•Safe and Informed Care of COVID-19 Patients• Just in Time Training for Clinicians at

• Northwestern Medicine

***FREQUENT UPDATES WILL OCCUR –PLEASE ENSURE YOU ARE USING the MOST RECENT VERSION***

Version: 1.5 - All Regions

Released on: April 17, 2020 at 0800

CME Credit

To claim credit:

Click on the link and then "Tests" to complete the evaluation andclaim credit: https://northwestern.cloud-cme.com/COVID19primer

Disclosures: There are no relevant financial relationships.

Accreditation Statement

The Northwestern University Feinberg School of Medicine is accredited by theAccreditation Council for Continuing Medical Education (ACCME) to provide continuingmedical education for physicians.

Credit Designation Statement

The Northwestern University Feinberg School of Medicine designates this live activityfor a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim onlythe credit commensurate with the extent of their participation in the activity.

Learning Objectives

• This educational primer is intended to introduce clinicians toCOVID-19 and give an overview of safe and informed care ofpatients with COVID-19.

• This primer is not intended to be comprehensive and reflects the best available evidence as of April 17, 2020 at 0800(Version 1.5 - All Regions).

SARS-CoV-2, the virus that causes Covid-19. From: NIAID-RML

Table of Contents –Section 1: Personal SafetyClick topic title to go directly to specific content

PPE Instructional Videos:• On NMI: https://nmi.nmh.org/wcs/page/nm-coronavirus-ppe → Videos• On Physician Forum: https://physicianforum.nm.org/covid-19-ppe-

resources.html → Videos

Topic

Identifying COVID-19 positive and negative patients in EPIC

PPE Guidelines

Re-Use of PPE

Safe Putting On of PPE

Safe Removal of PPE

How should COVID patients be transported?

PPE Tips & FAQs

What if I think I've been exposed?

Table of Contents –Section 2: Informed Care of COVID-19 PatientsClick topic title to go directly to specific content

Topic

Who should I contact with clinical questions?

COVID-19 Basics

COVID-19 Clinical Presentation

COVID-19 Typical Clinical Course

Clinical Classification of COVID-19

COVID-19 Patient Care – Emergency Department Pearls

What should I do if I suspect a patient has COVID-19?

What happens when a patient is confirmed COVID-19?

COVID-19 Patient Care – Emergency Department Pearls

Inpatient (non-ED) testing for COVID-19

COVID-19 Patient Care – Floor – Comorbidities, Vital Signs, and Lab Studies

COVID-19 Patient Care – Critical Care Pearls & Mechanical Ventilation

Active Treatment of COVID-19

Post-ICU Patient Care

Other COVID-19 Patient Care Pearls from Your Colleagues

NM COVID-19 General Resources

External References and Resources

Personal SafetyCOVID-19 EMR Flags, PPE, Safe PatientTransport, Guidelines if Personally Exposed

Identifying COVID-19 patients in EPICCOVID-19 Infection, Rule Out, and Negative status is included on the Epic StoryBoard

Positive COVID-19 Rule-out COVID-19 Negative COVID-19

Identifying COVID-19+ patients in EPICCOVID-19 test results can be found in Microbiology section of Results Review

How should I protect myself when caring for patients?

• Follow strict hand hygiene

• Learn correct use of PPE (in this module)

– Which PPE to use in different situations

– Safe putting on and removal

– Observe “Universal Masking” guidelines

– Current PPE Guidelines: Physician Forum PPE Resources pageGuidelines are updated frequently so please check NMI for most current guidelines

• NM and the CDC recommend shaving most facial hairstyles if you will be working with COVID patients

– Exception: facial hair due to religious belief

– PAPR will not be provided routinely for those with facial hair

Sources: CDC, IDPH, NM Infection Prevention; current as of 04/10/2020 0900

Universal Masking Guidelines

• All providers/staff in NM clinical areas that do not require additional PPE should wear a procedure mask or surgical mask– Includes both hospital and ambulatory clinics

– Only remove when you can consistently and reliably practice social distancing (e.g., private office, designated eating areas)

• The mask must cover your mouth and nose at all times

• Please preserve and re-use your mask according to NM guidelines

• Review videos of how to put on/remove PPE when re-using PPE at:https://physicianforum.nm.org/covid-19-ppe-resources.html → Videos

• Masks may also be worn in non-clinical areas (check NM PPE guidelines)

• All patients/visitors > 2 y.o. should wear masks in all clinical areas

– Not required when in own private room

– Patients/visitors should be offered a disposable mask, but may wear a cloth mask

– Those under the age of 2 y.o. should not wear masks due to suffocation risk.

Sources: CDC, IDPH, NM Infection Prevention; current as of 04/10/2020 0900

PPE Guidelines• Providers & staff in NM in clinical areas (non-COVID units) should wear a surgical or procedure

mask at all times. Please follow NM re-use guidelines in order to preserve PPE.

• Review table below for PPE guidance for COVID/ROCOVID patients in specific situations• These guidelines change frequently. Check for updated guidelines on Physician Forum COVID-19 PPE Resources page.

Sources: CDC, IDPH, NM Infection Prevention; current as of 4/14/2020 1200

*Aerosol generating procedures(AGP): tracheal intubation/ extubation, all airway management, non-invasive ventilation, exchange/ removal ofartificial airway, tracheotomy, tracheostomy care,CPR, Manualventilation before intubation, Bronchoscopy, non-bronchoscopic bronchoalveolar lavage (NB-BAL),sputum induction, speech therapy,nebulizer treatments, CPAP, BiPAP, opensuctioning, autopsy,placement or removal ofanNGtube, all respiratory therapy procedures. Theremay be otherAGPsinyourarea; pleasecontact Infection Preventionif unsure whetheraprocedureisan AGP.

• Airborne infection isolation (AIIR):A roomwith airflowengineering to reduce the risk ofairborne infection transmission.

