COVID-19 Testing Protocols

Inpatient COVID-19 Testing Protocol Updated 10/12/2020

A. Who to test?

  • BMC tests all patients being admitted to the hospital, with the exception of COVID-recovered patients who are within 90 days of their initial positive COVID test and remain asymptomatic (for outpatient testing algorithms, please refer to the outpatient testing protocol).
  • If a patient who is already admitted develops symptoms potentially attributable to COVID-19 and warrants testing per your clinical opinion, they should be retested (even if their admission test was negative). Note: For COVID-recovered patients who have new symptoms of COVID-19 within 90 days of initial positive test AND for whom an alternate etiology cannot be identified, consider retesting.
    • Promptly alert the nurse of your concern so precautions are instituted
    • There are a wide range of symptoms and presentations potentially compatible with COVID including: Fever, cough, shortness of breath, new anosmia, diarrhea (more than 3 watery bowel movements per day), nausea or vomiting, dizziness, headache, muscle aches, throat pain, rhinorrhea, fatigue and others.
  • In accordance with recent information/guidelines, testing should be conducted for patients with:
      • ST elevation MI
      • Unprovoked venous thromboembolism
      • Multifocal PNA or ground glass opacities on CT without clear alternative diagnosis
    • Diagnoses for which one should consider testing for COVID:
      • New seizure
      • New stroke
      • Myocarditis, stress cardiomyopathy, coronary spasm, right heart failure
    • ED guidelines are presently that abnormal chest imaging without a clear alternative diagnosis is HIGH probability, and unprovoked VTE is MODERATE probability; all other patients (including asthma, COPD, CHF, dyspnea, VOC) should be ranked based on their overall signs and symptoms as discussed below
  • Direct admissions to BMC should be assessed for symptoms of COVID (or results of prior COVID testing) by the accepting physician prior to accepting the patient.
    • A negative COVID test within 48 hours of transfer is acceptable for screening purposes.
    • For patients who are not tested prior to transfer
      • An asymptomatic patient should be admitted to a private room on a non-COVID floor without precautions and be tested immediately on admission
      • A symptomatic patient should be admitted as a PUI to a COVID floor with COVID precautions and have COVID testing as dictated by their probability.

B. How to test?

  1. Which test to order:
  • Specimen type
    • The following patients require a Nasopharyngeal swab (NP) (see below for how providers should collect the specimen)
      • All patients being admitted
      • Patients with confirmed exposure, symptoms, or who had a positive test upon admission
    • Once admitted, anterior nares swabs may be used for the following asymptomatic patients with no confirmed exposure (note NP swabs are preferred any time there is clinical suspicion for COVID):
      • Patients who had a negative admission test using an NP swab AND who require further testing for pre-procedure or pre-discharge purposes
      • Patients with anatomic reasons that preclude nasopharyngeal testing
      • Patients who absolutely refuse nasopharyngeal testing but for whom COVID-19 testing is required
    • Patients with initial negative testing who need retesting due to ongoing clinical concern, consider a lower respiratory tract specimen – see below for specific guidance on when to do this
      • These are send out tests presently 
  1. How to collect a specimen?
  • Nasopharyngeal (NP) swabs
    • General Instructions:
      • All specimen collection require use of an N95 mask and full PPE
      • Swab specimens should be collected by healthcare providers not patient self-collection
    • Advice on collection of nasopharyngeal (NP) swabs:
    • Place swab in a viral transport tube.
    • Label the tube with the patient label and small label.

 

  • Anterior Nares Swabs
    • General Instructions:
      • Swab specimens should be collected by healthcare providers not patient self-collection
  • They should be collected using the anterior nares collection kit.
    • Advice on collection of Anterior Nares swabs
      • Insert a nasal swab 1 to 1.5 cm into a nostril. Rotate the swab against the inside of the nostril for 10 seconds while applying pressure with a finger to the outside of the nostril.
      • Repeat on the other nostril with the same swab, using external pressure on the outside of the other nostril. To avoid specimen contamination, do not touch the swab tip to anything other than the inside of the nostril.
      • Remove and place the swab into the tube containing 3 mL of viral transport medium. Cap the specimen collection tube tightly.
  • If sending a sputum or BAL sample (if clinically warranted), you can choose the appropriate option under “Additional Testing,” and follow the instructions in EPIC

 

