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COVID-19: Evaluation of adults with acute illness in the outpatient setting

COVID-19: Evaluation of adults with acute illness in the outpatient setting
Authors:
Pieter Cohen, MD
Kelly Gebo, MD, MPH
Section Editor:
Joann G Elmore, MD, MPH
Deputy Editors:
Lisa Kunins, MD
Allyson Bloom, MD
Literature review current through: Jul 2022. | This topic last updated: Aug 08, 2022.

INTRODUCTION — At the end of 2019, a novel coronavirus rapidly spread throughout the world, resulting in a global pandemic. The virus was designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the illness it caused coronavirus disease 2019 (COVID-19). The spectrum of COVID-19 in adults ranges from asymptomatic infection to mild respiratory tract symptoms to severe pneumonia with acute respiratory distress syndrome (ARDS) and multiorgan dysfunction. Our understanding of the spectrum of disease as well as optimal management strategies continues to evolve, particularly with the emergence of SARS-CoV-2 variants.

This topic will address the evaluation of adult patients with acute COVID-19 in the outpatient setting (eg, <12 weeks after illness onset), including self-care advice, telehealth and outpatient evaluation, and emergency department (ED) or hospital referral. Data informing outpatient management strategies continue to evolve, and the approach described here is based upon a rapidly developing evidence base. In addition, clinicians should take into the account an individual patient's circumstances as well as available local resources when considering management options.

The treatment of COVID-19 in adult patients in the outpatient setting is discussed separately. (See "COVID-19: Management of adults with acute illness in the outpatient setting".)

Select topics reviewing the diagnosis and epidemiology and virology of COVID-19, the care of hospitalized patients, post-COVID-19 recovery, and considerations in special populations can be found elsewhere:

(See "COVID-19: Epidemiology, virology, and prevention".)

(See "COVID-19: Diagnosis".)

(See "COVID-19: Clinical features".)

(See "COVID-19: Management in hospitalized adults".)

(See "COVID-19: Evaluation and management of adults with persistent symptoms following acute illness ("Long COVID")".)

(See "COVID-19: Overview of pregnancy issues".)

(See "COVID-19: Management in nursing homes".)

(See "COVID-19: Vaccines".)

(Related Pathway(s): COVID-19: Initial telephone triage of adult outpatients.)

(Related Pathway(s): COVID-19: Anticoagulation in adults with COVID-19.)

In addition, please refer to our COVID-19 homepage to view the complete list of UpToDate COVID-19 topics.

GENERAL PRINCIPLES

Continuum of care — When possible, we favor evaluating and managing all patients with suspected or confirmed COVID-19 within an outpatient continuum of care management program that includes:

Self-assessment tools. (See 'Patient self-assessment tools' below.)

Initial telephone triage. (See 'Initial telephone triage' below.)

Coordinated outreach and management approach based upon individual patient risk, severity of symptoms, and time course of disease. (See 'Risk stratification' below and 'Determine if in-person evaluation warranted' below.)

Clinician telehealth (telephone call or video platform-based) visits (initial evaluation and follow-up visits) [1,2]. (See 'Home management without in-person evaluation for others' below and 'Reevaluation for worsening dyspnea' below.)

COVID-19 testing. (See 'Suspicion for COVID-19 and role of testing' below.)

A separate outpatient respiratory clinic or dedicated space within an ambulatory clinic appropriated for the care of patients with COVID-19 and other respiratory problems. Strategies to reduce the risk of exposure to SARS-CoV-2 by staff and other patients should be employed. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the health care setting'.)

In addition, the outpatient clinic should have a close, coordinated relationship with the local emergency department (ED) and function in partnership within the continuum of care program. (See 'Rationale for outpatient management and remote care' below.)

A close working relationship with local public health officials and community leaders.

In such a system, patients could enter the ambulatory COVID-19 care program by contacting their primary health care provider or following discharge from the ED or an inpatient hospital stay.

In addition, during the course of illness and recovery, patients would be able to transition to different sites of care for follow-up as dictated by clinical need (eg, from self-care home management, to outpatient clinic or ED evaluation, to telehealth follow-up, and back to self-care management).

