Brigham and Women's Hospitals

Ambulatory, ED, and Floor Management

Updated: October 14, 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. 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. Missing Equipment
  1. For missing hand sanitizer or missing PPE, you can use the FixIt website or app to report this to the Safe Care team: https://best.brighamandwomens.org (Partners login required)
  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. COVID positive or under investigation inpatients are not allowed visitors at this time
  3. Adult outpatients are not allowed visitors at this time, 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.