Our understanding of the spectrum of coronavirus disease 2019 (COVID-19) as well as optimal management strategies continues to evolve. There are limited data informing outpatient management strategies, and the approach described here is based upon our clinical experience; clinicians should take into account the individual patient's clinical and social circumstances as well as the available resources. Outpatient management is appropriate for most patients with suspected or confirmed COVID-19. When possible, we favor a coordinated care management program that includes initial risk stratification, clinician telehealth visits (telephone call or video platform-based), a dedicated outpatient respiratory clinic, and a close relationship with a local emergency department (ED). Patients who live in regions with widespread community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and have compatible symptoms are generally managed presumptively as having COVID-19, even if they have not been tested or have an initial negative test result . On initial evaluation, we assess risk factors for severe disease , dyspnea severity and duration (and oxygenation status of those with dyspnea), overall level of acuity, and the patientโs home setting to determine who warrants an in-person evaluation at an outpatient clinic or in the ED.
We typically refer patients with one or more of the following features to the ED for further management (see 'Criteria for evaluation in ED' above): โข Severe dyspnea (dyspnea at rest, and interfering with the inability to speak in complete sentences) โข Oxygen saturation on room air of โค90 percent, regardless of severity of dyspnea โข Concerning alterations in mentation (eg, confusion, change in behavior, difficulty in rousing) or other signs and symptoms of hypoperfusion or hypoxia (eg, falls, hypotension, cyanosis, anuria, chest pain suggestive of acute coronary syndrome)
We refer patients for evaluation in an outpatient clinic if they have one or more of the following features without any of the preceding features (see 'Patients appropriate for evaluation in clinic' above): โข Mild dyspnea in a patient with an oxygen saturation on room air between 91 to 94 percent โข Mild dyspnea in a patient at high risk for severe disease (table 1) โข Moderate dyspnea in any patient โข Symptoms concerning enough to warrant in-person evaluation (eg, mild orthostasis) but not severe enough to require ED referral
When managing outpatients with COVID-19 ------------------------------------------------------------------------ Symptoms of COVID-19 can overlap with those of many common conditions, so it is important to consider other possible etiologies of symptoms including other respiratory infections, congestive heart failure, asthma or chronic obstructive pulmonary disease (COPD) exacerbations, and even anxiety. For conditions that can be treated remotely, we will often treat without an in-person evaluation but with scheduled daily follow-up telehealth visits. A number of therapies are being evaluated for the treatment of COVID-19, but none have proven efficacy. None of these treatments should be prescribed in the ambulatory setting outside of a clinical trial; data are extremely limited, and there are concerns for potential toxicity in an unmonitored setting.
We counsel all patients on the warning symptoms that should prompt reevaluation by telehealth visit and in-person, including ED evaluations. All patients should have updated health care proxy and advance directive information in their electronic health record. We encourage all eligible patients to donate convalescent plasma after their recovery from COVID-19. On follow-up (eg, by telehealth visit), we evaluate a patient's respiratory status, focusing on assessing for new or worsening dyspnea. We use the same criteria for determining whether a patient needs to be evaluated in-person as in our initial evaluation. Most patients discharged from the inpatient setting warrant clinician follow-up within one to two days following discharge; whether a telehealth or in-person outpatient visit is most appropriate depends on their unique clinical and social situation.
