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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:
Milana Bogorodskaya, MD
Allyson Bloom, MD
Literature review current through: Dec 2022. | This topic last updated: Dec 15, 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 (eg, the first few weeks of illness onset) in the outpatient setting, including initial telephone triage, telehealth and outpatient evaluation, and when to refer to the emergency department or hospital. 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 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".)

The evaluation and management of COVID-19 in pregnant patients is discussed separately. (See "COVID-19: Overview of pregnancy issues" and "COVID-19: Antepartum care of pregnant patients with symptomatic infection".)

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: 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 — Evaluation of patients with COVID-19 necessitates a flexible outpatient management program that can provide timely in-person and telehealth evaluations of patients to assess their acuteness of illness, exclude other causes of symptoms, and assess eligibility for treatment.

Timely assessment for treatment eligibility – Most patients with COVID-19 do not require treatment, but when treatment is indicated, it should be provided as early as possible during the course of illness. Therefore, the focus of our evaluation of patients with COVID-19 is to provide a timely assessment that includes the timing of symptom onset, risk factors for hospitalization and death, and overall acuity of illness. This assessment permits us to determine who are appropriate candidates for COVID-19-specific treatment and, when appropriate, the best setting (eg, telehealth, outpatient clinic, emergency department) for treatment. (See 'Telephone triage' below and 'Determine eligibility for COVID-19 outpatient treatment' below.)

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 initial telephone triage with availability of telehealth or in-person clinician evaluation, if appropriate. (See 'Telephone triage' below and 'Initial clinical evaluation' below.)

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 [1,2]. In addition, remote (telehealth) management is preferred for most patients for the following reasons:

Remote management can prevent unnecessary in-person medical visits to urgent care facilities, primary care clinics, and emergency departments.

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.

Telehealth has been used for patient management during previous disease outbreaks, including SARS, Middle East respiratory syndrome (MERS), and influenza A H1N1 [3]. 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 [4-9].

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 [10]. (See "Telemedicine for adults", section on 'The telemedicine visit'.)

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 [11], as well as our own clinical experience of treating patients with COVID-19, and places additional emphasis on avoiding infection transmission and avoiding unnecessary health care usage. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Prevention' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'When PPE is limited' and "COVID-19: Diagnosis".)

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 [12].

TELEPHONE TRIAGE — 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, initial telephone triage to determine need for further evaluation is the preferred initial management approach [13-15]. The initial triage call should be conducted by clinical staff trained in assessing the acuteness of illness, eliciting risk factors for severe disease, and determining which patients are appropriate for self-care at home and which patients warrant a timely clinician telehealth visit (televisit) or an in-person visit [11,16]. Each of the aspects to be covered in the triage call are discussed in detail below in the section on initial clinical evaluation.

INITIAL CLINICAL EVALUATION — Initial evaluation includes ensuring early diagnostic testing (if necessary); assessing acuity of illness and social factors; excluding other causes of symptoms; determining whether laboratory testing, imaging, or treatment is necessary; and counseling. Some aspects of the initial evaluation may be conducted during telephone triage while others may be performed during a televisit call with a clinician. (See 'Determine eligibility for COVID-19 outpatient treatment' below and 'Counseling' below.)

Ensure early diagnostic testing — Identifying SARS-CoV-2 infection at the earliest possible opportunity is a key step in management. Patients presenting with symptoms consistent with COVID-19 who received COVID-19 vaccination and/or tixagevimab-cilgavimab should still be tested for SARS-CoV-2 infection as vaccines and preexposure prophylaxis may not be as effective against the newer variants of the virus and immunity wanes over time.

If a patient with suspected infection has not been tested, we suggest home testing or referral to a local testing center. In a symptomatic patient, we consider a positive antigen test or nucleic acid amplification test (NAAT) to be diagnostic of infection, regardless of where testing was performed (eg, at home or in a clinical setting) (table 1). An initial negative antigen test in symptomatic patients generally warrants a repeat test (algorithm 1). The diagnosis of COVID-19 is discussed in detail elsewhere. (See "COVID-19: Diagnosis", section on 'NAAT (including RT-PCR)' and "COVID-19: Diagnosis", section on 'Antigen testing'.)