In resource-limited settings, an extension of this continuum of care may include health care provider home visits to evaluate patients and at-risk family members [3,4]. In-person home evaluations may facilitate more effective medical management of the patient, assessment of potentially infected household contacts, and provide an opportunity to promote infection control measures.

Rationale for outpatient management and remote care — Outpatient management is appropriate for most patients with COVID-19; in the majority of patients, illness is mild and does not warrant medical intervention or hospitalization [5,6]. In addition, remote (telehealth) management is preferred for the majority of patients for the following reasons:

Remote management can prevent unnecessary in-person medical visits, including visits to urgent care facilities and EDs, thus avoiding additional, unnecessary strain on already overburdened and overwhelmed health care systems.

In-person health care provider visits require the patient to leave their home, traveling via public, private, or emergency transport and potentially exposing others to SARS-CoV-2. In addition, upon arrival at a health care facility, patients may expose other patients and health care workers to the virus.

Creating a comprehensive, coordinated outpatient care program that incorporates these components may allow more patients to receive supportive care at home and, if necessary, in the ambulatory clinic setting, further reducing ED and hospital resource utilization.

Telehealth has been used for patient management during previous disease outbreaks, including SARS, Middle East respiratory syndrome (MERS), and influenza A H1N1 [7]. Remote evaluation and management of patients with COVID-19 continues to be evaluated, and there is accumulating evidence demonstrating the appropriateness and efficacy of this approach [8-13]. (See "COVID-19: Considerations in patients with cancer".)

Telehealth evaluation for COVID-19 can be performed by telephone call, video-based telemedicine platform, or commercial video chat platform; the format chosen should be compliant with applicable patient privacy regulations [14].

Flexibility in approach to care — High-quality data supporting the superiority of any single outpatient management strategy are lacking, and treatment protocols are being developed and modified as understanding of the disease evolves.

Our approach is based upon guidelines [15], as well as our own clinical experience of treating patients with COVID-19, and places additional emphasis on avoiding infection transmission, preserving limited resources, and reducing the burden on overwhelmed health care systems. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Prevention' and "COVID-19: Diagnosis", section on 'COVID-19 testing not readily available' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'When PPE is limited'.)

Some institutions have been able to establish dedicated outpatient respiratory clinics devoted to managing COVID-19 patients, with available in-person and remote management options; in many other locations, these patients are being managed by primary care clinicians, often in consultation with a team of specially trained clinicians. Some health care systems have created “hospital-at-home” care with “virtual observation units” for COVID-19 patients [16,17].

Additionally, institutions may need to revise protocols, even in near real time, in response to surges in the number of patients with suspected infection they are managing [18].

INITIAL EVALUATION — Most patients who have concerns about COVID-19, even those with mild symptoms, will likely initiate contact with the health care system. For those patients, self-assessment tools, or remote (telehealth) evaluation are the preferred initial management approaches [19-21].

Patient self-assessment tools — Patient education materials, including self-assessment tools, can help patients determine if medical evaluation is necessary, and proactive dissemination of these materials may increase awareness and encourage their use. Various online self-assessment tools published by medical institutions [22] and governmental health agencies can guide patients through questions and suggest when to seek medical care; by following the guidance, most patients with mild illness can recover at home on their own without needing to come in direct contact with a health care provider. Before recommending a specific assessment tool, however, clinicians should vet the options carefully, as they may exceed the abilities of patients with limited health literacy or can become quickly out-of-date based upon rapidly changing guidelines. Clinicians should recognize that many of these self-assessment tools do not inform eligible patients about the possibility of COVID-19-specific therapy.

In one study, use of a self-assessment tool embedded into the electronic health record allowed 40 percent of symptomatic patients to be appropriately triaged to self-care [21]. This study, however, was conducted in the setting of relatively low community prevalence of SARS-CoV-2 and might not be representative of settings with widespread community transmission.

Initial telephone triage — In addition to self-assessment tools, an initial triage call by clinic staff can often determine which patients are appropriate for self-care at home, which patients warrant a timely clinician telehealth visit (televisit), which patients may be eligible for treatment with a COVID-19-specific therapy, and which patients warrant an outpatient clinic visit or urgent emergency department (ED) evaluation [23,24]. (See 'Risk stratification' below and "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Treatment with COVID-19-specific therapies'.) (Related Pathway(s): COVID-19: Initial telephone triage of adult outpatients.)

