Patient Assessment

Screening and TriagingCopy Link!

The screening and triaging process involves three parts:

  1. A Quick Symptom and Exposure Screen to determine which patients are at risk for COVID
  2. An Acuity Triage to determine how quickly and where patients need to be seen
  3. Categorization by Likelihood (Case Definitions) to help sort patients who might have COVID by their likelihood of having it, and to help reduce transmission from likely cases to unlikely cases.

Screening QuestionsCopy Link!

Updated Date: December 20, 2020

Goal of screening: To quickly identify patients with possible COVID infections and prevent transmission of infection to other patients and healthcare workers.

Where to screen: At the point of entry. Most healthcare facilities reduce the number of available entrances and set up screening stations with trained staff at every entrance.

Whom to screen: All people entering a healthcare facility should be screened (patients, visitors, staff). Patients who are coming in for routine care should be screened prior to patient arrival if possible (typically via telephone 24 hours before the appointment) and again at the designated point of entry (whether or not the patient was already screened).

Sample Screening Questions:

  1. Do you have any of the following new symptoms?
  • Fever
  • Cough
  • Shortness of Breath
  • Muscle Aches
  • Sore Throat
  • Runny Nose
  • Loss of Smell or Taste
  1. Have you been tested for or had COVID-19 in the last 14 days?
  2. In the last 14 days have you spent at least 10 minutes within 6 feet of anyone with COVID-19 or symptoms of COVID?
  3. Are you, or a household member, currently on home isolation or quarantine, or have you traveled to a place that requires quarantine?

If the patient answers “No” to all of the above, continue routine check in. People who screen negative should be separated from those who screen positive.

If the patient answers “Yes” to any of the above, give the patient additional PPE (a surgical mask) if screening in person and go to Acuity Triage below.

Acuity TriageCopy Link!

Updated Date: December 20, 2020

Literature Review (Virtual Care): Gallery View, Grid View

Facility Acuity TriageCopy Link!

Isolation: If the patient is positive during screening, they should be treated as a possible COVID-19 case, also called a “Person Under Investigation' (PUI) and be separated from patients who screen negative.

Acuity triage: After screening positive, patients should next undergo an acuity assessment to determine how urgently they need to be seen by a medical provider. For urgent care or emergency visits, this should be done with a standardized triage system. One triage system designed for LMICs is the WHO/ICRC/MSF Interagency Triage tool (see below). Patients who are designated as higher acuity by a triage system should be seen first.. Triage should be conducted in a dedicated space with equipment to measure vital signs, and there should be clear pathways from triage to a resuscitation area for patients who are identified as critical.

Tool: WHO/ICRC/MSF Interagency Triage Tool (Pages 11-15)

Home and Virtual Acuity TriageCopy Link!

When patients screen positive over the phone prior to a visit, a provider can assess symptoms over the phone or at a home visit to determine the urgency and best location of evaluation: at home via virtual visit (telephone or video), in person (outpatient), or in an emergency unit.

Below is suggested guidance, but individualized provider assessments should always take precedent. If a provider feels that evaluation in an outpatient clinic or emergency unit is necessary,, they should ensure that the specific location recommended has appropriate IPC and PPE to safely care for PUIs as not all facilities are equipped for this purpose.

Tool: PIH Intake and Symptom Screening Tool
Tool: BWH Telephone and Video Visit Tips

Lower Risk for Complications

High Risk for Complications Age ≥ 65; residence in care facility/correctional facility/dormitory/homeless; underlying conditions: chronic lung/heart/kidney/liver disease, mod-severe asthma, immunocompromised, obesity, diabetes, immunocompromise, psychiatric or substance use disorder

Mild Symptoms (No Dyspnea or Chest Pain)

Telephone/Video/Home

Outpatient Visit

Mild Chest Tightness/Pain

Outpatient Visit

Outpatient Visit or

Emergency Unit

Moderate or Severe Chest Tightness/Pain

Emergency Unit

Emergency Unit

Mild Dyspnea Dyspnea that does not interfere with daily activities (e.g. just mild dyspnea with activities such as climbing 1-2 flights of stairs or walking briskly

Outpatient Visit

Outpatient Visit or

Emergency Unit

Moderate Dyspnea Dyspnea that limits daily activities (e.g. dyspnea that limits the ability to walk up 1 flight of stairs without needing to rest or that interferes with meal preparation or light housekeeping

Outpatient Visit or

Emergency Unit

Emergency Unit

Severe Dyspnea or Home SpO2 94%* regardless of symptoms (or significant decline from baseline) Dyspnea so severe that it renders the patient unable to speak in complete sentences and interferes with basic activities such as toileting and dressing

Emergency Unit

Emergency Unit

Danger Signs:

  • Difficulty breathing/Shortness of breath
  • Bluish lips or face
  • Gasping for air when speaking
  • Coughing up blood
  • Pain/pressure in chest (NOT associated with coughing)
  • Altered mental status or severe sleepiness
  • Inability to eat/drink or walk
  • Any other significant change in condition

Emergency Unit

Emergency Unit

*If patient has home pulse oximeter, here are Instructions. Caution on the reliability of at home pulse oximeters: Trend may be more reliable than the value itself. Dyspnea does not always correlate with oxygen saturation (Shah et al).

Likelihood Categories (Case Definitions)Copy Link!

Updated Date: December 20, 2020

During or after the acuity assessment, a clinical staff member should verify the initial screening assessment classify patients by their risk (likelihood) of having COVID. Patients who are acutely ill or unstable should not have care delayed for this step.

Why Categorize?Copy Link!

Not all patients who screen positive on questionnaires will have COVID and it is important to try to separate patients by how likely they are to have COVID in order to avoid exposing patients who do not have COVID. Patients who have tested negative or who are not suspected to have COVID-19 should never be co-housed with COVID positive or PUI patients. Keep risk categories as separate as possible. See Levels of Isolation.

How to Categorize?Copy Link!

Someone with clinical training should categorize patients by their likelihood of having disease using standard case definitions. This process can be combined with Clinical Evaluation and can be done in multiple locations (telephone, near facility points of entry, dedicated/ prepared clinics, or COVID-ready acute patient care settings). It is important to note that:

  • Case categorization varies significantly in different hospitals and in different countries. Please follow your local guidance.
  • Clinician judgment is an important part of the decision. If the patient has an obvious alternative explanation for why they have a symptom, their risk could be downgraded. If a patient has significant exposure or classic symptoms, their risk could be upgraded even if they do not meet all criteria.
  • Testing: Test patients in these groups when possible, either before or during this evaluation.

Tool: WHO Case Definitions Handout

Adaptation of the WHO Guidelines for Case Definitions

Case type

Definition

Asymptomatic exposed

An individual who meets the definition of a COVID exposure (described under COVID Exposures but who does not have any symptoms of COVID-19. Treat as described under COVID exposure section.

Minimally symptomatic (sometimes called paucisymptomatic)

Patients not meeting suspected or probable case definitions with one or more new symptoms of fever, cough, shortness of breath, nasal congestion, sore throat, or myalgias. When testing is limited and symptoms mild, these patients may be considered lower priority for testing, but if at all possible they should be tested.

Suspected*Avoid negative terminology such as “COVID suspect”. instead say “person [or patient] with suspected COVID-19”

Anyone who meets both the following criteria:

Clinical Criteria: Acute onset of fever AND cough

OR Acute onset of three or more of fever, cough, generalized weakness and fatigue, headache, myalgia, sore throat, coryza, dyspnea, anorexia/nausea/vomiting diarrhea, altered mental status

Epidemiologic Criteria: Residing in an area with high risk of transmission of virus OR traveling to areas with community transmission OR working in any health care setting within 14 days prior to symptom onset

OR

Anyone with severe acute respiratory illness within the last 10 days who requires hospitalization

Probable*

Any of:

  1. A patient who meets clinical criteria above and has a contact with a probable or confirmed case (or known cluster)
  2. A suspected case with convincing chest imaging consistent with COVID-19 disease
  3. A person with newrecent anosmia (loss of smell) or ageusia (loss of taste) in the absence of any other known cause for these

Confirmed*

A case that has been confirmed with laboratory testing, regardless of signs and symptoms. The exact testing methodology may vary, please see Testing. Most places use RT-PCR. Many countries include positive rapid antigen tests with a contact or strong clinical history for COVID-19

*These case definitions are based on the World Health Organization classification system

Algorithm for Case Definitions

This outlines a potential flow chart for defining confirmed, probable, suspected, and minimally symptomatic potential cases.

Clinical EvaluationCopy Link!

Updated Date: December 20, 2020

HistoryCopy Link!

When assessing a patient with possible COVID-19, ask the following:

  1. Date of Symptom Onset
  1. Patients typically worsen on Day 5-10 after symptom onset and develop acute respiratory distress syndrome (ARDS) at days 7-15 (see Time Course). Patients with severe symptoms before Day 5, or with any progressive dyspnea, require close monitoring as they are more likely to decompensate.
  1. Ask about any known exposure to SARS-CoV-2 or sick contacts in the past 14 days.
  2. Ask about household members:
  1. Does anyone have increased exposure to SARS-CoV-2 (e.g. working in healthcare, schools, stores, transportation, etc.)?
  2. Is there anyone at home to help monitor the patient?
  1. Dyspnea (Difficulty Breathing)
  1. Mild: Dyspnea that does not interfere with daily activities (e.g. just mild dyspnea with activities such as climbing 1-2 flights of stairs or walking briskly)
  2. Moderate: Dyspnea that limits daily activities (e.g. dyspnea that limits the ability to walk up 1 flight of stairs without needing to rest or that interferes with meal preparation or light housekeeping)
  3. Severe: Dyspnea so severe that it renders the patient unable to speak in complete sentences and interferes with basic activities such as toileting and dressing
  1. Mental Status and Function
  1. Has there been a decline or change in alertness, memory, behavior and attention? If so, this should prompt in person evaluation
  2. Patients with recent falls or near falls should be evaluated in person and receive an assessment for traumatic injuries
  1. Chest Pain/Tightness
  1. Evaluate patients with chest pain or tightness in person. While chest pain is a feature of COVID-19 pneumonia, the high rates of cardiac and thromboembolic complications may necessitate ruling out acute coronary syndrome (ACS) or pulmonary embolism (PE).
  1. Dizziness and Hypotension
  1. Assess for orthostatic symptoms, dizziness, mental status changes, or reduced urine output as signs of possible hypotension.
  1. Age and Comorbidities
  1. See Patients with Comorbid Diseases below
  2. Geriatric patients: Older adults are at increased risk of adverse outcomes and are more likely to present with atypical symptoms such as altered mental status, decreased appetite, non-focal pain

ExamCopy Link!

In addition to standard physical exam, pay particular attention to:

  1. Vital Signs. Patients with COVID manifest significant hypoxemia without any subjective difficulty breathing (Tobin et al). See also Pulse Oximetry.
  2. Pulmonary Exam:
  1. Assess for tachypnea, cyanosis and use of accessory muscles. If present, these suggest a patient is having difficulty breathing and needs close monitoring even if oxygen saturation is normal. Dyspnea does not always correlate with oxygen saturation (Shah et al). Tachypnea can also suggest acidosis and shock.
  2. Assess lung exam: although lung exam is often NORMAL even in patients with COVID-19 pneumonia, always listen to the lungs to evaluate for wheezing or crackles that would indicate other possible or additional cause of illness (e.g. asthma/chronic obstructive pulmonary disease (COPD)/congestive heart failure exacerbation).
  1. Leg and calf swelling:
  1. COVID-19 induces a hypercoagulable state, so always assess for deep venous thrombosis (DVT). Ultrasound with Doppler is the standard modality for diagnosing DVT. D-Dimer is not validated as a tool for stratification of DVT probability in COVID-19, given elevated D-dimers in patients in the absence of thrombosis.
  2. Increased swelling in one leg should prompt consideration of deep venous thrombosis, while increased swelling in both legs more often reflects fluid overload or congestive heart failure

Differential DiagnosisCopy Link!

Keep a broad differential diagnosis, both in patients suspected of having COVID-19 and in patients with confirmed COVID-19, given the many diseases that can mimic features of COVID-19 and the risk of secondary infections or sequelae.

Mimics: Other diseases that can cause symptoms mimicking COVID-19 include tuberculosis, malaria, bacterial pneumonia, congestive heart failure, chronic obstructive pulmonary disease, urinary tract infections, and gastrointestinal illnesses. Any of these diseases can also coexist with COVID-19.

Patients should be evaluated for alternative or coexisting diagnoses based on the local burden of disease, patient risk factors, and clinical presentation. Over the course of their treatment, if a patient’s condition or symptoms change, providers should consider whether the cause is due to COVID-19 or if another process is contributing.

