Assessment, Monitoring and Management of COVID

For COVID@Home Monitoring, please see Ontario Health: Quick links overview of resources for care of COVID in the community

COVID-19 Key Messages for Family Practice Reception Teams

Boilerplate language for phone messages and websites

COVID Clinical Triage and Clinical Care: Quick links / FAQ support document for family practice clinical teams

Quick guide to a monitoring visit

PATIENT INFORMATION SHEETS 

Advice including red flags that can be emailed to patients is available here (includes pulse oximeter information)

Information for caregivers of children with COVID

Translated patient information documents for people being monitored at home

Evidence informed advice on how to carry out a remote consultation for COVID as recently published in the BMJ.  You may find the full paper and infographic useful.

COVID Remote ConsultationsDownload

Before the History

Do a quick assessment of whether the patient is sick or not sick?

  1. Is the patient too breathless to talk? Can you hear them gasping on the phone? Can they speak a full sentence or only a word at a time? Do they look very sick on the video (pale, cyanotic, gasping for breath)

If YES then will need an in-person assessment. If dyspnea is severe refer to ED immediately without examination.

  1. Do they have chest pain/pressure?  If yes, then will need at minimum an in-person examination and cardiovascular risk assessment. 

Refer to ED if chest pain suggestive of severe COVID or ischemia.*

Note COVID also commonly gives myalgia affecting chest wall which does not necessarily mean severe COVID

If the patient does not sound or appear SICK, clarify what they expect from the appointment.

  • Do they want a sick note?
  • Do they want reassurance?
  • Do they want advice on self-isolation?
  • Do they need a referral?
  • Do they want a clinical assessment? (may need to dissuade and reassure if not unwell)
  1. Record date of symptom onset OR date of positive test (important for calculating end of isolation period)
  2. Record symptoms and note change (see symptom algorithm for usual symptoms). Key symptoms are dyspnoea / hypoxia and GI symptoms for assessment of hydration risks.

Be on the lookout for atypical symptoms in children, seniors >70 years and people living with a developmental disability. These may include delirium, unexplained or increase in falls, acute functional decline, exacerbation of chronic conditions. Symptoms and signs in young children may include lethargy and/or decreased feeding (if no other diagnosis), croup and unexplained tachycardia (using age specific tachycardia reference ranges for children). Children have also been reported as presenting with lesions on extremities resembling chilblains / pernio, and rarely with atypical Kawasaki disease. Read more about emerging evidence on the syndrome from the CEP here as well as in the pediatric assessment subsection in this section (#11).

  1. Ask about urine output and fluid intake
  2. Note underlying chronic disease that indicates increased risk
  3. Check for red flag symptoms (see When to Refer to ED and Who to Call for Acute Care Advice section below)
    • RESPIRATORY
      • Severe shortness of breath at rest
      • Difficulty in breathing
      • Increasing significant fatigue (reported in some patients as a marker for hypoxemia without dyspnea)
      • Blue lips or face
      • Hemoptysis
    • OTHER
      • Cold, clammy, or pale and mottled skin
      • Reduced level of consciousness or new confusion
      • Little / no urine output
      • Pain or pressure in the chest
      • Syncope

Phone: Ask patient or caregiver to describe state of breathing (see questions below) and colour of face and lips

Video: In addition, assess demeanor, colour above, the extent of respiratory effort and count respiratory rate

Should I use the Roth score? NO Click here for more detail.

  1. Ask the patient (or caregiver) to describe the problem with their breathing in their own words, and assess the ease and comfort of their speech. Ask open-ended questions and listen to whether the patient can complete their sentences.
    • “How is your breathing today?”
  2. Then specifically check symptoms
    • “Are you so breathless that you are unable to speak more than a few words?”
    • “Are you so breathless that you need to pause when eating?”
    • “Are you breathing harder or faster than usual when doing nothing at all?”
    • “Are you so ill that you’ve stopped doing all of your usual daily activities?”
  3. Focus on change. A clear story of deterioration is more important than whether the patient currently feels short of breath. Ask questions like
    • “Is your breathing faster, slower or the same as normal?”
    • “What could you do yesterday that you can’t do today?”
    • “What makes you breathless now that didn’t make you breathless yesterday?”

Interpret the breathlessness in the context of the wider history and physical signs. For example, a new, audible wheeze and a verbal report of blueness of the lips in a breathless patient are concerning.

In addition, a video examination will add key detail such as whether the patient is blue, the extent of respiratory effort and the opportunity to count the respiratory rate.

Check out this resource for additional information on conducting a remote assessment in primary care.

Temp, pulse, BP and O2 sats depending on home equipment. Interpret self-monitoring results with caution in the context of your wider assessment.

Note change from previous

Oxygen Saturation

Helpful tool to indicate disease severity when available, especially if available at beginning and can monitor change.  

If previously healthy lungs or previously documented normal O2 sat – a new consistent background reading of < 92% is a red flag

If underlying lung disease with documented low normal O2 sat at baseline – a new reading of < 90% is a red flag If patient on home oxygen normally and their O2 requirements increase with COVID illness – this is a red flag.

 Low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg) is a red flag sign to consider admission.

This is rarely necessary for monitoring COVID positive patients. If red flags are present including hypoxia the patients should be transported without delay. Auscultating the chest does not generally help in deciding whether a COVID+ patient needs admission, which can be guided by red flags. 

Assessment may be needed for admission for IV fluid resuscitation but again if this is obvious in the virtual assessment transfer should not be delayed by in person assessment. Assessment for other conditions should be guided by usual clinical judgement and Full PPE should be worn if deemed necessary.  

Mild or moderate cases have been generally defined based on less severe clinical symptoms (low grade fever, cough, discomfort) with no evidence of pneumonia. 6,10

More Severe Illness

Pneumonia and Hypoxemia indicate more severe illness (O2 Sats <95%. In someone with pre-existing COPD, may be lower – depends on usual sats when well)

Diagnosing pneumonia

  • T > 38
  • RR > 20 breaths/ minute
  • HR > 100
  • New confusion

Plus clinical impression: The diagnostic accuracy of  “overall clinical impression” is close to ruling in pneumonia, in an emergency. (Systematic Review of 9 studies 2019)

Other distinguishing symptoms and signs that help identify patients with more severe illness to make the decision about hospital admission, see When to Refer to ED and Who to Call for Acute Care Advice in the next tab on this page.

