Patient-physician relationship questions

1. What tips should I give my patients to prevent the spread of novel coronavirus (SARS-CoV-2)?
   During a COVID-19 pandemic, patients should be careful to practice good hygiene:

Minimize contact with those who are sick
Avoid touching your eyes, nose and mouth
Stay home when you are sick
Cover your cough or sneeze with a tissue, then throw the tissue in the trash
Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe
If you suspect you may have COVID-19, call ahead before visiting your doctor
Those who suspect they may have been exposed to the virus should take care to minimize their contact with others if they experience a fever and symptoms of respiratory illness.

Read more advice from the CDC.

1. What are the most common myths about COVID-19 that physicians should dispel for patients?
   Misinformation about COVID-19 is being shared across social media and other platforms at alarming speed.

Physicians will want to address common myths on the origin of the virus, how it is spread and prevention efforts that could negatively impact patient health.

Read the biggest misconceptions.

1. What should I tell my patients about traveling during the COVID-19 pandemic?
   The CDC warns that individuals who travel to countries with a Warning Level 3 should stay home for 14 days and practice social distancing.

Travelers who visit countries with a Level 2 Warning should take routine hygiene precautions. Elderly travelers and individuals with chronic health conditions may want to consider postponing travel to these locations.

You can read the CDC’s answers to frequently asked questions on travel.

Clinical questions

1. When should I test patients for COVID-19?
   The CDC is regularly updating guidance on who physicians should test for COVID-19.

In general, physicians should watch for patients presenting with fever or signs of lower respiratory illness—especially in those who may have been exposed to the virus. Decisions on testing may be made based on local epidemiology of COVID-19. The CDC has outlined priorities for testing patients with suspected COVID-19.

Clinicians are strongly encouraged to test for other causes of respiratory illness, including infections such as influenza.

Full criteria for evaluating and reporting persons under investigation can be found on the CDC site.

1. How do I test patients for COVID-19?
   The CDC has developed a laboratory test kit for use in testing patient specimens called the “Centers for Disease Control and Prevention (CDC) 2019-Novel Coronavirus (2019-nCoV) Real-Time Reverse Transcriptase (RT)-PCR Diagnostic Panel.”

Laboratory testing is being conducted at public health laboratories. As the availability of diagnostic testing increases, physicians will be able to access lab tests through clinical laboratories authorized by the FDA under an Emergency Use Authorization. Clinicians should consult with their local or state health department or the labs that perform their diagnostic services.

Answers to frequently asked lab testing issues can be found on the CDC site.

1. How do I treat patients with confirmed COVID-19?
   People with COVID-19 should receive supportive care to help relieve symptoms either at home or in a clinical setting as symptoms demand. For severe cases, treatment should include care to support vital organ functions.

There are no antiviral drugs licensed by the FDA to treat patients with COVID-19. Some patients with COVID-19 have received intravenous remdesivir, an investigational antiviral drug that was reported to have in-vitro activity against SARS-CoV-2, for compassionate use outside of a clinical trial setting.

Hydroxychloroquine is currently under investigation in clinical trials for pre-exposure or post-exposure prophylaxis of SARS-CoV-2 infection, and treatment of patients with mild, moderate and severe COVID-19.

Read more clinical guidance from the CDC as well as information on therapeutic options for COVID-19 patients.

1. How do I know when it is safe for patients to discontinue home isolation?
   As of March 16, CDC updated their guidance for determining the appropriateness of ending isolation. Options now include both a test-based strategy and a time-since-illness-onset and time-since-recovery (non-test-based) strategy.

A test-based strategy is contingent on the availability of testing supplies and laboratory capacity as well as access to testing. For jurisdictions that choose to use a test-based strategy, the recommended protocol has been simplified so that only one swab is needed at every sampling.

In the absence of testing supplies, physicians may utilize the following non-test-based strategy.

Persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions:

At least three 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 seven days have passed since symptoms first appeared.
Read the full CDC guidance. There is separate guidance for immunocompromised patients.

Practice management questions

1. How do I establish effective staff safety protocols?
   When communicating with staff, the CDC recommends that health care facilities are aware of the following best practices:

Screen patients and visitors for symptoms of acute respiratory illness (e.g., fever, cough, difficulty breathing) before entering your health care facility
Ensure proper use of personal protection equipment (PPE)
Conduct an inventory of available PPE
Encourage sick employees to stay home
Read the full guidance for health care facilities on the CDC website.

