Grand&Round:&Clinical&Guidelines& for&the&patient&with

COVID -‐ 19 Be Safe -‐-‐ Be Smart -‐-‐ Be Kind

Grand Round: Clinical Guidelines for the patient with COVID-‐19

An overview of general management


Speakers and housekeeping

Dr James Bartlett-‐ Respiratory Physician, Medical Advisor for Quality, Safety and Patient Experience and Senior Medical Lead for COGS

Dr Michael Augello-‐ Emergency Physician and Deputy Director FootscrayEmergency Department

Dr James Molton-‐ Infectious Diseases Physician and part of the COVID-‐19 Response Team

Dr Claire Burrows-‐ Anaesthetist and Clinical lead for Intubation Team

Questions


Introduction

Questions? Go to slido.com #WH-‐C19


IntroductionCLINICAL ASSESSMENT

MILD MODER ATE SEVERE

NORMAL NORMAL NORMAL or DECREASED

NORMAL MILD SEVERE

< 20 20 - 30 > 30

> 94% on room air OR baseline for the patient

Requiring supplemental oxygen Sats critical or requiring >40% FiO2

CRITICALReduced GCS , shock and/or other

signs of other end organ failure

HOME +/- HOSPITAL IN THE HOME (HITH)If positive, notify DHHS for

routine follow-up

INTENSIVE CARE UNIT (ICU)WARD

Not for ICU

End of life care (EOLC)

ASKDoes this patient have the ability, understanding

and resources to self-isolate?

ADMITAdmit to most appropriate unit**

• Complete EMR admission template (via medical officer tab) including risk assessment

• Admitting team MUST complete an acute resuscitation plan (ARP).

• COVID-19 order set*• AVOID: nebulisers, high flow nasal

prongs (HFNP), non-invasive ventilation (NIV). For more information see ward

management guidelines

ASSESSDetermine resuscitation status

Not for intubation

YES

For intubation

NO

Follow criteria for isolation

step-down

SUPPORTIVE CARESee safe use of respiratory guideline

DETERIORATESHighest risk: Day 5 to 8

EM

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NC

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NT (E

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PATIENTS IN ED WITH SUSPECTED OR CONFIRMED COVID-19

IMPROVES DETERIORATESHighest risk: Day 5 to 8 • Reduced GCS • Severe WOB• Clinical concern• Rapid deterioration• RR > 24• Sats < 92% despite

6L/min or 40% FiO2

CRISIS MODE

GCS

WOB

RR

SaO2

Created by Western Health in collaboration with beauty within medicine.

GCS = Glasgow coma scale, WOB = work of breathing, RR = respiratory rate, SaO2 = oxygen saturations*FBE, UEC, LFT, CRP, D-Dimer, Troponin, Ferritin, VBG, Blood cultures, COVID-19 swab, influenza swab, CXR (mobile).**General Medicine, Respiratory, Acute Aged Care unless otherwise known to a specialty unit. See admitting guidelines.

Refer to ICU +/- activate intubation team

For ICU

CALL INTUBATION TEAM


• Footscray ICU ext 56093 • Sunshine ICU ext 50830

Anaesthetist in charge • Footscray ext 56540• Sunshine ext 53021



Case detail 1: Undifferentiated dyspnoea

Triage Note• 84yo male brought by private car from home with acute SOB and 4

days of cough• ‘’Increased WOB’’, Temp 37.7, Pulse 90, BP 138/76, RR 24, • Sa02 – 88% on RA. • Onset -‐ 4 days ago.

ED Triage Screening Risk Tool


The Emergency Department in the Time of COVID-‐19

• Challenges• Current low community prevalence• Infectious Risk impacting normal practice• Communication• Environment

• ED cubicles• Cohorting in ED unavoidable

• Oxygen therapy and AGP in ED • Numerous changes to usual practices• Additional Cognitive load


The Emergency Department in the Time of COVID-‐19

ED must ALWAYSmaintain capacity to receive, assess and manage the next undifferentiated

patient .

How does ED continue to provide BEST CARE to the public during a pandemic ?


Emergency Department Flowchart


CLINICAL ASSESSMENT



NORMAL MILD SEVERE

< 20 20 - 30 > 30






routine follow-up


Not for ICU











Not for intubation

YES

For intubation

NO


step-down



EM

ER

GE

NC

Y D

EP

AR

TME

NT (E

D)

PR

OG

RE

SSC

AR

E LO

CA

TION



6L/min or 40% FiO2

CRISIS MODE

GCS

WOB

RR

SaO2



REFER TO ICU +/- ACTIVATE INTUBATION TEAM

For ICU






Case Continued

• Responds well to 2 L/min Nasal Prongs (sats 94%)• Further History (from family over phone, EMR, patient) • Past History: HTN, IHD, asthma

• Recent echo shows EF 63%• Non-‐smoker, good exercise tolerance.