Any patient with symptoms suggestive of respiratory compromise or hypoxia (eg, significant dyspnea at rest, mental confusion) or significant hypovolemia should be referred for urgent in-person evaluation; the appropriate site of care depends upon the severity of symptoms and is discussed elsewhere. (See 'In-person evaluation for moderate/severe dyspnea, hypoxia, and concern for higher acuity level' below.)

Suspicion for COVID-19 and role of testing — Patients with COVID-19 typically experience a viral-type illness with symptoms ranging from a mild upper respiratory tract infection (eg, pharyngitis, rhinorrhea) to a lower respiratory tract infection (eg, cough, fever), influenza-like symptoms (eg, fever, chills, headache, myalgias), or gastroenteritis (eg, nausea, vomiting, diarrhea) (table 1) [25]. Loss of smell and taste may also occur, with olfactory loss typically reported early in the course of illness [26-30]. Dyspnea, if it develops, tends to occur between four to eight days after the onset of symptoms, although it can occur after 10 days [25]. Clinical presentation may also vary depending upon the individual's vaccination status and the particular SAR-CoV-2 variant. In addition, even in locations with a high prevalence of COVID-19, the possibility of other etiologies of symptoms should be considered. (See "COVID-19: Clinical features", section on 'Initial presentation' and "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Managing other potential causes of symptoms'.)

In the outpatient setting, initial testing is often performed with rapid antigen testing at home or at the point of care. However, antigen tests are typically less sensitive than nucleic acid amplification tests (NAATs) (table 2); clinicians and patients should be aware of the possibility of false-negative results with antigen tests and, if clinical suspicion is high, should not use a single negative antigen test to rule out SARS-CoV-2 infection. Testing for SARS-CoV-2 is discussed in detail elsewhere. (See "COVID-19: Diagnosis", section on 'NAAT (including RT-PCR) to diagnose current infection' and "COVID-19: Diagnosis", section on 'Antigen testing as an alternative to NAAT'.)

Antibody detection has no utility for diagnosis in the acute outpatient setting; we do not use serology to exclude or diagnose acute COVID-19 infection. (See "COVID-19: Diagnosis", section on 'Serology to identify prior/late infection'.)

Risk stratification — Our patient-centered continuum of care management approach is based upon stratification of risk for developing severe disease as well as evaluation of clinical acuity.

Assess risk for severe disease — Risk for severe disease informs the need for evaluation and eligibility for treatment with a COVID-19-specific therapy (see "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Treatment with COVID-19-specific therapies'). In addition to being unvaccinated [31], older age and certain chronic medical conditions are associated with more severe illness and higher mortality from COVID-19 [32]. Specific risk factors are detailed in the table (table 3).

Advancing age appears to be one of the most important risk factors associated with severe COVID-19 outcomes [33]. Using United States data collected from the beginning of the pandemic through June 2022, compared with adults younger than age 30, the risk of death from COVID-19 is 25 times higher among those ages 50 to 64, 65 times higher among those ages 65 to 74, 140 times higher among those ages 75 to 84, and 330 times higher among those age 85 and above.

Evidence on the impact of other risk factors comes from a variety of studies, including meta-analyses, systematic reviews, individual observational cohort studies, and case series, in which patients with these underlying conditions had higher rates of severe disease and death [6,34-42]. However, patients with a particular underlying condition do not all have a uniformly high risk of severe disease. As an example, the risk of severe COVID-19 among patients with cancer may depend upon several variables, including the type of malignancy as well as the use of chemotherapy (see "COVID-19: Considerations in patients with cancer"). It is also important to note that although patients who are older or have poorly controlled chronic medical conditions have a higher risk for hospitalization and death, infection with SARS-CoV-2 may cause catastrophic illness in any patient, even among those without any risk factors. (See "COVID-19: Clinical features", section on 'Risk factors for severe illness'.)

COVID-19 has disproportionately affected residents of nursing homes and long-term care facilities, in part due to the high proportion of frail older adults and those with underlying chronic conditions [43], particularly early in the pandemic. These factors increased both the prevalence and severity of infection, resulting in high mortality rates among this population [44]. (See "COVID-19: Management in nursing homes", section on 'Scope of the problem'.)

