Model of Coronavirus

Information for Health Providers

Updates

Guidance from Austin-Travis County Interim Health Authority to Providers (PDF) − March 13, 2020

Flow chart to be used in conjunction with the DSHS testing guidance (PDF) March 13, 2020

Austin-Travis County Emergency Operations Center

The Austin-Travis County Emergency Operations Center (EOC) plays a central role in the local response to COVID-19. The EOC ensures continuity of Austin-Travis County community essential functions throughout the incident, mitigating the threat and impacts of COVID-19 on our community. Additionally, the EOC maintains task forces to support medical and social service community needs, and provides medical, logistics, personnel, security, and safety plan support to those task forces. The EOC follows structure laid forth by the Federal Emergency Management Agency’s (FEMA)  National Incident Management System (NIMS), the national framework for managing activities across all five phases of emergency management: prevention, preparedness, response, recovery and mitigation.

Incident Command System

Incident Command System (ICS), established  and standardized by NIMS, is an all-hazards incident management system designed to expand and contract to meet the needs of managing incidents. In ICS, the Incident Commander manages the structural organization. The roles and functions of the ICS  in the EOC are defined as follows:

  • Command Staff: The staff who report directly to the Incident Commander, including the Public Information Officer, Safety Officer, and Liaison Officer. 
  • Operations Section: The staff who develop tactical organization and directs all resources to carry out the Incident Action Plan.
    • Branches: The organizational level having functional or geographic responsibility for major parts of the Operations or Logistics functions. Branches within the EOC’s activation for COVID-19 response include: Public Safety, Health, Public Works, Transportation, Social Services. Branches may have Task Forces and Strike Teams to help meet specific missions. 
    • Task Force: Any combination of resources assembled to support a specific mission or operational need. All resource elements within a Task Force must have common communications and a designated leader. Full list of Task Forces is provided below.
    • Strike Team: A set number of resources of the same kind and type that have an established minimum number of personnel, common communications, and a designated leader.
  • Planning Section: The staff who develop the Incident Action Plan to accomplish the objectives.
  • Logistics Section: The staff who provide resources and services needed to support efforts addressing the incident.
  • Finance/Admin Section: The staff who monitor incident-related costs and provides fiscal guidance.
  • Austin Public Health Department Operations Center: The APH Department Operations Center is located outside of the Austin-Travis County Emergency Operations Center and houses our nursing and epidemiology staff. These individuals are fundamental in hosting a medical hotline for our health care providers, conducting contact tracing for positive individuals, and implementing control orders for persons under investigation and positive cases.

