Harbor:Infectious Disease Threats

Coronavirus (COVID-19)

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

Current Harbor Guidelines

DHS Visitor Policy 6/15/21

  • Signage posted at the entrances (no individual screening)
    • In the last 24 hours, have you had a temperature of ≥100.4 ̊F and/or thought you had a fever?
    • In the last 24 hours, have you had a cough, shortness of breath, difficulty breathing, chills, muscle or body aches, new loss of taste or smell?
    • If you have not been vaccinated against COVID-19, have you had any contact with someone who had a confirmed case of COVID-19/coronavirus in the past 14 days?
      • If Positive screen, ok if with PED or patient who needs assistance (but the visitor must be masked)
        • Parents who have recently been exposed to COVID-19 may still come into building if they have received and are two weeks beyond all required doses of the COVID-19 vaccination and can show proof of vaccination.
  • MUST wear a facility-provided face mask at all times while in the hospital
    • Patients who refuse to wear a mask will be required to remain outside of building until the time of appointment at which time only the patient (no visitors) will be directly escorted to the appointment site
    • Failure of a visitor to mask will result in being asked to immediately leave the hospital; must stay in the patient’s room for the entire visit except as noted below
  • 2 visitors in the ED
    • Visitors may be required to wear appropriate PPE, per Nursing instructions based on isolation precautions. In some circumstances, visitors may only be able to view the patient from outside of the room.

Vaccines

  • COVID VACCINES AVAILABLE to ALL PATIENTS 12 and older with ORCHID MRN:
  • Pharmacy spectra x29012 for any questions about open vials/available doses
    • While in the ED
      • Provider will order the Janssen or Pfizer vaccine
      • RN will complete Ad Hoc COVID Screening Vaccine powerform
      • Pharmacy will notify RME Charge that dose is ready for pick up; RN to complete vaccine card and give pt info sheet (comes with the shot from pharmacy)
      • If Pfizer, for 2nd dose:
      • Option 1: Give patient the packet from pharmacy and they will call to schedule themselves into the vaccine clinic
        • Coming in July - DHS will reach out to patient to schedule 2nd dose.
          • Option 2: Clerk to schedule 2nd appt in Vaccine Clinic
            • appt type: PC Immunization COVID 19 New Nurse Walk-In
            • appt location: HAR Express
            • Confirm appt —> conversation: Immunization Prereg
        • Coming soon: Provider to schedule into Urgent Care Teams in evening nursing appts
    • Outpatient
      • Can be OOP or MHLA ... planning for OOP clinic in N-28 after COVID Vaccine Clinic closes
      • Can schedule or patient can call or walk in
        • Patient can call Patient Access Center (PAC) x66500 to schedule
        • Have patient pick a time, then mark depart process needs appt. ED clerk can schedule and give them the appointment confirmation page
          • clerk selects:
            • appt type: PC Immunization COVID 19 New Nurse Walk-In
            • appt location: HAR Express
            • Confirm appt —> conversation: Immunization Prereg
      • Fridays either 8a-noon or 1p-4p

Testing

  • Send COVID test on all patients likely to be admitted or transferred, or any deaths in the ED
    • Asymptomatic patients with repeated visits and a negative test within the past 72 hours do not need re-testing unless new symptoms
  • If asymptomatic with previous positive test:
    • If normal patient (including psych), consider GREEN after 10 days asymptomatic
    • If severe disease or immunocompromised, consider GREEN after 20 days asymptomatic
    • Repeat COVID-19 testing will be restricted for patients with a documented positive PCR test result in ORCHID within the past 17 weeks and may only be ordered in consultation with local COVID team / ID consultation
  • DHS patients can be tested at N26 for pre-op
    • Must be done within 3-7 days of the procedure (stress test, surgery, etc)
    • "AMB Coronavirus Covid-19" and make as a future order; RN collect; ant nares
    • Call x67786 (N-26) with any questions

SURGE

  • If waiting room >30 patients: Start RME hallway Fast Track
  • If waiting room >50 patients or >15 high acuity patients: Start RME hallway decompression near OCN office
  • De-operationalize when <10 in WR

Admit vs OBS

  • DO not admit to Short-Stay Medicine if Symptomatic COVID (ok if asymptomatic and happens to be positive)

