key: cord-0704247-va9exx6i
authors: Baker, Terrance L.; Greiner, Jack V.
title: Guidelines: Discharge Instructions for Covid-19 Patients
date: 2021-06-18
journal: J Prim Care Community Health
DOI: 10.1177/21501327211024400
sha: 93d953fd33b47a75b84473c22a89cc6a61556d5f
doc_id: 704247
cord_uid: va9exx6i

INTRODUCTION/OBJECTIVES: Clinicians treating COVID-19 patients face a major challenge in providing an effective relationship with patients who are discharged to return to home in order to optimize patient self-management after discharge. The purpose of these discharge instructions is to assist and provide guidance for physicians, nurses, and other health care personnel involved in discharging COVID-19 patients to home after encounters at hospitals, emergency departments, urgent care settings, and medical offices. METHODS: A systematic literature-search of studies evaluating both symptoms and signs of COVID-19 was performed in order to establish specific optimal performance criteria in monitoring a patient’s status with regard to disease safety. These optimal performance criteria parameters were considered with regard to the severity of morbidity and mortality. Strategies used to develop the discharge instructions included review of a broad spectrum of literature to develop the discharge criteria. RESULTS: These guidelines are presented for patient education and should achieve the essential goals including: enabling patients to understand their medical situation, preventing complications, supporting patients by providing instructions, helping patients make more effective use of available health services, and managing patient stress by giving patients comfort through the knowledge of specific recommendations including how to respond to situations. CONCLUSION: The COVID-19 pandemic requires clinicians to efficiently teach their patients self-management strategies and to provide a safe educated response to the patient and the surrounding community environment. The primary goal of the patient education discharge-instructions (PEDI) is to provide self-management strategies for preventing complications and disease transmission.

Hospitals, emergency departments, urgent care centers, and medical offices all across America are facing a major public health safety crisis related to the management of the coronavirus disease 2019 (COVID- 19) pandemic. Healthcare facilities need to have a consistent patient educational response in order to minimize the impact of the COVID-19 disease when patients are discharged to home. This is required to restrict and limit disease spread and the morbidity and mortality of the families and people to which these COVID-19 positive patients are being returned. A key component of the healthcare system is the ability to institute prompt detection, effective triage, isolation of potentially infected patients, and discharging patients to home safely with the goal of preventing unnecessary community exposure.

The vast majority of suspected COVID-19 patients experience only mild symptoms 1 and accordingly will be discharged to home with instructions to self-isolate while awaiting their test results and/or completing their recovery. Patients who test positive are advised to stay at home provided they are not experiencing complications and require follow-up care. Even those who have sought medical advice and tested COVID-19 negative must be warned that they remain at risk for the disease. 2 Preventing healthcare system overload depends on a patient's ability to care for themselves at home while minimizing the risk of infecting their families and others.

Even with vaccination, it is important to follow guidelines which focus on self-management strategies, symptom monitoring, appropriate and frequent hand hygiene, cough etiquette, social distancing, and strict self-isolation. Understandable instructions that promote compliance with guidelines must be at the center of the healthcare response especially when it comes to patient education. Triage is a key opportunity to begin the process of educating COVID-19 patients about the disease process and the steps necessary to prevent disease transmission. This educational process continues through discharge. Time constraints in the discharge setting can be overcome through standardized discharge instructions to improve future patient coherence. Patient education with written instructions can help health professionals (primary care physicians) who receive communications from patients and arrange for remote triage. Many times, and unavoidably, patients in the hospital setting, emergency room, urgent care center and medical office hospital setting often may be meeting the treating physician for the first time. Offering education is challenging in this context where clinicians may lack the skills or the time necessary to provide the basic necessary education. Accordingly, these guidelines represent a support tool that can serve as an important point of reference.

Patient education can be a key component against COVID-19, where healthcare providers have no clear guidance on how to proceed. Accordingly, these guidelines can provide basic, in person and remote patient, education to suspected or confirmed cases of COVID-19 in patients who are instructed to self-isolate at home.

Patients are admitted to the hospital who require special attention, will complete their hospital admission, and require discharge instructions for home. Patients need to understand that throughout the pandemic, discharge communications may be reduced to a brief exchange, leaving patients uncertain about what to do when they return to home. This is especially true for patients with no medical background. The guidelines contained herein (Appendix), serve as a practical, straight forward protocol, that improves the requirements for effective discharge. These guidelines consist of ten steps that clinicians and patients can use to develop a structured approach to discharge instructions.