• ROCOVID: Rule-out COVID-19;apatient receiving treatment while COVID-19testresults arepending.

Re-Use of PPE – NM Guidelines 1/2

Your safety depends on careful attention to hand hygiene and

doffing of PPE, in particular. Take your time.

Review videos of how to put on/remove PPE when re-using PPE at:https://physicianforum.nm.org/covid-19-ppe-resources.html → Videos

The top priority for your safety and that of our patients is to use the right PPE at the right time and to

conserve so that we have enough for weeks and months to come.

Sources: CDC, IDPH, NM Infection Prevention; current as of 4/14/2020 0900

Re-Use of PPE – NM Guidelines 2/2

Your safety depends on careful attention to hand hygiene and

doffing of PPE, in particular. Take your time.

Review videos of how to put on/remove PPE when re-using PPE at:https://physicianforum.nm.org/covid-19-ppe-resources.html → Videos

The top priority for your safety and that of our patients is to use the right PPE at the right time and to

conserve so that we have enough for weeks and months to come.

Sources: CDC, IDPH, NM Infection Prevention; current as of 4/14/2020 0900

Safe Putting On (Donning) of PPEVideos and Content available on Physician Forum1. Putting on PPE with a New Surgical Mask or N95

Respirator Mask

2. Putting on PPE with a Used N95 Respirator Mask

3. Putting on PPE while Wearing a Continuous UseSurgical Mask or N95 Respirator Mask andGoggles or Face Shield

4. Donning and Checking the Seal Patency on anN95 Respirator

5. How To Perform N95 Seal Check (PDF)

Additional content for specific mask brands available at:

https://physicianforum.nm.org/covid-19-ppe-resources.html

*If you are having difficulty fitting an N95 mask properly, try a different brand and/or contact Corporate Health.

Sources: CDC, IDPH, NM Infection Prevention; current as of 4/10/2020 0900

Safe Removal (Doffing) of PPE

Videos available on Physician Forum

1. Removing PPE

2. Removing PPE while Wearing aContinuous Use Surgical Maskor N95 Respirator and Gogglesor Face Shield

3. Wearing, Discarding, andStoring Masks

Sources: CDC, IDPH, NM Infection Prevention; current as of 4/10/2020 0900

1.Intubated patients (transport of intubated patients should be limited as much as possible)

• For transport of intubatedpatients fromICU to OR, watch this video: PPE for COVID Patient: ICU to OR Transport

• Designated transport ventilator should be used

• Transporting staff to wear Usual COVID PPE

• If Bag Valve (BV) ventilation is required wear Usual COVID PPE

• BV must have viral filter±PEEP valve (ETT/Trach → Viral Filter → Bag Valve Ventilator).

• Team should perform N95 mask seal check prior to transport

• When switching ventilators, ET tube must be clamped & gas flow turned off; use Usual COVID PPE when circuit disconnected.

2. Non-intubated patients

• Patient to wear surgical mask with nasal cannula underneath, if needed

• Transporting staff to wear Usual COVID PPE

• If Bag Valve Mask (BVM) is necessary, transporting staff to wear Usual COVID PPE and use viral filter as described above

How should COVID-19 patients be transported?These guidelines change frequently. Check for updated guidelines on Physician Forum PPE Resources Page.

Sources: CDC, IDPH, NM Infection Prevention; current as of 4/14/2020 0900

PPE Tips

• Always ensure proper PPE, even in emergencies such as CPR andcodes. Protect yourself first.

• Use buddy system for putting on/removing PPE, especially the first few times

• Avoid jewelry, name badges, stethoscope, tie back long hair, etc., prior to entering rooms to avoid contaminating yourself despite PPE

• Wear contacts rather than glasses, if possible, as it is hard to put on/remove N95 masks with glasses

• Nasal and oral swabs are not considered AGPs and do not requireN95 masks

• NM no longer requires contact precautions for VRE and MRSA

Sources: CDC, IDPH, NM Infection Prevention; current as of 4/10/2020 0900

PPE FAQs

• PPE guidelines change frequently

• Please refer to the Physician Forum PPE Resources page for the mostcurrent guidelines

• PPE FAQs • Surgery and Anesthesia in the OR: Additional hospital-specific

guidance is on may exist on NMI:https://nmi.nmh.org/wcs/page/nm-coronavirus- hospital-specific-guidelines

• Page Infection Prevention with any questions and/or for guidance

• Central Region: 312.695.9196

• North and Northwest regions: 312.695.9483

• West Region: 630.255.1293

Sources: CDC, IDPH, NM Infection Prevention; current as of 4/10/2020 0900

What if I think I've been exposed?If you think you have been exposed to a confirmed COVID-19 patient

• Call the COVID-19 hotline at (312)47COVID (x2-6843).

− Information verified by hotline team

• You will be contacted with next steps

• NMI Exposure/Return to Work FAQ: https://nmi.nmh.org/wcs/page/nm-coronavirus-faqs-exposure-return-to-work

James Gathany - CDC Public Health Image library ID 11162

Sources: CDC, IDPH, NM Infection Prevention; current as of 4/10/2020 0900

Informed Care of COVID-19 Patients Overview, Clinical Presentation, Guidelines forInvestigation and Testing, Principles of Evaluation and Management in Different Phases of Care (ED, Floor, ICU)

Who should I contact with clinical questions?Many contacts are specific to your region.

• For urgent clinical questions about COVID inpatients, ROCOVID* patients, orif patient should be ROCOVID:

– Central: COVID Infectious Disease Pager: COVID ID (26551)

– North, West, Northwest: Contact on-site or on-call Infectious Disease

• For ICU consultation for deteriorating COVID and ROCOVID* patients.

– Central: COVID MICU Pager: COVID-MICU (19075)

– North, West, Northwest: Contact on-site Intensivist

• All Regions: For non-urgent clinical questions:

– Email covid-19md@nm.org

– Review algorithms and general, ambulatory, and hospital- specific

clinical guidelines on NMI or on Physician Forum

(Physician Forum is available without employee login)

* ROCOVID = Rule-Out COVID

COVID-19 BasicsNomenclature:Virus: SARS-CoV-2, 2019 Novel Coronavirus (2019-nCov)Infection: Coronavirus Disease 2019 (a.k.a. COVID-19)

Virology:1

• “Animal” Coronavirus• Likely bat reservoir, possible

intermediate host, spread tohumans2

• ssRNA enveloped by a membrane• Viral Spike/Unit on membrane

binds to ACE2 receptor on Type 2pneumocytes• Virus infectivity is greater in

lower airway than upper airway• Soap and alcohol-based soaps

disrupt the membrane and thespikes, making the virus non-infective

• Spreadby respiratorydroplets1,3

• Virus able to survive on surfaces(need for frequent handwashing)

1-Michael Ison,MD;FeinbergSOMGrandRounds 3.16.20:https://imswebcast.feinberg.northwestern.edu/Mediasite/Play/7cce725c2dfe4a9eb680f21d32b71ae21d2-NatureMicrobiology. Doi:10.1038-s4156-020-0695z3-NMHResource Homepage:https://www.nm.org/conditions-and-care-areas/infectious-disease/covid-194-CDC.COVID-19FactPage:https://www.cdc.gov/coronavirus/2019-ncov/prepare/transmission.html?CDC_AA_refVal=https%3A%2F%2Fwww.cd

Epidemiology:1,3

• R0: expected # cases directly generatedfrom 1 known case

• R0 SARS CoV2: 2.5• R Influenza:1.30

• Attack Rate: number of new cases in apopulation, synonymous with risk of getting the disease in a specified timeperiod4

• Attack RateSARS CoV2: 30-40%• Median Incubation Period: 4 days (IQR 2-7)• Days to infection from exposure: 3-7 days1

•Viral Shedding: median 20 days4

• Additional mechanisms of viral shedding(i.e., enteric) not known

• Therisk of transmission is highest frompeople who are actively sick and exhibitingsymptoms.

• It is currently thought that rare for viral spread to occur from asymptomaticpersons3

Methods of Prevention and Slowing Spread:

• PREVENTION: Regular and Frequent Handwashing• Use soap and water for 20+ seconds• Use alcohol-based sanitizer and rub

hands until dry• FLATTEN THE CURVE: Social Distancing,

Self-Quarantine• EARLY CASE IDENTIFICATION: Community

Screening, Contact- tracing

COVID-19 TIMELINE OF EVENTS:12/31/19: China notifies WHO of clustering cases1/15/20: First US Case- Seattle3/11/20: WHO declares Pandemic3/12/20: US declares National Emergency

* Please note that certain rates, includingmortality, transmission, prevalence,and attack rate, may changeover time as more informationis collected

** All datacurrent as of 4/2/2020

c.gov%2Fcoronavirus%2F2019-ncov%2Fabout%2Ftransmission.html

COVID-19 Clinical Presentation

1. Jen Babik, UCSF COVID-19 ID Working Group. Last updated: March 14, 2020 https://infectioncontrol.ucsfmedicalcenter.org/sites/g/files/tkssra4681/f/COVID-19%20Clinical%20Evaluation%20Guide.pdf2. Guan et al. NEJM. 2020. DOI: 10.1056/NEJMoa20020323. Michael Ison, MD. Feinberg School of Medicine Medical Grand Rounds. COVID-19: An Update on the Current Situation.March 17, 2020.

*There is some emerging evidence, mostly anecdotal, that GI symptoms may bemore common than described

- There are also reports that patients may present early with only loss of sense of smell (anosmia) or taste (ageusia).

Common Symptoms Frequency

Cough(~50% productive)

~65%

Fever on presentation[≥37.5 °C (99.5 °F)]

~45%

Fever during admission[≥37.5 °C (99.5 °F)]

~90%

Fatigue ~40%

Uncommon Symptoms Frequency

Dyspnea (on admission) ~20%

Myalgias ~15%

Rhinorrhea /Nasal Congestion

~5%

Sore Throat ~15%

Headache ~15%

Diarrhea* ~5%

Nausea/Vomiting* ~5%

Comparing symptoms of COVID-19, Cold, and Flu

Symptoms

Fever

Fatigue

Cough

Sneezing

Aches andpains

Runny orstuffy nose

Sore throat

Diarrhea

Headaches

Shortness of breath

CoronavirusSymptoms rangt" hommllct 10 sever

Common

ColdGr. rtui'llonsetor .-,yrnptoms

Rare

FluAbrupt on In l l l l o m . ,

Common

Sometimes Sometimes Common

Common*(usuallydry)

No

Common

Sometimes

Sometimes

Sometimes for children

Common

No

Inte rm ounta in Hea Ithea re. ht tps :1/intermounta inheaIthea re .org /b logs/top ics/1ive-we II/2020/03/whats-the-d iffe renee-between-a-cold- the-flu-and

coronavirus/

Common*(usuallydry)

Mild

No Common

Sometimes Common

Rare Common

Sometimes Common

Rare No

Sometimes Rare

Sometimes No

COVID-19 Typical Clinical Course

Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep. ePub: 18 March 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6912e2

• Disease spectrum: asymptomatic, upper respiratory tract, lower respiratory tract

• Some suggestion of biphasic illness, with late stage decompensation and ARDS due toaberrant inflammatory response.

• Majority have milder disease

• Progression of Severe/Critical Disease Over Time:

- Dyspnea in ~6 days, ICU/Intubated in ~10 days

• Critically ill can progress rapidly, developing severeARDS in as soon as 72 hours

• Intubated: ~15-20 days of mechanical ventilation

• In largest report of Covid-19, 44,415 patients inChina:

– Disease severity: 81% mild-moderate, 14%severe, 5% critical

– Overall mortality 2.3%

• 14.8% in patients 80+, 8% in patients 70-79

• 49% of critical cases

References: https://jamanetwork.com/journals/jama/fullarticle/2762130https://jamanetwork.com/journals/jama/fullarticle/2762688https://jamanetwork.com/journals/jama/fullarticle/2763485

• As of 3/16/20, 38% of hospitalized COVID-19 patients in the US were between 20-55 years old; 12% of ICU patients were 20-44 years old

Clinical Classification of COVID-19

The First Affiliate Hospital, Zhejiang University School of Medicine. Handbook of COVID-19 Prevention and Treatment. 2020.

1 of 3

1. Mild: (Mild + Moderate = 81% of cases)

– Clinical symptoms are mild

– No pneumonia manifestations in imaging

2. Moderate: (Mild + Moderate = 81% of cases)

– Patient has symptoms such as fever, respiratory tract symptoms, etc.

– Pneumonia manifestations can be seen in imaging

3. Severe: (14% of cases)

Adults who meet any of the following criteria:

– Respiratory rate ≥ 30 breaths/min

– Oxygen saturation ≤ 93% at a rest state

– Oxygenation Index (PaO2/FiO2) ≤ 300 mm Hg

– Patients with > 50% progression within 24 to 48 hours on lung imaging

Mild, Moderate,Severe, CriticalSeverity Levels

Clinical Classification of COVID-19

The First Affiliate Hospital, Zhejiang University School of Medicine. Handbook of COVID-19 Prevention and Treatment. 2020.

2 of 3Mild, Moderate,Severe, CriticalSeverity Levels

4. Critical (5% of cases)

Adults who meet any of the following criteria:

– Occurrence of respiratory failure requiring mechanical ventilation

– Presence of shock

– Other organ failure that requires monitoring and treatment in the ICU

• Critical cases are further divided into stages according to oxygenation index andcompliance of respiratory system

A. Early stage

–Oxygenation Index (Pa02/Fi02) ≤ 150 mmHg, > 100 mmHg

– Lung Compliance ≥ 30mL/cm H2O

–Without organ failure other than lungs

–Patients can recover with aggressive supportive care

Clinical Classification of COVID-19Mild, Moderate, Severe, Critical Severity Levels

The First Affiliate Hospital, Zhejiang University School of Medicine. Handbook of COVID-19 Prevention and Treatment. 2020.

3 of 3

4. Critical (continued)

B. Middle Stage

– Oxygenation Index (Pa02/Fi02) ≤ 100 mmHg, > 60 mmHg

– Lung Compliance ≤ 15 mL/cm H2O, > 30 mL/cm H2O

– May be complicated by other mild or moderate dysfunction of other organs.

C. Late Stage

– Oxygenation Index (Pa02/Fi02) ≤ 60 mmHg

– Lung Compliance < 15 mL/cm H2O

– Diffuse consolidation of both lungs that requires the use of ECMO

– Multi-system organ failure

– High mortality

COVID-19 Patient Care – Emergency Department Pearls

1.2.

Society of Critical Care Medicine. Caring for Critically Ill Patients with Novel Coronavirus. https://www.sccm.org/Blog/January-2020/Caring-for-Critically-Ill-Patients-with-Novel-CoroWorld Health Organization. COVID-19 technical guidance: Patient Management. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/patient-management

3.

4.

[PREPRINT] Xing Q, Li G, Xing T, et al. Precautions are Needed for COVID-19 Patients with Coinfection of Common Respiratory Pathogens. Lancet Preprints. https://ssrn.com/abstract=3550013.

NM Emergency Department Covid-19 Diagnostic and Prognostic Aid

CONSIDER Notes

Consider testing for COVID-19 if:Moderate to severe influenza-like illness (ILI) symptoms (new/worsening cough OR SOB OR sore throat) INCLUDING a fever (≥100.4°F) AND any one of the following risk factors:Page ID (West, North, NW) or COVID-ID (Central) with questions re: testing

IDPH COVID-19 Testing Criteria1.Age > 652. Comorbidities at higher risk of complications from SARS-CoV-23.Persons (staff or patients) who in a more vulnerable residentialcongregate setting (e.g., SNF, assisted living facility, group home,homeless shelter, correctional settings).4. Patients likely to be hospitalized.5. Symptomatic healthcare workersMost current testing guidelinesat:https://physicianforum.nm.org/uploads/1/1/9/4/119404942/testing-criteria-covid19.pdf

Admission to the hospital if:Age > 65, significant dyspnea, hypoxia,tachycardia, tachypnea, comorbidities,lymphopenia, infiltrates on imaging

All higher risk for increased disease severity

Be more cautious about disposition if patient is early in disease course and has high risk factors

Nasal Cannula / Non-Rebreather (only if fits very well) if hypoxic

Reduces risk of aerosolizing particles exposing others.1 Make sure non-rebreathers fit very well or risk for aerosolizing.

Conservative fluid resuscitation Aggressive resuscitation can increase pulmonary edema - can worsen respiratory failure2

Empiric Antibiotics, especially if:Septic, neutrophilic predominant leukocytosis, elevated procalcitonin

Suspicion for bacterial co-infection3

Follow guidelines for treatment of CAP, HAP

COVID-19 Patient Care – Emergency Department Pearls

1.

2.3.4.

Northwestern Medicine. Self-protection Guidance when Providing Respiratory Care for Known or Suspected COVID-19 Patients, 3/12/2020. Access on NMInteractive COVID-19 Clinical Guidelines.NM Emergency Department Covid-19 Diagnostic and Prognostic Aid

Society of Critical Care Medicine. Caring for Critically Ill Patients with Novel Coronavirus. https://www.sccm.org/Blog/January-2020/Caring-for-Critically-Ill-Patients-with-Novel-CoroRussell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. The Lancet. 2020;395(10223):473-475.

