Additionally, you can find guidance on palliative care management during the pandemic here.
Symptoms
Fever, chills, dry cough, malaise, fatigue, dizziness, shortness of breath, pleuritic chest pain, sore throat, nasal congestion, loss of sense of smell and taste, diarrhea, hives.
Vitals
Often high fevers and hypoxia.
Often do NOT have marked tachycardia or sensation of dyspnea in setting of hypoxia.
Exam
Limited, especially in setting of using disposable stethoscopes, most commonly crackles on lung exam
+/- Respiratory distress, increased WOB, tachypnea
Labs
Leukopenia, lymphopenia
Thrombocytopenia
Hyponatremia
Elevated transaminases (usually AST/ALT, and mild)
Normal procalcitonin
Elevated CRP, ferritin, LDH, D-dimer
Imaging
CXR/CT chest: Patchy or multifocal or ground-glass opacities, often mid-to-lower lobe predominance
Management
Mostly supportive.
1. Tylenol for fevers. Can also give ibuprofen. (NSAIDS are OK to give in setting of COVID)
2. O2, goal O2 92-93% or above.
a. You should check their O2 sat daily in the room when you eval them and titrate O2 needs.
i. If O2 sat too low (less than 92%), always up titrate immediately in real time (as patients tend to be at high risk of rapid decompensation) and then update nurse about changes
ii. If satting well and patient can be down-titrated, do so in real time (nurses are busy and there may be
delay) - watch O2 sat for 5 minutes.
iii. Always update the nurse if you have changed the amount of O2 pt receiving.
b. Start with NC, can titrate up to 6L
c. If less than 92% on 6L, escalate to NRB
d. Max NRB is 15L
e. If desatting on 15L NRB (less than 90% persistently), and consistent with GOC, consider intubation (or HFNC if neg pressure room available)
3. AVOID fluids even if triggering sepsis. Keep these pts on the drier side, as they are high risk for ARDS. Okay to tolerate small amount of AKI.
4. Incentive spirometer
5. There is no RCT evidence for proning non-intubated patients, but anecdotal data suggests some improvement. Consider telling able-bodied patients to sleep in prone (or on their right lateral side). Not recommended if on NRB, obese, limited mobility, elderly and altered. (The department has worked with nursing and other services to create a protocol for proning.)
6. Use the COVID-19 Order Set (also found in the Admission Order Set) to easily select the medications and orders for patients with COVID-19. All patients should be placed on the COVID-19 pathway (ordered through the order set).
7. A COVID-19 tab ("Navigator") has been created to help you take care of patients with COVID-19. The tab includes vitals signs, lab trends, and respiratory flowsheets, along with real-time treatment recommendations for your patients.
Medications
1. Hydroxychloroquine and Azithryomycin ARE NOT recommended.
2. When to give CAP or HAP coverage?
a. If pt is acting more like they have a bacterial infection: leukocytosis, elevated procalcitonin, very dense opacity on CXR, discuss with ID and consider giving antibiotics
b. Typically will make this decision on admission OR if pt has a clinical decompensation, check a repeat CXR and procalcitonin (especially if admission procalcitonin was normal and now is elevated)
3. Convalescent plasma, remdesivir
a. ID consult is required for remdesivir
b. Patients may be eligible for convalescent plasma if they have a negative rapid antibody test on admission
i. Convalescent Plasma can only be ordered through the Convalescent Plasma Order Set. You can access the orderset and complete the necessary documentation using the COVID-19 tab ("navigator").
4. Steroids
a. Should only be started if the patient is on supplemental oxygen
b. Dexamethasone 6mg PO/IV daily based on RECOVERY Trial (alternatively, some pulmonologists use solumedrol 0.5mg/kg BID)
6. Anti-coagulation
a. Data is based on post-mortem assessment of a few patients with COVID-19.
b. Of note, evidence suggesting an association with decreased mortality in patients with COVID-19 used
prophylactic doses of enoxaparin or unfractionated heparin.
c. The hospital system has recommended a regimen of aggressive prophylaxis for patients with COVID-19. Please review the treatment recommendations.
Other important information and ways to minimize nursing exposure
- ACEi/ARBs are fine to give
- Avoid nebulizers, use MDIs instead (avoid aerosolization)
- Avoid SQH, use SQ Lovenox instead
- If BG within goal, consider stopping BG checks and stopping sliding scale insulin
- Cluster timings of med doses
Data to Trend
1. Check daily or every other day. Note: This is not hard and fast, but a choice that some of us make on our sick or rapidly changing pts. We don’t know exactly how to interpret these but in general, rising inflammatory markers = not good.
a. CBC, CMP (particularly LFTs), CRP, ferritin, D-dimer, LDH
2. Check once (ideally on admission)
a. Procalcitonin (and check if pt decompensating, having rapidly increasing O2 needs)
b. COVID-19 Antibody, CPK, fibrinogen, troponin, T&S (need two if getting plasma)
c. CXR (and check if pt decompensating, having rapidly increasing O2 needs)
When to Discharge
1. It is OK to discharge with fevers!
2. Use your labs to help support your decision making.
3. You do not need ID clearance for discharge
4. Goal O2 >92% on RA unless you’ve decided to pursue home O2
5. Ensure home quarantine plan and understanding (detailed instructions in DC paperwork will be given, also available in Spanish).
6. In general, pts must self-quarantine at home until the following three things have happened:
a. No fever for 72 hours without the use of anti-pyretics
b. Respiratory symptoms improving
c. At least 7 days have passed since symptom onset (For patients who have had symptoms longer than 7 days, we typically suggest the start date of the 7-day period should be from the day they felt their worst (usually on the day of admission)
NOTE: Patients are NOT allowed to take public transportation home if they are still within the quarantine window.
When to call RRT
Page "1RRT" (1778).
1. Your patient is on max (15L) non rebreather and cannot maintain a sat of 90%.
2. Your patient is decompensating in another way (new hypotension etc).
When to NOT call RRT
Unfortunately these are situations when we would normally call but given the surge of sick pts, RRT cannot accommodate these calls regularly.
1. Your pt is going from NC to NRB
Additional Things to Consider
1. Discuss GOC EARLY. We are not rationing care. However, in any patient that you would advise DNR/DNI in a situation outside of COVID, make sure to have that conversation early.
2. Confirm next of kin or HCP information as soon as possible.
3. Engage SW early, especially if patient has any HHA needs, VNS services, is from a facility. Services of any kind require documentation of negative COVID to resume services.
4. Try to make a point to update family, and with tenuous pts, update them regularly, daily if possible.
5. If you are in a patient room and need something: open the door slightly and ask anyone nearby for help to get you --- a stethoscope, a new pulse ox sticker, a NRB mask, goal is to limit unnecessary donning and doffing and wasted PPE.
6. There ARE outpatient dialysis centers that take COVID patients.