AMGA CMO Council: Return to Work Using Non-Test-Based Strategies

AMGA COVID-19 Resources

Discussion Summary
April 10, 2020

This summary is based on a discussion via AMGA’s Chief Medical Officer/Medical Director Council listserv as of April 10, 2020. For more information about the CMO Council, please click here.

Question: What templates have health systems created for return to work letters for both healthcare workers (HCWs) and non-HCWs using the non-test-based strategy?

Employers are demanding repeat COVID-19 testing of employees to keep their workplace and employees safe. But with limited testing capacity, providers are alternatively looking for safe approaches using “non-test-based strategies” to recommend when workers should stay home and when it is safe for them to return to work. Letter templates have been developed for a discontinuation of home isolation and on the need for an employee to self-isolate at home.

Return-to-work letters for HCWs in a non-testing-based environment include guidance about wearing a face mask. Some healthcare workers may also be required to get clearance from their office of occupational health. Most of these letters are generated by the EHR, either in the emergency room or urgent care center in case of a work excuse, or by outpatient clinicians in case of a return to work. Below is a summary of the criteria used by most practices in each case.

Symptoms for Non-Test-Based Home Isolation

  • Fever (>100.0 Fahrenheit)
  • Loss of smell (anosmia) or taste (ageusia)
  • Sore throat
  • Fatigue, headaches, body aches
  • Dry cough
  • May include diarrhea, running nose, nausea, and vomiting
  • Shortness of breath

Self-care isolation information is posted on the CDC website here.

Criteria for Return to Work
(For any Person Testing Positive for COVID-19 or with Symptoms of COVID-19 Infection)

  • No fever for at least 72 hours (without the use of medication that reduces fever)
  • Must be at least seven days since their symptoms first appeared
  • Improvement in other symptoms (cough, shortness of breath) for 72 hours
  • No other active symptoms or deterioration of any other chronic health condition

Up-to-date recommendations for businesses and employers are posted on the CDC website here.

As guidelines expand the “bucket” of people who may be in need of testing, tests are still limited within many practices. Several practices are following the Infectious Diseases Society of America (IDSA) guidelines and testing only for tiers 1 and 2 until collection and testing kits are more widely available. (Note: Up-to-date guidelines are posted on IDSA’s website here.)

COVID-19 Testing Criteria (Infectious Diseases Society of America, IDSA)

Tier 1

  • Critically ill patients receiving ICU level care
  • Individuals with fever or signs/symptoms of a lower respiratory tract illness who are also immunosuppressed
  • Individuals with fever or signs/symptoms of a lower respiratory tract illness who are critical to pandemic response, including healthcare workers, public health officials, and other essential leaders
  • Any person, including healthcare workers, with fever or signs/symptoms of a lower respiratory tract illness and close contact with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset or history of travel

Tier 2

  • Hospitalized non-ICU patients and long-term care residents with unexplained fever and signs/symptoms of a lower respiratory infection

Tier 3

  • Symptomatic patients in outpatient settings with co-morbid conditions including diabetes, COPD, congestive heart failure, age >50, immunocompromised hosts among others

Tier 4

  • Community surveillance as directed by public health and/or infectious diseases authorities

However, a few practices are starting to test patients with moderate symptoms, more in the ambulatory environment. Practices would like to ramp up testing for all patients and are seeking algorithms for testing/screening mild, moderate, and severe patients when they have the resources to ramp up testing for more patients.

Currently Tested/Screened for COVID-19

  • Healthcare workers (including clinicians)
  • First responders
  • Immediate family members of the above groups
  • ISDA Tier 1 (see above)
  • ISDA Tier 2 (see above)
  • Patients with anosmia and diarrhea (seen in 20-35% of cases in some sites)
  • Patients with encephalitis, stroke, and other neurological symptoms