Coinfection: Patients with confirmed COVID-19 commonly have concurrent secondary infections. Most studies on co-infection and secondary infection are done in high-income or upper-middle income countries; it is unknown if and how co-infection patterns vary in low-income countries

  • Viral coinfection depends on local epidemiology and season
  • Bacterial coinfection is not very common (~3%), secondary bacterial infection is somewhat more common (~7%). See Bacterial Infection)
  • Malaria, dengue and other tropical diseases can co-exist with COVID

Complications:

Patients with confirmed COVID-19 can also present with or develop a number of complications:

Disease Severity and DispositionCopy Link!

Updated Date: December 20, 2020
Literature Review (Emergency Department):
Gallery View, Grid View

The decision about severity of illness and where to admit varies considerably depending on the availability of beds, the location, and the patient’s resources to monitor and care at home. This is a general set of suggestions based on BWH, PIH, and WHO criteria, and should be adapted to local needs. In some settings, patients with severe or critical COVID may need to be transferred to facilities with higher-levels of care.

Tool: WHO Classification of Disease Severity (page 13)
Tool: PIH Algorithm for Initial Patient Assessment
Tool:
MEWS (The Modified Early Warning Score for Clinical Deterioration) can offer estimates based on vital signs of the probability of ICU admission or death, and has been validated in low-income settings as well (Kruisselbrink et al).

Severity

Mild

Moderate

Severe

Critical

Location

Home

Home or Inpatient

HDU, Step-down or ICU

ICU

Oxygen saturation

(If pulse oximetry is unavailable, monitor respiratory rate)

≥ 94% on room air (ambulatory ≥ 92%)

90-94% on room air (or ambulatory < 92%)

< 90% on room air

Meeting criteria for ARDS. Or needs O2 > 6 LPM to maintain SpO2 > 92% (or rapid escalation of oxygen requirement)

Respiratory Rate

12-22

Adults: 22-30

Children:

under 2 months: ≥ 60; 2–11 months: ≥ 50; 1–5 years: ≥ 40 (WHO)

Adults >30

Children: under 2 months: ≥ 60; 2–11 months: ≥ 50; 1–5 years: ≥ 40.

Variable depending on compensation

Blood Pressure and Heart Rate

BP > 90/60 (or not significantly lower than patient’s baseline)

BP > 90/60 (or not significantly lower than patient’s baseline)

Variable (depending on HDU criteria)

Adults: SBP < 90, MAP < 65, tachycardia, other signs of shock

Children: SBP < 5th percentile or >2 SDs below norm for age, HR <90 or >160 in infants, HR < 70 or > 150 in children, capillary refill > 2 sec

Clinical appearance

Reassuring

Variable

Adults: Concerning

Children: cyanosis, fast breathing, grunting, chest indrawing, inability to drink, lethargy, or convulsions

Adults: Concerning

Children: cyanosis fast breathing, grunting, chest indrawing, inability to drink, lethargy, convulsions, mottled or cool skin

Labs

No strict criteria

ABG with pH < 7.3 or PCO2 > 50 or above patient’s baseline, Lactate > 2

Other

Home isolation requirements are met

Need for intensive nursing care

It may not be within the goals of some patients to transfer to be hospitalized, to transfer to the ICU, or to be intubated.

Vitals and MonitoringCopy Link!

Updated Date: December 20, 2020
Tool: Normal vital signs by age
Tool:
Vitals signs monitoring framework

Pulse Oximetry: Please note that pulse oximeters are less reliable in patients with darker skin tones, and accuracy is improved by trending over time or using both resting and exertional measures. See Home Pulse Oximetry for more details.

We base these recommendations on the assumption of staff and equipment availability. These frequencies may need to be adjusted based on resource availability in different settings.

Severity

Mild

Moderate

Severe

Critical

Temperature Use lower fever criteria in immunocompromised or geriatric patients: one oral temp > 37.8C or two oral temps > 37.2C (IDSA criteria)

On initial assessment

Every 4 hours

At least every 4 hours

At least every 3 hours or continuously

Oxygen Sat, Respiratory and Heart Rate

On initial assessment

Every 4 hours

Continuous or as frequent as possible

Continuous or as frequent as possible

Blood Pressure (BP)

On initial assessment

Every 4 hours

Every 2-4 hours

Continuous, or every 5-15 minutes during resuscitation (30–60 minutes once stable).

