COVID-19

COVID-19

There’s no sense reinventing the wheel with yet another COVID-19 post.  Below are some fantastic links to information regarding the novel coronavirus SARS-CoV-2, responsible for causing COVID-19.1-5 

Background info at REBEL EM (link here)

Airway management at EM Crit (link here)

Advanced info at IBCC (link here)

Ventilating the Acute Respiratory Distress Syndrome (ARDS) patient at EM RAP (link here)

Further COVID-19 information from JAMA (link here)

Despite this, we think it wise to continue the discussion with a focus on preparedness.  We understand that we are not experts in this topic and that information/recommendations are changing daily.  However, we often see disjointedness between public health, health authorities and local infection control when it comes to recommendations regarding isolation, investigation and management of potential COVID-19 patients. 

COVID-19: Barebones Background

SARS-CoV-2 belongs to the b-coronavirus family and is responsible for the disease known as COVID-19.  Again, to clarify, SARS-CoV-2 is the actual virus and COVID-19 is the disease it causes.  COVID-19 is the third known zoonotic (disease that spreads from non-humans to humans) coronavirus disease after SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome).6

Thought to possibly have originated in bats, SARS-CoV-2 appeared to rear its ugly head in December of 2019 when a series of unexplained pneumonia cases came to light in Wuhan, China.  To date, the number of infections has exceeded that of the SARS outbreak in 2002. 6 

Case Fatality Rate (CFR)

As of March 3rd, 2020, the case fatality rate of SARS-CoV-2 was 3.4%.7 Compare this to SARS at 9.2% and MERS at 34.4%.  Many believe that the case fatality rate may actually be remarkably lower as this number relies heavily on the number of people being tested.  With community spread, the number of people with the virus is likely higher than we know.  This would certainly drive down the mortality rate as it stands now.  The Diamond Princess cruise ship acted like a natural human laboratory and may have given us a more accurate CFR of less than 1%.8 Only time will tell. 

COVID-19: Signs and Symptoms

The predominant symptoms of COVID-19 include:

  1. Fever
  2. Cough
  3. Shortness of breath

The incubation period appears to be somewhere between 2-14 days.  Some interesting anecdotal information from a recent Infectious Disease conference (March 8th, 2020) regarding disease progression in those COVID-19 patients in the California area.  Their experience caring for these patients demonstrated that the most common presentation was one week of viral prodrome (myalgias, malaise, cough and low-grade fever).  This developed into increased shortness of breath in week two of the illness.  Pneumonia/pneumonitis tended to occur around day 9, with Acute Respiratory Distress Syndrome (ARDS) and need for intubation on day 10.9 This is in contrast to influenza, which classically begins quite suddenly.

Please keep in mind that COVID-19 causes viral pneumonia.  It is not like influenza where we typically see a bacterial pneumonia superimposed illness.  This virus has an affinity for certain receptors in the lungs that results in alveolar and epithelial damage.3  

Identification: It all starts at triage (or does it?)

The role of the triage nurse is arguably one of the most important roles in the hospital on any given day and this is no different when it comes to potential COVID-19 patients.  It’s no secret that our front-line staff have an incredibly challenging job.  Moreover, potential COVID-19 patient identification just became a lot more difficult with evidence of community transmission of the virus.  No longer can we rely on screening questions that focus on travel to endemic areas.  Don’t get me wrong, these questions are still important and do provide valuable screening information.  But with what looks like community spread of COVID-19 in the midst of influenza season, the task of identification and isolation of these patients is a bit like finding a needle in a haystack. 

However, identification of potential COVID-19 patients should begin outside of the hospital setting.  Public health initiatives, telemedicine, community or “surge” clinics and drive-thru swabbing stations should all be implemented in order to keep those potential patients away from the elderly, medically frail and immunocompromised patient population.  Oh, not to mention away from front line health care workers.  We need to minimize our exposure to ensure our own health so that we can properly care for our patients. 

Keep these patients away from hospitals and long-term care facilities!

So, if patients present and/or require hospital care, what can be done as a front-line healthcare worker, whether that’s a triage nurse, charge nurse, paramedic, respiratory therapist or physician, to best protect ourselves and our patients? 