Distinguishing from bacterial pneumonia

It is difficult to distinguish between viral and bacterial pneumonia. However, as community prevalence becomes higher patients will be more likely to have a COVID viral pneumonia than a bacterial pneumonia. The UK National Institute for Clinical Excellence suggests these things may help:

COVID pneumonia more likely

  • Patient has had typical COVID symptoms for about a week
  • Has severe muscle pain (myalgia) including chest wall myalgia
  • Has recent onset loss of sense of smell / taste
  • Feels breathless but has no pleuritic pain
  • Has a history of potential COVID exposure (this may become less important as community prevalence increases)

Note also

Return of cough after period of improvement may signal development of COVID pneumonia Return of fever after afebrile period may signal development of COVID pneumonia

Bacterial pneumonia more likely

  • Becomes rapidly unwell after a few days of symptoms
  • No history of typical COVID symptoms
  • Pleuritic pain
  • Purulent sputum

Consider emergent transfer to ED (unless not congruent with goals of care*) if:

  • Note red flag vitals R >110, RR >24 
  • O2 sat red flags: SPO2 consistently ≤ 92%; Rapidly reducing O2 saturation (e.g. change of 3% in 24 hours despite being 93 or greater); Underlying lung disease with documented low normal O2 sat at baseline – a new reading of < 90% is a red flag, If patient on home oxygen normally and their O2 requirements increase with COVID illness. 
  • Severe shortness of breath at rest (e.g. Breathlessness RR >30 despite normal O2 sats)
  • Difficulty in breathing (work of breathing)
  • Reducing O2 saturation (see guidance under Examination/Assessing Vital Signs on this page)
  • Pain or pressure in chest
  • Decreased oral intake or urine output (dehydrated, needing IV fluids)
  •  Low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)  
  • Cold, clammy or pale mottled skin
  • New onset of confusion, becoming difficult to rouse, syncope
  • Blue lips or face
  • Coughing up blood

Other symptoms indicating severe illness, or significant or rapid deterioration including markedly increased fatigue if O2 Sats are not available.

The patients risk factors for more severe illness should be considered in making the decision to refer to ED: age (>65), comorbidities as above, immunocompromised, higher frailty score. In addition inability to self-isolate or lack of support at home may be other reasons to consider ED referral.

* see Managing Progressive Life Limiting Conditions (COVID and non COVID)

For Children: Indications to Send Patient for Paediatric Emergency Physician Assessment

  • Dehydration:
    • Poor fluid intake or feeding, significant losses (vomiting and/or diarrhea), decreased urine output
    • Signs and symptoms of dehydration
  • Respiratory Distress / Dyspnoea:
    • Tachypnoea
    • Grunting, nasal flaring, abdominal breathing, tracheal tug
    • Decreased air entry
  • Poor mentation:
    • Lethargic
    • Persistent irritability
  •  Concerning vitals (see normal range chart for age section 11)
  • Increasing Caregiver or Provider Concern:
    • If parent / caregiver or provider is concerned that child is progressively worsening
  • Fever greater than/equal to 5 days
    • Prolonged fever warrants the consideration of Kawasaki Disease or multisystem inflammatory syndrome in children up to 8 weeks from onset of COVID illness.

Do not hesitate to contact the Pediatric Emergency Medicine Physician on-call at MUMC (905-521-5020) if assistance is needed in clinical decision-making and management

For patients who are COVID+ that you may have questions about their acute care or potential need to transfer to ED. SJHH and HHS and MUMC have offered the following specific support:

  • At MUMC: Do not hesitate to contact the Pediatric Emergency Medicine Physician on-call (905-521-5020) if assistance is needed in clinical decision-making and management
  • At SJHH: an Emergency Physician at SJHH is available daily from 4-5 to provide any advice and support needed. To contact this physician, call the SJHH ED at 905-522-1155 x 32043 and a clerk will provide the contact number to connect directly with the ED physician covering that day
  • At Hamilton Health Sciences: Family Physicians can reach out to the on-call physician for the Connected Health Hamilton program at HHS by calling the Virtual Command Centre 7 days a week at: 905 577 1409. The VCC nurse will then take the contact details of the Family Medicine doctor and will convey the message to the on-call doctor during their daily check-in (usually between 1pm-2pm unless they have a conflict). The on-call doctor will call the Family Physician directly to discuss any issues /provide support.

Access to COVID-19 specific econsults for specialist advice is available through OTN for Infectious Diseases, Vaccine – Public Health, Vaccine – Allergy/Immunology, Autoimmune Disorders and Pregnancy

Hamilton COVID Care Clinic

Access to Paxlovid specifically is now predominantly through primary care and other treating physicians rather that the COVID Care clinic. Please see this page for information and supports for the prescribing process, The COVID Care clinic provides limited service (for those who may need remdesivir where Paxlovid is contraindicated or for extremely complex patient) Please see the new referral form on the Antivirals and Paxlovid page that provides the specific criteria for referral.

  1. Confirm date of first symptoms (if symptomatic) OR date of positive test and give current isolation advice
  2. Check whether patient has had public health contact. If not, direct them to the City of Hamilton Isolation Guide.
  3. Check equipment patient has available. (Instructions on this are in the patient handout pdf found at the end of the 7. Management / Patient Advice section. Patients can also be directed to a YouTube video for instructions on using a pulse oximeter on hfam.ca patient resources tab: found under “For Patient With COVID Illness” heading).
  4. Patient can be directed to other hfam guides for patient with COVID illness under the patient resources tab.
High Risk Average Risk Low Risk
Patients with any of the safety net flags Otherwise healthy fully vaccinated (primary series plus booster) adults with non-concerning symptoms2,4; asymptomatic adults
Patients with symptom deterioration or symptoms of concern (dyspnea or significant diarrhea)2 Pregnant women 1-60 years old with no medical comorbidities
Any age with medical comorbidities who are not fully vaccinated (primary series plus booster) Unvaccinated (excluding asymptomatic)*
Age > 60 not fully vaccinated Patients > 60 or with comorbidities at any age who are fully vaccinated (primary series plus booster) and have milder symptoms (i.e., no dyspnea or significant diarrhea)
MONITOR
Daily for 7 days then every few days, depending on progress until symptoms resolve		 MONITOR
Every few days x 7 days; then could recommend self-monitor for additional 7 days depending on progress		 MONITOR
Consider self-monitoring only; check-ins determined by individual patient. (Consider at 5-7 days for children and symptomatic adults especially in the 40-60 age group)3

NOTE 1: Adults and older children in High Risk category should have home pulse oximeter to assist monitoring if available. For Average Risk patients use clinical judgement. For example if comorbidities are of more concern e.g. significant COPD, or if there is prominent patient anxiety (remembering a goal of use is to reduce ED attendance and unnecessary healthcare use through reassurance). Pulse oximeters are not recommended for monitoring of younger children. 

NOTE 2: Patients (adults and children) in the low risk category with increasing symptoms move to the high risk/daily monitoring (including pulse oximeter) category. With current restriction of access to PCR and therefore later presentation of patients to primary care, otherwise healthy adults with concerning symptoms at presentation (i.e., dyspnea, significant diarrea) should be monitored more closely – i.e., treated as “symptom deterioration”.  Asymptomatic patients should have their risk category reassessed if they develop symptoms.

NOTE 3: Children with more prominent respiratory symptoms should be more closely monitored.

NOTE 4: in patients with significant fatigue in the low risk category, consider using pulse oximetry to determine this is not due to hypoxia.

NOTE 5: *Based on the latest data from 12 provinces and territories for the eligible population, 12 years or older: 0.08% of fully vaccinated people became infected, with the majority of recent cases and hospitalizations occurring in unvaccinated or partially vaccinated people.

  • The average weekly rate of new COVID-19 cases in unvaccinated people was 11 times higher than in the fully vaccinated.
    • The average weekly rate of hospitalized cases in unvaccinated people was 39 times higher compared to fully vaccinated people

*In patients who required hospitalization, the median time from symptom onset to dyspnea was 5 days.
In patient who developed ARDS the median time to onset was 3 days after development of dyspnea (around 8 days after symptom onset). 

Safety Net Flags

  • Socially isolated (Lives alone, unable to connect with others through technology, little to no social network)
  • Lack of caregiver support if needed (including safe environment for care of children)
  • Inability to maintain hydration (Diarrhea, vomiting, cognitive impairment, poor fluid intake)
  • Food/financial insecurity
  • Receive homecare support
  • Challenges with health literacy or ability to understand treatment recommendations or isolation expectations
  • Unable to self-manage
  1. Assess current symptoms and change (better / worse). See symptoms / atypical symptoms in history section above.
  2. Vitals – patient to record until symptoms resolve
    • once daily T, BP (if patient has access to a cuff)
    • twice daily HR, RR, +/- SPO2
    • Note normal age ranges for RR and HR are provided in Pediatric section 11)
    • Note red flag vitals R >110, RR >24 
    • O2 sat red flags SPO2 consistently ≤ 92%; Rapidly reducing O2 saturation (e.g. change of 3% in 24 hours despite being 93 or greater); Underlying lung disease with documented low normal O2 sat at baseline – a new reading of < 90% is a red flag;  If patient on home oxygen normally and their O2 requirements increase with COVID illness. 
  3. Assess level of dyspnoea (see Examination/Remote Examination on this page for tips on assessing dyspnoea virtually)
  4. Check urine output and fluid intake
  5. Check for respiratory and other red flag symptoms (See detail in When to Refer to ED and Who to Call for Acute Care Advice section which includes pediatric sections)
    • RESPIRATORY
      • Severe shortness of breath at rest (e.g., Breathlessness RR >30 despite normal O2 sats)
      • Difficulty in breathing
      • Increasing significant fatigue (reported in some patients as a marker for hypoxemia without dyspnea)
      • Blue lips or face
      • Hemoptysis
    • OTHER
      • Cold, clammy, or pale and mottled skin
      • Reduced level of consciousness or new confusion; poor mentation in children (lethargic; persistent irritability)
      • Little / no urine output / also poor feeding in children
      • Pain or pressure in the chest
      • Syncope
      • Parental or Provider concern about progressively worsening symptoms in children
      • Fever >38 > 5 days in children
  1. Note underlying chronic disease that indicates increased risk. For patients with diabetes increase to daily monitoring.
  2. Assess need for regular medication changes or advice (see “management” tab below).
  3. Check mental health, access to food, support or carer, financial or housing stress.
  4. Assess whether this patient can still be managed at home (see When to Refer to ED and Who to Call for Acute Care Advice tab: consider whether goals of care conversation is appropriate).
    For patients who are COVID+ that you may have questions about their acute care or potential need to transfer to ED. SJHH and HHS have offered the following specific support:
    • At SJHH: an Emergency Physician at SJHH is available daily from 4-5 to provide any advice and support needed. To contact this physician, call the SJHH ED at 905-522-1155 x 32043 and a clerk will provide the contact number to connect directly with the ED physician covering that day
    • At Hamilton Health Sciences: Family Physicians can reach out to the on-call physician for the Connected Health Hamilton program at HHS by calling the Virtual Command Centre 7 days a week at: 905 577 1409. The VCC nurse will then take the contact details of the Family Medicine doctor and will convey the message to the on-call doctor during their daily check-in (usually between 1pm-2pm unless they have a conflict). The on-call doctor will call the Family Physician directly to discuss any issues /provide support.
  5. Give detailed management advice (see management tab below)
  6. Set up time for next follow-up – If follow-up falls on weekend make plan for this.

COVID Care Clinics at St. Joseph’s Healthcare Hamilton Charlton Site

EMR Templates

You can download EMR templates of this COVID monitoring pathway, with embedded links to hfam, from the EMR tools section of HFAM.

One page summary guide to monitoring visits

Here also is an example of a monitoring template you could use all or parts of to track all your clinic patients. Download or save a copy of this template.

Billing codes are COVID Codes (effective March 14, 2020)             

  • K080A: minor assessment of a patient by telephone or video, <10 minutes $23.75
  • K081A: intermediate assessment of a patient by telephone or video ≥ 10 minutes $36.85
  • (And if applicable K082A: primary mental health care, psychotherapy or psychiatric interview conducted by telephone or video $67.75)
  • These codes are in basket.
  • They are eligible to be billed with Q012A (after hours premium and on weekend) if calling patient after hours or weekend/holiday.
  • Other billing codes can be found here.

Here is a summary sheet as a guide for a COVID care monitoring.

Here is an example of a completed COVID-19 Ward Monitoring Sheet.

Here also is an example of a monitoring template you could use all or parts of to track all your clinic patients.  Download or save a copy of this template

EMR Tools are available to assist with monitoring too.

1. Ministry of Health pulse oximeters

Oxygen saturation monitors from the Ministry of Health to primary care providers has restarted. They will have supplies and stat processing orders in the week of Jan 3, but you can order now using this weblink: COVID@Home Monitoring for Primary Care (alchemer.com). They will ask you details about practice size, etc., and will help you estimate how many you need. Delivery time previously was around 2 days from when they process the order.  

Pulse Oximeter Patient Instructions (ProResp) (note: These instructions are wrapped into the full patient information pdf in section 7 Management / Patient Advice as well.)

Translated Pulse Oximeter Patient Instructions are available in Arabic, Bengali, Chinese (simplified), Dari, French, Hindi, Portuguese, Russian, and Spanish.

Note on pulse oximeters in children

Specialized pediatric pulse oximeters are not available as while adults and older children in High and Average Risk categories should have home pulse oximeter to assist monitoring if available, pediatrics recommend against pulse oximeters for monitoring of younger children.

Public Health Guidance: Pulse oximeters should be cleaned with approved alcohol wipes and then ordered by return date in storage. Public Health advice suggests this cleaning plus a 24-hour “rest period” before re-allocating to protect those handling devices for the patient.

Please also see the pdf of a patient advice sheet that can be emailed to patients, found at the end of this section as well as on the patient resources tab on this website that patients could be directed to. This should be given to all patients whether self monitoring or needing ongoing monitoring, if at all possible. 

  1. Set expectations – similar to influenza this is most often a longer recovery than “A.Virus.” Explain that the typical symptoms are cough, fever and fatigue but they may also have breathlessness, muscle aches, sore throat, diarrhea, headache and loss of sense of smell / taste. A detailed description of the symptom timeline over 14 days is in the patient handout at the end of this section.
  1. REST – fatigue is often a marker for hypoxia, and experience with more unwell patients tells us increased mechanical work of breathing may lead to increased lung damage, so it makes sense NOT to do anything that triggers dyspnea / tachycardia. It patients have pulse oximeters they can measure after different activities and this is a way to reinforce this message.

  1. Change position to aid breathing (prone lying is used for inpatients, there is no evidence for outpatients either way but it makes sense to change positions including prone to move secretions and change mechanical work of breathing). Instructions are included in the emailable pdf at the bottom of this section and the patient resources tab on this website.

  1. Give clear guidance on who to contact if symptoms (such as breathlessness) get worse*
    For example, give patient a self-monitoring checklist with a plan for deterioration, as well as details about the contact process:
    1. Call 911 if:
      • You have severe trouble breathing or severe chest pain.
      • You are very confused or not thinking clearly.
      • You pass out (lose consciousness).
    2. Call clinic if:
      • You have new or worse trouble breathing.
      • Your symptoms are getting worse.
      • You start getting better and then get worse.
      • You have severe dehydration such as:
        • having a very dry mouth
        • passing only a little urine
        • feeling very light-headed
        • For patient with pulse oximeters: as outlined in the instructions for use, your care team will advise you what pulse oximetry levels are acceptable for you. Generally, an oxygen level of 93% or greater is acceptable. Call the clinic if your reading is below this level after rechecking or if your oxygen level changes by 3%.

  1. Give advice to ensure adequate hydration

  1. Direct to latest information on self-isolation / caring for someone with COVID

7. Direct patient and carers to information on mental health social supports etc. as appropriate (patient resources tab on HFAM)

PATIENT INFORMATION SHEETS  

*A pdf of advice including red flags that can be emailed to patients is available here.  it also includes pulse oximeter information. 

A PDF of Information for caregivers of children with COVID is available here. 

Translated Patient information documents for people being monitored at home are available in Arabic, Bengali, Chinese (simplified), Dari, French, Hindi, Portuguese, Russian, and Spanish. 

Treatment medications

Supply issues may constrain available treatments. Monitoring is the most important part of management however if accessible consider the following treatment options in eligible patients.

Think about using

Antiviral (Remdesivir/Paxlovid)

ACCESS: Paxlovid access for eligible patients is now primarily through primary care. For those patients who have complex interactions / are potentially ineligible for Paxlovid, remdesivir is accessed only through the Hamilton COVID Care Clinic (CCC) and outside Hamilton through other CACs (see Hamilton CCC Referral form lower down page). Sotrovimab is no longer recommended as effectiveness has changed against newer variants, so for those unable to take Paxlovid 3 days of Remdesivir will be offered. Please see the Antivirals and Paxlovid page for details on referrals and prescribing.

WHO: Antiviral (Remdesivir/Paxlovid) are recommended for mildly ill patients who present within 7 days of symptom onset (5 days for Paxlovid) and meet any one of the following eligibility criteria for being in a high risk population. Full details on criteria and referral process are available on this page.

Eligibility criteria have changed and as of Dec 9, 2022, the following higher-risk groups are eligible to be tested and assessed for antiviral treatments, such as Paxlovid, in Ontario.

Confirmed COVID-19 diagnosis (based on positive PCR, rapid molecular, or rapid antigen test result), present within 5 days of symptom onset, and meet one or more of the following criteria:

  • >60 years of age
  • 18 years of age or older and immunocompromised
  • 18–59 years of age and at higher risk of severe COVID-19. “higher risk” is defined below:
  1. One or more comorbidity with higher risk of severe COVID-19 disease (detailed list in link) 
  2. Inadequate immunity, i.e.: Unvaccinated or incomplete primary series OR Completed primary series AND last COVID-19 vaccine dose was more than 6 months ago AND last SARS-CoV-2 infection was more than 6 months ago
  3. Social determinants of health may confer an increased risk of disease progression. Individuals who are at a higher risk of poor outcomes from COVID-19 infection based on social determinants of health should be considered priority populations for access to Paxlovid. Individuals at higher risk include Indigenous people, Black people, other members of racialized communities, individuals with intellectual, developmental, or cognitive disability, people who use substances regularly (e.g., alcohol), people who live with mental health conditions, and people who are underhoused.

Combinations of risk factors are associated with higher risk of severe COVID-19.

Paxlovid Antiviral

Information updated March 2, 2022 (Note December 10, 2022: There is no substantive new trial evidence since this date. A trial is currently underway in Ontario in the primary care, vaccinated population.)

What is it?

Paxlovid consists of a drug that blocks an enzyme the coronavirus needs to reproduce – a similar mechanism to some anti-HIV drugs – as well as another drug that slows the drug’s breakdown. It has been approved for use in Canada in Jan 2022.

The only data available on the medication is from a trial in an unvaccinated population. This RCT among 2,246 high-risk non-hospitalized patients who were unvaccinated was reported to reduce the risk of hospitalization.

Over 28 days 0.7% vs 6.5% were hospitalized in paxlovid vs placebo arms (p<0.0001). (Deaths were 0% vs 1.3%). Laboratory based data suggests this effectiveness is likely to hold for the omicron variant. Pregnant or breastfeeding women, those with active HIV (viral load > 400 copies/ml) or on particular HIV medications, those with liver disease and significant renal impairment and low risk fully vaccinated individuals were excluded from the trial. You can read the trial publication here.

DOSE: 3 tablets (150 mg nirmatrelvir 2 tablets; 100 mg ritonavir 1 tablet) taken together twice daily for 5 days. It is important that all tablets are taken together twice daily. (note there is a dose adjustment for renal impairment which is why the nirmatrelvir comes as 2x150mg)

Most common side effects reported: dysgeusia (making everything taste bitter, sour or sweet)  diarrhea, hypertension, headache and myalgia.

Other important prescribing information

There is quite a long list of contraindications as well as potential serious interactions that require changes in drug dosing or scheduling.

1. There is a contraindication / dose adjustment for impaired renal function

Contraindicated if GFR <30ml/min; If GFR 30-60 dose adjust to:

150 mg of nirmatrelvir (one tablet rather than two) along with 100 mg of ritonavir, taken together, twice daily, in the morning and evening

2. Paxlovid is not recommended for use in severe hepatic dysfunction

3. There is no data on use in pregnancy and breastfeeding so there is an “only if the risks outweigh the benefits” statement– see full product info sheet for full information.

4. Paxlovid is CONTRAINDICATED with drugs that are highly dependent on CYP3A for clearance. There are also a large number of potentially serious interactions that REQUIRE DOSE CHANGE OR SCHEDULE MODIFICATION. See Table 1 for contraindicated medications and Table 4 for serious interactions requiring modification of therapy or monitoring in the attached tables from the drug datasheet.  Commonly used medications in primary care are flagged in green.  

5.  In addition Paxlovid cannot be started immediately after discontinuation of any of the following medications due to the delayed offset of the recently discontinued CYP3A inducer

Anticancer drugs: apalutamide

Anticonvulsants: carbamazepine, phenobarbital, phenytoin

Antimycobacterials: rifampin

Herbal products: St. John’s Wort (hypericum perforatum)

Health Canada approved Product Monograph including patient medication information

PAXLOVID PRESCRIBING PROCESS

Access to Paxlovid specifically is now predominantly through primary care and other treating physicians rather than the COVID Care Clinic. Please see this page for information and supports for the prescribing process. The COVID Care clinic provides limited service (for those who may need remdesivir where Paxlovid is contraindicated or for extremely complex patient) Please see the new referral form on the Antivirals and Paxlovid page that provides the specific criteria for referral.

Inhaled corticosteroids (ICS):
  • It seems reasonable to consider inhaled corticosteroid use in early COVID-19 in patients similar to the trial population group: symptom duration may be shortened.
  • WHO: Symptomatic + higher risk of serious illness (aged ≥65 years or ≥50 years with specific comorbidities) + interested in using them
  • DOSE: The dose in the trial was budesonide 800µg BID for 14 days. Budesonide is first choice as it is unclear if this is a class effect.  If there are supply issues with budesonide use the equivalent dose calculation of other inhaled corticosteroids.  

Budesonide (Pulmicort Turbuhaler) 400mcg/puff  Inhale 2 puffs bid (800mcg bid).  Rinse mouth after use (add to any rx below as well) how to use turbuhaler

Equivalents (not exceeding max dose per monograph) would be:

Fluticasone propionate diskus (Flovent diskus) 500mcg/puff 1 puff bid (500mcg bid) how to use diskus inhaler

Fluticasone furoate (Arnuity Ellipta) 200mcg/puff 1 puff once daily how to use ellipta inhaler

Mometasone (Asmanex Twisthaler) 400mcg/puff 1 puff bid (400mcg bid.  Usually dosed daily, but max dose is 400 bid) how to use twisthaler inhaler

Beclomethasone dipropionate (QVAR MDI) 100mcg/puff 4 puffs bid (400mcg bid) how to use metered-dose inhaler without spacer how to use metered-dose inhaler with spacer

Ciclesonide (Alvesco MDI) 200mcg/puff 2 puffs bid (400mcg bid. Usually dosed daily, but max dose is 400 bid) how to use metered-dose inhaler without spacer how to use metered-dose inhaler with spacer

Fluticasone propionate HFA (Flovent MDI) 250mcg/puff 2 puffs bid (500mcg bid) how to use metered-dose inhaler without spacer how to use metered-dose inhaler with spacer

(from rxfiles asthma ICS chart)

ODB coverage: all of the above are covered.

Oral steroids result in worse outcomes for mild-moderate COVID compared with more serious illness as above. There was initial uncertainty about the potential benefits / harms of ICS as some studies suggested better outcomes while some suggested worse. A new large randomised trial in primary care patients was published in August 2021, and in the patient group who are at risk of more serious illness ICS shortened the time to first self-reported recovery by an estimated median of 2·9 days (11·8 days in the ICS group versus 14·7 days in the usual care group). For the outcome of hospital admission or death the trial did not achieve the superiority threshold  for ICS vs usual care.

Various subgroup analyses in PRINCIPLE do not provide any pointers to which particular patient or illness characteristics in the included population might be more likely to predict benefit. These trial data do not support use in younger populations who are at lower risk of complications (<65 years with no comorbidities or anyone <50 years). Because vaccination was uncommon in trial participants, an important question is whether and what effect would be seen in the fully vaccinated population who have a different illness severity and trajectory. You can read here the more detailed commentary on this trial by Professor Dee Mangin and Assoc Professor Michelle Howard Department of Family Medicine McMaster University.