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'.)

Assess acuity of illness — We assess the patient's overall acuity level by asking questions regarding dyspnea, chest pain/pressure, 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. Presence of any of these symptoms is concerning and warrants in-person evaluation. Most patients without moderate or severe acuity of illness can remain at home for initial management. Mild orthostasis symptoms may be addressed with instruction to increase fluids.

Dyspnea – 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 [17-21]. Dyspnea, along with risk factors for developing severe disease (table 2), can be used to guide clinicians in determining whether a patient requires in-person evaluation. (See 'Disposition' below.)

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.

Hypoxia – Dyspnea may not correlate with the presence or degree of hypoxia in all patients [22]. If a patient with COVID-19 reports the results of a home pulse oximeter, we consider the oxygen saturation as an additional piece of information to assess their clinical status.

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. Further, the addition of remote oximetry to dyspnea monitoring has not been shown to improve patient outcomes [23]. Although normal oximetry can be reassuring, results may be not always be accurate, particularly in patients with darker skin pigmentation [24-26], and there is no guarantee that respiratory status will not deteriorate as illness progresses.

We do not advise that 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 [27]. The use of home oximetry monitoring is being evaluated for patients seen in the ambulatory or emergency department setting and discharged home [28]. However, there is no high-quality evidence that patient outcomes are improved using this approach.

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 to be adequately managed at home.

In addition, in accordance with interim Centers for Disease Control and Prevention (CDC) guidelines on home management, we assess if the patient's residential setting is appropriate for home management and recovery [29]; 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) (algorithm 2). 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 2). (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the home setting'.)

Exclude other causes of symptoms — As part of the evaluation, we assess for other potential causes of symptoms. Given the high prevalence and mild symptoms of most COVID-19 infections, clinicians should not assume that SARS-CoV-2 is responsible for a patient’s illness when a positive home rapid antigen test for SARS-CoV-2 is reported. Clinicians should be mindful that the SARS-CoV-2 infection might be incidental to the clinical process and have a low threshold to evaluate patients in person to determine if an alternative process is responsible for the symptoms. Given the decreasing acuity of symptoms from SARS-CoV-2 infections due to widespread immunization, immunity from previous infections, and prevalence of new variants associated with milder infection, it is increasingly important to evaluate all patients with moderate or severe illness to confirm that an alternative disease process is not responsible for the clinical presentation.

The typical clinical presentation of COVID-19 varies depending upon the individual's vaccination status and the particular SAR-CoV-2 variant (table 3). Patients 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 4) [30]. Loss of smell and taste was previously a common symptom, with olfactory loss typically reported early in the course of illness [31-35], but is less commonly reported now. Dyspnea, if it develops, tends to occur later [30]. (See "COVID-19: Clinical features".)

Since symptoms of COVID-19 can overlap with those of many common conditions, it is important to consider other possible etiologies of symptoms including other respiratory infections (eg, influenza, streptococcal pharyngitis, community-acquired pneumonia [CAP]), congestive heart failure, asthma or COPD exacerbations, and anxiety, even in locations with a high prevalence of COVID-19 [30].

Low utility of laboratory testing and imaging — Beyond the initial COVID-19 diagnostic testing, we find 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'.)

Determine eligibility for COVID-19 outpatient treatment — We assess the patient for eligibility to COVID-19 outpatient treatment by asking about the timing of symptom onset and their risk of progressing to severe disease. COVID-19 therapeutics are most beneficial when initiated within several days (≤5 to 9 days) of onset of symptoms (algorithm 3). In the United States, symptomatic outpatients who are 50 and older or have a risk factor for severe disease (table 2) are eligible for COVID-19-specific therapy according to Emergency Use Authorization (EUA) criteria. Among such patients, we treat those at particular risk of severe disease, based on advanced age, immune status, severity and number of comorbidities, and vaccination status. Our approach is discussed in detail elsewhere. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Treatment with COVID-19-specific therapies'.)

COVID-19-specific therapies can be prescribed at the time of the initial evaluation during a telehealth visit and should not be deferred to an in-person visit if SARS-CoV-2 infection has been established.

