Central Maine Healthcare



*References to other forms located in L drive: hospitalists: COVID 19CMH INPATIENT COVID-19 MANAGEMENT GUIDE10/6/20Useful Numbers: Infection Prevention Pager: 851-8612.Research: 207.782.9835WEBSITE WITH UPTODATE FDA INFO FOR REMDESIVIR AND CONVALESCENT PLASMA: AND TESTINGCOVID-19 Adult clinical evaluation guide (1)Presenting symptoms:Non-specific, flu like illness with myalgiasFever (44-98%)Cough (46-82%)URI symptoms (5-25%)Loss of smell and/or taste (20-70 %)GI symptoms (10%)Lab/Imaging abnormalities:WBC abnormalitiesLymphopenia (33-85%)Leukopenia Leukocytosis (<5%)Elevated LFTs (4-22%)Elevated CRP (61-86%)Low or normal procalcitonin, or elevated if bacterial co-infection or severe diseaseElevated LDH (27-75%)Elevated D-Dimer without other causeImaging abnormalities (60%)Bilateral ground glass opacities, scattered infiltrates (50%)Unilateral findings are possible (17%)Demographics associated with worse prognosis:Age >55MaleMedical HistoryCardiac disease (including HTN)Pulmonary diseaseDiabetesCKDMalignancyImmunosuppressionLabs and VitalsRespiratory Rate >24HR >125Hypoxia SpO2 <90%Severe lymphopeniaElevated troponinElevated CrElevated LDH (>245 U/L)Elevated CRP (>10 mg/dl)Elevated D-dimer (>1.0 ug/ml)CK >2x upper limit of normalElevated RDW poor prognostic sign: greater than 14.5% a/w increased mortalityCoinfections (i.e. Flu, bacterial infection) are reported Initial data from China <2%, more recent data suggests higher rate (up to 20%).Identification of a separate infection does NOT rule out COVID-19Test SensitivityUnclear sensitivity (dependent on technique, lab, stage of disease) Clinical suspicion and/or ID discussion should be used to determine need for repeat testingRepeat testing should be performed 24 hours after initialPERSONAL PROTECTIVE EQUIPMENTSee PPE guidance On COVID Unit: Use PAPR/CPAR or N95 plus shield (Must be PAPR/CAPR trained)Wear continuously for rounds, change gown and gloves between patients (use “Buddy System”)Wash and set aside in Re-Use area throughout shiftWash CAPR at end of shift and return to our storage box in officeIf PAPR used place in dirty area for final processingIn ED or Satellite Negative Pressure rooms:Use N95 and eye protection-preferably face shield to help preserve N95See PPE guide aboveReuse and conservation of PPE essentialADMISSION PROCESS:From EDAll Patients are undergoing testing (diagnostic or screening) in Emergency Dept.For patients sick with COVID-19: Use COVID-19 admission order setIsolation should include airborne (respirator), neg pressure room, eye protection/gown/glove Patient may be seen by either the COVID/E doctor or the SWING doctor:APS supports admission by taking patient history by phone, preparing documentation and med reconciliation, however will NOT see these patients at bedside (to limit to one clinician exposure and reduce PPE consumption).Patients screened positive with COVID who are being hospitalized for other reasons should be admitted to a COVID unit whenever possible. Utilize Isolation including airborne (respirator), neg pressure room, eye protection/gown/glove Transfer from another unit to COVID UNITTransfer order should be placed and patient taken to COVID unit immediatelyPatient should be seen by physician once in the COVID unit if not already seen on other floorUtilize COVID order set to ensure appropriate orders (Isolation, COVID swab, baseline labs etc)Connect/Transfer policyPatients from RH/BH and COVID-19 should be accepted in transfer to CMMC to access therapeutics (Remdesivir and Convalescent Plasma) as well as ID consultation.If transfer requested for COVID patient with critical illness or significant respiratory decline, this should be discussed with ICU team for acceptance directly to ICU COVID unitIf patient with suspected or confirmed COVID 19 has a separate medical problem requiring transfer (e.g. dialysis, NSTEMI, GI bleed), we will take these transfers to COVID unitIf the patient is COVID screen positive but not symptomatic/hypoxic with COVID-19, then their transfer should only occur if other factors require higher level of care. If patient