WLAVA:COVID19 ED Operational Updates

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

♦♦♦BREAKING NEWS 6/30/20♦♦♦

GLA UNIVERSAL MASKING POLICY

  • Please wear a mask at all times.
  • Please remind staff and patients to wear a mask appropriately.
    • It is for our own good to prevent spread of employee transmission.

ED BREAKROOM

  • No eating at MD workstations.
  • No more than 2 people in ED breakroom.
    • Eat outside or in private area.
  • No potlucks, parties, shared food/drinks.

EMPLOYEE SYMPTOM SELF-REFERRAL TOOL

SEROLOGICAL TESTING

  • Getting the test:
    • Free serological testing will be available to all employees on a voluntary basis
    • Blood draw occurs through the outpatient lab
      • Submit LEAF request (VA Intranet) PRIOR to blood draw
      • Expect 1-2 day delay in processing prior to being able to show up at outpatient lab
  • Serological testing results:
    • Serology results are now available online.
    • Click this link and you will be taken to this screen:
    • Enter your DOB and click "apply"
    • You will need both patient-level CPRS and your Network Username in VistA. Easiest way to do this would be at the VA.
    • Contact Employee Health (310) 268-3522 if you do not see your results
    • If you don't see the title "Covid-19 Employee Self-Lookup" after clicking the "Apply" button, please email VHAGLADataAnalysisHelp@va.gov with a screenshot of any other error message.

REVISED CARDIOLOGY ADMISSION CRITERIA

  • Please note that the Cardiology team cannot care for ICU level patients. Patients requiring ICU level of care will be admitted by the MICU team with mandatory cardiology consult. This includes, but not limited to:
    • Hemodynamically Unstable Arrhythmias:
      • Atrial fibrillation / flutter requiring titratable gtts for rate control
      • Ventricular tachycardia/VF electrical storm/multiple ICD shocks
      • High degree/complete heart block (with or without temporary pacing wire)
    • Cardiogenic shock, with or without mechanical support (ie. Impella), or heart failure requiring frequent titration of vasoactive gtts
    • Acute Coronary Syndrome
      • Unstable angina/NSTEMI that is hemodynamically unstable, requiring NTG gtt or other vasoactive gtts
      • STEMI

ED IPAD PROGRAM

  • Kat Yip is spearheading our iPad deployment program (SOP pending).
  • Aims of the program:
    • Allow Veterans to stay connected to family using video technology.
    • To decrease unnecessary face-to-face time (F2F) while evaluating a patient with symptoms of COVID.
  • Apple ID p/w (case sensitive): Covid2019**
  • Please clean, turn off after use (preserve battery), and return to locked cabinet.
  • Key to locked cabinet is in red lock box inside the ED Provider Workstation area.
  • Email Manny and Kat for feedback/issues.

GOOGLE GROUPS EMAILS

  • You might not be receiving important emails and they could be going to your spam email if you don’t white-list google groups (hopefully somehow you're getting this one or Jonie's previous email)
  • In case you don’t have it, here’s how.
    • Please whitelist these addresses – best way is to create a filter in your email settings or adding them to your email’s contact list.
      • vaed-all-providers@googlegroups.com
      • vaed-fee-basis@googlegroups.com
      • vaem-faculty@googlegroups.com -- (for faculty)
    • For Gmail
      • Click the gear icon on the top right and select see all settings
      • Click the Filters and Blocked addresses tab
      • Scroll down a little and click Create a New Filter
      • In the pop-up window enter @googlegroups.com
      • Click Create filter (it may look greyed out but you can click it)
      • Check “Never send it to spam”
      • Click “Create filter”

BYTEBLOC

  • Annoyed by the DAILY bytebloc emails reminding you of your shifts? Here’s how to turn them off
  • Log in to bytebloc
  • Click on Staff
  • Click User Options
  • Go to Email notifications tab and edit your preferences

SNF OUTBREAK

  • Low threshold to place SNF patients on enhanced isolation (please wear appropriate PPE!).
  • Asymptomatic patients, not able to isolate in SNF, will be directly admitted to inpatient. Symptomatic patients will go through the ED.
  • Expect that these patients will come to the ED and have a low threshold to admit.

