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.

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 (important for calculating end of isolation period)
  2. Record symptoms and note change:

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.

  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 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 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.

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

Try to take history by phone to limit contact.

Key equipment: pulse oximeter, a thermometer, BP cuff, and stethoscope

General condition: demeanour, colour, cyanosis, the extent of respiratory effort, hydration

Vitals: temp, pulse, RR and O2 sats

Decide whether auscultation necessary

Auscultation should be carried out ONLY where it is crucial to decision making. ***If auscultation is performed, examine from behind the patient only

COVID Pneumonia Diagnosis
The diagnostic accuracy of  “overall clinical impression” close to ruling in, in an emergency. (Systematic Review of 9 studies 2019)

Auscultation of the chest is not essential if this overall clinical judgement of CAP (partly based on temperature >=38, respiratory rate > 20, and heart rate >100, new confusion) is already met. 


Assessing blood pressure significantly increases contact time so consider only in those in whom it contributes to essential decision making to admit or not. low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg) is a concerning sign

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 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:

  • HR >110, SPO2 consistently ≤ 92%, RR >24
  • 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)
  • 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 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.

  1. Confirm date of first symptoms (if symptomatic) as well as date of positive test (for end of isolation calculation).
  2. Check whether has had public health contact. If not discuss self isolation and contacting contacts ASAP: see script for this. Instructions for Individuals who Test Positive for COVID-19 provided by Dr. Doug Sider, Hamilton Public Health.
  3. Patient can be directed to hfam guides for self isolating under patient resources tab.
  4. Check equipment patient has available. Check whether patient has or can borrow pulse oximeter. (patients can be directed to instruction YouTube video on using pulse oximeter on hfam.ca patient resources tab: found under “Self Isolation” heading).
High Risk Average Risk Low Risk
Patients with any of the safety net flags Otherwise healthy adults
Patients with symptom deterioration Pregnant women No comorbidities
Any age with medical comorbidities No safety net flags
Age > 60 40-60 years old with no medical comorbidities Age 1-39 years old with no medical comorbidities
MONITOR
Daily for 14 days
MONITOR
Every 2 days x 7 days; then recommend self-monitor for additional 7 days depending on progress
MONITOR
Consider self-monitoring only; check-ins determined by individual patient. (Consider at 7 days)

*In patients who required hospitalisation, 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
  • 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
  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 When to Refer to ED section)
    • 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
  6. Note underlying chronic disease that indicates increased risk. For patients with diabetes increase to daily monitoring.
  7. Assess need for regular medication changes or advice (see “management” tab below).
  8. Check mental health, access to food, support or carer, financial or housing stress.
  9. Assess whether this patient can still be managed at home (see When to Refer to ED 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.
  10. Give detailed management advice (see management tab below)
  11. Set up time for next follow-up – If follow-up falls on weekend make plan for this.

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

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.

Here is a summary sheet that can be used as a guide for a potential COVID care daily “rounds” for 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.

The Ministry of Health has now procured a stockpile of oxygen saturation monitors for monitoring COVID-19 positive patients through primary care. They will deliver these to your practice wherever you are, for you to lend to patients during monitoring.

Here is the information from them on how to access an oximeter, and a resource toolkit.

Other local Hamilton pulse oximeter access

HFAM has obtained a limited supply of pulse oximeters (oxygen monitors).

Pulse oximeters are available for patients you are monitoring who:

  • Do not have / cannot access a pulse oximeter in any other way;
  • Tested positive for COVID-19; and
  • Are in the high-risk category (visit HFAM website and click “Monitoring and Follow-up” for risk assessment tool) 

How to access:

Please call Anju Dalal (905-525-9140 ext. 28251), who will answer this line Monday to Friday 9 to 5, out-of-hours messages will be picked up on the next working day. Please have the following details to hand:

  • Patient full name, address and phone number
  • Family physician name and phone number
  • Arrangements for pickup or delivery of the pulse oximeter (see below)
Pick-up instructions Delivery instructions
If patient has someone who can come to the clinic to pick up the pulse oximeter:

– Name of person who will be picking it up (please confirm it is not a quarantining contact!)
– Phone number for person picking up (we will connect with them)

Pulse oximeter will be left with McMaster Family Practice clinic entry screeners on the 3rd floor of David Braley Health Sciences Centre. Package will be labeled with the names of the patient and the person picking up the unit.
If no-one is available to pick up the pulse oximeter, then a few volunteers are available to deliver it to the patient. Please include:

– Number to text or call when volunteer has arrived
– Where to leave the pulse ox (e.g. “place in mailbox” or “leave at front door”)
– Any other information that would be helpful for the volunteer (e.g. parking information, beware of dogs, etc.)

Volunteer will ring doorbell, or send a text to confirm arrival to patient.

How to return the pulse oximeters:

Please tell patients and caregivers that supply of pulse oximeters is very limited at present, so these need to be returned to the clinic as soon as they are no longer needed.  

