Brigham and Women's Hospitals

Ambulatory, ED, and Floor Management

Updated: August 19, 2020

Biothreats and Infection Control Contacts

  1. Inpatient COVID flag or precaution review/removal
  1. See Testing and Infection Control Guidelines (Partners login required)
  2. Flags can now be removed by providers with the help of an EPIC integrated decision support tool - instructions here
  3. Questions can be directed to the COVID Flag Management pager at p39635 (available 7 AM-10 PM; please only page after 10 PM for urgent bed flow issues that require a flag change)
  1. Inpatient and Outpatient Infection Control questions
  1. See Testing and Infection Control Guidelines (Partners login required)
  2. Page Infection Control at p11482 (available 8 AM-8 PM; please only page after 8 PM for emergencies) for questions regarding special precautions
  3. Bed flow questions/problems for inpatients related to COVID-19: Page COVID Nurse Administrator at p39284
  4. The biothreats pager has been retired. Please page Infection Control with questions.
  1. Inpatient Clinical questions about COVID
  1. For patients with COVID or suspected COVID who need ID input, please page the general ID consult pager.
  2. The COVID Clinical pager has been retired. Please direct all COVID clinical pages to the ID consult pager.
  1. Outpatient Clinical questions about COVID
  1. See Ambulatory content below, or place an Infectious Diseases e-consult

Case Definitions, Clearance, and Return to Work

Case Definition

  1. Currently BWH defines four statuses:
  1. SARS-CoV-2: COVID-19 (also referred to here as “confirmed”)
  1. Individuals who have tested positive for COVID-19 (either through NAAT or in select cases serologic testing)
  1. Presumed-CoV (also referred to here as a “Person Under Investigation” or PUI)
  1. Individuals with symptoms consistent with COVID-19 without positive NAAT to confirm.
  1. CoV-Risk (also referred to here as a “Person Under Investigation” or PUI)
  1. Individuals with symptoms consistent with COVID-19 and undergoing evaluation; some may have one or more negative test results, but interpretation of results is not complete or suspicion of infection persists.
  1. CoV-Exposed
  1. Asymptomatic individuals with known exposure to COVID-19.

Case Clearance and Return to Work

  1. Prolonged RT-PCR positivity is well documented but evidence indicates it does not correlate with ongoing infectivity, discussed in more detail in Clinical Course and Epidemiology: Transmission. Infectivity drops to near zero at approximately 10 days after symptom onset and 3 days after symptom resolution (CDC). The CDC and Partners’ guidance reflect this data with slight differences noted below.
  2. CDC Recommendations
  1. In the home setting, patients recovered from COVID-19 should be maintained in isolation for at least 10 days after illness onset and 3 days after recovery (whichever is longer).
  2. A test-based strategy can be used for recovered persons for whom there is low tolerance for virus shedding and infectious risk (e.g, working in healthcare facilities, residing in congregate living facilities, immunocompromised, etc).
  1. MGB COVID-19 resolution criteria
  1. Outpatients not requiring hospitalization/Employees for return to work:
  1. 14 days after symptom onset + 1 day after symptom resolution (defined as resolution of fever without the use of fever-reducing medications, and resolution of COVID-related symptoms or return to previous baseline)
  2. Note that this differs from 10 days as recommended by CDC and Massachusetts Department of Public Health. Note that MDPH recommends 14 days for return-to-work criteria for staff who care for immunocompromised patients. Since so many of the patients at BWH and Partners are immunocompromised, our 14 day rule deals with this caveat in a consistent manner.
  1. Severely immunocompromised outpatient:
  1. Defined by the CDC as patients on chemotherapy for cancer, untreated HIV infection with CD4 T lymphocyte count < 200, combined primary immunodeficiency disorder, and receipt of prednisone >20mg/day for more than 14 days
  2. 20 days after symptom onset (+ 1 days after symptom resolution)
  1. Previously hospitalized patients:
  1. This has not been clearly defined. A reasonable approach to consider would be: 14 days post-discharge, which generally translates into several weeks after symptom onset
  1. Currently hospitalized patients:
  1. Test based resolution: 10 days since first positive test + 1 day after symptom resolution + at least 2 negative PCR swabs
  2. Time based resolution: 30 days since first positive test + 1 day after symptom resolution
  1. See the latest Partners policy on infection status resolution (Partners login required)

Personal Protective Equipment and Transport

Personal Protective Equipment

  1. Partners PPE Guidance (Partners login required)
  1. There are location-specific differences (e.g., Shapiro SP-ICU versus Tower ICU COVID testing) in place, so refer to your location guidelines.
  2. Easy to read “grid” summarizing PPE here (Partners login required)
  1. Guidance for Aerosol Generating Procedures (Partners login required)
  1. Strict isolation (aerosol) PPE (including N95 masks) are needed during and for 47 mins after these procedures. This now includes all patients, not just COVID confirmed or PUI. These should be preferentially performed in negative airflow rooms:
  1. Intubation
  2. Extubation
  3. Bronchoscopy
  4. Sputum induction
  5. Cardiopulmonary resuscitation
  6. Open suctioning of airways
  7. Manual ventilation (e.g. manual bag- mask ventilation before intubation)
  8. Nebulization
  9. High flow oxygen therapy (15-60 L nasal cannula or mask)
  10. Non-invasive positive pressure ventilation (e.g., CPAP, BIPAP)
  11. Oscillatory ventilation
  12. Disconnecting patient from ventilator
  13. Upper airway procedures / surgeries
  14. Upper endoscopy (including transesophageal echocardiogram) and lower endoscopy
  15. Chest physical therapy
  16. Autopsy
  17. Thoracentesis/small-bore (pigtail) chest tube placement (due to the increased risk of cough)
  1. Personal Protective Equipment Donations
  1. BWH accepts donations of PPE or targeted funding for PPE
  1. ICU Strict Isolation Manual
  1. Step-by-step protocols for working in COVID-19 precaution patient rooms (e.g., transporting a patient, lab draws, micro testing like COVID-19 swab, sterile procedures like central venous catheters)

Transport

  1. Patient Transport Policy (Partners login required)
  1. Please review policy before transport
  1. Remember to communicate with the receiving department and technologists that the patient is COVID-19 positive or PUI. Patient should wear a surgical mask (or bacterial filter if intubated) and be covered with a sheet.

Visitors

  1. BWH Visitor Policy (public site)
  1. Partners Visitor Policy contains additional details (Partners login required)
  1. Presently one visitor per day is allowed for most inpatients
  2. Visitors with outpatients are not allowed with adult patients, unless they have a medical need for an assistant or guardian. Providing a letter stating medical need prior to the visit can be very helpful if needed.

Information for Patients

  1. Basic information about coronavirus can be found on the Partners COVID-19 page.
  2. COVID-19 Communication guide from Vital Talks and Ariadne Labs
  3. PCOI handouts: English, Spanish, Portuguese, Arabic
  4. CDC How to protect yourself and others
  5. CDC What to do if you are sick
  6. CDC Daily Life and Coping
  7. CDC People who need to take extra precautions

Ambulatory Clinic Workflow

COVID Screening

  1. Prior to in-person ambulatory visits, patients are screened for symptoms consistent with active COVID-19 infection or known COVID-19 infection. This screen is repeated on the day of a clinical visit when the patient enters a clinical care space.
  2. If a patient has no symptoms, he or she can complete the visit under routine precautions, including universal mask policy.
  3. If a patient has symptoms consistent with COVID-19 or has confirmed COVID-19 infection then options include:
  1. Deferring care (if reason for visit is unrelated to COVID) until clearance of the patient’s COVID status (Partners login required)
  1. Ensure timely follow-up for COVID symptoms with Primary Care or other provider if you are unable to assess
  1. Providing virtual care (see below) and obtain testing
  2. Performing the visit if your clinic has the capacity to treat COVID +/ enhanced respiratory precautions patients
  3. Refer patient to the Emergency Department if indicated
  1. Resources:
  1. Ambulatory Guidelines for In-Person COVID+ or Viral Illness Patient Visits
  2. COVID-19 Practice Operations Checklist

Screening Questions

  1. Patients are asked the following screening questions before their visit AND at the time of check in for all ambulatory visits (specific clinics may have variations):
  1. Do you have any of the following new symptoms (If yes, please note date symptoms began):
  1. New Fever, new cough, sore throat, runny nose or nasal congestion, shortness of breath, muscle aches, loss of sense of smell or taste.
  1. Have you been tested for COVID-19 outside Partners Healthcare (MGB)?
  1. If “yes”, when was the test and what was the result
  1. Have you spent at least 10 minutes within 6 feet of anyone with confirmed COVID-19?
  1. If “yes,” when was the most recent date this occurred?
  1. Are you, or a household member, currently on home isolation or home quarantine?
  2. Are you currently in quarantine, following the state’s recommendation for recent travel (MA Travel Order)?
  1. If “yes,” where did you travel, when did you return, and what is the expected end date of quarantine?

Ambulatory Evaluation of patients with COVID symptoms

  1. Determine where the patient should be seen and tested
  1. All patients who screen positive through the outpatient symptom-based screening process or who call providers with symptoms of COVID should get PCR-based testing. See Diagnostics for more information about testing modalities, and the Partners COVID Testing Criteria for up-to-date testing criteria (Partners login required).
  1. Mild symptoms: arrange Virtual Visit and order COVID-19 PCR test. Open Telephone Call, complete COVID-19 triage, and order PCR test. Detailed instructions here.
  1. Suggested criteria include any of:
  1. Pulse oximetry >95% in low or average risk patient
  2. Mild symptoms, excluding SOB or Chest Pain, in low risk patient
  1. Moderate, progressive symptoms or comorbidities associated with higher risk for severe illness should have a timely in-person evaluation in an ambulatory clinic.
  1. Suggested criteria for moderate include any of:
  1. Pulse oximetry between 90-95% in a low risk patient
  2. Dyspnea limiting usual ADLs in a low risk patient
  3. Any dyspnea or pulse oximetry 90-97% (if available) in a high risk patient
  1. Severe symptoms should be sent to the ED or directly admitted (requires admitting privileges, call Admitting x27450 to see if beds available; discuss with admitting service attending).
  1. Suggested criteria for severe include any of:
  1. Pulse oximetry less than 90%
  2. High risk patients with pulse oximetry less than 95% or moderate dyspnea
  3. Severe dyspnea with inability to speak in complete sentences
  4. Mental status changes
  5. Objective hypotension or orthostatic symptoms not responsive to oral fluid repletion
  6. Chest pain

Virtual Care and Outpatient Testing Sites:

  1. Remote evaluation of COVID-19 is challenging as progressive hypoxemia can occur rapidly, sometimes in patients with minimal symptomatology. It is important to evaluate both the duration of illness and trajectory of current signs/symptoms. Maintain a low threshold for referral to the ED or clinics for pulse-oximetry and in-person evaluation.
  2. Virtual Visit Resources:

  1. Virtual care options are described here; visits can be conducted from clinic or from home.
  2. Virtual visit training, tools and billing questions are answered here. (Partners login required)
  1. Additional tips for successful virtual visits are found here. (No login required)
  2. Order testing via an Epic telephone visit. See Ambulatory Epic Test Ordering Tip Sheet (Partners login required) at any of the testing-only locations.
  1. Testing can be performed as drive-through or walk-up. Both require a scheduled appointment, which will be made by the testing site after the order is placed
  2. See Partners list of testing locations. (Partners login required)
  1. Remote symptom evaluation:
  1. Dyspnea and hypoxemia
  1. If home pulse oximetry is available, have the patient measure their oxygen saturation. Patients with hypoxemia (oxygen saturation < 95%) should be evaluated in-person.
  2. No evidence-supported remote measure of hypoxemia is yet available. Strategies that may help risk-stratify patients include:
  1. Establish trajectory of dyspnea. Studies of hospitalized patients indicate that dyspnea, when it occurs, develops 5-8 days into symptomatic illness, with ARDS at 8-12 days. (CDC, accessed June 16, 2020) Thus, a patient with progressive dyspnea, particularly early in the course of symptoms, requires very close follow up.
  2. Assess whether dyspnea interferes with activities of daily living
  3. The Roth Score has been cited as a tool to help assess oxygenation virtually. However, institutions like the Centre for Evidence Based Medicine advise against using this tool as it could leave the provider with false reassurance.
  4. Assess for tachypnea, cyanosis and use of accessory muscles
  1. Mental status and function:
  1. Decline in change in alertness, memory, behavior and attention should prompt in-person evaluation.
  2. Patients with recent falls or near falls should be evaluated in-person
  1. Chest pain:
  1. Should prompt in-person evaluation in ED. While described extensively as a feature of COVID pneumonia, the high rates of cardiac and thromboembolic complications necessitate rule outs for ACS and PE
  1. Dizziness and hypotension:
  1. Assess for orthostatic symptoms, dizziness, mental status changes, reduced urine output as signs that blood pressure may be reduced.
  2. Ask patient to use a home BP cuff if available
  1. Leg and calf swelling:
  1. This should prompt evaluation for VTE as both arterial and venous clots are seen in COVID infection
  1. Fever:
  1. Very high fevers should prompt discussion of oral intake and whether the patient is able to keep up with insensible losses

In Person Evaluation

  1. Quick survey patient’s need for ED transfer:
  1. Always start with Pulse Ox as this is the most important indicator of current severity
  1. If rest SpO2 ≤94%, consider transferring to ED
  1. If rest SpO2 ≤96%, ambulate and if SpO2 ≤92% consider transferring to ED
  1. Assess RR and ability to speak in full sentences. Even if SpO2 stable, tachypnea can be precursor to decompensation, close monitoring in ED may be warranted.
  1. HPI:
  1. Determine the day symptoms started. Decompensation typically takes place Day 5-10 of symptom onset. Patients with severe symptoms before Day 5 require very close monitoring as they are more likely to decompensate.
  1. Ask about household members
  1. Household members at higher exposure to COVID-19 (healthcare, grocery)
  1. Who is at home that can help monitor patient if they decompensate?
  1. Exam:
  1. Degree of subjective dyspnea does not always correlate with SpO2%
  1. Lung exam is often NORMAL even in patients with COVID-19 pneumonia.
  1. COVID-19 is hypercoagulable, assess for LE edema/DVT

Outpatient Workup

  1. Consider EKG for most patients with chest pain.
  1. COVID-19 syndrome can mimic non-COVID etiologies; keep DDx open!
  1. Consider CXR for most patients with any respiratory symptoms.
  1. COVID-19 pneumonia can be present with negative PCR testing
  2. COVID-19 syndrome can mimic non-COVID etiologies; keep DDx open!
  3. Low-risk patient with mild symptoms do not routinely need CXR
  4. Most patients with CXR findings c/w COVID-19 pneumonia can safely be managed at home clinically unstable, high risk of decompensation, or PNA >50% of lung parenchyma
  5. Outpatient Chest CT to evaluate for COVID-19 pneumonia is discouraged
  1. Consider labs in higher risk patient and patients with moderate-severe symptoms
  1. CBC w/ diff, BMP
  2. Consider labs associated with Severe COVID-19 Illness (CRP, D-Dimer) with the caveat that the interpretation of D-Dimer in acute illness is challenging and relatively data free
  3. CRP >100 has been associated with severe illness (UpToDate)
  4. D-Dimer >1,000 has been associated with severe illness (UpToDate)
  5. We caution reflexively ordering CTPA in acute-phase illness

Ambulatory COVID Management

Outpatient COVID-19 Treatment:

Outpatient treatment options continue to be supportive, including:

  1. Antipyretics
  1. Either acetaminophen or NSAIDs are appropriate if there are no contraindications. For further detail, see Therapeutics: NSAIDs
  1. Short-acting beta agonists
  1. May be helpful for reactive airways in patients with underlying asthma or COPD, but otherwise not routinely indicated
  2. Use metered-dose albuterol inhalers whenever possible given the risk of aerosolization with nebulizers.
  1. If patients are unable to use these, it is reasonable to use nebulized therapy, ideally alone in a room with a closed door
  1. For further detail, see Therapeutics: Bronchodilator Therapy
  1. Expectorants
  1. Guaifenesin or other expectorants may be helpful, particularly for patients with difficulty clearing thick sputum
  1. Thrombosis prevention
  1. Arterial and venous thrombotic complications of COVID are now well documented. We do not recommend routine use of aspirin or anticoagulants in COVID-19 among ambulatory individuals without another indication outside of a clinical trial
  1. Recommend encouraging frequent ambulation to reduce DVT risk in ambulatory patients
  1. Self-proning
  1. The prone position improves dyspnea and hypoxemia in some patients with severe COVID. Proning could be used while awaiting ambulance transfer or as part of terminal palliation
  1. Vitamin Supplementation
  1. There is currently no evidence to recommend the use of vitamin supplementation for COVID prevention or treatment in the outpatient setting. For more information see the Therapeutics sections on Vitamin C and Zinc.

