Harbor:Infectious Disease Threats

Coronavirus (COVID-19)

  • Nurses will put everyone with recent travel from ANYWHERE IN CHINA, IRAN, ITALY, JAPAN, SOUTH KOREA or healthcare worker with FEVER and COUGH/SOB in airborne precautions for the teams to screen
    • Physicians will determine if patient meets definition (Any of the below combinations)
  1. Fever OR cough/dyspnea AND close contact with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset
  2. Fever AND cough/dyspnea AND any healthcare worker without an alternative diagnosis (negative Biofire)
  3. Fever AND cough/dyspnea requiring hospitalization AND travel to affected geographic areas within 14 days of symptom onset
  4. Fever AND cough/dyspnea requiring hospitalization AND radiographic findings compatible with a viral pneumonia and no alternative diagnosis (negative Biofire)
  5. Part of a cluster of 2 or more cases of an acute respiratory illness within a 72-hour period AND from group living setting with elderly and comorbid medical condition patients (eg, skilled nursing facility, homeless shelters) - assume anyone from a SNF with respiratory complaints may be infected
  • Commercial testing (Quest) for fever AND cough/dyspnea NOT requiring hospitalization AND travel to affected geographic areas within 14 days of symptom onset OR other exposure risk/CLINICAL judgment
  • Decision to Test (From R. Lewis' email on 3/14/20)
    • Only the ED Attending can approve COVID-19 testing in the ED so a resident should not initiate testing without explicit instruction from the attending to do so;
    • The decision to order COVID-19 testing should almost always be based on:
      • A clinical presentation that is consistent with current COVID-19 disease (e.g., do not test anyone who is asymptomatic); the latest Provider Checklist with the formal case definition is on the Harbor IPC website under "breaking News" and
      • A negative Influenza A/B and RSV PCR result. A negative Biofire Respiratory PCT is not a requirement for COVID-19 testing. Specifically, whether you send a Biofire respiratory PCR should be based on whether the anticipated yield and value is sufficiently high to warrant the laboratory time and cost or a specific clinical indication (e.g., to test for pertussis). Do not send a low-yield Biofire Respiratory Panel as a “gatekeeper” for clinically-indicated COVID-19 testing.
      • We will be sending all COVID-19 tests to Quest and will no longer be sending tests to the LA County DPH laboratory, unless the patient has been specifically sent by DPH for testing. The DPH turnaround is no longer faster than Quest and, moreover, communications with LA County DPH are time consuming and difficult to coordinate in the ED setting.
  • Importantly, the worried well, meaning patients who are presenting requesting COVID-19 testing (with or without a clear exposure to a laboratory-confirmed case) who have neither a new cough nor fever should be sent home ASAP after a very brief evaluation, and without testing of any sort (not even for RSV/Flu), with instructions to quarantine at home.
  • Logistics of Testing
    • Call the Microbiology lab prior to collecting the NP sample (no OP required for Quest) - x66289 - available 24/7. Be prepared to give the name of the requesting ED attending physician if asked;
    • If you do not have the Viral Transport Media/Swab, the lab will then send down the swab/media for NP collection;
    • Use a downtime form to order COVID test (you will NOT find a "COVID" test in Orchid, it is a lab-orderable item only). On the form write the Attending's name; and
    • Send out the batch text message to inform others (p9699) since your patient is now a Covid PUI
  • Follow Up of Test Results
    • COVID-19 testing for patients who require hospital admission due to their clinical severity of illness will be followed up by the admitting teams;
    • For the relatively rare patient who is tested and sent home, you must have a plan for following up the test, e.g.:
      • The patient’s PCP can contact Quest for the result;
      • The patient’s preexisting DHS empaneled provider can follow up (send message via ORCHID/message center);
      • If the patient would require CCC for other reasons, CCC can follow up; and
      • For Pediatric ED patients only, the usual laboratory follow up procedure may be followed.
    • Do not send COVID-19 testing on a patient who can be sent home unless there is a plan for the result to be checked. **Do not admit/OBS/CCC solely for the purpose of following up COVID-19 test results.
    • Do not rely on Public Health to follow up test results or contact patients unless the patient was specifically referred by Public Health for testing.
    • For the patient who is not ill enough to require hospitalization, it is always an option (and almost always the best option) to not test at all (not even for RSV/Flu) and instruct the patient to self-quarantine at home.
  • Airway management
    • Avoid BiPAP, high flow oxygen, and nebs
    • Use MDI/spacer
    • Pre-oxygenate with NRB and use apneic nasal cannula during intubation.
    • If using PAPR, then need pre-assigned RN outside the room to help decontaminate it by wiping it down with purple wipes before you take it off
  • Treatment
    • Supportive care
    • Avoid steroids unless strong non-COVID indication
    • Chloroquine or hydroxychloroquine
    • Remdesivir via compassionate use for severely hypoxemic (MV, high PEEP, FiO2 requirements >40%,).
  • Helpful Logistics
    • Write your name into the log by patient room
    • Use face shield, not just glasses or disposable trauma eye protection glasses
    • Double glove
    • If patient brought in by EMS, let MICN to decontaminate their rig and inform staff
    • If you are exposed to a confirmed patient, whether in PPE or not, self monitor for symptoms for 14 days. Ok to work as long as you don't have symptoms. Employee health and IPC will give recs for staff exposures