Current Task Forces

  • Alternative Care Sites Task Force: The Alternative Care Sites Task Force identifies and secures space for potential patient care outside of the traditional hospital setting. There are two types of Alternative Care Sites. A Type II Alternative Care Site (ACS) is hospital-level care provided at a facility outside a hospital, such as buildings that were previously purposed for patient care.  These are hospital-level care beds located somewhere other than a hospital. A Type I ACS is a facility similar to a combat surgical hospital or large ward. Type II ACS facilities are expected to be used once hospitals exceed surge capacity; Type I ACS facilities are expected to be used once hospitals and Type II facilities are at capacity. 
  • Isolation Facilities Task Force: The Isolation Facilities Task Force identifies, secures and operates an isolation facility, which is a leased hotel property, for those who are well enough to self-isolate at home, but do not have a safe means to do so, whether it is because their quarters are too close to other household members, they are an individual experiencing homelessness, or other potential reasons.
  • Nursing Homes/LTCF Task Force: The Nursing Homes/LTCF Task Force identifies and secures a location to transfer nursing home and long-term care facility patients who test positive to safely isolate them away from the other residents. This task force also includes a strike team that visits nursing homes to help develop plans to prevent spread.
  • Test Collection Sites Task Force: The Test Collection Sites Task Force ensures the smooth daily operations of the City-County test sites in St. John’s and Pleasant Valley. This task force has also developed a digital form to prioritize and streamline testing to maximize available supplies and resources.
  • Testing Innovation Task Force: The Testing Innovation Task Force addresses issues such as the novel supply chain to secure access to necessary testing materials including personal protective equipment (PPE) through alternative networks and solutions such as 3-D printing, among others. This task force also connects with potential supply partners such as tech industry companies and others.
  • Community Services Task Force: The Community Services Task Force ensures basic service needs of the community are met. These efforts include food distributions through Neighborhood and Community Centers, rent and utility assistance, and drive-by WIC services, among others.
  • Behavioral Health Task Force: The Behavioral Health Task Force will coordinate with the local mental health authority and other mental health providers to address emerging community needs.
  • Child Care Task Force: The Child Care Task Force works on emergency child care solutions for parents or guardians who work for essential businesses by connecting them to existing and open child care centers. The task force continuously monitors the capacity in the community to meet the emergency child care demand, and assesses the necessary supplies and other supports needed to continue operating while also working on solutions to meet the needs.
  • Group Homes Task Force: The Group Homes Task Force provides guidance, information, and support to minimize the risk of infection for residents, as well as expediting rapid intervention in the event of a COVID19 case to mitigate and control the spread of the virus.
  • Equity Task Force: The Equity Task Force will guide planning and implementing response, and recovery activities that address disparities to ensure that disparities are not inadvertently created or exacerbated.
  • Food Access Task Force: The Food Access Task Force works collaboratively with community partners to address food system issues related to the response, in addition to working on a longer-term strategy for addressing the anticipated increase in food access needs throughout the community.
  • Homelessness Task Force: The Homelessness Task Force focuses on developing short-term strategies (food access, personal hygiene) and long-term strategies (additional shelter beds, identification of quarantine facility) to address gaps in the homelessness response system related to COVID-19.

Austin-Travis County Surge Plans

The current hospital bed count for Austin-Travis County is approximately 4,300 on an average day; however, this number will continuously changes as we expand capacity. Modeling from the University of Texas estimates there are approximately 750 ventilators. As of early April, hospitals are currently operating at a about a 50% capacity. Should, COVID-19 result in an overcapacity of our hospital system, we have a surge plan in place to address additional patient care needs:

  • Type II Alternative Care Sites (ACS) have been identified as spaces for potential patient care outside of the traditional hospital setting that provide hospital-level care, such as former clinics or medical facilities. Type II ACS would be used once traditional hospitals approach the limits of their surge capacity.
  • Type I Alternative Care Sites (ACS) are similar to a combat surgical hospital or large ward. Type I ACS would be used once traditional hospitals and Type II ACS facilities approach the limits of their capacity.

As of early April, and based on current projects from the University of Texas, we don’t anticipate needing Type II or Type I ACS facilities, outside of traditional hospitals, for at least one month. However, as more data is received about the transmission of COVID-19 in Austin-Travis County, and the community impacts from social distancing and the Stay Home Order are realized, the data and modeling is subject to change.

Clinical Criteria

The CDC clinical criteria for COVID-19 Persons Under Investigation (PUI) have been developed based on available information about the virus:

Clinical Features & Epidemiological Risk
Fever or signs/symptoms of lower respiratory illness AND Any person, including healthcare workers, who had close contact with a lab-confirmed COVID-19 patient within 14 days of symptom onset
Fever and signs/symptoms of a lower respiratory illness requiring hospitalization AND A history of travel from affected geographic areas (China, Iran, Italy, Japan, South Korea) within 14 days of symptom onset
Fever with severe acute lower respiratory illness requiring hospitalization and without alternative explanatory diagnosis (i.e. influenza)   No source of exposure has been identified

If you suspect a patient has COVID-19, you will need to follow these procedures:

Mark and isolate the patient in a room following the CDC Infection Prevention Recommendations. Collect information about symptoms and travel history.

Click here to access a resource for your patients that are deaf or hard of hearing.

  • Call 512-972-5555 to talk with an APH employee to discuss and request testing.
    • If after hours or on the weekend, use the pager number provided on the answering machine.
  • Collect a nasopharyngeal (NP) swab
    • Place swab immediately into sterile tube containing 2-3 ml of viral transport media.
    • Label the vial with the name of the patient, the date of birth of the patient, and the date and time of collection.
    • Refrigerate the specimens until an APH employee picks up the specimen.