Time course – A detailed history should be obtained focusing on determining the first day of symptoms in relation to the current day of illness. All COVID-19-specific therapies currently available must be given within the first several days of illness. When indicated, we prefer to start COVID-19-specific treatment within 24 to 48 hours of symptom onset, whenever possible.

Presence of risk factors – In addition to being unvaccinated [36], older age and certain chronic medical conditions are associated with more severe illness and higher mortality from COVID-19 [37]. Specific risk factors are detailed in the table (table 2).

Advancing age appears to be one of the most important risk factors associated with severe COVID-19 outcomes [38]. 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 [1,39-46]. 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'.)

Selection of COVID-19-specific therapeutic agents, symptom management, and counseling on home infection control 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'.)

DISPOSITION — Based upon the above assessment, we determine whether the patient requires further in-person evaluation or if management of COVID-19 infection can be managed during the telehealth visit. Most patients do not require an in-person visit and can be prescribed COVID-19-specific therapy during the initial evaluation visit. Patients who are acutely ill warrant further evaluation.

While we use the following general criteria to determine the most appropriate clinical setting for in-person evaluation of those patients acutely ill, these criteria are not fixed and will vary by institution, by region, and over time with changing resource availability and treatment options. We also consider the patient's home setting and social factors in determining disposition. (See 'Assess acuity of illness' above and 'Assess home setting and social factors' above.)

In-person evaluation for acutely ill patients — For patients who are acutely ill (eg, moderate/severe dyspnea, oxygen saturation ≤94 percent on room air [if oximetry information available], or any symptoms suggestive of higher acuity level), we decide if outpatient clinic or emergency department evaluation is appropriate.

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

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)

Patients appropriate for evaluation in clinic — Patients with one or more of the following features are typically appropriate for evaluation in an outpatient clinic, provided they do not meet any of the above criteria for evaluation in the emergency department (see 'Criteria for emergency department evaluation' above):

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

Mild dyspnea in a patient with risk factors for severe disease (table 2)

Moderate dyspnea in any patient

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

In clinic, we assess the patient's respiratory and circulatory status, and we evaluate for other potentially treatable causes of symptoms [30].

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 (algorithm 3) (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 emergency department for further evaluation or possible inpatient hospital admission. (See 'Indications for hospitalization' below.)

Indications for hospitalization — Patients meeting the above criteria for emergency department evaluation 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 [47]:

An oxygen saturation of <94 percent on room air

Respiratory rate of >30 breaths/minute

PaO2/FiO2 <300 mmHg

Lung infiltrates >50 percent

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 [48].

Non-acutely ill patients — Patients who are not acutely ill can receive treatment (algorithm 3) and counseling via the initial telehealth visit. Eligibility, selection, and administration of COVID-19-specific therapy are discussed in detail elsewhere (see 'Determine eligibility for COVID-19 outpatient treatment' above and "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Treatment with COVID-19-specific therapies'). The need for a follow up visit is determined for each patient individually.

Patients who would be appropriate for home care but are unable to be adequately managed in their usual residential setting (eg, patients living in multigenerational households, patients living with individuals who have any risk factors for severe disease (table 2), patients experiencing homelessness) are candidates for temporary shelter in supervised residential care facilities, if available [49-53]. 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.

COUNSELING — All patients receive counseling on infection control measures, duration of isolation (algorithm 2), warning symptoms, expectations, and how to manage their symptoms at home.

Infection control and isolation period — Advice on infection control measures and duration of isolation (algorithm 2) are reviewed in detail elsewhere. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the home setting' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Discontinuation of precautions'.)

Warning symptoms — All patients also receive instructions to contact their clinician with any worsening or concerning symptoms. We do not schedule routine telehealth follow-up visits for patients managed at home, but when resources permit, we recommend reaching out to follow-up by telephone with 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).

We counsel all patients on the warning symptoms that should prompt reevaluation by telehealth visit and in-person, including emergency department evaluations. These include new onset of dyspnea, chest pain/pressure with exertion, 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. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Symptom management and recovery expectation' and "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Infection control and isolation period'.)

COVID-19 vaccination after recovery from acute illness — Advice on COVID-19 vaccination after recovery from acute infection, including individuals who received monoclonal antibody treatment, is reviewed in detail elsewhere. (See "COVID-19: Vaccines", section on 'History of SARS-CoV-2 infection'.)