• Social History: home alone, independent• No clear contacts/risks. Diligent social distancing

Case detail 2: Suspected COVID-‐19 for admission

v ED advises Inpatient Unit of admissionv Bed request with COVID risk documentedv Pertinent details shared via phone callv Interim 4 hour plan agreed upon. v Formal review and admission completed after transfer to the ward



Admission


Order COVID-19 nasopharyngeal/ oropharyngeal swab PCROrder COVID-19 sputum PCR

Patient meets current COVID-19 testing criteria

NO

NO

Swab – negativeAND

Sputum – negative OR not performed

COVID-19 NegativeDe-isolate

Can be placed in non-COVID ward


Sputum – not performed

COVID-19 Low Risk Suspected Case - AGP

Manage in a single room


Sputum – negative

COVID-19 Low Risk Suspected Case

Cohort with other low risk suspected cases

Swab – positiveAND/OR

Sputum – positive

COVID-19 Confirmed CaseCohort with

other COVID-19 confirmed cases

HIGH RISK SUSPECTED CASESManage in single room

YES

YES

Needs AGPOR

Severe cough

RISK ASSESSMENT (to be completed by admitting doctor)Does the patient have any of the following risk factors?1. Travel overseas or to NSW in the 14 days prior to symptom onset2. Close contact with a confirmed case of COVID-19 in the 14 days

prior to symptom onset3. Severe cough*4. Chest x-ray infiltrates5. Will likely need an Aerosol Generating Procedure (AGP)*Severe cough is defined as a new continuous cough, coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours.

LOW RISK SUSPECTED CASESCohort with other low risk suspected cases

Risk Assessment, De-isolation and Cohorting of Inpatients Tested for COVID-19

CLINICAL ASSESSMENT



NORMAL MILD SEVERE

< 20 20 - 30 > 30






routine follow-up


Not for ICU











Not for intubation

YES

For intubation

NO


step-down



EM

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GE

NC

Y D

EP

AR

TME

NT (E

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PR

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RE

SSC

AR

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6L/min or 40% FiO2

CRISIS MODE

GCS

WOB

RR

SaO2




For ICU






EMR



EMR



EMR



EMR



EMR




De-‐isolation



Fluids – run them dry• Restrictive fluid strategies, 1-‐2 litres of IV fluid per day (if no oral intake, acute kidney injury or clinically dehydrated)

• If hypotensive, give up to 3 x 250ml fluid boluses then call ICU

Indications for antibiotics – treat as CAP• hypoxaemic (oxygen saturation <92% on room air) • pleural effusion (uncommon, assess alternative cause) • purulent (yellow/green) sputum

Antiviral agents – not yet• Currently no RCT evidence of benefit (and potential exists for harm)• Avoid use outside context of a trial

Principles of ward management




Not achieving target O2 sat




Guidelines to supplemental oxygen use on the wards

DOCUMENT target oxygen saturation (usually 90 – 92%)

Nasal cannula (1 – 4 L/min)

Hudson mask (6-8 L/min)

Acute or chronic ventilatory failure (PaCO2 > 45mmHg)

Review ARPDiscuss the Respiratory or contact ICU if appropriate, and consider HFNC, or proning*

NO

Non-rebreather mask6 – 10 L/min

YES

Venturi maskAdjust flow to selected adapter

(up to FiO2 40% and 10L/min)

ARP = acute resuscitation plan, ICU = intensive care unit, HFNC = high flow nasal cannula

*There is new evidence suggesting that HFNC may assist in oxygenating the patient with COVID-19. However approval requirements persist. Talk to respiratory/ICU for more information.

Case detail 3: Deterioration

• On Day 2 of admission (Day 9 since symptom onset), oxygen demands start to increase.• Saturations 88% despite 6L via non-‐rebreather mask, therefore MET call is initiated and repeat CXR ordered.


Nb flow rates >6L/min are low risk AGPsSee PPE guideline


Case detail 3: Deterioration

• On Day 2 of admission (Day 9 since symptom onset), oxygen demands start to increase.• Saturations 88% despite 6L via non-‐rebreather mask, therefore MET call is initiated and repeat CXR ordered.

Ward CXR



CLINICAL ASSESSMENT



NORMAL MILD SEVERE

< 20 20 - 30 > 30






routine follow-up


Not for ICU











Not for intubation

YES

For intubation

NO


step-down



EM

ER

GE

NC

Y D

EP

AR

TME

NT (E

D)

PR

OG

RE

SSC

AR

E LO

CA

TION



6L/min or 40% FiO2

CRISIS MODE

GCS

WOB

RR

SaO2




For ICU

REFER TO ICU +/- ACTIVATE INTUBATION TEAMCall ICU department at hospital location:


Call anaesthetist in charge • Footscray ext 56540 • Sunshine ext 53021

MET Calls


MET Calls

ICU liaison to attend MET COVID status r sk suspected or con r ed

Clinicalconcern, rapiddeterioration,

RR >24 or SaO2 <92% on 6L HM?

Anaesthetist Incharge Footscray Ext 56540 Sunshine Ext 53021

Activate Intubation team

& call ICU registrar

Usual process -d/w home team or ICU registrar

Intubation teamattends with drug pack

Can patient be transferred to

ICU safely for escalation

of care?