Additionally, in the United States, Black American and Hispanic American patients have represented a disproportionately high percentage of hospitalizations and deaths [6,35,36,38,45,46]. The reasons for this finding are unclear but are most likely related to inequalities in the social determinants of health (eg, access to health care, economic stability, living environment, community experience, education) [47,48].

In addition, although the vast majority of children with COVID-19 have mild disease [49,50], infants and children with underlying medical conditions warrant close monitoring; severe disease is most likely to occur in children with underlying medical conditions [51]. Multisystem inflammatory syndrome in children (MIS-C) is a rare but serious condition that has been reported in children and adolescents in association with current or recent COVID-19 infection or exposure [52-56]. Rare cases of a similar syndrome have been reported in adults (multisystem inflammatory syndrome in adults [MIS-A]) [57]. This is reviewed in detail elsewhere. (See "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis" and "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) management and outcome" and "COVID-19: Cardiac manifestations in adults", section on 'Multisystem inflammatory syndrome in adults (MIS-A)'.)

Assess symptom duration and severity

Time course and development of dyspnea — For any patient with suspected or confirmed COVID-19, we establish the illness timeline: the first day symptoms began, the presence of dyspnea, and the day of dyspnea onset. While mild dyspnea is common, worsening dyspnea, particularly dyspnea at rest, and more severe chest discomfort/tightness, are concerning symptoms and suggest the development or progression of pulmonary involvement. The trajectory of dyspnea over the days following its onset is particularly important, as significant worsening and acute respiratory distress syndrome (ARDS) can manifest soon after the onset of dyspnea; in initial studies among COVID-19 patients who developed ARDS, progression to ARDS occurred a median of 2.5 days after onset of dyspnea [58-62]. In patients with any risk factors for severe disease (table 3), outreach efforts should be focused particularly on the days following the onset of dyspnea to assess for any worsening of respiratory status.

It is unclear what percentage of patients with COVID-19 develop dyspnea, as available reports are likely not representative of all patients with SARS-CoV-2 infection. In unvaccinated patients with symptomatic infection, dyspnea develops in only a subgroup of patients and is less likely to occur among vaccinated individuals. As examples, dyspnea developed in 19 percent of approximately 1000 unvaccinated COVID-19 patients admitted to a hospital in Wuhan, China [63]. However, in a CDC study of unvaccinated COVID-19 patients in the United States, 43 percent of symptomatic adults and 13 percent of symptomatic children developed dyspnea [51]. Among patients who develop dyspnea, it typically begins at least several days after the onset of illness. In one study of 41 hospitalized patients in China, dyspnea developed, on average, eight days after the onset of symptoms [64]. (See "COVID-19: Clinical features", section on 'Clinical manifestations'.)

Dyspnea assessment — Remote assessment of dyspnea should focus on the patient's subjective symptoms, as well as an objective assessment of breathing, including deterioration in respiratory function [65]. We begin by asking if patients have developed any difficulty with their breathing, other than that associated with coughing. If yes, we ask the patient to describe the difficulty in their own words and assess the ease and comfort of their speech (eg, if they can speak comfortably in complete sentences).

In addition, we ask questions that provide a more objective assessment of changes in respiratory status, including [65]:

"What activities that you could previously do without difficulty are now causing you to be out of breath?"

"Has this gotten worse over the last one, two, or three days?"

"Are you breathing harder or faster than usual when sitting still?"

"Can you no longer do your usual household activities due to shortness of breath?"

"Does walking cause you to feel dizzy?"

We use this assessment to categorize dyspnea by severity:

Mild dyspnea – Dyspnea that does not interfere with daily activities (eg, mild shortness of breath with activities such as climbing one to two flights of stairs or walking briskly).

Moderate dyspnea – Dyspnea that creates limitations to activities of daily living (eg, shortness of breath that limits the ability to walk up one flight of stairs without needing to rest, or interferes with meal preparation and light housekeeping tasks).

Severe dyspnea – Dyspnea that causes shortness of breath at rest, renders the patient unable to speak in complete sentences, and interferes with basic activities such as toileting and dressing.

