COVID-19 Management for Primary Care Providers

As the COVID-19 pandemic has taken the world by storm, health care professionals are left playing catch up. Primary care providers are no exception, and as COVID-19 cases continue to rise in the United States, understanding the key points of the virus is essential to providing patient care.

In this session presented at Practical Updates in Primary Care 2020, Christian Sandrock, MD, discusses these key points and the best practices for providing appropriate and quality medical care for patients with COVID-19. Dr Sandrock is a pulmonary, critical care, and infectious disease physician at the University of California Davis in Sacramento, California.

Although the current pandemic only began at the end of 2019, coronaviruses are not new. Prior to the current strain that makes up the pandemic, SARS-CoV-2, there were 2 previous novel coronaviruses. The first was Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) in 2003, and the second was Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in 2012.

Infection Prevention

“Most of the work we do as ID physicians, as you do as primary care physicians, is really reducing the spread of disease and keeping our patients healthy,” Dr Sandrock began.

SARS-CoV-2 spread differently than other respiratory viruses. The virus can be spread through droplets, similar to other respiratory viruses, but can also be spread through airborne droplets that can travel farther and be suspended longer. Therefore, prevention is key.

“Both wearing a mask and eye protection, this is the mainstay of protection we need for reducing the spread of disease … and you can show that risk reduction … of about 0.15. So that’s a dramatic risk reduction,” Dr Sandrock said about educating patients on these important preventive measures.

However, not all masks are made equal. While all masks offer some level of protection, generally the more affordable a mask is, the lower the efficacy of virus prevention. Cloth masks are generally the most cost-affordable but do not offer the efficacy of more-expensive options, such as a full-face respirator.  

Another significant challenge of SARS-CoV-2 is identifying the viral shedding patterns, as viral shedding, symptom onset, and patient activity are not directly correlated.

“This makes a very complicated picture that in some instances this virus certainly can be airborne, and spread can be enhanced. And how do you know that as a patient, and how do you educate patients? The answer is sometimes you really can’t, and it’s very difficult. But this really belies the fact that they need a mask,” Dr Sandrock continued.

Clinical Presentation

Unlike other respiratory viruses, there are 2 phenotypes in patients with COVID-19; type L and type H, as seen in Figure 1.

Dr Sandrock says the possible complications associated with type L “gives you the backbone of why we coagulate patients who have an elevated d-dimer levels and why anticoagulation is really the mainstay when you have this ARDS with associated vasculopathy.”

Typically, the severe signs of illness occur 7 to 11 days after the initial onset of symptoms. The 14-day mark from initial symptom onset marks an individual as less likely to progress to severe illness. Of the patients with symptoms, about 20% will need to be hospitalized. Of those 20% of patients, 15% will be critical. 

Management of COVID

While Dr Sandrock says that considering at-risk populations for COVID-19 is a complex issue, he spoke briefly on the biggest risk factors for hospitalization in patients with COVID-19, including race, age, insurance or Medicare status, and obesity. Acknowledging this increased risk and watching these at-risk patients more closely can help health care providers handle this disparity.

For patients with severe disease, lung protective strategies of low tidal volume with high peak are beneficial. It is important to take a stepwise approach (see Figure 2) when treating patients with severe COVID-19 as to not take too drastic of measures, such as BIPAP, that may ultimately make patients worse.

Dr Sandrock says that there is not a one-size-fits-all therapy or approach to treatment for SARS-CoV-2. Decisions regarding drug therapies such as remdesivir or steroids and determining the need of intubation or high-flow nasal cannula must be done on a case-by-case basis. It is important that clinicians utilize measurements such as a ROX score to determine which course of treatment is necessary.

—Leigh Precopio

Reference:

Sandrock C. A few thoughts on COVID-19 in the primary care world. Talk presented at: Practical Updates in Primary Care Virtual Series 2020: December 4-5,2020; Virtual.