To return the pulse oximeter, patients can call Anju at 905-525-9140 ext. 28251 to arrange for someone to drop it off at the clinic, or to have a volunteer return to the home to pick it up if there is no other option.  These instructions are included with the pulse oximeter also.

Patient instructions on using the pulse oximeter:

The instructions below are on the HFAM site, and will be included with the unit. These can also be printed and shared with patients as needed.

Pulse Oximeter Patient Instructions (ProResp)

  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, headache and loss of sense of smell / taste.
    Here is a pdf of instructions that can be provided to a patient (Georgian Bay Family Health Team).

  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).
    Here is a pdf of instructions that can be provided to a patient (Georgian Bay Family Health Team).

  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)

*A pdf of advice including red flags that can be emailed to patients is available here.

  • Treatment: there are NO treatment medications that have evidence for use in primary care.
  • Comfort: Acetaminophen is safer than NSAIDS (not specific to COVID but NSAIDs increase the cardiovascular risk in any viral illness). Read more here.
  • Existing
    • 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 – mod 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.

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).

Approach When to Use Instructions
Non-Test Based Waiting 10 days from symptom onset (or 10 days from specimen collection date if persistently asymptomatic) Mild to moderate illness AND no severe immune compromise Can discontinue isolation after 10 days from symptom onset (or 10 days from positive test collection date if never had symptoms), provided that the individual is afebrile (without the use of fever-reducing medications) and symptoms are improving for at least 24 hours. Absence of cough is not required for those known to have chronic cough or who are experiencing reactive airways post-infection. Mild to moderate illness includes the majority of cases of COVID-19, and includes all those who do not meet the definition of severe illness or severe immune compromise (below).
Non-Test Based Waiting 20 days from symptom onset (or 20 days from specimen collection date if asymptomatic and severe immune compromise) Severe illness (requiring ICU level of care) OR severe immune compromise Can discontinue isolation 20 days from symptom onset (or 20 days from positive test collection date if asymptomatic and severe immune compromise), provided that the individual is afebrile (without the use of fever-reducing medications) and symptoms are improving for at least 24 hours. Absence of cough is not required for those known to have chronic cough or who are experiencing reactive airways post-infection. Studies informing this approach did not have a consistent definition of severe illness or severe immune compromise. For the purposes of a clearance assessment:

 Severe illness is defined as requiring ICU level of care for COVID-19 illness (e.g.,respiratory dysfunction, hypoxia, shock and/or multi-system organ dysfunction).

• Examples of severe immune compromise include cancer chemotherapy, untreated HIVinfection with CD4 T lymphocyte count <200, combined primary immunodeficiency disorder,taking prednisone >20 mg/day for more than 14 days and taking other immune suppressivemedications.

• Factors such as advanced age, diabetes, and end-stage renal disease are generally notconsidered severe immune compromise impacting non-test based clearance.  
Changes were made to the provincial COVID-19 school and child care screening criteria on Feb 16 2021as a response to emerging “Variants of Concern”: All asymptomatic household contacts of symptomatic individuals are required to quarantine until the symptomatic individual receives a negative COVID-19 test result or an alternative diagnosis by a health care professional. If the symptomatic individual does not seek COVID-19 testing, all household contacts must quarantine for 14 days from their last contact with that symptomatic individual. Staff, students and children with any new or worsening symptom of COVID-19, even those with only one symptom, must stay home until:

• They receive a negative COVID-19 test result;
• They receive an alternative diagnosis by a health care professional; or
• It has been 10 days since their symptom onset and they are feeling better.    

See full Ministry of Health Assessment Guideline

A significant proportion (around 10%) of patients report ongoing symptoms beyond the initial acute COVID-19 infection period (so-called “long COVID”). Reports of usual duration of specific symptoms are variable at present. Other estimates in a recent not yet peer reviewed cohort study from the UK appear 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).

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

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
Trisha Greenhalgh, Matthew Knight, Christine A’Court, Maria Buxton, Laiba Husain.
BMJ 2020;370:m3026 | doi: 10.1136/bmj.m3026

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.
  • comparative study showed no evidence of additional benefit from intranasal steroids. Reference here

Primary Care — COVID-19 Pediatric Pathway

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

Where to send for Testing and MD Assessment

Click image for pdf

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.

At Home Pediatric COVID-19 Monitoring

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.

During Initial Assessment:

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

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:
    • Tachypnoea
    • Grunting, nasal flaring, abdominal breathing, tracheal tug
    • Decreased air entry
  • Poor mentation:
    • Lethargic
    • Persistent irritability
  • Increasing Concern:
    • If parent or caregiver 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

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)

Also see

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

Canadian Pediatric Society statement on paediatric inflammatory multisystem syndrome

Assessment centre triage and referral guidelines for children under 3 years

Leave a Reply