As patients are preparing for discharge, information being provided can cause great anxiety without understanding why they are being advised to return home when they are potentially infected or infected with COVID-19. Anxiety impairs patient's ability to understand and process new information. It is important that clinicians listen to, teach, and reassure their patients. Clinicians should communicate with open ended questions to determine how well the patient understands their medical condition. Patients should be told that in most people, the COVID-19 disease is not as severe as the multimedia reports, and that there are strategies for avoiding transmission to their families. 3-8 The vast majority of infected patients and/or suspected COVID-19 cases experience none or only mild symptoms. 9 Patients should however be warned that the SARS-CoV-2 virus appears to be highly contagious and requires quarantine. [10] [11] [12] [13] [14] [15] It is important to educate the patient about self-management strategies. [16] [17] [18] An important part of this step is to assist the patient in developing an accurate understanding of the process of transmission that provides a strong rationale for what they need to do, to prevent it. The guidelines herein provided herein give patients (1) clear instructions about what they should do and why, (2) instruct patients on how to take care of themselves, and (3) provide strategies to help patients better understand how to maximize their safety, the safety of their family, other occupants living in their home environment, and their caregivers. Additionally, evidencebased information supporting these guidelines to patients being discharged is presented elsewhere. 19, 20 The guidelines presented herein are designed to be easily understood and provide patients with basic necessary resources to safely transition from a healthcare facility to home. Furthermore, these guidelines explain to the patient what to do in case of worsening symptoms or changing conditions. Since it is essential that patients understand their instructions, accordingly healthcare providers should give patients and caregivers an opportunity to ask questions about the instructions prior to discharge. Healthcare providers are encouraged to provide adequate time for review of the provided guidelines, ask questions and respond.

The purpose of these discharge instructions is to assist and provide guidance for physicians, nurses, and other health care personnel involved in discharging COVID-19 patients to home after encounters at hospitals, emergency departments, urgent care settings, and medical offices.

A systematic literature-search of studies evaluating both symptoms and signs of COVID-19 was performed in order to establish specific optimal performance criteria in monitoring a patient's status with regard to disease safety. These optimal performance criteria parameters were considered with regard to the severity of morbidity and mortality. Strategies used to develop the discharge instructions included review of a broad spectrum of literature to develop the discharge criteria. The literature cited where possible included (1) refereed studies from periodicals published in PubMed recognized journals, (2) United States Center for Disease Control and Prevention (CDC) and World Health Organization (WHO) and, (3) publications presented by recognized medical center institutions which principally included Johns Hopkins Medicine, Mayo Clinic, and Harvard Medicine Publishing. Since to date, a paucity of information exists for children, referencing was broadened to include additional sources. Where references were unavailable, discharge instructions were created consistent with best practices and in accordance with standard of care. Each parameter comprising the discharge instructions was selected because of its importance related to outcome safety of the patient, household family, and surrounding community of people and animals which have been identified as SARS-CoV-2 carriers. 21

The instructional guidelines are presented in a numerical fashion. Of foremost importance, for COVID-19 patients having been discharged to home, is diarying daily oxygen saturation levels, pulse rate, and body temperature. Specific details regarding consultation with a physician include oxygen saturation levels declining below 93%; 22-26 pulse rate >100 heart beats per min; 27-29 fever above 100.4° Fahrenheit (38° Celsius) or excessive chilling with or without tremor (rigors); 30-33 difficulty breathing with >24 respirations per min; 27,30,34-36 shortness of breath 30 ; worsening cough with our without productive sputum 30,37-39 ; development of nausea, vomiting or diarrhea or worsening of any of these signs 33, [40] [41] [42] ; new onset chest pain or chest pressure that does not resolve; confusion [43] [44] [45] ; sleep disorder 46 ; evidence of cyanotic or erythematous skin discoloration of the oral labia or face or the skin of the toes or fingers 33,47-52 ; a generalized feeling of worsening 53-62 which may necessitate prompt remeasuring and dairying of the oxygen saturation level.

