WLAVA:COVID19 ED Operational Updates: Difference between revisions

Revision as of 03:06, 27 April 2020

Last Updated 4/26/20

♦♦♦XXX = New Information (w/in 3 days) with Update Date

♦♦♦BREAKING NEWS 4/26/20

CEPHEID SHORTAGE

We are running low on CEPHEID swabs
Be very conservative on usage until we receive our next shipment.

COMPELLED TESTING

Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

CEPHEID ORDERING CRITERIA

YES
- All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
- Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
NO (NOT YET)
- ED observation patients
CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
Order the test as early as possible for timely results
For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

HOW TO ORDER THE CEPHEID (Rapid)

Go to COVID WORKFLOW section below.

COVID (LB) TESTING FOR HIGH-RISK PATIENTS

Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
LA County Testing Recommendation 4.22.20
- Symptomatic Patients 65 years and Older
- Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
Make sure you use the ED-PACT tool to request PCP follow up on test results.

AIRWAY REMINDERS

Glidescope Go S4 Blade Shortage 4/22/20

There is a shortage of Glidescope S4 blades.
We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
Please use the S3 blades instead so we can preserve the S4s for those who need them.

Securing Airway Tube Video 4/22/20

Zahir and Derrick created a video on how to secure the airway tube
If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE

SECURING AN ET TUBE WHILE USING AN AIRWAY BOX

DEMONSTRATION OF USING A PONCHO WHILE INTUBATING

Daily Airway Cart Log

The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on top the Airway Cart.
Best practice is to refill the cart after an intubation because you know what is missing.
This daily log is a double check / insurance.
You also need to check that the COVID medication bags medications are NOT expired.

COVID Airway Item Checklist

Restocking Cart

If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

Airway Red Box in Med Room

Stored in Med Room
Check Daily (3 essential items)
- Glidescope Go (CHECK BATTERY)
- Grab and Go Bag (gather items from the Yellow duffel bag)
- COVID Medication Bag

Aerosol aka Airway or Intubation or Plexi-BOX

Stored in the Doctor's station.
This is available for use and is not mandatory.
- Added layer of protection (giant splash guard).
We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
Bed 4 has intubating manakin for you to practice.

Suggested Workflow for Airway Box

Remember to put what you need inside the box before intubating:
- BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
You have the option of draping the other end (extra drapes available on the counter along with tape)
After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.

Sterilize after use with germicidal wipes thoroughly and allow it to dry.
- Buddy can clean this along with glidescope. Should wear full PPE.

AIRWAY GENERAL INFORMATION

Treat All Intubations as PUIs:
- It is up to your discretion if you want to PAPR vs N95
  - please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
- Please remember to document your PPE in CPRS note.

See Airway Page for detailed ED attending airway duties:
- Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.
- Anesthesia can be called for impending COVID airways if 2 hours notice can be given.
- ED Attending Airway Responsibilities:
  - Write an Intubation Note in CPRS
  - Please hand off the pager to the responsible Intubating attending as below
  - Airway Team should restock cart and medications after each use
  - Report anything missing to Derrick, Miguel and COVID champions

ED COVID Airway Team:
- - Afternoons: Intubating 4P-MN Main ED; Buddy 4P-MN FT
  - Overnight: Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
  - Weekends: Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

AIRWAY MAIN PAGE

WLAVA: COVID-19 ED Airway Main

PPE REMINDERS

3M 8000 N95 Fit Testing

EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
- Monday 4/27/20 6:30-11:30, building 500 Rm 3232
  - Please complete questionnaire online if you have not done it within the past year.
  - URL: http://respiratormedicalevaluation.com

Mask Decontamination & ♦♦♦UV Sterilization Technique 4/24/20

SPS is no longer collecting masks. Discard the 8000 N95 respirators.
Save 1860s/1870s for future use as long as they weren't used for code/intubation.
- Use paper bag method x wait 5 days, 5x max.
UV Sterilization Technique 4/24/20
- Not institutionally advised and use at your own risk.
- The UVC machine on the top shelf in the med room would require 9 min 30 secs to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

♦♦♦PAPR Cleaning 4/24/20

After an intubation or CODE with PAPR use, remind the charge nurse to call SPS to pick it up for cleaning.
Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

PPE GENERAL INFORMATION

Mask Guidance

- 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
- ED is receiving only 3M 8000 N95 respirators.
- We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
  - We will not be resupplied with 1860/1870s.
- Remind consultants that 8000s are N95 respirators and this is an ID guideline.
  - They can request an 1860s/1870s is if they failed formal fit test for 8000s.

What Mask Should I Wear?

PAPR:
- Provider intubating. Nursing as per their leadership recommendations.
3M 8000 N95 Respirator:
- All providers working in the ED who passed fit testing.
  - Airway buddy.
  - Personnel seeing PUIs.
  - Nurse performing NP swab.
  - CODES or intubations.
- No need to wear a surgical mask over these.
  - Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
3M 1860/1870 N95 Respirator:
- Providers that failed formal 8000 N95 fit testing.
- Wear a surgical mask over this and discard surgical mask with every PUI.
- If used for a CODE or Intubation, discard the N95.
- If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

Patient Encounter Scenarios & Recommended PPE

Patient Encounter Scenarios and Detailed PPE

For Patients WITH COVID-19 Isolation Precautions

Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions

For Patients WITHOUT COVID-19 Isolation Precautions

Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions

Device Cleaning

If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
- Glidescope:
  - Super Sani-cloth (Purple top)
  - Contact time: 2 minutes
- Ultrasound (new): Sonosite EDGE II:
  - Monitor: Alcohol
  - Transducer: Bleach wipes (leaves residue)
- Ultrasound (old): Turbo:
  - Monitor: Alcohol
  - Transducer: Super Sani-cloth (purple top)
- Reference document on approved disinfectants:
  - File:APPROVED_20200408.1200_Disinfectants.pdf

PPE Main Page

Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos

WLA VA PPE Main Information Page

ENHANCED SCREENING TENT (EST) REMINDERS

♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20

Please see the EST Provider Disposition Tool that Manny created

https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB

This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

Employee Symptoms Self-Referral Tool

Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
We can use this tool, but mainly to assist other employees.
- Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
GLA VA Employee Symptom Self-Referral Tool

TENT (EST) Consults

When the tent calls you in the ED it is NOT a curbside.
- You are responsible for this patient moving forward.
- Your options are to see the person virtually (Skype Video) or go to the Tent.
- You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
For the the EST Provider Note you can cancel out of template and port over your own template.
Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
Verify COVID Screen for patients referred from the Tent
- Testing is still limited; many COVID possible patients will NOT receive testing

Screening & Testing for COVID (Tent EST Referrals)

The Tent is being staffed primarily by Non-EM providers including dental residents.
For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
The Tent providers, esp. dental residents, are really trying their best!
In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
Please review GLA testing guidelines for COVID located on WiKEM below.

TENT (EST) GENERAL INFORMATION

EST open M-F 7a-11p &Sa-Su 10a-10p
- EST Schedule (WLA Intranet Only)
- Weekday 4p-mn FT (covers 4p-11p) and weekend FT (covers 10a-5p)
- Weekend main ED 7p-7a attending (covers from 5p-10p)
Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
- - WLAVA:Enhanced Screening Tent Telehealth

TENT (EST) MAIN PAGES

Tent SKYPE Link (Remote Accessible)

https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

COVID WORKFLOW REMINDERS

CEPHEID Testing

CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
Order the test as early as possible for timely results.
If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

Isolation for PUIs

For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

How to Order CEPHEID (Rapid) Test

The CEPHEID test is a "secret order" in the ID Menu
Click the asterisks x 3 *** (see below)
- WLA Outpatient Clinic Order Menu
- Infectious Disease Clinic
- Left hand side-- Scroll Down find and Click " *** "
- Unnamed.png

♦♦♦COVID (LB) Testing for High-Risk Patients 4/23

Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
LA County Testing Recommendation 4.22.20
Symptomatic Patients 65 years and Older
Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
Make sure you use the ED-PACT tool to request PCP follow up on test results.

COVID Admissions 4/20/20

Back to MICU 4/20- and on

Patients Refusing COVID19 Test

If a psych patient is refusing a swab, DO NOT try to force them to get it done.
- This could endanger the staff.
Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
- After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
- May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

COVID WORKFLOWS GENERAL INFORMATION

♦♦♦COVID-19 Quick Guide 4/24/20

File:COVID-19 Quick Guide.022420.pdf

Last Updated: 4/24/20

COVID Quick Guide Approach to Stable Patients

Patients with Possible COVID-19 Home Aftercare

For patients discharged with possible COVID:
- Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
- Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
- A copy is uploaded on the Sharepoint under "ED Common Resources"

LA County URI / Possible COVID Handout

- Please distribute this and document you did so in the chart.
- Use the ED PACT tool for f/u for these patients

ED-PACT Tool: Checkbox Clinical Concern for Covid

WLA VA ID COVID-19 Testing Algorithm 4/23/20

Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.