Testing & Specimens

Specimen Collection Procedures

To collect specimens for suspected COVID-19 cases, you will need the following supplies:

  • Synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain substances that inactivate some viruses and inhibit PCR testing Universal viral transport media with 2-3 ml of media, such as BD universal viral transport system, Remel M4RT MircoTest Kits, Copan UTM®: Viral Transport A refrigerator to store the specimens.
  • The CDC's Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons Under Investigation (PUIs) for Coronavirus Disease 2019 (COVID-19) can be found here.
  • While performing the NP swabs, you should take the following precautions:
  • Collecting diagnostic respiratory specimens (e.g., nasopharyngeal swab) are likely to induce coughing or sneezing. Individuals in the room during the procedure should, ideally, be limited to the patient and the healthcare provider obtaining the specimen. HCP collecting specimens for testing for SARS-CoV-2, the virus that causes COVID-19, from patients with known or suspected COVID-19 (i.e., PUI) should adhere to Standard, Contact, and Airborne Precautions, including the use of eye protection. These procedures should take place in an AIIR or in an examination room with the door closed. Ideally, the patient should not be placed in any room where room exhaust is recirculated within the building without HEPA filtration.
    • Label the vials with the name of the patient, the date of birth of the patient, the date and time of collection.
    • Refrigerate the specimens until an APH employee picks up the specimen(s)
  • Testing requires a nasopharyngeal swab (NP swab). When you collect the swab, you must follow these procedures:
  • Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media. Make sure the swabs are in separate vials.

Testing Prioritization

Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing). Priorities for testing include:

  • Priority 1: Ensure optimal care options for all hospitalized patients, lessen the risk of nosocomial infections, and maintain the integrity of the healthcare system
    • Hospitalized patients
    • Symptomatic healthcare workers
    • First responders with symptoms
  • Priority 2: Ensure that those who are at highest risk of complication of infection are rapidly identified and appropriately triaged
    • Patients in long-term care facilities with symptoms
    • Patients 65 years of age and older with symptoms
    • Patients with underlying conditions with symptoms
  • Priority 3: As resources allow, test individuals in the surrounding community of rapidly increasing hospital cases to decrease community spread, and ensure health of essential workers
    • Critical infrastructure workers with symptoms
    • Individuals who do not meet any of the above categories with symptoms
    • Health care workers and first responders
    • Individuals with mild symptoms in communities experiencing high COVID-19 hospitalizations

Testing Enrollment

  • If a patient is exhibiting COVID-19 symptoms fever and acute respiratory symptoms, they may use telehealth virtual visits (see a list of services on our webpage here) or call a healthcare provider.
  • Healthcare providers should first determine if there is another plausible diagnosis with similar symptoms (i.e. influenza). 
  • For suspected COVID-19 cases, physicians will fill out a form. Austin Public Health will use this information to assess risk and criteria to determine whether a test is appropriate. Patients will be notified on whether you qualify for a test and will be provided with a test-site location. 
    • Some local healthcare providers are providing their own testing, if this is the case for your hospital or practice please provide your patient with further guidance for that process. 

The CDC's Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons Under Investigation (PUIs) for Coronavirus Disease 2019 (COVID-19) can be found here.

Clinical Care

Presentation

The signs and symptoms of COVID-19 present at illness onset vary, but according to the CDC over the course of the disease, most persons with COVID-19 will experience the following:

  • Fever (83–99%)
  • Cough (59–82%)
  • Fatigue (44–70%)
  • Anorexia (40–84%)
  • Shortness of breath (31–40%)
  • Sputum production (28–33%)
  • Myalgias (11–35%)

Severity

According to the CDC, The largest cohort of >44,000 persons with COVID-19 from China showed that illness severity can range from mild to critical:

  • Mild to moderate (mild symptoms up to mild pneumonia): 81%
  • Severe (dyspnea, hypoxia, or >50% lung involvement on imaging): 14%
  • Critical (respiratory failure, shock, or multiorgan system dysfunction): 5%

Progression

Among patients who developed severe disease, the medium time to dyspnea ranged from 5 to 8 days, the median time to acute respiratory distress syndrome (ARDS) ranged from 8 to 12 days, and the median time to ICU admission ranged from 10 to 12 days, according to the CDC. Clinicians should be aware of the potential for some patients to rapidly deteriorate one week after illness onset. 

