STAFFING

Plan to have a double back-up system in place ensuring that if staff members are sick, there is an easy system to call in relief without having to scramble. This system also protects against staff members feeling remorse or hesitance about calling in sick and contributing to dangerous “presenteeism” (coming to work sick).

Consider:

  • Canceling communal food in meetings/care areas, and moving towards tele-education/meetings online.
  • Updating staff flu shots
  • Requiring use of scrubs instead of personal clothes to work, and encouraging minimization of jewelry/personal items as fomites.
  • Gel-in/Gel-out hand hygiene; redouble efforts to ensure 100% compliance for all patients.
  • A hospital-wide plan for back-up childcare so nurses/physicians are not staying home to care for their children if schools close.

TRAINING

Arrange in-person Donning/Doffing training by “super-trainers” for all ICU/ED/Radiology staff. Once an airway plan has been established, use simulation training to get staff comfortable with new procedures and protocols (eg. intubating using the glidescope while in a PAPR with a shroud).

INTER-FACILITY TRIAGE

A process for accepting outside transfers should be developed that includes department of health, hospital administration, infection control, and the intensivist.

  • Anticipate and build protocols after discussing risks and benefits of different models for patient movement.
  • Weigh the infective risk to the community and EMS with transport vs potential benefit to the individual patient for higher levels of ICU care.
  • Discuss options to support “shelter in place” to reduce disease transmission and overwhelming ICU resources at large urban centers.
  • Operationalize telemedicine to support critical care in lower resource hospitals.
  • Weigh benefits of differing models of cohorting patients at COVID hospitals vs spreading burden of intensive care among many hospitals.
  • Determine thresholds for transfer of a patient to a large urban hospital, e.g., no intensive care unit, over capacity (ventilators, beds).

If your center is a receiving center for stroke/other transfers, ensure that there are COVID-19 screening questions being asked by all accepting physicians/services (eg. trauma, stroke physicians accepting patients should screen).

GOALS OF CARE

Partner with palliative care or other teams to develop plans to address goals of care early. Develop talking points for clinicians. A resource from our palliative care team is hereFor many critically ill patients with COVID-19, CPR may not be medically appropriate. 

CRISIS STANDARDS OF CARE

Develop processes around implementation of crisis standards of care. In the face of limited resources (e.g., ventilators, ICU beds, etc.), the process of allocating these resources should be based on a utilitarian framework, often stated as providing the greatest good for the greatest number.

Initially, focus on building capacity, conserving existing resources, and reallocating and redistributing resources. If crucial resources truly become so scarce that they need to be allocated on a case-by-case basis, consider developing multi-professional teams, which may include clinical ethicists and community members, to assist.

  • Note: the UW system is not currently functioning at crisis standards of care.

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Consider risks and benefits of citywide and regional referral of patients to ECMO centers. Risks of transport may include: disease spread, risk to transport personnel, and overwhelming ECMO centers’ general ICU resources. Develop strict criteria for ECMO initiation only to those with the highest chance of survival given the high number of potential ECMO candidates and limited capacity. If patients require transfer from low resource hospitals consider triaging potential ECMO candidate patients (young, otherwise healthy, single organ failure) to large urban ECMO centers. This may decrease the frequency of patient transports for eventual ECMO referral.

Consider how mobile ECMO retrieval teams may be used to maximize ICU care at referral facilities. Once patients have failed conventional hypoxemia therapies, they will be too unstable for transport without ECMO. Coordinate with neighboring ECMO centers to exchange experience and knowledge, and potentially develop care guidelines for this patient population.

INTUBATION & RESPIRATORY SUPPORT

Personnel from critical care, respiratory therapy, and anesthesiology should convene to develop approaches to support for suspected or confirmed COVID-19 patients with respiratory failure.

We recommend careful consideration of noninvasive positive pressure ventilation (NIPPV) and high-flow nasal cannula, which may disperse secretions and therefore virus. There may be specific clinical circumstances where NIPPV (e.g., COPD or CHF exacerbation plus viral syndrome) or HFNC (e.g., patient has “do not intubate” status) might be considered. This should be done in concert with respiratory therapy and nursing teams in a negative pressure room and strict airborne precautions. The approach may change during periods of high-volume or acuity.

Some NIPPV circuits may be fitted with a viral filter, but secretion dispersion may still occur (especially if mask seal is not perfect). Oxygen flows should be limited, but an exact cutoff is undefined (some advocate for 15 or 30 L/min). Airway clearance therapies such as chest percussion or mechanical insufflation-exsufflation should likely be avoided.

Intubation/Airway Algorithms

Review plans for limiting staff exposure to aerosolization of COVID-19.

Consider:

  • High flow nasal cannula or non-invasive positive pressure ventilation should ideally be used in a negative pressure room with airborne precautions
  • Limiting use of nebulized medication
  • The timing of intubation is controversial. We suggest using usual criteria (e.g., hypoxemia or hypercarbia refractory to noninvasive measures, distress or work of breathing, mental status, or anticipated course).

Intubation should occur only by those trained in how to intubate while in a PAPR with Shroud. Follow a COVID-19 specific protocol for intubation developed by your hospital’s airway leads.

Consider:

  • PPE
  • Use of video laryngoscopy
  • Pre-made med airway kits
  • RSI to decrease aerosolization of particles with bag valve mask

We have opted to perform early tracheal intubation for these patients with placement on mechanical ventilation with a viral filter. Intubation should occur ideally in negative pressure rooms using airborne precautions.

  • The intubating clinician should use a PAPR with shroud and follow donning and doffing procedures.
  • Additional staff should be minimized (ideally, one nurse and one respiratory therapist).
  • We favor the use of video laryngoscopy to increase the distance between the intubating clinician and patient’s aerodigestive tract, and the rapid sequence intubation technique to minimize coughing or dispersion of secretions during bag-mask ventilation.
  • Viral filters can be placed in-line with bag-valve masks.
  • If sidestream waveform capnography devices are used, make sure a viral filter is placed in line proximal to the ETCO2 adapter (i.e., directly on the end of the ET tube, mask, or LMA). Otherwise, contaminated secretions may theoretically leak into the ETCO2 tubing and perhaps back to the monitoring module.

CODE BLUE/CLINICAL EMERGENCY RESPONSE

A dedicated plan for response to clinical emergencies should be created for patients with suspected or confirmed COVID-19. The plan should include: limiting responding personnel, ensuring isolation precautions are maintained, and limiting aerosolizing procedure.

Consider appointing dedicated isolation “captain” to ensure only essential staff enter the room, appropriate PPE are used, and equipment is decontaminated appropriately. The plan should include early discussions about “do not resuscitate” status with next of kin for critically ill infected patients.

PORTABLE RADIOGRAPHY

Imaging

Assess methods of portable one-view chest X-ray through a door (eg. Patient/nurse holds plate, or it is slid between back/stretcher, and film is shot through the door from the ante-chamber of the negative pressure room to minimize X-ray staff exposure to patients. Film cover wiped with bleach wipes by RN in the room before handing into ante-chamber.

Radiology teams from our institution have minimized staff and equipment exposure by performing single-view portable radiographs through the windows on doors to isolation rooms.

  • The patient is positioned standing or sitting in front of the door inside the isolation room with a nurse/staff wearing a lead shield, holding the plate to the patient’s chest.
  • The portable machine camera is brought close to the glass, and adjustments are made to the machine to optimize the film.
  • The film is passed by the gowned nurse outside the room with removal of the plastic sheet while passing to the X-ray staff outside the room, keeping the plate clean.
  • While artifact from the window is sometimes present on the film, our radiologists have been able to read from these for multi-focal pneumonia and tube placement.

For more detailed information on Portable Radiography, see our COVID-19 Patient Portable Chest X-Ray Protocol.

See images below:

university of washington school of medicine department of emergency medicine

 

TRACKING SYSTEMS

Review the current system or create a new one for tracking exposures/symptoms when a COVID-19 exposure happens for staff, or when staff members are sick:

  • When will they return to work?
  • How will they get results of their testing?

BUNDLE CARE

  • Plan ahead for blood draws, EKGs, and medication administration in order to minimize trips into and out of the patient’s room.
  • Build kits with pre-assembled supplies to be used in isolation areas.
  • Create scripts for 911 call centers to ask about COVID-19 risk factors before sending in EMS to a scene.
  • Have EMS call ahead to alert ED for high risk COVID-19 patients from the field.
  • Develop scripts for your transfer center to use screening questions regarding symptoms and COVID-19 status with the goal of identifying potential COVID-19 patients prior to ED arrival.
  • Establish protocols for testing patients in conjunction with your lab’s ability to run these tests.
  • Draft outward facing documents with clear instructions for the community to call their doctor prior to coming to the ED to reduce over-crowding.

RESOURCES

UW Medicine COVID-19 Resource Site

See UW Medicine COVID-19 Resource Site for more screening and testing algorithms, policy statements, and additional links.

DISCLAIMER

This site is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. All information is meant for use by healthcare workers and not the general public. If you think you may have a medical emergency, call 911 or go to the nearest emergency room immediately. No physician-patient relationship is created by this web site or its use. Neither the University nor its employees, nor any contributor to this web site, makes any representations or warranties, express or implied, with respect to the information provided herein or to its use.

All copyrights to the UW Department of Emergency Medicine website and its contents are the property of the University of Washington unless otherwise noted. Except when indicated, permission is hereby granted to reproduce, distribute, and display copies of content material for nonprofit educational and nonprofit library purposes, provided that: (i) copies are distributed at or below costs; (ii) author and source are acknowledged; and (iii) a copyright notice is attached to the copies, such notice being in the form "University of Washington 2020" (or as otherwise indicated on the materials as posted here). No commercial uses are allowed without the prior express permission of the University of Washington.