Home O2

  • See Microsoft Teams under ED Provider files in 'Home O2' folder
  • Be sure to give patient:
    • O2 tank and concentrator with nasal cannula, educate on how to use, and patient to call SuperCare if issues and to pick up empty O2 tank
    • Patient copy of 'Consignment Form' that was filled out for SuperCare
    • DC instructions for home O2, self proning, COVID home care & isolation
    • Arrange for CCC for 24 hour phone follow up (even if OOP/MHLA)

Public Health Quarantine & Isolation Housing

  • Homeless patient or other patient's that CANNOT safely self-isolate with mild symptoms that could be discharged,
    • Placement needed if:
      • homeless
      • congregate housing
      • has home but unable to safely self-isolate due to
        • inability to access supplies/food/medicine
        • very high likelihood of infection other household residents who are at high risk of severe complications).
      • Call SW early
      • SW will coordinate with DPH intake center (833-596-1009) 8a-8p every day File:Workflow_QI Call Center Intake 4.2.20.pdf
        • Helps with transportation
        • Need Covid test, send as 'outpatient cannot isolate'.
          • Currently is done in-house but if testing is short might be send out
        • Must be able to perform ADLs
        • There is a new intake form that needs to be filled out with a section of medical questions. Please help SW fill out the medical portion of the DPH Shelter intake form. File:DPH Shelter Isolation and Quarantine Referral Form 4-5-2020.pdf
        • If placement is available, then intake coordinator will contact and coordinate EMS transportation to arrange pick up
        • If placement is NOT available, then we will be notified that the placement is pending. Provider(s) and SW will need to consider best place for patient to wait until placement is ready.
        • If patient’s test was sent out and ends up being negative, then patient will be discharged home the isolation site.
        • If the patient’s test is positive, then patient will stay for duration of illness per DPH recommendations.
        • If COVID positive and patient wants to AMA or refusing isolation housing, patient can be discharged with education and PPE. SW will contact DPH to let them know so they can follow-up. Having as much information as possible will be helpful i.e. where patient was going to go (if known), date of last test, fever, etc.

iPads

Treatment

    • Low dose dexamethasone 6 mg PO or IV in patients who require hospitalization with supplemental oxygen (including high-flow oxygen and BiPAP)
    • Remdesivir for patients who require hospitalization with supplemental oxygen, excludes mechanical ventilation, BiPAP, and high-flow.
  • Monoclonal antibodies - see below
  • Convalescent Plasma - see posters on C3PO study in ED
  • 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).

Airway Management

  • File:Airway Checklist v5 8-19-20.pdf
  • File:Airway Management for PUI-COVID v10 8-19-20.pdf
  • If on oxygen, HFNC, or intubated, give dexamethasone 6 mg (IV or PO)
  • Obtain basic labs including liver function testing to allow the inpatient team to start remdesivir.
  • High flow nasal cannula (HFNC)
    • If requiring >6L NC, then consider HFNC, start at 30-40L/min
    • Higher flow rates likely cause higher rates of aerosolization and higher complication rates
    • Can increase to 60L/min as necessary.
    • FiO2 can be started at 100% but should be titrated at bedside prior to leaving the room to the patient’s goal SpO2
    • If require ≥40L/minute of flow or ≥60% FiO2, then MICU consultation/admission
    • If lower HFNC settings may be PCU appropriate.
    • If ≤30L/minute flow and ≤40% FiO2, they may no longer require HFNC
      • PCU: <40L/min AND <60% FiO2
      • ICU: >40L/min OR >60% FiO2
    • ROX index:
      • Proposed tool to determine success or failure in HFNC.
      • Prospectively validated for pneumonia, but not validated for COVID-19.
      • ROX Index = (SpO2/FiO2)/RR.
      • Lower scores (meaning higher respiratory rates and/or a lower SpO2/FiO2 ratio) are associated with higher intubation rates.
      • ROX Index ≥4.88 measured at 2, 6, or 12 hours after high-flow nasal cannula (HFNC) initiation is associated with a lower risk for intubation
      • ROX Index <3.85, risk of HFNC failure is high, and intubating the patient should be considered
      • ROX Index 3.85 to <4.88, the scoring could be repeated one or two hours later for further evaluation
    • https://www.fphcare.com/us/hospital/adult-respiratory/optiflow/frequently-asked-questions/#q_protocol
  • Endotracheal intubation (ETI)
    • Video laryngoscopy with a screen separate from the insertion blade is the preferred
    • Direct laryngoscopy should be used when COVID is not suspected.
    • RSI w/ high dose (1-1.2 mg/kg ideal body weight) rocuronium preferred
    • If first pass unsuccessful, consider a LMA as an oxygenation and ventilation strategy to reduce aerosolization compared with BVM.
  • Preoxygengation
    • Keep the HFNC @100% FiO2 on during RSI. Turn off the HFNC immediately prior to inserting the laryngoscope.
    • Remove HFNC and use a BVM with attached viral filter and with waveform capnography.
    • If using apneic oxygenation, use the lowest flow necessary.
  • Post-Intubation
    • Post-intubation sedation with fentanyl and propofol is preferred
    • Should be in the room during the ETI of the patient and immediately started.
    • Post-intubation CXR delayed until after NG/OG, +/- central line insertion to minimize the number of entries into the room.
    • Consider norepinephrine to mitigate or manage post-intubation hypotension.
    • PPE should be removed with a “spotter” and disposed of properly.