==

  • ED Phase 1: Covid-19 Screening
    • Router
      • ID screening: fever & cough, sore throat, SOB or secondary questions (travel history, contact with case) - apply surgical mask
      • Register as “Disaster1”
      • Set chief complaint for triage as “COVID” (need this to see patient priority on triage screen)
    • Triage Priority
      • “Routine” priority
        • Prehospital Disaster Tag Number (to sort in disaster filter)
          • COVID FT – ILI symptoms
          • COVID AED – not PUI criteria but ILI with other medical issues that are too complex for FastTrack
      • “High” Priority
        • COVID PUI – for patients meeting DPH criteria going to neg pressure room
    • AED
      • Send to chairs by Triage 5 (3 seats); if >3 patients, NW corner of WR
    • PED
      • Send to the masked patient side of the Peds WR
    • Triage:
      • Use Triage room 5
      • Triage priority: Cardiac > High > COVID > Routine
      • Team triage: if the patient meets PUI criteria on further screening by triage provider, patient taken directly to negative pressure room and AED team notified
      • Change QuickReg to “COVID PUI”
      • If not eligible for FT but not a PUI, change QuickReg to “COVID AED”
        • A nurse or PFS can change the disaster status after quick reg. They copy the FIN, open quick reg, and re-enter it.
    • If the patient does not meet PUI criteria, send directly to RME 1 (or chairs 1&2) for immediate discharge
      • if RIPT positive, portable CXR to be done in RME1
    • Ambulance Triage
      • All patient (including those going to Psych ED) must be screened per above
    • Psych ED
      • All patients must be screened per above
      • If a patient meets PUI criteria, they should be immediately transferred to the AED and placed in a negative pressure room
    • PED
      • If the patient meets PUI criteria, patient taken directly to negative pressure room and notify PED team
        • Change QuickReg to “COVID PUI”
        • If not eligible for FT but not a PUI, change QuickReg to “COVID PED”
      • If the patient does not meet PUI criteria, send directly to PED 8-10 for immediate discharge
      • If >3 patients, send to the masked patient side of the Peds WR
    • Registration
      • AED
      • After registration complete, send patient directly to RME1 (or chairs 1&2 if R1 is occupied)
      • If >3 patients, send to NW corner of WR for cohorting
    • PED
      • PED 8-10
    • Discharge
      • AED
        • NP in RME1
          • Chart with “.edcovid” – include reference that patient given COVID ED instructions
          • Discharge with pre-printed paper discharge
      • PED
        • NP or resident in PED 8-10
        • Chart with “.edcovid” – include reference that patient given COVID ED instructions
        • Discharge with pre-printed paper discharge
    • UCC
      • If patient meets the infectious screening criteria - fever & cough, sore throat, SOB or secondary questions (travel history, contact with case) - apply surgical mask
      • Register as “Disaster1”
      • Set chief complaint for triage as “COVID UCC”
      • Send to chairs in segmented area of WR
      • If the patient meets PUI criteria, notify the AED Charge (23910) and immediately transfer to an AED negative pressure room
        • AED will change QuickReg to “COVID PUI”
      • Designated NP to DC the COVID patients from room 8
        • If larger volume of patients, use room 2 as 3 curtained beds
      • Chart with “.edcovid” – include reference that patient given COVID ED instructions
      • Discharge with pre-printed paper discharge

