This is our current medical practice. These recommendations and practices are evolving constantly – even daily. Osler staff are reminded to check Oslernet for direction on processes and IPAC advice.
We align with the Ministry of Health Provincial Guidance for the Province of Ontario.
Testing for COVID-19 is currently done by performing a nasopharyngeal swab. In special circumstances, an endotracheal aspirate or bronchoalveolar lavage may be required.
Any patient who feels they need a test, even if they are not showing symptoms, can go for testing at an Assessment Centre. According to the provincial direction, we will honor requests for testing by patients.
We will now test patients with symptoms, with no symptoms but who are concerned they have been exposed to COVID-19 OR who have a high risk of exposing others.
In patients who are symptomatic, who should I swab?
Symptomatic patients/residents experiencing one of the following symptoms:
- Fever (temperature of 37.8 degrees C or greater) without an alternate cause OR
- Any new or worsening:
- cough, shortness of breath
- sore throat or hoarse voice
- runny nose or sneezing, nasal congestion (if this is the only symptom, consider not testing if explained by other reasons such as seasonal allergies / post-nasal drip)
- new olfactory or taste disorder(s), e.g. anosmia (loss of smell)
- nausea & vomiting or diarrhea or abdominal pain without an alternate diagnosis
- Influenza-like illness
- Clinical or radiologic evidence of pneumonia or ARDS
Atypical symptoms should be considered particularly in children, older persons and people living with a developmental disability as well as any individuals from congregate living settings.
In patients without symptoms (asymptomatic), who should I swab?
Testing of asymptomatic patients is generally not recommended except:
- all patients being admitted from long-term care or retirement home settings or other congregate living settings
- under the direction of an outbreak committee or Public Health Ontario (including if attending an in-centre hemodialysis unit where an outbreak is declared)
- cancer patients tested prior to starting an immunosuppressive cancer treatment
- patients booked for radiation treatment simulation 24-48 hours prior to their appointment (with the time between treatment and result preferably less than 1 week with consideration for retesting)
- any patient booked for systemic treatment where their treatment would be cancelled if COVID-19 positive
- patients booked for hematopoietic cell therapy 24-48 hours before their appointment
- all patients who have a scheduled elective procedure
- all hemodialysis patients (when point prevalence study recommendations)
Provincial guidance in late May 2020 has recommended testing those who wish to have a test, especially those who believed they may have been exposed or who are at risk of exposing others.
If directed by Public Health or their current facility administration in the setting of an outbreak of COVID-19, health care workers (including personal support workers), caregivers, care providers, or first responders can receive testing at an assessment centre by appointment.
Who should I test in the maternal or newborn setting?
Regardless of symptoms:
- Newborns born to mothers with confirmed COVID-19 at the time of birth within 24 hours of delivery and if the initial test is negative, repeated testing again at 48 hours of life
- Newborns with mothers with pending COVID-19 testing. If the maternal test is positive, the newborn should have repeat testing.
Who should I test in those being admitted to the critical care unit?
Patients are admitted to the critical care unit typically for respiratory or hemodynamic supports.
If the patient has a clinical syndrome consistent with COVID
a COVID nasopharyngeal swab is negative:
We recommend an endotracheal aspirate for COVID-19.
We recommend against routine bronchoscopy and bronchoalveolar lavage.
Patients Admitted from Long-Term Care or Retirement Home Being Admitted to Hospital
Included facilities: Long term care home, retirement home.
All patients will also receive a COVID NPS swab at admission AND at any time during admission where symptoms arise (see above criteria).
All patients in this category will be isolated using droplet/contact isolation for 14 days or the length of their admission, even if the COVID nasopharyngeal swab is negative.
Under current guidance, hospitals may discharge patients to Long-Term care homes where all of the following are true:
- It is a readmission (returning resident) AND
- The receiving home is NOT in a COVID-19 outbreak AND
- The resident has been tested for COVID-19 and is negative within 24 hours of receiving the result; AND
- The receiving home has a plan to ensure the readmitted resident can complete 14-days of self-isolation.
A single negative COVID-19 NPS does not exclude COVID-19 if the pretest probability is high.
Isolation should only be modified or discontinued in consultation with IPAC and the MRP.
Other Routine Investigations or Procedures
Avoid unnecessary investigations or procedures (examples noted below) unless absolutely required and likely to change patient treatment or outcome.
Please try to avoid:
- Daily chest x-ray in an otherwise stable patient. Monitor the oxygen requirement instead.
- Echocardiography when unlikely to change management.
- Leg dopplers where suspicion is low for DVT.
- CT scans when you are not looking for an alternate diagnosis. Do not perform CT scans routinely as a normal CT scan does not rule out or rule in a COVID-19 infection.
- More than once per day bloodwork unless it is likely to change management.
- We suggest only labs on day 0 and 3.
- CBC, CRP, Creatinine, Trop. Others as indicated only. Think carefully.
- Remember you may expose staff in the lab unnecessary.