COVID-19 created a global public health emergency that caused significant morbidity, mortality, strain on the healthcare system, and socioeconomic fallout.1,2 SARS-CoV-2, the viral etiologic agent of COVID-19, was initially identified as pneumonia of unknown etiology. Genetically, SARS-CoV-2 is related to SARS-CoV and Middle East Respiratory Syndrome-CoV (MERS-CoV), two coronaviruses that have caused infections of concern.3 The virulence and transmissibility of the virus through respiratory droplets necessitated wearing a mask, social distancing, and lockdown strategies.1,2 This article discusses the outpatient management of patients with COVID-19 that reflects current evidence and best practices. Variants of concern (VOC), clinical presentation, assessment of the patient's clinical status, vaccination, medication management, and patient teaching are presented.
Variants of concern
SARS-CoV-2 VOCs have mutations on the spike protein receptor-binding domain, allowing for viral replication, increased transmissibility, resistance to treatment, and reduction in vaccine protection, resulting in severe illness.4-7
The Alpha variant (B.1.1.7) was the first VOC, primarily because of its affinity to activate epithelial cells of the lungs, subsequently causing pneumonia.4-7 The Delta variant (B.1.617.2), has a similar clinical presentation as the Alpha variant, including lung involvement, and is 50% more contagious than the Alpha variant.4-7
The Omicron variant (BA.1) and its subvariant (BA.2) became the dominant variants by early 2022 and are more transmissible than the Delta and Alpha variants.4-7
Omicron BA.4 and BA.5 became the variants of concern by mid-2022, and are especially concerning because they are more transmissible than previous variants and evade some of the immunity from current COVID-19 vaccines and previous COVID-19 infection.8-10 Approximately 80% of new COVID-19 infections are related to BA.5.8-10 The US FDA recommended that vaccines be updated to target the spike protein on BA.4 and BA.5 to provide full protection against these variants. Omicron-specific vaccines became available in September 2022. These new vaccines are bivalent, which means that half of the vaccine target the original COVID-19 strains and the other half target the BA.4 and BA.5 lineages.8-11 The CDC is tracking other variants across the world that could be VOC at some point.8-10
Symptoms related to the Omicron variants are generally confined to the upper respiratory tract with rhinorrhea, nasal congestion, sore throat, and cough. Omicron variants are slow to affect the lungs.4-7
Hospitalizations have been lower with Omicron than with Alpha and Delta.4-7 An infection by an Omicron variant is generally milder than in Delta and Alpha variants, but it can still lead to severe illness, including lung involvement, and depends on host susceptibility.4-7 Older adults and individuals with comorbidities, including the immunocompromised, are especially at risk for severe disease.5,6
Clinical presentation
A SARS-CoV-2 infection ranges from asymptomatic to severe disease.12-15 The incubation period in symptomatic patients is between 2 and 14 days when the virus rapidly replicates and the patient is highly contagious.12-15 Patients develop a viral syndrome that may include nasal congestion, cough, fever, headache, fatigue, myalgia, anorexia, nausea, vomiting, and diarrhea.12-15 About 80% of patients with the Alpha and Delta variants experience a loss of smell (anosmia) from inflammation of the nasal epithelium and olfactory neurons and a loss of taste (ageusia) from inflammation of gustatory cells (taste buds) and salivary glands.12-15 Less than 20% of patients with Omicron variants experience loss of smell and taste.4,6
Some patients experience a hyperinflammatory state (cytokine storm) even when the viral load drops.12-15
Nurses should assess patients for cytokine storm regardless of the variant. A cytokine storm may not occur or be less severe with the Omicron variant than with the Alpha and Delta variants.4,6
Cytokines are proteins that mediate an immune and inflammatory response.12-15 Researchers postulate that the attachment of the COVID-19 spike glycoprotein with the angiotensin-converting enzyme-2 (ACE-2) triggers a cytokine storm.16 ACE-2 is an enzymatic protein that enables the virus to infect a patient, is significantly expressed in the lungs, heart, kidneys, brain, and gastrointestinal tract, and is eliminated in the plasma.16 A cytokine storm causes systemic inflammatory response syndrome resulting in edema, vasoconstriction, and ischemia, culminating in organ failure.12,13,16
A cytokine storm may lead to interstitial pneumonia and pulmonary fibrosis with or without hypoxia and acute respiratory distress syndrome (ARDS).12,17 On chest X-ray and computed tomography (CT), patients usually have bilateral areas of consolidation with ground-glass opacity.4,13 Pneumonia is associated with lymphopenia and C-reactive protein elevation.12,17,18 Evaluating breath sounds, respiratory rate, depth, and oxygen saturation is a priority during the head-to-toe assessment.19 Inflammation, endothelial dysfunction, and platelet activation create a hypercoagulable state causing arterial and venous thrombosis, myocardial infarction, and stroke.12,19,20 Patients experiencing sudden apprehension (from hypoxia), shortness of breath, chest pain, dizziness, and hemoptysis may have a pulmonary embolus.12,19,20 A high D-dimer and prolonged prothrombin time are biomarkers in COVID-19 infection that predispose a patient to thrombotic events.12,19,20 Anticoagulant prophylaxis should be considered in hospitalized patients.12,19,20 A cytokine storm may cause myocarditis leading to heart failure and dysrhythmias.12,19,20 Elevated brain-type natriuretic peptides and troponin levels are biomarkers of myocardial inflammation.12,19,20 Correlating heart sounds, heart rate, and rhythm, and fluid volume balance with pulmonary status is crucial.19