Precautions at home to avoid spreading the virus include the following: self-isolation including staying at home 4,63-72 ; avoiding touching other people [73] [74] [75] [76] [77] ; staying isolated in a specific room away from other people 4,11,78-80 ; use of a separate bathroom or washroom if possible [80] [81] [82] [83] [84] [85] [86] [87] ; avoidance of sharing personal household items with other people or pets where possible and if not possible, these items should be cleaned with soap and warm water 88, 89 ; avoid handling pets 90, 91 ; and wearing a mask covering the nose and mouth when around other poeple. 16, 19, 20, 81, [92] [93] [94] Cleaning and disinfection are recommended on a daily basis including all high-touch surfaces, 95-98 the practice of meticulous washroom hygiene, and any surfaces that may be contaminated with blood, 95 stool, 83 or body fluids. 99, 100 Laundry protocols should be practiced as described in detail elsewhere. 19, 101, 102 In order to reduce the spread of the SARS-CoV-2 virus, hand and finger sanitation should be practiced often with either soap and warm water or hand sanitizer. 19 Hands and fingers should be air-dried. 4, 19, 103, 104 Hand and finger washing should be practiced after blowing or exhaling through the nostrils, coughing, or sneezing into them, using the toilet or before handling or preparing food. 105-108 Masks should be worn when in a room with others including caretakers who are not ill 63, 69, 70, 72 and when around other people. [109] [110] [111] [112] [113] [114] [115] [116] Notification of close contacts when diagnosed with COVID-19 with instructions for them to self-isolate for 14 days, 2, 11, 14, 15, 69, 117, 118 including caregivers and intimate partners. Close contacts should self-monitor for COVID-19 symptoms and signs. These should include the measurement of body temperature, every 12 hours for fever, cough, or shortness of breath. [119] [120] [121] [122] [123] [124] [125] [126] [127] [128] [129] If such symptoms and signs develop, close contacts should contact their doctor. 2, 9, 11, 15, 56, [130] [131] [132] [133] In addition, close contacts should self-monitor oxygen saturation.

It is important to take prescribed medications and to maintain hydration as recommended. [134] [135] [136] [137] [138] [139] Several weeks may be required before returning to a feeling of well-being consistent with that experienced prior to COVID-19. 2,132,140-142 Selfisolation should continue to be practiced until resumption of regular daily activities is approved by a physician.

Home precautions and self-isolation may be discontinued when the following occur: no fever for at least 72 hours without the use of antipyretic medications; 2,11,143-148 all other symptoms have improved and 14 days have passed since symptoms started; two consecutive negative COVID-19 tests; and a physician approves. 148 Considering stress and anxiety associated with COVID-19, patients should be advised to limit exposure from multimedia coverage. [149] [150] [151] Those patients with pre-existing mental conditions should continue treatment and report new or worsening signs and symptoms. [152] [153] [154] Discussion Clinicians treating COVID-19 patients face a major challenge in providing an effective relationship with patients who are discharged to return to home in order to optimize patient self-management after discharge. These guidelines for patient education are designed to achieve essential goals including: These goals are consistent with the core competencies described in the World Health Organization report on patient education. 154 Healthcare providers must teach patients current information about measures necessary to protect the patient's family and to adhere to safe self-isolation and hygiene measures to avoid transmitting the disease. These guidelines provide a patient education format that facilitates discharge of COVID-19 suspected and positive patients to home. These guidelines provide written instructions advising patients of the steps necessary for safe discharge and returning home and provide economy of healthcare provider teaching time. Written instructions make it easier for patients to understand and assimilate the information being provided. COVID-19 patient education requires communicating self-isolation and hygiene measures appropriate to the patient's home situation. These guidelines for patient education-instructions provide a unique opportunity for teaching patients those strategies that are necessary for the patient to take care of themselves and to limit disease spread. We believe that guidelines for patient education-instruction during COVID-19 needs to be adopted and adapted by healthcare providers. The strategy of patient education with written instructions that can be shared with family, extended family, and others in the home as well as external to the home will allow all to play a significant role in recovery and in limiting disease spread.

In conclusion, prompt detection, effective triage and isolation of potentially infected and infectious patients are cornerstones of the pandemic response. Discharge from the hospital, emergency department, urgent care centers, and medical office settings, provides an opportunity to educate patients for being instructed to return home and self-management strategies which are the primary measures currently recommended for prevention of COVID-19 transmission. 155 The COVID-19 pandemic requires clinicians to efficiently teach their patients self-management strategies and to provide a safe educated response to the patient and the surrounding community environment. The primary goal of the patient education discharge-instructions (PEDI) is to provide self-management strategies for preventing complications and disease transmission.

