COVID-19 Patient Guidelines : At Risk Populations

March 21, 2020  //  FOUND IN: Updates & Resources

The UMMG has rapidly mobilized resources to provide uniform screening for patients who contact us with concerns.  A COVID-19 hotline, staffed 24 hours per day, began operation on Tuesday, March 17.  That service will screen concerned patients and triage them to self-care, ambulatory sites for testing and treatment, or to the Emergency Department for evaluation and potential admission.  Curbside screening and specimen collection will open with the activation of the hotline.  A tiered huddle system in ambulatory care and the hospitals is operational to provide uniform system-wide communication and to escalate problems identified with the screening process.

An important part of the health system’s response to COVID-19 is our commitment to protecting all of our faculty, staff and learners and, particularly, the vulnerable members of our community. The following criteria for distinct populations, aligned with the CDC recommendations, should be used:

PATIENTS – Pregnancy & Breastfeeding

  • Pregnancy.  Pregnant patients merit special consideration. At the present time, there is no conclusive evidence that patients that are pregnant and become infected with the COVID-19 virus have a worse course compared to similar patients that are not pregnant.  Preliminary evidence suggests that, unlike influenza which may cause more aggressive disease in pregnant women, COVID-19 does not. These are early data, so we will continue to monitor the evidence as it becomes available and update any guidelines if this changes. Our obstetrical providers will be managing prenatal outpatient care on a case-by-case basis.  Urgency of non-obstetric care for pregnant women should be at the judgement of the clinician.
  • Breastfeeding. Women who are breastfeeding merit special consideration. Breastfeeding does not increase the complications from COVID-19 for the mother or infant. The virus does not appear to pass through the breast milk.  Breastfeeding and bottle feeding both have close proximity of the mother and child, therefore a COVID-19 positive mother should use PPE precautions when feeding her infant via breast or bottle.

PATIENTS – Vulnerable Populations

  • Patients who are immuno-compromised are considered vulnerable.
    • Persons with primary or acquired immunodeficiency
    • Persons on anti-rejection therapy following solid organ transplant or bone marrow transplant
    • Persons on biologic therapeutic agents such as tumor necrosis factor inhibitors
    • Persons with malignancy and ongoing or recent chemotherapy
    • Persons receiving systemic immunosuppressive therapy, including corticosteroids equivalent to 20 mg/day of prednisone for ?2 weeks
  • People age 70 or above are considered vulnerable.

We are relying on the judgments of our clinicians to identify other patients who have increased risk of several diseases related to COVID-19.  Patients who fall into these vulnerable categories and whose ambulatory visit is judged to be non-urgent, should have their in-person appointments deferred.  If an appointment is deferred, a process must be in place to secure a future appointment within 60 days.

STAFF, LEARNERS & PHYSICIANS

Michigan Medicine leadership is dedicated to protecting our community of staff, learners and physicians.  The presence of any one of the following in care providers precludes participation in the direct care of patients with or under investigation for COVID-19:

  • Pregnant and breastfeeding staff, learners and physicians can continue to work regular assignments, including care of adults and children who are negative for COVID-19 risk-screening questions. Pregnant and breastfeeding staff, learners or physicians should not care for:
    • COVID-positive patients
    • Patients Under Investigation (PUI) while testing is pending
  • Pregnant staff, learners or physicians with additional risk factors, such as cardiac or pulmonary conditions, should call their obstetric provider’s office and discuss with the provider whether to continue to work or to self-isolate.
  • Immuno-compromised
    • Persons with primary or acquired immunodeficiency
    • Persons on anti-rejection therapy following solid organ transplant or bone marrow transplant
    • Persons on biologic therapeutic agents such as tumor necrosis factor inhibitors.
    • Persons with malignancy and ongoing or recent chemotherapy
    • Persons receiving systemic immunosuppressive therapy, including corticosteroids equivalent to 20 mg/day of prednisone for ?2 weeks
  • Age 70 or above
  • Physical restrictions that prevent donning and/or removing PPE safely.

Adoption of virtual care options, utilized in the appropriate clinical context, provides an important means to ensure continued access by providing patient care at a distance.  The UMMG has mobilized all of its Virtual Care resources to assist in physician enrollment in virtual care for the next two weeks.  This allows us the capacity to enable 200 providers per day to participate in virtual care.  Within the next two weeks, we can potentially enroll 2,000 providers at Michigan Medicine.  Successful enrollment requires preparation on the part of the provider.  Details on enrollment will be sent under separate cover today.

We are sensitive to the apprehension that the current situation causes regarding the personal health of front-line staff and providers, even with rigorous screening procedures in place.  Though not part of recommended PPE and not required, direct patient-facing employees and physicians may, at their discretion, use a mask for personal protection.  We ask that the use of masks be judicious due to supply constraints. Supply management may require that we change this in the future.

With all of these changes in our usual processes, there will remain patients with non-COVID-19 illnesses requiring in-person care.  As physicians, we will all be asked to care for sick patients who are not in high-risk categories, are asymptomatic and have negative screening questions.  We must continue to see these patients in our clinics if alternatives are not immediately available.  To close ambulatory care would have immediate and devastating consequences on our Emergency Department and inpatient units and have significant negative health consequences to the population. In addition, the complex health care ecosystem we have built together would be greatly damaged, and not ready for the backlog we will face when the current crisis abates.  Finally, and most importantly, our moral standing with our patients would be permanently eroded.  This is not the first, nor will it be the last instance when health care providers are called upon to step into the breach.  Past generations confronted SARS, AIDS, infectious hepatitis, tuberculosis. Our generation will do the same for COVID-19. 

Thank you for your hard work in these unprecedented times.

UMMG Leadership

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