WLAVA:COVID19 ED Operational Updates

  • Website Last Updated 4/19/20

Breaking News

Number of COVID-19+ cases at GLA: 49 (mostly CLC)

New Mask Guidance

  • COS (Chief of Staff) new 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 only have about 50-60 of the 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
      • We will not be resupplied with 1860/1870s.
    • If consultants come down to the ED asking for 1860s/1870s, please inform them that ED does not have those masks for distribution to consultants.
      • They will be receiving 8000s N95s.
    • Remind consultants that 8000s are N95 respirators and this is an ID guideline.
      • The only legitimate reason they can request an 1860s/1870s is if they failed formal fit test for 8000s.

What Mask Should I Wear?

  • PAPR:
    • Provider intubating.
  • 3M 8000 N95 Respirator:
    • All providers working in the ED who passed fit testing. Please get fit tested for these.
      • Airway buddy.
      • Personnel seeing PUIs.
      • Nurse performing NP swab.
      • Consultants evaluating patients in ED.
    • Do not need to wear a surgical mask over these.
      • Discard with every PUI. Can continue to wear if evaluating non-PUI.
  • 3M 1860/1870 N95 Respirator:
    • CODES or intubations.
    • 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, save these using paper bag method.

ED PSYCH OBS

  • We are expanding ED psych obs to include all “soft SI admits”. Previously ED psych obs was only for patients that were intoxicated. Given the current environment and to best preserve COVID tests, please allow patients that are conditional SI that are likely to clear by morning time to be placed in ED PSYCH OBS for reassessment by psychiatry in the morning IF there are beds available in the ED.
  • If no beds in the ED, please collaborate with the charge nurse to discuss whether it is feasible to keep the patient in a medical bed until the next day. Otherwise, admit to the psychiatric service.
  • If the patient is likely to be discharged the next day, DO NOT ORDER A COVID PANEL. There is always the option of ordering a CEPHEID if the patient converts to a true admit.

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 4/22 8am-11:30am – Room 3232.
    • Tuesday 4/21 6am-11am – ED (tentatively).

Airway Reminders

WLAVA: COVID-19 ED Airway Main

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

ED Attending Shift Responsibilities

  • See Airway page for more details on airway duties:
  • Extra weekday night and weekend shift coverage has been added to flex to tent and cover airway.

Airways

    • 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 intubation note
      • Helps us keep track of how often we are intubating
    • Please hand off the pager to the responsible Intubating attending as below
    • You may reassign the intubator/buddy amongst designated members
    • Airway Team should restock cart after each use
    • For intubations, make sure you dispose of all meds in the packet after use. Pharmacy does not want them returned.
    • COVID 11p-7a and 7p-7a overnight attendings always recheck the cart at the beginning of the shift
    • 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)

PPE Reminders

WLA VA PPE Main Information Page

Tent Reminders

    • EST open M-F 7a-11p and Sa-Su 10a-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).
    • Please pick up the VA iPad assigned for EST Telehealth so you can see patients using FaceTime (so you don’t have to walk back-and-forth).
      • We are still working out if the ED MSA or the ED Charge Nurse will be in charge of EST VA iPad sign in/sign out. This will hopefully be resolved tomorrow.
      • See the following WikEM pages for details on the EST mission and protocols:

Administrative Reminders

LAC DPH COVID19 Resources

LAC DPH Website

Definition of COVID19 Person Under Investigation (PUI) updated 3.24.20

LADPH PUI Criteria
  1. Note that all healthcare workers are advised to self-monitor for symptoms and not report to work if they are experiencing symptoms.

LAC DPH COVID19 Physician Checklist

LAC DPH Provider Checklist

LAC DPH Home Isolation Handout

File:COVHomeCare(1).pdf

WLA VA ID COVID-19 Testing Algorithm

  • Do not need to consult ID to order COVID-19, please review algorithm below to determine if your patient is eligible for COVID-19 testing.
WLA VA Tent Testing Algorithm

Criteria for Ordering COVID Testing

  • Every admitted patient will receive COVID testing for surveillance.
  • For medical admissions we do not wait for the test result before sending patient upstairs.
  • Patient does not need isolation precautions apart from when nurses do the swab.
  • For psychiatric admission, we DO need to wait for test results.
    • If a psych bed is available, order the rapid CEPHEID test with ID/MOD approval to get them upstairs.
  • FROM ED:
    • Obtain COVID-19 test on all patients admitted to hospital.
    • Use PUI criteria to determine level of suspicion for COVID-19.
      • Please differentiate between surveillance testing and suspected COVID-19 on EDIS
    • Surveillance testing:
      • Only reason COVID-19 is being sent is because patient is being admitted to hospital.
        • Does not meet PUI criteria.
      • DOES NOT NEED ENHANCED DROPLET ISOLATION
  • FROM TENT:
    • Symptomatic healthcare workers
      • Asymptomatic COVID ward attending/resident coming off rotation
    • Patient requiring HD
    • Patients requiring transfusion/infusion center
    • Patients in congregate living or long-term care facility

COVID-19 Tests and Characteristics=

  • We have two types of test the Roche (LB send out) and Cepheid test (run in-house).
    • The LB test has a turn around time (TAT) ~12-36 hours.
    • The Cepheid test TAT ~45min.

CEPHEID COVID-19 Test

  • Very limited availability (only have 20 test kits/week).
  • Only order of results will significantly alter the disposition of a patient and/or affects patient flow.
    • For example, available inpatient psych beds and a questionably well-appearing symptomatic patient being admitted to psych--- however do not order if we are boarding patients since they will remain in ED anyway and can wait on results

Order process:

  • 8a-5p: ID needs to approve (and order).
  • 5p-8a: MOD can order it for you.

Psychiatry Admissions & Surveillance Testing

  • Patients cannot go upstairs until COVID negative
    • If beds available, order CEPHEID (ID approval 8a-5p, hospitalist overnight)
    • If no beds and boarding, order "regular" COVID test (send out to LB).


COVID-19 Admission Guidelines

  • Please have low threshold to admit patients to higher level of care or discuss cases with MOD.
  • Most COVID Admissions will go to ICU team
    • MICU and SICU teams are sharing the load of PCU/ICU admissions.
      • If the patient is stable enough for GMED (see triage guidelines), you can admit to GMED COVID unit
  • MICU vs SICU Schedule:
    • 4/6 through 4/12: Primary team SICU
    • 4/13 through 4/19: Primary team MICU
    • If 5SD is full, admissions alternate between MICU and SICU
    • MOD can help sort any confusion
  • New Isolation Note
    • Specific to COVID19 - indicate if ICU level of care and high risk for aerosolizing procedures vs usual care.

COVID-19 Direct Admission Guidelines

  • Same as our previous direct admission policy.
  • Patients in clinic can be admitted directly if stable and clinic is still open.
  • Provider that made admission disposition decision must call MOD/OTS for coordination.
  • If patient coming from home, provider can still call MOD/OTS. Holding area will be Tent if there is not immediate inpatient bed available.
  • Anyone coming from community nursing home that is confirmed COVID+ can be directly admitted as long as they are STABLE.
    • Since these patients can deteriorate rapidly, we must make sure they can wait for an available bed without being monitored in the ED.
    • This includes ALL community nursing homes, not just the CLC
  1. OTS or Transfer Office (x31448)
  2. Call MOD and they will take care of admitting orders

Disposition of Homeless PUI Patients

  • If homeless and can self-isolate AND does not want to be placed in a shelter
    • Discharge with self-isolation instructions
  • If homeless and was previously living in a congregate living facility (board and care, shelter) OR requesting housing OR cannot self-isolate AND is able to self care completely
    • Social work consult for DOM COVID unit/building 214 (see below for process). The patient does not need to have substance use in order to stay here
  • If homeless and patient is not able to self care or has other specific needs
    • Admit to medicine 5SD, gmed/PCU/ICU depending on level of clinical care
  • If no DOM beds are available
    • Consider admitting to medicine

