BOSTON MEDICAL CENTER MICU COVID-19 BEST PRACTICES

The MICU COVID-19 best practice document can be downloaded here, or view the html page here. Note: We plan to update this document on Friday afternoons; however, BMC policies are changing daily and thus this information may be outdated in some cases.

RAPID MANAGEMENT OVERVIEW

CLINICAL COURSE PRIMER

SARS-CoV-2 (the virus that causes COVID-19) is a coronavirus. These are large, enveloped, single-strand RNA viruses. Summary of available data:

Incubation period

  • 4 days (range 2-7)

Typical symptoms

  • Fever 89% but only 44% at time of admission
  • Cough 68%, productive in 34%
  • Dyspnea 31%
  • Anosmia 30%
  • Sore throat 14%
  • Nasal congestion 5%
  • Diarrhea 4%

Severity

  • 80% of patients with mild symptoms
  • 20% require hospitalization
  • 5% require ICU for ARDS (20-30% of hospitalized patients)
  • Mortality: Age >60 years 3.6%, 70-79 years 8%, >80 years 14.8%, Respiratory failure/shock/multi-organ dysfunction 50%

Timeline

  • Hospitalized ~8 days after exposure
  • Respiratory failure ~12 days after exposure, 10 days after onset of dyspnea (late but rapid deterioration is characteristic feature)
  • Cardiac injury ~17 days (increased incidence of cardiac arrest, cardiomyopathy)
    -Viral shedding ~20 days after exposure

Lab abnormalities

  • Lymphopenia (83%)
  • CRP >10mg/l (61%) – associated with poor survival
  • PCT <0.5 (94%)
  • ALT/AST>40 (22%)
  • Elevated ferritin, LDH, and troponin

PHYSICAN ARRIVAL

General Suggestions

  • Watch the Donning/Doffing video multiple times
  • General PPE information is located here
  • Practice donning/doffing
  • Have a spotter
  • Even in an emergency situation, taking time to apply appropriate PPE is essential to maintain the health of medical workers
  • BMC command center: 617-414-6860
  • Working Well Clinic

Personal Care Checklist

  • Have you been fit tested for N-95? Have you shaved?
  • Have you received your flu vaccination?
  • Are you sick?
  • Hungry? Thirsty? Empty bladder?
  • Have you removed all jewelry?
  • All items (stethoscope, badge, pager, phone, pen, papers) removed from pockets?
  • Cell phone: consider bringing a transparent bag to store and avoid contaminating your cell phone.
  • Shoes impermeable to liquids?
  • Scrubs and underwear only as bottom layer? (Scrubs are available MICU A in the charge nurse office)
  • Hair pulled back?

Enhanced PPE

Enhanced PPE consists of N95 mask or PAPR, face shielf, gown and double gloves.

Please review video for donning and doffing PPE on the BMC website. These guidelines may change, and the most updated version will be there.

In addition to using enhanced precautiosn in the ICU, all employees must wear a hospital-issued mask continuously throughout their shifts when at BMC where clinical care is provided, and when delivering home care. When entering a BMC clinical building you will be given a mask and at the end of the shift, the mask will be disposed of upon exiting the building

Donning steps

  • Perform hand hygiene (alcohol hand rub or soap and water)
  • Don inner gloves (choose usual size, inspect for tears or holes)
  • Don isolation gown, putting thumb through hole at end of arm sleeve and securing gown at neck and waist
  • Don second set of gloves (consider one size up from usual), extend to cover wrist of gown
  • Don N95 mask
    • Bottom strap below ears on your neck
    • Upper strap is placed toward the crown of head (no crossed straps) – Mold nose piece of N95 or surgical mask over bridge of nose to obtain tight seal
      • If wearing glasses, perform a moderate exhalation test around seal to minimize fogging of glasses
  • Don goggles/face shield (shield must extend below chin)
  • Now ready to care for patient