Physical exam

On initial assessment

On admission & once a shift

Once a shift minimum

Every 30–60 minutes during resuscitation.Every 2–4 hours once stable.

Mental Status

On initial assessment

Every 4 hours

Every 2-4 hours

Continuous observation or intermittent, every hour

Intake & Output

Every shift

Every 4 hours

Every 1 hour

Chest X-ray

As needed

As needed

As needed

12-lead ECG

On admission and as needed

As needed

As needed

Telemetry

As needed for clear indication

Ideally continuous for all patients, otherwise as needed for clear indication

Lab MonitoringCopy Link!

Laboratory FrequenciesCopy Link!

Updated Date: August 19, 2021

The table below provides a summary of the laboratory monitoring at a well-resourced academic tertiary institution. Monitoring labs such as IL-6 levels will not be possible in most institutions, and excellent care can still be provided without these specialized labs.

Laboratory

On Admission

Trending

De-escalating (non-ICU)

CBC with Differential

Once

Daily

Daily

BMP

Once

Daily

Daily

Magnesium

Once

Daily

Daily

LFTs

Once

QOD*

Discontinue (if stable/improving)

CPK

Once

Trend only if abnormal or clinical decline

Discontinue (if stable/improving)

Troponin

Once

Trend only if abnormal or clinical decline

Discontinue (if stable/improving)

Nt pro-BNP

Once

Trend only if abnormal or clinical decline

Discontinue (if stable/improving)

D-Dimer

Once

QOD*

Discontinue (if stable/improving)

PT/INR

Once

ICU only: QOD*

Discontinue (if stable/improving)

Fibrinogen

Once

ICU only: QOD*

Discontinue (if stable/improving)

CRP

Hospital dependent (some use to risk-stratify for baricitinib or tocilizumab)

Hospital dependent

Discontinue (if stable/improving)

IL-6

Hospital dependent (some use to risk-stratify for baricitinib or tocilizumab)

Hospital dependent

Discontinue

Ferritin

Once, or provider discretion

QOD

Discontinue (if stable/improving)

Procalcitonin

Once

Provider discretion

N/A

EKG

Once

Provider discretion

N/A

*Note: Consider discontinuation on day 8 if patient status and lab values are stable or improving

If the patient is acutely worsening

  1. Redraw all admission labs above to assess the cause of the acute change, and include any other workup that may be needed (e.g. blood cultures, urine strep pneumo and legionella, chest x-ray, EKG)
  2. Resume the regular trending lab frequency with the exception of troponin and Nt-Pro BNP which can be discontinued as soon as downtrending

When lab availability is limited, this is an alternate lab schedule:

Laboratory

On Admission

During Admission

Evaluation of Clinical Worsening

CBC/FBC with Differential

Once

Every other day or twice a week

Once

Glucose

Once

Daily

Once

Electrolytes (Na, Cl, HCO3, K)

Once

Every other day or twice a week

Once

Magnesium

Once

Once

BUN/Cr

Once

Every other day or twice a week

Once

Liver function tests

Once

Once

LDH

Once

Once

CRP

Once

Once

D-dimer

Once

Once

Common Laboratory FindingsCopy Link!

Updated Date: May, 2020

Laboratory abnormalities are more frequent and significant in patients presenting with severe disease. Many of these are associated with more severe disease or death. (Arentz; Chen; Du et al; Guan et al; Young et al; Zhang et al; Zhou et al). Some common abnormalities in COVID patients include:

Interpretation:

  • Coagulopathy:
  • Elevations in PTT and/or INR can be a sign of coagulopathy (i.e. dysfunction in the body’s clotting system which leads to an increased risk of bleeding and increased risk of clotting). Suspect disseminated intravascular coagulation when platelets drop and D-dimer, PTT, and INR increase.
  • D-Dimer:
  • An elevated D-dimer in patients with COVID-19 is not always a sign of thrombosis, though it can be. Consider other signs and symptoms and use available diagnostic methods such as ultrasound and/or CT scan to further evaluate these cases.
  • Inflammation and Cytokine Storm:
  • Inflammatory labs such as D-dimer, LDH, CRP, and ESR are often elevated in patients with severe COVID-19, so if a previously stable patient deteriorates, check these. Cytokine Storm Syndrome, an inflammatory response that can lead to shock and multi-organ failure, should be considered if the following lab parameters are met (though some patients may not meet these cut-offs):
  • CRP >50mg/L
  • And at least two of the following:
  • Ferritin >500 ng/mL
  • LDH >300 U/L
  • D-dimer >1000 ng/mL

ImagingCopy Link!

