virus cells with thermometer

Flu season is here, but it doesn’t look anything like what urgent care is used to. As the number of COVID-19 cases continue to rise, urgent care clinics across the nation have stepped to the forefront as the ideal solution for COVID-19 testing, seeing an unprecedented number of patients every day. What they’re not seeing, however, are many flu cases.

The double threat of flu + COVID is not showing up

Is the widespread use of masks protecting people from contracting flu? Does limited social contact restrict the spread of the flu virus? Are immunities acquired from previous flu bouts and immunizations stronger when combined with COVID-19 precautions? While we may not be able to answer these questions with certainty, it’s becoming more and more likely that the “twin apocalypse” of COVID-19 plus flu is not materializing as previously feared.

Urgent care clinics today are seeing 51 patients per day on average, which is well above the three-year average. Of those visits, 80 percent or more (roughly 50,000-60,000 visits) are COVID-related. What’s most surprising, however, is that the majority of visits are not flu-related—something we generally expect this time of year.

In fact, when we compare urgent care data for September 2019 and 2020, flu testing is down 81 percent with 96 percent fewer positive tests. (See Figure A.)

Caption: Figure A: Urgent Care Flu Data September 2019 vs. September 2020

September
2019 2020 Change
Flu Tests Performed 7,940 1,539 -81%
Positive Flu Tests 477 21 -96%
Positive Rate 6% 1%

Fewer Influenza tests being performed, Positive Influenza tests are way down, Data based on subset of EMR clients

According to the World Health Organization (WHO), “The various hygiene and physical distancing measures implemented by Member States to reduce SARS-CoV2 virus transmission have likely played a role in reducing influenza virus transmission.”

Flu seasons across the globe are at historically low levels, according to the Centers for Disease Control and Prevention (CDC). They reported that in the Southern Hemisphere countries of Australia, Chile, and South Africa (where flu season is ending), only 33 of 60,031 specimens tested influenza-positive in Australia, 12 of 21,178 were positive in Chile, and six among 2,098 were positive in South Africa. That’s a total of 51 influenza positive specimens among 83,307 tested in these three countries during April–July 2020 (weeks 14–31). In contrast, during April–July in 2017–2019, 24,512 specimens tested positive for influenza 178,690 tested in these three countries.

And that’s good news, because COVID alone will continue to be a challenge through the rest of the year and as we head into the spring.

Managing COVID-19 in the coming months

With the likelihood of a light flu season ahead, the industry will continue to see record visit volume with sporadic peaks and valleys. While urgent care will continue to lead testing efforts as patients present upper respiratory and other COVID-19 symptoms in addition to other traditional urgent care complaints, we’re learning more about how to manage the virus.

There are a variety of tests being used for COVID-19, but there is no gold standard.

  • Nasal swab (polymerase chain reaction/PCR) – Its effectiveness is operator-dependent and when administered properly, it’s likely the most effective. For patients, it feels like a mini brain biopsy.
  • Antigen tests – Options are available from many manufacturers.
  • Antibody tests – Many emergency-use antibody tests have been approved to determine whether a person has had COVID-19; however, many are fraudulent or inaccurate.

When a patient’s risk level is high due to health history, age, or other factors, it may be a good practice to follow antibody and antigen test with PCR.

We’re also seeing what’s being called “long COVID.”

Dr. Matt McCarthy, an infectious disease expert, presented data that supports the current thinking behind long COVID during a recent Experity webinar.

According to McCarthy, frontline healthcare professionals noticed in May that some COVID-19 patients were not getting better, and were instead exhibiting symptoms of four different COVID-related syndromes:

  • Lingering COVID-19 symptoms
  • Organ damage
  • Post viral chronic fatigue syndrome
  • Immune system abnormality

Most of those suffering with long COVID had been sick and were hospitalized during their initial bout with the infection, said McCarthy. There are many patients with persistent symptoms, and he estimated one in 20 patients will experience long COVID symptoms which includes shortness of breath and chronic fatigue.

The majority of patients are women in their mid-forties with moderate to severe disease; however, they are not the only affected demographic group. For some of these patients, McCarthy said, the immune system goes into overdrive and determining appropriate treatment can become difficult.

The CDC and other agencies released information about the long-term effects of long COVID in a recent statement.

According to the CDC, “As the pandemic unfolds, we are learning that many organs besides the lungs are affected by COVID-19 and there are many ways the infection can affect someone’s health.” In the United Kingdom, the government set up long COVID clinics in October to help patients suffering from the persistent, longer-term conditions associated with the disease.

For the healthcare community, managing COVID cases in the upcoming months will continue to prove challenging. Because of the long COVID risks, it will be crucial for providers to review patient histories for previous records of the disease to better diagnose and treat patients.

Urgent care clinics will continue to lead testing efforts alongside traditional urgent care complaints. Determining how to approach these complaints in light of the COVID-19 pandemic and lingering effects will add a new concern as the industry responds.

Urgent Care and COVID-19 immunizations

Operation Warp Speed is a public–private partnership, initiated by the Trump administration, to facilitate and accelerate the development, manufacturing, and distribution of COVID-19 vaccines, therapeutics, and diagnostics. This operation has researchers developing and testing different types of vaccines in the fight against COVID. In early November, Pfizer/BioNTech announced promising early results from its vaccine trial: It suggested that people who received the vaccines in two doses, three weeks apart, experienced 90 percent fewer cases (with no serious side effects) than those who received placebos. This is good news as the FDA only requires that a vaccine is at least 50 percent effective.

Eleven vaccines are in late-stage trials including:

  • Moderna
  • Johnson & Johnson
  • AstraZenica
  • Novavaz

Despite these promising trials, many unknowns still remain. Experts are unsure how long vaccine-produced immunity will last. Like flu vaccinations, COVID vaccinations will likely be seasonal. The uptick in visits will likely continue after mass vaccination begins and masks will still be recommended. We may only see COVID-19 infections decrease in severity once herd immunity starts to build.

There are logistical considerations that may determine which of the many approved vaccines will be most widely adopted. Some require more than one inoculation, while others have storage challenges. In addition, “critical populations” are being identified and will be the first groups immunized since early supplies will be limited.

The initial distribution plan for COVID-19 vaccines has not been finalized. The CDC reports that it is establishing and testing logistics plans with manufacturers and commercial partners. It updated its “COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations” on October 30, 2020. For the initial distribution, the CDC will partner with traditional community vaccination providers, such as pharmacies, occupational health settings, and doctor offices.

The playbook states, “Many of these partners are engaged regularly in seasonal influenza and other outbreak vaccination campaigns, and many served as vaccination providers during the 2009 H1N1 pandemic.” At the same time, the CDC is planning to operationalize the vaccine response in larger-scale ways due to the widespread and duration of the pandemic.

Urgent care clinics have not been identified as an early distribution point.

In addition to antibodies, T-cells also contribute to immunity. Once a person has COVID, the body’s internal defense system may recognize it when it shows up activating the body’s defense system, to improve immunity. Combined with immunizations and preventative behavioral changes, this natural defense system will help determine how the healthcare industry addresses COVID-19 in the near future.

COVID-19 Best Practices

As we head into the winter months, COVID-19 infections are on the rise and many countries are seeing their highest rates to date.

According to Dr. McCarthy, hospitalizations are the best indicator of the severity. “We may experience a second wave of lockdowns including ‘circuit breaker’ lockdowns.” A “circuit breaker” lockdown is a short-term lockdown designed to break the chain of infections and reduce pressure on health services. We could also see more field hospitals and long COVID clinics.

As urgent cares continue to see more patients, McCarthy shared the following recommendations:

  • Assume every patient has COVID-19.
  • Recommend 14-day quarantine.
  • Pay attention to vitals and data collection.
    • Rely on vitals more than symptoms.
    • Oxygen saturation is the most important vital. Use supplemental oxygen when saturation is below 94 percent.
  • Watch for silent hypoxemia.
  • Watch high-risk groups and assess risk.
  • IV hydration can help manage condition.
  • Recognize that patients can develop clots all over their body with this infection.
    • Consider the patient’s risk factors.
  • Burnout is real—create an avenue for staff to share frustrations.
  • When performing aerosol-generating procedures and specific types of testing, consider an N-95 mask.
  • For most urgent cares, surgical masks and regular sanitizing procedures should be adequate.

Some drugs and therapeutics have shown promise.

  • Dexamethasone is a corticosteroid and the only drug that has shown a mortality benefit, decreasing mortality by about 30 percent. It should be used with caution because it’s a steroid and it’s not indicated for mild cases. It should be considered for patients with hypoxia.
  • Remedsivir is an antiviral and is available under and emergency use authorization. This drug is proving to help shorten the duration of symptoms but has no impact on mortality and is expensive.
  • Antibody cocktail (Regenron) is in Phase III trials and shows promise as a bridge to strengthening immunity until an effective vaccine is approved. There is a limited supply available and it is expensive.
  • Vitamin supplements have been suggested to boost immunity, although no vitamins or supplements have been proven to help prevent coronavirus. Some nutrients may help strengthen the immune system, such as vitamin D, high-dose vitamin C, zinc, and potassium (if a person is deficient). According to Dr. McCarthy, these supplements are relatively harmless.

What to tell your patients

McCarthy advises people to follow the guidelines put in place by the CDC and health professionals:

  • Wear a mask.
  • Wash your hands.
  • Keep a six-foot distance in public.

McCarthy also said he sees people letting their guard down in smaller group settings. Flare-ups are primarily happening in two ways: with blanket non-maskers, and with people who don’t wear masks around people they know.

“Masks provide protection for both wearers. The double barrier is what keeps us both safer,” said McCarthy. He also doesn’t think herd immunity will happen by next summer. Even with a vaccine, he believes mask-wearing is a good choice as the effectiveness of the vaccine is hard to gauge without real data.

This has been a year of firsts for urgent care, and we’re likely to see more changes to our industry and healthcare in general. Yet despite the challenges, the urgent care industry will continue to evolve as more is learned about COVID-19 and clinics continue to serve their communities with new, improved approaches to patient care.

Coming Soon! The Experity team is developing a Visit Volume Tracker on our website to help urgent care clinics stay tuned in to the metrics and what’s happening in the industry.  In the meantime, get the most recent coding updates here.

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