Doffing steps

  • Remove outer gloves and discard
    • Grasp outer glove with opposite hand, peel off and hold in double gloved hand
    • Slide fingers under the outer glove at wrist and peel off
  • Remove gown and discard
    • Grab gown at shoulders, tear or untie neck and peel away and down, touching inside only
    • Remove, rolling inside out
  • Sanitize inner gloves with alcohol hand rub or soap and water
  • Remove inner gloves and discard
  • Exit patient room
  • Hand hygiene on bare hands
  • Don a new pair of gloves
  • Remove goggles/face shield
    • Remove touching only the back, avoid the front aspect
    • If using reusable face shield, wipe it down with purple SuperSani wipe
  • Sanitize gloved hands with alcohol hand rug or soap and water
  • Remove gloves and discard
    • Grasp outside of the glove with opposite gloved hand, peel off and hold in gloved hand
    • With other hand slide fingers under the glove at wrist and peel off
  • Sanitize bare hands with alcohol rub or soap and water
  • If continuing to see COVID-19 patients or PUI, re-don face shield, walk to next patient room and don new gloves and gown (keep face mask in place)
  • If finished with patient care
  • Remove N95 respirator
    • DO NOT TOUCH FRONT OF MASK (contaminated)
    • Grasp the bottom strap, pull over head and allow to dangle
    • Remove top strap and drop into waste bin
  • Use alcohol rub on bare hands, and then wash hands thoroughly

Staying Clean in the Room

  • Disposable Stethoscope use
    • Enter the room, immediately put hand sanitizer on your glove and clean stethoscope. (Do at the beginning, rather than after using it because it’s hard to be sure you’re not just continually recontaminating it with your dirty gloves)
  • Putting on and taking off the stethoscope
    • It’s tricky with the large face shields. Grab the scope at the base of the Y to put it in your ears. To remove it, trace your hands up from the bell of the scope to the base of the Y and spread the prongs that way to remove it
  • Use the interpreter iPad, rather than phone
    • Patients use the phone

INITIAL ICU EVALUATION

SARS‐CoV‐2 (COVID‐19) and Comprehensive Respiratory Panel Testing

  • BMC now has in-house COVID-19 testing with expected turnaround time to be 6-8 hours after receipt by the laboratory
  • Following hospital guidelines, use the EPIC COVID-19 Order Panel with the preferred/high risk testing selected to test for both SARS‐CoV‐2 (COVID‐19) and the Comprehensive Respiratory Panel from the same nasopharyngeal sampling.
  • Since nasopharyngeal swabs often generate a strong cough reflex, enhanced PPE are recommended.
  • For safety reasons, specimens from a patient with suspected or documented COVID-19 should not be submitted for viral culture.

Laboratory Testing of Patients with Severe COVID-19

Severe COVID-19 is defined as respiratory failure (e.g. dyspnea, hypoxia, or >50% lung involvement on imaging within 24-48 hours) or critical ilness (e.g. shock, or multi-organ dysfunction)

COVID-19 specific tests

  • Chemistry panel
  • LFTs including albumin
  • CBC with differential (lymphopenia most common)
  • Procalcitonin (normal in 95% of patients; more likely to be elevated in ICU patients)
  • Ferritin
  • Triglycerides
  • Fibrinogen
  • CRP
  • ESR
  • Troponin
  • LDH
  • CPK
  • D-dimer
  • PT

Rationale

  • Evidence suggests that a subgroup of patients with severe COVID-19 develop a cytokine storm syndrome similar to secondary hemophagocytic lymphohistiocytosis (sHLH) or macrophage activation syndrome-type syndrome. These syndromes may include worsening respiratory failure, other organ failure, increasing ferritin, CRP, decreasing platelet counts, or increasing erythrocyte sedimentation rate. It is unclear if immunosuppression in this subset may improve mortality, but identification of these syndromes warrants consideration of biologics agents and discussion with ID. The Hscore may be useful to identify patients for which to consider immunosupression. NOTE: Therapies are experimental in COVID-19 infection (see below)
  • CRP, ferritin, LDH, D-dimer are markers that may track with disease severity and prognosis
  • Regular repeat testing of CBC, Chemistry panel, LFTs, procalcitonin, ferritin, triglycerides, fibrinogen, CRP, ESR, LDH, d-dimer, and troponin to track disease severity
  • Check troponin/EKG in a deteriorating patient to assess for cardiomyopathy, and conduction disturbance. Higher than expected cardiovascular deaths (VT/VF, asystole) have been seen in COVID-19 patients.

Discontinuation of precautions after a negative test

  • The Precuations banner in EPIC will automatically discontinue when a negative nasopharyngeal swab test result returns and a patient has none of the following: fever, high procalcitonin, lymphopenia, a COVID-19 contact, travel history, no alternative virus present on viral respiratory panel. However, the initial nasopharyngeal swab test may be a false negative. The current test is not 100% sensitive and the chance of a positive test decreases over time in those with COVID-19. Precaution status will remain even though the banner is removed as long as an active order for precautions remains in EPIC.
  • Prior to removing the precuations order, contact the COVID-19 ID team (Pager 5236 ).
  • In addition, in intubated patients with an initial negative nasopharyngeal swab test result, send paired tracheal aspirate sample to state and a repeat nasopharyngeal swab sample
    • COVID-19 order set “Additional Testing” section

Imaging

  • Portable chest x-rays are sufficient in most cases for assessing the patient’s lung parenchyma
    • Bilateral patchy infiltrates are most common (may evolve rapidly)
  • Lung POC ultrasound Peng et al.
    • Pleural line thickening and irregularity
    • B-lines
    • Consolidations
    • A-lines appear in recovery phase
    • Pleural effusions are uncommon and alternative diagnoses should be considered
  • Routine Chest CT is NOT recommended
    • Common findings include ground-glass opacification with or without consolidative abnormalities, consistent with viral pneumonia Kanne et al.
      • CT Chest should only be considered in specific cases where there is diagnostic uncertainty and/or it will lead to changes in clinical management when other diagnostic methods are unreliable. CT Chest can overwhelm resources (e.g., need for transport, cleaning of CT scan suite, nursing effort), and increase risk of exposure.

Bronchoscopy

  • Bronchoscopy is NOT recommended or necessary for the purpose of ruling COVID-19 in or out and should be avoided to minimize risk of aerosolization.
  • Bronchoscopy should only be done if it will change clinical management and if at all possible should be completed in a negative pressure room.

ORGAN DYSFUNCTION MANAGEMENT

Supportive care, and first DO NO HARM

Acute Respiratory Failure

  • Use a conservative fluid approach, use vasopressors over large volume (>30cc/kg) initial resuscitation FACTT Algorithm
  • Be aware of reported hypercapnia (PaCO2 >45) and respiratory failure without symptoms of dyspnea, possibly related to central effects of virus
  • Avoid NIV, HFNC and nebulizers
    • Highly aerosolizing and risk viral spread
    • In ARDS/hypoxemic respiratory failure NIV is generally ineffective
    • Although WHO and SCCM guidelines make weak recommendations for HFNC in select patients, we feel that the risk of aerosolization to healthcare workers, the observed rapid decompensation of COVID-19 patients and the risk of patient self-induced lung injury (P-SILI) outweigh the potential benefits at this time.
  • Nasal cannula up to 6Lpm or NRB up to 10L goal SpO2 sat >90% after initially stabilized
    • During transport, use nasal cannula for oxygen administration or NRB if additional oxygen is needed
    • Patients being transported with oxygen should wear droplet masks during transport over oxygen tubing
    • If inability to effectively oxygenate (SpO2 sat <90%) or ventilate (arterial pH <7.3 with PaCO2 > 50), and/or if patient has signs of respiratory distress (accessory muscle use, abdominal paroxysmal breathing), then strongly consider CONTROLLED ELECTIVE intubation
    • Make sure anesthesia and respiratory therapy are aware pt is COVID-19 + or PUI
      • Clinician hand don appropriate PPE
      • Ensure utilization of appropriate filters during bag mask ventilation (e.g. white bacterial/viral ENVE filter between the bag and the mask) and mechanical ventilation (e.g. PALL or N100 HEPA filters)
  • Consider central line (avoid RIJ to leave for renal replacement therapy access) and a-line (if frequent abg) at same time as intubation to minimize patient contacts

ARDS Management

  • The most common severe complication of COVID-19 is ARDS
  • ARDS Definition: Bilateral infiltrates PaO2/FiO2 <300 or SatO2/FiO2 <315, PEEP 5 or more, acute onset, not explained by heart failure
    • Preliminary data suggest that 15-20% of hospitalized patients will develop ARDS Guan et al. Wang et al.
    • Time from illness onset to ARDS 12 days
  • Mainstay of ARDS treatment is mechanical ventilation designed to not cause further injury
  • We recommend ventilator settings that target the following
    • Good enough oxygenation (ideally PaO2 90-105, SpO2% >96% given recent evidence, but PaO2 55-80 is historical standard and a reasonable target)
    • Good enough ventilation (pH >7.15)
    • Initial settings
      • Volume Assist Control with tidal volume 4-8cc/kg Predicted body weight
      • 5-10 PEEP, may need titration to 10-15 (see above ARDSnet table)
        • evaluate for improvement in oxygen at risk for hypotension with PEEP increases
      • RR enough to meet estimated pre-intubation minute ventilation (MV = TV * RR, goal 10-15 for sick patients, then readjust, usually will need RR 25-30 to start)
      • Goal plateau pressure <30
  • ARDS adjunctive therapies
    • Prone position Guerin et al. (BMC Protocol BMC login required)
      • Recommend if P/F <150 for 12 hours or worsening oxygenation after intubation without other cause
      • Prone position for 12-16 hours daily provides mortality benefit through reduced lung injury
      • Positive criteria for stopping prone treatment:
        • PaO2:FiO2 ratio of ≥150 mm Hg with PEEP of ≤10 and an FiO2 of ≤0.6 in the supine position at least 4 hours after the end of the last prone session
      • Negative criteria for stopping prone treatment (either criteria is sufficient alone to discontinue prone treatment):
        • Decrease in the PaO2:FiO2 ratio of more than 20% relative to the ratio in the supine position, before two consecutive prone sessions
        • Complications occurring during a prone session and leading to its immediate interruption (e.g., extubation, main-stem bronchus intubation, endotracheal tube obstruction, hemotpysis, hemodynamic instability, worsening hypoxemia, cardiac arrest, bardycardia)
        • NOTE: prone position patients do NOT routinely require neuromuscular blockade
    • Inhaled NO
      • adjunctive therapy designed to improve oxygenation. No known mortality benefit. It complicates routine vent FiO2 changes, so recommend only for life-threatening hypoxemia, e.g., consider if P/F <100, strongly consider if P/F<60. Watch for renal failure complication. Avoid inhaled epoprostenol dur to aerosolization.
    • Neuromuscular blockade
      • As needed for ventilator dyssynchrony and high respiratory drive resulting in injurious tidal volumes, airway pressures, double-triggering, breath stacking, or inability to oxygenate or ventilate
      • Analgesia, sedation, and amnesia are absolutely necessary PRIOR to inducing paralysis
      • Discuss with pharmacy about optimal neuromuscular blockade agent given potential shortages and medication interactions
    • Corticosteroids: Routine use of steroids is not indicated for the treatment of COVID-19. Corticosteroids can be used to treat conditions generally requiring corticosteroids (e.g., 0.5 mg/kg prednisone in moderate-severe COPD or asthma exacerbation, or hydrocortisone 50mg qid in refractory septic shock) in COVID suspects. Please consult with ID and pulmonary/critical care to discuss risks/benefits if high dose steroids are being considered. Risk of 3-fold increased time to viral clearance evidence from MERS, hyperglycemia, and psychosis.
      • Balance societal risk with potential individual pt benefit
      • In life-threatening severe ARDS with refractory hypoxemia, consider use of steroids on an individual basis, especially with concomitant refractory shock, as steroids improve oxygenation and blood pressure.
      • Recent (very low quality) observational JAMA IM paper shows potential benefit in COVID-19; also Observational study in MERS (RR 0.75 95% CI 0.52–1.07) and Cochrane meta-analysis of non COVID ARDS 68 trials (RR 0.77, 95% CI 0.57 to 1.05) show similar effect estimate of potential benefit, and recent trial in ARDS showed survival benefit in non-COVID-19 ARDS: N=277 36 vs 21% 60-day mortality, p=0.0047 with Dexamethasone 20mg daily for 5 days then 10mg for 5days.

Shock Management

  • Evaluate for underlying cause of shock (septic, cardiogenic, obstructive, adrenal insufficiency) – TTE, capillary refill, central venous O2 sat
  • Preferential use of vasopressors rather than large volume fluid resuscitation to avoid exacerbating ARDS
  • Initial vasopressor of choice norepinephrine, 1-30 mcg/min
    • Secondary vasopressor vasopressin 0.4 units if distributive shock
    • Consider epinephrine, or consideration of milrinone, dobutamine if cardiogenic component, cardiology consult
  • Goal MAP 60 is associated with fewer complications than 65, but with similar outcomes
  • Sedation (spontaneous awakening and breathing trials), Nutrition, Glucose, DVT-GI Prophylaxis all managed per standard ICU protocols.

HOME MEDICATIONS

ACE Inhibitors/ARBs

Summary: The decision to discontinue outpatient ACEi/ARBs should be made based on underlying cardiac comorbidities and the risk/benefit of discontinuation. In critically ill patients at risk for AKI (e.g., shock, multi-organ failure), it is reasonable to discontinue ACEi/ARBs at ICU admission. The associations between ACEi/ARBs and COVID-19 are unclear.

Evidence: There are hypotheses that ACEi/ARBs could improve Gurwitz or worsen Fang et al. COVID-19 related outcomes. Patients with hypertension and diabetes are at increased risk for COVID-19 Guan et al. and COVID-19-related complications Zhou et al., but no studies have evaluated the specific association between ACEi/ARBs and COVID-19. The AHA, ACC, and Heart Failure Society of America recommend contination of ACEi/ARBs in patients with cardiovascular disease but that individualized decisions be made according to each patient’s hemodynamic status and clinical presentation.

NSAIDs

Summary: In most patients, it is reasonable to discontinue NSAIDs at ICU admission given the risk of AKI and bleeding with NSAID use during critical illness. There are anecdotal reports of more severe disease among those taking NSAIDS prior to hospitalization, the significance of which is unclear. Consider substitution with acetaminophen if necessary.

Evidence: The association between NSAIDs and COVID-19 is unclear. On March 14th, 2020, The French health ministry updated guidelines stating that paracetamol should be used for the treatment of COVID-19-related fever and pain and that there have been reports of NSAID-related serious adverse events. WHO does not recommend avoiding NSAIDs for COVID-19 symptoms. In general, NSAIDS should be avoided in critically ill patients given risks of renal failure Hoste et al. and bleeding.

Corticosteroids

Summary: The decision to discontinue systemic corticosteroids at the time of ICU admission should be based on underlying comorbidities and the risk/benefit of discontinuation rather than COVID-19 status. In those on choronic corticosteroids, consider adjustment of dose (“stress dose steroids”) to prevent adrenal insufficency. Consider discontinuing intranasal corticosteroids and inhaled corticosteroids in those with COPD who do not require these medications acutely (inhaled corticosteroids may enhance viral shedding)

Evidence: In a study of 84 patients with COVID-19 complicated by ARDS in Wuhan, China Wu et al., patients who recieved methylprednisolone were less likely to die in unadjusted analyses (HR 0.38 [95% CI 0.20-0.72]), not accounting for confounding by indication. A study of 309 patients with the related viral disease MERS Arabi et al. found no association between mortality and corticosteroid use but an increased risk of delayed respiratory tract clearance with corticosteroid use. WHO interim guidance from March 13th, 2020 recommends against routine administration of systemic corticosteroids for treatment of viral pneumoniaWHO.

QTC prolonging medications

Summary: If Hydroxychloroquine is initiated, review home medications for QTC prolonging agents and consider the risk/benefit of continuing. The risk of QTC prolongation with hydroxychloroquine is generally low.

TREATMENTS

All anti-viral therapies and immunomodulatory therapies are EXPERIMENTAL and based on pre-clinical data, expert opinion, small and emerging clinical studies and consensus statements. The WHO currently advices against the use of anti-viral therapy or corticosteroids outside of a clinical trial context.

Antivirals

Chloroquine/Hydroxychloroquine

Summary: The data for COVID-19 is based on in-vitro data of efficacy against COVID-19 infection at drug concentrations achievable in humans and expert opinion from China based on reported clinical experience in 100 patients. Furthermore, we have clinical experience with these drugs in chronic inflammatory diseases where immunomodulatory effects are observed, plus they are low cost and generally safe. However, toxicity in acutely ill patients is unknown. Hydroxychloroquine may have less severe side effects than chloroquine Weniger et al.. The use of hydroxychloroquine in COVID-19 patients is experimental.

  • Dosing: Hydroxychloroquine Day 1: 400mg BID, Day 2-5: 200mg BID
  • Adverse effects: severe hypoglycemia (rare), cardiomyopathy (rare), prolonged QTC (rare), macular degeneration
  • Monitoring: baseline EKG and blood glucose
    • If after initial dose the QTC is <410 and no other QTC prolonging medications are being administered, consider decreasing frequency of EKGs to reduce healthcare worker exposure

Mechanism: Chloroquine is a 9-aminoquinolone and a weak base. Intracellularly it accumulates in acidic organelles such as the endosome, Golgi and lysosomes. The proposed antiviral mechanisms of chloroquine and hydroxychloroquine are through inhibiting endosome-mediated viral entry or at the late stages of replication. Chloroquine can inhibit pH-dependent replication steps of several viruses including coronaviruses. Chloroquine may also have an immunomodulatory effect: it accumulates in macrophages and in in-vitro studies treatment with chloroquine decreased the secretion of IL-6 and TNFa.

Remdesivir

Summary: Remdesivir demonstrates in-vitro activity against COVID-19, SARS-CoV (also murine model) and MERS-CoV. Human data is limited to the first patient treated for COVID-19 in Washington, ongoing clinical trials and limited data in a clinical trial treating Ebola patients. Per CDC there is insufficient data to support recommending its use. For moderate to severe COVID-19 infection consider treatment with Remdesivir, however its use is experimental.

  • Dosing: Day 1: 200mg, Day2-5: 100mg daily
  • Adverse effects: unknown, one patient developed hypotension and cardiac arrest after loading dose in ebola trial
  • Requires compassionate use agreement from Gilead. Complete form while awaiting SARS‐CoV‐2 test results to streamline process in those who may benefit.
    • NOTE: Remdesivir compassionate use is currently inactivated (further guidelines to follow)

Mechanism: Remdesivir is a nucleotide analogue inhibitor of RNA-dependent RNA polymerases developed mainly for Ebola. Remdesivir acts as a “chain terminator” – it is competitively incorporated into the RNA strand and causes premature termination and non-replication. There is published in vitro data (primary human airway cells) that Remdesivir inhibits SARS-CoV and MERS-CoV. There is 96% overlap between SARS-CoV and SARS-CoV-2 RNA-dependent RNA polymerases suggesting similar efficacy in SARS-CoV-2. A recent study demonstrated in vitro activity of Remdesivir against COVID-19 in VERO E6 cells. Gilead compassionate use and trial programs require AST/ALT <5x normal.

Anti-inflammatory

Corticosteroids

Summary: Routine use of corticosteroids is NOT INDICATED for the treatment of COVID-19. Corticosteroids can be used to treat conditions generally requiring corticosteroids (e.g., 0.5 mg/kg prednisone in moderate-severe copd or asthma exacerbation, or hydrocortisone 50mg q6h in refractory septic shock) in COVID-19 suspects. Please consult with ID and pulmonary/critical care to discuss risks/benefits if high dose steroids are being considered.

IL-6 Blockade (Tocilizumab)

Summary: Tocilizumab is a monoclonal antibody against the interleukin-6 receptor. Clinical trial underway in China in Covid-19. IL6 is elevated in a subset of COVID-19 patients and correlated with higher mortalityRuan et al.. The role of IL6 activity in COVID-19 is unknown and it may be protective against viral infection or contributing to a hyperinflammatory reaction. A recent small non-peer reviewed clinical trial of 20 COVID19+ patients demonstrated efficacy.

  • Discuss with ID for patients with elevated Hscore suggestive of secondary HLH and in patients with COVID-19 and 1) progressive acute respiratory failure or early ARDS, 2) early distributive shock, 3) elevated CRP (>100) or ferritin (>700) and 4) 2 or more cytopenia, elevated LDH (>450), elevated D-dimer (>1000), or decreased fibrinogen (<250)
  • Adverse effects: abnormal LFTs, neutropenia, infection, gastrointestinal perforation (rate 1.5/1000)
    • NOTE: CRP may not be a reliable marker of inflammation after tocilizumab is administered

IL-1 Blockade (Anakinra)

Summary: Anakinra is a recombinant antagonist of interleukin-1 receptor. There are anecdotal reports and expert statements suggesting a potential role in managing the cytokine storm seen in a subset of COVID19 patients. Consider using the Hscore to identify patients who may benefit from immunosuppression. Re-analysis of a recent RCT examining the role of Anakinra in septic shock identified a mortality benefit in patients with hyperinflammation manifested as hepatobiliary dysfunction or DIC

Other medications

Medications that are unavailable, potentialy ineffective, or with no evidence to guide use

ACE inhibitors/ARBs

Summary: Role unknown, see under home medications section for discussion of evidence regarding these medications in COVID-19

Lopinavir-ritonavir

Summary: No benefit in unblinded trial

Umifenovir

Summary: Not available in the US. Clinical trial planned in China Harrison

Statins

Summary: Role unknown

NSAIDS

Summary: Role unknown, anecdotal reports that NSAID are associated with more severe disease. Consider substituting acetaminophen

END OF LIFE CONSIDERATIONS

Please review “Ethical Guidance for BMC during COVID-19 Pandemic” distributed recently (link to final draft forthcoming)

Important contact information

  • Ethics pager: 4636
  • Legal pager: 1523
  • Patient advocate pager: 7178
  • Palliative care pager: 0179

Current visitor policy

  • No visitors permitted on inpatient units and ED
  • Care team can make a visitor exception
    • Visitor must be over 18, and will be screened for COVID-19 symptoms

On arrival for all patients

  • Confirm patient code status, document details in note
  • Priority to establish HCP early, with accurate contact information
  • Designate (with guidance of pt/HCP) one “contact person” for family/friends

Goals of Care in Patients at High Risk of Death

  • CPR may not offer benefit for COVID-19 patients, particularly those with advanced age (>80 years old) and/or comorbid cardiovascular disease, diabetes, hypertension, and respiratory disease.
  • Performing CPR on patients with COVID-19 will increase transmission to healthcare workers, threatening their own well-being and reducing their availability to treat future patients.
  • Attending physicians are not obligated to offer or provide CPR if resuscitative treatment would be medically inappropriate, even at the request of a patient or legally authorized representative.
  • In patients with COVID-19 the risks to healthcare providers of performing CPR may influence a determination that CPR is not medically appropriate, if coupled with considerations of individual patient’s prognosis.

Palliative Care

With the expected increase need for palliative care services, we will need to efficiently utilize the BMC palliative care team.

Self-education

Palliative care service

  • When making a palliative care service consult, the palliative care service will work with the primary team to determine the level of care needed by the team, ranging from tips/suggestions to full outreach to patient/family.
  • Triggers for palliative care consult
    • Pre-existing palliative care patient
    • Symptoms refractory to palliative symptom protocols
    • On ventilatory support
    • Difficult-to-control emotional symptoms
    • Patient, family, or physician uncertainty regarding prognosis
    • Patient, family, or physician uncertainty regarding non-beneficial treatment options
    • Patient or family psychological or spiritual/existential distress
    • Patient or family request
  • If you feel particularly comfortable having end of life, or other difficult conversations with patients/families, please consider reaching out to the palliative care team about being a “palliative care champion” to learn how to train colleagues.

ACLS

Preparation

  • A member of the primary team should meet with nursing/RT team at beginning of every shift to identify patients at high risk for arrest, make an action plan in case it occurs
  • For high risk patients, consider having pre-filled syringe of epinephrine/atropine ready at the bedside
  • If ACLS unlikely to be beneficial, discuss with patient/family to see if adjustment in code status is appropriate (frequent re-evaluation). See above section regarding physician decision to not offer CPR, particularly in patients on multiple pressors, receiving CVVH, and/or proned.
  • Always take time to apply PPE. There is NO SITUATION for which you should enter a COVID/PUI room without proper PPE
  • Contact family/HCP early in code. If family members are in room, please escort them out of room.

Personnel

Inside Room
All personnel in room must wear enhanced PPE – N95 or PAPR, face shield, gown and double gloves.