Updated Date: December 20, 2020
Literature Review (CT and Chest X-Ray):
Gallery View, Grid View
Literature Review (Ultrasound):
Gallery View, Grid View

Chest X-rayCopy Link!

Chest x-ray can help identify alternate causes of shortness of breath. Some chest x-ray findings can suggest a diagnosis of COVID-19. Normal chest x-rays do not rule out COVID: Chest X-rays may be normal in up to ~30% of COVID patients requiring hospitalization, particularly in early disease (Wong). Sensitivity 59% in one study, as compared to 86% for CT scan (Guan).

Low-risk patients with mild symptoms and confirmed PCR testing do not routinely need chest imaging. Most patients with Findings of COVID-19 Pneumonia can safely be managed at home unless clinically unstable, at high-risk of decompensation, or with pneumonia involving >50% of lung parenchyma. Where possible, portable chest X-rays are usually sufficient and require less personnel.

Consider chest x-ray in these circumstances:

  1. High clinical concern for concomitant lobar pneumonia, CHF, TB, or other etiology that could be discovered on plain film.
  2. Patients with oxygen saturation < 92% on supplemental oxygen, increased work of breathing, or new decompensation to rule out new or secondary causes
  3. High clinical suspicion but negative PCR testing (patient could have a false negative test or have been tested too early in the course).
  4. Sudden clinical change in a known COVID patient
  5. To check critical care interventions (line and endotracheal tube placement)

Tool: BWH Guide on Radiology in COVID and Guidance for Radiologists

CT ScanCopy Link!

CT scan plays no role as a screening test for patients for COVID-19, for either diagnosis or exclusion (Simpson).

CT can be used if there is a concern for other pathology. Consider CT in these circumstances:

  1. High clinical suspicion for pulmonary embolism (angiogram contrast scan)
  2. High clinical concern for concurrent abscess, empyema, loculated effusion, significant hemoptysis, pneumomediastinum, etc or if clinician feels it would substantively change management

Tool: BWH Guide on Radiology in COVID and Guidance for Radiologists

Tool: Radiopedia on COVID

UltrasoundCopy Link!

Serial ultrasound is showing promise as a low-cost method to assess disease progression. Although ultrasound findings in COVID-19 have been shown to correlate with CT scan results, the false negative rate of ultrasound is not currently known (Zani et al). A standardized approach using 12 designated zones has been proposed and is strongly recommended to allow for serial comparison (Kruisselbrink et al; Convissar et al).

Tool: POCUS 101 Complete Guide to Lung Ultrasound

Patients with Comorbid DiseasesCopy Link!

Updated Date: December 20, 2020

Patients with chronic conditions have specific risks and needs related to COVID-19 diagnosis, treatment, and social support (e.g. to allow safe isolation/quarantine if needed.) Patients with diabetes, hypertension, heart disease, and obesity have been shown to have higher rates of hospitalization and severe illness due to COVID-19. (See Prognostic Indicators)

Relevant comorbidities are covered in greater detail in different chapters, and include the following:

  • Immunosuppressed patients may have atypical presentations of COVID-19 (e.g no fever). Patients with HIV who present with respiratory symptoms should be evaluated for TB in addition to COVID-19 as clinically indicated.

Management of existing medications is an important consideration in these patients. These medications are discussed in Treatments for Comorbid Diseases and may include the following.

  • ACE inhibitors
  • Immunosuppressants
  • Nonsteroidal anti-inflammatory drugs
  • Steroids
  • Inhalers

Interfacility TransferCopy Link!

Updated Date: January 11, 2021

Reasons to transferCopy Link!

