+ Recent Updates Earlier this WEEk + COMMITTEE UPDATES

PHH Updates 4/4

• PHH has opened up the IMCU for ICU patients. It will be called ICU 2.
• IMS will remain primary and our team will consult.
• Anesthesia is now available to do intubations and procedures (lines).
• New nursing staffing model: the nurses are initiating their surge plan starting Monday 4/6

• It is a team nursing set up with 1 ICU nurse and 2 med surge nurses working together to manage 6 patients

• Staffing and Supply Committee:

• Advanced Respiratory Care Committee:
• Surge Committee:
• Team Science:
  • Amy Case - Inhaled Nitric Oxide or iNO is used to treat hypoxia and is approved for compassionate use. It requires approval from FDA and the manufacturer and Informed Consent from the patient. It is approved on a case by case basis. We have the first referral from Dr Carrasco and is pending approval. To qualify patients must be on 10 liters or less.
  • Dr. Miller – working on a small trial of inhaled iloprost in vented covid patient. Awaiting IRB approval. Call him if you'd like to try on your patients.

+ Staffing and Supply Updates Committee Previous Updates

• Staffing and Supply Updates Committee Updates:
  • General: have gotten disaster privileges for most providers at PFH, PHH, PNH.
  • ICU APPs: currently working in conventional, normal staffing models, have mobilized a daily flex position for volume. Have a plan for crisis staffing that will move into place if 3 or more APPs go out.
  • Acute Care APPs: working with a furlough pool of acute care and ambulatory APPs, adding an ambulatory to daily staffing M-F. Will transition 1 APP to a modified swing for pulmonary volumes. Plan to pull in additional staffing according to census.
  • Physicians: each site has a contingency and crisis plan. PFH and PHH have moved into contingency staffing, working with leaders in each zone. Physician furlough pool serving as reserve pool for staffing.
  • Supply: working on intubation bags, code bags, and alternatives to ultrasound and Echo images.
  • Peachtree City office suspended to support PFH operations
  • Stockbridge office down to periodic half day clinics to support PHH operations
  • PNH Staffing acceptable but will need to move to 2 hospital physicians soon.
  • Dr. Hedelius office time reduced to allow more time at PMH
  • eventual 3rd MD to PAH PACT staffing
  • eventual pulling clinicans from Austell, Marietta, Buckhead, and Brookhaven to support PAH inpatient services.

+ ARC: Advanced Respiratory Care Committee Previous Updates

• ARC: Advanced Respiratory Care Committee:
  • We are NOT at a vent shortage but we are preparing in case that is coming
  • Tracking all available ventilators at all hospitals
  • projecting needs and deficits at all sites
  • process to move to sites of need
  • Vent vs HFNC vs BiPAP is always a debate given the aerosolized generating properties of HFNC and BiPAP but that must be weighed against the ventilator shortages we might face. There has also been some anectodotal experiences of patients doing well on BiPAP or HFNC. Consider on a case by case basis if clinically indicated
  • Working on using BiPAP v60’s as ventilators. Use the AVAPS mode to make this happen. As your local RT leader how to do this

+ Surge Committee Previous Updates

• Surge Committee
  • Dr. Coley and team has been working with the system command center on surge plans. Just know they are working hard to be as well prepared as possible if/when the surge happens.
  • Working with anesthesia colleagues on what that looks like

+ Terminology

PUI (Person under investigation): in the inpatient world this is now anyone that is suspected to have COVID19 but not yet confirmed. This can include those the test has been sent off or those the team is determining if they should test COVID19 Positive

PPE (Personal Protective Equipment)

SARS-COV-2, coronavirus, COVID19- all terminology for the novel coronavirus (COVID19)

Isolation: different than quarantine this is for someone who is symptomatic and has been exposed. They are not allowed to return to work until they have been afebrile for 72 hours.

Quarantine: for those exposed who are asymptomatic; typically monitored for 14 days. Whether they are self quarantined at home or allowed to return to work and monitor their symptoms depends on the staffing and if we are at crisis.

+ Piedmont Command Center

Piedmont Visitor Guide
Pulm Decision Ambulatory Policies 3/18/20

+ Daily Readiness Assessment Tool and GA Trackers

• GA DPH Will update this list of cases in GA every day at noon and 7 PM.

GA Heatmap of cases

+ EXPOSURE management 3/19/2020

Our providers are rightly concerned with what their exposure risks are. This is currently the document (picture below) that Piedmont is working off of to determine that. COVID PUIs outside of the ICU are FULL PPE + Surgical Mask. COVID PUIs inside the ICU are higher risk for aerosolized generating procedures thus are FULL PPE + N95.

3/16/2020 Employee Health Update

• ALL employees who have contact with an COVID positive patient will complete a COVID Postexposure Monitoring Log from day of contact of with patient until 14 days after their last contact with the patient.
• On days they are working, these employees will be required to have their leader/designee sign off on their tracker prior to starting work.
• If the employee has symptoms or a temperature of 100, they must be sent home. If you have to send an employee home, please send an e-mail to Employee Health so they can follow up with the Employee.
• If an employee calls out sick, leader should notify local EH&S
• Once log is completed, please email to EmployeeHealthandSafety@piedmont.org

What’s my exposure risk when a patient hasn’t been identified, in the general population, or family member walking through the hospital? Remember the 6FT and 2 minute rule. If you are exposed to a COVID19 carrier farther than 6 feet and for under 2 minutes your risk is low.

