In this post I link to and excerpt from “Primary Care Practice Habits in the Setting of COVID-19” [Link is to the PDF]. 3-31-2020 by Shawn Corcoran, MD. This resource is from #205 COVID Cakes and Hot Takes with Rahul Ganatra MD
APRIL 10, 2020 By MATTHEW WATTO, MD
Here are excerpts from the above:
Postpone all routine testing
We should aim to avoid cancer screening and routine lab draws. This would include surveillance of electrolytes for an ACE/ARB/thiazide, thyroid function tests, and lipids who are asymptomatic.
Attempt to choose therapy that doesn’t require monitoring
The clearest example here is opting, when possible, for calcium channel blockers over ACE/ARB/thiazide options for hypertension.
Increase empiric management
Our normal practice habit may to be obtain testing to confirm a diagnosis whose pre-test probability is moderate or high based on the history. In this setting, we should treat empirically and have close follow-up. Examples include increasing diuretics for a CHF exacerbation, prescribing antibiotics a UTI or diverticulitis, and pain management +/- alpha blocker therapy for nephrolithiasis.
For acute problems, order tests that will change management
If the pre-test probability of a problem is unclear and the test will change management, or if worsening of the problem could eventually result in hospitalization, then testing, including an office visit for a physical exam, is likely justifiable. Examples include an office for exam of a new mass, a CBC for suspicions for symptomatic anemia or mild GI bleeding, an EKG and labs for unexplained syncope, and an X-ray for a suspected fracture. Notice that the bar for testing is pretty high.
Opt for outpatient testing and home management over sending to the ED or admission, when possible
When the acuity of the problem warrants a consideration for an ED evaluation or admission, we aim to limit use of these options wherever possible, both to decrease the risk of COVID to our patients and to preserve hospital resources for the sickest COVID and non-COVID patients. This involves partnering with patients to accept higher levels of risk with non-hospital management, for the benefit of these two personal and public health priorities.
Over the past week we have dramatically shifted how we deliver care, opting for a near-100% telehealth interface to achieve our primary goal of reducing COVID transmission. Our achievement of this goal carries with it a similarly significant practice change in how we manage patients, specifically in how we order tests, place referrals, and arrange follow-up. Our guiding principle in this setting is the secondary goal of avoiding hospitalization for non-COVID problems.
There is a natural tension between these two goals – reducing COVID transmission risk by minimizing interactions with the healthcare system and reducing the risk of hospitalization non-COVID reasons, which typically involves increased interaction with the healthcare system.
All medical providers who have worked in an austere setting have experienced this tension. While in Afghanistan in 2009, a fellow Army internist had a Soldier with an ankle injury that met the Ottawa criteria. X-rays were available at a regional Combat Support Hospital. His team called a routine MEDEVAC to come get the Soldier. On the flight to their location, the helicopter crashed. Thankfully, no one died as a result, but it was terrifying to consider someone could have died in pursuit of managing a non-emergent medical condition.
This is the essence of the COVID-19 practice environment, of attempting to weigh the risk of COVID transmission and the risk of the clinical problem at hand.
The process of attempting to weigh the risk of COVID exposure against the risk of the clinical problem at hand can be an exceptionally difficult one. As mentioned above, weighing the relevant factors of each these risks is approximate at best. Thankfully, there are some additional steps we can take to reduce the risk all around:
– if testing is warranted, encourage the patient to obtain it, if feasible, at a lower risk facility, such as an outlying clinic instead of the medical center
– order sequential testing – obtaining tests for the most likely or worrisome diagnoses first, then conducting follow-up testing, if needed, based on the evolving clinical circumstances; for example, obtaining labs and initial basic imaging first, especially if possible to do at a single location, followed by advanced imaging at a later date
– conduct close tele-health follow-up to monitor progress
Most importantly, we can and should conduct this risk analysis in full partnership with patients, getting
their perspectives on where they’re willing to accept risk, and determining how to proceed together