How will we deal with patient care in the Orchard Health Care office during our Covid-19 epidemic? We need to clarify our approach both for sick care and wellness care.

Respiratory sick care episodes

We will do a more detailed phone screening when any patient calls with a respiratory illness and asks to be evaluated. We have to be cognizant of the increasing prevalence of Covid-19 and the risks of having infected patients in the office, at the same time as continuing to offer appropriate diagnosis and care to anyone who is ill.

  1. Serious respiratory disease: If a person calls with cough, respiratory distress, and fever over 101F, together with any firm history of contact with others with known Covid-19 infection, we most likely will refer that member to the Newton-Wellesley or other hospital emergency room. That is because the likelihood of Covid-19 infection is high, and evaluation including X-rays and the use of a negative-pressure room for everyone’s protection is best care. We will track you during that ER evaluation.
  2. Moderate respiratory disease: The member calls with cough, some shortness of breath, temp of 100F, some runny nose and not feeling well, but no known even indirect contacts with people with Covid-19. We will see those patients in our office, after telephone screening. We’ll give the person a surgical mask at the door and use one exam room. We will be using masks, gowns, gloves and goggles for our protection, and will take a nasopharyngeal swab to test for Covid-19 as well as other more likely pathogens such as influenza or respiratory syncytial virus.
  3. Mild respiratory disease with possible Covid-19 exposure: If a person reports mild respiratory symptoms with minimal fever and is clearly not seriously ill, but has suspicious exposure to Covid-19, we will give general supportive advice by phone but probably won’t ask that person to be seen in the office. As an alternative, especially with increasing community spread, we may ask that member to meet us outside our building to get a nasal swab for the virus so we can definitively determine if they do have the virus, or not. That will clarify followup for everyone, since 14 days of self-quarantine is currently required for mild cases of Covid-19.

General office visits and checkups

We think that normal office visits and checkups can safely continue on an organized basis. We will be screening anyone with significant respiratory disease so they will not be in our waiting room and will not put others at risk. We have plenty of antiviral wipes and hand sanitizer available for use. We do not think our office will be a higher risk environment, under these precautions. That said, most routine follow-up visits are not time critical and can be postponed for a few weeks or month or so. But we don’t think it warranted or wise to cancel all normal surveillance visits until a distant future. Timely monitoring does have value.

Covid-19 testing now available after all

I am pleased to announce that on Wednesday morning I was called by Quest regional laboratory director in Framingham to let me know that Quest will in fact immediately start accepting specimens to test for Covid-19 infections. They also sent us same-day supply of culture media and swabs, which we lacked. So now we are able to do Covid-19 PCR tests on any member who has meaningful risk of exposure to someone with Covid-19 or a clinical respiratory infection that is suspicious for Covid-19.

The clinical illness criteria are a significant pulmonary infection with cough, shortness of breath and fever likely over 101F. Other symptoms can include sore throat and GI disturbances. Of course these symptoms can also be caused by influenza and other serious respiratory viruses.

The epidemiological contact criteria by CDC and the state for testing for Covid-19 have been exposure to a person who was symptomatic with cough who was later shown to have Covid-19. In general the CDC and state have refused to test anyone who was in contact with a person later documented with Covid-19 during the incubation period before symptoms, typically 4-14 days.

Testing for contacts during incubation

Infectivity during incubation may be lower than when a person is actively coughing, but there is little or no data to conclude it is negligible. Most patient concerns we are encountering have been of this sort, with a presymptomatic person who later was diagnosed. We will make efforts to test such patients even when they are not symptomatic.

However, if you are farther removed from possible infection (you were in contact with a person whose brother was in contact with a person who later was diagnosed with Covid-19), then in the absence of symptoms you are almost certainly safe and we will not now be pushing for testing. The details matter, and while testing should regularly be available now, we should exercise appropriate judgment.

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