=

Airway Management of COVID PUI

  • When intubating patients, for any unclear cases, wear N95, face shield, gown and gloves since they might not have a temp yet or clear history if the patient has a respiratory illness.
  • Avoid nebs, BiPAP and high flow oxygen
  • Use MDI/spacer
  • Pre-oxygenate with NRB
  • Use apneic nasal cannula during intubation
  • The trauma rooms are now negative pressure

==

  • Logistical things to know for COVID PUI
    • Write your name in the log by the room whenever you enter the patient's room
    • Use a face shield, not just glasses or disposable trauma eye protection glasses
    • If patient comes in by EMS or the MICN to let them know you suspect COVID so they can decontaminate their rig.
    • PAPR - get from Charge RN or central supply.
    • If using a PAPR - get a preassigned nurse outside the room decontaminate it for you before you take it off (Purple wipes)
    • If you are exposed to a confirmed patient - whether in PPE or not - you should self-monitor for symptoms for 14 days. OK to work as long as you do not have symptoms. IPC and Employee Health will give recs for staff exposures.
  • Per CDC, do not treat with steroids (prolongs viral replication) unless for a secondary reason (ie, COPD)

==

  • ED Phase 1: Covid-19 Screening
    • Router
      • ID screening: fever & cough, sore throat, SOB or secondary questions (travel history, contact with case) - apply surgical mask
      • Register as “Disaster1”
      • Set chief complaint for triage as “COVID” (need this to see patient priority on triage screen)
    • Triage Priority
      • “Routine” priority
        • Prehospital Disaster Tag Number (to sort in disaster filter)
          • COVID FT – ILI symptoms
          • COVID AED – not PUI criteria but ILI with other medical issues that are too complex for FastTrack
      • “High” Priority
        • COVID PUI – for patients meeting DPH criteria going to neg pressure room
    • AED
      • Send to chairs by Triage 5 (3 seats); if >3 patients, NW corner of WR
    • PED
      • Send to the masked patient side of the Peds WR
    • Triage:
      • Use Triage room 5
      • Triage priority: Cardiac > High > COVID > Routine
      • Team triage: if the patient meets PUI criteria on further screening by triage provider, patient taken directly to negative pressure room and AED team notified
      • Change QuickReg to “COVID PUI”
      • If not eligible for FT but not a PUI, change QuickReg to “COVID AED”
        • A nurse or PFS can change the disaster status after quick reg. They copy the FIN, open quick reg, and re-enter it.
    • If the patient does not meet PUI criteria, send directly to RME 1 (or chairs 1&2) for immediate discharge
      • if RIPT positive, portable CXR to be done in RME1
    • Ambulance Triage
      • All patient (including those going to Psych ED) must be screened per above
    • Psych ED
      • All patients must be screened per above
      • If a patient meets PUI criteria, they should be immediately transferred to the AED and placed in a negative pressure room
    • PED
      • If the patient meets PUI criteria, patient taken directly to negative pressure room and notify PED team
        • Change QuickReg to “COVID PUI”
        • If not eligible for FT but not a PUI, change QuickReg to “COVID PED”
      • If the patient does not meet PUI criteria, send directly to PED 8-10 for immediate discharge
      • If >3 patients, send to the masked patient side of the Peds WR
    • Registration
      • AED
      • After registration complete, send patient directly to RME1 (or chairs 1&2 if R1 is occupied)
      • If >3 patients, send to NW corner of WR for cohorting
    • PED
      • PED 8-10
    • Discharge
      • AED
        • NP in RME1
          • Chart with “.edcovid” – include reference that patient given COVID ED instructions
          • Discharge with pre-printed paper discharge
      • PED
        • NP or resident in PED 8-10
        • Chart with “.edcovid” – include reference that patient given COVID ED instructions
        • Discharge with pre-printed paper discharge
    • UCC
      • If patient meets the infectious screening criteria - fever & cough, sore throat, SOB or secondary questions (travel history, contact with case) - apply surgical mask
      • Register as “Disaster1”
      • Set chief complaint for triage as “COVID UCC”
      • Send to chairs in segmented area of WR
      • If the patient meets PUI criteria, notify the AED Charge (23910) and immediately transfer to an AED negative pressure room
        • AED will change QuickReg to “COVID PUI”
      • Designated NP to DC the COVID patients from room 8
        • If larger volume of patients, use room 2 as 3 curtained beds
      • Chart with “.edcovid” – include reference that patient given COVID ED instructions
      • Discharge with pre-printed paper discharge

