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Primary care

Information for family physicians and primary care nurse practitioners about testing and caring for patients with a confirmed or suspected case of COVID-19.
Last updated: September 22, 2021
This page includes recommendations to primary care practitioners (family physicians and nurse practitioners) for the assessment and management of adult patients with symptoms suggestive of COVID-19, suspected COVID-19, or confirmed diagnosis of COVID-19.

Click here for the full Guidance for Primary Care Management of Adult Outpatients with Suspected or Confirmed COVID-19 - last updated July 16, 2021.

On this page
Links to related topics primary care practitioners may be asked about: 

Signs and symptoms (Adult)

Clinical judgement remains important in the diagnosis and work-up of individuals presenting with these symptoms, regardless of immunization status.

Maintain awareness that patients with this symptom profile may have other serious illnesses such as influenza, COPD exacerbation pneumonia, other infectious diseases, etc.

People can be infectious 48 hours before onset of symptoms and up to 10days after onset of symptoms (up to 20 days depending on factors including immunocompromised status and severity of disease). Refer to Interim Guidance: Public Health Management of Cases and Contacts Associated with Novel Coronavirus (COVID-19) in the Community.

Continue to pre-screen patients for symptoms of COVID-19 in advance of in-person care. 

Symptoms strongly associated with COVID-19
  • Fever or chills
  • Cough (either new onset or worsening of chronic cough)
  • Difficulty breathing
  • Loss of sense of smell or taste
General symptoms
  • Sore throat
  • Loss of appetite
  • Extreme fatigue or tiredness
  • Headache
  • Body aches
  • Nausea, vomiting or diarrhea
Non-specific symptoms:
  • Nasal symptoms (runny nose, sneezing, congestion, sinus involvement)
  • Conjunctivitis
  • Dizziness
  • Confusion
  • Abdominal pain
  • Skin rashes
  • Discoloration of fingers or toes

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Testing 

Testing guidance changes as new information becomes available. 

Refer to the viral testing page for the latest guidance both adult and pediatric populations.


Primary care providers should continue to evaluate and treat other serious conditions regardless of whether a patient requires testing. In-patient visits may be needed. Refer to the guidance for conducting safe office visits Infection and Prevention Control Guidance for Community-Based Physicians, Nursing Professionals and Midwives in Clinic Settings.


It is particularly important to test symptomatic individuals who:
  • Are residents or staff of long-term care facilities
  • Require admission to hospital or are likely to be admitted
  • Are healthcare workers
  • Are contacts of a person diagnosed with COVID-19
  • Are travellers who in the past 14 days returned to B.C. from outside Canada, or from an area with higher infection rates within Canada
  • Are residents of remote, isolated, or Indigenous communities
  • Live in congregate settings such as work-camps, correctional facilities, shelters, group homes, assisted living and seniors’ residences
  • Are homeless or have unstable housing
  • Are essential service providers, such as first responders.

Refer to the B.C. COVID-19 Collection Centre online finder.


Some practitioners perform testing in the office; refer to specimen collection instructions.

COVID-19 test results are available online, by text, or by phone. Refer to the test results page to learn about accessing test results.

 
Please advise all patients being tested for COVID-19 to self-isolate until negative test results have been received.

Refer to
Testing of asymptomatic persons for occupational, travel or other non-medical indications is not funded by the Medical Services Plan (MSP). The BCCDC website includes a list of private pay clinics.

FAQ for health providers explaining how the test works, what the test results mean, reasons for false negative results, the levels of virus shedding, and the sensitivity of the test.

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Outpatient management of patients with COVID-19

Most patients with confirmed COVID-19 will have mild to moderate symptoms (e.g., cough, sore throat, fever, and rhinorrhea) and can be safely managed as an outpatient in the community setting. 

Practitioners and patients should be aware that rapid deterioration may occur at any point after illness onset. If the patient has any concerns or signs of deterioration, they should immediately consult a health-care practitioner in person at an urgent clinic, emergency department or call 9-1-1. 

The following patient management recommendations are the same regardless of patient immunization status.
Severe illness can still occur in patients who are partially or fully immunized.

Severe illness can still occur in patients who are partially or fully immunized.

