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4428490-52387500COVID-19?CLINICAL GUIDELINES????SUBJECT: INPATIENT ENDING ISOLATION IN NON-CRITICALLY ILL COVID PATIENTSSCOPE: Sinai Hospital of Baltimore, Northwest Hospital and Carroll Hospital adopts the following guidelines for clinical services provided during the COVID-19 pandemic.????APPROVED BY:?LBH Clinical Guidelines Council???????APPROVAL DATE:7/31/20;?LAST REVIEW DATE: 8/14/20????(DOES NOT APPLY TO PATIENTS ON CONTINUOUS AEROSOL-GENERATING PROCEURES SUCH AS NIPPV OR HFNC)Background: Viral RNA may persist for up to 12 weeks after initial infection. As detecting viral RNA via PCR does not necessarily mean that infectious virus is present, we will begin instituting a symptom-based strategy for discontinuation of isolation precautions in accordance with the most recent CDC guidelines (). Repeat PCR testing is not indicated or recommended in known COVID-positive patients unless an outside facility requires it for transfer.Symptom-based criteria for discontinuation of isolation precautions, for known OR suspected COVID+ patients with mild-to-moderate illness, NOT severely immunocompromised:Patient with symptomsAt least 10 days have passed since symptoms first appeared, ANDAt least 24 hours have passed since resolution of fever without the use of fever-reducing medications , ANDImprovement* in respiratory symptoms (e.g., cough, shortness of breath)Patient with NO symptomsAt least 10 days have passed since initial positive viral PCR testSymptom-based criteria for discontinuation of isolation precautions, for known OR suspected COVID+ patients with severe-to-critical illness, OR severely immunocompromised:Patient with symptomsAt least 20 days have passed since symptoms first appeared, ANDAt least 24 hours have passed since resolution of fever without the use of fever-reducing medications, ANDImprovement* in respiratory symptoms (e.g., cough, shortness of breath)Patients with no symptoms (but severely immunocompromised)At least 20 days have passed since initial positive viral PCR testPatients with no history of COVID-19 infection and no respiratory or fever symptoms, who are admitted for other reasons or procedures, do not require isolation precautions. COVID testing will be performed as follows:Pre-operative/pre-admission COVID-19 PCR test to document negative status (outpatient) followed by home quarantine until admissionIf the patient may need to be discharged to a rehabilitation or nursing facility, a second COVID-19 PCR test completed on the day of admission (TAT 24-48 hrs) to satisfy the requirement for two negative tests.*Improvement in respiratory symptoms is defined as a marked decrease in oxygen requirements. The patient may no longer be on continuous AGP such as the vent, NIPPV or HFNC; patients who have been covid positive and are on continuous AGP will stay on transmission-based isolation.Definitions:Mild Illness: Individuals who have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal chest imaging.Moderate Illness: Individuals who have evidence of lower respiratory disease by clinical assessment or imaging, and a saturation of oxygen (SpO2) ≥94% on room air at sea level.Severe Illness: Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room air at sea level (or, for patients with chronic hypoxemia, a decrease from baseline of >3%), ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50%.Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.In pediatric patients, radiographic abnormalities are common and, for the most part, should not be used as the sole criteria to define COVID-19 illness category. Normal values for respiratory rate also vary with age in children, thus hypoxia should be the primary criterion to define severe illness,?especially in younger children.CDC guidelines for discharge:If discharged to home:Isolation should be maintained at home if the patient returns home before discontinuation of Transmission-Based Precautions.If discharged to a nursing home or other long-term care facility (e.g., assisted living facility), ANDTransmission-Based Precautions are still required, they should go to a facility with an ability to adhere to infection prevention and control recommendations for the care of COVID-19 patients. Transmission-Based Precautions have been discontinued per above and the patient’s symptoms have resolved, they do not require further restrictions, based upon their history of COVID-19.Maryland Dept. of Health guidelines for discharge ():Patients who have been hospitalized for suspect or confirmed COVID-19 can be discharged from the hospital whenever it is clinically indicated. They do NOT require re-testing to be discharged.A nursing home can accept a resident diagnosed with COVID-19 and still under Transmission-Based Precautions for COVID-19 as long as the facility can follow CDC guidance for Transmission-Based Precautions. If a nursing home cannot follow this guidance, it must wait until these precautions are discontinued.Patients who do not yet meet criteria for discontinuation of Transmission Based Precautions for COVID-19 should be admitted to a private room with a private bathroom on Standard, Contact, and Droplet Precautions (including eye protection). These patients should be isolated to their rooms except for necessary medical procedures until they meet criteria for the discontinuation of Transmission Based Precautions. Patients who meet criteria for discontinuation of Transmission Based Precautions for COVID-19 can be admitted to the general population using Standard Precautions.Discontinuation of Transmission-Based Precautions does not require patients to be tested or re-tested for COVID-19. See symptom-based strategy, above. (Note that the Maryland Dept of Health guideline is less stringent than the CDC, at 7 days since symptom onset.) ................
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