Protection

  1. Establish appropriate signage at the entrance of the emergency department to encourage those patients with cough, fever and/or shortness of breath to wear a mask and wash their hands with either hand sanitizer or soap and water.
  2. Have them present themselves to triage immediately.  They shouldn’t be left to mingle in your main waiting rooms.   
  3. Ask appropriate questions that will give you the best opportunity you may have at identifying possible COVID-19 patients. 
    1. Has there been travel to one of the endemic areas (currently China, Iran, Italy, Japan, South Korea) or contact with anyone who has traveled to these locations?
    2. Has there been a history of travel anywhere in the past two weeks?
    3. Are there symptoms such as fever, cough and shortness of breath?
  4. Be prepared!  Ensure your department/ambulance service/etc. stocks the appropriate personal protective equipment (PPE) at triage, in the hospital and on the trucks.  Ensure all PPE is labelled and easily accessible (i.e. on a cart or a wall, not tucked away in an unlabelled bag or located in another area).
  5. If there is risk of a patient having COVID-19, ensure you take the appropriate precautions.   
    1. Ensure the patient has put on a surgical mask (remember, this only helps spread of the virus from the potentially infected patient to others). 
    2. Ensure your department, or ambulance service, has the appropriate PPE available at the triage station or on the truck.  Current recommendations from the literature vary; however, contact precautions and either droplet or airborne precautions are advised.10,11

Triage

As of February 27th, 2020, the World Health Organization (WHO) recommends a medical mask be applied to a potential COVID-19 patient and the triage nurse maintain a 1 metre distance from said patient (with no PPE required).10  Placing a mask on a patient (if they haven’t already done so themselves) involves frontline nursing staff getting closer than 1 metre.  Moreover, the taking of vital signs would involve the same (if even done at triage in this circumstance).  Therefore, quickly placing a medical, or an N-95 mask on your own face may be wise.  Also, gown, gloves and eye protection would be encouraged.  This would of course need to be balanced out with the duration the patient is left sitting in the triage area.

Ambulance

Paramedics directly involved in transporting suspected COVID-19 patients to hospital facilities are recommended by the WHO to wear medical masks, gowns, gloves and eye protection.  The Centers for Disease Control and Prevention (CDC) would encourage the use of N-95 masks.  Drivers with zero patient contact and are physically separated from a potential COVID-19 patient in the driver’s compartment require no PPE (as per the WHO).  If there is no physical separation, a medical mask is recommended.10-11 Remember to take extra caution with patients presenting with shortness of breath. This might not be a simple COPD exacerbation.

Bottom line:  Wear your PPE!

Do not leave these patients in the main waiting room of your department.  Current recommendations are to isolate these patients in a negative pressure room.   

Isolation

At this juncture, it is recommended to place potential COVID-19 patients into negative pressure isolation.  Once there, these patients still require care.  Here is where both creativity and caution come into play. 

Be Creative

In this day and age of technology, one may consider the use of a cell phone to communicate with an isolated patient.  Most negative pressure rooms will have windows.  It’s not inconceivable to carry out an appropriate and accurate history with a patient on the other side of the glass by using cellphones.  Keep in mind, you will still need to assess the patient with a physical exam.  And this is where we use caution. 

Be Cautious

Take your time!  All recommended PPE equipment should be properly labelled and placed immediately outside (or within your anteroom) for ease and accuracy of donning (let’s be honest and call it “putting it on”).  Current recommendations vary between droplet/contact and airborne/contact precautions.  Ensure you carefully put on your PPE prior to entering the room. Now is also a good time to have a “buddy” or a spotter to ensure this process is done properly.  There are many references available that demonstrates proper technique.  Below is the link to recommendations by the CDC (see link below).

Ensure you have everything available within the room that you may require for patient assessment.  Charts, computers, pens, clipboards should not be taken into and out of the room.  A checklist can be worth millions in this case! 

After your assessment, and with the assistance of your spotter, ensure that you properly doff (again, “take off”) your PPE equipment.  Ensure visual aides are posted in this areas to assist both you and your spotter. This is a critical time when many of us will tend to contaminate ourselves!  Please pay full attention while removing your PPE.  Hand washing between each step would be highly recommended (see link below).

Available from CDC website

An excellent video from the National Ebola Training & Education Center on how to donn and doff PPE for COVID-19 is located below. 

Donning at 05:05 min and Doffing at 11:11 min

Again, current recommendations vary when it comes to what PPE we should be using.10,11,12 However, if you were to ask us, here’s what we’d be using for PPE before entering a room with a potential COVID-19 patient.

  1. Gown (needs to be waterproof)
  2. Surgical mask or N95 mask (make sure you get fitted and know which size fits you…having a list of names and sizes in the department would be wise).  We understand that we don’t want to unnecessarily use up precious resources and be left with no N-95 masks when they’re needed (i.e. for high-risk, aerosolizing procedures such as intubation).  However, one could argue using the safest piece of equipment at our disposal would be wise until more information surrounding SARS-CoV-2 is available. 
  3. Face shield and/or goggles for eye protection.
  4. Gloves (preferably long ones that cover the wrists well)

*If you were to have ready access to PAPRs (powered air-purifying respirator), give strong consideration to these, especially for high-risk aerosolizing procedures (i.e. intubation, swabs, bronchoscopy).  Use extra caution taking these types of PPE off as we typically do not do this on a daily basis and can be at increased risk for contaminating ourselves.13

COVID-19: Screening & Management

Screen these patients early.  Ensure you follow local screening recommendations, provided you have received them.  If you haven’t received them, get them!  Push your local public health authorities to make this information readily available.  Recommendations are ever changing; however, at the moment, those patients who have traveled outside the country within the past 14 days OR had contact with someone who did, AND has symptoms (fever, cough, shortness of breath) would be a candidate for testing. 

Remember, well patients do not (and likely should not) require visitation and screening in the ED.  These patients should be screened elsewhere, like over the phone and/or at COVID-19 clinics within the community.  The less transmission to the hospital, the better!

Management of COVID-19 patients will be largely supportive. Patients with symptoms such as fever and cough, with negative influenza/viral screen and are stable, should be presumed to be possible COVID-19 and could be sent home to self-isolate.  Ensure that all positive and presumptive cases are reported to your local public health authorities.  Those who require hospitalization should be maintained on isolation/negative pressure room precautions. 

Image from REBEL EM website

Hospitalized patients are often hypoxemic.  Basic care strategies apply here. 

  1. Avoid non-rebreathers to reduce aerosolization of the virus.
  2. Avoid nebs!  Stick with MDIs and spacers devices for the same reason as why you avoid non-rebreathers. 

Airway Management in COVID-19

There are definite variations in airway management of COVID-19 patients.2,14 We will briefly skim the surface here and would encourage you to read about this topic further.  We do not claim to be experts in this area.   

  1. Avoid the use of high-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV), such as BiPAP, in these patients.  We often use these measures regularly in the ED to prevent the need of intubation; however, these only help to aerosolize the virus more.  On the flip side, we also understand the need to balance resources.  Therefore, it may become inevitable that you need to use HFNC and/or NIPPV.  Placing a mask over the patient on HFNC and/or use of PAPRs can help to reduce viral aerosolization.    
  2. Move to intubation early in these patients.  As stated above, you want to minimize aerosolizing this virus into the atmosphere.  If a confirmed (or presumptive) COVID-19 patient is in respiratory distress, move early to advanced airway management.  This also acts as a means of source control.    
  3. Intubation of these patients should occur in a negative pressure room. 
  4. Maximal PPE protection should be used prior to undergoing this procedure.  Gown, gloves, N-95 respirator mask, goggles and face shield should be worn.  If available, give consideration to the use of PAPRs. 
  5. Your “best” intubator should be your first intubator.  This is not the time to allow learners to try to get an intubation.  Here, you want to maximize your first-pass success rate. 
  6. Video laryngoscopy is preferred over direct laryngoscopy to avoid the need of getting any closer than you need to the oropharynx.  A normal geometry blade and bougie are always recommended to improve first pass success.
  7. DO NOT preoxygenate these patients with a bag-valve mask (BVM).  That is to say, do not squeeze the bag as this too can increase aerosolization of the virus.  Give consideration to placement of a PEEP valve onto your BVM and place one of the viral filters that are used in your ventilator into your BVM apparatus as well.  Then use this method to perform apneic oxygenation prior to intubation. 
  8. Ventilate these patients as per the ARDSNet protocol.15 Keep in mind that many intubated COVID-19 patients seem to be requiring larger amounts of PEEP.
Infographic from CanadiEM website

All of this information still leaves us with so many questions.

1. Why aren’t we preparing accordingly? 

Certain areas across the country and around the world for that matter are!  But, when your “how to access the wifi” signage in your department is more prominent than infection control precautions, you have a huge problem!

2. Do we have the right equipment in the right locations? 

We bet you anything that if you took a verbal survey within your department about what PPE is recommended, available and where it’s located, you’d receive a multitude of answers.  Hospital administration, nursing leadership and physician leaders need to step up and ensure that all our healthcare providers are provided with the best, most up-to-date information and recommended protective equipment to keep us all safe while providing care to both potential and confirmed COVID-19 patients.

If this isn’t happening, make it happen!  Don’t wait!  Do it at a departmental level. 

3. How do you get a portable x-ray machine into your negative pressure room?  Does it fit?  If so, how (and where) do you properly clean it afterwards?  How long is that machine out of commission before it can be used for other sick patients within your department?

These are questions we are not sure we have the answer to.  But we need to find the answers and find them soon!  In all likelihood, the machine will fit into the room.  However, do a dry run.  Test it to make sure on your next shift. 

Proper cleaning protocols vary, but in some instances these machines are off-line for upwards of 2 hours after use and cleaning.  Data from previous coronaviruses shows it can live on surfaces for up to 9 days without proper cleaning.3  Give consideration to this downtime as you may need to balance its use with other ill patients in the department and communicate regularly with your cleaning staff.   

4. What if the patient requires advanced imaging, like a CT scan?

Some of these patients, especially the sickest, will require advanced imaging.  If so, what are the best means to transfer these patients to the radiology department?  And, of course, place a mask on the patient. 

Once the scan is completed, the scanner/room will inevitably require cleaning.  How long is that scanner out of commission for (i.e. how long until it can be used for other patients in the department/hospital)? How will this impact flow/throughput of your department/hospital? 

Should patients be taken directly to ICU or floor isolation immediately after their CT (if they are coming from the emergency department)?

Logistically, and if at all possible, yes.  Rather than bring patients back to the ED, continue moving them from CT to their area of disposition.  It doesn’t make sense to potentially re-expose more individuals. 

What’s the plan if/when your negative pressure room(s) are fully occupied? 

We’ll just leave this one here for everyone to chew on as this will vary from location to location.  Just ensure you have an agreed upon plan within your department. 

Summary

  1. Knowledge around SARS-CoV-2 is changing daily.  Make a point to keep up-to-date on the latest health information.
  2. Be prepared!  Know the current recommendations from local public health authorities.  Push local health authorities for support, appropriate signage, hand washing stations and appropriate PPE.
  3. Ensure your PPE is labelled and available in ALL areas (including triage).  Administration should be doing everything they can to protect their staff.
  4. USE YOUR PPE!  Get mask fitted and know your N-95 size. 
  5. Be creative.  Accurate history taking can be conducted over the phone.
  6. Work as a team!  Have buddies and spotters when taking off PPE.  For more on team function click here.
  7. Know where you are going to place these patients.  When those areas become occupied, have a clear plan as to where incoming patients will go. 
  8. When supporting these patients, try to minimize aerosolization of the virus.  Minimize nebs and use of HFNC and NIPPV.  Move to intubation early if the patient is in respiratory distress. 
  9. Take an opportunity to simulate out how your department/hospital will handle COVID-19 patients.  This can be done with a low-fidelity approach and can often find the answers to most questions.
  10. Be a responsible healthcare provider. 
    1. Always practice good hand hygiene technique.
    2. Consider using hospital scrubs that can be left to be laundered by the hospital, rather than taking home “work clothing.”  Good health hygiene should trump any and all “dress code policies” and therefore should be supported by administration. 
    3. Think twice before traveling abroad and cancel all unnecessary travel.  Your colleagues will need your assistance when you return and self-quarantine at home will not help in this instance. 

References

  1. Salim Rezaie, “COVID-19: The Novel Coronavirus 2019”, REBEL EM blog, March 1, 2020. Available at: https://rebelem.com/covid-19-the-novel-coronavirus-2019/.
  2. Scott Weingart. Some Additional COVID Airway Management Thoughts. EMCrit Blog. Published on March 10, 2020. Accessed on March 12th 2020. Available at https://emcrit.org/emcrit/some-additional-covid-airway-management-thoughts/
  3. Josh Farkas.  COVID-19.  Internet Book of Critical Care.  Published March 2, 2020.  Available at https://emcrit.org/ibcc/COVID19/
  4. Anand Swaminathan and Haney Mallemat.  EM RAP Breaking News.  Published March 6, 2020.  Available at https://www.emrap.org/episode/emrap2020march2/emrap2020march
  5. del Rio, Carlos and Malani, Preeti.  COVID-19-New insights on a rapidly changing epidemic.  JAMA. Published online February 28, 2020. doi:10.1001/jama.2020.3072
  6. Giwa A t al. Novel Coronavirus COVID-19: An Overview for Emergency Clinicians. Emerg Med Pract 2020. PMID 32105049
  7. https://www.worldometers.info/coronavirus/coronavirus-death-rate/#who-03-03-20
  8. Faust, Jeremy.  COVID-19 isn’t as deadly as we think it is.  Slate.  Published March 4, 2020.  Available at https://slate.com/technology/2020/03/coronavirus-mortality-rate-lower-than-we-think.html
  9. https://twitter.com/Chenbariatrics1/status/1237025250853847040
  10. World Health Organization. Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19).  Available at https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf
  11. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
  12. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/interim-guidance-acute-healthcare-settings.html#a4.10
  13. Jorge E. Zamora et al.  Contamination: a comparison of 2 personal protective systems. CMAJ Aug 2006, 175 (3) 249-254; DOI: 10.1503/cmaj.060094
  14. Minzhang Zuo et al.  Expert recommendations for tracheal intubation in critically ill patients with novel coronavirus disease 2019.  Chinese Medical Sciences Journal.  2020 Feb 27. doi: 10.24920/003724

Cite this article as: Jacquelynn Carter and Angus MacDonald, COVID-19. EMcenterED blog. March 12, 2020. Available at https://emcentered.com/covid-19/

This Post Has One Comment

  1. Great summary. Thanks for putting this together.

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