Other Medication Considerations

  1. Angiotensin Converting Enzyme Inhibitors (ACEI) and Angiotensin II Receptor Blockers (ARB):
  1. In line with guidance from the American Heart Association, American College of Cardiology, and Heart Failure Society of America, we recommend against discontinuing ACEIs/ARBs in the outpatient setting.
  2. For further detail, please see Therapeutics: ACEIs and ARBs.
  1. Non-steroidal anti-inflammatory drugs (NSAIDs)
  1. We recommend against discontinuing NSAIDs in patients who use them chronically.
  2. For further detail, please see Therapeutics: NSAIDs.
  1. Immunosuppressive agents:
  1. The role of immunosuppressive medication in COVID-19 risk is complex, and discussed in more detail in Immunosuppressed Patients.
  2. Continuation of these agents in the setting of COVID-19 disease should be addressed on a case-by-case basis with the primary prescriber and/or appropriate subspecialist.
  1. Inpatient medication considerations/awareness: There are now effective therapies that can be used in the inpatient setting. Ambulatory providers should be aware of these therapies so they can refer patients appropriately (such as those that are worsening) so they can benefit from these treatments. At this time, the use of these treatments in the outpatient setting is likely not appropriate and may delay needed hospital level care.
  1. Antiviral therapy
  1. Remdesivir, an intravenous RNA polymerase inhibitor has been shown to improve clinical recovery among inpatients with COVID (discussed in more detail in Therapeutics: Remdesivir), but is not available for outpatients
  2. Benefit appears greatest when started promptly after development of hypoxemia (oxygen saturation < 95%), so consider early referral for inpatient management in high risk patients
  3. Trials of other direct-acting antivirals are ongoing and upcoming (see Rally).
  1. Anti-inflammatory and immune modulating therapy
  1. We do not recommend routine use of corticosteroids in outpatients with COVID-19. A recent unpublished study shows that corticosteroids may be beneficial in hospitalized patients with severe or critical COVID-19. This evidence is discussed in more detail in Therapeutics: Corticosteroids. However, the use of corticosteroids has not been studied in outpatients, who would not meet enrollment criteria for this study. If indicated for other reasons, such as asthma or COPD exacerbation, corticosteroids should not be withheld.
  2. Hydroxychloroquine (discussed in more detail in Therapeutics: Hydroxychloroquine) does not have any known benefit in the outpatient management of COVID. Trials of hydroxychloroquine for prevention and for treatment of hospitalized COVID did not demonstrate any clinical benefit and suggested increased adverse events. We do not recommend use of hydroxychloroquine outside of a clinical trial.
  1. Other agents
  1. Multiple other agents including azithromycin, ivermectin, vitamin C, and zinc have been suggested for use in COVID-19 outpatients, though no evidence supports their use. We do not recommend use of these agents outside of a clinical trial.

Isolation and Follow-Up

  1. Isolation Counseling
  1. Stay up-to-date with evolving CDC guidance and PHS return to work policies!
  2. All COVID-19 PUI should follow strict isolation precautions at least until results return within 24 hours.
  1. If PCR is negative but there is high clinical suspicion for COVID-19, consider following isolation guidance as if the test resulted positive, given known false-negative rate
  1. Suggested frequency of Virtual Visits:
  1. Routine follow up for low risk patients: Day 5 of symptoms
  2. Routine follow up for high risk patients : Day 4, 7, and 10 of symptoms
  1. More frequent follow up may be needed for patient with particularly high risk, concerning symptoms, or concerns about reliability
  2. Instruct patients to call if worsening or new symptoms
  1. Post Hospital Discharge follow-up: 2 days
  2. High risk patient and/or patient with severe symptoms: remain low threshold to request in-person reevaluation to monitor SpO2
  3. Specific clinical questions can be directed to Infectious Diseases through e-consult as needed

Healthcare proxy designation

  1. For all patients with COVID a goals of care conversation and a healthcare proxy form should be completed (regardless of age, comorbidity, severity, and virtual vs in-person visit)
  1. Tips for completing HCP and MOLST forms
  2. Health Care Proxy form

