key: cord-1046940-atsuh8e2 authors: Bryson-Cahn, Chloe; Duchin, Jeffrey; Makarewicz, Vanessa A; Kay, Meagan; Rietberg, Krista; Napolitano, Nathanael; Kamangu, Carole; Dellit, Timothy H; Lynch, John B title: A Novel Approach for a Novel Pathogen: using a home assessment team to evaluate patients for 2019 novel coronavirus (SARS-CoV-2) date: 2020-03-12 journal: Clin Infect Dis DOI: 10.1093/cid/ciaa256 sha: 306ef95a3a91e13a93bcc37fb2c509b67c0b5640 doc_id: 1046940 cord_uid: atsuh8e2 Thousands of people in the United States have required testing for SARS-CoV-2. Evaluation for a special pathogen is resource intensive. We report an innovative approach to home assessment that, in collaboration with public health, enables safe evaluation and specimen collection outside the healthcare setting, avoiding unnecessary exposures and resource utilization. The 2019 novel coronavirus (SARS-CoV-2), identified as the cause of an outbreak of respiratory infection in Wuhan, China, is rapidly spreading around the globe. The first case in the United States was identified on January 20 th , 2020. 1 As of March 6, 2020, 164 additional cases in the United States have been diagnosed, though thousands of people have been tested for SARS-CoV-2. 2 We anticipate many more will require testing in the future. The transmission dynamics of SARS-CoV-2 remain under study, and conservative infection control processes and intensive contact tracing are required for confirmed or suspected cases of infection. Public health agencies are charged to monitor persons with SARS-CoV-2 exposures and perform assessments if symptoms develop. Depending on the outcome of these assessments, testing for SARS-CoV-2 might be recommended. Safe evaluation of persons for suspected infection with a special pathogen (including SARS-CoV-2) in the traditional healthcare environment is costly and resource intensive. It requires specialized rooms, use of personal protective equipment (PPE), monitored donning and doffing, logistically-complicated patient transportation from the community to the healthcare facility and back (typically through emergency medical services), and appropriate decontamination of transport and hospital environments. Additionally, evaluating a patient for emerging pathogens in a healthcare setting runs the risk of exposing patients and staff to infection. In a clinically stable patient with mild symptoms, alternative methods for special pathogen evaluation/testing are vital to preserve healthcare resources and prevent unnecessary exposures. Patients with symptoms of illness and possible exposure to SARS-CoV-2 are identified either by Public Health or through a call to any part of the University of Washington healthcare system, with calls routed to the IPC team responsible for HAT activities. If the patient meets Center for Disease Control and Prevention (CDC) criteria for testing, 3 Public Health determines appropriateness of a HAT visit and SARS-CoV-2 testing in the field. Once Public Health determines that a HAT visit is indicated, a HAT member calls the patient to confirm that they are safe for a visit (breathing comfortably, able to eat and drink, mobilizing around their home), discuss details of the visit, determine locations for donning/doffing, and to register the patient within our system to allow for medical record documentation. Each HAT is made-up of 1 physician, 1 nurse, 1 or more trained PPE observers, and a site-commander, and uses one or two vehicles to transport personnel, PPE, and testing materials. The physician and nurse enter the patient's dwelling in appropriate PPE recommended by the CDC, using standard, contact, and airborne precautions with eye protection. 4 The patient is evaluated by the physician, who gathers a focused history and All involved HAT members complete a daily log including temperature and respiratory and gastrointestinal symptom reporting through employee health for 14 days or until SARS-CoV-2 testing returns negative from the index visit. To date, HAT has successfully conducted 15 community-based assessment visits, including in single-family homes and commercial properties where patients were isolated. All patients were deemed clinically stable and appropriate to remain out of the hospital; none have required subsequent hospitalization. Approximate time from dispatch to return is 3 hours on average; including 10 minutes for donning, 30 minutes for face-to-face patient care, and 30 minutes for doffing/waste procedures. To date, 2 patients have tested positive for SARS-CoV-2. Other evaluated patients have tested positive for human coronavirus, rhinovirus, parainfluenza, or had negative results. Patients have reported that evaluation in this setting is highly acceptable. We noted no instances of contamination of healthcare worker PPE with visible blood or other body fluids and no instances of breech of PPE doffing protocol. . No HAT members have developed symptoms requiring evaluation. To our knowledge, this is the first hospital team-based COVID-19 assessment program in the United States to evaluate patients outside of the traditional healthcare setting. This model benefits both the public health and clinical healthcare systems by increasing safety and efficiency while reducing the costs and complexity of SARS-CoV-2 testing for patients who do not require emergency evaluation or hospitalization. Given concerns with healthcare exposures and healthcare-associated outbreaks with SARS-CoV-2, as well as historical experiences with SARS-CoV and MERS-CoV transmission in healthcare settings, minimizing the exposure risk to clinics, emergency departments, and hospitals is crucial. 5, 6 As healthcare workers are known to be at risk of contamination during doffing of PPE, even when caring for patients with routine respiratory infections, 7 the importance of well monitored appropriate PPE doffing for special pathogens cannot be over-emphasized. Given the novel nature of this pathogen, that the exact mechanisms of transmission have yet to be defined and unclear morbidity and mortality, this is an important yet often overlooked step in keeping our healthcare workers safe. Following initiation of our protocols, the CDC has released new guidance for COVID-19 assessment in residential settings 8 with waste management recommendations that differ from ours. For future novel pathogen assessments prior to release of national guidance, especially for pathogens with a greater risk of transmission, our protocol regarding secure PPE waste control remains pertinent. The HAT program is a scalable, cost-saving model that cuts-down on resources required to isolate and care for patients. Importantly, this model can likely be used for other novel outbreaks and potentially in unconventional settings like ships, planes, and airports that can be served by scaling-up HAT size to allow large scale screening of individuals. Our hospital has a long history of collaborating closely with Public Health on routinely occurring and emerging infectious disease responses. The use of home assessment teams in the setting of novel infectious disease epidemics demonstrates the value of integrated and coordinated public health and healthcare systems and corresponding benefits to our patients and the public. First Case of 2019 Novel Coronavirus in the United States Novel Coronavirus (2019-nCoV) in the U Centers for Disease Control and Prevention. Evaluating and Reporting Persons Under Investigation (PUI Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) or Persons Under Investigation for 2019-nCoV in Healthcare Settings SARS Transmission among Hospital Workers in Hong Kong Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China Respiratory viruses on personal protective equipment and bodies of healthcare workers Interim Guidance for Public Health Personnel Evaluating Persons Under Investigation (PUIs) and Asymptomatic Close Contacts of Confirmed Cases at Their Home or Non-Home Residential Settings We thank the leadership of Harborview Medical Center, UW Medicine, and Washington State Department of Health for supporting this project. Dr. Lynch reports funding for the program from Washington State Department of Health, during the conduct of the study.None of the authors has potential conflicts to disclose.