becomes ill/hypoxic then we would re-discuss and accept in transfer.If a patient with COVID-19 elects hospice level care- they may remain at BH/RH/outside hospital Consults and Co-managementCOVID/E doctor will be the primary doctor for all hospitalist or family medicine residency patients admitted to the COVID unitOther services will remain primary team on their patients who are sent to COVID unit (e.g. Surgery, Oncology)As much as possible, only 1 clinician should be seeing a COVID patient bedside each day. Coordinate with consulting teams to manage this. IPad consultation available. COVID doctor may be asked to provide guidance in the management of non-medicine patients in the COVID unitMEDICAL MANAGEMENT OF COVID-19Initial ManagementCOVID/FLu SwabAdmission labs: CBC with diff*CMP*Blood CulturesSputum culture (no induction)CRP*Procalcitonin- follow if elevatedTroponinNT-ProBNPLDHPT/PTT/DDimer* Elevation = poor prognosis and risk of VTE- follow and adjust DVT px/VTE screening per therapeutic guidelinesConsider: Mag, CK, fibrinogen Ferritin**= check every other day or daily if inflammatory markers elevatedECGChest XR- PortableID consultation (Confirmed positive cases or for guidance in testing)Daily ManagementClose monitoring of respiratory status and oxygen needs- see belowSee above table for close follow of laboratory studies. If patient worsening repeat: CBC w/ diff, CMP, Top, CK, BNP, LDH, CRP, DDIMER, Procalcitonin, PT/PTT, Fibrinogen, ferritin, ABG, repeat EKGIf initial procalcitonin elevated follow per ID recommendationsIf initial Troponin abnormal, Reevaluate based on clinical judgement and monitor for myocarditisTelemetry: recommended, required with cardiac abnormalityOn T2 COVID unit:In-room cardiac monitoring is available for all patients to assist staff on floor with immediate visualization of rhythm whenever needed.Patients who require telemetry should be connected through central tele to T3 in addition to in-room monitor.Review advanced care plan on all patients; educate family on disease course and prognosis.Point of Care Ultrasound (POCUS) can be utilized as an effective way of evaluating and monitoring lung appearance or heart function without the delay or increased exposure and PPE use required for formal imaging. There will be training available for all who are able to learn basic lung and eventually heart examination using POCUS.Medications:See CMH COVID-19 Therapeutic Management GuidelineInfectious Disease consult recommended on all COVID-19 patients for therapeutic guidance.Inpatients with hypoxia and/or critical illness will be considered for COVID specific treatments.Convalescent Plasma is available at CMMC. Consent MUST be obtained with CMMC consent form and FDA EUA MUST be given to patient/family.Remdesivir is available at CMMC. Consent with CMMC consent form must be obtained and FDA EUA MUST be given to patient/family. Must follow protocol precisely: See Remdesivir Treatment Protocol. USE REMDESIVIR ORDER SET- refer to therapeutics guideline for details.Hydroxychloroquine is no longer in use at CMHMedical DVT prophylaxis should be utilized unless bleeding or already anticoagulated. Follow D-Dimer for possible need for intermediate dose DVT px or screening for VTE and full anticoagulation- details available in See CMH COVID-19 Therapeutic Management GuidelineAvoid nebulizerThere is now auto-substitution for Neb orders to MDI. IF you must have neb note in order to not sub. We do have small supply of filtered/one-way vlave devices for nebs.ACE/ARB can be continued unless AKI, hypotension, per inpatient usual. Do not start as new medication.Signs of decompensation/RESPIRATORY declineMedian time from symptom onset to development of ARDS: 8-12 daysRisk FactorsAge >55MaleCardiac disease (including HTN), Pulmonary disease, Diabetes, Malignancy, ImmunosuppressionSevere lymphopenia, elevated troponin, elevated Cr, elevated LDH, elevated CRP, elevated D-dimer, Respiratory distress>6L oxygen requirementRapid escalation of oxygen requirementSignificant work of breathingHemodynamic instabilitySystolic BP <90, MAP <65, HR>120Lab changespH <7.3, pCO2 >50 (or above baseline), Lactate>2Management of progressive hypoxic respiratory failure1-4L NC - goal SpO2 92-96%, (lower if chronic resp acidosis)If requiring >4L NC but not in distressCheck ABG, initiate HFNC, initiate self-proning if able. See HFNC.NIPPV COVID-19High Flow Nasal Cannula RecommendationsPrecautions: Novel Respiratory Precautions (NRI) (lime green signage): Negative pressure room in designated COVID unit, Airborne/Contact and full face shield/eye protection and essential personnel only in the room.? Device specifics: Units have heated wire circuits, with decreased to no condensation build up, lowering ?aerosolization riskPatient selection: Acute Hypoxic respiratory Failure> 4lNC /hemodynamically stable/ NO acute distressObtain ABG: PaO2/FiO2?>?200?mmHg has higher likelihood of success. HFNC may still be used if PaO2/FiO2<200 but critical care medicine should be consulted due to increased risk of failure and need for NIV/ventilator bine HFNC with cooperative proningOngoing Close monitoring: over first 1-2 hours on HFNC: look for reduction in RR, successful oxygenation with sat >87% tolerable provided remains hemodynamically stable/ NO acute distress. See: Prone positioning for the awake, non-intubated patientRecommend early consultation of Critical Care for respiratory decompensationVenturi or NRB Mask:Goal 92-96%, NOT humidified (to reduce aerosolization) (lower if chronic resp acidosis)PULM/CCM consultationNIPPV:NIPPV/BIPAP Recommendations: See HFNC.NIPPV COVID-19Precautions: Novel Respiratory Precautions (NRI) (lime green signage): Negative pressure room in COVID unit, Airborne/Contact and full face shield/eye protection and essential personnel only in the room.? Device specifics: Viral Circuit utilized to reduce aerosolizationPatient Selection: Undifferentiated patient in ED with disease process that would benefit from NIV (ex. AECOPD/Pulm edema)PUI/COVID patient with Acute on CHRONIC hypoxic respiratory failure >4l, with hypercarbia for whom BIPAP would be preferential based on ABG: Discuss with pulm/CCM.Intubation/Mechanical VentilationIntubation is high risk, aerosolizing procedure which should be done in negative pressure room with full PPE by most experienced personnelConsult CCM for transfer of vented COVID 19 patients to critical care setting. Non-respiratory complications of COVID-19Cardiac – incidence 7-22%Acute Cardiac InjuryCause: Myocarditis, Demand ischemia, Acute Coronary SyndromeTroponin elevations often a late manifestation (14 days)Determine management with Cardiac ConsultationArrhythmias (17%) - higher in ICU patientsManagement as standardShockStandard shock management initiallyAvoid excessive IVF – IF no response to initial fluid bolus OR JVD forms, STOP IVFFirst line pressor: Norepinephrine Start 0.1-0.5 mcg/kg/min – titrate to MAP >65Max 1mcg/kg/hrNOTE: Critical Care/ICU should be called on any patient requiring pressorsThrombotic/Coagulative diseaseDIC (Blood clots, low plt, high INR/PTT, low fibrinogen)Hypercoagulable state with microthrombi in lungs, macrothrombi-stroke, VTE: Aggressive laboratory monitoring and VTE screening and prophylaxis Renal ManifestationsIncidence 2-29%Unclear timing: 7-15 daysCheck UA proteinuria (44%) hematuria (27%)Early nephrology consultMonitor daily CrGIElevated LFTs (53%) tend to spare bilirubin/alk phosAdditional Clinical ItemsCode Blue: See COVID CODE BLUERRT StrokeSee RRT Stroke COVID document (5) Will be run by COVID/E doctorRun like normal RRT strokeEvaluate clinically, Order Head CT/CTA MGHAfter CT head, patient returns to COVID unit directlyMGH stroke fellow can be reached by phoneEnabling IPAD to allow MGH visual evaluationPost-TPA may stay in COVID unit if RN skills can be brought to unit to monitor as neededRRT STEMISEE RRT STEMI COVID document (6)Samples of Resources and References (references also listed in detail in therapeutics guideline): Brigham and Women’s COVID 19 Critical Care Guidelines, COVID-19: Free COVID articles: of Washington COVID 19 Clinical Guidelines: COVID 19: management guidelines: : ................
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