Reducing household transmission

  1. COVID-19 patients should be recommended to self-isolate at home to the extent possible, to reduce risk of infection of other household contacts.
  1. Housing on a separate room or floor, if possible
  2. Using separate bathroom, if possible
  3. Maintaining 6 foot distance from other household contacts
  4. Masking when around other individuals in the household
  5. Cover coughs and sneezes
  6. Frequent hand hygiene
  7. Avoid sharing household items, such as dishes or silverware
  8. Clean “high-touch” surfaces with a household disinfectant daily
  1. For additional information on masks, social distancing, pets, and more see Transmission
  2. Contact tracing:
  1. Recommend that patients advise their close contacts to get tested
  2. For patients with positive test results, the BWH lab automatically notifies the DPH; the DPH conducts contact tracing.

Ambulatory COVID Exposure Management

  1. Patients may call for counseling about COVID exposure risks. Carefully assessing the context of possible exposures is important to minimize anxiety of lower-risk exposures and identifying higher-risk exposures to prevent onward transmission.
  2. Definition of COVID exposure
  1. By CDC criteria, a person is considered infectious:
  1. If symptomatic, from 2 days before symptom onset until meeting criteria for discontinuing isolation.
  2. If asymptomatic, from 2 days before date of positive test until meeting criteria for discontinuing isolation.
  1. An exposure is defined as being within 6 feet of a known COVID+ person for greater than 15 minutes.
  2. Using a similar exposure definition, investigators found 13% of exposed individuals subsequently developed COVID-19 (Boulware et al, NEJM, 2020)
  3. Features that likely increase transmission risk including: actively cough/sneezing, close proximity, confined indoor spaces, and physical contact with individual or shared objects.
  4. Contacts that occur outdoors and/or with both individuals wearing masks should be likely be considered as low risk.
  1. Recommended isolation precautions
  1. COVID-exposed people should self-isolate at home and maintain 6 feet distance from other individuals.
  2. They should avoid exposure to individuals at high risk of severe COVID disease.
  3. Symptoms should be self-monitored throughout this time and prompt testing following development of symptoms.
  4. Duration of isolation is 14 days from time of last exposure.
  1. Prophylaxis
  1. At this time, there are no known effective pre- or post-exposure prophylaxis for COVID-19.
  2. A large trial of hydroxychloroquine as post-exposure prophylaxis demonstrated no benefit and increased risk of self-reported adverse events in the treatment arm. (Boulware et al, NEJM, 2020)

Ambulatory Care of the Recovered COVID Patient

  1. Recommendations for after care/monitoring is being developed.
  2. Plasma Donations from Recovered Patients - can be given through the Red Cross

Emergency Department Protocols

  1. ED Assessment Algorithm
  1. This includes screening, patient and provider PPE, rooming, testing
  1. ED Disposition Algorithm
  1. This includes decision to discharge, monitor, admit to Special Pathogens Unit, or admit to ICU
  1. EMWeb (Specific access required, limited to ED personnel)
  1. This is shared protocols and documents specific to the emergency department
  1. ED Discharge Planning Tool
  2. ED Intubation Protocol
  3. ED Out of Hospital Cardiac Arrest Protocol

Inpatient COVID Management

Note and Lab Templates

  1. Add the COVID Dashboard to your EPIC patient list (Partners login required)
  2. Brigham and Women’s Specific Epic smartphrases
  1. Inpatient COVID admission note (SPUADMITNOTE)
  1. IMPORTANT: This is an example of possible templated note/phrase. Smartlinks are NOT universal across computer systems. This note should not be copied and used directly for patient care. We are working to make templates available through the Epic Community Library.
  1. Inpatient progress note (PACEPROGRESSNOTE)
  2. COVID discharge counseling (SPUCOUNSELING)
  3. Discharge instructions for PUI or COVID positive patients (SPUDISCHARGECOVIDPOSITIVE)
  4. Discharge instructions for COVID negative patients

(SPUDISCHARGE COVIDNEGATIVE)