EMS runs

  • AGPs should not be performed in the hallways.
    • Includes BVM without ETT/King airway. EMS should stop bagging until in a room.
    • Includes CPAP. EMS should place on NRB with surgical mask over it until in a room.
  • Thus, for ROSCs/Critical medical arrivals, a physician should meet the EMS crew on the ambulance ramp and:
    • 1) determine if an AGP is being performed,
    • 2) ask the EMS crew to hold the AGP until in the room,
    • 3) escort them directly to the room, and
    • 4) instruct recommencement of the AGP as soon as safely possible.
    • Note: BVM via a King airway or other supraglottic airway (SGA) or ETT with a viral filter is not an AGP.

OLD COVID INFO (...so 2020)

COVID physician leads

  • AED Flow/Discharges- Andrea/Brad
  • COVID testing - Andrea
  • Drug/Non-PPE Shortages - Andrea
  • Email Updates - Andrea
  • Triage/Fast Track Tents/RME - Brad
  • PED issues - Patricia
  • PPE - Shira
  • EMS - Shira
  • Airway - Ryan
  • ACLS - Shira
  • Palliative Care/End-Of-Life Issues - Tim J.
  • Environmental Services/Cleaning Protocols - Moh
  • Non-Emergency Physicians in the Emergency Department - Andrea
  • Back-up Attending Schedule - Kelly


COVID Terminology

  • “Pink”
    • respiratory complaint/Not PUI
    • Need droplet/contact PPE
    • pink wrist bands = need mask.
  • “PUI”
    • Meet DHS Testing Criteria (See below)
  • Disaster track categories
    • The router will place initial category,
    • Ask nurse to change as necessary (can use communication order)
      • Categories
        • COVID EXPOSURE – no symptoms but at risk
        • COVID FT – ILI symptoms (Cough, fever or SOB)
        • COVID AED – not PUI but too complicated for quick dispo
        • COVID PUI – meet DHS testing criteria
  • Direct to clinic for GREEN patients:
    • Triage provider speaks to the consultant after medical screening exam (MSE) to determine if patient can:
      • 1) be seen immediately in clinic (during business hours)
      • 2) needs to stay in ED for consult
      • 3) can be scheduled as outpatient if DHS eligible or 4) sent back to PCP or CCC referral, if needed.
      • Examples include isolated ortho, ophtho, ENT, OMFS complaint.


Covid Surge Plan Summary, details see below.