If available, telemedicine consultation with video capability may allow an even better evaluation of respiratory status, by allowing the clinician to observe the patient's respiratory pattern, including the use of accessory muscles of respiration [19].

Dyspnea may not correlate with the presence or degree of hypoxia in all patients [66], but dyspnea, along with risk factors for developing severe disease (table 3), can be used to guide clinicians in determining whether a patient requires in-person evaluation. (See 'Assess risk for severe disease' above and 'Determine if in-person evaluation warranted' below.)

Oxygenation assessment — If a patient with COVID-19 already has access to a pulse oximeter at home and can adequately measure and report the results to the clinician, we consider the oxygen saturation as an additional piece of information to assess their clinical status. Patients are advised to use their pulse oximeter on warm fingers, as readings obtained on cold digits may not be as accurate [67,68]. In the outpatient setting, we instruct patients to check their oximetry twice daily and inform us if the value drops below 95 percent.

For any patient with an oxygen saturation of ≤94 percent on room air, in-person evaluation is warranted. (See 'In-person evaluation for moderate/severe dyspnea, hypoxia, and concern for higher acuity level' below.)

For patients who have an oxygen saturation of ≥95 percent on room air, the decision on in-person evaluation depends on other clinical features such as severity of dyspnea, risk for severe disease, and assessment of overall acuity. (See 'Determine if in-person evaluation warranted' below.)

However, oximetry should only be considered within the context of the patient's overall clinical presentation; a normal oxygen saturation level cannot be used to exclude clinically significant respiratory involvement in a patient with concerning symptoms such as progressive or severe dyspnea or high overall acuity level (see 'Assessment of overall acuity level' below). Further, the addition of remote oximetry to dyspnea monitoring has not been shown to improve patient outcomes [69]. In addition, although normal oximetry can be reassuring, results may be not always be accurate, particularly in patients with darker skin pigmentation [68,70,71] (see "Pulse oximetry", section on 'Falsely normal or high reading'), and there is no guarantee that respiratory status will not deteriorate as illness progresses.

We do not advise that all patients diagnosed with COVID-19 purchase a pulse oximeter. Further, we do not consider oxygen saturation readings obtained through an application ("app") on a mobile telephone accurate enough to depend upon for clinical use [72].

As with dyspnea, the availability of telemedicine with video capability may allow the indirect assessment of hypoxia by the observation of cyanosis, if present [19].

Assessment of overall acuity level — In addition to evaluation of respiratory status, we assess the patient's overall acuity level by asking questions regarding orthostasis, dizziness, falls, hypotension (if home blood pressure measurement is available), mental status change (eg, lethargy, confusion, change in behavior, difficulty in rousing), observed cyanosis, and urine output. While mild orthostasis symptoms may be addressed with instruction to increase fluids, mental status changes, falls, cyanosis, hypotension, anuria, and chest pain suggestive of acute coronary syndrome are concerning and warrant in-person evaluation. (See 'In-person evaluation for moderate/severe dyspnea, hypoxia, and concern for higher acuity level' below.)

Assess home setting and social factors — We assess the ability of patients to monitor their symptoms and to understand the importance of seeking medical attention should symptoms progress. Patients who lack the ability to self-monitor and self-report may need more intensive staff outreach in order to be adequately managed at home.

In addition, in accordance with interim CDC guidelines on home management, we assess if the patient's residential setting is appropriate for home management and recovery [73]; patients managed at home should be capable of adhering to appropriate infection control and isolation precautions for the duration of illness and recovery (including using a separate bedroom if not living alone). Other important home resources include an available caregiver, adequate access to food, and assistance with activities of daily living if necessary. Whether the patient has any household members who have risk factors for severe disease is another consideration (table 3). (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the home setting'.)

DETERMINE IF IN-PERSON EVALUATION WARRANTED — Based upon the above assessment, in particular the risk for developing severe disease, dyspnea and oxygenation, and overall acuity level, we determine the urgency and appropriate setting (in-person evaluation versus scheduled telehealth follow-up or self-care) for further management.

For those patients who warrant in-person evaluation, we decide if outpatient clinic or emergency department (ED) evaluation is appropriate. (Related Pathway(s): COVID-19: Initial telephone triage of adult outpatients.)

While we use the following general criteria to determine the most appropriate clinical setting for in-person evaluation, these criteria are not fixed and will vary by institution, region, and over time with changing resource availability and treatment options.

In-person evaluation for moderate/severe dyspnea, hypoxia, and concern for higher acuity level — All patients with moderate or severe dyspnea, an initial oxygen saturation ≤94 percent on room air (if oximetry information available), or any symptoms suggestive of higher acuity level warrant in-person evaluation, either in the ED or in an outpatient clinic, depending upon the severity of findings.

Criteria for ED evaluation and likely hospital admission — We typically refer patients with one or more of the following features to the ED for further management and likely hospital admission:

Severe dyspnea (dyspnea at rest, and interfering with the ability to speak in complete sentences) (see 'Dyspnea assessment' above)

Oxygen saturation on room air of ≤90 percent, regardless of severity of dyspnea (see 'Oxygenation assessment' above)

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) (see 'Assessment of overall acuity level' above)

Patients meeting the above criteria will typically be admitted to the hospital for inpatient evaluation and management. In the United States, the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel suggests hospitalization for patients with any of the following: an oxygen saturation of <94 percent on room air, respiratory rate of >30 breaths/minute, PaO2/FiO2 <300 mmHg, or lung infiltrates >50 percent [74]. While most patients with this presentation will require inpatient care, there are no fixed criteria for inpatient hospital admission with COVID-19; criteria vary by country, region, and availability of COVID-19-specific therapy (see "COVID-19: Management in hospitalized adults", section on 'COVID-19-specific therapy'). Further, in areas of high infection prevalence, the criteria may also vary with the availability of hospital resources; a lower threshold for hospitalization may be feasible in settings where the burden of disease does not exceed resource availability. In addition to clinical considerations, there are social factors that might support earlier hospitalization. Models to predict the likelihood of critical illness in hospitalized COVID-19 patients are being developed, although none have been validated for the evaluation and management of outpatients [75].

We have established an outpatient system to closely follow-up and monitor such patients who do not get admitted. However, this approach may not be appropriate in settings with more limited outpatient resources. (See 'Patients appropriate for evaluation in clinic' below.)

Patients appropriate for evaluation in clinic — Patients with one or more of the following features are typically appropriate for evaluation in an outpatient clinic (ideally a dedicated respiratory/COVID-19 clinic if available), provided they do not meet any of the above criteria for evaluation in the ED:

Mild dyspnea in a patient with an oxygen saturation on room air between 91 to 94 percent (see 'Dyspnea assessment' above)

Mild dyspnea in a patient with risk factors for severe disease (table 3) (see 'Assess risk for severe disease' above and 'Dyspnea assessment' above)

Moderate dyspnea in any patient

Symptoms concerning enough to warrant in-person evaluation (eg, mild orthostasis) but not severe enough to require ED referral (see 'Assessment of overall acuity level' above)

Clinic evaluation — For patients evaluated in an outpatient clinic (if feasible, a respiratory/COVID-19 clinic), we assess the patient's respiratory and circulatory status, and we evaluate for other potentially treatable causes of symptoms [25]. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Managing other potential causes of symptoms'.)

Based upon a careful clinical history and physical examination, including vital signs as well as measurements of oxygen saturation at rest and with ambulation, we then determine if the patient is appropriate for home-management/self-care, initiation of COVID-19-specific therapy (see "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Treatment with COVID-19-specific therapies'), or transfer to the ED for further evaluation or possible inpatient hospital admission.

In our practice, we have found laboratory testing and chest imaging to be of limited utility in the evaluation of most patients with COVID-19 in the outpatient clinic; the patient's clinical presentation is a more important consideration in our management decision. (See "COVID-19: Clinical features", section on 'Laboratory findings' and "COVID-19: Clinical features", section on 'Imaging findings'.)

Patients who require supplemental oxygen are transferred to the ED for hospital admission. Management of hospitalized adults with COVID-19 is discussed elsewhere. (See "COVID-19: Management in hospitalized adults", section on 'Defining disease severity' and "COVID-19: Management in hospitalized adults", section on 'Approach'.)

Some patients without a supplemental oxygen requirement may also need further ED evaluation and possible hospital admission (eg, those with confusion, weakness, progressive dyspnea). (See 'Criteria for ED evaluation and likely hospital admission' above.)

Other patients with less severe disease may be referred for inpatient admission or treated in the outpatient clinic; the decision to manage such patients in an ambulatory setting (eg, the ability to administer intravenous fluids, COVID-19-specific therapy [if appropriate], or other medications, and to arrange for outpatient follow-up) or admit as inpatients will vary between institutions, by region, by hospital resource availability and capacity, and over time, and thus influence this determination. We also consider the patient's home setting and social factors in determining the appropriateness of continued outpatient management.

The use of home oximetry monitoring is being evaluated for patients seen in the ambulatory or ED setting and discharged home [76]. However, there is no high-quality evidence that patient outcomes are improved using this approach.

Home management without in-person evaluation for others — The majority of patients without moderate or severe dyspnea, hypoxia (if oximetry information available), or symptoms suggestive of higher overall acuity level can remain at home for management without in-person evaluation.

Patients who have any risk factors for severe disease (table 3) are evaluated by telephone for consideration of COVID-19-specific therapy. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Treatment with COVID-19-specific therapies'.)

Patients without risk factors for severe disease (table 3) are not scheduled for in-person evaluation or follow-up telehealth visits.

At the time of initial contact, all patients receive instructions to contact their clinician with any worsening or concerning symptoms (see 'Counseling on warning symptoms' below). Although we generally do not schedule routine telehealth follow-up visits for patients managed at home, we reach out to those patients about whom we have concerns (eg, older adults living alone, individuals who may not be able to reliably self-report worsening of symptoms) by telephone as our resources permit.

In addition, all patients receive counseling on home management. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Other management issues'.)

Supervised residential care to facilitate isolation — Patients who would be appropriate for home care but are unable to be adequately managed in their usual residential setting are candidates for temporary shelter in supervised residential care facilities, if available [77].

In particular, patients who may be unable to adequately self-isolate (eg, patients living in multigenerational households, patients living with individuals who have any risk factors for severe disease (table 3), patients experiencing homelessness) should be provided resources such as dedicated housing units, where available [78-81]. Disruption of families should be minimized as much as possible. Every attempt should be made to avoid hospitalization simply for the purpose of facilitating self-isolation, as this option is not realistic in regions with widespread disease.

Unfortunately, dedicated residential care facilities for COVID-19 patients are not widely available in many countries and regions, and community-based solutions to self-isolation should be explored.

ONGOING EVALUATION

Counseling on warning symptoms — We counsel all patients on the warning symptoms that should prompt reevaluation by telehealth visit and in-person, including ED evaluations. These include new onset of dyspnea, worsening dyspnea, dizziness, and mental status changes such as confusion. Patients are educated about the time course of symptoms and the possible development of respiratory decline that may occur, on average, one week after the onset of illness. In addition, we assess the availability of support at home, ensure that they know who to call should they need assistance, and reinforce when and how to access emergency medical services.

Patients with obstructive lung disease (eg, COPD or asthma) are specifically advised to closely monitor their respiratory status and are cautioned not to presume that any worsening shortness of breath is due to an exacerbation of their underlying lung disease.

Reevaluation for worsening dyspnea — All patients who develop worsening dyspnea require further evaluation and management. Even though some patients with worsening symptoms may be managed remotely, we perform an in-person evaluation if their complaints are suggestive of progression to more severe COVID-19 or conditions that are not amenable to telehealth management, such as severe CAP (eg, new productive cough, pleuritic chest discomfort), asthma or COPD exacerbation (eg, cough, increasing wheezing), pulmonary embolism (eg, worsening dyspnea, pleuritic chest pain, hemoptysis), heart failure (increasing dyspnea, edema, orthopnea) or acute pericarditis (eg, chest pain). This evaluation can take place in a respiratory (COVID-19) clinic or appropriate clinical care setting. Discussion of the evaluation and management of these conditions can be found in the relevant UpToDate topics.