+ Return to Work Criteria for Healthcare Personnel with Confirmed or Suspected COVID-19 4/2/20 (subject to change)

• If the employee has a POSITIVE (+) test, they should be out until 7 days from start of symptoms and 72 hours fever free and improvement/near resolution of symptoms, whichever is longer.

• We are not retesting employees at this time

• If the employee has a NEGATIVE (-) test, they should be out until they are 72 hours fever free and improvement/near resolution of symptoms

• All must adhere to the "Return to work Practices and Restrictions."

+ Return to Work Practices and Work Restrictions

• After returning to work, you should:

  • Wear a facemask at all times while in the healthcare facility until all symptoms are completely resolved or until 14 days after illness onset, whichever is longer

  • Be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) until 14 days after illness onset

  • Adhere to hand hygiene, respiratory hygiene, and cough etiquette in CDC’s interim infection control guidance (e.g., cover nose and mouth when coughing or sneezing, dispose of tissues in waste receptacles)

  • Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen

+ Cleaning

SCCM ICU Preparedness Checklist

+ How to Don and Doff

### + PPE Updated guidelines 4/3/20

Piedmont PPE Signage Outside of Rooms

summary : FULL PPE+ Surgical mask for non ICU ; FULL PPE + N95 for ICU

negative pressure in ICU only if available

1 Aerosol Generating Procedures: Examples include intubation, non-invasive ventilation, CPR, bronchoscopy, open suction, nasotracheal suction, nebs.

PPE for Specimen Collection: Nasopharyngeal swabs often generate a strong cough reflex. Standard/Contact/Droplet precautions are recommended.

Piedmont N95 Mask Reuse Document

Some Pearls about Personal Protective Equipment

• Pay attention to the junction between gloves and gowns. The gown should be tucked into the gloves (leaving no gap in-between). Using gloves with extended cuffs facilitates this (similar to sterile surgical gloves). Gloves with long cuffs may facilitate removal of the gown and gloves as a single unit (see 12:30 in the above video if this doesn't make sense)
• When removing PPE, always start by first applying alcohol-based hand sanitizer to your gloves. * After fully removing PPE, sanitize hands and wrists with alcohol-based hand sanitizer again.

Standford PPE EBM Data

+ Screening/Testing Criteria 3/17/2020

This is currently the most recommended testing criteria from the GLA COVID19 Team. Call infection prevention when you do so. The buttons below have an inpatient and outpatient testing guideline updated from Piedmont.

Piedmont Inpatient Testing Guidelines 3/13/20

Piedmont Ambulatory Testing Guideline

UW Testing Tool 3/9/20

Mass Gen Toolkit

+ Re-testing Previous Negative Patients

+ Ordering the Test 3/16/20

The “Send to GA DPH COVID Test” order in Epic includes some information about how to access and fill out the COVID-19 Persons Under Investigation (PUI) Form for Clinicians. This web form must be completed and saved to request testing through GA DPH. Link to GA DPH PUI form (also on the COVID-19 Disease Focused Order Set in Epic).

NOTE: Providers will NOT be able to return to the form to make changes, so need to complete it in one session. YOU MUST use the contact information guidance shown in the Epic order when filling out the form. Not following this guidance will cause significant result reporting delays. * If GA DPH approves test, hospital lab will process and send specimen. Results will be manually updated in Epic when received from DPH, and hospital lab will follow critical result communication process to get the information to the care team.

ICD-10 Codes:

+ Invasive and Noninvasive Ventilation STrategies

+ Airway Management

• Intubating a patient with COVID19 is new and scary for the provider who is concerned about their exposure risk. Below are some tips to mitigate that risk as much as possible. Intubation and other similar procedures are considered “Aerosolized Generating Procedures” and puts the healthcare provider at higher risk.
  