Could be considered with caution

Fluvoxamine:
  • In the face of the current omicron surge and its yet unknown effect on a hospitalization spike the Ontario Science table have made a recommendation that fluvoxamine may be considered for mildly ill patients presenting within 7 days of symptom onset who are at a higher risk of serious illness. This recommendation is based on very low certainty evidence of reduction in hospitalization (one pre-print meta-analysis of 3 RCTs, mostly driven by one main trial).
  • The Ontario Science tables notes “This recommendation balances the very low certainty evidence of benefit for preventing hospitalization with the need for management options for mild illness with a reasonable safety profile during a surge in COVID-19 cases due to the Omicron variant.”
  • Note that the SSRI fluvoxamine is not widely used as an antidepressant as it has many side effects and interactions with commonly used medications, so it is important to read further to understand the potential risks and potential benefits before considering prescribing.
  • WHO: Patients at higher risk for more serious illness (Symptomatic + higher risk of serious illness i.e., aged ≥60) years or ≥50 years with specific comorbidities) + interested in using them; Prioritize those unvaccinated or >6 months since last vaccine dose.
  • DOSE: 50mg BID titrated up to 100mg BID over the first few days as tolerated. This was the most commonly used dose used in the main positive RCT (one smaller RCT used 300mg however was stopped for futility so the effect of a higher dose is unclear and tolerability will be better at lower doses). Note as with all SSRIs gradual dose reduction should occur at course completion.

Summary by Dee Mangin, Shelley House, Michelle Howard and Inge Schabort:

Points to consider when prescribing:
  • Detailed pharmacological / pharmacy assessment and patient advice and informed decision making is imperative prior to initiation (a consultation with a pharmacist would be a helpful approach) or a note on the prescription “feel free to contact re: drug interactions or concerns”.
  • Close clinical follow-up is also essential for adverse effects.
Potential Risks:

The detail you need on adverse effects and potential interactions is available here in the product monograph, Sections 7-9, as well as the supplementary material from the main trial on their medication contraindications. Most notable risks: numerous drug interactions/duplication, bleeding risk, Serotonin syndrome, SIADH (particularly important in older adults). It is also worth noting that caffeine and NSAIDS were prohibited medications during the trial and that pregnancy and breastfeeding were among a range of other important exclusions* (see below for list). The patient discussion should include the usual red flag warnings with SSRIs about emergent suicidality or akathisia/agitation.

Potential Benefit:

Evidence Summary:

A meta-analysis that has yet to be peer reviewed was based on three trials, one smaller one was stopped for futility and one larger one was stopped for benefit. The meta-analysis concludes fluvoxamine could be considered “particularly in people without access to SARS-CoV-2 monoclonal antibody therapy” and this seems a reasonable caveat given the access in Hamilton to monoclonal antibodies.

The risk ratio of hospital admission compared with placebo was 0.75 (95%CI 0.57-0.97). The meta-analysis effect was largely driven by one main trial in an unvaccinated population in Brazil, which has a number of potential biases reducing certainty in the estimate of effect (hence the Science Table’s low certainty rider). You can read a summary of the evidence here with links to the papers and a meta-analysis.

On the basis of these data, and if there is an emergency situation of rapidly increasing hospitalisation seen, fluvoxamine could be considered for use in early COVID-19 in patients similar to the trial population group (people who are symptomatic with COVID-19 confirmed on PCR or RATs ≥65 years or ≥50 years with specific comorbidities) who are interested in using it.

These trial data do not provide evidence for effect of use in younger populations who are at lower risk of complications (<50 years and no risk factors).

Are other SSRIs the same?

It is not clear that there is a class effect. The mechanism of effect is unclear. Besides being a SSRI, Fluvoxamine also has a putative/presumed anti-inflammatory effect which was the hypothesis behind the trials.

Click here for more information.

Information for Prescribers and Pharmacists on Fluvoxamine (Ontario Science Table, January 12, 2022)

Antibiotics

DON’T USE

  • Hydroxychloroquine should NOT be used. Recent studies indicate there is no evidence for benefit from azithromycin, HCQ or the combination in outpatient management of COVID in time to recovery or risk of hospitalization.
  • Recent studies indicate there is no evidence for benefit from doxycycline.
  • Ivermectin, there is no convincing evidence for benefit on mortality, need for invasive mechanical ventilation, hospital admission, duration of hospitalization and time to viral clearance.
  • Oral steroids should not be used in ambulant community dwelling primary care patients. Meta-analysis shows the evidence for benefit is only in patients requiring oxygen. There is evidence that if used in milder patients (not requiring oxygen) mortality is increased. Think: COVID is not like a COPD exacerbation.

Clinical Practice Guideline Summary: Recommended Drugs and Biologics in Adult Patients with COVID-19 (Ontario Science Table, January 8, 2022)

Comfort Medications

  • Acetaminophen is safer than NSAIDS (not specific to COVID but NSAIDs increase the cardiovascular risk in any viral illness). Read more here.

Existing Medications

  • ACEs and ARBs seem safe. Read more here.
    • Medications for COPD and Asthma should be continued. Read more here.
    • If the patient is at risk of dehydration (e.g. diarrhoea) think of acute kidney injury risk (SADMAN) if they are on an ACE / ARB plus diuretic plus aspirin these may need pausing to avoid AKI which is a significant feature of more severe COVID illness.
    • If the patient is on immunosuppressant medications consult with the relevant specialist – they may need pausing.
  • No specific investigations are necessary for monitoring mild – moderate COVID in the community setting, except as guided by comorbidities
  • CXR may be indicated to assess for bacterial pneumonia

Aim is to keep O2 saturation between 92% but not above 96% for best outcomes for COVID-19.  This can help agitation and confusion. For other symptom management and management of dyspnoea please see the palliative symptom management resources pathway.

You can obtain a pulse oximeter for patients who do not have one here.

Steroids

Consider also initiating steroids in patients in whom oxygen is required. Usual dose is dexamethasone 6mg OD for 7 days. Appropriateness will be determined by patient context and safety.

NOTE: Patients with COVID-19 undergoing treatment with dexamethasone and/or tocilizumab who have Strongyloides may be at increased risk of disseminated Strongyloidiasis, which can carry a mortality rate of greater than 85%. Infection is usually asymptomatic so all patients should be screened for epidemiological risk of Strongyloides prior to starting steroids or tocilizumab and treated with Ivermectin.  Epidemiological risk includes patients born in or residing consecutively for more than 6 months in any of the following regions: Southeast Asia, Sub-Saharan Africa, South America, Caribbean, Mediterranean, Middle East, North Africa, Indian Sub-continent, Asia, Oceania (exclude non-aboriginal Australians and New Zealand). These patients should all receive Ivermectin prior to steroids or toculizimab or other immunosuppressant treatment for COVID. Detailed information and dosing here.

