Coronavirus COVID-19 Updates: uc.edu/publichealth
We are going to open the RESPIRATORY ED tomorrow (in almost all certainty).
Here is how things will go down, KEEPING IN MIND that things WILL change, perhaps
frequently, depending on what this looks like. Planning for continued escalation
is ongoing. I very much appreciate your patience in the coming days, and
the strain that we are about to put on our staff to accomplish this herculean
Attendings: I know this is nuts. We are asking so much,
and for that, I apologize and am profoundly thankful. We have looked at the next
2 weeks thus far, and found only 2 people who have conflicting shift obligations the
next day after a move from the normal S2 to a night shift S2. We will work on
9) Respiratory ED OPS stuff:
That is all I have for tonight. More to come in the next few days- I will
review what has gone well and what hasn’t. Be ready for emails
requesting for volunteer coverage for shifts to be paid at our OT rate, starting
already for this weekend Saturday and Sunday night in the Respiratory ED.
Hopefully some of you were privy to Sanjay’s amazing email to his WCH
team, including this excerpt that was particularly incredible-
“But MOST IMPORTANTLY, what I want you to know is that there is no other
department I’d rather face this with. We’re going to get hit by this
impending storm, but we’re going to face it together. And we will get
through this. Times will get hard, and every person in our family will need a
pick-me-up here and there- I know I will. I have always felt we had the
coolest job in the world. It's now become one of the most important jobs in the
world. While everyone else is ordered to stay home, we’re asked to come in,
and that’s for a reason. Because we’re needed to make a
difference. And we will”
Outstanding. THIS is why we went into Emergency Medicine, right?
EVERYONE is looking at us right now- let’s stand up and show ‘em
why we are the best damn department in the country.
Jack P. Palmer III, M.D., M.S.
Provided by Calhoun 3/10/20
Criteria to Guide Evaluation and Laboratory Testing for COVID-19
Clinicians should work with their local and state health departments to coordinate testing through public health laboratories. In addition, COVID-19 diagnostic testing, authorized by the Food and Drug Administration under an Emergency Use Authorization (EUA), is becoming available in clinical laboratories. This additional testing capacity will allow clinicians to consider COVID-19 testing for a wider group of symptomatic patients.
Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever1 and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing). Priorities for testing may include:
There are epidemiologic factors that may also help guide decisions about COVID-19 testing. Documented COVID-19 infections in a jurisdiction and known community transmission may contribute to an epidemiologic risk assessment to inform testing decisions. Clinicians are strongly encouraged to test for other causes of respiratory illness (e.g., influenza).
Mildly ill patients should be encouraged to stay home and contact their healthcare provider by phone for guidance about clinical management. Patients who have severe symptoms, such as difficulty breathing, should seek care immediately. Older patients and individuals who have underlying medical conditions or are immunocompromised should contact their physician early in the course of even mild illness.
Updates from the last 24 hours. Continually honored to work with this team who selflessly do whatever is asked without hesitation, even if it changes hour to hour. Protocol changes, shift changes, shift pick-ups, extra work, you name it, EVERYONE is pitching in. It’s awesome.
1) The Respiratory ED ribbon cutting was yesterday at 3pm, performed by Dr. Conal Roche. By all accounts, he was the perfect person to kick us off, as you'd expect. Thank you to Conal for his great attitude, flexibility, and great ideas as we got started.
2) Saw a good number of patients through the Respiratory ED. Note the following protocols and lessons learned:
2) Please see the new attached testing algorithm. Much clearer, and thanks to Dustin for advocating for us to make this clear and as simple as they would allow, and Sanjay for laying it all out. STRONG WORK. We did this over the past 18 hours in the Respiratory ED and it is smooth. ODH was helpful the few ODH cases we did, and for the rest that were more “clinical judgement” testing, LabCorp was easy.
3) Thanks to Lisa Kiser for getting that discharge dot phrase together. You can add yourself to it by going to “My Smartphrases”, searching “Kiser, L”, and finding her .lwcovid discharge phrase, which is based off of the CDC recs for testing suspected patients who can/should go home and self quarantine. We are also telling patients to register and log into MyChart where they can follow up their results, and LabCorp SHOULD be calling (but have them logon just in case).
4) BIG MISS from JP: I failed to mention in our new staffing model- because the OBS2 APP is covering in the Respiratory ED from 7p-7a, overnight the POD docs will managed ED CDU OBS Protocols that exist in their care space, and if not, from where they originated. The Attendings are already “aware” of the protocol patients that they own, but now the care team in their space truly owns their care- pain control, lab/imaging follow up, etc. The OBS1 APP will find the appropriate attending and inform them around signout the final plan, and the Attendings and residents must manage these patients to the best of their abilities overnight. Ultimately, not much happens with OBS patients overnight, but often times results are completed, sometimes patients are discharged, and often admitted overnight. The OBS2 can help with operational issues (showing how to admit, how to order something, figure out if we can get a DVT study, etc.), but they are committed to the Respiratory ED and will NOT be caring for these patients for the foreseeable future.
5) A new OBS clarification- due to the high concern of asthmatics and COPD patients to potentially have COVID-19 and possibly decompensate rapidly, we will NOT be admitting any Asthma/COPD patients to ED OBS Protocols until we have a better control over this disease process. From my readings, these patients are getting incredibly sick, but the interval at which this occurs is hard to determine, and many rapidly decline over 8-12 hours and I do not want that falling on our Respiratory ED “keeping” these patients and managing them for 24 hours. Further, we may be falsely reassuring that a patient is “stable” for a day and ok to go, when they may crump shortly thereafter.
6) Last intubation update: Please officially clean the King Vision with a Blue Top Bleach wipe, which are on top of the intubation cart currently stationed in room 16. While that room is the largest and best for intubations, that cart is meant to be mobile from room to room. Keep the cart in the hallway and bring your clean supplies in with you when you don. Clean the King with the Blue top wipe after an intubation, place it in a clean biohazard bag (for now), doff your PPE, and bring the King out with you and replace it in the cart.
7) We are working to come up with the best strategy for asthma/COPD patients who need bronchodilators- nebs are a no-no unless they REALLY need them. Taking inventory of our MDI supply and may use more aggressive MDI protocols- more to come. Also, I mentioned the progression of O2 as NC to HFNC in my last email. Newer recs are stating that we should likely transition from NC to Face Mask (less aerosols) and if they aren’t doing well on NRB FM- intubate.
8) SCRUBS!!! There is a big bin outside of CPod doors next to the elevators in the Lab Building (like you are walking to the Men’s Locker room/CDU). PLEASE do yourself and your family a HUGE favor- wear clean clothes to work, change into scrubs, work, DOFF those scrubs, change into clothes and go home. Consider the same thing for shoes. It’s NOT WORTH IT. I know cargo pants are comfortable. I know black polos are back in style. Wear scrubs!
Thats all I’ve got for now, other than check out these pics! OPENING NIGHT AT THE RESPIRATORY ED!! Since everything else was closed, we decided to throw down.
Specific updates regarding workflow at WCH during the pandemic.
Feedback, as always, is welcome.
Thank you for your continued flexibility as we work on improving processes in anticipation of what’s to come. A few EPIC updates for both Emergency Departments:
Medical Screening Exam (MSE) template – ATTENDINGS ONLY AT THIS TIME – for use in the respiratory ED’s and Tents.
Trackboard Changes - This is a work in progress, but temporarily, a column has been added to the left side of your screen to include patients in the tents, to differentiate them from the main waiting room.
Thank you and stay safe everyone,
Jack and Sanjay
Thank you again for the continued flexibility and patience with this ever dynamic COVID-19 situation. Things have been fairly mild at this point, but we are definitely starting to see some positives and sicker patients, though volumes remain low. I have attached our daily volume graphs for your continued awareness. Updates below:
1) Given low volumes anticipated for the next 1-2 weeks, we are going to try and get some people a break while we still can. Here is the deal:
2) Cardiac arrests with COVID concerns:
3) Surge planning
Thanks again, more to come in a few days.
A reminder that the new WCH ED attending schedule (announced a few months ago) will go into effect Wednesday, April 1 as below:
(Changes are in red and bolded)
As if you needed any more change in your lives right now. I appreciate everyone being understanding and flexible.
My goal with these changes were:
APP and resident schedules will remain the same at this time (morning APP still comes in at 7am)
We should have a better idea in a couple months (hopefully, when the pandemic is dying down) how these changes work, but please let me know if you have any feedback as we proceed through the new schedule.
Stay safe and healthy,
West Chester ED attendings,
Updates on a couple services and referrals to the WCH ED, where you may receive phone calls:
Psychiatry — referral calls
OB/GYN – Christ Liberty L&D Closed
Thanks for your time, and I hope you’re all able to enjoy this beautiful day.
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