UTMB Patient Care ProtocolsCOVID-19 Information

The following are resources for UTMB Health staff that outline processes and procedures for COVID-19 should a patient present with symptoms in a UTMB patient care setting.

Two females wearing masks bumping elbows

Contact Infection Control

Have questions or need information, contact Infection Control by paging (409) 643-3133 or calling (409) 772-3192.

Testing Info & Protocol  

COVID - Healthcare Team

  • Patient Evaluation - Who and When to Test

    COVID-19 Testing Policy for Patients:

    Effective September 29, universal pre-procedure/admission COVID testing are NO longer required.

    Patients who are being hospitalized with an acute respiratory illness or deterioration of chronic respiratory illness should be tested for COVID even if another cause has been identified (eg. flu).

    Note: Due to multiple patients being housed in a room, all patients admitted to TDCJ Hospital Galveston will continue to be tested for COVID.

    Updated 9/30/22

  • COVID-19 tests performed at non-UTMB laboratories

    COVID-19 tests performed at a non-UTMB laboratory are only acceptable under the following conditions:

    1. COVID-19 testing platform must be an RNA test using Nucleic Acid Amplification (NAT) techniques with an FDA-EUA. This includes the PCR method.
      1. i. There are molecular (RNA) tests that do not have EUAs. Any reported test with an FDA-EUA would be required to state that as a disclaimer. If the disclaimer is present, providers can conclude that the test is acceptable. In the rare case that the FDA-EUA language is missing from the test result, a repeat test can be ordered. Most major manufacturers have FDA-EUA approval. However, some Laboratory Developed Tests (LDTs) may not have FDA-EUA approval.
    2. Negative and Positive Antibody results are NOT accepted
    3. Negative Antigen tests are NOT accepted
    4. Positive antigen tests are accepted and do not need confirmation with a molecular test. Home tests are not accepted.
    5. Patient or transferring facility must provide a copy of the COVID-19 lab results (notes or emails referencing results are not accepted).
      1. Negative Lab results: If unable to obtain a copy of lab results, repeat testing at UTMB following testing and isolation protocols.
      2. Positive lab results: If unable to obtain a copy of lab results, place the patient in COVID-19 isolation until reviewed by Infection Control & Healthcare Epidemiology.
    6. All non-UTMB tests must be reviewed and approved by ICHE when patients are admitted/transferred to UTMB hospitals, and before discontinuation of isolation. Page ICHE 24/7 (409) 643-3133

    Updated 9/30/22

  • Patient Disposition and Notification of Results

    • Suspected cases of COVID-19 can be discharged to the patient’s home or hospitalized, based on clinical severity. COVID-19 test results will be usually available within three days.
    • The Infection Control Department staff will notify the health department of positive and negative laboratory test results.
    • Patients who have been tested but are awaiting results should be instructed to isolate themselves at home. This process is not monitored by the health department.
    • All clinicians who are ordering the test must have a mechanism in place to notify the patients of negative results when they are available so that the self-isolation can be discontinued. COVID-19 results will be available in Epic and will be accessible through MyChart.
    • The Infection Control Department will also undertake evaluation of exposures in our healthcare facility.

    Updated 9/30/22

  • Laboratory Test - How to Test

    How to test:

    Molecular tests:

    ID Now COVID-19 Rapid Testing:

    Orderable in Epic as COVID-19 Testing ID Now (LAB 002117)

    COVID-19 by PCR Molecular Test:

    Orderable in Epic as COVID-19 by PCR (LAB 002110)

    Antigen Test:

    Point-of-care COVID-19 antigen test is available for initial rapid diagnosis; if negative, a molecular test must be performed. Antigen test is also be used for return-to-work process for persons with COVID-19 infection or for discontinuation of isolation in high-risk hospitalized patients.

    Updated 9/30/22

  • NEJM Procedure:Collection of Nasopharyngeal Specimens with the Swab Technique

PPE/Environmental Control  

Frequently Asked Questions

COVID - Healthcare Team

  • Can I bring my own PPE from home?

    Please utilize PPE supplies provided by the hospital as they are designed as PPE. Hospital-provided eyewear does provide a greater area of facial coverage than a majority of personally bought eyewear. Also, by using hospital-provided eyewear, you will be able to reduce the number of steps in doffing and the continuous requirement of disinfecting personal items between COVID and non-COVID patients.

  • What about shoe covers or bouffant caps?

    Shoe covers and bouffant caps are not recommended at UTMB for PPE use. Incorrect removal of additional PPE may increase the risk of self-contamination if removed incorrectly.

    Why no shoe covers: Scrubs can become contaminated while removing shoe covers. If you are concerned about contamination on your shoes, you may use a disinfectant wipe after completing your shift and leave your shoes outside the home and/or separated from other items.

    Why no Bouffant caps: Inappropriate removal of the bouffant cap can cause a displacement of eyewear and/or mask which may result in incidental contamination closest to your eyes, nose and mouth.

  • If no bouffant caps are permitted, what about the fabric surgical caps?

    Shoe covers and bouffant caps are not recommended at UTMB for PPE use. Incorrect removal of additional PPE may increase the risk of self-contamination if removed incorrectly.

    Why no shoe covers: Scrubs can become contaminated while removing shoe covers. If you are concerned about contamination on your shoes, you may use a disinfectant wipe after completing your shift and leave your shoes outside the home and/or separated from other items.

    Why no Bouffant caps: Inappropriate removal of the bouffant cap can cause a displacement of eyewear and/or mask which may result in incidental contamination closest to your eyes, nose and mouth.

  • Donning and Doffing - CDC Sequence

    All staff with an N-95 should have a fit test card that identifies exactly which N-95 they are fit tested for. Please always follow the manufacturer's instructions for your personal PPE.

Isolation Criteria