1. What can physicians do to manage increased capacity and conserve PPE in practices and health systems?
   Health care facilities and clinicians should prioritize urgent and emergency visits or procedures now and for the coming several weeks.

The following actions can preserve staff, personal protective equipment and patient care supplies; ensure staff and patient safety; and expand available hospital capacity during the COVID-19 pandemic:

Delay all elective ambulatory provider visits
Reschedule elective and non-urgent admissions
Delay inpatient and outpatient elective surgical and procedural cases
Urge patients to postpone routine dental and eyecare visits

1. What options are available for private practices to continue to treat patients during the pandemic?
   Private practices have the option to begin implementing telemedicine to treat patients outside the exam room.

Given the special circumstances of the COVID-19 pandemic, the federal government has announced that the Office for Civil Rights (OCR) will not impose penalties on physicians using telehealth in the event of noncompliance with regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA).

Read the AMA’s quick start guide to telemedicine to start implementing digital tools in your practice.

1. What steps can doctors take to stay healthy during the COVID-19 pandemic?
   The CDC recommends specific safety measures that health care professionals can take to minimize exposure to PUI and confirmed COVID-19 cases and prevent the spread of infection within health care facilities. Those steps include:

Set guidelines to help triage patients with symptoms congruent with COVID-19
Utilize sanitation and hygiene stations
Demonstrate proper use of PPE, including eye protection
Assist in monitoring and restricting access for visitors and other nonessential personnel
Read the full interim infection prevention and control recommendations.

1. How can health care facilities manage Personal Protective Equipment (PPE) supplies during the COVID-19 pandemic?
   The CDC’s updated infection prevention and control guidance (as of March 10) notes that face masks are an acceptable alternative when the supply chain of respirators cannot meet the demand. In this case, respirators should be prioritized for procedures likely to generate respiratory aerosols, which pose the highest risk to health care professionals.

If there are shortages of gowns they should be prioritized for aerosol-generating procedures, care activities where splashes and sprays are anticipated and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP.

Read the full CDC guidance on optimizing supply PPE and the interim infection prevention and control recommendations.

1. What should physicians do when they have been exposed to COVID-19?
   All health care professionals are at some risk for exposure to COVID-19, whether in the workplace or in the community.

Health care professionals in any of the risk exposure categories (high, medium, low or no risk) who develop signs or symptoms compatible with COVID-19 must contact their established point of contact (public health authorities or their facility’s occupational health program) for medical evaluation prior to returning to work.

Facilities could consider allowing asymptomatic health care professionals who have had an exposure to a patient with COVID-19 to continue to work after options to improve staffing have been exhausted and in consultation with their occupational health program.

Read the full interim U.S. guidance from the CDC.

Ethical questions

1. How do physicians enforce quarantine while respecting patients’ autonomy?
   A physician’s primary duty during a public health emergency like the COVID pandemic is to protect the health of the community.

In a quarantine situation, each individual physician’s role is to engender cooperation by communicating clearly and by acknowledging the natural fears and feelings of powerlessness that infectious disease outbreaks create. In some circumstances, however, when persuasion fails and a patient poses a risk to others but won’t voluntarily adhere to isolation, physicians should support mandatory quarantine.

The AMA Code of Medical Ethics (E-8.4) states that during a public health crisis, it is a physician’s duty to:

Educate patients and the public about the nature of the public health threat, potential harm to others and benefits of quarantine and isolation.
Encourage patients to adhere voluntarily to quarantine and isolation.
Support mandatory quarantine and isolation when a patient fails to adhere voluntarily.
Inform patients about and comply with mandatory public health reporting requirements.
Read more on quarantine from the AMA Journal of Ethics or read the Code guidelines.

1. How do physicians respond to colleagues who fail to report an exposure to COVID-19?
   No one relishes the prospect of confronting a friend, but when a colleague poses a threat to patient welfare, physicians are ethically obligated to report their suspicions in the interest of patient safety.

The AMA Code of Medical Ethics (9.4.2) recommends that physicians who become aware of or strongly suspect that conduct threatens patient welfare or otherwise appears to violate ethical or legal standards should:

Report the conduct to appropriate clinical authorities in the first instance so that the possible impact on patient welfare can be assessed and remedial action taken. This should include notifying the peer review body of the hospital, or the local or state medical society when the physician of concern does not have hospital privileges.
Report directly to the state licensing board when the conduct in question poses an immediate threat to the health and safety of patients or violates state licensing provisions.
Report to a higher authority if the conduct continues unchanged despite initial reporting.