AVOID Rationale

Non-invasive positive-pressure ventilation (CPAP/BiPAP)

Risk of aerosolizing virus particles, increases risk of exposure for staff.1

Using CXR/CT Chest toprimarily diagnose COVID-19

Non-specific (abnormal w/any viral pneumonia). Protects scanners, radiology staff.

CAUTION Rationale

Non-rebreathers, Venturi mask, nebulizer treatments, high flow nasal cannula

Risk to aerosolize virus particles, may increase risk of exposure for staff; avoid if possible.Ensure non-rebreather fits very well, if using.

Systemic corticosteroidswithout other indication

Potential prolonged viral replication seen in MERS-CoV2; only use if other indication [shock, steroid responsive condition (i.e., asthma)]

Bag-valve ventilation(e.g. Ambu Bag)

If absolutely necessary, use a viral filter (VF) ± PEEPvalve to reduce risk to staff.3 VF should be placed asclose to patient as possible to minimize aerosol risk(e.g., ETT→VF→AmbuBag)

What should I do if I suspect a patient has COVID-19?Protect andDiagnose

1.Place surgical mask on patient

2.Move patient to empty room or area not within general public space

3.Don appropriate PPE depending on clinical situation

4.Do not transport without proper notifications and precautions

5.Follow appropriate testing guidelines6.Flag in EPIC StoryBoard will change to Rule-out COVID as

soon as COVID testing is ordered

7.Page Infection Prevention for PPE and isolation assistance.Page ID (West, North, NW) or COVID-ID (Central) for clinical assistance

Sources: NMI COVID Guidelines; current as of 4/10/2020 0900

What happens when a patient is confirmed COVID-19?

• Flag will appear in EPIC StoryBoard

• There are evolving systems to notify potentially exposedproviders

• Please refer to NM Exposure Guidelines for COVID-19

• Instructions for how to flag a patient as COVID-19positive or ROCOVID in EPIC

Sources: NMI COVID Guidelines; current as of 4/10/2020 0900

COVID-19 Patient Care – Emergency Department PearlsTips for Discharge vs. Admission

❖ Most patients can be safely discharged

• Especially if Mild disease:

• Young

• Mild Clinical Symptoms

• No evidence of pneumonia

• Home with self-supportive care and quarantine instructions

- EPIC dotphrases exist to assist with discharge instructions/documentation

• Must be able to comply with self-isolation.

Be more cautious with high risk patients who may be early (< 6 days) in disease course (elderly, comorbidities, immunosuppressed)

NM Emergency Department Covid-19 Diagnostic and Prognostic Aid

•

Inpatient (non-ED) testing for COVID-19

• As soon as you clinically suspect a patient has COVID-19

– Central Region: Page the COVID-ID team (26651)

– North, West and North West Region: Call ID on site or on-call

• ID team will evaluate whether testing should occur

• Check Physician Forum for current testing guidelines

https://www.cdc.gov/coronavirus/2019-ncov/about/testing.html

Sources: NMI COVID Guidelines; current as of 4/10/2020 at 0900

COVID-19 Patient Care – Floor – Comorbidities and Vital Signs

1. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19. 2. Zheng, YY et al. COVID-19 and the cardiovascular system. Nat Rev Cardiol. 2020 Mar 5. doi: 10.1038/s41569-020-0360-5. 3. Huang, C. et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5. Epub 2020 Jan 24. 4. NMH ICU Care Guidelines for Patients with COVID-19, last update 4/7/2020.

• High Alert Values: Higher level of vigilance for deterioration and consider additional studies

• Page COVID-MICU (Central) or Intensivist on-site (North, NW, West) for consultation if: Any Red Flag Value, ≥2 High Alert Values (including lab values), and/or high clinical suspicion for active deterioration.

• Assess vital signs q4h for patients in ED/on floor

Assess Vital Signs q4h

Key Parameters

Normal Range/ Goal

High Alert Values Red Flag Values

Comorbidities Age > 60, Cardiovascular Disease, Chronic Lung Disease, Immunosuppression, Cancer, History of Sepsis, DM, CKD, HIV+

Comorbidity High Alert Value + Any Other High Alert Value

Respiratory Rate 12-20 >24 breaths per minute

**Try to prevent emergent intubation on floor**

Impending Respiratory Failure

Oxygen Saturation

>93% Persistent SpO2 <90% without O2.≥3-4L O2 by NCContinuous pulse oximetry when O2 required. Consider CXR, ABG, RT evaluation. Asymptomatic hypoxemia has been reported.

≥4-6L O2 by NC, rapidly increasing O2

requirement, persistent SpO2 <90% with O2, PaO2<65 (ABG).

May be < 24 hours until intubated.

Pulse and Cardiac Rhythm

60-100, NSR

HR > 125High Sensitivity Troponin I > 28 pg/mL Signs of cardiac dysfunctionEKG, telemetry if suspected dysfunction

Hard signs/high suspicion of significant dysfunction, persistent arrhythmia

Limit routine echocardiograms

Blood Pressure 100-140/60-90 SBP>140-150 or SBP<100Consider gentle fluid challenge if hypotensive

Persistent hypotension after volume challenge

Temperature <100.4 Persistent fever >100.4High fever + altered mental status / ↑ serum CK

COVID-19 Patient Care – Laboratory Studies• Labs to obtain at presentationif ED/Floor: CBC with diff, CMP, LDH, INR, D-Dimer, Procalcitonin, CRP,

Ferritin, Respiratory Pathogen Panel, COVID-19 Order Panel•May not need daily labs if stable/improving; often drawn more regularly/often in ICU• Page COVID-MICU (Central) or Intensivist on-site (North, NW, West) for consultation if: Any Red Flag

Value,≥2 High Alert Values (including lab values), and/or high clinical suspicion for active deterioration.

1. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19. 2. Zheng, YY et al. COVID-19 and the cardiovascular system.Nat Rev Cardiol. 2020 Mar 5. doi: 10.1038/s41569-020-0360-5. 3. Huang, C. et al. Clinical features of patients infected with 2019novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5. Epub 2020 Jan 24. 4. NMH ICU Care Guidelines for Patients with COVID-19, last update 4/7/2020.

Lab High Alert Values Notes Lab High Alert Values Notes

WBC Lymphopenia (<0.7) or Leukocytosis (possible

bacterial coinfection)

Order as “CBC with Differential”

D-Dimer ↑(>1000)

If elevated, may be a sign of severe illness

Procalcitonin ↑ If elevated, consider bacterial co-infectionPlatelets Thrombocytopenia Order as “CBC with

Differential”CRP ↑

(>20)

May indicate disease severityAST, ALT ↑

(ALT > 24 IU/mL)

Order as “Comprehensive Metabolic Panel” Ferritin ↑

(>300)

May indicate disease severity

Creatinine ↑(worsening ARF)

Order as “Comprehensive Metabolic Panel”

ESR ↑ May indicate disease severity

LDH ↑(> 245)

Blood/Sputum Culture

+ Draw only when clinical suspicion

INR ↑(persistent increase)

Other Labs Notes

Respiratory Viral Panel

Includes RSV, Flu, others.Up to 22.4% of COVID-19 patients co-infected (data from Stanford).

CK ↑(>2x upper limit nl)

COVID-19 Order as “COVID-19 Order Panel

COVID-19 Patient Care – Additional Labs and Studies•Draw these labs on floor if clinical suspicion warrants•May be drawn more regularly/often in ICU• Page COVID-MICU (Central) or Intensivist on-site (North, NW, West) for consultation if: Any

Red Flag Value, ≥2 High Alert Values (including lab values), and/or high clinical suspicion foractive deterioration.

NM ICU Care Guidelines for Patients with COVID-19 Update: 4/7/2020https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19https://lookaside.fbsbx.com/file/COVID%20Protocols.docx?token=AWw2ceEiOGWpRgg_R7pqdeo7_p1EvzPUWvFNhaWe4oNo796QlPHh4Yp9JKQAjtKwNFNQA2cgwX2K77-yfBuQ1NKX0dnAEYcpET8mZJMbQHPdgMUaJhP9qfcU5Zgfcy-fCht9uma8gT2bGNwaVBJaOyo-Hcbhn40fxh_zmhkKU_IkNEw8eZugXatxEcAWJK-uhcb7QInHzVnLLSUKtAgQWAHlhttps://medium.com/@nigam/higher-co-infection-rates-in-covid19-b24965088333

Lab/Study (Cardiac)

COVID-19Abnormalities

Troponin ↑

CKMB ↑

Echocardiogram EF < 50%

Lab (ABG) COVID-19Abnormalities

pH Red Flag:< 7.3

PaO2 Red Flag:< 65

when FiO2≥0.5 (<4-6L NC)

PaCO2 Red Flag:>50

Base Deficit < -2

Bicarbonate ≤ 20

Lactate Red Flag:> 2

Examples of CXR from patients with COVID-19The First Affiliate Hospital, Zhejiang University School of Medicine. Handbook of COVID-19 Prevention and Treatment. 2020.

COVID-19 Patient Care – Imaging – CXR• Imaging findings are generally non-specific (similar to other viral pneumonias)• Transport to and from scanners increases risk of transmission to others• It is not recommended that CXR be used for diagnosis but can be considered in

ED if results will impact management• Normal imaging should prompt evaluation for alternate dx and/or co-infection

Imaging Purpose Findings Timing

CXR Initial evaluation and clinical assessment of lung consolidation for immobilepatients or patients not suitable for CT scan.

CXR findings are often non-specific and include patchy infiltrates that are often bilateral, peripheral, and basilar.

Admission and then more often for critically ill patients.

• Imaging findings are generally non-specific (similar to other viral pneumonias)• Transport to and from scanners increases risk of transmission to others• It is not recommended that CT imaging be used routinely for diagnosis• Normal imaging should prompt evaluation for alternate dx and/or co-infection

Examples of non-contrast CT from patients with COVID-19

The First Affiliate Hospital, Zhejiang University School of Medicine. Handbook of COVID-19 Prevention and Treatment. 2020.

COVID-19 Patient Care – Imaging – CT Scan

Imaging Purpose Findings Timing

CT Chest Initial evaluation and clinical assessment of lung consolidation.

Early COVID-19 presents with bilateral, multifocal,ground glass opacities along the lung periphery and lower lobes.

Currently, routine imaging is not recommended.CT for COVID-19 do not require contrast.Contrast may be used to evaluate for other pathology.

COVID-19 Patient Care – Critical Care Pearls 1 of 3

1. NMH ICU Care Guidelines for Patients with COVID-19, last update4/7/2020. 2. Society of Critical Care Medicine. Caring for Critically Ill Patients with Novel Coronavirus. https://www.sccm.org/Blog/January-2020/Caring-for-Critically-Ill-Patients-with-Novel-Coro. 3. Wax RS, Christian MD. Practical recommendations for criticalcare and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Canadian Journal of Anesthesia. 2020. 4. Murthy S, Gomersall CD, Fowler RA. Care for Critically Ill Patients With COVID-19. JAMA. 2020. 5. World Health Organization.COVID-19 technical guidance: PatientManagement. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/patient-management 6. [PREPRINT] Xing Q, Li G, Xing T, et al. Precautions are Needed for COVID-19 Patients with Coinfection of Common Respiratory Pathogens. Lancet Preprints. https://ssrn.com/abstract=3550013 7.MacLaren G, Fisher D, Brodie D. Preparing for the Most Critically Ill Patients With COVID-19: The Potential Role of Extracorporeal Membrane Oxygenation. JAMA. 2020. 8. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered,

retrospective, observational study. The Lancet Respiratory Medicine.