Management and Treatment

  • Mild Clinical Presentation: Patients may not initially require hospitalization, and many patients will be able to manage their illness at home. The decision to monitor a patient in the inpatient or outpatient setting should be made on a case-by-case basis. This decision will depend on the clinical presentation, requirement for supportive care, potential risk factors for severe disease, and the ability of the patients to self-isolate at home. 
  • Severe Clinical Presentation: Some patients with COVID-19 will have severe disease requiring hospitalization for management. Complications of severe COVID-19 include pneumonia, hypoxemic respiratory failure/ARDS, sepsis and septic shock, cardiomyopathy and arrhythmia, acute kidney injury, and complications from prolonged hospitalization including secondary bacterial infections. Inpatient management of COVID-19 revolves around the supportive management of the most common complications of severe COVID-19: pneumonia, hypoxemic respiratory failure/ARDS, shock, multiorgan failure, and the complications associated with prolonged hospitalization including secondary nosocomial infection, thromboembolism, gastrointestinal bleeding, and critical illness polyneuropathy/myopathy.

Supplies & Protection

Personal Protective Equipment

Standard Precautions assume that every person is potentially infected or colonized with a pathogen that could be transmitted in the healthcare setting. Elements of Standard Precautions that apply to patients with respiratory infections, including COVID-19, are summarized below. Attention should be paid to training and proper donning (putting on), doffing (taking off), and disposal of any PPE. This document does not emphasize all aspects of Standard Precautions (e.g., injection safety) that are required for all patient care; the full description is provided in the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

  • Hand Hygiene: HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.
  • Respirator or Facemask: Put on a respirator or facemask (if a respirator is not available) before entry into the patient room or care area. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure.
  • Eye Protection: Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area. Personal eyeglasses and contact lenses are NOT considered adequate eye protection. Remove eye protection before leaving the patient room or care area.
  • Gloves: Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene.
  • Gowns: Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use.

Accessing Supplies

Healthcare providers and first responders should follow their normal processes of trying to locate Personal Protective Equipment (PPE) with their regular vendors and exhaust all possible options. PPE supplies are extremely limited within our region. If you have exhausted all means possible, you may submit a PPE Request Form with the CAMOC. Completion of this form does not guarantee that your agency/facility will receive supplies.

Preserving Supplies

Healthcare facilities and clinicians should prioritize urgent and emergency visits and procedures now. These actions can preserve staff personal protective equipment (PPE) and patient care supplies, ensure staff and patient safety, and expand available hospital capacity:

  • Delay all elective ambulatory provider visits
  • Reschedule elective and non-urgent admissions
  • Delay inpatient and outpatient elective surgical and procedural cases
  • Postpone routine dental and eyecare visit

Infection Control Recommendations

  • Minimize Chance for Exposures: Ensure facility policies and practices are in place to minimize exposures to respiratory pathogens. Measures should be implemented before patient arrival, upon arrival, throughout the duration of the patient’s visit, and until the patient’s room is cleaned and disinfected. It is particularly important to protect individuals at increased risk for adverse outcomes from COVID-19, including HCP who are in a recognized risk category.
  • Patient Placement: For patients with COVID-19 or other respiratory infections, evaluate need for hospitalization. If hospitalization is not medically necessary, home care is preferable if the individual’s situation allows. If admitted, place a patient with known or suspected COVID-19 in a single-person room with the door closed. The patient should have a dedicated bathroom. Airborne Infection Isolation Rooms (AIIRs) should be reserved for patients who will be undergoing aerosol-generating procedures. As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for known or suspected COVID-19 patients. Dedicated means that HCP are assigned to care only for these patients during their shift.
  • Manage Visitor Access and Movement Within the Facility: Establish procedures for monitoring, managing and training all visitors. Limit visitors to patients with known or suspected COVID-19. Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets.
  • Implement Engineering Controls: Design and install engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals. Examples of engineering controls include: 
    • Physical barriers or partitions to guide patients through triage areas
    • Curtains between patients in shared areas
    • Air-handling systems (with appropriate directionality, filtration, exchange rate, etc.) that are installed and properly maintained
  • Monitor and Manage Ill and Exposed Healthcare Personnel: Facilities and organizations providing healthcare should implement sick leave policies for HCP that are non-punitive, flexible, and consistent with public health guidance.
  • Implement Environmental Infection Control: Dedicated medical equipment should be used when caring for patients with known or suspected COVID-19. All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer’s instructions and facility policies. Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly.