METFORMIN RECALL

PSYCH ED PATIENTS

  • Order a CEPHEID for any patient that is placed in the psych ED regardless of whether or not you believe they are going to be discharged
  • There was a incident where a patient was asymptomatic and exposed multiple patients in the psych ED and therefore we are allowing CEPHEID for these patients specifically

ED PHARMACIST

  • We now have in house ED pharmacists: My "Phoung" Pham - program manager, Srjit "Surj" Singh, and William Duong
  • They will be sitting next to Dexter (UR) for now
  • They are available from 7a-7:30p (with 30 minute lunch)
  • Please ask for any pharmacy/medication related issues
  • They are also able to dispense naloxone from the ED and will help with patient education
  • If questions or problems, ask Cindy Koh

ED FELLOWS

  • We will be having rotating UCLA Fellows rotating through the ED as attendings a few shifts a month
  • Max Berger - UCLA MedED Fellow
  • Abdulkareem "Kareem" Agunbiade - UCLA Ultrasound Fellow
  • They will be allowed to staff patients with residents

CHAPERONE POLICY REMINDER

  • Chaperones must be present for sensitive exams
  • Chaperones must be the same gender as the patient identifies
  • Chaperones cannot be residents, who are considered an 'extension' of the attending
  • Document the name of the chaperone in the chart
  • Males must be offered a chaperone. If they decline, document this in the chart

N95 8000S

  • We are no longer collecting the 8000s for reuse, you can discard them.
  • We are still collecting 1860/1870 in brown paper bags and placing them in the bins
  • We are not collecting the newer masks for now

FIT TESTING DATES

  • Room 0413B is in the Sim Center.
  • The Thursday sessions are still occurring but have been moved to 1pm-3pm in Room 3232
    • June 30, Room 0413B (Sim Center) 6am-12pm
    • July 1, Room 0413B (Sim Center) 6am-2pm
    • July 2, Room 0413B (Sim Center) 6am-12pm
    • July 2, Room 3232 1pm-3pm
  • FIT testing by appointment otherwise, notify us if you have not been FIT tested for the 8000 series

ED SHAREPOINT

FACULTY CME REIMBURSEMENT

  • Jonie has put the procedure here (sharepoint only)
  • Submit your educational stipend requests asap. Deadline is Sept 30, 2020
  • You will need to place the LEAF request early prior to any start date
  • Aim for August 15, 2020
  • You can purchase the product and send receipt with form ; make sure the start date is after purchase
  • No travel will be approved due to COVID-19
  • If you have any other questions, please call Patricia Moonyeen Gamboa/Patricia Cruz x43512

AIRWAY REMINDERS

AIRWAY COVERAGE

  • Expanded airway coverage by anesthesia (7a-11p DAILY) ends on 6/30 since elective surgeries will be restarting
  • We will return to covering evenings and weekends
  • We are opening up airway shifts for July
    • 11p-7a M-F
    • 7a-7p Sat/Sun
    • 7p-7a Sat/Sun
  • Please let Scott know if you can cover these shifts
    • Please continue to drop off at 7a (5 North, Rm 5003), if ED is not covering airways.

HOW TO CONTACT ANESTHESIA

  • Daytime: Vocera "COVID AIRWAY" or the airway pager.
  • After 11p: Use the call list on ED SharePoint (see below).
    • To find the call list, follow these steps:
      • Go to GLA home page
      • Go to intranet on right side of page
      • Go to Patient care on the top of the page
      • Go to big red box "WLA VA on Call Schedule"
      • Scroll down to anesthesia

ED ATTENDING AIRWAYS

  • We are still responsible for non-covid airways and crash airways in the ED or after 11p (triple night coverage).
    • You get first dibs on any airway you want.

AEROSOLIZING PROCEDURES

  • Per Dr Goetz, aerosolizing procedures are okay in PUIs as long as patients are in a negative pressure room (all private rooms in the ED currently) and all staff entering the room is donning appropriate PPE. This means N95, eye protection, face shield, gown, and gloves. This includes:
    • CPAP
    • Nebulizer treatments
    • High flow nasal cannula

UNUSED MEDICATION BAGS

  • Please make sure all used med bags are discarded.
  • Request a new bag from pharmacy.
  • It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
    • If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

GLIDESCOPE GO SHORTAGE

  • There is a national shortage of Glidescope S4 blades.
  • Please use the S3 blades instead so we can preserve the S4s for those who need them.

SECURING ETT VIDEOS

  • 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

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  • SECURING AN ET TUBE WHILE USING AN AIRWAY BOX

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  • DEMONSTRATION OF USING A PONCHO WHILE INTUBATING

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AEROSOL BOXES

  • Moved to Jonie's office (code 1453).
  • 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 AEROSOL 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, attach 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.

Box sink.jpg

  • 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 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-11p 7 days a week.
    • 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 Airway Attending.
  • Airway Team should restock cart and medications after each use.
  • Report anything missing to Derrick, Miguel and COVID champions.

ED COVID AIRWAY TEAM

  • Overnight:
    • Intubating COVID: 11p-7a
    • Buddy: A) 12a-8a B) 11p-7a

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 of the Airway Cart.
  • Best practice is to refill the cart after 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.

Clipboard.jpg COVID Airway Item Checklist

RESTOCKING CARTR

  • 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

Red box.jpg

AIRWAY MAIN PAGE

WLAVA: COVID-19 ED Airway Main

PPE REMINDERS

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

UPDATED GUIDANCE ON PPE

  • Summary of COS Guidance Document:
    • Since in the ED we won’t necessarily know the COVID status of a patient prior to doing a potentially aerosol-generating procedure on a patient (including things like peri-coronal or peri-apical abscess drainage, PTA drainage, nasal packing):
      • Our best strategy in the ED is to wear PPE assuming that the patient is COVID+ (face shield, N-95 respirator, gown, gloves)
    • Other salient points:
      • All patients and staff should always wear a mask
      • All patients and staff should maintain 6 feet of distance when possible
      • Gloves should be worn in all patient encounters and changed in between encounters
      • Hands should be washed (for 20 seconds) or hand sanitizer used after all patient encounters

USE OF DISINFECTANT WIPES

  • We are running low on Saniwipes and other disinfectant wipes
  • Please use Saniwipes to clean medical equipment only – reusable PPE, ultrasound machine, etc.
  • Do not use disinfectant wipes to clean work areas.
  • For all work areas (areas not directly involved in patient care), EMS will be providing bottles of Virex Plus Disinfectant spray or a Glance General Purpose Cleaner along with disposable rags (white) or reusable rags (green) that can be deposited in the dirty linen bins. Please ask the charge where it is being kept.
  • File:Disinfecting Procedures.pdf

3M 8000 N95 FIT TESTING

  • EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out.
    • EVERY Thursday Room 3232 12-2 is scheduled until end of July:
      • Primary purpose of this FIT testing is for rotating residents so please set aside a time for them to go to this.
      • Make sure you complete the questionnaire ahead of time.
  • Please notify us if you have not been FIT tested for the 8000 series and cannot make one of these dates before your next shift! They are really flexible and will work with our schedules but we need to know ahead of time what works for you so they can be available.

PAPR CLEANING

  • After intubation or CODE with PAPR use, remind the charge nurse to call SPS to pick it up for cleaning.
  • Place 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 there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team ASAP.

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.