Flu/ILI

  • Influenza-like-illness (ILI) is defined as fever >100.0 F / 37.8 C AND cough or sore throat.
  • Per our DHS policy, please consider treatment for high-risk populations.
    • Antivirals for influenza are most effective when administered when symptoms have been present for <48 hours.
    • May benefit for severely ill patients who have had >48 hours of symptoms.
  • High risk patients for complications include:
  1. Age < 2 years or > 65 years
  2. Pregnancy
  3. Chronic disease. Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes)
  4. Immune suppression, including that caused by medications or HIV
  5. Persons younger than 19 years of age who are receiving long term aspirin therpay
  • Don't send POC influenza test, due to low sensitivity (50-70%).
  • Please send the Biofire / Respiratory Panel PCR for admitted ILI patients.
  • Don't send POC RSV unless it will change your management.


Measles

  • Report suspected measles immediately to DPH
    • Weekdays 8:30 AM – 5 PM: call 888-397-3993
    • After-hours: call 213-974-1234 and ask for the physician on call.
  • Risk factors: international travel, never immunized of born after 1956
  • Symptoms
    • Fever, including subjective fever.
    • Rash that starts on the head and descends.
    • Usually 1 or 2 of the “3 Cs” – cough, coryza and conjunctivitis.

Hepatitis A

The County Department of Public Health has declared a Hepatitis A Outbreak in Los Angeles County and we are being asked in the emergency department to do our part to stem this outbreak. 　 In order to help we need to do the following things for all ADULTS (>18 years): 　

  1. Suspect: Consider acute viral hepatitis, especially in homeless patients or patients using illicit drugs.
  2. Test: If you suspect the patient may have acute viral hepatitis, order appropriate serologic studies (Hep A IgM, Hep B Core IgM, Hep B Surface Ag, Hep C Antibody Ab.) These are all available in the "AMB Hepatitis Workup" order set. STAT 45 minute turnarounds for the Hep A IgM is available, must be ordered as a standalone STAT test from the ED Quick Orders Page. If it is bundled with other Hepatitis tests, the machine runs all of them, delaying the turnaround time.
  3. Report: All suspected and confirmed cases of Hepatits A should be immediately reported to both the Dept of Health at (888) 397-3993 or after hours (213) 974-1234 AND Harbor Infection Control at x3838 While Patient Is Still in the Emergency Department
  4. Vaccinate: Anyone (regardless of why they are here) who is or has been homeless in the last two months, or uses illicit drugs (NOT JUST IV; except marijuana) should be offered the initial dose of Hep A vaccine while in the ED (the Cerner order is "Hepatitis A adult vaccine" on ED Quick Orders Page). They can be referred to the Department of Health for their second injection in six months. Check the "immunizations" area in Cerner to make sure they are not already immunized.
  5. Protect Yourself: If you haven't gotten the hepatitis A vaccine, it is recommended that you go to employee health to get vaccinated.


Harbor Ebola Precautions

  • Never enter a room with an Ebola PUI (Person Under Investigation) without full Ebola level PPE.
  • The definition of a PUI is simple - possible exposure to Ebola and subjective complaints consistent with Ebola infection (basically viral syndrome symptoms or abdominal pain or bleeding). No fever or other visible findings are required to classify the patient as a PUI patient.
  • Currently countries identified as travel locations we should be concerned about are coded into the "ID Risk Screen" the routers perform and you can find on Cerner under "Provider Notes"
    • As of October 2022, outbreak is isolated in Uganda
  • There are other ways to be exposed to Ebola virus: including sexual intercourse with a patient who has recovered from an Ebola infection.
  • As soon as the patient is identified as a PUI - they should go straight into isolation (in AED or PED, not RME), ideally one with a restroom inside the room; all further evaluation is done there.
  • Residents should not be in a room with a PUI patient - only attendings and fellows acting as attendings should be involved in wearing PPE and entering a PUI room
  • Notify the infectious disease (ID) service that you have a PUI patient in the emergency department - they will guide further screening to determine if the patient can be cleared or not. ID will then notify infection control prevent (IPC).
  • PUI patients are not allowed to use the sink or toilet. Mechanical should bring a porta-potty for patient use if there is not one in the room.
  • The policy of the County of Los Angeles is that any provider may decline to care for a PUI patient. Nursing has a list of nurses who have volunteered to care for PUI patients.
  • Extreme care should be taken in any situation where a PUI patient may undergo a procedure that aerosolizes body fluids - the best PPE in this case is a PAPR unit - which is a helmet with a positive pressure fan.
  • Call the OCN to obtain a PAPR and PPE equipment for Ebola, put out a log to record who goes in and out of a PUI room.
  • In the top drawer of the Ebola PPE cart is a binder that has step by step instructions for getting into and out of PPE for both the treating provider and that provider's "buddy". We will plan more training to refresh everyone on this.
  • UCLA Medical Center in Westwood will be our referral center for patients who cannot be cleared in a reasonable timeframe' or become confirmed Ebola patients. The decision for the timing of transfer will be made in conjunction with the infectious disease consultant.
  • EMS has a special unit to transport such patients - make sure they're aware that you have a PUI or confirmed case of Ebola.

Monkeypox

  • See Monkeypox for clinical info
  • See LAC DHS Expected Practice
    • Consider in patients with travel history w/in 21d of symptom onset to West Africa, Europe (CDC link of non-endemic countries with cases)
    • Rash typically preceded by fever, lymphadenopathy, malaise, HA, and muscle aches, but not all patients have prodrome in current outbreak
    • Vesicular or pustular rash, well-circumscribed, may be umbilicated or become confluent and progress over time to scabs. Could be in different stages.
    • Higher likelihood in MSM patients, presenting with lesions in the genital area
  • Move directly to a private room, cover rash; airborne (N-95) and contact precautions (gown), eye protection, gloves - order special precautions
  • Call Lab x66289 and get a monkeypox collection kit from Microbiology
  • Unroof lesion to swab, try to get cutaneous and genital lesions. Need separate order for each swab.
  • Send out to Quest, 3days turnaround time
  • Put patient onto lab follow up list.
  • Inform patient to self isolate until all lesions scabbed over
  • If get a call for positive test, double check patient is on the lab follow up lists.
    • Lab will inform LA County Public Health and HUCLA Infection & Prevention Control
  • Treatment is tecovirimat (TPoxx) - experimental antiviral agent needs ID approval
    • For painful lesions preventing ability to do ADLs (unable to urinate/defecate, eat/drink), intraocular lesion
    • Obtain written consent or Spanish written consent
      • Only available in English and Spanish for now. Do verbal consent for other languages then have patient sign the English consent form
    • Write e-script using ‘misc prescription’
    • Fill out TNF form (prior-authorization form) and inform ED pharmacist
    • RN to call OPD to have someone send Tpoxx from Outpatient Pharmacy to ED (can be RN or pharmacy tech

See Also

References

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