  • If waiting room >30 patients: Start RME hallway Fast Track
  • If waiting room >50 patients or >15 high acuity patients: Start RME hallway decompression near OCN office
  • If waiting room >30 patients AND >10 ward bed boarders: Contact OCN to notify Hospital Admin to see if can have ward patients go out of nursing ratios upstairs.
  • Maximize ED space:
    • FT in PED, Middle Track (MT) in R5-10
      • PED 6-11 use for adult FT patients if PED has capacity
      • Provider staffing
        • Assign to purple/green from Midnight to 9am
        • NP @ 9am
        • PGY 4 + PGY 2 @ 3p-MN
        • If NP unable to keep up, PEDS can help or assign to ED team
      • PED Charge RN to pull from Orange FT list (ESI 4&5)
      • If DHS & labeled “ok for UCC”, send to UCC not FT
      • FT provider: Label anyone in WR you want to see as “FT”
      • 3:1 RN ratio.
      • RN to DC as you see next patient
      • If adult attending in PED, can staff with them; otherwise, green (or purple) attending
      • If PED gets busy, flex P10-11
      • MT in R5-10
        • ESI 3s completed work ups
      • R4+R2 M-F 3p-12a
      • R5-7 to Green, 8-10 to Purple other hours
      • Charge RN pull from Orange FT list (ESI 3)
    • Coordinate with OCN to free up beds:
      • Option 1: Consider moving stable patients (such as FT and Middle Track, or other that's do not need a monitor) patients from rooms into hallway chairs to open up more monitored ED beds for sick patients or to see the next patient FT/MT patient.
      • Option 2: RME rooms may need to be used for AED patients rather than Middle Track
      • Option 3: Additional PED rooms may need to be used for AED patients if PED has capacity
  • ED Surge Plans
    • Waiting rooms includes AWR, PWR, R12 (as the internal waiting room for sick patients), and R1-5 for tasking.
    • Before requesting additional space, we need to make sure all ED space is being utilized fully. Therefore, all monitored rooms, including PED + RME hallway are being used.
    • De-operationalize when <10 in WR
  • ED Surge 1
    • Trigger: if > 30 in waiting rooms
    • Space: RME hallway chairs (aka X chairs 1-8)
    • Decision: The ED attending and OCN have the ability to make this decision together.
    • Communicate: Please just FYI text the DEM admin on call. The OCN should FYI text J. LaGrone, the Clinical Nursing Director (CND). Hospital admin has requested that we just notify them when this space is needed.
    • Time: Takes ~30 min to operationalize.
    • Staff: Need 2 additional nurses to staff (1 per 4-chair assignment)
    • Similar to FT process above
    • Keep Green if possible
  • ED Surge 2
    • Trigger: > 50 in waiting rooms
    • Space:
      • requesting Gold beds.
      • If Gold already being used by ED, then move stable patients that do not need monitor out into RME hallway near OCN office. (separate area from RME hallway X unit FT chairs)
    • Decision:
      • must by made by hospital admin if need to request additional space.
      • If opening RME hallway near OCN office, then FYI DEM admin on call and OCN to notify CND, J. LaGrone, to FYI inform hospital admin need to use hallway space.
    • Communicate:
      • The ED attending and OCN must agree that additional space is needed, and have enough nursing staff for additional rooms
      • Then the ED attending should call the DEM admin on call, and the OCN will contact CND J. LaGrone.
        • DEM admin on call and CND will joint decide need to request for Gold, or other additional space if Gold is already being used by ED.
      • J. LaGrone will then contact hospital admin to request Gold for ED use.
    • Time: Takes ~1 hour to operationalize.
  • High acuity surge >15 higher acuity patients (sick ESI 2 or 3s)
    • Trigger: >15 sick high acuity patients
      • Sick = critically abnormal vital signs, critically abnormal lab(s), labeled as ‘R12’, ‘AED Next’ or critical medical or trauma activation patient coming in with EMS.
    • Space:
      • request for Gold beds.
      • If Gold already being used by ED, then move stable patients that do not need monitor out into RME hallway near OCN office.
    • Decision: must by made by hospital admin to request for additional space. Otherwise, FYI hospital admin need to use hallway space.
    • Communicate: Follow steps above for communication
    • Time: Takes ~1 hour to operationalize.
    • Coordinate with OCN to free up beds:
      • Start labeling who is stable to move out of monitored rooms early. Get patients discharged and admitted patients upstairs.
      • Consider moving stable patients from AED to open PED rooms if available
  • If continued severe ED overcrowding persistently over several days, then there are plans potentially use the 'Spine' and 'Disaster Tents' can be implemented by ED operations team and Hospital Administration.