Consider a conversation about advance care directives. Remember to review code status and complete a Medical Orders for Scope of Treatment (MOST) form for patients at risk of decompensation or being referred to hospital.


Determine if outpatient management is appropriate and if the patient is capable of self-care. Consider the following:


Adult patients should
  • Be able to: stay well hydrated; to manage their comorbidities at home; reliably report worsening symptoms (e.g. speech, cognitive status); and, carry out their usual activities of daily living.
  • Have appropriate resources and social supports to self-isolate and manage their comorbidities.
  • Have stable vitals and no signs of respiratory distress or persistent tachypnea.
  • Some patients have pulse oximetry at home. They should be specifically counselled to ensure they understand what an appropriate value is on their monitor and when to seek care. 
  • (If pulse oximetry is available) should have an SpO2 >93% on room air. SpO2 of 90% to 93% on room air may be acceptable if a patient has a pre-existing chronic lung disease. If outside these parameters, they should be assessed for possible admission to hospital.
Encourage all patients to monitor their symptoms very closely and contact their provider if symptoms change.

Possible risk factors for progression to severe illness
  • Age: risk increases with each decade; Older age >60* having very large increase in risk of severe disease and mortality;
  • Conditions associated with severe outcomes: asthma, cancer, cardiovascular, chronic kidney disease, chronic respiratory disease, diabetes, Down syndrome, immunosuppression and immunodeficiency, obesity, organ transplant, pregnancy, sickle cell disease and substance use.
  • Be aware of other risk factors and that they may not be visibly apparent, e.g. obesity, substance use disorders.

  • Other factors that may warrant additional consideration include: race, ethnicity, socio-economic factors, and their intersection and sex at birth.

  • For more information refer to: Risk factors for severe COVID-19 disease
The decision regarding the location of care should be made on a case-by-case basis and will depend on the clinical presentation, need of supportive care, potential risk factors for severe disease, and living conditions, including the presence of other care providers and/or vulnerable persons in the household.

The BC COVID-19 Therapeutics Committee meets regularly to discuss the most current research on the use/misuse of therapies in the management of COVID-19. Refer to their current treatment recommendations, which are revised regularly as evidence changes.


Supportive treatment should be based on the provider’s assessment of the patient’s clinical condition. For patients being cared for or recovering at home, standard treatment for cold-like symptoms and influenza-like illness is recommended.


For symptomatic management, there is limited data to suggest acetaminophen should be used preferentially over nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. NSAIDs can be considered if needed and patients who are already taking them can continue to do so.


ACE inhibitors and ARBs should not be discontinued solely on the basis of COVID-19.


NSAIDs should not be discontinued solely on the basis of COVID-19.


There is no evidence to support the use of chloroquine, hydroxychloroquine or ivermectin in patients with COVID-19. Patients who inquire about alternative remedies should be advised against them infection.


Advanced imaging, and even conventional radiography should not be used for the diagnosis of COVID-19.



At this time, there are two potential treatments for patients with COVID-19 infection in the outpatient setting:


Inhaled budesonide 

Dose
800 µg BID twice daily x 14 days

Indication
May be considered within 14 days of symptom onset for adults with mild COVID-19 who are: 
  • aged ≥65 or 
  • aged ≥50 with underlying health conditions (weakened immune system due to illness or medication, heart disease and/or hypertension, chronic lung disease, diabetes mellitus, hepatic impairment, stroke or other neurological condition, obesity or BMI above 35)
Possible benefit
Reduces time to symptomatic recovery by one to three days. Based on emerging research, COVID-19-related hospitalization may be reduced.

Possible harm
Adverse effects associated with short course inhaled budesonide include oral thrush and dysphonia. Instruct patient on proper technique, including rinsing mouth with water after use.

Cost
Budesonide Turbuhaler® 200 mcg/dose (200 doses/inhaler) is approximately $75 and 400 mcg/dose (200 doses/inhaler) is approximately $110, plus professional dispensing fee. PharmaCare coverage: Regular benefit.