Transfer to ICU

CALL

CODE

BLUE

Code blue cartarrives with airway

equipment and resus drugs

INTUBATE

ON WARD

INSIDE ROOM

Intubating team with airborne precautions

PPE (N95 mask)1. Anaesthetist

2. Anaesthetic nurse3. ICU liaison nurse

OUTSIDE ROOM CCU nurse

and ward staff (droplet

precaution PPE)

NO

YES

YES

NO

COVID MET CALL WORKFLOW


• Intubation team objectives• Provide satellite service to ED, ward and ICU

• Provide prompt, definitive airway intervention

• Standardized approach

Intubation Team

COVID-19 INTUBATION TEAM CHECKLIST

PATIENT EQUIPMENT PLAN

¦ Set up Airway Trolley• Select CMAC blade

¦ Induction Drugs• Ketamine (Pack A) OR

• Propofol/Midazolam (Pack B)

• Sux & Rocuronium in both packs

¦ Vasopressor¦ Post-Intubation

Planning• Ventilator & Settings

• Sedation

¦ Patient Assessment• Airway

• Allergies

• Medication

• Past History

¦ Haemodynamics optimised

¦ IV access• 2 preferable

¦ Positioning• Head up 45o,

Oxford Pillow/Ramp

� Contact Anaesthesia• FH – 8345 6540

• SH – 9055 3021

� Allocate Roles• Team Leader

• Airway Doctor

• Airway Nurse

• Runner

• Scribe

� Don PPE in Anteroom& Buddy Check

� INDUCTION PLAN• Induction

• Paralysis

• Vasopressor

� AIRWAY PLANSA – INTUBATION

• CMAC

• Stylet/Bougie

B – LMA (I-GEL)C – MASK VENTILATION

• 2 handed grip

• 2 person technique

• Consider OPA/NPA

D – SURGICAL AIRWAY • Scalpel-Bougie-ETT

� Patient PositioningOptimised

� Turn CMAC on� Suction working

¦ Connect Monitoring• BP (1min cycle)

¦ Confirm ETCO2 Trace

¦ Pre-oxygenation¦ a - ilter-ETCO2-PEEP al e-

elf inflating ag com lete¦ Oxygen 15l/min

� Fluid Running� Induction Plan Clear� Airway Plans Clear� E eryone ea y

CHECKS BEFORE ENTERING ROOM

FINAL PRE-INDUCTION CHECKS INSIDE ROOM

TEAM



• Intubation team structure• 1-‐2 Consultant anaesthetists• Anaesthetic nurse• ED/ICU/ICU liaison nurse

Intubation Team



Basic Life Support

LOOK for absence of signs of life,

absence of normal breathing

Check COVID status and don PPE as required

Minimise responders to essential staff only

NO airway adjuncts

Apply O2 @ 10L/min via

Hudson maskDO NOT listen or feel for

breathing by placing face close

to patient’s mouthAVOID bag mask ventilation

COMPRESSION ONLY CPR until code response team

arrives

Early rhythm check in AED mode

STOP O2 flow at wall

(do not remove mask)

Re-start O2 flow when compressions

start

100-120 compressions/minute

BLS modifications for ALL ADULT patients during the

COVID-19 pandemic

v1.2 9/4/2020



• If not for intubation-‐ what then?• Supportive management• Consider Palliation

• Consult service only, due to hospital wide limitation on transport of patients• Due to risk to staff and public, community palliative care would not be available

• Can be considered on case by case basis

Palliation



• Submit questions to slido.com #WH-‐19

• Special thanks to Dr Lucy Desmond from Beauty Within Medicine for her assistance with graphics

• Next week: Dr Richard Horton speaks about the roll out of telehealth in our clinics

Questions


Questions


PPE



AGPs



Essential documents Location

Clinical Guidelines for Doctors V8 QRG/CG

PPE-‐ Western Health COVID-‐19-‐PPE Guidelines QRG

Safe Use of Respiratory Therapy QRG/CG

Risk Assessment, de-‐isolation, and cohorting of patients with COVID-‐19 QRG

Others of importance to Medical Staff

Emergency department triage & workflow CG

Deteriorating Patient Systems-‐ Modifications to ALS QRG

Deteriorating Patient Systems-‐ Modifications to BLS QRG

Care of the Deceased Patient with COVID-‐19 QRG

EMR-‐ COVID-‐19-‐ template guidelines QRG

Medical Imaging-‐ COVID-‐19 series of documents QRG

Victorian DHHS COVID-‐19 Notification requirements QRG

PPE-‐ all documents QRG

Guidance with Addressing Goals of Care and ARPs CG

COVID-‐19 Direct Admission guideline CG

Obstetric and neonatal guidelines CG

Anaesthetic documents Anaes microsite

Intubation team CG

Guidelines developed

Documents

Grand&Round:&Clinical&Guidelines& for&the&patient&with