Harbor Checklists & Resources

Triage

  • PUI going direct to room - do not order triage labs
  • PINK wristband = mask + respiratory isolation area (R2 IWR, R4 tasking, alcove in WR)
  • Patient waiting in car - documentation needed.
    • Router identifies which patient wants to go to the car
    • Team triage provider has convo w/ patient, then updates MSE note to document
    • Excludes ESI 2. Ok if patient requests it and ESI 3-5.
    • Suggested script: “Patient chose to go wait in their car after discussion with staff. Patient understands their evaluation is not yet complete and currently the wait time for a patient with your complaint is XX. Patient understands that there is some risk to go wait in their car, as he/she is unable to be monitored and reassessed, and is aware that waiting in the waiting room is preferred. Patient has capacity to make this decision.”
    • Call patient when patient is next up for room. If don’t answer then is NA1, 2, 3, etc., document called patient’s preferred phone number.
    • Don’t have to call for reassessments.
  • If you have a patient that does not have any symptoms of COVID and has an isolated complaint that can be managed in a specialty clinic:
    • Triage provider speaks to the consult person right away after medical screening exam (MSE) re: Green patients and determining if they can:
      • Be seen immediately in clinic (during business hours),
      • needs to stay in ED for consult,
      • can be scheduled as outpatient if DHS eligible or
      • sent back to PCP or CCC referral, if needed.
      • Examples include, isolated ortho, ophtho, ENT, OMFS complaint.

COVID Visitor Policy 9/22/2020 File:DHS COVID Visitation.pdf

  • Policy was revised to reflect expansions in visitor/family access to patients.
  • The major changes include:
    • Adding COVID+ patients to those patients for whom end-of-life visitors is permitted.
    • Permitting a single person who is needed to assist a patient while s/he is seeking care in the ED
      • e.g., parent of Pediatric patient or caregiver for patient who requires assistance
    • Up to 2 visitors for ED patients in critical condition (including COVID+ patients) and end of life
      • At the discretion of the clinical care team.
    • Up to 2 visitors in ED t to view a patient who has expired
      • For COVID+ patients, visitors may only be able to view the patient from outside of the room.

DHS PUI Testing Criteria

  • Outpatient testing criteria:
    • No longer have to refer such patients elsewhere for testing.
    • Test indication dropdown “Outpatient – CAN self-isolate”, so it does not take up one of our limited rapid in-house test spots (it will be sent out with a turnaround of 1-2 days)
    • Criteria for outpatient testing:
  1. cough, OR
  2. shortness of breath, OR
  3. any two of the following symptoms:
    1. Fever
    2. Chills
    3. Repeated shaking with chills
    4. Muscle pain
    5. Headache
    6. Sore throat
    7. New loss of taste or smell
  • Please remember to CCC under the “Lab Follow-up HAR” for any tests you send that do not result before discharge.
  • ID is available 24/7 if you are unclear if they meet PUI criteria (pager 0343)

Harbor COVID-19 Testing Expected Practice

  • Test all admits unless recently recovered from COVID
  • Recovered COVID 10/20d rule:
  1. If asymptomatic, recently tested positive, but symptom free for 10d AND resolution of fever for at least 24 hours, then do not need special precautions. DO NOT TEST these patients, even if getting admitted. Admit with standard precautions (Bed Control will take this as cue not to wait for COVID test result)
  2. If previously had severe illness or severely immunocompromised then isolate for 20d after symptom onset in special precautions. If outside this 20d period à DO NOT TEST these patients, even if getting admitted.
  3. If recovered from COVID, and have NEW symptoms that could be COVID, test again and isolate in special precautions. Discuss with ID or IPC if test is +
  4. Psych patients still need to be tested negative before going to Psych ED
  • Based on CDC and California DPH guidelines, patients who have recovered from COVID-19 that had previously tested positive, should not be re-tested for 3 months.
  • Possible testing for needed for cohorting of symptomatic dialysis patients for outpatient HD

In house testing approved for:

  1. Admissions
  2. Transfers where accepting facility is requiring COVID test
  3. Symptomatic outpatient HD (in order to cohort outpatient HD, consult SW early!)
  4. Psych ED bound patients
  • Anything outside of this needs to be approved by CMO.