You have been diagnosed with a viral infection called COVID-19 that can cause fever, cough, and trouble breathing as it causes a lung infection. Some patients may also have chills, muscle aches, runny nose, loss of taste, loss of smell, sneezing, sore throat, upset stomach, diarrhea, headache, and generalized fatigue.

At this time, your doctor has determined that you are medically stable enough to be discharged from the hospital or healthcare facility to continue managing your illness at home. You will likely be required to wear a mask when leaving the hospital or clinic and should continue to wear this mask until you are safely home and isolated from other people in your household. You will need to continue monitoring your illness at home to watch for worsening signs and symptoms of COVID-19 because some changes could indicate that your condition is worsening and you may need to contact your doctor.

The best way to keep track of your health is to maintain a daily diary so that you can track changes in your symptoms. A diary is included at the end of these instructions. Two of the most important measurements are your temperature and oxygen levels. Temperature is measured with a thermometer. Oxygen levels are measured with an oximeter. Although everyone understands why a thermometer is important, few of us have an "oximeter" (also known as a pulse oximeter) or know how to use it properly to measure the oxygen levels in your blood (Figure 1 ). Why is this important? The oxygen level in your blood is a very good indicator of how well your lungs are functioning. It is especially important because, for a lot of people, the first sign that they may have COVID-19 (or that their COVID-19 condition is deteriorating) is when the oximeter shows that oxygen levels have decreased 156 when measuring blood oxygen saturation level sit still, be sure the hand is warm, relaxed, and held still and below the level of the heart. Remove fingernail polish from the finger nail. 157 (dropped) to an unhealthy level. This decrease can happen even before a thermometer shows you have a fever. A drop in oxygen levels can also happen even before you feel any COVID-19 symptoms such as chills, muscle aches, runny nose, loss of smell, loss of taste, sneezing, sore throat, upset stomach, diarrhea, headache, and generalized fatigue. So, measuring blood oxygen levels with an oximeter seems to be the best way to monitor your condition when you have tested positive for COVID-19, are self-isolating at home, and/or recovering at home after treatment in the hospital or clinic. Pulse oximeters to monitor oxygen saturation and determine heart rate are available at most pharmacies and online for $18-40. Insurance and healthcare companies may cover the cost of a pulse oximeter with a doctor's prescription.

Fill out your diary (attached) daily with your temperature, oxygen level and heart rate (pulse) as measured with our pulse-oximeter.

b. Contact Your Doctor If. . . (1) Your oxygen level measured on your oximeter drops below 93% since this can be the first sign of a worsening COVID-19 infection. (2) Your heart rate (measured using your pulse oximeter) when sitting is greater than 100 beats per minute.

(3) You have a fever that increases above 100.4° or excessive chilling with or without shaking. (4) Your ability to breathe is getting worse (breathing harder or faster than before or you feel like you are getting less air) and or you have trouble breathing when lying down and or your respiratory rate (number of breaths you take per minute) becomes greater that 24 breaths per minute. (5) You have shortness of breath. (6) Cough is worsening. When you cough into a tissue, what do you see? If there is something in your tissue this is called mucus or phlegm. The color is very important, and you should record this in your diary. For example, the appearance of color that is not clear or white, is often associated with worsening when the color is gray, green, yellow, brown, red or a mixture of these. (7) You develop nausea, vomiting, diarrhea or any of these are getting worse. (8) You have chest pain or chest pressure that does not go away, new confusion, difficulty waking up, and bluish lips or face skin. (9) The skin of your toes or fingers changes (either red or blue). (10) You start to feel worse at any time in your illness. If this should occur, your oxygen level should be promptly remeasured and logged into your diary.

These precautions are necessary in order to keep other occupants in your home including caregivers as safe as possible. You may be able to spread the COVID-19 disease to others even if you feel fine and have no symptoms. The COVID-19 virus is spread easily through tiny droplets when you breathe out (exhale), talk, whistle, sing, cough or sneeze. You should take the following steps to help prevent the disease from spreading to people in your home.

(1) Stay at home and limit contact with others to avoid spreading the virus. Limit contact with pets. If possible, ask someone else to care for your pets while you are sick. If this is not an option wear a mask when you interact with your pet. (7) Wear a mask when you are around other people. Some people may not be able to wear a mask because the mask makes it difficult to breathe. In this case it is very important that other people in your home wear a mask when they are around you. If family members or others including caregivers must enter the room you occupy, they must wear a mask.

