  • Age >60 or
  • People who live in a nursing home or long-term care facility
  • Other high-risk conditions could include:
  • People with chronic lung disease or moderate to severe asthma
  • People who have serious heart conditions
  • People who are immunocompromised including cancer treatment
  • People of any age with severe obesity (body mass index [BMI] >40) or certain underlying medical conditions, particularly if not well controlled, such as those with diabetes, renal failure, or liver disease might also be at risk
  • People who are pregnant should be monitored since they are known to be at risk for a severe viral illness, however, to date data on COVID-19 has not shown an increased risk

Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications

 

MULTI-SYSTEM INFLAMMATORY SYNDROME IN CHILDREN (MIS-C)

On May 15, the Maryland Department of Health (MDH) released a clinician letter to alert providers on Multi-System Inflammatory Syndrome in Children (MIS-C) and its potential link to COVID-19. The full CDC Health Advisory on MIS-C can be found here.

Case Definition for Multi-System Inflammatory Syndrome in Children (MIS-C): 

An individual aged 21 years presenting with feveri, laboratory evidence of inflammationii, and evidence of clinically severe illness requiring hospitalization, with multisystem (≥2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND No alternative plausible diagnoses; AND Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms

iFever ≥ 38.0°C for ≥ 24 hours, or report of subjective fever lasting ≥ 24 hours

iiIncluding, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes, and low albumin.

All cases of MIS-C must be immediately reported to the Baltimore City Health Department at 410-396-4436 (business hours) OR 410-396-3100 (after hours, weekends)

 

INFECTION CONTROL IN HEALTHCARE SETTINGS

The following infection control guidelines should be followed for patients with suspected or confirmed COVID-19 disease:

  • If possible, place the patient in a negative air pressure room. If none are available, place the patient in a private room with the door closed.
  • Place a surgical mask on the patient.
  • When collecting diagnostic respiratory specimens (i.e. nasopharyngeal swab) from a possible COVID-19 patient, the healthcare provider should wear an N-95 respirator, eye protection, gloves, and gown. CDC guidance can be found here
  • If an N-95 respirator is not available, a surgical facemask with eye protection is an alternative.
  • Refer to your institution’s guidance for details of the implementation of these guidelines

PPE RESOURCES

Baltimore City PPE Emergency Medical Material Request Form

Maryland Manufacturing Network Supplier Portal

MEDICATION SAFETY AND COVID-19

  • Non-pharmaceutical Chloroquine Phosphate
    • The Centers for Disease Control and Prevention (CDC) released a HAN, Severe Illness Associated with Using Non-Pharmaceutical Chloroquine Phosphate to Prevent and Treat Coronavirus Disease 2019.
      • The CDC recommends that clinicians counsel their patients on the importance of taking medications only as prescribed and as directed by healthcare providers.
      • Chloroquine phosphate, when used without a prescription and supervision of a healthcare provider, can cause serious health consequences, including death.
      • At this time there are no routinely available pharmaceutical products that are FDA-approved for the prevention or treatment of COVID-19.
  • NSAIDs and COVID-19
    • Currently, evidence has not shown that NSAIDs may contribute to poorer outcomes in persons with COVID-19
  • ACE Inhibitors and COVID-19
    • The American Heart Association, the Heart Failure Society of America, and the American College of Cardiology (ACC) jointly published a statement urging patients with cardiovascular disease diagnosed with COVID-19 to continue taking their ACE inhibitors and ARBs as prescribed. 

GENERAL RESOURCES

 

ADDITIONAL INFORMATION FOR PROVIDERS