SPS N95 COLLECTION

  • SPS Collecting ALL N95s.
  • You will NOT be getting these masks back to you.
    • The VA intends to stockpile these in case of an emergency.
    • Therefore if you need to keep them for a certain reason (I.e. failed 8000 testing), please keep them yourselves. * Chief of Staff published another guidance document outlining collection of all N95 face masks (including the 8000 series)
    • We ARE collecting the mask if used for intubation/buddy/aerosolizing procedure (if not visibly soiled or ruined).
    • DO NOT SAVE N95 IF THE FOLLOWING CRITERIA ARE MET:
      • If the mask is visibly soiled or deformed/destroyed.
  • Please label the mask with your name and date, place in paper bag and again label your name and date, then deposit in the red bin the dirty utility room.
    • The care team is also responsible for providing necessary precautions to ensure safety of visitors, Veterans, and staff.

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

  • Avoid having symptomatic patients enter Building 500 if they do not require emergency care.
    • Try to accommodate their needs from the tent (i.e., page consult service if they came for appt, call pharmacy to prepare meds if came for refill, skype PCP, etc.)

TENT COVERAGE

  • Tent hours are now 8a-4:30p M-F
  • We will no longer be proctoring beyond 6/23 and tent will be staffed by other services
  • Anticipate patients will be showing up to the ED (primarily FT) during off tour hours
  • Please send out the Roche (LB) swab on these patients (do not send CEPHEID unless patient being admitted)
    • If a patient doesn't meet criteria for testing, please educate him/her. If insistent, then go ahead and swab because we do not want them tested outside the system
  • Make sure to use the ED PACT tool liberally for patients that have an assigned PMD to f/u on test
    • Alternatively, if an employee, make sure that they make an appointment to f/u with employee health
  • OP swabs are acceptable alternative if the patient is unable to tolerate the NP swab

EST PROVIDER ORIENTATION CHECKLIST

TENT ORIENTATION/PROCTORING CLARIFICATION

TENT DISPO TOOL

  • Please see the EST Provider Disposition Tool for EST workflow.
  • This decision-making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

EMPLOYEE SELF-REFERRAL TOOL

  • Please refer asymptomatic employees to Employee Health and NOT the tent
  • We are trying not to co-mingle symptomatic and asymptomatic patients
    • The Best time to test is 4-5 days after exposure so they can usually wait for an employee health appointment.
  • 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

PROPOSED WORKFLOW FOR PUIS IN TENT SEEKING TO ENTER MEDICAL CENTER

  • Many patients have been trying to re-enter the hospital after having been seen in the tent, especially if they are here for a scheduled appointment.
  • Make sure that PUIs know they cannot enter the hospital unless they have a serious medical disease requiring the ED evaluation/stabilization.
  • EST provider can help facilitate their outpatient care by doing the following:
    • Have them skype the clerk to set up a follow up appointment.
    • If the patient is insistent about being seen, you can set up a telehealth encounter with the clinic.
      • Page the desired service
      • They can see the patient in the EST.
      • They can arrange for outpatient VVC appointment.
      • If medications are ordered for the patient, have the service order the medications and call the pharmacy to prepare them. Then have the service call EST to notify that they are ready for pickup and EST can send a runner to the pharmacy.
  • The purpose of this is to allow the patient to have his appointment but with a virtual encounter instead.
  • We will be seeing more of this as clinics start re-opening.
  • Please make sure you proctor the dental residents as such.

SYMPTOMATIC EMPLOYEES IN EST

  • Please test all symptomatic employees in EST, do not refer to Employee Health (unless EST is overwhelmed with patients).
  • Please test all asymptomatic employees presenting to the EST if they are within optimal testing window (4-6 days from known exposure).
    • Ideally these employees are reaching out to EH to schedule their testing. Please, do not turn away walk-ins unless they are not at least 4 days from known exposure.
    • In the rare event that you have to transfer a symptomatic patient to EH, please call in advance so that the employee remains outside the EH waiting room (it is a shared area for asymptomatic employees and job applicants).
    • Employee Health Contact Information:
      • Mirasol Button X44325
      • Angella Burrell x40281
      • EH main line x53522

NEW CPRS NOTE TEMPLATES

  • Search "Tent" in CPRS Note library:
    • Enhanced Screening Tent Provider Note
    • Employee Health Enhanced Screening Tent Note
  • Please pay attention to the *** sections as they provide guidance to make the flow less redundant or clunky.

