COVID-19 Clinical Conference for Providers€¦ · 3/3/2020 · – Patients with a travel history to a geographic area with community transmission (Level 2 or 3 CDC Travel Notices)

100 Top Hospitals® is a registered trademark of IBM Watson Health™

COVID-19 Clinical Conference for Providers

Sarah Prebil, MDJustin Kirven, MD3/12/2020

2 100 Top Hospitals® is a registered trademark of IBM Watson Health™

• Describe the current status of the COVID-19 outbreak

• Discuss clinical presentation and clinical course

• Review testing for COVID

• Review PPE needed for COVID-19 patient care

Objectives


Novel Coronavirus (2019-nCoV)

• December 31, 2019 – China confirms pneumonia cluster associated with seafood market

• January 7, 2020 – confirmed cluster associated with novel coronavirus (2019-nCoV)

• January 20, 2020 – first case in US

• March 6, 2020 - first case in MN


WHO Coronavirus Case Counts


Johns Hopkins

China-81,000 (3056)Italy- 12,462 (827)Iran- 9,000 (354)South Korea-7,755 (60)US-1,311 (38)


COVID-19 in the US as of 3/11/20

https://www.cdc.gov/coronavirus/2019-ncov/cases-in-us.html

https://www.cdc.gov/coronavirus/2019-ncov/cases-in-us.html


MDH Case Count as of 3/12/20

• https://www.health.state.mn.us/diseases/coronavirus/situation.html

https://www.health.state.mn.us/diseases/coronavirus/situation.html


• Frequently reported signs and symptoms of patients admitted to the hospital:– fever (77–98%)– cough (46%–82%)– myalgia or fatigue (11–52%)– shortness of breath (3-31%)

• Other less commonly reported symptoms include– sore throat– headache– cough with sputum production and/or hemoptysis

• Some patients have experienced gastrointestinal symptoms such as diarrhea and nausea prior to developing fever and lower respiratory tract signs and symptoms.

Clinical Presentation


• Some reports suggest the potential for clinical deterioration during the second week of illness– Mean time from illness onset to hospital admission with pneumonia was

8-9 days

• Acute respiratory distress syndrome (ARDS) developed in 17–29% of hospitalized patients

Clinical Course


• Leukopenia (9–25%)

• Leukocytosis (24–30%)

• Lymphopenia (63%)

• Elevated alanine aminotransferase and aspartate aminotransferase levels (37%)

• Most patients had normal serum levels of procalcitonin on admission

Lab Abnormalities


• Co-infection with Influenza/other viruses and COVID is possible

• Bacterial co-infection seems to be low

• Can have false negatives early on in the disease

Other clinical considerations


Imaging

Figure 1: CT images in a 54-year-old woman with severe COVID-19 pneumonia. Transverse and coronal images

reveal patchy peripheral ground-glass opacities with upper lobe predominance.

Images in Cardiothoracic ImagingFree Access

Severe COVID-19 Pneumonia: Assessing Inflammation Burden with Volume-rendered Chest CT

Lei Tang, Xiaoyong Zhang, Yvquan Wang, Xianchun ZengAuthor AffiliationsPublished Online:Mar 6 2020https://doi.org/10.1148/ryct.2020200044

http://orcid.org/0000-0003-1582-1023

https://pubs.rsna.org/author/Tang,+Lei

http://orcid.org/0000-0003-3329-1302

https://pubs.rsna.org/author/Zhang,+Xiaoyong

http://orcid.org/0000-0002-3546-2905

https://pubs.rsna.org/author/Wang,+Yvquan

https://pubs.rsna.org/author/Zeng,+Xianchun

https://pubs.rsna.org/doi/10.1148/ryct.2020200044

https://doi.org/10.1148/ryct.2020200044


Imaging

CT chest may be helpful in patients with high likelihood of COVID but negative PCR testing initially

Use of Chest CT in Combination with Negative RT-PCR Assay for the 2019 Novel Coronavirus but High Clinical Suspicion

