Providing Acute Care in the Ambulatory Setting During the COVID-19 Pandemic

This interim guidance helps pediatricians through the unprecedented challenges of caring for acutely ill children during the COVID-19 pandemic. The value of pediatric expertise within the medical home for all children, especially those with special health care needs, is key to providing optimal care. 

While every patient/family request must be viewed through a family-centered lens that improves the quality of care and health of populations, enhances the patient care experience for individuals and is cost-effective, the complexities of the prolonged and continually evolving public health emergency have placed unique stress on patients and families as well as pediatricians. Surges in pediatric SARS-CoV-2 infections and COVID-19 cases related to variants, as well as other circulating respiratory viruses such as respiratory syncytial virus (RSV) and influenza, increase the demand for acute care. To meet this challenge, the American Academy of Pediatrics (AAP) supports collaboration with community and regional partners to ensure coordinated access to care so pediatricians can provide the right care for the right patient in the right place at the right time. 

Although no single solution applies to every practice, creative models should consider these key elements:

• Vaccine access
  • Access to vaccine for age-eligible individuals
  • Opportunity for catch-up on routine immunizations, given decreasing immunization rates, particularly in children 0 through 5 years of age
  • Development and dissemination of vaccine information for parents/families who have questions about vaccines
  • Local information on location and availability of vaccines if not available in the medical home
• Safety of patients, families and office teams, which includes availability of appropriate personal protective equipment (PPE). This includes being able to address patients/families presenting for care without a well-fitting face mask, when it is recommended.
• Ongoing communication, education and support to patients and families within the medical home
• Timely and equitable access to safe and appropriate care, including utilization of telemedicine
• Recognition of disparities, especially in underresourced populations, including those with language and technology barriers
• Access to COVID-19 testing, whether in-office or referring to local testing facilities, as well as protocols for addressing home test results
• Coordination with community resources, including urgent and emergency care
• Bi-directional communication within the medical home neighborhood, both referring patients outside the medical home and receiving timely and accurate reports for care delivered elsewhere
• Implications for total cost of care delivered, including family cost-sharing, which may result in care being refused or deferred
• Impact on schools, child care and home settings
• Local data on SARS-CoV-2 infections and COVID-19 cases and local/state public health recommendations
• Close collaboration with local health department and school districts to remain up to date on school policies for illness, exposure, testing and isolation that will impact patient/families

How do I provide “sick care” and keep my practice safe?

• The single best way to keep staff, patients, families and communities safe is through vaccination. Practices should reach out to eligible patients and use every opportunity to administer or encourage receipt of COVID-19 and influenza vaccines, as well as to catch-up on routine vaccines to protect their patients, families and other members of the community.
• In-person care can be provided to all patients, including those who test positive for SARS-CoV-2, by following recommended risk mitigation strategies:
  • Appropriate use and wearing of PPE in accordance with CDC recommendations and the AAP interim guidance on PPE, as well as education and regular review of donning/removing PPE, are important to improving confidence of practice teams as well as communicating a safe environment to patients and families.
  • In communities with high COVID-19 community transmission, the risk mitigation strategies of physical distancing, universal mask wearing and hand hygiene continue to be recommended. Practices should have a mask-wearing policy that is consistent with the AAP interim guidance on masks and communicated to families along with available parent education materials.
  • Facility management and disinfection and cleaning should be aligned with evolving safe work practices. In addition, considerations should include waiting room management/elimination and alternate waiting and care delivery sites (eg, outdoors).

Consideration at the point-of-care

• Following evidence-based care, including antibiotic stewardship, is important regardless of venue. 
• Guidance on identification and treatment of multisystem inflammatory syndrome in children (MIS-C) should be distributed to all practice team members, including clinical staff, to increase awareness and identify potential patients as early as possible.
  • Special attention is necessary when assessing children with ≥3 days of fever to assess for signs of MIS-C, in accordance with the MIS-C interim guidance. 
  • History should be taken to determine whether the child has had a positive test for SARS-CoV-2 or COVID-19 exposure within the 4 weeks prior to onset of symptoms, as MIS-C is a rare complication temporally associated with COVID-19.
  • Initial evaluation should include measurement of vital signs, perfusion and oxygen saturation for those who are moderately to severely ill with clinical signs of organ dysfunction.
  • Early consultation and coordination with the nearest infectious diseases or rheumatology specialist and pediatric referral center for possible hospital admission, optimal testing and management should be considered.

How do I adapt patient scheduling and triage?

Consider how to efficiently triage calls and determine those patients that can be managed remotely as opposed to in-person. Practices that offer self-scheduling or same-day walk-in visits for acute illnesses might consider workflow redesign during times of surge. Practices should consider replacing self-scheduling for acute visits with nurse triage conversations (via phone or secure chat). Walk-in hours for acute visits might be replaced with walk-in virtual visits. Balancing a practice’s physical limitations with the need to provide access for in-person acute care when appropriate will be an ongoing process and can be supported by daily practice team huddles. 

Accommodating all patients who want to be seen in-person may not be possible, especially if there are limitations in the number of patient rooms, the ability to follow cleaning protocols or the ability to provide safe areas to separate sick and well patients. When a patient calls the office with an acute care need, updated triage processes can help determine the best practice approach. This might involve giving advice for home care, using telemedicine, being seen for an in-person visit or referring to a partner in the medical neighborhood. As always, caution should be used against delaying necessary care for acute illnesses. In smaller-sized practices, it may not be possible to assign separate providers to sick and well care, and appropriate PPE can and should be used as recommended to safely provide in-person care for both well and sick visits throughout the day, including for patients who are SARS-CoV-2 positive.

Practices can also proactively provide information to their patients and families via communication channels such as websites, social media accounts and on-hold messages, which may help to decrease practice call volumes during times of surge and decrease stress on the practice team. This might include information such as COVID-19 symptom checkers, answers to frequently asked questions or updates on local/state public health guidance.

When should I consider using telehealth?

Telehealth visits are powerful alternatives for improving access to quality, timely, and cost-effective care particularly during surges. However, telehealth should not be used as a substitute or replacement for in-person care when a more detailed physical examination or intervention is necessary.

Telehealth visits can be used to facilitate care for patients with various acute illnesses, such as enhancing patient triage, providing care and patient/family education and monitoring patients who require close follow-up. Telehealth visits may also be effective in addressing emotional and behavioral health concerns, which have increased significantly during the pandemic, and may also increase access for patients/families who are fearful of seeking in-person care or experience external barriers such as transportation and cost. While optimal to utilize video during telehealth visits, not all patients/families have access to the resources necessary, so alternate communication, such as through phone (audio only), can be considered.

Telehealth may be an ideal tool to screen patients with respiratory illness during the cold/flu season. Patients presenting with symptoms suggestive of possible COVID-19 (fever, cough, myalgia, fatigue, sore throat, anosmia, ageusia, runny nose, vomiting, diarrhea or abdominal pain) can be assessed initially within the medical home via telehealth to clinically evaluate, counsel/educate on COVID-19 or refer for appropriate testing. Testing can be performed on site at the practice (“hybrid visit”), at a community testing site, or at home. In addition, when dealing with surge and increased demand, innovative models, such as drive through testing in a practice’s parking lot or outdoor testing at a designated site during specific days/hours, may help to increase access for a larger number of patients. 

For patients who require further assessment or in-person intervention, the virtual visit can be turned into an in-person visit or the patient can be referred to a higher level of care for further evaluation, management or hospitalization.

Telehealth can also facilitate follow-up care for patients with confirmed COVID-19 illness, as outlined in the AAP interim guidance on Post-COVID Conditions.

Telehealth regulations remain liberalized per order of the US Department of Health and Human Services throughout the public health emergency with expansion to equitable payment. AAP policy supports expanded ongoing telehealth use during and after the COVID-19 pandemic.

When should I consider testing?

• AAP interim guidance for COVID-19 testing is available to help practices make appropriate decisions. Be aware of local testing requirements relating to isolation, quarantine and return to school.
• Testing also should be considered for other upper respiratory infections (ie, influenza or RSV) when clinically appropriate and likely to change treatment and management.

What else should I consider during an acute care visit?

• Pediatricians should assess whether age-eligible patients (and household contacts) have received COVID-19 vaccine, be able to answer any patient or family questions and provide vaccine counseling and administer the COVID-19 vaccine to eligible patients and family members or provide guidance on where to obtain a vaccine locally. Patients who have a current SARS-CoV-2 infection should receive COVID-19 vaccine after they have recovered from their acute illness, have completed their recommended isolation period and have been cleared by their pediatrician, if appropriate, per CDC guidance. These patients should be scheduled for their vaccine appointment at an appropriate future date while in the office.
• In response to decreased routine immunization rates during the pandemic, pediatricians should also determine whether patients are behind on routine immunizations and provide catch-up vaccines as soon as possible. Ensuring that patients receive COVID-19, influenza and other routine vaccines, which can all be coadministered at the same visit, is critical to the reduction of vaccine-preventable disease burden, now and in the future.
• Pediatricians play an important role in educating patients and families about rapidly changing national, state and local guidance on topics such as masking, isolation and quarantine, testing and therapeutics.

How can I protect and support my practice team during the pandemic?

It is incumbent on practices to keep their staff as safe as possible during the pandemic. One key element is for all staff to be up-to-date on COVID-19 vaccines, including receiving the recommended bivalent vaccine booster. Additionally, practices should follow the Occupational Safety and Health Administration’s Healthcare Emergency Temporary Standard, which outlines specific guidelines including the provision of appropriate PPE.

The unknown duration of the pandemic has led to burnout and fatigue among pediatricians and members of their practice team. Additionally, there has been an increase in resignations and COVID-19 illnesses, which has led to some practices being short-staffed. The surge in COVID-19 and other viral illnesses, the increase in emotional and behavioral health needs and hesitancy around COVID-19 vaccines also impact practice capacity and stress the system.

It is important for all members of the practice team to work together to create a culture of caring and support. Creative solutions are necessary to protect and support the physical and emotional well-being of pediatric practice staff, including:

• Referring staff to available wellness programs and mental health resource networks
• Collaborating with community partners (eg, regional call center, billing service) to delegate work and reduce burden on practice staff
• Implementing new visit models, like telehealth, to provide care to a greater number of patients

How do I best use community resources?

Practices should work collaboratively with hospitals, academic medical centers and other community health care partners to make sure that all patients have access to appropriate and safe care. Innovative partnerships may include working with schools, child care centers or public health resources. Community education targeted to accessing appropriate care for acutely ill children should be considered. Attention should be focused on forming a referral network with entities that have pediatric expertise to help patients/families become better consumers of acute care. Local practices may work together through affiliations with other practices, health care systems or other collaborators to provide appropriate after-hours care to their collective patients. 

• There is value in recognizing the pediatric capabilities and expertise of acute care partners, such as testing centers and urgent care and emergency department resources. 
• Similarly, the limitations of community partners – including, but not limited to, operating hours, age restrictions and cost/payment issues – should be understood. 
• With acute care being provided in multiple settings, it is important to promote the use of community partners that communicate effectively with the medical home to best provide continuity of care during the pandemic. 
• Utilizing community partners may be advantageous to eliminate redundant or unnecessary care for patients with persistent or worsening symptoms for whom additional testing, monitoring, procedural care or further management are necessary.

In summary, providing appropriate access to high-quality, safe, timely and cost-effective care to all pediatric patients can be challenging during the COVID-19 pandemic but is achievable if communities work together to provide a coordinated medical home neighborhood/regional network. Pediatricians should use interim and updated guidance from the AAP and CDC to improve their confidence and ability to provide care. This care includes preventive care, immunizations, acute illnesses, injuries, management of chronic conditions and behavioral/mental health support. Barriers should be mitigated to improve access to appropriate care with consideration of the patient/family at the center of these efforts. Child health professionals should also work together to create a culture of caring and support for their practice teams.

Additional Information  

• COVID-19 Testing Guidance 
• Guidance on Providing Pediatric Well-Care During COVID-19 
• Newborn Screening During the COVID-19 Pandemic 
• FAQs: Management of Infants Born to COVID-19 Mothers