Due to the increased concern and ongoing changes regarding the spread of (COVID-19) Novel Coronavirus, Integritas has created this page to ensure that our team has the most recent, up-to-date information, including education on newly released information (CDC,  IDPH, NIH, etc.), best practices and also providing resources to the facilities we serve.

Stay updated here:

Resources: 

Preparation Checklists:

Important Miscellaneous Notes: 

  • Don’t panic.
  • Do not make your own protocol(s). Contact your medical director or CMO if you have questions
  • Shave your face.  PAPRs and CAPRs are in limited supply. We can use N95s for the whole shift while they are still available.
  • Please do not publicly disagree with the current processes while in the hospital.  You are the leader when you are on shift and it is important for effective teamwork that your team is not fearful and frustrated.  Please reach out to your director or CMO if you have concerns.
  • Up to half of patients present with a digestive symptom as chief complaint, they have worse clinical outcomes and higher risk of mortality. half covid patients present just with diarrhea 

Pre-visit: 

  • Limited visitor policy.
  • EMS should avoid nebs and should be wearing PPE for all their calls.

 Triage:

  • Registration staff need to be protected. If they cannot be behind glass, then consider fit testing and use of an N95 during their shift.
  • Patients and visitors should be screened and immediately masked at facility entrance.
  • No handshaking.  Upsell to the patients that while you are so thankful for them, you cannot shake their hand at this time. Remind them that you have seen a lot of patients already and you want to protect everyone by reducing the spread of germs.  We have to reduce contact and perform excellent hand hygiene.
  • Respiratory and Gastrointestinal Febrile Illness Questionnaire
  • Guidelines For Completing COVID rev

PPE Use and Cleaning:

Workup, Testing, and Management:

  • Be Agile and just use the portable CXR in the department or start using ultrasound for evaluation.
  • Refrain from moving Covid-suspicious patients out of the ED for X-rays or CT scans.
  • Workup of Covid-19 patients, lab tests, etc COVID-19 Clinical Evaluation Guide
    • Lymphopenia, thrombocytopenia, and elevated INR seen sometimes.
    • Covid labs prior to admission:
      • CBC, CMP, troponin
      • d-dimer, LDH, Ferritin, coag studies
      • CRP, PCT
      • CXR, EKG
      • Consider ordering on admission: blood cultures, urine legionella & pneumococcal antigens
  • COVID – ED Clinical Guidelines 3.25.20
  • Sick Covid-19 patient management in the ED – SCCM-COVID-19-Infographics1

Medications for Covid:

Outpatient/ stable:

Inpatient/ Aggressive Outpatient:

  • Dexamethasone 6mg daily for 10 days for hypoxic patients.
  • Remdisivir for hospitalized patient – follow hospital protocol.  As of mid 2021, this has been found to not be as useful.
  • Tocilizumab, sarilumab, baricitinib – potentially useful to prevent intubation or improve outcomes in intubated patients. Novel.
  • Convalescent plasma – found to not be effective.
  • Monoclonal antibodies: bamlanivimab (does not work), Regeneron– may work, follow outpatient infusion protocol.

 

  • Zithro/Chloroquine, antivirals, and others have inadequate determination as to helpfulness right now.
    • If you really want to try something, you can explain side effects of medications and the risks of a controversial treatment.
      Our preference is shared decision making.  It may be reasonable to offer this protocol for anyone over 50, or some comorbidities, or sick on presentation but who don’t meet admission criteria.  Get an EKG and go over the risks of the medications (and put everything discussed in the discharge instructions).

      • Zinc 50mg daily
      • Vit C 1gm daily
      • Vit D 200IU daily
      • Aspirin 81mg daily

       

      Trial – Vit C, steroids, blood thinner, z-pack. https://www.trialsitenews.com/advent-health-ocalas-icam-protocol-takes-on-covid-19-clinician-drives-real-world-evidence-breakthrough/

      International Journal of Antimicrobial Agents publication on this alternative protocol – https://doi.org/10.1016/j.ijantimicag.2020.106214

      I am not trying to dive into politics and controversy.  I hope that this provides you with some clarity on the discussions about early Covid treatment so you can decide for yourself how you would like to take the risk.  Some of you will point to the research that shows HCQ is  not a slam dunk treatment and can introduce some serious patient harm.  Some of you would rather risk medication side effects over non-treatment.  Either way you decide to practice, talk with your patients – take the time to educate them and come to a shared decision on the treatment plan.

    • Trial of metformin, ivermectin, fluvoxamine, or a combination. University of Minnesota.
      https://covidout.umn.edu
    • Inhaled Budesonide – NNT = 8

 

Hospitalized Covid patients:

 

Intubated patient/ ICU:

    • Rebel EM guide
    • Try to avoid NIV (Bipap or CPAP).
    • Use your HFNC.
    • Intubation with Glidescope using PAPR/CAPR is preferred. At a minimum Full PPE and N95 or respirator.
    • Nebulizers will spread the virus. Avoid all nebulizers unless in negative pressure room and all staff uses PAPRs in room. Use MDI when able.
    • Consider “long acting B’s”, like Brovana (BID). We can have “auto-sub” neb to MDI when we have more…
  • Prone Positioning Protocol
  • Prone Positioning Protocol and Checklist

Intubation guide options (pick one):

Disposition:

  • Dartmouth Guide – DH COVID ED Algorithm Revised
  • Documentation should include “contact with and/or suspected exposure to Covid-19 patient” when appropriate.
  • Discharge when O2 sats >94%, no respiratory distress, no increase WOB.
  • Patient to be informed they have viral illness, no easy way to test for Covid (yet).  Recommend that they isolate themselves for 14 days and until >24hrs afebrile in order to prevent spread (of whatever they have).
  • Peds Seattle covid-19_org_pathway (July 2021)

Discharge instructions

Patient instructions for post-covid recovery

Hospital at home

Providers – Health and Exposure:

Palliative Care:

Protocols: 

Printable Resources for Facilities:

 

Forms and tracking sheets:

Airborne – NOT droplet only: