Brigham and Women's Hospitals

Ambulatory, ED, and Floor Management

Updated: April 27, 2020

Case Definitions

Case Definition

  1. Infectious Status and Resolution (Partners login required)
  1. Outlines the transitions between each of these states, and testing needed to clear.
  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.

Personal Protective Equipment and Infection Control

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

Infection Control

  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)
  1. BWH Visitor Policy (public site)
  1. Partners Visitor Policy contains additional details (Partners login required)
  1. Presently no visitors are being accepted, with exceptions for end-of-life, labor and delivery, pediatric patients, and several other special populations
  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.

Ambulatory Protocols

  1. Ambulatory Triage Algorithm (Partners login required)
  2. Screening and PPE for Home Visits (Partners login required)
  3. PCOI Handouts for Patients (Partners login required)
  4. More content is in development

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 Protocols

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. 24/7 COVID-specific procedure teams are available to do bedside procedures (pager #39299). Specific teams, hours of availability, and instructions are outlined here.

Triage to ICU and Transfers

Consult the ICU triage team EARLY for

  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.

Transfers

  1. See Transport Policy for more information (Partners login required)
  2. Floor / ED to ICU
  1. ICU RN brings ICU bed to the floor for transfer (to avoid bed transfer in COVID precautions room and subsequent bed cleaning).
  2. Patient wears a surgical mask, with an extra clean gown and sheet on top.
  3. Providers wear standard PPE during transport.
  4. Security facilitates the shortest and fastest transfer route, walks 6 ft away from patient and providers, not required to wear PPE
  5. Necessary tests (e.g. CT), should be obtained during transfer if possible.
  1. ICU to floor
  1. RN wears standard PPE
  2. Patient travels in wheelchair or stretcher
  3. Security facilitates the shortest and fastest transfer route, walks 6 ft away from patient and providers, not required to wear PPE
  1. Floor to discharge
  1. RN wears standard PPE
  2. Patient travels in wheelchair
  3. Security facilitates the shortest and fastest transfer route, walks 6 ft away from patient and providers, not required to wear PPE
  4. Patient is escorted directly into vehicle; contact care management if patient does not have access to a personal vehicle

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)

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)