What dropdowns get you in-house vs send out testing:

  • The following are done in-house:
    • Admit Symptomatic
      • Choose also for symptomatic HD patient. If positive, call SW to coordinate cohorted outpatient HD
    • Admit Asymptomatic
      • Choose also for transferring OOP if required by accepting facility
    • Psych-Symptomatic and Psych Asymptomatic
    • Outpatient-CANNOT self-isolate
    • Other / Per COVID consult (When approved by ID)
  • The following are sent out to reference lab for testing:
    • Pre-procedure
      • For urgent procedures/surgeries, need to write in comments, typically ordered by consultants.
      • If patient in ED, consultant will order. But consultant should NOT send patient to ED for in house testing.
    • Employee health service
    • Outpatient-CAN isolate
    • Transfer – Asymptomatic (meant for SNF or rehab placement, NOT OOP transfers)

ADMISSIONS New Adult ED Admission Flow 6/1/20

  • Decide to admit the patient, request Interqual review.
  • Stable OOP patients, transfer
    • For transfers, do not test unless requesting facility requests it
  • Patient's being redlined to OR or going to cath lab, order and send test from ED
  • Once you have contacted the admitting team, place the request for admit
    • Send the COVID test (with indications: admit symptomatic / admit asymptomatic)
    • Admitting team should place orders, and may wait for rest result to determine isolation bed type
    • MICU report will be based on suspicion for COVID. If no/low suspicion, admit to non-COVID MICU team. If moderate/high suspicion, admit to COVID MICU team.
  • Patient flow will not assign the bed until the COVID test is resulted

MICU boarders coming back to ED:

  • For inpatients that get moved to the ED for intubation or for boarding for an ICU isolation bed
  • Inpatient teams give report to ED attending.
  • ED attending places a pre-arrival note. **To streamline communication, the new Spectralinks are
    • COVID MICU Team #1 29040
    • COVID MICU Team #2 29031
    • COVID MICU Team #3 29036
    • COVID hospitalist - check banner bar
  • MICU team and Spectralink, and code status should be written on doors

PED

  • Our PICU has no negative pressure rooms.
  • Pediatric ward has 5 rooms that are negative pressure.
  • For children with URI/ILI symptoms that need to be admitted they will need to go into a negative pressure room upstairs.
  • If they require SDU or PICU placement we will need to discuss with the PICU attending.
  • The PICU has converted room 15 on the pediatric ward to be used for ICU level care and may turn a few more of the negative pressure rooms into ICU level care rooms.
  • Per ID, if a PED asthmatic patient is well enough to go home, we should not be doing COVID-19 testing.

Follow Up of Test Results for Discharged Patients

Discharge

  • Please CCC-Lab Follow-up any patient being discharged with a COVID test sent
  • DHS eligible, not empaneled: Inform clerk need to have f/u and clerk needs to write :COVID F/U or COVID +" in the Comment box…that guides PAC in terms of when to follow-up and to express empanel.
  • For DHS empaneled patients: scheduling request is with PCP
  • For DHS eligible, non-empaneled patients: scheduling request is for INT MED Discharge Clinic within CCC
  • Non-DHS patients: f/u with designated PCP


  • Anyone suspected or proven to have COVID are now REQUIRED BY LAW to
  • Consider giving patient a pulse ox to go home with.
    • Call OCN for pulse ox and give instructions on how to use.
    • Give attached discharge instructions with how to use and log for patient. File:PulseOxDischargeWIKEM.pdf
    • Home Pulse Oximeter Clinical Criteria: (Given limited supply)
      • Mild COVID-19-like illness and/or known positive
      • Well appearing, with comorbidity (elderly, DM, HTN, obesity, and/or pulmonary/cardiac disease)
      • Mild vital sign derangement in ED that does not require admission
        • Mild tachypnea (RR<22)
        • Mild resting hypoxia (Oxygen saturation 92-95%)
        • Mild tachycardia (100-115 BPM)
        • Walking pulse oximeter of 92% or greater with no respiratory distress
      • No access to pulse oximeter at home (please ask patient)
      • Patient, caretaker and/or family member has ability to understand and perform home pulse oximeter checks
      • Provider clinical judgment
      • NOTE: Patients who have more than tachypnea, hypoxia, or tachycardia that is greater than the reference numbers provided above (i.e. those who likely require admission) or those who are not able to understand how to use the device should be excluded from this home pulse oximetry program.
  • If known or suspected Covid, RN/clerk/NA can pick up prescriptions for patients from outpatient pharmacy. If after hours the patient can call 67427 to arrange for home delivery