REEVALUATION FOR WORSENING CLINICAL ACUITY — All patients who develop worsening acuity of illness 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 community-acquired pneumonia (CAP; eg, new productive cough, pleuritic chest discomfort), asthma or chronic obstructive pulmonary disease (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".)

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

General principles – Evaluation of COVID-19 includes efficient telephone triage to the appropriate evaluation setting and the timely assessment for treatment eligibility. 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. (See 'General principles' above.)

Telephone triage – The initial telephone triage should be conducted by clinical staff trained in assessing the acuteness of illness, eliciting risk factors for severe disease, and determining which patients are appropriate for self-care at home and which patients warrant a timely clinician telehealth visit (televisit) or an in-person visit. (See 'Telephone triage' above.)

Initial clinical evaluation

Evaluation of acuity and risk stratification – On initial evaluation, we assess risk factors for progression to severe disease (table 2), 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 emergency department. The additional criteria we use to make this determination are not fixed and will vary by institution, by region, and over time as resource availability and treatment options evolve. (See 'Assess acuity of illness' above and 'Assess home setting and social factors' above and 'Disposition' above.)

Excluding other causes of symptoms – Since symptoms of COVID-19 can overlap with those of many common conditions, it is important to consider other possible etiologies of symptoms including other respiratory infections (eg, influenza, streptococcal pharyngitis, community-acquired pneumonia [CAP]), congestive heart failure, asthma or chronic obstructive pulmonary disease (COPD) exacerbations, and anxiety, even in locations with a high prevalence of COVID-19. (See 'Exclude other causes of symptoms' above.)

Determine eligibility for COVID-19-specific therapy – Timely assessment for treatment eligibility is necessary to facilitate timely initiation of treatment. In the United States, symptomatic outpatients who are 50 and older or have a risk factor for severe disease (table 2) are eligible for COVID-19-specific therapy according to Emergency Use Authorization (EUA) criteria. Among such patients, we treat those at particular risk of severe disease, based on advanced age, immune status, severity and number of comorbidities, and vaccination status (algorithm 3). COVID-19 therapeutics are most beneficial when initiated within several days (≤5 to 9 days) of onset of symptoms (algorithm 3) and should not be delayed until an in-person visit if SAR-CoV-2 infection has been established. (See 'Determine eligibility for COVID-19 outpatient treatment' above and "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Treatment with COVID-19-specific therapies'.)

Disposition

Criteria for emergency department evaluation – 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 'Assess acuity of illness' above)

-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) (see 'Criteria for emergency department evaluation' above)

Criteria for outpatient clinic evaluation – Patients with one or more of the following features are typically appropriate for evaluation in an outpatient clinic, provided they do not meet any of the above criteria for evaluation in the emergency department:

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

-Mild dyspnea in a patient with risk factors for severe disease (table 2)

-Moderate dyspnea in any patient (see 'Assess acuity of illness' above)

-Symptoms concerning enough to warrant in-person evaluation but not severe enough to require emergency department referral (eg, mild orthostasis) (see 'Patients appropriate for evaluation in clinic' above)

Indications for hospitalization – There are no fixed criteria for inpatient hospital admission with COVID-19; criteria vary by country, region, and availability of COVID-19-specific therapy. However, hospitalization is warranted for most 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

-Lung infiltrates >50 percent (see 'Indications for hospitalization' above)

Non-acutely ill patients – Patients who are not acutely ill can receive treatment and counseling via the initial telehealth visit (table 2). (See 'Non-acutely ill patients' above.)

Counseling – All patients receive counseling on infection control measures, duration of isolation (algorithm 2), warning symptoms, expectations, and how to manage their symptoms at home. Warning symptoms that prompt reevaluation include new-onset or worsening dyspnea, dizziness, and mental status changes such as confusion. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Other management issues'.)

Follow-up – Follow-up should be individualized to each patient based on their home situation, severity of symptoms, and risk of progression to severe disease. Patients with mild symptoms who are generally healthy may not need any follow-up after the initial visit. (See 'Counseling' above and 'Reevaluation for worsening clinical acuity' above.)

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

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