Difference between revisions of "Harbor:Infectious Disease Threats"

(Latest Numbers)
(Latest Numbers)
Line 9: Line 9:
 
**PCU:              3/24=  x/50
 
**PCU:              3/24=  x/50
 
**ICU:              3/24=  x/48
 
**ICU:              3/24=  x/48
**Hospital          3/24~200
+
**Hospital          3/26231
  
 
*COVID Cases
 
*COVID Cases
 
** Harbor
 
** Harbor
 
***POSITIVE        3/24=  3 (2-in-house)       
 
***POSITIVE        3/24=  3 (2-in-house)       
*** PUI (pend)      3/23=  12 (4 ICU)
+
*** PUI (pend)      3/23=  10 (4 ICU)
 
*** Negative        3/24=  ~50
 
*** Negative        3/24=  ~50
 
*LA County
 
*LA County
**COVID +ve=        3/26=  1230    
+
**COVID +ve=        3/26=  1216    
*** Age <17=              10
+
*** Age <17=              19
*** Age 18-40=            268
+
*** Age 18-40=            462
*** Age 41-65=            250
+
*** Age 41-65=            462
*** Age >65=              107
+
*** Age >65=              223
*** Deaths=         3/26=  21
+
*** Deaths=               21
** Predicted trajectory: 3/25=  3/26= 3/27= 3/28= 3/29= 3/30= 3/31= 4/1= 4/2= 4/3= 4/4= 4/5= 4/6= 4/7= 4/8=
+
** Predicted trajectory:  3/27=1238, 3/28=1535; 3/29=1903; 3/30=2360; 3/31=2926; 4/1=3628; 4/2=4499; 4/3=5579; 4/4=6918; 4/5=8578; 4/6=10,636; 4/7=13,189; 4/8=16,355; 4/9=20,280; 4/10=25,147; 4/11=31,182; 4/12=38,666; 4/13=47,946; 4/14=59,452; 4/15=73,721; 4/16=91,414; 4/17=113,353
  
 
*Supplies
 
*Supplies
**Viral swabs      3/24~600
+
**Viral swabs      3/26578
** Surgical masks  3/24enough
+
** Surgical masks  3/26>9-day supply
** N-95            3/246-day supply
+
** N-95            3/2635-day supply
** Face shields    3/24=  ?
+
** Face shields    3/26=  ?
 
** PAPR (ED)              3           
 
** PAPR (ED)              3           
 
** CAPR (ED)              6
 
** CAPR (ED)              6
** Gloves          3/24=  enough
+
** Gloves          3/26=  enough
** Gowns            3/24=  enough
+
** Gowns            3/26=  enough
  
 
===Latest Updates===
 
===Latest Updates===

Revision as of 08:11, 27 March 2020

Coronavirus (COVID-19)

See COVID-19 for non-Harbor-specific information; please feel free to contribute to the further development of these pages

Latest Numbers

THIS IS A DRAFT DASHBOARD - numbers currently not accurate

  • Census
    • AED Volume: 3/24= ~120
    • PED Volume: 3/24= ~30
    • PCU: 3/24= x/50
    • ICU: 3/24= x/48
    • Hospital 3/26= 231
  • COVID Cases
    • Harbor
      • POSITIVE 3/24= 3 (2-in-house)
      • PUI (pend) 3/23= 10 (4 ICU)
      • Negative 3/24= ~50
  • LA County
    • COVID +ve= 3/26= 1216
      • Age <17= 19
      • Age 18-40= 462
      • Age 41-65= 462
      • Age >65= 223
      • Deaths= 21
    • Predicted trajectory: 3/27=1238, 3/28=1535; 3/29=1903; 3/30=2360; 3/31=2926; 4/1=3628; 4/2=4499; 4/3=5579; 4/4=6918; 4/5=8578; 4/6=10,636; 4/7=13,189; 4/8=16,355; 4/9=20,280; 4/10=25,147; 4/11=31,182; 4/12=38,666; 4/13=47,946; 4/14=59,452; 4/15=73,721; 4/16=91,414; 4/17=113,353
  • Supplies
    • Viral swabs 3/26= 578
    • Surgical masks 3/26= >9-day supply
    • N-95 3/26= 35-day supply
    • Face shields 3/26=  ?
    • PAPR (ED) 3
    • CAPR (ED) 6
    • Gloves 3/26= enough
    • Gowns 3/26= enough

Latest Updates

  • If you have a homeless patient with mild Covid symptoms that could be discharged, call SW early. There is a DPH call center 8 am to 6 pm (833-596-1009) every day that helps with intake, transportation and placement into temporary shelters, but space is limited. May need to hold patient in ED or Alcove area of WR afterhours.
  • In order to better staff our COVID efforts and free up monitored beds in preparation for a significant increase in our COVID+/PUIs, we have been instructed to close Obs/CORE services for the time being. This will allow for increased hospitalist staffing on inpatient COVID teams as well as open up GOLD for tele/PCU PUIs, ideally helping with ED throughput for when we have an even bigger strain on our beds upstairs and more PUIs showing up at our doorstep
  • Any questions regarding PUI testing should be directed to ID consult. Available 24/7.
  • Any MDIs used in the ED to sent home with the patient instead of prescribing the patient another MDI and throwing the one used in the ED away. To do so, three simple steps needs to happen:
  1. Fill out a pre-printed rx sticker - available in English and Spanish with patient's name, the date, your name, patient's MRN. The stickers will be on the same clipboard as the logs (see #3 below) in each doc box.
  2. Put sticker on box for inhaler or inhaler itself and hand to patient
  3. Put patient sticker (or write patient name and MRN), your name, and circle drug given on the log. There will be a log in each doc box (purple, green, pediatrics).
  • CAPRs available - call OCN to get one. Working on getting 2 PAPR or CAPR with airway bag. OCN will listen for special precautions overhead page with airway mgmt. pages.
  • Process now to discharge patients from Team Triage after screening and FT provider can discharge from Alcove WR
  • Tent plans approved - will open based on volume triggers, for low acuity Covid patients, staffed by Fam Med
  • COVID physician leads:
    • Disaster planning, PPE – Shira Schlesinger
    • RME (screening, FT), phase 1-2 of Covid response plan, tent plans – Brad Chappell
    • AED, admission workflow, discharge planning, drug shortages, daily emails to providers – Andrea Wu
    • PED – Patricia Padlipsky
    • Residents – Madonna Fernandez-Frackelton
    • Non-EM workforce in ED, testing – Mike Peterson

Harbor Checklists

Harbor (DHS) PUI Testing Criteria

  • Nurses will put everyone suspected of meeting PUI in a room in droplet precautions for the teams to screen
    • ED Attending will determine if patient meets definition (any of the below combinations) from DHS testing criteria:
  1. Fever AND (cough OR shortness of breath AND NOT requiring hospitalization). Must be MEASURED fever in ED or at home (>100.4 F/38.0 C) AND:
    1. healthcare worker OR
    2. age>65 OR
    3. works or lives in group environment (SNF/group home/rehab center/jail) OR
    4. immunosuppression (includes prednisone>20mg daily OR
    5. malignancy OR
    6. severe chronic lung disease OR
    7. CAD OR
    8. pregnancy
  2. Fever OR cough OR shortness of breath AND REQUIRING HOSPITALIZATION without an alternative diagnosis (positive blood culture, cavitary lesion, chronic (>14d))
    • ID (p7804) is available 24/7 if you are unclear if they meet PUI criteria

Commercial testing (Quest) for PUI criteria above

The Flu/RSV order in the SARS-CoV-2/COVID-19 testing order set has been separated from the actual SARS-CoV-2 and the SARS-CoV-2 test is no longer visible (it can only be ordered by lab personnel with appropriate approval). Here is the new ordering process:

  • PROCEDURE
    • Carefully determine if meets PUI criteria
    • Order the Flu/RSV through the SARS-CoV-2/COVID-19 testing order. You will only be able to initially select the Flu/RSV test;
    • If the Flu/RSV is positive, please consider if that excludes the patient from being a PUI/needing testing
    • ED Attending calls lab to approve testing as add-on (no new swab)
    • Complete and submit "Laboratory Miscellaneous Lab Form"File:Laboratory Miscellaneous Request Form.pdf
  • 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 without testing of any sort (not even for RSV/Flu), with instructions to quarantine at home
  • If Testing, Send out the batch text (p9699). Please include Patient Name, MRUN, and Location (e.g. "AED Room A12")

==

  • Follow Up of Test Results
    • For the relatively rare patient who is tested and sent home, you must have a plan for following up the test
      • DHS empaneled patients: message the provider via ORCHID/message
      • AED patients: Lab Follow-up - HAR (like UCx and STI's)
      • PED patients: Peds - HAR/USC (the usual laboratory follow up procedure may be followed)
    • COVID-19 testing for patients who require hospital admission due to their clinical severity of illness will be followed up by the admitting teams;
    • 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

  • Airway management File:Harbor COVID Airway Management v3-16-20.pdf
    • Intubate early, use VL so you’re face is further away. Clean VL with grey wipes, observe 3 min wet time
    • Avoid BiPAP, high flow nasal cannula (HFNC), nebulizers
      • Use MDI/spacer instead of nebs
      • If needed HFNC with surgical mask over patient is preferred over BiPAP
    • Use viral filter on BVM/ETT, vent or BiPAP. RT is stocking then with our BVMs. Have already been on our vents and BiPAP.
    • Per CDC, do not treat with steroids (prolongs viral replication) unless for a secondary reason (ie, COPD)
    • When intubating patients, for any unclear cases, wear N95, face shield, gown and gloves
      • 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
      • Pre-oxygenate with NRB and use apneic nasal cannula during intubation.
      • Avoid using bag-valve-mask if possible
        • Only bag patient after cuff on ETT is inflated
      • RSI to ensure paralysis. Consider higher range of dosing of paralytic to avoid patient coughing.
      • Follow ARDSnet protocol, TV ~6ml/kg ideal body weight, high PEEP - http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

Treatment Tips

  • Patient Presentation
    • Patient may have preceding GI symptoms prior to developing respiratory illness
  • Treatment
    • Supportive care
    • Avoid steroids unless strong non-COVID indication
    • Limited data on chloroquine or hydroxychloroquine
    • Remdesivir via compassionate use for severely hypoxemic (Mechanical vent, high PEEP, FiO2 requirements >40%,).

PPE

  • Helpful Logistics
    • In triage, recommend wearing surgical mask, eye protection, gloves +/- gown
    • Only need terminal clean if aerosol generating procedure (AGP) done, otherwise just droplet precaution cleaning with wipes
    • Write your name into the log by patient room if sick suspected COVID patient getting admitted
    • If AGP, use face shield, not just glasses or disposable trauma eye protection glasses, and N95, double glove, gown. Otherwise, can use surgical mask or disposable trauma eye protection glasses.
    • Aerosol generating procedures (AGP) include: intubation, NIPPV, nebs, high flow nasal cannula (HFNC). If need to do NIPPV, nebs, HFNC try your best to place surgical mask over.
    • 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 patient brought in by EMS, let MICN know you suspect COVID so they can inform the EMS crew & decontaminate their rig

==

  • 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 based on CDC criteria.
  • Infection Prevention confirms the exposure and provides Employee Health with a list of affected departments. Employee Health then notifies all dept chairs or supervisors of exposure and request list of names of staff with potential exposure. Supervisor provides staff with a confidential notice to present to Employee Health
  • Employee presents to Employee Health for evaluation

Based on CDC exposure risk either self-monitor with or without work restrictions are initiated

Screening L&D Patients

  • If >14 weeks with fever or cough, keep in ED
  • If febrile, immediately consult OB and place in AED 15, 16, 17, 21, Tra 1-7, or peds 4 for FetalLink monitoring capabilities

COVID ACTION PLAN (Phases 1-3)

  • Phase I: “COVID-19 Screening”
    • Pre-router - mask patients with fever, cough, dyspnea
    • Router - register on disaster track (“COVID Possible”)
      • “Routine” priority
        • COVID EXPOSURE – no symptoms but at risk
        • COVID FT – ILI symptoms
        • COVID ED – not PUI criteria but ILI with other medical issues that are too complex for FastTrack
      • “High” Priority
        • COVID PUI – for patients meeting DPH criteria
      • Patients in respiratory isolation to AWR Alcove / back half of PWR
    • Triage
      • Triage priority:  Cardiac > High > COVID > Routine
      • Temporarily suspending CXR for RIPT scoring
    • Ambulance Triage
      • All patient (including those going to Psych ED) must be screened per above
    • Psych ED
      • EMS to Psych ED will receive screening at psych
        • If a patient meets PUI criteria, they should be immediately transferred to the AED and placed in a room
      • Patients arriving in Triage or AED for clearance to psych need MSE note
        • If no infectious or other medical concerns, the patient can go directly to the Psych ED after physician evaluation
      • Labor & Delivery
        • ED will perform infection screening on all patients presenting to the ED including L&D patients >14 weeks gestation
          • If negative, they will be directed to L&D
          • If positive with fever (subjective or recorded in past 24 hours), they will be triaged as usual and OB will be consulted
          • If >24 weeks gestation, they will be prioritized to AED 15, 16, 17, 21, Tra 1-7, or PED 4 for Fetal Link monitoring, with the goal of door to monitoring in <20 minutes
          • If the patient is in active labor, the patient will be moved to one of the trauma bays and the L&D team will decide the best location for impending delivery
  • Triage Rapid DC
    • RN completes portion of team triage and goes to open triage room for next patient after provider interview completed
    • Provider
      • Completes MSE Note: “definitive treatment provider”; “please see chart for details”; tracking acuity “5”; no typing in History/Exam section
      • Completes paper chart or .phrase and pre-printed paper discharge (English/Spanish/Korean)
      • Give discharge paper work to registration and patient (provider to sign the discharge paperwork and state “patient verbally consents” to avoid fomite transmission)
      • Takes patient to registration windows A-C and hands paper forms (H&P and signed DC) to Patient Access Staff
      • Join RN in new room after discharge process from prior patient complete
    • PAS will complete registration then sticker the paper forms, and place the chart in box to be scanned
    • Patient leaves from registration
    • RN wipes down exposed/touched surfaces per droplet protocol using Grey Cavi-wipe to clean all surfaces (door handle, chair, etc.)
    • Discharge off the tracking board
      • DETAILED STEPS:
  1. 1 - click pt recented seen x 6
  2. 2 - "H" for home, "T" for today, "N" for now
  • PED Rapid DC
    • 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 NP or resident in PED 8-10
      • Chart with “.edcovid” – include reference that patient given COVID ED instructions
      • Discharge with pre-printed paper discharge
      • Registration in PED 8-10
    • If the patient meets PUI criteria, patient taken directly to a room and notify PED team
      • Change QuickReg to “COVID PUI”
      • If not eligible for FT but not a PUI, change QuickReg to “COVID PED”
  • Phase 2
    • DHS/OOP ESI 4/5 can go to UCC
    • FT Team Rapid Dispo (ESI 3 or 4) - low risk, COVID suspected (but not meeting DHS PUI criteria), but still needs simple workup
      • Complete triage, rapid history & exam
      • Apply PINK wrist band to patient indicating COVID suspected/DHS PUI patients.
      • Provider & triage RN exit the room and initiates a new triage process in the open room for the next patient
      • Patient goes to COVID suspected/DHS PUI specific tasking rooms
        • RME 7 (internal waiting room)
        • RME 9 (phlebotomy)
        • These two rooms will be designated COVID suspected rooms and will have more frequent housekeeping cleaning
        • Tasking LVN to ensure droplet precautions are followed in these rooms and will escort patient to XR & EKGs
      • After tasking, patient will be escorted to Registration windows A-C
        • Registration sends patient to respiratory isolation area of the waiting room
      • FT team/NPs evaluates disposition from the Alcove if appropriate (use privacy screen)
    • Non-FT Candidate
      • Notify RME charge nurse for available bed in ED

.edcovid, paper charts, & discharge material

  • History:
  • Chief complaint _
  • HPI _
  • Pertinent ROS:
  • _ Fever
  • _ Cough
  • _ Rhinorrhea
  • _ Headache
  • _ Vomiting
  • Other: _
  • Past Medical History
  • _ No significant Past Medical History
  • _ High-risk Conditions: Age >65, Heart disease, Diabetes, Pregnant, Immunocompromised
  • Other: _
  • Allergies: _
  • _ No known drug allergies
  • Physical Exam:
  • _Vital signs normal
  • General: Patient is well nourished, well developed, awake and alert, in no acute distress
  • Head: Normocephalic and atraumatic
  • Eyes: Normal inspection, extraocular muscles intact
  • _ Ears: normal external exam and tympanic membranes
  • Nose & Throat: Normal external exam, moist mucosa
  • Neck: Non-meningeal
  • Cardiovascular: Patient is not tachycardic
  • _ Regular rate and rhythm without appreciable murmur
  • _ Heart rate appropriate for fever
  • Respiratory:
  • _ Patient is in no respiratory distress
  • _ Lungs are clear to auscultation bilaterally
  • Back: Normal inspection of the back with good range of motion
  • Extremities: Normal strength, capillary refills <2 seconds
  • Neuro: Normal mentation, alert and oriented, appropriately conversive, coordination appears to be adequate, ambulatory without assistance
  • Skin: Warm, dry, and intact
  • Medical Decision Making
  • _ The patient appears well, is in no respiratory distress, and does not meet the clinical inclusion criteria for COVID-19 testing. The patient is not in the high-risk category for flu testing and treatment with anti-viral medication. The lung exam does not support a diagnosis of pneumonia. The history and physical are inconsistent with pulmonary embolism.
  • Clinical Impression/Plan
  • _ Influenza-like illness/viral syndrome: The patient was counseled on self care: rest, staying hydrated, taking acetaminophen/ibuprofen for fever, and avoiding close contact with others fever-free for >24 hours. We discussed returning to the emergency department if fevers persist more than 5 days, they develop difficulty breathing, they are unable to tolerate liquids, or they become confused or develop neck stiffness.

==

  • Orchid electronic discharge available under “Understanding 2019 Novel Coronavirus”

COVID FAQ's

  • Start Here

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"
  • 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 AAED or PED, not RME); 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 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.
  • PUI patients are not allowed to use the sink or toilet. Mechanical should bring a porta-potty for patient use.
  • 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. We will receive additional training on these in the future.
  • There is a cart in the AAED that contains all of the PPE equipment to care for a PUI patient. It is currently across from the B side desk in the AAED, and looks like all the other yellow PPE carts. We are in the process of having it marked with a large "E" to distinguish it from the other PPE carts.
  • 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.
  • The instruction book also contains a log to record who goes in and out of a PUI room.
  • 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.

M. Peterson 5/8/15

See Also

References