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ARISE Covid Practice Guide, Is Intended for Internal Circulation and Reference by ARISE MD, Ltd

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ARISE Covid Practice Guide, Is Intended for Internal Circulation and Reference by ARISE MD, Ltd COVID-19 PRACTICE GUIDE 1 of 23 COVID-19 PRACTICE GUIDE Compliments American Medical Association 2 of 23 Guiding Principles: • We follow CDC guidelines • We belong to the FLCCC Alliance, led by Dr. Paul Marik • We add the wisdom we’ve gained from caring for Covid-19 patients • We remember that SARS-Cov2 is a novel virus and disease and adapt our guidelines as new insights become available. There is no perfect plan. • COVID-19 is primarily a clinical diagnosis • Testing is used to guide social distancing, quarantine schedules, and presence of immunity. Who is at the highest risk? (CDC) • Cancer • Chronic kidney disease • COPD (chronic obstructive pulmonary disease) • Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies • Immunocompromised state (weakened immune system) from solid organ transplant • Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2) • Severe Obesity (BMI ≥ 40 kg/m2) • Pregnancy • Sickle cell disease • Smoking • Type 2 diabetes mellitus • Asthma, Type 1 diabetes and Hypertension are likely high risk also according to the CDC • 80 % of deaths have been in patients over 65 years. 3 of 23 Limiting Spread :::: According to CDC and OSHA, our office is considered “High Exposure Risk” because we handle specimens that may have SARS Cov-2 (saliva, nasal swabs). We do not however perform procedures that aerosolize saliva, which lowers our risk profile. (versus an ENT office for example.) https://www.osha.gov/Publications/OSHA3990.pdf Pracitioner Schedules We restrict each of our three medical providers to separate days in office Social Distancing We keep 6 feet between people when in-office as much as possible Masks • N95 are worn at all times in office by both patients and staff • When N95 are not available then 3-layer cotton or 2-3 layer surgical masks at all times in office • Although the CDC says the effectiveness of “gaiters” is still unknown we discourage use (see Duke Study) • Cloth masks with 2-3 layers of fabric are acceptable for COVID-negative patients • Behind a closed door in the consult room a patient should maintain their mask Duke Study : https://hartfordhealthcare.org/about-us/news-press/news-detail?articleid=27691&publicId=395 CDC : https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care.html Gowns Disposable gowns (and gloves) are worn with any symptomatic patient, and patients with known contact or positive test Face Shields Shields should be worn with any symptomatic patient who is within 10 days since testing positive. 4 of 23 Office Barriers Symptomatic patients or those with positive tests who are within the first 10 days should remain behind a closed door with a room air filter at all times while in our office. Our front desk staff function as medical assistants also therefore we do not have pexiglass barriers at our front desk Office Hygiene All surfaces in treatment rooms are disinfected in between patient encounters as is the bathroom if a patient visits the bathroom Air Purifiers Symptomatic patients and patients known to be COVID-positive are only seen in our Treatment Room, which has a continuously running HEPA filter portable air purifier. How Long Are Patients Infectious? CDC: • Mild to Moderate COVID-19 patients remain infectious for 10 days after symptom onset • A large contact tracing study demonstrated that high-risk household and hospital contacts did not develop infection if their exposure to a case patient started 6 days or more after the case patient’s illness onset (Cheng et al., 2020). • Patients should be assumed infectious 2 days prior to the onset of symptoms (and can contact trace based on that timeline) 5 of 23 When to End Isolation and Precautions? Asymptomatic: 10 days after the first postive PCR test Mild-Moderate Symptoms: 10 days after symptoms started and 24 hours after patient’s temperature is normal without medication. CDC: https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration- isolation.html#:~:text=Available%20data%20indicate%20that%20persons,days%20after%20symptom%20onset. How Long Are Patients Immune to Reinfection? Most likely, 3 months. For persons recovered from SARS-CoV-2 infection, a positive PCR without new symptoms during the 90 days after illness onset more likely represents persistent shedding of viral RNA than reinfection. CDC: https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration- isolation.html#:~:text=Available%20data%20indicate%20that%20persons,days%20after%20symptom%20onset 6 of 23 Testing Notes :::: Nasal Swabs: The likelihood of recovering replication-competent virus declines after onset of symptoms. For patients with mild to moderate COVID-19, replication-competent virus has not been recovered after 10 days following symptom onset (CDC, unpublished data, 2020; Wölfel et al., 2020; Arons et al., 2020; Bullard et al., 2020; Lu et al., 2020; personal communication with Young et al., 2020; Korea CDC, 2020). Nasal Swabs - False Positives Although replication-competent virus was not isolated 3 weeks after symptom onset, recovered patients can continue to have SARS-CoV-2 RNA detected in their upper respiratory specimens for up to 3 months (Korea CDC, 2020; Li et al., 2020; Xiao et al, 2020). Investigation of 285 “persistently positive” persons, which included 126 persons who had developed recurrent symptoms, found no secondary infections among 790 contacts attributable to contact with these case patients. Efforts to isolate replication-competent virus from 108 of these case patients were unsuccessful (Korea CDC, 2020). When the language “some patients may be contagious for up to 20 days” is used it is in reference to a study that showed that 88% at 10 days and 95% at 15 days had no replicating virus and that many of the patients in the study were immunocompromised. (van Kampen et al., 2020 and CDC) The True Accuracy of Tests for COVID-19 is Uncertain Unfortunately, it’s not clear exactly how accurate any of these tests are. There are several reasons for this: 7 of 23 • We don’t have precise measures of accuracy for these tests — just some commonly quoted figures for false negatives or false positives, such as those reported above. False negative tests (2-37%) provide false reassurance, and could lead to delayed treatment and relaxed restrictions despite being contagious. False positives, which are much less likely, can cause unwarranted anxiety and require people to quarantine unnecessarily. • How carefully a specimen is collected and stored may affect accuracy. • None of these tests is officially approved by the FDA. They are available because the FDA has granted their makers emergency use authorization. And that means the usual rigorous testing and vetting has not happened, and accuracy results have not been widely published. • A large and growing number of laboratories and companies offer these tests, so accuracy may vary. At the date of this posting, more than 170 molecular tests, two antigen tests, and 37 antibody tests are available. • All of these tests are new because the virus is new. Without a long track record, assessments of accuracy can only be approximate. • We don’t have a definitive “gold standard” test with which to compare them. Source : https://www.health.harvard.edu/blog/which-test-is-best-for-covid-19-2020081020734 Time-of-Appointment Policy for Patient Care During the Pandemic :::: Telemedicine Pre-Screening All patients at the time of scheduling will be asked about COVID symptoms, COVID exposures, and prior COVID tests. Patients will be encouraged to take their temperature at home prior to departing for our office. Entry to Office for Appointment All patients will have their temperature checked prior to entering the office. Anyone with a temperature of 100 F or higher will not be permitted to the office and will be recommended to have a COVID test either by our staff (outside the office) or will be directed to a rapid test center. Afebrile patients will enter the office and go directly to the Treatment Room or the Consult Room. Restrooms are available as usual for patients, but will be cleaned between patients. 8 of 23 Patients who are atleast 14 days after either the start of symptoms or their first positive COVID test that have documented antibodies against SARS Cov-2 and are afebrile will be treated as a non-COVID patient if they are less than 90 days since the presence of antibodies was established. Exiting the Office After Appointment Covid-positive patients who are within 10 days since testing positive and symptomatic patients (with unknown COVID status) will have payment information collected prior to arriving at the office. All other patients will follow a normal check-out process at ARISE MD. Visitors We make every effort to limit the number of non-patient visitors to our practice during the pandemic. Patients are encouraged to come alone to their appointments. They are permitted to bring one relative (who is a member of their household) with them to the appointment if needed. Exposure Procedure If a staff member has a known exposure he or she will have a rapid COVID test and a PCR COVID test done as soon as possible and will go into quarantine until the rapid test results are back. If the patient’s rapid test is negative and he or she is not symptomatic then the staff member will take 12mg of Ivermectin and be observed for 24 hours after taking Ivermectin. He or she will also be encouraged to do hydrogen peroxide nebulizer treatments 3 times per day for the first 24 hours. If the person remains asymptomatic 24 hours after taking Ivermectin he or she may return to work following all COVID care precautions listed in this document. The person will take a second dose of Ivermectin 3 days after the first dose.
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