|
|
|
|
|
|
|
Travel / Exposure History
|
|
|
Has the patient traveled anywhere outside of Kansas or Missouri
|
Where?
|
|
Has the patient traveled to China, Iran, Italy, Japan, or South Korea in the last 14 days?
|
Where?
|
|
Airline Carrier
|
Flight Number
|
|
Seat Number
|
|
|
In the 14 days prior to illness onset, did the patient have any of the following exposures?
• • •
|
Comments
|
|
|
|
|
Johns Hopkins COV-19 Interactive Map:
|
|
|
https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
|
|
|
CDC Travel Health Notices List:
|
|
|
https://www.cdc.gov/coronavirus/2019-ncov/travelers/
|
|
|
Criteria to Guide Evaluation of PUI for COVID-19:
|
|
|
https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
|
|
|
|
|
|
FIRST Criteria for Person Under Investigation MET IF:
|
|
|
Patient has fever (either subjective or confirmed)
|
|
|
OR patient has signs/symptoms of lower respiratory illness
|
|
|
AND any close contact** with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset
|
|
|
Does patient have a fever?
|
Comments
|
|
OR
|
|
|
Does patient have any of the following signs/symptoms of lower respiratory illness?
• • •
|
Comments
|
|
AND
|
|
|
Any close contact** with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset?
|
|
|
** Per CDC, close contact is defined as:
|
|
|
a) being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of time
|
|
|
close contact can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room w/ a COVID-19 case
|
|
|
– or –
|
|
|
b) having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on)
|
|
|
If such contact occurs while not wearing recommended personal protective equipment or PPE
|
|
|
(e.g., gowns, gloves, NIOSH-certified disposable N95 respirator, eye protection),
|
|
|
criteria for PUI consideration are met.
|
|
|
US Guidance for Risk Assessment/Public Health MNGT of Healthcare Personnel w/ Potential Exposure to COVID-19 Patients:
|
|
|
https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
|
|
|
|
|
|
SECOND Criteria for Person Under Investigation MET IF:
|
|
|
Patient has a fever (either subjective or confirmed)
|
|
|
AND patient exhibits signs/symptoms of lower respiratory illness requiring hospitalization
|
|
|
AND has a hx of travel from affected geographic areas (China, Iran, Italy, Japan, South Korea) within 14 days of symptom onset
|
|
|
Does patient have a fever?
|
Comments
|
|
AND
|
|
|
Does patient have any of the following signs/symptoms of lower respiratory illness requiring hospitalization?
• • •
|
Comments
|
|
AND
|
|
|
Any history of travel from affected geographic areas** (China, Iran, Italy, Japan, South Korea) within 14 days of symptom onset
|
Comments
|
|
** Per CDC, affected geographic areas are defined as
|
|
|
geographic regions where sustained community transmission has been identified.
|
|
|
Relevant affected areas will be defined as a country with at least a CDC Level 2 Travel Health Notice.
|
|
|
CDC Travel Health Notices List:
|
|
|
https://www.cdc.gov/coronavirus/2019-ncov/travelers/
|
|
|
|
|
|
THIRD Criteria for Person Under Investigation MET IF:
|
|
|
Patient has a fever with severe acute lower respiratory illness requiring hospitalization & without alternative etiology
|
|
|
AND No source of exposure has been identified
|
|
|
Does patient have a fever w/ severe acute lower respiratory illness requiring hospitalization & w/o alternative etiology?
|
Comments
|
|
AND
|
|
|
Any identifiable source of exposure?
• • •
|
Comments
|
|
|
|
|
Review of Symptoms
|
|
|
Fever > 100.4F (38C)
|
Comments
|
|
Subjective fever (felt feverish)
|
Comments
|
|
Chills
|
Comments
|
|
Myalgia
|
Comments
|
|
Rhinorrhea
|
Comments
|
|
Sore throat
|
Comments
|
|
Cough (new onset)
|
Comments
|
|
Cough (worsening of chronic cough)
|
Comments
|
|
Dyspnea
|
Comments
|
|
Nausea or vomiting
|
Comments
|
|
Headache
|
Comments
|
|
Abdominal pain
|
Comments
|
|
Diarrhea (>= 3 loose / looser than normal stool / 24 hour period)
|
Comments
|
|
Other symptoms
|
|
|
Pre-existing Medical Conditions
|
|
|
Asthma
|
Comments
|
|
Emphysema
|
Comments
|
|
COPD
|
Comments
|
|
Diabetes Mellitus
|
Comments
|
|
Cardiovascular disease
|
Comments
|
|
Chronic Renal disease
|
Comments
|
|
Chronic Liver disease
|
Comments
|
|
Immunocompromised condition
|
If yes, specify
|
|
Neurologic /neurodevelopment / intellectual disability
|
If yes, specify
|
|
Other chronic illness
|
If yes, specify
|
|
If female, currently pregnant
|
Comments
|
|
Social History
|
|
|
Current smoker
|
Comments
|
|
Former smoker
|
Comments
|
|
Vaping
|
Comments
|
|
|
|
|
Result
|
|
|
Does patient meet Person Under Investigation Criteria?
|
Comments
|
|
If a patient is classified/suspected as a PUI for COVID-19,
|
|
|
IMMEDIATELY notify infection control personnel at your facility and your state or local health department
|
|
|
|
|
|
Disposition of Patient
|
Comments
|
|
Patient education given and Patient (if laboratory-confirmed sick with COVID-19 or under investigation) advised to
• • •
|
|
|
|
|
|
|
|
|
|
|
|
Created 03/2020
|
|