  1. Where should the patient be when collecting the specimen
  • Patients with a concern for COVID-19 should be placed on COVID-19 precautions and tested with full PPE once isolated
  • If testing a patient because a facility or procedure requires it (i.e., NO concern for COVID-19), they can stay on their initial floor and team.
  • Testing with Anterior Nares swabs: Patient may be tested in any location without precautions and provider does not need to wear PPE (just usual standard of eye protection, surgical mask, and gloves)
  • Testing with Nasopharyngeal (NP) swabs:
    • If the patient is in a private room, they can be tested there.
    • If the patient is in a semi-private room or an observation bay, they must be tested in a private room with a closed door; they can then return to their original room to await test results. Patients sharing a room can be tested in their room if their roommate wears a mask or is removed.
    • [As of 10/15/20] Plexiglass enclosures that fit over patients have been specifically recalled by the FDA, and should not be used when taking swabs
  • Room cleaning
    • COVID positive cases or Moderate Risk/High Risk patients who have not been ruled out when they leave the room: The room must be terminally cleaned once the patient leaves. The clinician needs to ask the unit coordinator to request EVS.
    • No risk patients or patients who are ruled out prior to leaving the room: routine cleaning (i.e. no terminal cleaning necessary)
  1. What if I get an inconclusive rest?
  • If results will change your clinical management, consider sending another sample for testing (see info on COVID-19 probability assessment below).
  1. What if the patient refuses to be tested?
  • All patients who refuse testing will be sent to a private room on a COVID floor until they allow testing to occur. Patients should be informed on refusal in the ED and on arrival to the floor that they cannot leave their room while under COVID investigation.
  • They can be offered an anterior nares swab as an alternative to an NP swab.

C How to assess COVID-19 probability

      • Interpretation of the test result depends on your pre-test probability (how likely is the diagnosis). Attendings and APPs should update the COVID-19 probability as new information comes in.
      • Factors consistent with higher COVID-19 probability:
        • Exposure (defined as less than 6 feet for more than 15 minutes) to a laboratory confirmed COVID-19 case
        • Fever and dry cough
        • Ground glass opacities/multifocal pneumonia on chest imaging
        • Low/normal WBC count on presentation, leukopenia during hospital course, low procalcitonin, elevated CRP, LDH, and/or ferritin
      • Based on those factors, probability should be stratified into:

      High probability: Known exposure to a confirmed COVID-19 case within the preceding 2 weeks and/or history/signs/symptoms consistent with COVID-19 with no clear alternative diagnosis. Cannot have precautions removed without infection control review.

      Moderate probability: History/signs/symptoms not clearly high or low probability.  If the initial COVID test is negative, the COVID banner will remain in place pending a second negative result >24 hours from the first and an EPIC questionnaire.

      Low probability: Clear alternative diagnosis much more likely than COVID-19 AND no known exposure to a confirmed case within preceding 2 weeks.

      No suspicion/concern: Patient shows no signs or symptoms of COVID-19, has had no potential exposure to COVID-19 in the last 14 days, and has had no travel outside of New England in the last 14 days.  Testing is being done as clearance prior to procedure or transfer to another facility.

       

       D. How to Remove COVID-19 Precautions:

      E. Special Testing Considerations based on hospital location:

        • Surgery/procedures: See surgical guidelines on Hub. Retesting is not recommended for recovered patients who are within 90 days of initial positive test and do not have new COVID-related symptoms. Tests are valid for 72 hours for the purposes of procedures or surgeries at BMC.

        F. Testing considerations at discharge:

        • Patients with COVID-19 – Isolation precautions are resolved by symptom-based or test-based resolution. A test-based strategy is no longer recommended for most patients. See separate guidelines.
        • Symptom-based removal of precautions alone can be considered if the patient has not developed new symptoms
        • A test-based strategy for precautions removal is no longer recommended except:
          • If a patient has new symptoms of COVID-19 and an alternate etiology cannot be identified OR
          • For persons who are severely immunocompromised or have conditions that require test-based removal from isolation[i] (test-based strategy recommended) OR
          • The receiving institution at discharge requires testing
        • For most patients, repeat tests for the purposes of removal of isolation precautions should not be ordered unless the patient does not meet criteria for symptom-based clearance.
          • If a test-based strategy is needed and a repeat test is positive, wait 3 days before repeating the test, or 2 days from the resolution of fever and symptoms (whichever comes first).
        • Patients who are immunocompromised and have COVID-19: Discharging patients who are immunocompromised and require testing confirmation of clearance post-discharge should have this arranged via EPIC message BMC COVID retesting pool prior to discharge, and they will arrange repeat testing either at home or in the ILI clinic.
        • Asymptomatic patients who never had COVID-19 and are being discharged to LTAC/NH/facility/dialysis enter where a negative COVID test is an admission requirement
          • There is a special order for patients who can potentially be discharged on the same day that will use our quickest turnaround platform
        • Patients being discharged to shelter:
          • Confirm with shelter regarding their requirements, many will accept letter of health detailing negative COVID swab on admission

        [i] Patients who require retesting for removal from isolation (The following is based on Retesting guidelines for patients with immunocompromising conditions, available here):

        Immunocompromising conditions

        • Persons living with HIV with CD4 0.5mg/kg/day for children prednisone equivalent, for at least 1 month) or other significantly immunocompromising medications (most biologics, active chemotherapy)
        • Individuals with hematologic malignancies or other severe immunodeficiency syndromes o Individuals who received biologic therapy for treatment of COVID-19 (e.g. tocilizumab, anakinra, sarilumab)
        • Any other patients who are considered immunocompromised but do not fall into these categories and are deemed immunocompromised and at risk for prolonged viral shedding by their physician, discuss on a case-bycase basis with designated clinician leading this effort

        Other conditions that require test-based removal from isolation:

        • Patients on hemodialysis (to return to their facilities)
        • Postpartum women who need to visit their babies in NICU
        • Pregnant women who were admitted to ICU for COVID-19 infection o Consider patients with prolonged intubation for ARDS due to COVID-19 prior to tracheostomy or extubation to NIPPV- see inpatient ICU guidelines for additional information

         

        ED COVID Testing Protocol *updated 9/28/2020

         COVID-19 ED TESTING – LOW COMMUNITY PREVALENCE GUIDELINES

        *These guidelines are for during periods of low community prevalence of COVID-19, as determined by BMC leadership based on the number and trajectory of cases in the community and the hospital. 

         

        COVID-19 TESTING

        • Testing can be done either in a private room with closed door, or in a designated testing room with a closed door and good airflow.
        • Use enhanced/COVID PPE to obtain the swab.
        • Enter the pre-test probability prior to test results to allow auto-removal in EPIC.
        • All patients pending admission with a LOW probability of COVID-19 will remain in the ED while waiting for their test results.
          • If the test is negative, admit to non-COVID floor.
          • If the test is positive, admit to a COVID floor.
        • MODERATE and HIGH probability patients can be admitted to the COVID floor once the initial swab is collected.
        • Environmental management after a COVID-19 NP swab:
          • Moderate Risk, High Risk and/or COVID positive cases: The room must be terminally cleaned once the patient leaves the ED
          • No Risk patients, and Low Risk patients who receive a negative test result: routine cleaning (i.e. no terminal cleaning necessary)

        SYMPTOMS ASSOCIATED WITH COVID-19

        • Symptoms of COVID-19 include fever, cough, shortness of breath, new anosmia, diarrhea (more than 3 watery bowel movements per day), nausea or vomiting, dizziness, headache, muscle aches, throat pain, rhinorrhea, fatigue and others.
        • Chest imaging suggestive of COVID-19 includes multifocal pneumonia, bilateral infiltrates on CXR, and GGO on CT.
        • Laboratory studies suggestive of COVID-19 include low WBC/leukopenia and unexplained elevation in CRP, LDH, and/or ferritin with low PCT.
        • Diagnoses for which COVID-19 should be considered include seizure; stroke; myocarditis, stress cardiomyopathy, coronary spasm, right heart failure; STEMI; venous thromboembolism.

         

        I. PATIENTS WITH NO PRIOR COVID DIAGNOSIS

         

        A. ASymptomatic PATIENTS

        ASYMPTOMATIC patients being tested for either admission or for ED discharge to a congregate living situation (including those that require a single negative test (inpatient psychiatric facility, homeless shelter, or other congregate living situation such as substance abuse housing), are NOT considered PUI.  These patients should have a NP swab for rapid testing, unless they already have a documented test result from within the prior 24 hours.

        Asymptomatic patients with exposure (closer than 6 feet for more than 15 minutes) to laboratory-confirmed COVID-19 cases within the last 2 weeks are not considered PUI, but should be admitted to a COVID floor for quarantine while in the hospital.