Peikai Huang*, Tianzhu Liu*, Lesheng Huang, Hailong Liu, Ming Lei, Wangdong Xu, Xiaolu Hu, Jun Chen, Bo Liu* P.H. and T.L. contributed equally to this work.Author AffiliationsPublished Online:Feb 12 2020https://doi.org/10.1148/radiol.2020200330

Images in a 36-year-old man with a 2-day history of fever, sore throat, and fatigue 5 days after visiting Wuhan, China, and a negative sputum real-time fluorescence polymerase chain reaction assay for the 2019 novel coronavirus. (a, b) Chest CT scans obtained at presentation show ground-glass opacities (red box) in the right upper lobe and the lingular segment and left lower lobe

https://orcid.org/0000-0003-3463-5154

https://pubs.rsna.org/author/Huang,+Peikai

https://pubs.rsna.org/doi/10.1148/radiol.2020200330#fn1

https://orcid.org/0000-0001-6213-9356

https://pubs.rsna.org/author/Liu,+Tianzhu

https://pubs.rsna.org/doi/10.1148/radiol.2020200330#fn1

https://orcid.org/0000-0002-6913-458X

https://pubs.rsna.org/author/Huang,+Lesheng

https://pubs.rsna.org/author/Liu,+Hailong

https://orcid.org/0000-0001-9689-6750

https://pubs.rsna.org/author/Lei,+Ming

https://pubs.rsna.org/author/Xu,+Wangdong

https://pubs.rsna.org/author/Hu,+Xiaolu

https://orcid.org/0000-0001-5049-5759

https://pubs.rsna.org/author/Chen,+Jun

https://orcid.org/0000-0002-9159-1226

https://pubs.rsna.org/author/Liu,+Bo

https://pubs.rsna.org/doi/10.1148/radiol.2020200330

https://doi.org/10.1148/radiol.2020200330


• Older patients and those with chronic medical conditions may be at higher risk for severe illness

• 19% of hospitalized patients were severely or critically ill

• Among critically ill patients admitted to an intensive care unit:– 11–64% received high-flow oxygen therapy

– 47-71% received mechanical ventilation

– 3-12% supported with ECMO

Severity of Illness


• Likely falsely high due to lack of testing in asymptomatic/minimally symptomatic patients

• Case-fatality proportion among cases aged ≥60 years was: – 60-69 years: 3.6%– 70-79 years: 8%– ≥80 years: 14.8%

• Comorbidities: – None: 0.9%– Cardiovascular disease: 10%– Diabetes: 7%– Chronic respiratory disease: 6% – Hypertension: 6%– Cancer: 6%

• Case fatality for patients who developed respiratory failure, septic shock, or multiple organ dysfunction was 49%

Case Fatality


National Geographic



Predictors of Mortality

• Older and cardiovascular involvement have higher risk of death• Respiratory• Respiratory + Cardiac


Allina Testing Algorithm


• Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Most patients with COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing).

• New: There no longer needs to be a consultation with MDH Epidemiology before submitting samples for testing, it is now up to the judgement of the clinician.

• Patients with underlying co-morbidities are at higher risk for severe illness and mortality. Clinicians are strongly encouraged to test for other causes of respiratory illness, including infections such as influenza prior to testing for SARS-CoV. Influenza is still circulating in Minnesota. In particular, the following factors are important considerations:– Patients with a travel history to a geographic area with community transmission (Level 2 or 3 CDC Travel Notices) within 14 days

of onset of fever and cough/difficulty breathing who are influenza test negative

– Patients who are a close contact of a confirmed case patient with fever or cough/difficulty breathing

– Patients who are part of a case cluster of patients with fever or cough/difficulty breathing and influenza test negative

– Patients with pneumonia/ARDS of unknown etiology (testing negative for respiratory pathogens)

– Patients who are healthcare workers with direct patient care who present with fever and cough/difficulty breathing, or with pneumonia who are influenza test negative

