Information for Clinicians

Last updated: 3/20/2020

If providers have questions, call Baltimore City Health Department Acute Communicable Diseases 410-396-4436 (business hours); 410-396-3100 (after hours, weekends)

If providers have questions, call Baltimore City Health Department Acute Communicable Diseases 410-396-4436 (business hours); 410-396-3100 (after hours, weekends)

 

Reporting Test Results

  • Providers should report all positive test results to the Baltimore City Health Department immediately.
  • Fax either a) a lab report or b)  Form 1140  to 410-625-0688.
  • Please include the ordering provider’s contact information for the public health investigation.
  • It is also extremely helpful to include the admission note and other applicable notes (Emergency Department note, Infectious Disease consult, imaging results, etc.) in the fax.

Key Points

The  Directive and Order Regarding Availability of Testing signed by Health Secretary Neal on 3/20/20 states that:

  • Testing shall be made available only to those who meet testing criteria
  • Any person presenting to a testing site who meets criteria must be offered testing
  • Cost of testing will be made available by the Maryland Department of Health in some situations
  • Maryland Department of Health Guidance on Testing is available in their:
  • Given the evidence of community transmission in Maryland, patients no longer need to meet travel criteria for evaluation of COVID-19
  • Currently, COVID-19 testing is not widely available. Testing should be prioritized for:
    • Patients who are severely ill OR
    • Patients with fever and respiratory illness who have risk factors for severe disease OR
    • Those meeting MDH testing criteria

  • Testing should not be performed on those who are asymptomatic or those who have mild symptoms. Mildly symptomatic patients who are otherwise healthy can self-isolate, monitor temperature, and symptoms and check in with their provider as needed. These patients do not need to be tested. See Recommendations for Patients with Mild Illness. Patients who are clinically stable should NOT be sent to Emergency Departments for testing. Emergency Departments have limited tests, and patients with mild disease will be discharged home without a test. Patients with mild symptoms should not be unnecessarily exposed, or unnecessarily expose others, by visiting the emergency room.
  • There will be patients who want to be tested and patients for whom clinicians would like to perform a test, who will not be able to receive testing. Patients who have severe symptoms, such as difficulty breathing, should seek care immediately. Older patients and individuals who have underlying medical conditions or are immunocompromised should contact their provider early in the course of even mild illness. In most situations, those patients will need to be evaluated in an emergency department.
  • Some patients have presented initially with mild symptoms, and develop worsening at day 5-9 into illness. Counsel patients on monitoring their symptoms especially those  with risk factors for severe disease
  • If you do perform a COVID-19 test, given shortages of N95 respirators, MDH advises contact and droplet precautions with a surgical mask and eye protection, in an examination room with the door closed.
  • At this time, the Baltimore City Health Department is not providing COVID-19 testing
  • A link for patient FAQs is available at the Maryland Department of Health
  • Age >60 or
  • Underlying medical conditions such as chronic heart disease, lung disease, kidney disease, or diabetes

COVID-19 Testing Availability in Baltimore

Testing Availability as of 3/20/20:

Maryland Department of Health (MDH) lab. If you would like to test via the Maryland Department of Health Lab, testing must be approved by the local health department or MDH prior to submitting samples. MDH testing is now available from inpatient, ED, and outpatient settings. The criteria to receive approval for testing is described in clinician letters on March 13, 2020:

  • A person who had close contact with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset AND signs of infection including either fever or signs/symptoms of a lower respiratory illness.
  • A person who resides in a nursing home or long-term care facility AND who has either fever or signs/symptoms of a lower respiratory illness AND who tested negative for influenza on initial workup and no alternative diagnosis.
  • Hospitalized patients who have signs and symptoms compatible with COVID-19 and no alternate explanation in order to inform decisions related to infection control.
  • MDH has detailed information on sample collection

    • Only one swab (NP or OP) is needed. Collect NP or OP swabs in viral transport media. Use only synthetic fiber swabs with plastic shafts. Place swabs, after collecting patient specimens, into 2-3 ml of viral transport media. NP/OP swabs may be combined at collection into a single media tube. Refrigerate at 2-8C and ship on ice to MDH Lab.
  • Contact information for requesting MDH testing: 
    • Baltimore City Health Department Acute Communicable Diseases 410-396-4436 (business hours); 410-396-3100 (after hours, weekends)
    • Maryland Department of Health Infectious Disease Bureau 410-767-6700 (business hours); 410-795-7365 (after hours Emergency Call Center)
  • Providers should report positive test results to the local health department immediately.​

Commercial laboratories. Testing is available through LabCorp,  Quest Diagnostics and other private labs. However, there is currently limited availability to order through commercial labs given limited testing capacity nation-wide. Availability is expected to expand in the coming weeks.  Contact your representative for requisitions and submission instructions, and for updates regarding testing availability and turnaround time in Baltimore. 

  • Samples must be collected in physician offices.
  • Turnaround time is expected to be several days
  • Patients with health insurance plans regulated by the state of Maryland should not have to pay for the test.  Patients should contact their plan to see if it is regulated by Maryland.
  • No prior approval by the city or state health department is needed for testing by commercial laboratories.
  • Providers should report positive test results to the local health department immediately.​

Hospital centers. Some medical providers are developing in-house COVID-19 diagnostic testing. Consult with your institution to determine if they have in-house testing, and for specific instructions and guidance.  Providers should report test results to the local health department immediately. 