TENT 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 GENERAL INFORMATION

  • EST open M-F 7a-11p &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).
  • Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff

PRE-PROCEDURE TENT

  • The pre-procedure tent will be getting more volume as the hospital expands operations.
  • If you haven't noticed, there are two sides to the tent - symptomatic tent and the pre-procedural tent for those needing surveillance screening prior to their operations, infusion, dialysis, etc.
  • For patients to show up in the pre-procedure tent, they must have an appointment and order by the original provider.
  • Some of these asymptomatic patients are being sent to the tent without orders or an appointment and then need to be seen in the symptomatic side because they need an order from the tent provider.
  • If they end up being seen by the tent provider, please perform the test. Then try to locate the service/individual who sent them to provide directed feedback that they should be placing the order and having the patient make an appointment.
  • If you are unable to locate the sending provider, email

vhawlaest@va.gov (or for any other tent issues) with the information so that the tent leadership can follow up.

  • Our goal is to keep the pre-procedure patients (who are higher risk usually) separate from the symptomatic ones in the screening tent.

TENT MAIN PAGES

Tent Remote SKYPE

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

COVID WORKFLOW REMINDERS

COVID-19 TRIAGE SCREEN

  • Please make sure to review the COVID-19 Screen section of the ED RN Triage Note.
  • ED Nurses are supposed to notify the Charge Nurse of any patient that screens positive (these patients should be placed in a private room with isolation orders).
  • This information is supposed to be relayed to ED provider, but it may not be happening routinely (please let Manny know if it isn’t).
  • If after you see the patient, you feel that their COVID-19 screen is actually negative (i.e., patient cough is chronic without acute change) please document that in your note.

TESTING ASYMPTOMATIC PATIENTS

  • If a patient insists on being swabbed while being asymptomatic, please try your best to educate the patient about why it is not necessary.
  • If the patient is still insistent and says they’ll get swabbed elsewhere (e.g. county), please just go ahead and swab them. We do not want our patients to be swabbed outside or system.
  • Send the LB (Roche) tests on these people and NOT the CEPHEID

CEPHEID TESTING

  • CEPHEID results are required prior to bed 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.

NP SWABS

  • If the patient is unable to tolerate a nasopharyngeal swab (coughing, gagging, restlessness), it is fine to do an oropharyngeal swab. These are the same swabs, just inform the nurse that the sampling is different.

COVID TESTING FOR TRANSFERS

  • GLA's unwritten policy is that COVID testing is not a prerequisite for transfer of a patient to WLA from another facility
    • If the patient is stable for transfer, then the transfer should occur
    • COVID testing can be done in the ED and the patient's destination determined as a results
  • Please let Manny know when this happens as he is keeping track of the volume of these patients

NEGATIVE PRESSURE ROOMS

  • All private rooms in the main ED are negative pressure rooms.
  • Move patient to negative pressure room if plan to perform aerosolizing procedure.

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.

CLARIFICATION ON NIPPV

  • There is no absolute contraindication for NIPPV in COVID unknown patients. We do not have an institutional policy against it.
  • However, we must continue to be very judicious with its use.
  • It is generally not recommended in COVID PUIs and decision should be made with consideration for HCW exposure (risk higher with BIPAP vs HFNC).
  • If suspicion for COVID is low and patient may benefit from NIPPV, have a discussion with care team (RN and RT) to weigh risks/benefits.
  • Obtain CEPHEID early on these patients.

HOW TO ORDER CEPHEID (RAPID) TEST

  • CEPHEID order in ED Order Menu Screen
CEPHEID Order

CEPHEID REPEAT TESTING

  • If a patient had a CEPHEID done for an anticipated admission, left AMA or eloped briefly and returned to the ED for admission, the COVID-19 test does not need to be repeated.
  • COVID test is assumed good for 5 days provided that the patient is not newly symptomatic.
    • We have not clarified other bouncebacks yet with the other services.

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.

COVID Admissions

  • Back to MICU

DIRECT ADMISSIONS

  • Direct admissions will not require COVID results.
  • They can be admitted as a PUI and have it done on the ward.
  • Therefore, you should not be receiving patients in the ED just to get COVID testing before going upstairs if direct admit.

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 WORKFLOW GENERAL INFORMATION

COVID-19 Quick Guide 4/24/20

  • Last Updated: 4/24/20
COVID Quick Guide Approach to Stable Patients

POSSIBLE COVID-19 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

HOME ISOLATION/QUARANTINE RECOMMENDATIONS

  • LA DPH home isolation handouts available in the wire rack.
    • Please send all PUIs home with handout.
  • Current advisement is to stay at home until at least 10 days after your symptoms first appeared AND 3 days after your symptoms have recovered.
    • Recovery defined by:
    • Resolution of fever for 72 hours without using antipyretics AND significant improvement in respiratory symptoms.
    • This applies even if you had URI sx, were retested and had a negative COVID-19.

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 ISOLATION PRECAUTIONS

  • 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:

[[File:Iso order.jpg|thumb|center|Isolation Order]

COVID 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:

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

OPENING OUTPATIENT SERVICES

  • Hospital is delaying opening outpatient services to 5/26 (was previously 5/18).

INPATIENT VISITATION POLICY CHANGE

  • Check your email for the policy document, highlights include:
    • Inpatient visitation under a public health emergency with social-distancing guidance
      • Visitation is prohibited with the exception of Veterans who are at the end-of-life, defined as having a prognosis of hours to short-term days.
      • Compassionate visitation exceptions will be considered on a case-by-case basis only with recommendation from the Attending Physician or Nurse Manager, and concurrence of the Chief of Staff.
    • The Attending Physician, in consultation with the Nurse Manager/Charge Nurse, will make the final decision as to whether a veteran patient may have visitors if there is conflict or concerns between staff.

EDUCATION/SIMULATION REMINDERS

MOCK CODE DRILLS REMINDER

  • Try to perform mock codes if clinical duties permit. DHS is expecting a second spike soon and nursing needs to be trained up in PPE and for these codes.
  • In particular, make sure that the RNs are familiar with the donning/doffing procedure and practice it
  • 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.

PROCTORING DOCTORS-IN-TRAINING

  • Medical students returning, not allowed to see PUIs.
  • Interns get oriented every Thursday at 10am of their new rotation.
  • Please make sure that the interns are informed of COVID, where to get appropriate PPE, and how to don and doff.
    • 8000 Masks are available from charge nurse
    • 3D printed face shields are in the upper cabinets
    • Hospital face shields are in the med room
    • Goggles will be with nursing, although it is unclear if we have enough for everyone and this will be a shared resource between physicians and nurses.
  • If the intern is not fit tested for the 8000 series, please tell them to coordinate with their chief resident.
  • If the intern is not fitted for 8000 series, please advise him/her against seeing PUIs until tested.
    • They would have to use the 1860/1870 masks and we have a limited number of those remaining and reserving those for staff that failed out of the 8000 masks.

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:

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...

UPCOMING FIT TESTING DATES

ADMINISTRATIVE REMINDERS

MEDICAL RECORDS

  • Try not to use the medical record to litigate administrative issues. Please try to make your documentation an objective record of the care you provided (including timestamps if appropriate), the consultants you spoke with, and their verbal recommendation (including name and timestamps if appropriate).
  • If you encounter an administrative or interpersonal issue (i.e., the consultant did not page you back or was rude) try to keep that off the medical record. If you have issues with a consultant paging you back, please make sure to escalate up the chain of command in realtime. We should address any patient care delays in realtime, since documenting delays in care without going up the chain of command does not necessarily release anyone from liability. The escalation should be as follows:
  1. Resident on-call
  2. Attending on-call
  3. Service Chief
  4. ED Chief and MOD
  5. CoS
  • If you come across any interpersonal issues or people making up fake policies, please email Manny a summary of the encounter and he will f/u with the corresponding service (use encryption if sending PHI).

NALOXONE NOTE

  • When signing the Naloxone note, make sure you sign your ED Note FIRST.
  • When you sign the Naloxone note first, it uses "Opioid Use Disorder" as a primary diagnosis and causes the encounter to fall out
  • By signing the ED note first, you can fill out the encounter form appropriately and give the proper diagnosis.

RAPID ACCESS/DIRECT

  • Please remember to have ED clerk obtain an appointment PRIOR to DC for any ED patient being sent to Endocrine for DM management for urgent/Rapid Access Follow-up.
  • Please confirm that this actually happens before the patient leaves the ED. Our clerks must schedule an appointment prior to ED discharge for all Rapid Access/Direct Scheduling consults.

Mask Policy

  • To mitigate exposure risk, please make sure that all ED patients (and staff) are complying with our universal masking policy. When evaluating any patient, at minimum wear eye protection and a face mask.
  • Please see attached document that outlines indications and processes for prevention of COVID transmission in the outpatient setting.

SEE ALL PATIENTS PRESENTING TO ED

  • Do Not Send Patients to the Tent from ED (EMTALA Violation).
  • If patients present to the ED but should have been screened out to the tent or seen in the tent, please do not send patients back to tent from the ED.
  • Our goal is to make sure to keep potential “walking well” COVID patients outside the hospital.
  • However, once a patient has walked into the ED for one reason or another, please just see them. We do not want these patients moving around the hospital.
  • This goes for all patients – once they have presented to the ED, we “own” them and should complete the encounter.
  • This helps us as well in terms of increasing capture for the work we are doing.

SENSITIVE EXAMINATIONS

  • Female patients must have a female chaperone
  • Male patients must be offered to have a male chaperone, document if patient declines
  • The chaperone must be the same gender as the patient identifies
  • Physician must document the name of the chaperone in the chart
  • Chaperone may not be your resident, who is considered an extension of the attending.

SHIFT SWAPS

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

AT RISK RESIDENTS

  • At-risk resident will be working on a WOW outside a room to socially isolate.

JONIE/BABY CHIEF OFFICE

  • As a reminder, please do not eat in Jonie’s office or use it for clinical work. There was an open mug of coffee with spoiled milk on Jonie’s desk that spilled. It was gross and a pain to clean, and nearly destroyed a bunch of valuable PPE and the viral filters.
  • If you need to finish charting, please use the 3rd-floor office

REMOTE ACCESS AND CHECKING VA EMAIL

  • Detailed instructions on Slack (email Manuel for access).
  • Please check your VA email while you are on shift.
  • If you need remote access, apply through this link
    • Click on “request access” and choose the “Rescute/CAG/GFE Mobile” option.
    • You will need the CAG access (using personal computers to remotely log in).

PIV EXEMPTIONS

  • There may be some problems with the mass PIV exemption. If you run into issues, you can try one of these avenues

call *14 - Enterprise Service Desk

  • Dwight.Brown2@va.gov
  • Shawn.Arnold@va.gov
  • Incident/Ticket number is IVC1043797

UCLA BADGE & MEDNET EMAIL 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 & FREE APPS

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
  • 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

COVID-19 VA Cases Nationally

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

Emergency Alerting & Accountability System (EAAS)

Other WLA VA Pages

WLA VA COVID19 Page Listing