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72104259525COVID-19?CLINICAL GUIDELINES??SUBJECT: COVID TESTING ALGORITHM AND ISOLATION GUIDELINES – I/P?SCOPE/PURPOSE: Sinai Hospital of Baltimore, Northwest Hospital, Grace?Medical Center and Carroll Hospital adopts the following guidelines for clinical services provided during the COVID-19 pandemic.??APPROVED BY:?Inpatient COVID19 Taskforce??APPROVAL DATE:?5/01/2020;?LAST REVIEW DATE:??GUIDELINES:Clinical FeaturesRisk FactorsTESTING**ISOLATIONMandatory consults/attendingsHOSPITALIZED PATIENTSSymptomatic patients*NONECOVID19Influenza only if clinically indicatedCT Chest***According to risk assessmentR/o COVID and positive COVID cases MUST be on hospitalist/intensivist service or have a hospitalist/intensivist consult placed immediatelySymptomatic patients*ImmunocompromisedHematologic malignancyNeutropeniaAll organ transplant patientsCOVID19Influenza and RVAP only if clinically indicatedCT Chest***According to risk assessmentR/o COVID and positive COVID cases MUST be on hospitalist/intensivist service or have a hospitalist/intensivist consult placed immediately*Symptoms defined as: fever, new cough, shortness of breath, sore throat, chest tightness or wheezing, myalgias, diarrhea with no easily identifiable cause**Co-infection can occur so bacterial infection and other respiratory viruses in a severely ill patient does not exclude COVID19***See CT Chest guidance on website for detailsClinical and Lab/study reported findings: Most recent known symptom rates:Most recent known laboratory and study findings:Imaging findings:Fever seen in >75% at some point but almost 50% afebrile on admissionCough (dry or productive) 45-80%SOB 20-50%Myalgias 10-50%URI symptoms (HA, sore throat, rhinorrhea) <15%GI symptoms—do occur: N/V in <10%; diarrhea <25%Normal to low wbc countLeukocytosis is found <25%Lymphopenia 33-85%Slight decrease in platelets <35%AST/ALT increase 4-35%CRP increased 61-86%LDH increased 27-75%Mild INR increaseD-dimer elevationProcalcitonin low except in severe cases Increased ferritinCXR abnormal 60% (77% in severe disease)CT chest abnormal in 86% (95% in severe disease)Most common chest findings: -GGO, patchy consolidation >50%-Peripheral distribution >50%- Effusions <10% ( except later in course likely from volume resuscitation)RISK STRATIFICATION FOR ISOLATIONThe following is based on the current CDC recommendationRISK LBH ISOLATION **Characteristics LOWERDoor ClosedDroplet, Contact, Standard: (Surgical mask*, eye shield, gown, gloves)Trained observer for donning and doffing when availableAll rule out covid19 patients who are not critically ill or receiving aerosol generating treatmentsHIGHESTAirborne, Contact, Eye Shield: (N95 or PAPR***, eye shield, gown and gloves)Negative pressure (if available) Trained observer for donning and doffing when availableCritically illAerosol generating procedures* *N95s, PAPRS or equivalent and protective eyewear should ALWAYS be used with aerosol generating procedures (sputum collection, nebulizers), use of HFNC or non-invasive ventilation, or when provider is physically performing COVID19 testing on a patient**Isolation precaution orders may be placed by the Hospital designated COVID reviewing physician when indicated***If intubating recommended full protection and PAPR when available—see other guidance Asymptomatic ScreeningIn situations where asymptomatic screening is being conducted, e.g. procedure clearance, surveillance swabbing, return to nursing home, behavioral health unit placement, etc. no isolation precautions are warranted. Patients are managed according to Standard Precautions with the addition of an N95/PAPR, full face shield/goggles. Our LBH employee’s health and safety are primary importance. We are monitoring the CDC recommendations as well as the nationwide practice several times daily and this will be updated as needed. ................
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