Refer to COVID-19 Critical Care Guidelines and Educational Resources on NMI for current details:https://nmi.nmh.org/wcs/page/nm-coronavirus-critical-care-clinical-guidelines (login required)

CONSIDER Rationale

Intubation early in the course of disease and early in the day

Promotes proper usage of PPE in a controlled setting vs. urgent intubation.1,2 Increased anesthesia availability.Red Flags: Respiratory Rate > 24, ≥3-4L O2 by NC, rapidly increasing O2 requirement, persistent SpO2 <90% with/without O2, PaO2<65 (ABG).

Low tidal volume ventilation NMLung COVID+ARDS ventilator management protocol

Metered Dose Inhaler Likely lower risk for providers vs nebulizer2,3

8 puffs of albuterol MDI w/spacer as good as a nebulizer.

Prone positioning Facilitates recruitment, ventilation-perfusion match, and clearance of secretions.4

Manual Proning Protocol on NMI Critical Care Guidelines (login required)

Antibiotics Coinfection with other respiratory pathogens has been suggested.5 Empiric tx may be appropriate, especially if septic

Conservative fluid strategy Similar to pulmonary edema tx, avoid volume overload4

VTE Prophylaxis Lovenox 40mg SC qd (unless bleeding, Plt < 25k, CrCl < 30, acute kidney injury). Alternate: Heparin 5000u SC bid

ECMO Uncommon, but possible benefit.6 Usually VV ECMO at NMH. High mortality if needed.6

COVID-19 Patient Care – Critical Care Pearls 2 of 3

1. NMH ICU Care Guidelines for Patients with COVID-19, last update 4/7/2020. 2. Society of Critical Care Medicine. Caring for Critically Ill Patients with Novel Coronavirus. https://www.sccm.org/Blog/January-2020/Caring-for-Critically-Ill-Patients-with-Novel-Coro. 3. Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. The Lancet. 2020;395(10223):473-475.4. Northwestern Medicine. Self-protection Guidance when Providing Respiratory Care for Known or Suspected COVID-19 Patients, 3/12/2020. Access on NMInteractive COVID-19 Clinical Guidelines.

Refer to COVID-19 Critical Care Guidelines and Educational Resources on NMI for current details:https://nmi.nmh.org/wcs/page/nm-coronavirus-critical-care-clinical-guidelines (login required)

AVOID Rationale

Non-invasive positive-pressure ventilation (CPAP/BiPAP)

Risk of aerosolizing virus particles, increases risk of exposure for staff1

CAUTION Rationale

CPR and Codes Review most recent Critical Care Guidelines(login required)(Chapter 4)

High-flow nasal cannula, Non-rebreathers, Venturi mask, nebulizer treatments

Risk to aerosolize virus particles, may increase risk of exposure for staff.Ensure non-rebreather fits very well, if using.

Systemic corticosteroids without other indication

Potential prolonged viral replication seen in MERS-CoV2; can be used, if indicated.

Bag-valve ventilation(e.g. Ambu Bag)

If absolutely necessary, use a viral filter +/- a PEEP valve to reduce risk to staff3

COVID-19 Patient Care – Critical Care Pearls 3 of 3

1. NMH ICU Care Guidelines for Patients with COVID-19, last update 4/7/2020. 2. Winichakoon P, Chaiwarith R, Liwsrisakun C, et al. Negative Nasopharyngeal and Oropharyngeal Swab Does Not Rule

Out COVID-19. J Clin Microbiol. 2020:JCM.00297-00220. 3. American Association for Bronchology and Interventional Pulmonology (AABIP) Statement on the Use of Bronchoscopy and Respiratory SpecimenCollection in Patients with Suspected or Confirmed COVID-19 Infection. https://aabronchology.org/announcements/

Refer to COVID-19 Critical Care Guidelines and Educational Resources on NMI for current details:https://nmi.nmh.org/wcs/page/nm-coronavirus-critical-care-clinical-guidelines (login required)

CAUTION Why

Aerosol-generating procedures: (see NMI/Critical Care

Guidelines for complete list)• Intubation/extubation• Tracheotomy/cricothyroidotomy• Cardiopulmonary Resuscitation

(CPR)• Bronchoscopy• Suctioning• Possibly ECMO (check current policy)

Risk to aerosolize virus particles, may increase risk of exposure for staffUse PPE recommended for high risk patients

Note that bronchoscopy may be indicated for inconclusive COVID results1, particularly for alternative diagnoses or urgent life-saving intervention2

Note: Bronchoscopy Consider bronch while paralytic remains onboard from intubation to minimize cough. Can also confirm tube position

COVID-19 Patient Care – Critical Care - Mechanical VentilationRefer to COVID-19 Critical Care Guidelines and Educational Resources on NMI COVID-19

Other Ventilator-RelatedLinks:

1. NMHC Vent Quick Reference Sheet

2. NMH COVID-19 NIV Vent Setup Guide

3. Draeger as ICU Ventilator Quick Reference

4. Manual Proning Protocol

*note, this is similar tothe"High PEEP"algorithm fromtheARDSnet Protocol.

http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

NMH ICU Care Guidelines for Patients with COVID-19; current as of 4/10/2020

Active Treatment of COVID-19 – Evidence• Some antivirals (remdesivir, lopinavir, ribavirin, ritonavir), IL-6 inhibitors (tocilizumab, sarilumab),

and chloroquine drugs (chloroquine, hydroxychloroquine) have demonstrated effect in vitro andin small case series.

• Non-randomized, problematic study of 36 patients from France found effective nasopharyngeal viral clearance at 6 days using hydroxcholoroquine + azithromycin.

– However, 6 patients from treatment arm excluded – 3 to ICU, 1 died, 1 withdrew, 1 left hospital

– Multiple small series from China have reported improved imaging, virus negative conversion, and shortened disease course with chloroquine

• Currently there is only limited data to support chloroquine, hydroxychloroquine, or azithromycin – only use within NM guidelines and/or in consultation with COVID-ID

• IL-6 inhibitors being investigated for their role in dampening aberrant inflammatoryresponse

• However, first major randomized trial of antiviral agent (Kaletra) = Negative− Kaletra (lopinavir-ritonavir) – No difference in time to clinical improvement

− No difference in mortality (19.2% antiviral vs 25% standard)

• Currently, there is no data to support stopping ARB and ACE-I medications or NSAIDs

• Review most recent NM evidence review for inpatient treatment options at:Physician Forum Critical Care Guidelines→ Diagnosis and Treatment

* Datacurrent as of4/10/2020

Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively inhibitthe recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Research 2020 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7054408/);Gautret et al. (2020) Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. International Journal of AntimicrobialAgents – In Press 17 March 2020 – DOI : 10.1016/j.ijantimicag.2020.105949(https://www.mediterranee-infection.com/wp-content/uploads/2020/03/Hydroxychloroquine_final_DOI_IJAA.pdf)Gao J, Tian Z, Yang X. Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinicalstudies. (https://www.jstage.jst.go.jp/article/bst/14/1/14_2020.01047/_pdf/-char/en) Cao B Wang Y Wen D et al A trial of lopniavir-ritonavir in adultshospitalized with severe covid-19 NEJM (https://www nejm org/doi/full/10 1056/NEJMoa2001282)

* Data current as of 4/10/2020

Active Treatments and Clinical Trials

• The “Clinical Treatment Pathway for Inpatientswith COVID-19” describes current activetreatment of COVID-19, including clinical trials

• Pathways differ between NMH and other regions

• The pathway will rapidly evolve and change often

• For current pathway details: CoronavirusGeneral Clinical Guidelines → Diagnosis and Treatment → NM COVID-19 Clinical Resources

Current Active Treatment Availability at NM

• Remdesivir:

– NMH: Clinical trial use only [contact: COVID ID Pager (26651)]

– Other regions: Contact ID (possible expanded access through Gilead)

• Sarilumab: Only available at NMH through clinical trial [Contact: Research Pager (59285)]

• Hydroxychloroquine, azithromycin, and other medications should only be used withinNM guidelines and/or in consultation with Infectious Disease

Post-ICU Patient Care

• Anecdotal reports suggest slow recovery after ICU.1

• Lung compliance may be better than SARS-CoV, lower incidenceof barotrauma2

• Protocol to discharge is evolving, but many centers requiring multiple negative naso-/oro-pharyngeal PCR3

1.

2.

3.

Rosenbaum L. Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line. N Engl J Med. 2020.

Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet Respiratory Medicine.

Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA. 2020. Figure: New York Times, 3/19/2020

Other COVID-19 Patient Care Pearls from Your Colleagues1 of 2

• Use a “buddy system” to help put on/remove PPE safely

• Ensure there is a disposable stethoscope in each room for reuse

• Collaborate with your colleagues (clinical, nursing, environmental) to decrease transmission risks by bundling tasks

– Ask your colleagues if there are tasks you can help with while in the room (e.g., bring in/out meal tray)

– High-risk procedures should be performed by the most experienced team member or by dedicated procedure teams

• Consider developing a special form of communication (i.e., havespare phones in room) to indicate patient emergencies with your nursing team since you will be unable to read pages while in PPE

– Leave your pager with another team member or forward to them

Other COVID-19 Patient Care Pearls from Your Colleagues2 of 2

• Communicate with patients and set expectations for contact

– Consider calling into the room to “pre-round”

– Tell patients you will round in-person once per day unless clinical deterioration

• Patients are very anxious and scared. Be present, listen, and even hold their hand (sit side-by-side rather than face-to-face) even if you’re in PPE

• The family visitor policy is evolving and affects DNR/DNI patients.Please refer to current guidelines on NMI

• Use pre-existing “.covidxxxx” smartphrases in Epic and other documentation resources (AVS) on Physician Forum:

– https://physicianforum.nm.org/covid-19-clinical-guidelines.html– https://physicianforum.nm.org/covid-19-telehealth-resources.html

NM COVID-19 General Resources

• Email for general questions: covid-19@nm.org

• Physician Forum COVID-19 Website:

https://physicianforum.nm.org/covid-19.html

External References and Resources

• Centers for Disease Control and Prevention (CDC)

− https://www.cdc.gov/coronavirus/2019-ncov/index.html

• Illinois Department of Public Health (IDPH)

– http://dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/coronavirus

• World Health Organization (WHO)

– https://www.who.int/emergencies/diseases/novel-coronavirus-2019

• Internet Book of Critical Care – COVID-19 Resource

– https://emcrit.org/ibcc/covid19/

• PubMed “LitCovid” - Resource for all published studies on COVID-19

– https://www.ncbi.nlm.nih.gov/research/coronavirus/

• NEJM - Coronavirus (Covid-19) articles and resources

– https://www.nejm.org/coronavirus

Thank YouPlease direct all clinical questions to covid-19md@nm.orgPlease direct feedback about this module to Anthony Yang (ayang@nm.org)

Authors: Lindsey Kreutzer, MPH; Kristina Davis, MS, MSN, MPH, RN, CNL, CPHQ ; Maya Cotton, MPH; Susan Metzger, RN, BSN,CPHQ; Brian Brajcic, MD; Matthew Chia, MD; Martha Ingram, MD; Rhami Khorfan, MD; Cary Schlick, MD; Tarik Yuce, MD; Karl Bilimoria, MD; Anthony Yang, MDReviewers: Cindy Barnard, PhD; Ajay Bhasin, MD; Shannon Galvin, MD; Michael Ison, MD; JackyKruser, MD; Clara Schroedl, MD; Michael Shapiro, MD; Paul Tamul, MD; David Cooke, MD