         

        B. Symptomatic PATIENTS (aka PUI)

        1. PATIENTS DISCHARGED DIRECTLY FROM THE ED:
          Obtain NP swab for routine testing regardless of probability.
        2. ADMITTED PATIENTS: 
          1. moderate OR high probability for COVID-19
            Obtain NP swab for rapid testing  
            • Patients with URI symptoms should have their COVID test as part of the comprehensive respiratory panel
            • Patient goes to a COVID floor pending test results
          2. LOW probability for COVID-19
            Obtain NP swab for rapid testing
            • The patient may have some symptoms consistent with COVID-19 but the probability assessment must be LOW (see below)
            • If the test is negative, admit to a non-COVID floor
          3. NO probability for COVID-19
            • If the test is negative, admit to a non-COVID floor

          C. *COVID-19 Probability Assessment:

          • High probability: Known exposure to a confirmed COVID-19 case within the preceding 2 weeks and/or history/signs/symptoms consistent with COVID-19 with no compelling alternative diagnosis. Even if COVID test result is negative, the COVID banner will remain in place.
          • Moderate probability: History/signs/symptoms not clearly high or low probability. If the initial COVID test is negative, the COVID banner will remain in place pending a second negative result >24 hours from the first & further review.
          • Low probability: Clear alternative diagnosis much more likely than COVID-19 AND no known exposure to a confirmed case within preceding 2 weeks. If COVID result is negative, infection status will be automatically removed.
          • No suspicion/concern probability: Patient shows no signs or symptoms of COVID-19, has had no potential exposure to COVID-19 in the last 14 days, and has had no travel outside of New England in the last 14 days.

          D. NOTES:

          • The probability assessment must be entered in Epic before the test results return in order for a negative test to auto-resolve the COVID banner
          • Only LOW PROB COVID-19 can be cleared with a single negative test, allowing the patient to be admitted to a non-COVID floor.
          • *Shortness of breath with a compelling alternative diagnosis/trigger and no known exposure may be coded as LOW PROB
          • Shortness of breath without a compelling alternative diagnosis/trigger should be coded as MODERATE PROB
          • Chest imaging consistent with COVID-19 (multifocal pneumonia, bilateral infiltrates on CXR, GGO on CT) should be coded HIGH PROB unless there is a compelling alternative diagnosis
          • *Sickle cell vaso-occlusive crises may be coded as LOW PROB if they meet other LOW PROB criteria
          • Unprovoked venous thromboembolism should be coded as MODERATE or HIGH PROB, depending on clinical context
          • *Patients who are homeless should be risk stratified based on symptoms and signs
          • Patients should have 24 hours between each COVID test
          • If there is disagreement between the ED attending and the accepting attending about the probability assessment, the patient should go to a COVID floor and team (lowest risk placement to other patients and staff)

          II. PATIENTS WITH A PRIOR COVID-19 DIAGNOSIS

          A. Within 90 days of initial positive COVID test

            1. Refer to: Guidelines for Removal of Isolation Precautions for PUI and COVID-19 patients; and Retesting Criteria and Process for Immunocompromised Patients.
          • For COVID-recovered patients (applies to patients with blue banner that have a COVID-19 Confirmed infection status that has been resolved)
            • Provider will be prompted to assess patient for new symptoms of COVID-19 or new exposures to COVID-19 + cases. Patients who remain asymptomatic should not be retested.
              • If a patient has new symptoms of COVID-19 and an alternate etiology cannot be identified, consider retesting.
            • Once provider makes an active decision not to retest the patient, place an order indicating decision not to retest.
          • For patients with COVID+ test within the last 30 days (applies to patients with red banner that has not yet been resolved)
            • The banner will still be red if the COVID-19 Confirmed infection status is still present. Provider will be prompted to complete attestation to remove the banner, this has been updated to align with the new guidelines for clearance.
            • Symptom-based clearance is recommended for most immunocompetent patients. See guidelines for Removal of Isolation Precautions for PUI and COVID-19 patients.
              • For patients with COVID+ test within the last 10 days but two negative tests since then, admit to non-COVID floor

          B. Greater than 90 days since initial positive COVID test

          • Patient qualifies as LOW probability for COVID, if they meet all low probability criteria
            • Get a rapid test
            • A negative test rules them out

           

          III. PATIENTS WHO REFUSE TESTING

          • All patients who refuse testing and lack a negative test within 24 hours of admission will get admitted to a COVID floor and managed as PUI; they may go to a non-COVID team depending on the guidelines of the department they are admitted to.
          • HCW should wear COVID PPE when caring for the patient.
          • Refusing patients should be informed that they cannot leave their room on the COVID floor for the safety of other patients and staff, unless they have tested negative for COVID.