(1) High-touch surfaces include counters, tabletops, doorknobs, fixtures, phones, keyboards, tablets, water faucets, appliances, and bedside tables. (2) Bathroom hygiene. Whenever you use a bathroom, you must pay special attention to washing hands and then spray or wipe the following surfaces with disinfectant: toilet handle, all faucets, light/fan switches, and porcelain/stainless steel.

(3) Clean any surfaces that may have blood, stool, or body fluids on them, wearing disposable gloves when available. Use a household disinfecting cleaning spray or wipe according to the label instructions for safe and effective use of product including precautions you should take when applying the product. You can be injured by not using cleansing products correctly. Do not mix cleaning products.

(1) Remove and wash clothes or bedding that may have blood, stool, or body fluids on them and then wash your hands right away. Store used clothes and bedding in a separate container or plastic bag if you cannot wash them right away. Laundry is best cleaned by using laundry detergent (and bleach if consistent with fabric care guidelines), in hot water followed by a full cycle of drying with the maximum temperature set on high heat (if consistent with fabric care instructions).

(a) Clean your hands and fingers often. (b) Wash your hands and fingers with soap and warm water for at least 20 seconds or use an alcohol-based hand sanitizer that contains at least 60% alcohol, covering all surfaces of your hands, and letting your hands air-dry. (c) Wash your hands after blowing your nose, coughing, or sneezing into them, going to the bathroom and before eating and preparing food. (d) Avoid touching your eyes, nose, and mouth with unwashed hands. (e) Cover your mouth and nose with a tissue when you cough or sneeze. Throw used tissues in a trash can lined with a plastic or paper bag, clean your hands right away either with a 20-second warm water and soap scrub or a gel-based hand sanitizer. (f) Wear a facemask when you are around other people or caregivers for example, sharing a room or vehicle before you enter a healthcare providers office, hospital or clinic, grocery shopping, or any other public or private activity that involves a number of other people. 

Take all medications that your physician determines are necessary and stay hydrated with 6 to 8 twelve-ounce glasses of water daily.

(a) It may take several weeks for you to feel like you have returned to normal. (b) You should remain at home until the risk of infecting others is low. Check with your physician before resuming your regular daily activities.

(a) If you are in contact with or room with others who are not sick. (b) Whenever you are in a public place that requires masks, contact your local and state government websites for additional guidance.

(a) You can stop isolating yourself when all of these things have happened:

(1) You have no fever for at least 72 hours (3 full days of no fever without the use of medication that reduces fever such as Tylenol or ibuprofen). (2) Other symptoms have improved (for example coughing has stopped or shortness of breath have improved) and approximately 14 days have passed since your symptoms first started. (3) You have two negative COVID-19 tests, and your doctor agrees that it is okay for you to stop isolation.

(a) Being diagnosed with COVID-19 can be stressful and cause anxiety.

(1) Being ill with COVID-19 might be especially stressful because it is a new disease and there is a lot of multimedia coverage. Take breaks from reading, watching, or listening to news stories including social media. 

Prevalence of asymptomatic SARS-CoV-2 infection. A narrative review

Harvard Medical School: If you've been exposed to the coronavirus

Children's Hospital of Philadelphia. How to protect yourself and your family from coronavirus disease

Harvard Medical School: preventing the spread of the coronavirus

Community transmission of SARS-CoV-2 at two family gatherings

Help stop the spread of coronavirus and protect your family

SARS-CoV-2 transmission from people without COVID-19 symptoms

Center for Disease Control and Prevention

Coronavirus, social and physical distancing and self-quarantine

COVID-19): what do quarantine, and isolation mean? Accessed

COVID-19 (coronavirus) quarantine, selfisolation and social distancing

COVID-19: when to quarantine

Treating COVID-19 at home: care tips for you and others

Center for Disease Control and Prevention. Mental health and coping during COVID-19

Guidelines for frontline healthcare staff safety for COVID-19

SARS-CoV-2 safety guidelines for frontline nurses

Considerations for target oxygen saturation in COVID-19 patients: are we undershooting

Remote management of covid-19 using home pulse oximetry and virtual ward support

doi:10.1136/ bmj.m4151 27. Academy of Pediatric Physical Therapy. Vital sign considerations for physical therapy practice during the COVID-19 pandemic