Evidence for Oxygenation targets

Current NIH guidelines for oxygenation targets in COVID-19 are congruent with local GIM advisers recommendations and state:

“The optimal oxygen saturation (SpO2) in adults with COVID-19 is uncertain. However, a target SpO2 of 92% to 96% seems logical considering that indirect evidence from experience in patients without COVID-19 suggests that an SpO2 <92% or >96% may be harmful.”

In one trial of ventilated patients with COVID-19 and ARDS, those randomised to a lower target range (88-92%) had poorer outcomes and a higher mortality rate. However this trial has been assessed by the McMaster Evidence Review group as high risk of bias so the evidence remains uncertain.

Regarding the potential harm of maintaining an SpO2 >96%, the NIH guidance refers to a meta-analysis of 25 randomized trials involving patients without COVID-19 found that a higher SpO2 was associated with an increased risk of in-hospital mortality compared to a lower SpO2 comparator (relative risk 1.21; 95% CI, 1.03–1.43).

This applies to test positive (PCR, rapid molecular, or rapid antigen) or clinical symptom diagnostic algorithm positive.

Changes to ministry guidance include elimination of minimum isolation periods for most cases. Here’s a summary of current guidance:

  • Individuals who have symptoms of ANY respiratory illness should stay home until symptoms have been improving for at least 24 hours (48 hours if nausea, vomiting or diarrhea)
  • If they have a fever, they should stay home until the fever is completely gone.
  • Avoid non-essential visits to vulnerable people for a full 10 days starting the day after symptoms appear.
  • Symptomatic and test-positive individuals should wear a mask when in public spaces for 10 days from the start of symptoms/positive test result
  • For those who are hospitalized, immunocompromised or reside in a highest-risk setting (i.e., acute care, long-term care and retirement homes, group homes, shelters, etc.), 10-day isolation remains and symptoms must be improving as noted above. Note: does not include primary care (see points above which apply to Primary Care, and page 7 of Guidance).

For healthcare workers in highest-risk settings referenced above:

  • Close contacts of someone with a positive COVID test or symptoms may work in their highest-risk work setting if asymptomatic.
  • No change to isolation requirements for symptomatic or test positive individuals who work in highest-risk settings – may return to work 10 days after onset of symptoms or positive test result. Testing for clearance is generally not recommended. See Appendix A of Guidance for more, including options for critical staffing shortages and workplace measures for reducing risk.

Estimates of the prevalence of persistent COVID symptoms vary widely depending on the definition and the population (eg hospitalized vs all positive cases). For example the WHO suggests a significant proportion (around 10%) of patients report ongoing symptoms beyond the initial acute COVID-19 infection period (so-called “long COVID”), while another review suggested up to half of individuals can be affected. Other estimates in a recent UK study appeared to show significant rates of persistent abnormalities in investigations relating to different organs in low risk individuals, however it is not clear to what extent these measures represent pre-existing measurement abnormalities (as there were no premorbid measures).

Background Resource

Understanding the Post COVID-19 Condition (Long COVID) and the Expected Burden for Ontario (Science Table COVID-19 Advisory for Ontario)

Post-COVID Condition: Guidance for Primary Care (Ontario Health)

Persistent COVID Symptoms: Resources for Primary Care (Recording of Dr. Dee Mangin for Guelph-Wellington Education in Medicine Series (GEMS)) [slides]

Postural orthostatic tachycardia syndrome (POTS) is associated with Long COVID and can have debilitating effects on patients. The OCFP has developed this summary of information for diagnosing and treating POTS, including steps for the 10-minute standing test, and here is additional information in this BMJ Practice Pointer (Feb. 24) – Orthostatic tachycardia after COVID-19.

A virtual program for Long COVID patients is now available from Providence Healthcare. The program includes online educational meetings led by members of an interdisciplinary team, follow-up care and a tailored rehab plan. Get more information and refer eligible patients using this referral form. 

A one-page summary, guidelines and checklists to assist you in completing income support applications on behalf of patients, including for the Ontario Disability Support Program (ODSP).

Respiratory symptoms

  • Breathlessness
  • Cough

Cardiovascular symptoms

  • Chest tightness
  • Chest pain
  • Palpitations

Generalised symptoms

  • Fatigue
  • Fever
  • Pain

Neurological symptoms

  • Cognitive impairment (‘brain fog’, loss of concentration or memory issues)
  • Headache
  • Sleep disturbance
  • Peripheral neuropathy symptoms (pins and needles and numbness)
  • Dizziness
  • Delirium (in older populations)

Gastrointestinal symptoms

  • Abdominal pain
  • Nausea
  • Diarrhoea
  • Anorexia and reduced appetite (in older populations)

Musculoskeletal symptoms

  • Joint pain
  • Muscle pain

Psychological/psychiatric symptoms

  • Symptoms of depression
  • Symptoms of anxiety

Ear, nose and throat symptoms

  • Tinnitus
  • Earache
  • Sore throat
  • Dizziness
  • Loss of taste and/or smell

Dermatological

  • Skin rashes

These should be tailored to people’s signs and symptoms to rule out acute or life‑threatening complications and to help understand if symptoms are likely to be caused by ongoing symptomatic COVID‑19, post‑COVID‑19 syndrome or could be a new, unrelated diagnosis. It is important to avoid over investigation – patients with long COVID report this as a burden, so the question “Will this change my management / referral?” is useful

  • Blood tests may include a full blood count, kidney and liver function tests, C‑reactive protein test, and thyroid function tests.
  • Chest imaging: In the UK the National Institute for Clinical Excellence suggests offering a chest X-ray by 12 weeks after acute COVID-19 if the person has not already had one and they have continuing respiratory symptoms. They note Chest X-ray appearances alone should not determine the need for referral for further care, and may not be sufficient to rule out lung disease

Cardiac Symptoms and Complications

See guidance from the Canadian Cardiovascular Society COVID-19 Rapid Response Team

General Management

There is still limited understanding of the case and mechanisms underlying persistent symptoms, and limited evidence for management of the symptoms. Most recommendations favour a general rehabilitation model focussed on symptoms and functional improvement.

A study of healthcare professionals who experienced “long COVID” indicated that while family physicians cannot “fix” the symptoms, listening, validating and empathizing with the experience of the person’s suffering is a very valuable therapeutic tool, and that continuity of care and a single co-ordinator are very helpful.