Testing criteria: MDH

3/6/2020


Testing Considerations (Washington State)

• The following patients with COVID-19 symptoms are considered at highest priority for testing (Washington State Dept. of Health)– Healthcare workers

– Patients in other public safety occupations (e.g., law enforcement, fire fighter, EMS)

– Patients involved in an illness cluster in a facility or institution (e.g., healthcare, school, corrections, shelters)

– Patients with severe lower respiratory illness (hospitalized or fatal)

– Patients with worsening symptoms

– Patients older than 60 years

– Patients with underlying medical conditions

– Pregnant women


COVID testing

• Call Infection Prevention-make them aware of the PUI• Testing occurring at MDH currently, but there are commercial tests available

– You do not have to call MDH to get approval– Turn around time <24 hrs - depends on when it is received by the lab– MDH lab is not a 24/7 lab– Requires oropharyngeal swab and nasopharyngeal swab and sputum (but do not induce

sputum, able to run on OP and NP samples alone)• No serum needed

• MDH physician & provider only hotline 651-201-3900, Monday through Friday 8 a.m. to 5:30 p.m.

• Epic order for COVID-19, IP Consult to Infection Control, Strict Airborne and Contact• Make sure staff collecting the test have appropriate PPE as obtaining the samples often

causes patients to cough– Minimize number of people in the room during testing, but don’t dof PPE just to leave the

room and then come right back in


• Don’t hospitalize unless necessary– Counsel on possibility of worsening symptoms during 2nd week of illness– Counsel on calling health care facility PRIOR to arriving so patient can be received with

appropriate PPE • Minimize use of nebulizers because it aerosolizes the virus• No steroids unless indicated for COPD or septic shock• Remdesivir clinical trials and compassionate use may be available for severe and

moderate COVID– “Compassionate use requests must be submitted by a patient’s treating physician. Gilead is

currently assessing requests on an individual basis and require, at a minimum, that the patient be hospitalized with confirmed COVID-19 infection with significant clinical manifestations.”

• Cohort patients in one physical location and limit group of healthcare workers– This is both an infection control tactic and a supply shortage mitigation tactic

Management of COVID patients


Logistics of caring for COVID patient


• Airborne: N95, CAPR or PAPR

+

• Contact: Gown and gloves

+

• Eye protection

• Doffing is the riskiest part

PPE



CDC PPE guidelines

Updated 3/10/2020


PPE Availability

• We have shortages of masks

• Reuse of N95/CAPR face shields started 3/9/2020

• Reuse of droplet isolation facemasks started 3/9/2020

• Limited entry for essential staff only for current Airborne and Droplet patients– No students, scribes, etc.

• Concern for improper overuse of N95s and surgical masks– Please correct misusage if you see it (scribes, nurses, NPs, MDs, etc.)

• Known theft of boxes of masks by the public within the hospital



Staying up to date

• Literature search– https://www.doh.wa.gov/

Emergencies/NovelCoronavirusOutbreak2020/HealthcareProviders

• AKN– http://akn.allinahealth.or

g/news/Pages/Update-on-spread-of-Novel-Coronavirus-outbreak.aspx

https://www.doh.wa.gov/Emergencies/NovelCoronavirusOutbreak2020/HealthcareProviders

http://akn.allinahealth.org/news/Pages/Update-on-spread-of-Novel-Coronavirus-outbreak.aspx


References

• Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS; China Medical Treatment Expert Group for Covid-19. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032. [Epub ahead of print]

• Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet. 2020 Jan 24.

• Wang D, Hu B, Hu C, Zhu F, Liu X et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan. Published online February 7, 2020.

• Chen N, Zhou M, Dong X, Qu J, Gong F. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Jan 30. [Epub ahead of print]

• Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020 Jan 31. doi: 10.1056/NEJMoa2001191. [Epub ahead of print]Huang C, Wang Y, Li X, Ren L, Zhao J, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Jan 24. [Epub ahead of print]

• Li Q, Guan X, Wu P, Wang X, Zhou L, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020 Jan 29.

• Chan JF, Yuan S, Kok K, To KK, Chu H, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020 Jan 24. [Epub ahead of print]

• Hoehl S, Berger A, Kortenbusch M, Cinatl J, Bojkova D, Rabenau H, Behrens P, Böddinghaus B, Götsch U, Naujoks F, Neumann P. Evidence of SARS-CoV-2 Infection in Returning Travelers from Wuhan, China. New England Journal of Medicine. 2020 Feb 18.

• Novel Coronavirus Pneumonia Emergency Response Epidemiology Teamexternal iconexternal icon. [The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) in China]. Zhonghua Liu Xing Bing Xue Za Zhi. 2020;41(2):145–151. DOI:10.3760/cma.j.issn.0254-6450.2020.02.003.

https://pubmed.ncbi.nlm.nih.gov/32064853-the-epidemiological-characteristics-of-an-outbreak-of-2019-novel-coronavirus-diseases-covid-19-in-china/


References

•Chang D, Minggui L, Wei L, Lixin X, Guangfa Z et al. Epidemiologic and Clinical Characteristics of Novel Coronavirus Infections Involving 13 Patients Outside Wuhan China. Published online February 7, 2020.

• Zhu N, Zhang D, Wang W, Li X, Yang B, et al; China Novel Coronavirus Investigating and Research Team. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020 Jan 24. [Epub ahead of print]

• Phan LT, Nguyen TV, Luong QC, Nguyen TV, Nguyen HT et al. Importation and Human-to-Human Transmission of a Novel Coronavirus in Vietnam. N Engl J Med. 2020 Jan 28. doi: 10.1056/NEJMc2001272. [Epub ahead of print]

• Lei J, Li J, Li X, Qi X. CT Imaging of the 2019 Novel Coronavirus (2019-nCoV) Pneumonia. Radiology. 2020 Jan 31:200236. doi: 10.1148/radiol.2020200236. [Epub ahead of print]

• Bernheim A, Mei X, Huang M, Yang Y, Fayad ZA, Zhang N, Diao K, Lin B, Zhu X, Li K, Li S. Chest CT Findings in Coronavirus Disease-19 (COVID-19): Relationship to Duration of Infection. Radiology. 2020 Feb 20:200463.

• Xu X, Yu C, Qu J, Zhang L, Jiang S, Huang D, Chen B, Zhang Z, Guan W, Ling Z, Jiang R, Hu T, Ding Y, Lin L, Gan Q, Luo L, Tang X, Liu J. Imaging and clinical features of patients with 2019 novel coronavirus SARS-CoV-2. Eur J Nucl Med Mol Imaging. 2020 Feb 28. doi: 10.1007/s00259-020-04735-9. [Epub ahead of print]

• Yang W, Cao Q, Qin L, Wang X, Cheng Z, Pan A, Dai J, Sun Q, Zhao F, Qu J, Yan F. Clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (COVID-19):A multi-center study in Wenzhou city, Zhejiang, China. J Infect. 2020 Feb 26. pii: S0163-4453(20)30099-2. doi: 10.1016/j.jinf.2020.02.016. [Epub ahead of print]

• Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, Tao Q, Sun Z, Xia L. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology. 2020 Feb 26:200642. doi: 10.1148/radiol.2020200642. [Epub ahead of print]

• Shi H, Han X, Jiang N, Cao Y, Alwalid O, Gu J, Fan Y, Zheng C. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis. 2020 Feb 24. pii: S1473-3099(20)30086-4. doi: 10.1016/S1473-3099(20)30086-4. [Epub ahead of print]


Feedback/Questions

• Dr. Justin Kirven, MD

• Dr. Sarah Prebil, MD

• Ellie Carter, IP

Documents

COVID-19 Clinical Conference for Providers€¦ · 3/3/2020 · – Patients with a travel history to a geographic area with community transmission (Level 2 or 3 CDC Travel Notices)