Colchicine

Dose
0.6 mg PO BID x 3 days, then 0.6 mg PO daily x 27 days

Indication
May be considered for adults aged 40 years or over with mild COVID-19 with at least one risk factor (indication) and no contraindications to colchicine.
Indications: age >70 years, obesity (BMI >30 kg/m2), diabetes, hypertension (systolic >150 mmHg), respiratory or coronary disease, heart failure, fever >38.4̊C, or dyspnea.

Possible benefit
Colchicine may reduce hospitalization in one out of 71 patients (4.5% colchicine vs. 5.9% placebo)..

Possible harm
Side-effects include diarrhea (14% colchicine vs. 7% placebo) and nausea (2% colchicine vs. 2% placebo), and pulmonary embolism (0.5% colchicine vs. 0.1% placebo).

Cost
Course of colchicine treatment is approximately $15, plus professional dispensing fee. PharmaCare coverage: Regular benefit.

Contraindications
GFR <30 mL/min, inflammatory bowel disease, chronic diarrhea or malabsorption, neuromuscular disease, severe liver disease, chemotherapy, current colchicine treatment, hypersensitivity to colchicine, or concurrent medications that interact with colchicine (e.g. amiodarone, azoles, carvedilol, cyclosporine, estradiol, macrolides, propafenone, protease inhibitors, quinidine, quinine, verapamil). *In clinical practice, these are relative contra-indications and one could consider trial of colchicine if potential benefits outweigh potential risks. See product monograph.

Please refer to the Treatments page for information about clinical use.

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Self-isolation guidance

For patients that require self-isolation and need to be seen in the clinic setting, refer to theIPC guidance for Community Healthcare Providers for appropriate measures and how to conduct a point-of-care risk assessment before any patient interaction to determine the appropriate personal protective equipment.

Public health provides self-isolation direction to COVID-19 infected persons and close contacts, based on provincial guidance. For details, refer to Interim Guidance: Public Health Management of Cases and Contacts Associated with Novel Coronavirus (COVID-19) in the Community.

MHOs have discretion in the implementation of these guidelines and use their clinical judgement to manage cases, clusters, outbreaks and the COVID-19 pandemic in their region. There may be local variations.

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Referrals to and discharges from hospital

Counsel patients with mild COVID-19 and their caregivers about the signs and symptoms of complications that should prompt urgent care. If the patient has any concerns or signs of deterioration, they should consult a health-care practitioner in person through urgent care, emergency department or 9-1-1. 

If they develop any of the symptoms below, they should be referred for further assessment:
  • Uunstable vitals
  • Dehydration
  • Sustained or downward trending SpO2≤93% (or <90% with a chronic lung condition)
  • Shortness of breath, pain or pressure in the chest, confusion, drowsiness, or weakness
  • Any other deterioration in status
If the patient’s status deteriorates and they require a higher level of care or cannot be managed at home, refer to hospital. Maintain a low threshold for referring patients to hospital.

Early identification of those with severe illness, pneumonia, or high risk for deterioration allows for optimized supportive care treatments and safe, rapid referral and admission to a hospital.

Identify if there is an advance care plan and clarify code status. Complete a MOST form for patients at risk of decompensation or being referred to hospital, see the MOST form summary. Palliative care should be explored early if appropriate.

If transferring a patient from the community to an acute care facility, notify BC Emergency Health Services (BCEHS) and the receiving facility prior to transfer/arrival to ensure appropriate infection prevention and control measures can be put in place.

Discharge discussions should take place in collaboration with the primary care practitioner and/or community of care, and public health. In some locations, patients may be transferred to a bed at home via Hospital at Home and remain under hospital care. Ensure that the patient’s individual context, including access to transportation, living situation and family/household supports, is taken into consideration when deciding when and how to discharge. Ensure that the patient knows who to contact if they are feeling unwell or their condition worsens after discharge.

Patients may be discharged in the following situations:
  • when medically well and not on oxygen, unless previously on home O2; or
  • palliative care at home.
When patients are discharged back to home, either alone or with family:

  • Routine follow-up takes place with the primary care practitioner. Patients who have been hospitalized because of COVID-19 infection are at higher risk of complications and  primary care follow up should be arranged.
  • Older people are more likely to experience pronounced functional decline and may require coordinated rehabilitation or convalescent care.