In particular, patients with COVID-19 and dyspnea who have underlying obstructive lung disease (including COPD and asthma) present unique management challenges. For such patients, dyspnea may be simply due to an exacerbation of obstruction, and it is generally not possible to differentiate clinically between an isolated exacerbation of underlying pulmonary disease and an exacerbation related to COVID-19. In such cases, an in-person evaluation is usually indicated. (See "An overview of asthma management", section on 'Advice related to COVID-19 pandemic' and "COPD exacerbations: Management".)

MANAGEMENT — Outpatient management of COVID-19 includes symptom management, counseling on home infection control, and, in some cases, treatment with COVID-19-specific therapy. These issues are discussed in detail elsewhere. (See "COVID-19: Management of adults with acute illness in the outpatient setting" and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Isolation at home'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: COVID-19 overview (The Basics)" and "Patient education: COVID-19 and pregnancy (The Basics)" and "Patient education: COVID-19 and children (The Basics)" and "Patient education: Recovery after COVID-19 (The Basics)")

SUMMARY AND RECOMMENDATIONS

Continuum of care – When possible, we favor a coordinated care management program that includes initial risk stratification, clinician telehealth visits, a dedicated outpatient respiratory clinic when feasible, and a close relationship with a local emergency department (ED). (See 'Continuum of care' above.)

Outpatient management appropriate for most patients – Management strategies continue to evolve, particularly in the setting of emerging SARS-CoV-2 variants (table 4), but outpatient, remote management is appropriate for most patients with COVID-19. Clinicians should take into account the individual patient's clinical and social circumstances as well as the available resources when considering evaluation and management options. (See 'Rationale for outpatient management and remote care' above.)

Initial evaluation; evaluation of acuity and risk stratification – On initial evaluation, we assess risk factors for progression to severe disease (table 3), dyspnea severity and duration (and oxygenation status of those with dyspnea, if that information is available), overall level of acuity, and the patient’s home setting to determine who warrants an in-person evaluation at an outpatient clinic or in the ED. The additional criteria we use to make this determination are not fixed and will vary by institution, region, and over time as resource availability and treatment options evolve. (See 'Risk stratification' above.) (Related Pathway(s): COVID-19: Initial telephone triage of adult outpatients.)

Determining site of care/evaluation – We determine the urgency and appropriate setting for evaluation and care based on the risk of severe disease, dyspnea and oxygenation, and overall acuity level.

Features that prompt ED referral – We typically refer patients with one or more of the following features to the ED for further management and likely hospital admission (see 'Criteria for ED evaluation and likely hospital admission' above):

-Severe dyspnea (dyspnea at rest, and interfering with the ability to speak in complete sentences)

-Oxygen saturation on room air of ≤90 percent, regardless of severity of dyspnea

-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)

Features that prompt in-person outpatient evaluation – 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):

-Mild dyspnea in a patient with an oxygen saturation on room air between 91 to 94 percent

-Mild dyspnea in a patient with any risk factors for severe disease (table 3)

-Moderate dyspnea in any patient

-Symptoms concerning enough to warrant in-person evaluation (eg, mild orthostasis) but not severe enough to require ED referral

The decision to refer patients for hospital admission or manage at home depends upon several factors, including their requirement for supplemental oxygen, an assessment of their overall acuity level, and hospital resources and capacity. (See 'Clinic evaluation' above.)

Defer in-person evaluation for others – Other patients can generally remain at home for management without in-person evaluation if they can reliably report worsened symptoms and can self-isolate for the anticipated duration of illness. We generally do not schedule routine telehealth follow-up visits for patients managed at home, although we reach out to those patients about whom we have concerns (eg, older adults who live alone, individuals who may not be able to reliably self-report worsening of symptoms) by telephone as our resources permit. (See 'Home management without in-person evaluation for others' above.)

Counseling on warning symptoms – We counsel all patients on the warning symptoms that should prompt reevaluation, including new onset or worsening dyspnea, dizziness, and mental status changes such as confusion. (See 'Counseling on warning symptoms' above.)

Specific management issues – Outpatient management of COVID-19 includes symptom management, counseling on home infection control, and, in some cases, COVID-19-specific therapy. These issues are discussed in detail elsewhere. (See "COVID-19: Management of adults with acute illness in the outpatient setting" and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Isolation at home'.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jessamyn Blau, MD, who contributed to an earlier version of this topic review.

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References