 

Table 1. Baltimore City COVID-19 testing options (As of 3/20/2020)

Testing Facility

MDH/BCHD approval needed prior to testing

Currently available in Baltimore

MDH Lab Testing

Yes

Yes, for patients meeting MDH Criteria

Commercial test (LabCorp, Quest) and ARUP

No

Check with representative

In-house labs

No

Check with your institution

Reporting Test Results

Providers should report all positive test results to the Baltimore City Health Department immediately. Fax either a) a lab report or b) Form 1140  to 410-625-0688.

Please include the ordering provider’s contact information for the public health investigation.

It is also extremely helpful to include the admission note and other applicable notes (Emergency Department note, Infectious Disease consult, imaging results, etc.) in the fax.


Providers in Outpatient/ Ambulatory Settings

Outpatient Providers Flowchart

 

  • Additional guidance to outpatient providers is available in MDH Clinician letters on 3/11 and 3/13
  • A suggested screening and testing algorithm is here
  • PATIENTS WHO ARE STABLE WITH MILD DISEASE SHOULD NOT BE SENT TO EMERGENCY DEPARTMENT CENTERS FOR COVID-19 TESTING. ED referrals should be reserved for patients who are severely ill and require hospital admission.
  • Providers should make every attempt to use telemedicine or telephonic communications to evaluate patients and avoid unnecessary visits to healthcare facilities and outpatient offices
  • Asymptomatic persons do not need to be tested.
  • Mildly symptomatic patients who are otherwise healthy can self-isolate, monitor temperature, and symptoms and check with the provider as needed. These patients do not need to be tested. Guidance for providers and patients is available.
  • Patients who have severe symptoms, such as difficulty breathing, should seek care immediately. Older patients and individuals who have underlying medical conditions or are immunocompromised should contact their physician early in the course of mild illness. In most situations, those patients will need to be evaluated in an emergency department.
  • Encourage patients to CALL AHEAD to provider offices to discuss questions regarding testing criteria. If patients are instructed to come to the clinic for testing, correct infection control practices should be followed:
    • Patients should call ahead so staff is aware they are coming.
    • Ensure patients wear a mask immediately upon entering the office
    • Limit contact with other patients. This can include patients not remaining in the waiting room, being placed in a private room with the door closed, or being evaluated and tested outside the clinic building (for example, in their cars). 
    • Encourage patients to come with as few family/friends as possible. 
  • Early studies indicate some patients may develop worsening conditions around five to nine days after initial symptom onset. Patients who are told to monitor symptoms at home should be encouraged to call their provider or go to the Emergency Department with signs of worsening illness. We encourage providers with telehealth capability to use it as much as possible for initial and follow up evaluation of patients.
  • Consider testing for influenza, RSV, and other respiratory viruses (respiratory virus panel) if available.
  • Other resources for clinicians:

We recognize the many challenges associated with advising clinically stable patients to stay home. These can include situations of unstable housing. Baltimore City Health Department and our partners are actively pursuing options for these challenging situations. 

We expect that this guidance will change as the situation evolves.

Providers in Inpatient Settings

Follow your institution’s guidance on inpatient testing criteria and PPE guidance.

CDC guidance currently states clinicians should use their guidance to determine if a patient has signs and symptoms compatible with COVID-19 and if they should be tested. Most patients with COVID-19 have a fever and/or symptoms of acute respiratory illness. Priorities for testing may include:

  1. Hospitalized patients who have signs and symptoms compatible with COVID-19 in order to inform decisions related to infection control.
  2. Other symptomatic individuals such as, older adults and individuals with chronic medical conditions and/or an immunocompromised state that may put them at higher risk for poor outcomes (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease).
  3. Any persons including healthcare personnel2, who within 14 days of symptom onset had close contact3 with a suspect or laboratory-confirmed4 COVID-19 patient, or who have a history of travel from affected geographic areas5 (see below) within 14 days of their symptom onset.

 

Infection Control Guidelines

The following infection control guidelines should be followed for patients with suspected or confirmed COVID-19 disease:

  • If possible, place the patient in a negative air pressure room. If none are available, place the patient in a private room with the door closed. 
  • Place a surgical mask on the patient
  • When collecting diagnostic respiratory specimens (i.e. NP swab) from a possible COVID-19 patient, the healthcare provider should wear an N-95 respirator, eye protection, gloves, and gown. CDC guidance can be found here. 
  • If an N-95 respirator is not available, a facemask is an alternative.

 

Recommendations for Patients with Mild Illness

We encourage patients with mild illness to call triage lines prior to presenting to their doctor’s office. Not everyone needs a COVID-19 test. Patients with mild symptoms may be advised to stay home, remain isolated from others, and monitor disease symptoms. 

Patients with risk factors should be monitored closely at home. These patients are at higher risk of clinically worsening, especially 5-9 days into the course of illness. Patients who are told to monitor symptoms at home should be encouraged to call back or go to the Emergency Department with any signs of worsening illness.

We understand the difficulties in managing patients at home and encourage either telemedicine, phone calls, or other means to monitor patients while at home.

Patients should be encouraged to stay home while they are symptomatic. Click here to find advice for those who are self-isolating.

We recognize the many challenges associated with advising patients with minor symptoms to stay home. These can include situations of unstable housing. Baltimore City Health Department and our partners are actively pursuing options for these challenging situations. We also encourage you to work with your social work departments and other partners to assist in the management of these patients.

 

Removing Patients from Home Isolation

 

For patients with COVID-19, including confirmed patients (who were tested) and suspected patients (who were not tested), home isolation can discontinue under the following conditions*:

  • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
  • At least 7 days have passed since symptoms first appeared.

*This recommendation will prevent most, but may not prevent all instances of secondary spread.  The risk of transmission after recovery is likely very substantially less than that during illness.

 Additional Information for providers can be found at these websites: