Difference between revisions of "WLAVA:Enhanced Screening Tent"

(Primary Screen)
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* Occurs at the entrance to Building 500.
 
* Occurs at the entrance to Building 500.
  
[[File:Primary screening.png|thumb|center|Primary Screening WLA VA MC]]  
+
[[File:Primary screening2.png|thumb|center|Primary Screening WLA VA MC]]
  
 
==Secondary Screen==
 
==Secondary Screen==

Revision as of 01:55, 27 March 2020

Mission of EST

  • The mission of the tent is to rapidly triage ambulatory patients presenting to WLA VA MC that failed primary COVID-19 screen when attempting to enter the medical center or who presented directly to EST.
  • This is not a clinic that provides a comprehensive evaluation but we can facilitate coordination of urgent telehealth visits.

Patient & Staff Safety

  • All persons inside of the tent must be wearing at least a Level 1 surgical mask (may not enter tent without a surgical mask).
  • We want to minimize the time that patients spend inside the EST so that we minimize their exposure to persons that may have COVID-19.
  • Staff safety is a priority and we must help/remind each other maintain proper precautions when involved in direct patient care.
    • Also important to ensure that staff break area is clean (do not bring soiled PPE to break area).

How To Keep Yourself Protected

  • The virus (SARS-CoV-2) cannot jump on you or go through your intact skin. If you keep a distance and do not touch your eyes, nose, or mouth (mucosa) you will be safe.
  • The EST Team has built in multiple lines of defense to keep you safe:
    • The 1st line of defense is ensuring that patients are wearing surgical mask appropriately.
    • The 2nd line of defense is good/frequent hand washing AND maintaining a safe distance (at least 3 feet) from the patient.
    • The 3rd line of defense is wearing a surgical mask and face shield.
    • The 4th line of defense is wearing gloves.
    • The purpose of gown, bouffant, and shoe covers is to keep your clothes from becoming contaminated. We suggest bringing an extra pair of clothes to change into prior to getting into car (or using disposable scrubs provided by EST Team).

Staff PPE for All Suspected COVID-19 Patients Seen in EST

  • Standard
  • Droplet
  • Contact precautions (with eye protection)
  • Eye protection (face shield or goggles)

Close Contact Definition

  • Being within approximately 6 feet (3 feet if person is wearing a mask) 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.

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.

Patient Transport to the Hospital/ED

  • 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 (surgical mask and face shield at least).
  • 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.

General PPE Training

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

Primary Screen

  • Occurs at the entrance to Building 500.
Primary Screening WLA VA MC

Secondary Screen

  • Occurs in the first stage tent, completed by RN.

You Will Always Be Supported

  • Providers working the tent always have the option to phone a friend:
    • ID is on call 24/7 for discussions regarding COVID-19 testing.
      • UCLA Pager 89321 (Call 310-206-8477)
    • ED is on call 24/7 for help with disposition of patients if you think you need an ED consult prior to disposition.
      • x53169 or 310-268-3169
      • ED provider would be added as a co-signer on your EST note, if ED provider agrees with disposition decision.
      • If ED provider does not agree with your disposition, then send to ED for further evaluation.

Minimize Close Contact With Patient

  • Staff safety is our primary priority.
  • We are a triaging tent, not a comprehensive primary care or urgent care clinic.
  • Our job is to ensure that patients are stable enough to wait a few days for a telehealth appointment.

Focus On What Will Change Patient Management

  • We are here to rapidly triage and reassure patients/employees.
  • We are NOT here to provide a definitive diagnosis.
  • The majority of patients can be triaged at a distance using the "eyeball" test (i.e., sick versus non-sick).
  • If you are about to touch the patient, always STOP to think "is what I am about to do going to change my management?"
    • We encourage empiric treatment/management in the EST.
    • For example:
      • Patients reported mild dyspnea but they are speaking in full sentences, are afebrile, are not tachypneic, and have unremarkable oxygen saturation on room air.
        • The lung auscultation exam is unlikely to change your management, so why expose yourself?
        • This patient is likely stable to wait a few days for a formal telehealth evaluation after recommending empiric treatment in EST.
          • If you are worried that the patient is wheezing, treat them empirically and discharge them with albuterol.
          • If you are worried that the patient has a pneumonia (unlikely if they are afebrile and have unremarkable respiratory vitals) you have the option to treat empirically with antibiotics (dispensed in the tent).

Help Coordinate Urgent Telehealth F/U

  • For assigned patients we use the ED PACT Tool to notify their PCP.
  • For unassigned patients we will place a Primary Care Consult AND add lead for the clinic as a cosigner.

Testing for COVID-19

  • We are not testing ANY asymptomatic patients presenting to the tent.
    • We at screening for patients with symptoms of an acute respiratory illness.
  • You always have the option of discussing a case with ID (UCLA Pager 89321) to decide on COVID-19 testing as the criteria change day-to-day.
  • We perform testing for COVID-19 in symptomatic patients meeting PUI criteria, if knowing their COVID-19 status will change our management:
    • Symptomatic GLA Employees with direct patient care.
      • It guides our return to work instructions.
    • Symptomatic resident of a long-term care facility (i.e., CLC, CalVet).
      • Patient may require admission to avoid outbreak at their living facility.
    • Symptomatic patient in congregate living setting (i.e., DOM, senior assisted-living facility, homeless shelter).
      • Patient may require admission to avoid outbreak at their living facility.
    • Symptomatic patients that are at high risk for severe disease (age > 65, h/o lung or heart disease, immunocompromised, active cancer treatment, severe obesity, uncontrolled DM, HTN).
      • They do not require admission if otherwise well, but will require close f/u.
  • All asymptomatic patients or mildly symptomatic patients that do not meet the above criteria will not receive COVID-19 testing at this time.

WLA VA ID COVID-19 Testing Algorithm

  • Last Updated 3/26/20
WLA VA Tent Testing Algorithm

LADPH PUI Criteria

LADPH PUI Criteria

Employee Health Mission

  • We are testing symptomatic employees with a history of exposure to COVID19 for COVID19 if they are involved in direct patient care as it will guide our return to work instructions.
  • Employee Health (x53522).

Suggested Management Algorithm for Patients Presenting to EST

  • Is patient ambulatory?
    • YES -> Go to next step
    • NO -> Go to ED
  • Is patient obviously sick appearing (i.e., in severe pain, visibly tachypneic, somnolent, diaphoretic, etc.)?
    • YES -> Go to ED
    • NO -> Go to next step
  • Check focused vital signs:
    • HR >110, SBP < 100, RR> 25 SaO2 < 94%
      • YES -> Send to ED with warm handoff
      • NO -> Go to next step
  • Does patient have a fever AND...?
    • Fever alone is not a reason for ED evaluation if the patient is well appearing, is able to care for self and has no obvious finding suggestive of serious bacterial illness or SIRS criteria.
    • Does patient have a fever AND:
      • Meet SIRS criteria or acute/new significant dyspnea or chest pain or productive cough or unable to care for self or obvious signs of serious bacterial illness (abdominal pain, pyelo, cellulitis, etc).
        • YES -> Send to ED with warm handoff or consider ED consult
        • No --> go to next step
  • Does patient meet "Wild Card" criteria?
    • Wild Card = Patient with a high-risk co-morbidity (Immunocompromised, Age > 65 years, significant lung or heart disease history, active malignancy, severe obesity, uncontrolled DM)
      • YES -> consider ED or ID consult (if patient has URI sx and concern for COVID19).
      • NO -> Go to Step 6
  • Significant acute/new shortness of breath that affects activities of daily living?
    • No -> Treat empirically and discharge home with urgent f/u
    • Yes -> consider ED consult

LIP Orientation

Provider Orientation

EST Handouts

Educational Materials

Other WLA VA Pages

Authors:

Manuel Celedon