SARS-CoV-2 permeates glomerular cells and renal tubular epithelium; a cytokine storm causes ischemia leading to acute kidney damage.12,13 Hepatobiliary damage may occur from a cytokine storm and medications used to treat COVID-19.12,13 Patients may have hepatomegaly, elevated bilirubin levels, liver failure, elevated alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and lactate dehydrogenase.12,13 Liver failure may cause hepatic encephalopathy, leading to mental status changes.12,13 Mental status changes may also occur from cerebral vasculitis, which can also cause stroke secondary to cerebral ischemia.12,13 Viral entry into the gastrointestinal tract through ACE-2 receptors may cause abdominal pain, malabsorption, diarrhea, and hemorrhage.14,16 Cutaneous features secondary to a cytokine storm may include erythematous and urticarial rashes, petechiae, vasculitis lesions, and vesicles.20 Inflammation of muscles and joints may lead to myalgia and arthritis.12,13
Vaccination
Vaccination is the best defense to prevent or reduce the severity of infection because it creates a greater immune response to SARS-CoV-2 than having the infection.21,22 After having a COVID-19 infection, vaccination further boosts the immune system to help protect a person from another COVID-19 infection.21,22 The primary series of COVID-19 vaccinations help prevent infection with the Alpha, Delta, and Omicron variants and reduce hospitalization, though they are slightly less effective against the latter.5,23 Primary vaccine efficacy diminishes over time, requiring boosters to help prevent infection and hospitalization.5,23 Patients who are immunocompromised may have an inadequate immune response to the vaccination and still develop severe COVID-19.21,22
Two long-acting monoclonal antibodies, tixagevimab and cilgavimab, may be used to help prevent COVID-19 in patients who are not infected and who have not recently been exposed to an individual infected with SARS-CoV-2.24-26 They are packaged together and administered in two separate I.M. injections during one visit.24-26
Patients may receive these medications if they are 12 years of age or older, weigh at least 40 kg, are moderately or severely immunocompromised, or have a severe adverse reaction to any of the available COVID-19 vaccines.24-26 These monoclonal antibodies should be included in the arsenal of preexposure prophylaxis strategies for immunocompromised patients and anyone who has had a severe adverse reaction to any of the COVID-19 vaccine components.24-26
Managing patients at home
Managing patients at home begins with the healthcare provider (HCP) understanding the patient's health history and determining if they are at risk for severe COVID-19 by asking the following questions:
* Is the patient an older adult?
* Is the patient obese?
* Does the patient have chronic heart, lung, kidney disease, or diabetes? and
* Is the patient immunocompromised?
The HCP must also understand COVID-19 pathology, signs, symptoms, and the patient's vaccination status as presented in the previous sections of this article.5,15,27 Patients in the home setting are stable, but that may change at any point because of the uncertainty of the disease.5,15,27 A high-level critical thinking HCP should be ready to address the deterioration in the patient's clinical status and prepare them for hospitalization.5,15,27
Adult patients with mild-to-moderate COVID-19 who do not require hospitalization can be managed in the home setting.5,15,27 They should perform hand hygiene often, practice respiratory hygiene and cough etiquette, clean all surfaces, avoid sharing personal items, wear a mask, and stay in a separate bedroom while they are contagious. They can limit their exposure to others in the home by staying in one space or room away from others all the time.5,15,27 Patients should be encouraged to drink plenty of fluids; get plenty of rest; take over-the-counter antipyretics/analgesics, such as acetaminophen unless contraindicated, for fever, headache, and myalgia; and have someone help them with household duties including grocery shopping, cleaning the house, taking care of pets, and filling prescriptions.5,15,27 Patients should report symptom changes, such as a fever that is not responding to antipyretics or the onset of difficulty breathing, to the healthcare provider.5,12,15,24,27 Clinicians should teach patients how to monitor their oxygen level and report a pulse oximeter level of less than 92% or any changes in breathing pattern based on discharge instructions.28,29 An oxygen saturation below 92% may indicate ARDS onset and require supplemental oxygen in an in-patient setting.28,29
Other factors that warrant immediate notification of the HCP or emergency medical services are increasing breathing difficulty, chest pain, and disorientation.28,29
After about 2 weeks of mild-to-moderate disease, the viral load drops, adaptive immunity in the form of antibody production occurs in most patients, and signs and symptoms usually improve.14
Patients with comorbidities including but not limited to diabetes mellitus, pulmonary disease, cardiovascular disease, sickle cell disease, chronic kidney disease, cancer, immunosuppression, or obesity may receive the monoclonal antibody bebtelovimab and antiviral therapy, including remdesivir, ritonavir-boosted nirmatrelvir (oral), and molnupiravir (oral) to prevent severe disease.27,30-33 Bebtelovimab prevents severe disease by targeting the interplay between the surface spike protein and the human ACE-2 receptor, preventing the virus from entering the cells, and is effective with the Omicron variant.27,30,33
Bebtelovimab and remdesivir must be administered in an outpatient treatment center.27,30-33 The patient must be monitored for severe hypersensitivity reactions during administration and for at least 1 hour after injection is complete.27,30-33
Systemic corticosteroids, such as dexamethasone, are not generally recommended for nonhospitalized patients who do not require supplemental oxygen.27,30-33
Patients who were hospitalized with COVID-19 in an in-patient setting or evaluated for COVID-19 in an ED may be discharged home with supplemental oxygen by low flow nasal cannula and need to self-monitor oxygen saturation.28,29,34 Patients will be instructed to check their oxygen saturation with supplemental oxygen in place and when it is removed.28,29,34 Patients should follow the same reporting process as patients who were never hospitalized with COVID-19 when they have an oxygen saturation below 92% and other symptoms indicating a decline in airway efficacy.28,29,34 Patients who were hospitalized and discharged to home may also be prescribed dexamethasone orally for no more than 10 days and remdesivir for up to 5 consecutive days in an outpatient treatment center.34
Managing a patient with COVID-19 in the home setting requires a multifaceted, integrated, and interdisciplinary approach.12-15 The nurse and healthcare team should ensure that medications, equipment, oxygen supplies, social support, and human resources are available in the home setting.11-14 Patients may be weak from the viral syndrome and take weeks to months to recover.12-15 Priority interventions also include:15,21,27-38
* Conducting a health history interview, performing a head-to-toe physical assessment, evaluating comorbidities and disability, evaluating medication history, and determining COVID-19 vaccination status.
* Encouraging patients to receive primary vaccinations and boosters unless contraindicated. Explain the efficacy of vaccinations in the prevention of infection and reduction of the need for hospitalization.
* Determining if the patient lives alone or with others and where they receive their social support.
* Assessing how the patient copes with loneliness and isolation. Consider counselors, psychologists, and support groups, including on the internet and telecommunication.
* Teaching the patient and their family about the COVID-19 disease process, signs and symptoms, the purposes of good hygiene, social distancing and wearing a mask, oxygen therapy, and medication management in an easy-to-understand manner.
* Teaching patients and families about the airborne transmissibility of SARS-CoV-2. They need to understand that the virus is transmitted by talking, coughing, and sneezing. Transmission is significantly reduced by wearing a secure-fitting high-filtration N95 or KN95 mask. Transmission is also reduced by social distancing and being in large rooms with adequate ventilation. Wearing a mask should be done in the home setting and when engaging in activities of daily living such as keeping an appointment with the healthcare provider and grocery shopping.
* Instructing caregivers of patients with COVID-19 in the home setting to perform hand hygiene before and after the preparation of food, before and after eating, and before and after toileting.
* Instructing caregivers of patients with COVID-19 in the home setting to wash the patient's clothes and bed linens separately from other individuals in the home and not to share towels and bed linens.
* Quarantining individuals with asymptomatic or mild disease for 5 days, generally; extending that period for individuals with moderate disease or who are immunocompromised.
* Instructing caregivers to monitor their health status and report any signs or symptoms of infection.
* Instructing caregivers to remain at home after caring for the patient during the acute phase of the patient's infection. Caregivers may leave the home setting after the quarantine period, which is generally 5 days after their last contact with the patient.
* Assessing the patient's responses to any COVID-19-specific medications (see Monoclonal antibodies for COVID-19, Antiviral medications in SARS-Cov-2 infection, and Dexamethasone for COVID-19).
* Assessing the patient's knowledge of the use of a pulse oximeter, ambulatory portable oxygen cylinders, and rechargeable oxygen machines.
* Teaching about the safe use of home oxygen. For example, keeping the oxygen tank away from smoking, flames from a gas-powered stove, and a household heater.
* Encouraging a balanced diet with sufficient fluid intake.
* Ensuring that patients retain either in-person or telehealth provider appointments.
* Teaching the patient that recovery from COVID-19 takes time.
Conclusion
Patients with mild-to-moderate COVID-19 may be managed and cared for in the home setting. The rapid onset and spread of COVID-19 necessitated the development of vaccines and medications to reduce morbidity, mortality, and human suffering. Nurses need to assess the patient's responses to medications and other therapies and provide measures that prevent or reduce the physical and mental sources of distress caused by the virus. Continued research and clinical trials are necessary to develop new and improved medications to manage the infection, especially as new variants emerge from virus mutation that may lead to severe illness.
REFERENCES