This useful paper from the UK provides some specific guidance for management in primary care as well as indications for referral:
Management of post-acute covid-19 in primary care

You might find this short tool useful to assess functional limitation as well as progress:
The Post-COVID-19 Functional Status scale: a tool to measure functional status over time after COVID-19

Management of Persistent (> 2 weeks) COVID-19 olfactory disorder

  • Maintain smoke and natural gas detectors
  • Monitor food expiration dates and nutritional intake.
  • Olfactory training:
    • Deliberately smelling rose, lemon, cloves and eucalyptus for 20 seconds each twice a day, for at least 3 months.
  • A comparative study showed no evidence of additional benefit from intranasal steroids. Reference here

Rehabilitation

See links throughout for more references.

Signs and Symptoms of COVID-19 that Warrant Testing

  • Fever (38.0 °C)
  • Cough
  • Shortness of breath
  • Gastrointestinal symptoms (diarrhea, nausea, vomiting)
  • Loss of taste and smell
  • Lethargy
  • Sore throat, difficulty swallowing
  • Conjunctivitis, rhinorrhea in combination with other symptoms
  • Direct contact with a COVID-19 positive patient

NOTE: actively consider other diagnoses in COVID negative children e.g. pneumonia)

Where to send for Testing and MD Assessment

A PDF of a Pediatric COVID-19 Assessment Tool is available here.

Do not hesitate to contact the Pediatric Emergency Medicine Physician on-call at MUMC (905-521-5020) if assistance is needed in clinical decision-making and management.

Approach care as you would with any viral illness – screening for signs and symptoms of an unstable child. If an in-person assessment is not possible, video would be preferable to phone.

For COVID Positive Patients

During Initial Assessment:

  • Determine date of COVID positive swab
  • Length of Illness
  • Confirm family members are able to provide care for child

Then Monitor and Manage as per Main Monitoring and Management Risk Assessment and Pathway Templates

Indications to Send Patient for Paediatric Emergency Physician Assessment

  • Dehydration:
    • Poor fluid intake, significant losses (vomiting and/or diarrhea), decreased urine output
    • Signs and symptoms of dehydration
  • Respiratory Distress/Dyspnoea:
    • Tachypnoea
    • Grunting, nasal flaring, abdominal breathing, tracheal tug
    • Decreased air entry
  • Poor mentation:
    • Lethargic
    • Persistent irritability
  • Concerning Vitals — See normal range chart for age
  • Increasing Concern:
    • If parent/caregiver or provider is concerned that child is progressively worsening
  • Fever greater than/equal to 5 days
    • Prolonged fever warrants the consideration of Kawasaki Disease or multisystem inflammatory syndrome in children up to 8 weeks from onset of COVID illness

Four Horsemen (Discharge instructions) (YouTube Video Dr. Crocco)

Click image for pdf

Screen for Multisystem Inflammatory Syndrome in Children (MIS-C)

MIS-C appears to be a post-infectious inflammatory syndrome occurring in children and youth.

Consider MIS-C if history of COVID-19 positive (can have a delayed presentation) or consider if previously at risk for COVID-19 (e.g. previous direct contact with COVID patient but tested negative, high rates of community transmission).

  • Associated Clinical Features:
    • Fever for 5+ days (though can be seen in shorter time periods)
    • Mucocutaneous involvement (including rash, conjunctivitis, and other features that can be seen in Kawasaki Disease)
    • Respiratory distress
    • Cardiovascular symptoms/signs (eg. arrhythmias, shock, increased troponin)
    • Abdominal pain, diarrhea, vomiting
    • CNS symptoms/signs (eg. encephalopathy, seizures, coma)

A description of the clinical characteristics and timing of MIS-C in a cohort of children is available in this open access paper

Multisystem Inflammatory Syndrome in Children (MIS-C) Temporally Associated with COVID-19: Guidance for Clinicians in B.C. (BC Centre for Disease Control)

Images of Multisystem Inflammatory Syndrome

Please see these Images

  • Child's hand with red area
  • Child's hand with red splotches

Also see

Canadian Pediatric Society statement on paediatric inflammatory multisystem syndrome

Click image for pdf

A PDF of Information for caregivers of children with COVID is available here.

Resources

COVID, Cold and Flu Care Clinics

CCFCCs or COVID, Cold, and Flu Care Clinics are medical clinics that can test, assess, and provide treatment for people with COVID-19 and other cold and flu-like illnesses. To help us explain CCFCCs to our patients, Ontario Health has put together some plain-language messaging (please share widely!).

The McMaster Children’s Hospital (MCH) CCFCC, under the name “Flu, COVID and Cold Clinic,” opened on December 12, 2022. You can find additional details about the clinic on their website. Please note that while this CCFCC is a walk-in clinic for patients 17 and younger, patients are encouraged to contact their primary care provider first.

Flu Shots

Pediatric flu shots are now available at the Hamilton Public Health Services Mountain Vaccine Clinic at LimeRidge Mall (999 Upper Wentworth St., Hamilton). This walk-in service is open to all community members aged six months and older. The clinic is open Monday-Friday with the clinic’s final day of administering vaccines on December 21, 2022.

As a reminder, patients can find local locations to receive their flu shot, including pop-up clinics with pediatric vaccines, at hamilton.ca/flu.

Virtual Appointment (phone or video)

Do they just need a COVID swab and have non concerning viral symptoms? No need to be assessed in person office – get caregiver to perform rapid test if they have access to one and assume and act as though COVID until swab obtained i.e., 10 days of isolation. Virtual follow-up as clinically indicated.

Concerning acute symptoms needing in-person exam, but low suspicion due to COVID – in person assessment with full PPE.

Concerning acute symptoms needing in person exam, but high suspicion due to COVID – in person assessment with full PPE – given illness trajectory consider whether emergent transport to ED required for in person assessment.

Red flags for in person assessments of infants and children

  • Diarrhea and vomiting + has no tears, dry mouth, or is not peeing.
  • Baby under three months of age has a fever over 38oC or 100.4oF.
  • Difficulty breathing.
  • Non blanching rash
  • Fever and/or is difficult to rouse/very sleepy
  • Significant fall/injury
  • Assessment of infants/newborns for acute or routine care

Using the HFAM.ca Pathway for COVID Care in the Community