Workplace Exposure

Proper adherence to currently recommended infection control practices, including all recommended PPE, should protect HCP having prolonged close contact with patients infected with COVID-19.  However, to account for any inconsistencies in use or adherence that could result in unrecognized exposures HCP should still perform self-monitoring with delegated supervision.

  • High-risk exposures refer to HCP who have had prolonged close contact with patients with COVID-19 who were not wearing a facemask while HCP nose and mouth were exposed to material potentially infectious with the virus causing COVID-19.  Being present in the room for procedures that generate aerosols or during which respiratory secretions are likely to be poorly controlled (e.g., cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum induction) on patients with COVID-19 when the healthcare providers’ eyes, nose, or mouth were not protected, is also considered high-risk.
  • Medium-risk exposures generally include HCP who had prolonged close contact with patients with COVID-19 who were wearing a facemask while HCP nose and mouth were exposed to material potentially infectious with the virus causing COVID-19. Some low-risk exposures are considered medium-risk depending on the type of care activity performed. For example, HCP who were wearing a gown, gloves, eye protection and a facemask (instead of a respirator) during an aerosol-generating procedure would be considered to have a medium-risk exposure. If an aerosol-generating procedure had not been performed, they would have been considered low-risk. 
  • Low-risk exposures generally refer to brief interactions with patients with COVID-19 or prolonged close contact with patients who were wearing a facemask for source control while HCP were wearing a facemask or respirator. Use of eye protection, in addition to a facemask or respirator would further lower the risk of exposure.
Epidemiological Risk Factors Exposure Category Recommended Monitoring (until 14 days after last potential exposure) Work Restrictions for Asymptomatic HCP
Prolonged close contact with a COVID-19 patient who was wearing a facemask (i.e., source control)      
HCP PPE: None Medium Active Exclude from work for 14 days after last exposure
HCP PPE: Not wearing a facemask or respirator Medium Active Exclude from work for 14 days after last exposure
HCP PPE: Not wearing eye protection Low Self with delegated supervision None
HCP PPE: Not wearing gown or gloves Low Self with delegated supervision None
HCP PPE: Wearing all recommended PPE (except wearing a facemask instead of a respirator) Low Self with delegate supervision None
Prolonged close contact with a COVID-19 patient who was not wearing a facemask (i.e., no source control)      
HCP PPE: None High Active Exclude from work for 14 days after last exposure
HCP PPE: Not wearing a facemask or respirator High Active Exclude from work for 14 days after last exposure
HCP PPE: Not wearing eye protection Medium Active Exclude from work for 14 days after last exposure
HCP PPE: Not wearing gown or gloves Low Self with delegated supervision None
HCP PPE: Wearing all recommended PPE (except wearing a facemask instead of a respirator) Low Self with delegated supervision None

For additional information, visit the CDC’s Frequently Asked Questions for Healthcare Professionals

Clinic Materials

Austin Public Health has created a flyer for clinics to post in their entrances. A printable version of this flyer is available in English (PDF), Spanish (PDF), Vietnamese (PDF), Chinese Simplified (PDF), and Chinese Traditional (PDF).

Attention! Health Alert - If you have a fever, cough, shortness of breath, call the clinic before entering.