General Management of Nonhospitalized Patients With Acute COVID-19
Last Updated: July 8, 2021
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials without major limitations; IIa = Other randomized trials or subgroup analyses of randomized trials; IIb = Nonrandomized trials or observational cohort studies; III = Expert opinion
This section of the Guidelines is intended to provide information to health care providers who are caring for nonhospitalized patients with COVID-19. The COVID-19 Treatment Guidelines Panel’s (the Panel) recommendations for pharmacologic management can be found in Therapeutic Management of Nonhospitalized Adults With COVID-19. The Panel recognizes that the distinction between outpatient and inpatient care may be less clear during the COVID-19 pandemic. Patients with COVID-19 may receive care outside traditional ambulatory care or hospital settings if there is a shortage of hospital beds, staff, or resources. Settings such as field hospitals and ambulatory surgical centers and programs such as Acute Hospital Care at Home have been implemented to alleviate hospital bed and staffing shortages.1 Patients may enter an Acute Hospital Care at Home program from either an emergency department (ED) or an inpatient hospital setting. Health care providers should use their judgment when deciding whether the guidance offered in this section applies to individual patients.
This section focuses on the evaluation and management of:
- Adults with COVID-19 in an ambulatory care setting;
- Adults with COVID-19 following discharge from the ED; and
- Adults with COVID-19 following inpatient discharge.
Outpatient evaluation and management in each of these settings may include some or all of the following: telemedicine, remote monitoring, in-person visits, and home visits by nurses or other health care providers.
Managing Patients With COVID-19 in an Ambulatory Care Setting
Approximately 80% of patients with COVID-19 have mild illness that does not warrant medical intervention or hospitalization.2 Most patients with mild COVID-19 (defined as the absence of viral pneumonia and hypoxemia) can be managed in an ambulatory care setting or at home. Patients with moderate COVID-19 (those with viral pneumonia but without hypoxemia) or severe COVID-19 (those with dyspnea, hypoxemia, or lung infiltrates >50%) need in-person evaluation and close monitoring, as pulmonary disease can progress rapidly and require hospitalization.3
Health care providers should identify patients who may be at high risk for progression to severe COVID-19; these patients may be candidates for anti-SARS-CoV-2 monoclonal antibody treatment (see Figure 1 in Therapeutic Management of Nonhospitalized Adults with COVID-19). Management of COVID-19 patients in the outpatient setting should focus on providing supportive care, taking steps to reduce the risk of SARS-CoV-2 transmission (e.g., wearing a mask, isolating the patient),4,5 and advising patients on when to seek in-person evaluation.6 Supportive care includes managing symptoms (as described below), ensuring that patients are receiving the proper nutrition, and paying attention to the risks of social isolation, particularly in older adults.7 Other unique aspects of care for geriatric patients with COVID-19 include considerations related to cognitive impairment, frailty, fall risk, and polypharmacy. Older patients and those with chronic medical conditions have a higher risk for hospitalization and death; however, SARS-CoV-2 infection may cause severe disease and death in patients of any age, even in the absence of any risk factors. The decision to monitor a patient in the outpatient setting should be made on a case-by-case basis.
Assessing the Need for In-Person Evaluation
When possible, patients with suspected or laboratory-confirmed COVID-19 should be triaged via telehealth visits before they receive an in-person evaluation. Outpatient management may include the use of patient self-assessment tools. During initial triage, clinic staff should determine which patients are eligible to receive supportive care at home and which patients warrant an in-person evaluation.8 Local emergency medical services, if called by the patient, may also be of help in deciding whether an in-person evaluation is indicated. Patient management plans should be based on the patient’s vital signs, physical exam findings, risk factors for progression to severe illness, and the availability of health care resources (AIII).
All patients with dyspnea, oxygen saturation (SpO2) ≤94% on room air at sea level (if this information is available), or symptoms that suggest higher acuity (e.g., chest pain or tightness, dizziness, confusion or other mental status changes) should be referred for an in-person evaluation by a health care provider. The criteria used to determine the appropriate clinical setting for an in-person evaluation may vary by location and institution; it may also change over time as new data and treatment options emerge. There should be a low threshold for in-person evaluation of older persons and those with medical conditions associated with risk of progression to severe COVID-19. The individual who performs the initial triage should use their clinical judgement to determine whether a patient requires ambulance transport. There are unique considerations for residents of nursing homes and other long-term care facilities who develop acute COVID-19. Decisions about transferring these patients for an in-person evaluation should be a collaborative effort between the resident (or their health care decision maker), a hospital-based specialist (e.g., an emergency physician or geriatrician), and the clinical manager of the facility.9
In some settings where clinical evaluation is challenged by geography, health care provider home visits may be used to evaluate patients.10 Patients who are homeless should be provided with housing where they can adequately self-isolate. Providers should be aware of the potential adverse effects of prolonged social isolation, including depression and anxiety.7 All outpatients should receive instructions regarding self-care, isolation, and follow-up, and should be advised to contact a health care provider or a local ED for any worsening symptoms.11,12 Guidance for implementing home care and isolation of outpatients with COVID-19 is provided by the U.S. Centers for Disease Control and Prevention.
Clinical Considerations When Managing Patients in an Ambulatory Care Setting
Persons who have symptoms that are compatible with COVID-19 should undergo diagnostic SARS-CoV-2 testing (see Prevention and Prophylaxis of SARS-CoV-2 Infection). Patients with SARS-CoV-2 infection may be asymptomatic or experience symptoms that are indistinguishable from other acute viral or bacterial infections (e.g., fever, cough, sore throat, malaise, muscle pain, headache, gastrointestinal symptoms). It is important to consider other possible etiologies of symptoms, including other respiratory viral infections (e.g., influenza), community-acquired pneumonia, congestive heart failure, asthma or chronic obstructive pulmonary disease exacerbations, and streptococcal pharyngitis.
In most adult patients, if dyspnea develops, it tends to occur between 4 and 8 days after symptom onset, although it can also occur after 10 days.13 While mild dyspnea is common, worsening dyspnea and severe chest pain/tightness suggest the development or progression of pulmonary involvement. In studies of patients who developed acute respiratory distress syndrome, progression occurred a median of 2.5 days after the onset of dyspnea.14-16 Adult outpatients with dyspnea should be followed closely with telehealth or in-person monitoring, particularly during the first few days following the onset of dyspnea, to monitor for worsening respiratory status (AIII).
If an adult patient has access to a pulse oximeter at home, SpO2 measurements can be used to help assess overall clinical status. Patients should be advised to use pulse oximeters on warm fingers rather than cold fingers for better accuracy. Patients should inform their health care provider if the value is repeatedly below 95% on room air at sea level. Pulse oximetry may not accurately detect occult hypoxemia, especially in Black patients.3,17,18 Additionally, SpO2 readings obtained through a mobile phone application may not be accurate enough for clinical use.19-21 Importantly, oximetry should only be interpreted within the context of a patient’s entire clinical presentation (i.e., results should be disregarded if a patient is complaining of increasing dyspnea).
Counseling Regarding the Need for Follow-Up
Health care providers should identify patients who are at high risk for disease progression. These patients may be candidates for anti-SARS-CoV-2 monoclonal antibody treatments, and clinicians should ensure that these patients receive adequate medical follow-up. The frequency and duration of follow-up will depend on the risk for severe disease, the severity of symptoms, and the patient’s ability to self-report worsening symptoms. Health care providers should determine whether a patient has access to a phone, computer, or tablet for telehealth; whether they have adequate transportation for clinic visits; and whether they have regular access to food. The clinician should also confirm that the patient has a caregiver who can assist with daily activities if needed.
All patients and/or their family members or caregivers should be counseled about the warning symptoms that should prompt re-evaluation through a telehealth visit or an in-person evaluation in an ambulatory care setting or ED. These symptoms include new onset of dyspnea; worsening dyspnea (particularly if dyspnea occurs while resting or if it interferes with daily activities); dizziness; and mental status changes, such as confusion. Patients should be educated about the time course of these symptoms and the possible respiratory decline that may occur, on average, 1 week after the onset of illness.
Managing Adults With COVID-19 Following Discharge from the Emergency Department
There are no fixed criteria for admitting patients with COVID-19 to the hospital; criteria may vary by region and hospital facilities. Patients with severe disease are typically admitted to the hospital, but some patients with severe disease may not be admitted due to a high prevalence of infection and limited hospital resources. In addition, patients who could receive appropriate care at home but are unable to be adequately managed in their usual residential setting are candidates for temporary shelter in supervised facilities, such as a COVID-19 alternative care facility.22 For example, patients who are living in multigenerational households or who are homeless may not be able to self-isolate and should be provided resources such as dedicated housing units or hotel rooms, when available. Unfortunately, dedicated residential care facilities for COVID-19 patients are not widely available, and community-based solutions for self-care and isolation should be explored
Treatment with an anti-SARS-CoV-2 monoclonal antibody is recommended for patients with mild to moderate COVID-19 who are not on supplemental oxygen and who have been discharged from the ED but who are at high risk for clinical progression (see Therapeutic Management of Nonhospitalized Adults With COVID-19).
In the cases where institutional resources (e.g., inpatient beds, staff members) are scarce, it may be necessary to discharge an adult patient and provide an advanced level of home care, including supplemental oxygen (if indicated), pulse oximetry, and close follow-up. Although early discharge of those with severe disease is not generally recommended by the Panel, it is recognized that these management strategies are sometimes necessary. In these situations, some institutions are providing frequent telemedicine follow-up visits for these patients or providing a hotline for patients to speak with a clinician when necessary. Home resources should be assessed before a patient is discharged from the ED; outpatients should have a caregiver and access to a device that is suitable for telehealth. Patients and/or their family members or caregivers should be counseled about the warning symptoms that should prompt re-evaluation by a health care provider. Special consideration may be given to using certain therapeutics (e.g., dexamethasone) in this setting. For more information, see Therapeutic Management of Nonhospitalized Adults With COVID-19.
Anticoagulants and antiplatelet therapy should not be initiated in the ED for the prevention of venous thromboembolism (VTE) or arterial thrombosis if the patient is not being admitted to the hospital, unless the patient has other indications for the therapy or is participating in a clinical trial (AIII). For more information, see Antithrombotic Therapy in Patients With COVID-19. Patients should be encouraged to ambulate, and activity should be increased according to the patient’s tolerance.
Managing Adults With COVID-19 Following Hospital Discharge
Most patients who are discharged from the hospital setting should have a follow-up visit with a health care provider soon after discharge. Whether an in-person or a telehealth visit is most appropriate depends on the clinical and social situation. In some cases, adult patients are deemed to be stable for discharge from the inpatient setting even though they still require supplemental oxygen. Special consideration may be given to using certain therapeutics (e.g., dexamethasone) in this setting. For more information, see Therapeutic Management of Nonhospitalized Adults With COVID-19. When possible, these individuals should receive oximetry monitoring and close follow-up through telehealth visits, visiting nurse services, or in-person clinic visits.
Hospitalized patients with COVID-19 should not be routinely discharged while receiving VTE prophylaxis, unless they have another indication or are participating in a clinical trial (AIII). For more information, see Antithrombotic Therapy in Patients With COVID-19. Patients should be encouraged to ambulate, and activity should be increased according to the patient’s tolerance.
Considerations in Pregnancy
Managing pregnant outpatients with COVID-19 is similar to managing nonpregnant patients (see Special Considerations in Pregnancy). Clinicians should offer supportive care, take steps to reduce the risk of SARS-CoV-2 transmission, and provide guidance on when to seek an in-person evaluation. The American College of Obstetricians and Gynecologists (ACOG) has developed an algorithm to aid the practitioner in evaluating and managing pregnant outpatients with laboratory-confirmed or suspected COVID-19.23 ACOG has also published recommendations on how to use telehealth for prenatal care and how to modify routine prenatal care when necessary to decrease the risk of SARS-CoV-2 transmission to patients, caregivers, and staff.
In pregnant patients, SpO2 should be maintained at 95% or above on room air at sea level; therefore, the threshold for monitoring pregnant patients in an inpatient setting may be lower than in nonpregnant patients.24 In general, there are no changes to fetal monitoring recommendations in the outpatient setting, and fetal management should be similar to the fetal management used for other pregnant patients with medical illness.25 However, these monitoring strategies can be discussed on a case-by-case basis with an obstetrician. Pregnant and lactating patients should be given the opportunity to participate in clinical trials of outpatients with COVID-19 to help inform decision-making in this population.
Considerations in Children
Children and adolescents with acute COVID-19 are less likely than adults to require medical intervention or hospitalization, and most can be managed in an ambulatory care setting or at home. In general, the need for ED evaluation or hospitalization should be based on the patient’s vital signs, physical exam findings (e.g., dyspnea), and risk factors for progression to severe illness. Certain groups, including young infants, children with risk factors, and those with presentations that overlap with multisystem inflammatory syndrome in children (MIS-C), may require hospitalization for more intensive monitoring. However, this should be determined on a case-by-case basis.
Most children with mild or moderate COVID-19, even those with risk factors, will not progress to more severe illness and will recover without specific therapy (see Special Considerations in Children). There is insufficient evidence for the Panel to recommend either for or against the use of anti-SARS-CoV-2 monoclonal antibody products in nonhospitalized children with COVID-19 who have risk factors for severe disease. The available efficacy data for adults suggests that anti-SARS-CoV-2 monoclonal antibody products may be considered for use in children who meet the Food and Drug Administration Emergency Use Authorization (EUA) criteria, especially those who have more than one risk factor. The decision to use these products in children should be made on a case-by-case basis in consultation with a pediatric infectious disease specialist. The risk factors that predict progression to severe disease in adults can be used to determine the risk of progression in children aged ≥16 years (see the Panel’s statement on the EUAs for anti-SARS-CoV-2 monoclonal antibodies).
In general, pediatric patients should not continue receiving remdesivir, dexamethasone, or other COVID-19-directed therapies following discharge from an ED or an inpatient setting. Clinicians should refer to Special Considerations in Children for more information on the management of children with COVID-19.
- Centers for Medicare & Medicaid Services. CMS announces comprehensive strategy to enhance hospital capacity amid COVID-19 surge. 2020. Available at: https://www.cms.gov/newsroom/press-releases/cms-announces-comprehensive-strategy-enhance-hospital-capacity-amid-covid-19-surge. Accessed March 3, 2021.
- Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus disease 2019 case surveillance—United States, January 22–May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69. Available at: https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6924e2-H.pdf.
- Centers for Disease Control and Prevention. Interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19). 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html. Accessed March 3, 2021.
- Centers for Disease Control and Prevention. COVID-19: how to protect yourself & others. 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html. Accessed March 15, 2021.
- Centers for Disease Control and Prevention. COVID-19: if you are sick or caring for someone. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/. Accessed March 15, 2021.
- Cheng A, Caruso D, McDougall C. Outpatient management of COVID-19: rapid evidence review. Am Fam Physician. 2020;102(8):478-486. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33064422.
- Morrow-Howell N, Galucia N, Swinford E. Recovering from the COVID-19 pandemic: a focus on older adults. J Aging Soc Policy. 2020;32(4-5):526-535. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32336225.
- Centers for Disease Control and Prevention. Coronavirus self-checker. 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/coronavirus-self-checker.html. Accessed March 3, 2021.
- Burkett E, Carpenter CR, Hullick C, Arendts G, Ouslander JG. It's time: delivering optimal emergency care of residents of aged care facilities in the era of COVID-19. Emerg Med Australas. 2021;33(1):131-137. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33131219.
- Close RM,Stone MJ. Contact tracing for native americans in rural Arizona. N Engl J Med. 2020;383(3):e15. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32672426.
- Centers for Disease Control and Prevention. COVID-19: what to do if you are sick. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html. Accessed March 15, 2021.
- Centers for Disease Control and Prevention. COVID-19: isolate if you are sick. 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/isolation.html. Accessed March 15, 2021.
- Cohen PA, Hall LE, John JN, Rapoport AB. The early natural history of SARS-CoV-2 infection: clinical observations from an urban, ambulatory COVID-19 clinic. Mayo Clin Proc. 2020;95(6):1124-1126. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32451119.
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- The American College of Obstetricians and Gynecologists. Outpatient Assessment and Management for Pregnant Women with Suspected or Confirmed Novel Coronavirus (COVID-19). 2020. Available at: https://www.acog.org/-/media/project/acog/acogorg/files/pdfs/clinical-guidance/practice-advisory/covid-19-algorithm.pdf. Accessed April 2, 2020.
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