Healthcare Providers

Long-Term Care Settings Outbreak Protocol

• COVID-19 Case and Outbreak Reporting Protocol 
• COVID-19 Outbreak Summary Form
• COVID-19 Outbreak Testing Guidance 

RIDOH COVID-19 Reporting Portal

• Training and FAQs

Visitation

• Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes

• Additional information about visitation for nursing homes and intermediate care facilities for individuals with intellectual disabilities and psychiatric residential treatment facilities is available from the Centers for Medicare & Medicaid Services.

Nursing Home Guidance

• COVID-19 Information for Nursing Homes
• Answers to Frequently Asked Questions About COVID-19 Information for Nursing Homes

Assisted Living Residence Guidance

• COVID-19 Information for Assisted Living Residences
• Answers to Frequently Asked Questions About COVID-19 Information for Assisted Living Residences

Long-Acting Monoclonal Antibodies (LA-MABS)

LA-MABS to help prevent COVID-19 before exposure are available for adult and pediatric outpatients who:

• Have a moderately to severely compromised immune system,
• Are age 12 or older,
• have not recently tested positive for COVID-19,
• have not recently been exposed to someone with COVID-19, AND
• have not gotten a COVID-19 vaccine in the last two weeks.

Available Therapeutic 

• Tixagevimab and cilgavimab (EVUSHELD) – (age 12 and older) EUA | EUA Provider Fact Sheet | EUA Patient Fact Sheet

Additionally, clinicians and patients should be aware of decreased effectiveness against the pre-exposure prophylaxis, tixagevimab and cilgavimab (EVUSHELD) due to the proportion of circulating variants. However, other antiviral treatments remain effective. Expect breakthrough infections and have a treatment plan in place for patients taking EVUSHELD and instruct them to seek prompt medical care if symptoms develop.

To refer a patient for pre-exposure prevention of COVID-19, find current providers using the COVID-19 Therapeutics Locator. This website is updated every 24 hours.

There are two options currently authorized for treatment for outpatients who test positive for COVID-19: oral antivirals and intravenous (IV) antivirals. 

Treatment is most important for people at high risk for progressing to severe disease and/or hospitalization. For details on medical conditions and other factors associated with increased risk for progression to severe COVID-19, including race and ethnicity, review the Centers for Disease Control and Prevention (CDC)’s People with Certain Medical Conditions website.

Oral Antiviral

Oral antiviral treatment is available for outpatients age 12 and older who test positive for COVID-19 and started having mild to moderate symptoms in the last five days.

Treatment Options

• Nirmatrelvir, nsp5 and ritonavir (Paxlovid) – (age 12 and older) EUA | EUA Provider Fact Sheet | EUA Patient Fact Sheet
• Molnupiravir – (age 18 and older) EUA | EUA Provider Fact Sheet | EUA Patient Fact Sheet

How to Get Treatment for Patients

Encourage patients to get tested as soon as they have COVID-19 symptoms so eligible patients can start oral antiviral treatment as early as possible to maximize treatment effectiveness. Oral antivirals should be prescribed as soon as possible after a COVID-19 diagnosis and within five days of symptom onset.

The oral antivirals will be available in certain pharmacies across the state. To view current availability before submitting a script to a participating pharmacy in Rhode Island, go to the COVID-19 Therapeutics Locator. This website is updated every 24 hours.

Oral Antiviral Resources

• RIDOH, Guidance for Providers About use of Molnupiravir
• COVID-19 Treatment Guidelines
• Paxlovid Patient Eligibility Screening Checklist Tool for Prescribers

IV Antivirals

IV antiviral treatment is available for those who test positive for COVID-19, started having mild to moderate symptoms in the last seven days, and are not a candidate for the oral drugs to treat COVID-19. Children who test positive for COVID-19, are age 28 days or older, weigh 3 kg (approximately 6.5 pounds) or more, and have had mild to moderate symptoms in the last seven days, are also eligible for treatment.

The monoclonal antibody treatment bebtelovimab is no longer effective against BQ.1 and BQ.1.1. As of November 30, the Food and Drug Administration no longer authorizes bebtelovimab for emergency use because of circulating variants. 

Treatment Options

Treatment must be administered by IV over three days and might only be feasible for hospitalized patients. However, its use should still be strongly considered in patients where Paxlovid is contraindicated. Remdesivir has fewer drug interactions than Paxlovid.

How to Get Treatment for Patients

Remdesivir (Veklury) is highly effective when administered within seven (7) days of symptom onset. This treatment must be administered by IV over three days and might only be feasible for hospitalized patients. However, its use should still be strongly considered in patients where Paxlovid is contraindicated. Remdesivir has fewer drug interactions than Paxlovid.

• HHS, COVID-19 Therapeutics Locator
• NIH, COVID-19 Treatment Guidelines
• CDC, Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19)
• IDSA, Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19

The Rhode Island Department of Health (RIDOH) recommends COVID-19 testing for patients who have symptoms of COVID-19 or may have been exposed to someone with COVID-19.

RIDOH strongly recommends that healthcare providers offer on-site COVID-19 testing to their patients for three reasons:

• Patients value getting COVID-19 testing and advice about treatment from a trusted healthcare professional who knows them and their health history.
• As we enter year three of the pandemic, resources will need to shift back to regular healthcare channels to create a sustainable system.
• If a patient tests positive, they may need to provide formal documentation to schools or their employer while they isolate. This letter, like other forms of medical documentation, should come from their primary care provider.

Primary care providers can offer PCR specimen collection or point-of-care antigen testing to test their patients for COVID-19.

PCR Specimen Collection

Providers interested in collecting PCR specimens should reach out to their partner laboratories to determine if they provide this service. Most clinical laboratories in Rhode Island can test respiratory specimens for COVID-19.

Primary care providers and respiratory clinics that are already performing in-office PCR specimen collection and sending tests to a laboratory for processing should order tests according to the office’s or laboratory’s protocol.

Point-of-Care Antigen Testing

Point-of-care antigen tests are a fast and easy way to test your patients for COVID-19 in your office. Any office can procure rapid antigen test kits themselves through medical supply vendors. Most of them are relatively inexpensive to purchase and can be reimbursed through insurance.

• If your office already has a CLIA certificate of waiver to perform on-site testing, you can start testing patients right away. Any office currently performing strep or influenza testing should already have a CLIA certificate of waiver to perform on-site testing.
• If your office doesn’t already have a CLIA certificate of waiver, you will need to submit an application for licensure to RIDOH to begin testing patients on site. Send your completed application to RIDOH’s State Health Laboratories (SHL) via an email to [email protected]. You can learn more about how to submit an application for a CLIA certificate of waiver at cms.gov.

COVID-19 Testing Referral Options

Outpatient healthcare providers who don’t offer in-office specimen collection or point-of-care antigen testing can direct patients to a local pharmacy or respiratory clinic. Patients may also test themselves for COVID-19 at home.

For more information about COVID-19 testing options in Rhode Island and to find the test site closest to you, visit covid.ri.gov/testing.

ICATT Program

CDC’s Increasing Community Access to Testing (ICATT) program supports free COVID-19 testing for people who have symptoms or have been exposed to someone with COVID-19. To find an ICATT site near you, visit cdc.gov/icatt/AboutICATT.html.

Test to Treat

Rhode Island also has several Test to Treat sites, where patients can get tested for COVID-19 and, if they’re positive and eligible, get a prescription for treatment all at one location. To find a Test to Treat site near you, visit aspr.hhs.gov/TestToTreat. 

Provider Resources

The following resources and tools help providers assess whether a staff member or patient who tests positive for COVID-19 may have exposed others in the practice. RIDOH encourages practices to use these tools to identify and inform staff and patients who are close contacts and should quarantine, and to instruct them to self-monitor for symptoms for 14 days from exposure.

• Exposure, Quarantine, and Isolation Guidance by Population
• COVID-19 Infection Prevention and Control Guidance for Ambulatory Care Settings

• Learn about and enroll to be a COVID-19 vaccine provider.
• For answers to frequently asked questions about COVID-19 vaccination, please see COVID-19 Vaccine FAQs

The most effective way to prevent the spread of COVID-19 and to protect against severe illness, hospitalization, and death is to stay up to date with your COVID-19 vaccinations. Rhode Island regulations (216-RICR-20-15-7) require that healthcare workers or assisted living residence workers shall be up to date with their COVID-19 vaccines, meaning a person has received all recommended doses of COVID-19—including a booster dose when eligible—or wear a National Institute for Occupational Safety & Health (NIOSH)-approved N95 mask while working in healthcare facilities during a period in which the COVID-19 prevalence rate in the State is greater than or equal to 50 cases per 100,000 people per week.

For more information on these regulations, please see the covid.ri.gov page on Healthcare Worker Vaccine Requirements.

• Immunization, Testing, and Health Screening for Health Care Workers (216-RICR-20-15-7)
• Medical Immunization Exemption Certificate for COVID-19 Vaccination
• Vaccination Requirement FAQ

Report any positive cases of COVID-19 to RIDOH within 24 hours, including reinfection and vaccination breakthrough cases. The ordering provider should direct anyone with a positive test result to isolate, whether from rapid antigen or PCR testing.

For reporting positive results from testing you have ordered and sent out through a laboratory system:

• Report positive results only. 
• Please include the patient’s name, DOB, testing date, and testing site. 
• For reinfection and vaccination breakthrough cases, include the initial infection date and/or the patient's vaccine product and injection dates.
• You may report by either of the following methods. We strongly encourage you to send by secure email if possible, as our fax machine can get backed up. For the time being, we do not recommend calling 401-222-8022 with positive results due to phone waiting times.  
  1. Email using secure email. Send the test result to [email protected] with the subject: LAB POSITIVE. Attach the result report to the email or copy and paste the report into the body of the email.
     • Please note: This email address is for healthcare providers only. To submit a self-test result to RIDOH, visit portal.ri.gov/s/selftestresult. 
  2. Fax to 401-222-2488. Include a cover letter (re: LAB POSITIVE). 

For reporting point-of-care and rapid test results performed at your site:

• Report all positive and negative results. 
• Email Chris Jenkins for information on how to send POC results: [email protected]  
• Do not send results to Christine Jenkins.  

It's no longer necessary to report Patients Under Investigation (PUIs). Do not use the PUI form to report positive results to RIDOH.

For reporting possible cases of Multi-Inflammatory Disease in Children (MIS-C), please call the RIDOH Center for Acute Infectious Disease Epidemiology at 401-222-2577 Monday-Friday 8:30 a.m-4:30 p.m. (401-276-8046 after-hours).

Centers for Disease Control and Prevention (CDC) now recommends reporting of MIS-C and MIS-A. Clinical criteria for each condition follows. Report cases to Rhode Island’s Center for Acute Infectious Disease Epidemiology by calling 401-222-2577 Monday through Friday from 8:30 a.m. to 4:30 p.m. If after hours, please call RIDOH’s answering service at 401-276-8046 to connect with the medical staff on call.

Multi-System Inflammatory Syndrome in Children (MIS-C)

MIS-C is a condition associated with infection from COVID-19. Clinical criteria for MIS-C diagnosis include:

• Younger than age 21 and
• Fever, laboratory evidence of inflammation, severe illness requiring hospitalization, multisystem organ involvement and
• No alternative plausible diagnosis and
• Positive for current or recent COVID-19 infection by RT-PCR, serology, or antigen test or exposure to a suspected or confirmed COVID-19 case within the four weeks before symptoms started

Click here for clinical information from Hasbro Children's Hospital and additional resources on MIS-C.

Multi-System Inflammatory Syndrome in Adults (MIS-A)

MIS-A is a condition similar to MIS-C, but in adults. For the MIS-A case definition, providers can use either the same definition for MIS-C or the definition used in the Morbidity and Mortality Weekly Report (MMWR) series.

The MIS-A case definition used in the report includes the following five criteria:

• Severe illness requiring hospitalization in a person age 21 or older and
• Positive test result for current or previous COVID-19 infection (nucleic acid, antigen, or antibody) during admission or in the previous 12 weeks and
• Severe dysfunction of one or more extrapulmonary organ systems (e.g., hypotension or shock, cardiac dysfunction, arterial or venous thrombosis or thromboembolism, or acute liver injury) and
• Laboratory evidence of severe inflammation (e.g., elevated CRP, ferritin, D-dimer, or interleukin-6) and
• Absence of severe respiratory illness (to exclude patients in which inflammation and organ dysfunction might be attributable simply to tissue hypoxia)

Long COVID

Long COVID, also known as "long haul" COVID, has been described as subacute and chronic multi-system post-infectious sequelae of acute COVID-19 infection. It is distinct from MIS-C and MIS-A.

Referrals

For specialty care of patients with Long COVID, primary care providers can refer their patients to the Infectious Disease and Immunology Clinic at Lifespan.

• Fax referrals to the Infectious Diseases and Immunology Center at 401-793-7401
• Send referrals within Lifespan through LifeChart as "Referral to Infectious Diseases"

Resources

CDC, Evaluating and Caring for Patients with Post-COVID Conditions: Interim Guidance

Oral healthcare is recognized as an essential component of overall health. It’s critical that infection prevention and control practices are in place to protect the health and safety of patients and dental healthcare personnel (DHCP). We continue to learn about the transmission and severity of COVID-19 and the implications for dental practice. DHCP have a very high potential for exposure to COVID-19 if performing certain aerosol-generating procedures on known or suspected COVID-19 patients. Therefore, when providing care, these patients should be isolated in a room with effective ventilation.

Dental settings should balance the need to provide necessary services while minimizing risk to patients and DHCP. The Centers for Disease Control and Prevention (CDC) has developed a framework for healthcare personnel and healthcare systems for delivery of non-emergent care during the COVID-19 pandemic. DHCP should use their clinical judgment in determining those procedures that can be performed safely and effectively at this time. The Rhode Island Department of Health (RIDOH) recommends continued review of Guidance for Healthcare Personnel from CDC for guidance on screening, source control, use of personal protective equipment, and more, and defers to this guidance in areas of question.

Individual dental practices should review guidance for healthcare providers and dental-specific information below and customize it for their clinical setting. This guidance represents suggested minimum standards, and some practices will choose to exceed these standards. For example, practices treating vulnerable patients, including older adults at greater risk for severe COVID-19 outcomes, should use effective source control, including N-95 respirators, when caring for unmasked high-risk patients.

Place signs and posters at facility entrances and in strategic places, such as restrooms, registration desks, waiting rooms, and exam rooms, providing instruction on washing hands, wearing face coverings, and cough etiquette.

Individual healthcare facilities can choose whether to require the use of face masks outside of the clinical areas. RIDOH recommends wearing a mask in all healthcare settings when community transmission rates of COVID-19 are high (greater than or equal to 100/100,000 people) and more routinely when interacting with patients likely to have chronic illness.

Fundamental to safe practice is effective ventilation. The American Society of Heating, Refrigerating and Air-Conditioning Engineers has provided information on dental office design to reduce airborne disease transmission.

Questions are welcome and answered via email at [email protected].