Process of Placing in DOM COVID Unit (B214)

  1. Consult social worker
  2. Make sure patient ruled out for TB with cxr or quant ifn within the past 12 months. pCXR an be done in the tent if needed.
  3. Fill out CERS <ATTENDING ATTESTATION-INDEPENDENCE/ELIGIBILITY-CERS PROGRAM>
  4. Social worker will contact DOM for bed between 8am -10pm. If overnight, will need to be observed

CODE Situation for COVID-19 Cases

  • Will be called out as "CODE 99 SPECIAL"
  • DO NOT be a hero and RUSH IN
  • PPE: N95, Face Shield, bouffant, gloves x2 and gown x2
  • Place a surgical mask on patient while getting airway set up, chest compressions ok
  • Do not BAG patient
  • Limit # of staff
  • Staff safety is #1 PRIORITY

Miscellaneous Reminders

Location of N95 Masks at GLA

  • Stored in Med Room (badge access only)
  • GLA N95 Brand/Model:
    • We primarily carry: 3M 1870+
    • We have a stock of small masks: 3M 1860S

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
  • 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

  • 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.

Education/Simulation Reminders

Mock Code Drills

  • If you are having a slow shift, please consider running a few mock code drills so that we can ensure our nursing staff is well prepared. Our nursing staff is a little rusty when it comes to critical care, so it isbetter we iron out any issues in preparation for the future.
  • Hospitalists are doing daily weekday drills (M-F) at 11AM in 3rd floor conference room (there will be no overhead announcements).
  • Reference Documents:

General PPE Training

  • PPE training 3/17 to 4/17 @ 8:30a - 4:00p Bldg 500, Rm 6043 (no reservation required)

SIM Lab Training

  • Email Cindy Koh or Carol Lee 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...

WLA ED Workflow

ID Contact Information

  • GLA ID COVID consult p89324 (UCLA).

Misc Numbers:

  • Infectious diseases fellow (x40270/40271)
  • Microbiology Department (x41259)

Limiting Staff Exposure to PUIs

  • We are hoping the following changes in workflow will limit staff exposure to PUIs as well as conserve PPE.
    • In stable patients with febrile illness, acute respiratory, or GI symptoms, the nurse will wait until MD assessment to see the patient.
    • Please see patient in tandem with resident to limit staff exposure and expedite workups (we can reassess if volumes pick up over coming days).
      • This will allow you to practice donning/doffing and creates a buddy system to ensure we are doing it properly.
    • Notify nurse of patient's isolation status, place isolation note, and sign isolation order.
    • Place all of your workup and treatment orders upfront (including decision on COVID-19 testing) to limit nurse interaction with patient.
      • Not all patients need COVID-19 testing, please follow WLA VA ID COVID-19 testing algorithm above. If unsure, consult ID.

How to Place Patients on Enhanced Droplet Precautions in CPRS

  • Please have a low threshold to place patients on isolation for COVID-19.
  1. Start a new note:
Start New Note
  1. Type in 'Isolation Note:'
Isolation Note
  1. Select Enhanced Droplet Precautions for COVID-19 patients:
Enhanced Droplet Precautions
  1. Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:
Isolation Order




Close Contact Definition

  • Being within approximately 6 feet (2 meters) of a confirmed COVID-19 case for a prolonged period (5 minutes)
  • Having unprotected direct contact with infectious secretions of a COVID-19 case.
    • NOTE: Examples of Brief Interactions include:
      • Briefly entering the patient room without having direct contact with the patient or their secretions/excretions.

NOT Close Contact Definition

  • Brief conversation at a triage desk with a patient who was not wearing a face mask.
  • These encounters are NOT close contacts, except when an aerosol-generating procedure is or has been recently performed.