• TIPS FOR INTUBATING A SUSPECTED/CONFIRMED COVID-19 PATIENT (PIEDMONT CREATED 3/17/20)
  • Limit number of personnel in room
  • Intubation should ideally be performed in a negative pressure room with all PPE in place
  • Most qualified to perform intubation
  • Use Video laryngoscope and limit additional equipment inside room
  • Support person outside room to manage additional equipment needs
  • Pre-oxygenate patient with 100% Fio2 before intubation and use RSI to minimize BVM
  • Use viral filter on BVM between mask and bag
  • Fully inflate ETT cuff before manually ventilating or connecting to ventilator to prevent potential aerosolization of secretions
  • Have ventilator set up with ETCO2 and ready to connect as soon as patient is intubated to avoid BVM
  • Capnography is the preferred method of confirmation over colormetric device.
  • If bagging between attempts is required place LMA and bag via LMA
  • Use proper donning/doffing of PPE
• WHAT TO WEAR
  • Surgical Mask over N95
  • Goggles that surround eyes with facial contact, face shield, or full joint-replacement-hood with visor
  • Bunny suit, preferably with hood or disposable fluid-proof gown
  • If no hooded suit available, sterile disposable cap
  • 2 pairs gloves, 1 under sleeves of bunny suit or gown and 1 over, under-layer gloves would ideally be long cuffed
• INTUBATION STRATEGY
  • RSI with high-dose paralytic
  • BVM or Vent for Reoxygenation (only if needed!) with viral filter at the wye of vent or stem of BVM, can be by mask or LMA. EtCO2 monitoring should be behind the viral filter to allow monitoring of mask/LMA seal, both for REOX efficiency and team safety—i.e. a crappy seal puts you and the patient at risk
  • Highest-Level Physician should do the Intubation
  • Use CMAC or Glidescope with new bougies to maximize 1-attempt success
  • Visualize black line to avoid having to auscultate for depth
  • Cuff fully inflated and viral filter on the ETT prior to bagging/hooking to vent
  • Confirm with ETCO2
• VENT SETTINGS AND POST-INTUBATION MANAGEMENT
  • Strict ARDSnet settings
  • Call ED Critical Care Staff and/or MICU Fellow/Attending if PEEP required hits 20 cm H20
  • Tube should be clamped or have the viral filter on for any vent disconnects
  • If suction is used, it should be closed circuit suction
• General Tips (from NIH SOP)
  • A minimum of one ICU nurse, one ICU physician, and a respiratory therapist are recommended for endotracheal intubation.
  • Prior to entering the patient room, ensure all necessary supplies are at the bedside or brought into the patient room
  • Have immediately available outside of the patient room a minimum of one alternative airway devices
    
    
    

+ Code Blue

In patients with COVID19, ACLS and running codes is difficult due to the staffs appropriate concern at being higher risk for exposure. There hasn’t been a lot written on the topic just yet but there is a NIH SOP (Standard Operating Procedure) on running codes in COVID19.

General advice: limit the number of staff in the room. Have available staff outside the room with plenty of PPE ready in case more support is needed.

Team Composition

• 1 Team Leader (highest ranking provider)
• 1 Nurse (IV access and pushes medications)
• 1 RT (BVM)
• 1 staff for CPR
• Recorder outside the room
• Additional staff outside to alternate CPR

General Tips

• put on your PPE slowly so you do it correctly
• consider code cart outside the room if feasible; if inside the room the contents will need to be removed
• perform ETT if needed with COVID intubation guidelines (see our page for that)
• LMA a good quick choice
• procedures requiring “deep tissue manipulation” should not be “routinely performed” in a code (Chest tubes, surgical cric.

+ A Message from Dr. Amy Case and the Science Team: COVID-19 INFORMATION ON THERAPEUTICS

There are no FDA-approved or clinically proven therapies for treatment of COVID-19. There is limited pre-clinical, in vitro rationale, extrapolated experience from other viruses such as SARS and MERS, or non-randomized reports of benefit in the current COVID-19 pandemic with the agents listed below. It is imperative to remember that best practice remains high-quality critical care medicine with adherence to established best practices for treatment of ARDS and sepsis and prevention of hospital acquired complications. The following information and diagram is set forth for the consideration of the treating physician to help inform decision making at the bedside and balance the risks and safety considerations for each intervention. Positive in vitro data, anecdotal reports of benefit, and non-controlled studies do not rule out the risk of harm. It is important that these therapies not be oversold to patients or anxious families, as their clinical benefits are not assured.

Randomized clinical trials are ongoing worldwide, and this information will be updated as additional information becomes available.

The Centers for Disease Control, National Institutes of Health, US Food and Drug Administration, World Health Organization, and recent guidelines from the Society for Critical Care Medicine do not endorse any disease specific pharmaceutical therapy for COVID-19 outside of controlled clinical trials. Front line physicians are encouraged to consider the ethical principle: “primum non nocere” – first, do no harm – and evaluate carefully the risks of unapproved treatments against the possible benefits.

For those considering one or more experimental or off-label treatments, please click the off label therapeutic options below to access additional rationale and safety information.

+ The Surviving Sepsis Campaign COVID19 Guidelines

Infographics for the 104 page document. The full document can be found by clicking the button below

• surgical mask okay if on vent from SSC perspective (unless doing an AGP)
• perform AGPs in a negative pressure room if possible
• LRTI samples considered higher yield; if intubated use endotracheal aspirate (considered lower risk of aerosolization); if not intubated still do nasopharyngeal swab to minimize bronchoscopies
• conservative fluid strategy as opposed to liberal (due to risk of ARDS)
• Buffered balanced crystalloids recommended over unbalanced or colloids
• vasopressors similar to normal
• HFNC recommended? (contradicts other guidelines; pulm leaders discussing)
• early intubation
• ARDSnet vent strategy; higher PEEP table recommended
• in mod-severe ARDS proning recommended
• boluses of paralytics if needed and continues if vent pressures or dyssynchrony are issues
  

+ Treating A Patient with COVID19

Proposed Recommendations for Intra-hospital Transport of Suspected or Confirmed COVID-19 Patients