  • First responder: continue CPR while others enter, can then transition to one of the roles below
  • Code leader/Primary Physician (walkie-talkie if available)
  • Patient’s RN: administer medications, manage defibrillator, and update leader regarding changes in cardiac rhythm
  • Airway expert physician: only if airway needed (airway team should be notified of code)
  • Respiratory therapist
  • Two additional RNs: assist with CPR and any other activities in room, can substitute house officer for one RN if needed

Anteroom

  • RN for room assistance (in enhanced PPE)
    • Relieve personnel after 8 rounds of 2-minute compressions (two rounds per compressor) to minimize risk of safety breaches when fatigued
    • Ready to pass medications/items to team in room
    • Facilitate communication
    • Observe for PPE breaches

Outside room, not in anteroom (6+ ft from door opening)

  • Additional “code-whisperer”” physicians with walkie-talkie (if available) to communicate inside the room
  • RN for documentation and time-keeping
  • Pharmacist
  • RT on standby, ready to don PPE and replace RT in room
  • Runner to assist with supply of equipment on the unit and activation of other HCW if required by team inside room
  • Logistic officer (charge nurse, intensivist, senior medical resident)

Equipment

Limit single-use equipment entering room, as it will need to be discarded if not used

Inside Room

  • Defibrillator
  • Backboard for CPR
  • Intubation equipment
  • Manual resuscitation bag with bacterial/viral ENVE filter placed between mask/endotracheal tube and the bag
  • Mechanical ventilator (if in ED or ICU)

Passing Items into Room

  • RN outside room prepares item to enter room, opens door slightly, and using gloved hand passes item to person inside room without touching anything in the room.
  • Only critical patient specimens should leave the room during the code.
  • Samples should be wiped down by team in room. Door opened slightly by outside RN, and using gloved hand and wipe, outside RN takes sample from room. Sample is decontaminated again outside room, and placed in biohazard bag.
  • Unless wearing enhanced PPE, outside RN then performs hand hygiene with alcohol gel, removes gloves and washes hands.
  • No other items should leave the room until the end of the code. This enables decontamination in a controlled fashion without distractions.

Outside Room

  • Videolaryngoscope (brought in to room at request of anesthesiology)
  • Difficult airway cart
  • Bronchoscope

Modifications to ACLS

In general, the goal is to limit the aerosolization of respiratory secretions while still providing excellent ACLS. Any recommendations in this section should superseded by anesthesia department policies on airway management in COVID-19 patients

  • Intubate patients early and hold CPR during intubation to minimize aerosolization
  • Pre-oxygenation
  • minimize techniques that can aerosolize droplet
  • NRB mask with filter and FiO2 is preferred
  • Avoid manual ventilation before intubation
  • Avoid coughing or becoming agitated (rapid sequence intubation)
  • Immediately connect patient to resuscitation bag + filter, or mechanical ventilator and inline suction catheter.
  • For intubated patients
  • Increase FiO2 to 100%
  • Leave patients on vent during CPR and RT stabilize connection to vent and monitors for administered breaths
  • RT to instruct compressors to pause compressions for vent-administered breath, this limits possibility of patient becoming disconnected from vent and aerosolizing respiratory secretions
  • For proned patients CPR may be performed by first responder over thoracic spine with bed on full inflate. Once RNs in PPE have arrived in room, the first priority is to turn the patient supine

After End of Code

Inside Room

  • Take time to carefully doff PPE (best to have a doffing buddy)
  • All non-disposable equipment must be decontaminated per BMC protocols
  • All disposable equipment must be discarded

Outside Room

  • If note made of any break in PPE, have employee immediately contact supervisor and fill out the Exposure Form from Working Well Clinic.
  • Hot debrief to identify lessons learned. Identify who will document recommendations and forward on to nursing and medical leadership
  • Involved personnel may take a “work pause” after debrief
  • Consider changing scrubs
  • Take some time to decompress
  • Environmental services should be notified of a COVID-19 positive room and instructed to clean room and region surrounding room.

COMMUNICATION

Communication is crucial to the successful delivery of safe and effective clinical services.

Information management plans should be established for effective and consistent dissemination of information to relevant stakeholders. These should include daily situation reports and regular updates on unit, organizational, regional and state responses.

A variety of information dissemination methods should be considered to account for physical distancing needed for infection control purposes. These may involve video and teleconferencing, and electronic communication platforms.

Effective lines of communication must be established to ensure that stakeholders are apprised of evolving clinical scenarios and changes in clinical practice guidelines and processes. ICU load and capacity must be measured in real-time and communicated to relevant in-hospital administrative and jurisdictional authorities. It is vital to track both patient outcomes and staff well-being. Specific stakeholders and considerations may include:

  • Organizational chains of command
  • State and national health authorities
  • Inter-departmental communications
  • Staff