WLA VA ED & Tent Testing Algorithm

Reference file (for printing):

File:COVID19 WLA Tent algorithm updated 4.23.20.pdf

How to Place Patients on Isolation Precautions

Please have a low threshold to place patients on isolation for COVID-19.

Start a new note:

Start New Note

Type in 'Isolation Note:'

Isolation Note

Select Enhanced Droplet Precautions for COVID-19 patients:

Enhanced Droplet Precautions

Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:

Isolation Order

Coding COVID-19 Encounters

For Suspected or Exposure to COVID19 or Exposure: Z20.828
For Confirmed COVID19: B97.29
Other suggested ICD10 codes include (but not limited to):
- Acute Upper Respiratory Infection, J06.9
- Cough, R05
- Viral Infection unspecified, B34.9
- Fever unspecified, R50.9

EDUCATION/SIMULATION REMINDERS

Mock CODE Drills

If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
COMMUNICATION is the most challenging part of these scenarios:
- "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
- Baby monitor or Vocera seem to be best
Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
Be very familiar with Airway COVID cart/and box.

CODE General Info

NRB hanging in front of beds 6& 7 (please replenish if used)
LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
Will add EPI laminated sign to COVID cart
If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
Reference Documents:
- File:ED COVID CODE Protocol_033020.pdf
- File:COVID Practice Drills 4.0.pptx

SIM Lab Training

Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

FIT Testing

To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

FIT Testing Sessions:
- Please complete online form prior to testing:
  - URL: http://respiratormedicalevaluation.com
  - Organization Code: vala

ADMINISTRATIVE REMINDERS

Shift Swaps

Scott Jacobs is managing all scheduling edits through June.
- Please email him directly with any proposed swaps.

UCLA Badges & Mednet E-mail Account

For Full-time faculty: How to apply for UCLA badge and mednet email address
- Slack: gla-va-em.slack.com
  - Under the left sidebar, you will see ucla-va-faculty-appointment-faq

MS Office and Free Apps

We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
- Microsoft Home Use Program (HUP)

For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
- UCLA IT Mednet Applications

WLAVA:COVID19 ADMINISTRATIVE

MISCELLANEOUS REMINDERS

VA Scrubs

Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
It took some effort but we finally secured enough scrubs to cover all ED/FT provider shifts each day.
However, we have to make sure to return them at the end of each shift. If you do not return it then that means the provider coming in after you will not have scrubs.

GLA Showers

No Lockers - Bring your own towel/clothes
- Wirecutter best packable camp towel
Ground Floor (Basement):
- Women’s Locker Room: Rm 0435 passcode 2169
- Men’s Locker Room: Rm 0403 passcode 2168
5th Floor (OR Showers):
- Women’s Locker Room: Rm 5076 passcode 5324
- Men’s Locker Room: Rm 5075 passcode 5321

Alternative Housing for Staff

The Fisher house is available for those who are interested and need housing options away from family.
Please contact Neil if interested and include exact dates and details.
- Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

UM Review

Use ‘UM Review’ label on EDIS to communicate with UM.
- Here are ways to contact UM if you have questions:
  - VA cell: 626 314 9774
  - VA Pager *11 p73284

Donations (PPE/Food Etc.)

Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.

File:VA COVID-19 Donation Form 4-2020.pdf

GLA WEBSITES

COVID-19 ED Sharepoint

Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

COVID-19 VA Cases Nationally

https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

Emergency Alerting & Accountability System (EAAS)

If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
Any issue please contact Lonnie Miller at x40863

Other WLA VA Pages

Authors:

@@ Line 407: / Line 407: @@
 ==Other WLA VA Pages==
 * [[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]
-* [[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]
+* [[WLAVA:COVID-19_PPE|WLAVA: COVID-19 PPE Main Information Page]]
 * [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
-* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
+* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
-* [[WLAVA:Enhanced Screening Tent Telehealth]]
+* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA:Enhanced Screening Tent Telehealth]]
 * [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 ADMINISTRATIVE]]