  • Public health follow-up takes place regarding any ongoing COVID-19 public health issues for patient or family, including living arrangements, isolation, and follow-up COVID-19 testing.
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Remote and Rural Considerations

There is limited capacity in remote and rural areas to provide care for those with severe illness. Variation may exist from community to community regarding the types of acute care services available, telehealth and medivac capacities.

Supports are available for practitioners in rural areas: refer to Practitioner Resources.

Mild to moderate disease, including uncomplicated pneumonia, may be managed within the community, with appropriate precautions in place.
  • Mild cases may progress to lower respiratory tract disease. Be aware of the risk factors for progression to severe ilnness including older age and underlying chronic medical conditions.
  • Some communities may need to consider arrangements for patients at higher risk to live closer to an acute care facility.
Alternate arrangements for self-isolation may be needed for people in crowded living arrangements.

Fluid management should be conservative when there is no evidence of shock because aggressive fluid management may worsen oxygenation.

Patients should be carefully monitored for signs of impending deterioration (i.e. escalating O2 needs) so that transfer can be arranged before intubation is required. Clinicians should be aware of the potential for some patients to rapidly deteriorate at any point after illness onset.

Anticipate delays in accessing hospital care (e.g., awaiting air-ambulance, weather issues). Therefore, a low threshold should be considered for medevac options. Receiving hospitals may need to tailor their policies for accepting COVID-19 patients.

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Pediatrics

MIS-C continues to be a rare complication of COVID-19 in children.
  • It can occur in children who have had asymptomatic or symptomatic COVID-19 infection.
Children affected by MIS-C can present with a spectrum of symptoms.
  • Prominent features include shock/hemodynamic instability, rash, mucocutaneous inflammation, peripheral extremity changes, gastrointestinal symptoms and cardiac dysfunction.
  • Respiratory symptoms can occur but are less frequent.
Common laboratory features associated with MIS-C include:
  • Lymphopenia, thrombocytopenia, elevated inflammatory markers, evidence of coagulopathy and elevated cardiac markers.
MIS-C symptoms overlap with a broad range of conditions.
  • It is important to consider other diagnoses with similar presentation to MIS-C including:
    • Kawasaki Disease
    • Toxic Shock Syndrome
    • Sepsis
There should be a low threshold to evaluate for MIS-C in children who present with unexplained fever for three or more days, even if they are well-appearing on initial presentation.
  • Although children with MIS-C may appear well, their condition can deteriorate within hours to days.
  • Caregivers of children who appear well and are discharged should be counselled about symptoms of MIS-C and told to return to the emergency department if:
    • Symptoms worsen;
    • Symptoms do not improve within 48 hours; or
    • Fever does not abate after a total of five days since onset.
  • Clinicians should liaise with the relevant specialist at BC Children’s Hospital regarding the MIS-C patient’s management and determine whether a higher level of care is needed.
The mainstay of MISC-C treatment is:
  • Early fluid resuscitation, as needed.
  • Intravenous immunoglobulin (IVIg).
  • Systemic steroids.
  • Consultation with rheumatology, infectious diseases and cardiology is suggested for children being evaluated for MIS-C.
Long-term sequalae of MIS-C is unknown at present but some children may have lingering symptoms after
discharge.

Children with possible MIS-C require evaluation by a pediatric specialty team experienced in the diagnosis of KD and other inflammatory conditions of childhood. Consultation with pediatric rheumatology and infectious disease is recommended if querying MIS-C. If cardiac imaging is needed outside of BCCH, liaise with the pediatric cardiologist at BCCH. Any of these specialists can be reached through central paging at 1-604-875-2000 or toll free 1-888-300-3088.

Cases of MIS-C are reportable under the Reporting Information Affecting Public Health Regulation and Public Health Act. Please contact your local Medical Health Officer to report cases of MIS-C. For MIS-C reporting or questions, please email MISC@cw.bc.ca
 

Immunization

Encourage all patients to obtain COVID-19, influenza and other appropriate immunizations (e.g., pneumococcal).

  • If patients have symptoms of COVID-19, they should stay home from the immunization clinic and use the COVID-19 self-assessment tool to determine if they need to be tested. 
  • If they have a new illness preventing them from performing their regular activities, they should wait to get immunized until they have recovered. This will help to distinguish side effects of the vaccine from worsening of their other illness. If they had a recent, confirmed COVID-19 infection, they should  complete their self-isolation and wait until they no longer have symptoms before attending an immunization clinic. 
  • Patients should defer COVID-19 immunization for at least 90 days following receipt of anti SARS-CoV-2 monoclonal antibodies or convalescent plasma for the treatment or prevention of COVID-19 to avoid potential interference of the antibody therapy with vaccine-induced immune response. Deferral is not required following treatment with tocilizumab or sarilumab.

Vulnerable Populations

BC Care Bundle Supporting High Risk Patients

Current information suggests that older people, and those with chronic health conditions are at higher risk of developing more severe illness or complications.


Read and share this reference page about risk factors for severe COVID-19 disease.

 
 
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Long-term complications of COVID-19

Many patients report long-term health effects after recovering from acute COVID-19 infection that may persist for months. This is an area of emerging evidence. Public Health England has found that approximately 10% of mild COVID-19 cases who were not admitted to hospital have reported symptoms lasting more than four weeks. A number of hospitalised cases reported continuing symptoms for eight or more weeks following discharge.

PHSA's Post COVID-19 Interdisciplinary Clinical Care Network supports patients who were infected with COVID-19 and who experienced serious disease to manage their condition over time. Post COVID-19 recovery clinics are designed to see patients at or following 12 weeks post-symptom onset and are not meant to address acute concerns.

Patients have experienced the following health problems after recovery from acute COVID-19:
  • Extreme fatigue
  • Muscle weakness
  • Low grade fever
  • Inability to concentrate
  • Memory lapses
  • Changes in mood
  • Depression, anxiety, and cognitive difficulties
  • Sleep difficulties
  • Headaches
  • Paresthesia in arms and legs
  • Diarrhea and intermittent vomiting
  • Loss of or change of taste and smell
  • Sore throat and swallowing difficulties
  • New onset of diabetes or hypertension
  • Respiratory symptoms and conditions such as chronic cough, ongoing shortness of breath, lung inflammation and fibrosis, and pulmonary vascular disease
  • Skin rash
  • Chest pains, chest tightness
  • Acute myocarditis
  • Heart failure
  • Palpitations
  • Inflammatory disorders such as myalgia, multisystem inflammatory syndrome, Guillain-Barre syndrome
  • Liver and kidney dysfunction
  • Clotting disorders and thrombosis
  • Lymphadenopathy
Referral information for the provincial post-COVID recovery clinics, post COVID-19 clinical resources, and patient self-management guides are available here. Patients can be referred from any geographic location in B.C. Physicians are also available for rapid consultation on the provincial Rapid Access to Consultative Expertise (RACE) line.

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Mental well-being 

Practitioners are reminded that in assisting patients with suspected or known COVID-19, there may be heightened levels of both new and worsening anxiety, depression and
post-traumatic stress disorder. Be aware of the emotional impacts and impacts on all areas of life. Pay particular attention and make your instructions to patients clear, simple and empathetic.

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Practitioner Resources

For First Nations community members and their families: First Nations Virtual Doctor of the Day.
 

Printable resources for patients who are being tested, self-isolating and/or monitoring for symptoms of COVID-19 are available on the Patient Handouts page.



For First Nations community members and their families who have limited or no access to their own doctors: First Nations Virtual Doctor of the Day offers virtual appointments with doctors of Indigenous ancestry, and all doctors are trained to follow the principles and practices of cultural safety and humility.


Patients can also find up-to-date public information at bccdc.ca/covid19.


Learn more about how public health conducts contact tracing.

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Schools

Schools are low-risk settings for COVID-19 transmission. When transmission does occur, it usually results in only one or two additional cases. There is widespread support amongst pediatricians to have children attend in-person learning, including most children with medical complexity and/or immune compromise, when safety measures are in place. 


This guidance is intended for pediatricians, primary care providers and other health-care professionals working with school-aged children and youth and their parents/caregiver.


 

Visit the K-12 Schools and COVID-19 website for resources and information about preventing COVID-19 in schools for students and families.

 

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