There are many potential reasons to transfer a COVID19 patient to another facility including:

When deciding whether or not to transfer, consider:

  1. Resources and specialty service availability: What resources are currently needed or will soon be needed for patient care? Are those resources available at the current facility? Are they available at the receiving facility? Consider specialized and subspecialized services such as critical care, OB/GYN, pediatrics/neonatology, and surgical specialty teams.
  2. Receiving facility capacity: Does the receiving facility have sufficient capacity to accept the patient? Receiving facilities that may normally be able to accept transfers may be overburdened as a result of the COVID-19 pandemic. Prior to transfer, the receiving facility should be contacted to discuss the transfer and verify that they have adequate resources and space to accept the transfer.
  3. Patient goals of care: What are the goals of care for the patient and family, and how does transfer fit within those goals? For example, unless there is another reason for transfer, a patient who does not want intubation and mechanical ventilation may not benefit from transfer to a facility where these services are available
  4. PPE availability: Is adequate PPE available for transfer, and at the receiving facility?
  5. Stabilization: Has the patient been stabilized as much as is reasonably possible at the current facility, or do the benefits of transfer outweigh the risks? For example, if a patient is currently at a facility without surgery capacity or the ability to perform blood transfusions, it may not be possible to fully stabilize a patient with an intra-abdominal hemorrhage and the patient may need to be transferred while still unstable. Patients should always be transferred with medications and supplies needed for ongoing treatment en route.

Stabilization Prior to TransferCopy Link!

A full discussion on stabilization for transfer is beyond the scope of this site. For the transfer of COVID19 pneumonia patients the top concern is generally is the amount of oxygen required by the patient safe for transport and whether to intubate prior to transfer. This is especially true as patients considered for transfer often have a rapidly worsening trajectory and are at high risk for deterioration.

Whether to Intubate Prior to TransferCopy Link!

Intubation should not be done if it is not indicated (see Candidacy for Intubation). Intubation carries risks, especially in certain patients (e.g. patients with right heart failure or a difficult airway). The decision about whether to intubate prior to transfer should balance risks and benefits and take into consideration the following questions:

  1. Is the patient likely to require intubation en route?
  1. Consider the current clinical status of the patient (including work of breathing, vital signs, and mental status).
  2. Consider what the projected clinical course for the patient is over the time it will take for them to arrive at the receiving facility.
  1. If a patient is rapidly worsening (including a rapidly escalating oxygen requirement), intubation may be appropriate before departure regardless of transport time.
  1. If a patient is slowly worsening, but does not currently warrant intubation, transport without intubation may be appropriate if transport time is brief, while intubation prior to transfer may be needed if transport times are prolonged
  1. Is safe intubation feasible at the transferring facility? Is the transporting team able to perform a safe intubation? If neither is possible, maximize oxygen and other respiratory support (such as non-invasive ventilation, if available) for transport.
  2. Is emergent intubation possible during the transfer? Intubation during transfer may not be possible or may be higher-risk depending on provider training, vehicle space and layout, equipment available, and road conditions during transport. If emergent intubation during transfer would be difficult or impossible, intubation prior to transfer may be indicated.
  3. Are there conditions that would make emergent intubation challenging? If so and there is possibility the patient may need intubation en route, early intubation in a controlled setting prior to transfer may be preferred. This is particularly relevant if there is:
  1. Known or suspected difficult airway. Challenging airways are always difficult to manage in emergent situations, and even more so during transport when equipment is limited.
  2. Hemodynamic instability. Unstable patients are difficult to intubate under controlled circumstances and even more challenging to manage during an emergent intubation during transport.
  1. What is the capacity for monitoring, sedation and ventilation available during transport?
  1. Consider the level of training of personnel accompanying the patient, and the availability of battery-powered transport ventilators versus need for bag-valve mask ventilation during transport.
  2. In settings where transport of ventilated patients is uncommon, ensure that transport ventilators can connect to the available oxygen canisters. Ensure all ventilators have sufficient back up electrical supplies, and that providers are trained to bag patients as a back up.
  3. When transport resources are limited, it may be necessary to send trained medical staff with the patient to manage advanced equipment.
  4. In settings where monitored transport is not possible and where medical staff cannot accompany the patient, risks and benefits of intubation prior to transfer should be carefully weighted, as a dislodged endotracheal tube or an accidental disconnect of a ventilator can be fatal.
  1. Can the receiving facility manage an intubated patient? It is important that the receiving facility has the capacity and resources to manage an intubated patient. Capacity may fluctuate depending on patient volume at the receiving facility.
  2. Is the patient nearing the limits of oxygen delivery capability of the transport system? See below for specifics on air transport. Generally, mechanical ventilation for intubated patients consumes less oxygen supply than non-intubated patients on oxygen delivery devices with high oxygen flows (e.g. high flow nasal cannula or CPAP/BIPAP with a significant leak).

Calculating Transport Oxygen NeedsCopy Link!

Non-intubated patients on oxygen delivery devices with high oxygen flows (e.g. high flow nasal cannula, non-rebreather facemask, CPAP/BIPAP/NIPPV) may rapidly exhaust or exceed the available oxygen supply during transport. This can be life threatening.

  1. Calculate total oxygen demand in advance. For example, for an 8-hour transport time, a patient on a non-rebreather facemask at 15 liters per minute will require either 2 portable oxygen concentrators (may vary depending on device output) and a reliable portable power generator, or two full J cylinders (See Oxygen Cylinder Duration Calculator).
  2. Factor in a buffer in case oxygen demand increases, or the trip is longer than expected.
  3. Make sure there is at least one power backup for electrically-powered delivery devices.

Additional air transport needs: During air transport barometric pressure drops, while FiO2 stays constant. The result is less partial pressure of oxygen delivered to the alveoli and the volume expansion of any trapped gas. This can precipitate the deterioration of a patient in two ways:

  1. Worsening hypoxia at altitude. Pressurized aircraft are generally maintained at the equivalent of 5000ft (~1500m) to 8000ft (~2500m) above sea level. This is roughly the equivalent of three quarters of the oxygen delivered at sea level that is delivered in each breath. The effective altitude during transport should be accounted for when estimating oxygen needs during transport. At higher effective altitudes more oxygen will be required and less potential oxygen can be delivered than at sea level (i.e. a patient on requiring 100% FiO2 with an SpO2<100% at sea level, will desaturate when brought to altitude).
  2. Air transport can lead to expansion of gas in body cavities and can lead to pneumothorax or tension pneumothorax. Providers should be trained to recognize tension pneumothorax and perform a needle decompression if needed.

Other Factors that May Affect Transfer DecisionsCopy Link!

Factor

Recommendation

High levels of support from noninvasive ventilation with depressed level of consciousness, marginal oxygenation, tachycardia or hypotension

Consider intubation before transfer

Severe, uncorrected, electrolyte disorders

Evaluate risk of delaying transfer to correct versus starting correction and continuing to correct en route or at receiving facility

Severe obesity that cannot be accommodated in transport bed and vehicle

Consider alternate means for transfer

Unable to tolerate supine position for duration of transport

Assess if transport can be safely done in a manner tolerable to patient, including in seated position

Use of accessory muscles for spontaneously breathing patients

Consider increasing oxygen delivery or respiratory support before transfer

Receiving facility unable to provide higher level of care

Look for a different receiving facility

Receiving facility does not have available PPE or cohorting capacity for droplet and airborne transmission.

Look for a facility that has COVID care capacity

Transport team does not have adequate PPE

Transferring Facility may give PPE to transit team if possible, or alternative transport team can be selected

Pneumothorax without a chest tube

Place the chest tube prior to transit if clinically indicated and can be safely done at the transferring facility (may not be for all pneumothoraces). If the chest tube is not placed, ensure the patient transferred with trained personnel equipped for needle decompression in case of sudden worsening.

Severe hemodynamic instability

Support hemodynamics as much as possible with medical interventions; anticipate potential worsening en route and ensure transport team equipped with medications and materials as needed to address ongoing instability

Patient or family opposed to transfer

Follow guidance about patient’s Rights to Refuse Recommended Care

Futility with extremely poor short-term prognosis

Discuss goals of care with family to decide on if transfer is consistent with goals of care

Pregnancy at greater than 22 weeks gestation age without adequate obstetrics and pediatrics care available at the receiving facility

Seek a facility that has this capacity. If none is available, transfer to the location that optimizes maternal and then fetal welfare

Lack of access to a transport team capable of safe transport

Consider sending staff from the transferring facility to accompany and treat the patient en route.

Inadequate portable oxygen supply for patient’s needs

Try to obtain

Inadequate power supply for equipment

Try to obtain; assess what the minimum necessary equipment is

Tool: Tools for Interfacility Transfer and Documentation (OCC)

Tool: Interfacility Transfer Checklist

Tool: IPC Guidelines for Interfacility Transport Without Ambulance Systems (PIH)

Tool: Algorithm for COVID-19 Triage and Referral by WHO

Tool: Medical Transport Accreditation Standards, 11th Edition by Commision on Accreditation of Medical Transport Systems