What Should EPs Say about COVID-19 to Discharged ED Patients?
The March 16 Centers for Disease Control and Prevention recommendations for patients discharged from the ED with COVID-19 begin with two essential caveats that cannot be overemphasized:
- The CDC recommendations (not requirements) are a moving target and will change with newer and better data. They could be revising them right now.
- These recommendations should be made in the context of local circumstances. How these are used in New York City will look dramatically different from how they are used in a small Kansas town. And they should.
The CDC offers two options for COVID-19 patients: symptom-based or test-based. Symptom-based requires these four criteria to be met:
- Seventy-two hours must pass after illness is improved.
- Patients must have no fever without antipyretics for 72 hours.
- Patients must have improvement in respiratory symptoms.
- Seven days must have passed since the beginning of symptoms.
A patient who tested positive for COVID-19 and has no symptoms must wait seven days before returning to work. A patient who tested positive and has symptoms must have two consecutive negative tests and meet the symptom-based criteria above.
The same two options exist for health care workers with additional recommendations:
- You must wear a mask at all times at work for at least 14 days following the beginning of your symptoms.
- You must restrict your interaction with patients who could be viewed as immunocompromised. These conditions are not listed, but I would assume a short list would include at least the elderly; those with COPD, congestive heart failure, diabetes, or HIV; and patients on dialysis, chemotherapy, or immunosuppressive drugs such as those who had a transplant or have rheumatoid arthritis and multiple sclerosis, among others.
I am not being critical of the CDC; this is a moving target, and we will all have to make modifications daily, sometimes twice a day. But there are some issues with this approach:
- We will (or should) move to a no-test recommendation for all outpatients from EDs, minor emergency clinics, health clinics, and drive-through testing sites. We need a good test with the highest specificity and highest sensitivity we are able to achieve with almost no false-negatives and an attempt to minimize false-positives. We need to use this test very selectively in our sickest patients in the highest areas of prevalence, so that we have enough tests, reagent, and human and material resources to do rapid target testing. If we open this up to anyone who drives a car through a line or comes to the ED, we will run out of tests. We will need the CDC testing option for those equine tests that have already been let out of the barn, but I believe the testing option will become a moot point for the vast majority of EDs.
- Telling a patient four different if-then scenarios is like teaching a 5-year-old how to play baseball. There are too many rules that will be misunderstood. I had to read the CDC recommendations multiple times, and this is my profession. Am I supposed to translate this into understandable language for the patient?
Here are details in the CDC recommendations I take issue with:
- No fever without antipyretics for 72 hours. For how many decades have we been saying that a 99°F temperature or even 100°F is not a low-grade fever? And how many times do we say a shift, “Even if your normal temperature is 96°F, we don't call it a fever until it is greater than 100.4°”? And then you have the whole axillary thing and adding a degree. What if they are taking an NSAID or acetaminophen for myalgias or headache or some flu elixir bought over the counter that has an antipyretic in it? How are we going to tell patients not to take anything for fever, headache, and body aches for 72 hours and then check their temperature regularly to see if their fever is gone?
- Improvement in your respiratory symptoms for 72 hours. Improvements are too subjective and may not be clearly linear. Do you have to start over if you have two really good days and a really lousy evening? Can any of us really keep track of 72 hours of anything? What if a patient smokes and has a cough for the next three weeks or the next two months?
- Seven days from the beginning of your symptoms. How many patient interviews have you had where you spent a couple of minutes with the patient, family, and friends trying to figure out when a condition began? It's not easy and takes detective work. We will hand them a paper like the one from the CDC that asks them to count seven days from the start of symptoms and 72 hours after symptoms are improving and not to use antipyretics or over-the-counter products for 72 hours and to determine if respiratory symptoms like coughs are improving for 72 hours. This is a Little League infield pop fly with men on first and third with one out and not enough volunteer parents to coach first and third. We just stand on base with everyone yelling.
- We need to play soccer on this field. Tell everyone we are not testing. Tell all patients if they have a fever, cough, sore throat, difficulty breathing, or flu-like symptoms to stay home under quarantine-type conditions (and you figure out with them the day this started and add seven days and write down the date). Tell them they can go back to life (with restrictions if it's a health care worker) if they are feeling much better with minimal cough and no fever. If they have a cough but it is better, wear a mask for another week. Then write them a work note for the entire time; employers will demand this kind of hard date.
- The no-test return seven days after beginning of symptoms if better. Saying that everything depends on the context of the local circumstances is so much easier to understand for all of us. With simplicity comes compliance. At least we are on the same field knowing where to run to make our goal.
Dr. Mosleyis an emergency physician in Wichita, KS.Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.