COVID-19 and its cardiovascular effects: a systematic review of prevalence studies

COVID-19 basics

Moderate fever cycles as a potential mechanism to protect the respiratory system in COVID-19 patients

Center for Disease Control and Prevention. Interim clinical guidance for management of patients with confirmed 2019-nCoV

Assessment of physiological signs associated with COVID-19 measured using wearable devices

Vital signs (body temperature, pulse rate, respiration Rate, blood pressure)

Analyzing changes in respiratory rate to predict the risk of COVID-19 infection

Confronting COVID-19-associated cough and the post-COVID syndrome: role of viral neurotropism, neuroinflammation, and neuroimmune responses

Is there (will there be) a post-COVID-19 chronic cough

COVID-19 patients' clinical characteristics, discharge rate, and fatality rate of meta-analysis

Covid-19: UK studies find gastrointestinal symptoms are common in children

The roles of nausea and vomiting in COVID-19: did we miss something?

Gastrointestinal involvement in COVID-19: a systematic review and meta-analysis

How COVID-19 can damage the brain

Could COVID delirium bring on dementia?

A rapid review of the pathoetiology, presentation, and management of delirium in adults with COVID-19

The immediate impact of the 2019 novel coronavirus (COVID-19) outbreak on subjective sleep status

Extrarespiratory manifestations of COVID-19

COVID-19-associated apnea and circumoral cyanosis in a 3-week-old

Nicklaus Children's Hospital. Cyanosis. Accessed

Skin discoloration -bluish information

A review of the dermatological manifestations of coronavirus disease 2019 (COVID-19)

Dermatological manifestations in patients with SARS-CoV-2: a systematic review

Panic disorder: when fear overwhelms

Associations of social isolation with anxiety and depression during the early CPVOD-19 pandemic: a survey of older adults in London

6-month consequences of COVID-19 in patients discharged from hospital: a cohort study

Persistent symptoms in patients after acute COVID-19

Breaking bad news training in the COVID-19 era and beyond

Impact of the COVID-19 pandemic on the core functions of primary care: will the cure be worse than the disease? A qualitative interview study in Flemish GPs

Anxiety and depression in COVID-19 survivors: role of inflammatory and clinical predictors

Covid-19: A systemic disease treated with a wide-ranging approach: a case report

Something to feel good about in these bad times

Dealing with the COVID-19 infodemic: distress by information, information avoidance, and compliance with preventive measures

Evaluating the impact of stay-at-home orders on the time to reach the peak burden of Covid-19 cases and deaths: does timing matter?

Timing of state and territorial COVID-19 stay-at-home orders and changes in population movement -United States

Impact of COVID-19 on adolescents' mental health: a systematic review. Middle East Curr Psychiatry

Identifying airborne transmission as the dominant route for the spread of COVID-19

Suicide deaths during the COVID-19 stay-at-home advisory in Massachusetts

Stay-at-home policy is a case of exception fallacy: an internet-based ecological study

When you can be around others after you had or likely had COVID-19

Center for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19) -checklist for older adults

Center for Disease Control and Prevention. Social distancing. Accessed

Staying home, distancing, and face masks: COVID-19 prevention among U.S. women in The COPE study

COVID 19-An eye on the virus

The right to touch and be touched

Preventive behaviors adults report using to avoid catching or spreading influenza, United States, 2015-16 influenza season

How can I protect myself (and others) from the New Coronavirus and COVID-19? Accessed

Center for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19) -checklist for teachers

daily-life-coping/ living-in-close-quarters.html#:~:text=Provide%20a%20 separate%20bedroom%20and,anyone%20who%20is%20 sick 81. Center for Disease Control and Prevention. COVID19 -Caring for someone sick at home

Infectious SARS-CoV-2 in feces of patient with severe COVID-19

Assessment of air contamination by SARS-CoV-2 in hospital settings

Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient

Open defecation and squat toilets, an overlooked risk of fecal transmission of COVID-19 and other pathogens in developing communities

Toilets dominate environmental detection of severe acute respiratory syndrome coronavirus 2 in a hospital

Food safety during and after the era of COVID-19 pandemic

Sanitization during and after COVID-19 pandemic: a short review

Center for Disease Control and Prevention. If you have pets

What to do if your pet tests positive for the virus that causes COVID-19

Interim guidance on duration of isolation and precautions for adults with COVID-19

World Health Organization. When and how to use masks

Coronavirus (COVID-19): how to quarantine or isolate at home (for parents

Center for Disease Control and Prevention. Coronavirus (COVID-19) frequently asked questions

Diarrhea during COVID-19 infection: pathogenesis, epidemiology, prevention, and management

wwksfroutes-transmission-mar-06-2020.pdf 101. Center for Disease Control and Prevention. Guidance on management of coronavirus disease 2019 (COVID-19) in correctional and detention facilities

Center for Disease Control and Prevention. Characteristics associated with adults remembering to wash hands in multiple situations before and during the COVID-19 pandemic -United States

Johns Hopkins Medicine. Hand-washing and coronavirus prevention for children: infographic. Leave it in and not say anything

Center for Disease Control and Prevention. When and how to wash your hands

WHO declares COVID-19 a pandemic

Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis

Effectiveness of mask wearing to control community spread of SARS-CoV-2

Universal masking during COVID-19 pandemic-current evidence and controversies

The role of masks and respirator protection against SARS-CoV-2

An evidence review of face masks against COVID-19

Universal use of face masks for success against COVID-19: evidence and implications for prevention policies

Mask-wearing and control of SARS-CoV-2 transmission in the USA: a crosssectional study

Effectiveness of face masks in preventing airborne transmission of SARS-CoV-2. mSphere

14-Day-Quarantine-Incubation-Period 118. Center for Disease Control and Prevention. Public health guidance for community-related exposure

Remote patient monitoring program for hospital discharged COVID-19 patients

Remote patient monitoring

Monitoring approaches for health-care workers during the COVID-19 pandemic

Active monitoring of persons exposed to patients with confirmed COVID-19 -United States

Individual quarantine versus active monitoring of contacts for the mitigation of COVID-19: a modelling study

risk assessment, surveillance and management of SARS-CoV-2 infection in health workers: a scoping review

Public health guidance for community-related exposure

Home monitoring for COVID-19

DMHAS-Protocols-for-COVID-Qand-I.pdf 128. Clinical Trials.gov. Sensor based vital signs monitoring of Covid 19 patients during home isolation

COVID-19) update: FDA allows expanded use of devices to monitor patients' vital signs remotely

Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen China

Freidin MB et al: Real-time tracking of self-reported symptoms to predict potential COVID-19

Clinical questions about COVID-19: questions and answers

Fighting COVID-19 with water

Hydration-Induced disorder lowers the energy barriers for methyl rotation in drug molecules

Electrolyte imbalances in patients with severe coronavirus disease

Hydrating the respiratory tract: an alternative explanation why maskslLower severity of COVID-19 disease

Hypotheses about sub-optimal hydration in the weeks before coronavirus disease (COVID-19) as a risk factor for dying from COVID

Would we recover better sleep at the end of Covid-19? A relative improvement observed at the population level with the end of the lockdown in France

Follow-up studies in COVID-19 recovered patients -is it mandatory?

COVID-19 lung damage

science/sciencebriefs/scientific-brief-options-to-reduce-quarantine. html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc. gov%2Fcoronavirus%2F2019-ncov%2Fmore%2Fscientific-brief-options-to-reduce-quarantine.html 146. Center for Disease Control and Prevention. Screening K-12 students for symptoms of COVID-19: limitations and considerations

Interim guidance for ships on managing suspected or confirmed cases of coronavirus disease 2019 (COVID-19)

Center for Disease Control and Prevention. Disposition of non-hospitalized patients with COVID-19

The magnitude of COVID-19 related stress, anxiety and depression associated with intense mass media coverage in Saudi Arabia

COVID-19 and the 24/7 news cycle: does COVID-19 news exposure affect mental health?

The novel coronavirus (COVID-2019) outbreak: amplification of public health consequences by media exposure. Health Psychol

managing-stress-anxiety.html 154. World Health Organization. Therapeutic patient education: continuing education programmes for health care providers in the field of prevention of chronic diseases: report of a WHO working group

Coronavirus: clinical information

Comparison of SpO2 value from different fingers of the hands

Pulse oximeter accuracy and limitations: FDA safety communication

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported in part by the American Association of Physician Specialists Foundation, Tampa, FL; Sollay Kenyan Foundation, Baltimore, MD, and New African Broadcasting Network-TV, East Orange, NJ.

Jack V. Greiner https://orcid.org/0000-0003-1659-1020