  1. Last set of COVID labs (LASTCOVID)
  1. Lab ordersets:
  1. COVID Admission Orderset (COVID 19 Add On)

Early Advance Care Planning

  1. In conscious patients, review or sign Health Care Proxy form and discuss and document goals of care on admission
  1. Educate patient and family on disease course and prognosis
  2. Focus on desired quality of life and tolerance for ICU measures
  3. Early consultation of palliative care if appropriate. See “Palliative Care”

Medical management

  1. Management is largely supportive. Antiviral and immune-modulating therapies are investigational. Please see Therapeutics and Infectious Disease for further details

Fluid management

  1. Fluid management should be conservative due to risk of hypoxia/CHF. Please see Sepsis for more information on dynamic fluid management

Hypoxemia Management

  1. Please see “Hypoxemia Management”

Geriatric Patients

  1. Frailty, immunosenescence and multimorbidity placed older adults for increased risk of adverse outcomes
  2. Older patients may present differently:
  1. Use lower fever criteria: one oral temp > 37.8C or two oral temps > 37.2C (IDSA criteria)
  2. More likely to present with atypical symptoms such as altered mental status, decreased appetite, non-focal pain
  1. If patient presenting from facility, call facility to notify of COVID-19 positivity
  2. Include FRAIL frailty screen on initial assessment.
  1. If patient screens positive for frailty or has a history of dementia, delirium, or is a nursing home resident, page geriatrics tele-consult pager (Pager #38251)

Bedside Procedures

  1. Specific teams, hours of availability, and instructions are outlined here.

Triage to ICU

  1. Provider concern
  2. Respiratory distress
  1. Need O2 > 6 LPM to maintain SpO2 > 92% or PaO2 > 65.
  2. Rapid escalation of oxygen requirement.
  3. Significant work of breathing.
  1. Hemodynamic instability after initial conservative fluid resuscitation
  1. SBP < 90, Mean arterial pressure < 65, or Heart rate > 120.
  1. Acidosis
  1. ABG with pH < 7.3 or PCO2 > 50 or above patient’s baseline.
  2. Lactate > 2.
  1. Need for intensive nursing care or frequent laboratory draws requiring arterial line.
  2. Severe comorbid illness / high risk for deterioration.

Discharge Planning

Clinical Discharge Criteria

  1. Consider discharge for patients who meet the following clinical criteria:
  1. Resolution of fever >48 hours without antipyretics
  2. Improvement in signs and symptoms of illness (cough, SOB, and oxygen requirement)

Followup

  1. Schedule routine follow up within 2 days of discharge with PCP as long as infectious status has been cleared, vs virtual visit if infectious status has not been cleared

Disposition Options

  1. Home with or without support services
  1. Post-discharge phone call: ALL PUIs and COVID+ patients admitted to BWH and BWFH will have a post-discharge phone call with an Advanced Practice Practitioner (APP) within 24-48 hours of discharge.
  2. Partners Homecare: Fully operational and accepting all appropriate PUI and COVID+ patients in need of visiting nurse services. Patients will be triaged for virtual and in person visits.
  3. Home Digital Monitoring Program: Patients will receive an oximeter, thermometer, and will record symptoms, O2 saturation, and temperature daily on a mobile device or computer for 14 days. A nurse (with 24/7 MD backup) will call patients on the day of discharge and if recorded symptoms or vitals worsen. Contact care coordination for enrollment.
  1. Facility - LTAC, short-term rehab, skilled nursing facility, Barbara McInnis House (undomiciled), Boston Hope Medical Center (low acute housing facility)
  1. CMS has waived the 3-midnight rule for discharge to a facility for all Medicare patients.
  2. Please contact care coordination to assist with screening for all facility discharges and for the most up-to-date guidance on the need for COVID-19 testing prior to discharge, which varies by facility.

Discharge Against Medical Advice

  1. People are able to sign themselves out of the hospital against medical advice if they demonstrate decision making capacity. Please see the Psychiatry section on assessment of capacity.
  2. For all discharges who are unable or unwilling to self-isolate, including undomiciled patients, call the Boston Public Health Commission at (617)-645-9680.
  3. If you are unsure about whether a patient poses a significant threat to another individual, there is a legal representative available 24/7 to discuss.

Inpatient Discharge Checklist

  1. Inpatient Discharge Checklist Tool
  1. Includes pre-discharge checklist, medications, transport, instructions, followup, and community resources (PDF version is in development)