Discharge with Home Oxygen

  • See Microsoft Teams under ED Provider files in 'Home O2' folder
  • Be sure to give patient:
    • O2 tank and concentrator with nasal cannula, educate on how to use, and patient to call SuperCare if issues and to pick up empty O2 tank
    • Patient copy of 'Consignment Form' that was filled out for SuperCare
    • DC instructions for home O2, self proning, COVID home care & isolation
    • Arrange for CCC for 24 hour phone follow up (even if OOP/MHLA)


Treatment Tips

  • DHS COVID medicaton treatment expected practice File:EP COVID-19 Medications.pdf
  • NIH guidelines
  • Treatment
    • Low dose dexamethasone 6 mg PO or IV in patients who require hospitalization with supplemental oxygen (including high-flow oxygen and BiPAP)
    • Remdesivir for patients who require hospitalization with supplemental oxygen, excludes mechanical ventilation, BiPAP, and high-flow.
  • Monoclonal antibodies - see below
  • Convalescent Plasma - see posters on C3PO study in ED
  • 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).
  • STEMI
    • if stable consider TNK in consultation with cardiology
    • if unstable, cath lab

Monoclonal Antibody Infusion Clinic

  • Consider it for patients that are getting discharged that decline C3PO, then give monoclonal flyer
  • Monoclonal Ab Info Website from the EMS Agency. Has info about the Fairview and other clinics offering to the public.
  • Info sheet for providers on who qualifies File:2- ICF mAb Flyer for Providers.pdf
    • BMI =/> 35
    • CKD
    • DM
    • Immunosuppressive disease
    • Receiving immunosuppressive treatment
    • Age ≥ 65 years of age
    • Age ≥ 55 years of age AND one of the following
      • Cardiovascular disease, OR
      • Hypertension, OR
      • COPD/other chronic respiratory disease
  • Flyer for patients
  • California EMS Authority (EMSA) is currently sponsoring a Regional Monoclonal Antibody Infusion clinic at the Fairview site, administering either Bamlanivimab or Casirivimab+Imdevima (Regeneron) patients from Southern California counties who meet criteria for monoclonal antibody infusion.
  • By appointment only, and accepts referrals from any SoCal physician, as well as patient self-referral.
  • As of now, we are encouraging ED providers to give out the flyers only, not necessarily arranging the referral phone call yourself.
  • Infusions are provided in 3 hour blocks between 8am-8pm.
  • Patients should bring a copy of their test result if available. However, if the referral is originally placed by a physician they will accept that phone referral as sufficient.
  • The site is located at the current Fairview Alternate Destination Center for COVID treatment, housed at the Fairview Developmental Center: 2501 Harbor Blvd, Costa Mesa, CA 92626
  • This may have limited utility for many of our patients with limited transportation access, since it is located in Orange County. But is a valuable resource for those who can make the trip, and it is entirely free.

Ventilator Management

  • PRVC mode, initial tidal volume: 6-8 mL/kg of predicted body weight (link)
  • If initial plateau pressure is persistently > 30 cm H2O, reduce the tidal volume by 1 mL/kg, until plateau pressure <30 H2O
  • Goal: SpO2 88-96%: Adjust PEEP and FiO2 as per table below
FiO2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
PEEP 12-14 14-16 18 18-20 18-20 22 22 22-24
  • If SpO2 <88% despite maximum FiO2 and PEEP on table above, intervene in the following order. If goal SpO2 is not achieved, proceed to the next step on the list.
    • Prone the patient
    • Observe for signs of dyssynchrony with the ventilator (e.g. initiating a new breath before full exhalation, coughing/auto-triggering). If present, first increase sedation to RASS of -4. If persistent, give single dose non-depolarizing paralytic (e.g. vecuronium 0.1mg/kg)
    • Seek expert (MICU) consultation to place patient on APRV
    • If above steps and MICU consultation fail to stabilize oxygenation of patient, V-V ECMO may be considered for select patients. Contact trauma attending to reach Dennis Kim.

