Revised Testing Algorithm
Dear EYRND OHT Primary Care Physicians,
It’s less than 3 days since my last update, but there’s yet another major change to COVID-19 testing criteria. As we move towards mitigation, the focus is on testing mildly symptomatic patients in groups at high risk of transmission and seriously ill admitted patients. Removed from the testing criteria are travel history and risk of more severe illness (age > 60, chronic disease, immunocompromised).
Below is an email from Dr. Allan Grill, Chief of Family Medicine at MSH that details the new assessment centre criteria and associated attachments. We've also organized a local Tele-town Hall with Dr. Jeya Nadarajah, ID physician leading the COVID-19 response at MSH, scheduled for Tuesday March 24th from 7 - 8 PM. I will send another email with more details.
Emilie Lam
Primary Care Lead
EYRND OHT
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MESSAGE FROM DR. ALLAN GRILL, CHIEF OF FAMILY MEDICINE, MSH
Hi everyone,
Just got off a call lead by Dr. Nadarajah.
The criteria for the AC has changed. I am attaching the new AC triage info sheet as well as the take-home sheet given to patients (STREAM 1 & 2). I am also attaching some handouts on self-isolation designed for patients from public health. Below, I will explain in more detail the main message she gave and some of the nuances.
The new goal is to keep as many people at home as possible, which is reflective of the shift from containment to mitigation.
If asymptomatic and no travel – do not send to the AC.
If asymptomatic and have traveled outside of Canada within the last 14 days – they should stay home and self isolate for 14 days (STREAM 1).
If asymptomatic and have had close household contact with someone who has symptoms AND has been outside of Canada within the last 14 days, they should stay home and self isolate for 14 days (STREAM 1).
If symptomatic, but mild – do not send to the AC unless they belong to one of these groups:
o Long-term care
o Complex Care/Rehab
o Acute Care Hospital
o Paramedics
o Dialysis Centre
o Retirement home
o School or childcare center
o Prison
o Shelter/group home
o Other congregate setting
o Other vulnerable sector population
The hospitals are still interested in swabbing these people (STREAM 3). For those not falling into this category, they should be told to self-isolate for minimum 7 days and not stop until 48 hours symptom free (STREAM 2).
If symptomatic, but mild, and have travelled outside of Canada or been exposed (close household contact) to someone that has been sick and was outside of Canada within 14 days – they should stay home and self-isolate for minimum 14 days and not stop until 48 hours symptom free (STREAM 1).
If symptomatic and severe (e.g. SOB) – do not send to the AC – send directly to the ER (STREAM 4).
Hopefully the above aligns and makes the attached algorithm makes sense.
You should also check out the following website: www.covid19Toronto.ca. This tool was designed by the GTA hospitals including ours. It is a guide for patients and aligns with the above. The ONLY difference is if the public member using it clicks they are someone who fits into the category above where MSH still wants people swabbed. It doesn’t tell them to go to the AC. It tells them to call their Occ. Health department or talk to their residence’s manager. BUT because they may call us first or even afterwards, we should direct these folks to the AC for now. It will also take some of the load off our Occ. Health department (even though I heard they are ramping up staff as we speak).
Other helpful info for your offices:
It is believed now that COVID-19 is spreading within the community. That means that any patient presenting with URI symptoms (cough, shortness of breath, sore throat, headache, muscle aches, fatigue, runny nose, and joint aches; may also include nausea, diarrhea and stomach pains) should be assumed they may have COVID-19 until proven otherwise. These patients should only be assessed by providers wearing full PPE (gown, gloves, mask, eye protection). This is supported by the OMA and infection control experts. This means that if your office doesn’t have PPE, you should be managing these patients virtually. If your office is able to see these patients, please review proper PPE donning and doffing techniques and I suggest you mount specific directions or check list on the wall outside for donning and the wall inside for doffing (https://www.publichealthontario.ca/-/media/documents/rpap-recommeded-ppe-steps.pdf?la=en). Please also make sure you have a way of separating symptomatic patients from non-symptomatic patients in your offices, and are able to clean your rooms properly, to prevent the spread of infection.
For those who are not assessing these patients in their offices, due to PPE barrier issues, the other question you may ask is, what if I think the symptomatic patient calling my office has a treatable condition that is not COVID-19, like strep throat or acute otitis media or pneumonia? The challenge is that patients with sore throat fall under the URI category, and patients with AOM often have secondary URI symptoms. So these patients fall under the category of probable COVID-19 infection. Again, management is based on clinical judgement. Consider empiric antibiotic treatment where applicable along with self-isolation at home, or consider symptomatic treatment alone and self-isolation with close virtual follow-up. These patients should not be sent to the assessment centre as they are often not in the severe category. Maybe you can use a video visit to look at their throat, etc. to help.
Thanks,
Allan Grill MD, CCFP(COE), MPH, FCFP, CCPE
Associate Professor, Dept. of Family & Community Medicine, University of Toronto
Chief, Department of Family Medicine, Markham Stouffville Hospital
Lead Physician, Markham Family Health Team
Twitter: @allan_k_grillMD