Patient Placement

  • Patients with suspected or confirmed COVID-19 disease will be cared for in single rooms with the door closed.
  • Airborne isolation rooms (negative pressure rooms) will be used for patients with suspected or confirmed COVID-19 disease who
    • Are receiving ICU-level care OR
    • Undergoing procedures that are likely to generate a high concentration of respiratory aerosols.
      • NOTE: If negative pressure rooms are unavailable for a patient receiving ICU care, patients will be placed in a standard room with staff using N95 with eye protection/PAPRs, gowns and gloves. If hospitalization is not medically needed, home care is preferable if the individual’s situation allows.

Aerosol-generating procedures

  • Endotracheal intubation or extubation
  • Cardiopulmonary resuscitation
  • Non-invasive positive pressure ventilation (BiPAP)
  • Bronchoscopy
  • Open oropharyngeal or nasopharyngeal suctioning (closed circuit suctioning is considered non-aerosol generating)
  • Nebulizer therapy. Use of metered dose inhalers with spacers is strongly preferred for patients being tested for or diagnosed with COVID-19.
    • NOTE: The number of healthcare workers present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure.

COVID-19 Specimen Collection (Nasopharyngeal Swabs)

  • Standard/Contact/Droplet precautions are recommended.
  • The number of persons present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for specimen collection.
  • Specimen collection can be performed in a normal examination room with the door closed.

Patient Transport in the Hospital

  • If transport personnel must prepare the patient for transport (e.g., transfer them to the wheelchair or gurney), transport personnel should wear all recommended PPE.
  • Patients should wear a face mask to contain secretions during transport. If patients cannot tolerate a face mask or one is not available, they should use tissues to cover their mouth and nose.
  • The transporter should wear a face mask.

AVOID AEROSOLIZING Procedures (if Possible)

  • Do not use NEBS - use MDI/SPACER (we have some in stock- if not in FT- check main ED)
  • NO to High flow NC (generally - if done place a surgical mask on patient)
  • NO to BIPAP
  • Intubate early & in a negative pressure room
  • AVOID any bagging

GLA/CDC Return to Work Guidance

Your Health (and Ours)

  • If you develop a fever and/or resp symptoms- notify Neil/Jonie immediately. We know how hard y'all want to work - but it's important to stay healthy and keep away from others to avoid further spread of disease to coworkers and patients and additional need for quarantine.

GLA Provider Exposure Risk Algorithm

  • Please protect yourself from inadvertent exposure by making sure patients that have any hint of being a potential PUI (i.e., epidemiological risk factors, URI sx, any respiratory sx, etc.) are wearing a face mask (can use conical or level 1/yellow mask).
Interim Guidance at GLA during regular staffing mode for ASYMPTOMATIC employees WITH PROLONGED CLOSE CONTACT with a COVID-19 patient

CDC Return to Work Guidance

  • Guidance on what to do if you think you were exposed to COVID-19 and are asymptomatic:
    • We are using the CDC updated recommendations on public health management of healthcare personnel (HCP) with potential exposure in a healthcare setting to patients with COVID-19 (see below). This updated guidance allows for asymptomatic HCP who have been exposed to a COVID-19 patient to continue to work AFTER consultation with their occupational health program (see table below for details on exposure risk).
  • We are counting on your self-referral.

Miscellaneous Admin

iMED Consents for COVID PUI Patients in Isolation

Detaining PUI or COVID19 Confirmed Patients

  • It seems that without any specific quarantine order (rare that we will have an official order on our patients)- we cannot detain patients against their will unless we do not think they have capacity- which is a separate issue.

Medical Student & Resident Rules Regarding PUI Pt Care

Coding COVID19 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

Dexter Moved Out

  • Use ‘UM Review’ label on EDIS to communicate with him.
  • If you are interested in not having to change your admission orders 50 times.
    • Here are ways to contact me 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.
  • Staff members are not permitted to solicit funds or items on behalf the hospital.

GLA Sites

COVID19 ED Sharepoint

High Consequence Infection (HCI) Sharepoint

Emergency Alerting and Accountability System (EAAS)

Other WLA VA Pages


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