Antibiotics

  • CAP treatment for intubated patients with ARDS per surviving sepsis guidelines

Fluid resuscitation

  • For hemodynamically stable patients with ARDS, avoid fluid resuscitation
  • For hemodynamically unstable patients with ARDS, consider small (500mL) fluid boluses and early norepinephrine

PPE

  • Recommendation for PPE File:Guidelines for PPE Use_7_13_2020.pdf
    • https://www.youtube.com/watch?v=syh5UnC6G2k&feature=youtu.be
    • In general, wear surgical masks (ties) or procedure mask (ear loops) and eye protection (goggles or face shield) while working in the ED since we often deal with limited information when evaluating patients. Personal glasses or the traditional ED disposable plastic glasses are not sufficient.
    • If a patient is getting a high-risk aerosol generating procedure (AGP) then airborne precautions are preferred in addition to contact and droplet precautions. AGP include intubation, NIPPV (BiPAP/CPAP), high flow oxygen, nebulizers, CPR, and suctioning, to name a few relevant in the ED. If need to do NIPPV, nebs, HFNC try your best to place surgical mask over.
    • Once intubated, or after an AGP is completed, patient needs airborne precautions x 1 hr if vent is not being disconnected or if patient is not getting suction. Since an ETT connected to a vent is a closed circuit, after 1 hour the patient goes back onto droplet/contact precautions. If other AGP done again then 1 hr clock restarts needing airborne precautions. If patient was dispositioned out of the ED while still in airborne precautions, then will need terminal clean with 1-hour air exchange.
    • If no AGP, then patient needs to wear a mask and have contact and droplet precautions with closed door. So for example, if a masked ‘pink’ patient is going to CT without an AGP, only need a wipe down as per usual contact/droplet cleaning, and does not need a terminal clean.
    • After a Pink or PUI patient leaves the ED, the room may be cleaned immediately per droplet/contact precautions, unless there was an AGP was done in the previous 1 hour.
    • Only need terminal clean if aerosol generating procedure (AGP) done, otherwise just droplet precaution cleaning with wipes
  • ILC-Dover PAPR in purple Acute doc box.
  • CAPRs and Max Air PAPRs available - call OCN x23902
  • “Special Precautions” are announced for an EMS patient and airway management pages, please ensure that all involved healthcare workers are wearing appropriate PPE.

Exposures

  • 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
  • If >14 weeks and asymptomatic, goes up to L&D without COVID-19 test

Screening Gyn UC Patients

  • If DHS eligible, asymptomatic, can schedule for Gyn UC
    • If not urgent, GYN UCC appointment in 48 hours, may be phone visit or face to face if needed
      • E.g. vaginal bleeding with Hgb above 9, UTI sx checks, chronic pelvic pain, etc.
    • If urgent and need same day, then can send during business hours/subject to available appointment
  • If symptomatic, Gyn consult in ED.
  • DRAFT: 12-14-2020 - Ramy & Jen surge ideas
    • 8a-5p: Gyn UCC; go back to book into clinic same day or next day ... ok to start immediately
      • GREEN patients only
    • 5p-8a: 7W Room 10
    • Charge spectra: xxxxx ... DC ED encounter ... reg to XLB"Z" ... gyn admit if necessary
      • 1 chair, gurney, gyn cart
      • 1 patient at a time
      • PINK & RED patients ok
      • can transfuse; if require admission, Gyn will take care of deal with it

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

  • Carts in airborne precaution rooms only need to be wiped down - Zangwill 3/30
  • Reasonable to clamp ET tube after cardiac arrest death - Zangwill 3/30
  • Do NOT put patient info on pink armband - Martee 3/30
  • No morgue viewings of COVID patients - Dr. Bolaris 3/30
    • no Pt identifiers on outside pink tag - Nancy Blake 3/31
  • Homeless patients
    • If eligible for DC, need COVID test sent
    • Consult SW - DPH intake center 8a-8p; 833-596-1009

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