Covid-19

RespED – flow chart

To improve management and maintain protection for staff and patients we have created a RespED at both sites, much of the flow chart is based on information from the Italian society of emergency medicine

As time more information becomes avalible this will inevitably change

 

Awake Self-Proning

There is increasing evidence that Awake Self-Proning of our Covid-19 patients can improve oxygenation. Proning the patient can has several effects which can dramatically improve their SaO2

  • Improves Ventilation to back of the lung (the back of the lung contains more alveoli than the anterior lung)
  • Improves Perfusion – as blood supply to the back of the lung is always better than the front
  • Improves Clearance of secretions

NIV/CPAP
  • NIV/CPAP  is an Aerosol Generating Proceedure (AGP)
    • Staff must wear full APG PPE
    • In Side room with a door
    • Door Marked with APG sign – HERE
  • CPAP/EPAP levels of 8-15cmH2O is suggested to work well by the Italian society of Emergency medicine
  • BTS has released the guidanceHERE 
    • Masks
      • Well-fitting oronasal facemasks, masks over the total face, or helmets should produce least droplet dissemination.
      • Vented masks could worsen contamination of the environment
      • Any patient on acute NIV should be managed with a non-vented mask and an exhalation port in the circuit.
      • Ensure that the ventilator mode employed supports the use of non-vented masks and exhalation ports.
      • Sequence of actions: NIV mask on >ventilator on; ventilator off > NIV mask off.
    • Filters
      • A viral/bacterial filter should be placed in the circuit between the mask and the exhalation port (Figure below).
      • This viral/bacterial filter can replace any filter at the machine end of the circuit.
      • Viral/bacterial filters should ideally be changed every 24 hours or sooner. (There is a risk that they will become wet due to exhaled gas and that this may increase resistance to flow.)
      • An external humidifier must not be used.
      • Blocked filters can be mistaken for clinical deterioration; this issue is remedied by changing filters.
    • Oxygen – entrained at patients end (on mask

Destinations

      • Failing on NIV/CPAP – Consider either escalation to intubation OR palliation
      • Maintaining Oxygenation – At CRH negative pressure room, at HRI side room acute floor
Treatment

 

Avoid NSAIDS

Tamiflu – Only if confirmed influenza

CPR

Deteriorating Patients

  • Early senior decision making around DNACPR, is vital for both staff, patients, and families.
  • Document decsion making and communications clearly
  • There will be regular updates in “handover” about ICU admission criteria – as these may change over time

CPR (Aerosol Generation Proceedure)

  1. Recognise cardiac arrest.
    • Look for the absence of signs of life and normal breathing.
    • Feel for a carotid pulse if trained to do so.
    • Do not listen or feel for breathing
    • If there are any doubts – start chest compressions until help arrives.
    • When calling for help/2222, state the risk of COVID 19.
  2. Minimum PPE; gown, eye protection, gloves and FFP3 mask/Hood before starting chest compressions
    • No chest compressions or airway procedures such as those detailed below should be undertaken without full AGP PPE.
  3. Start compression-only CPR and monitor the patient’s cardiac arrest rhythm as soon as possible.
    • Avoid mouth-to-mouth ventilation and the use of a pocket mask.
    • Place oxygen face mask on the patient’s face during chest compressions (may limit aerosol spread).
    • Restrict the number of staff in the room (if a single room). Allocate a gatekeeper to do this.
  4. Defibrillate shockable rhythms rapidly 
  5. LMA/ETT insertion –  must be carried out by experienced individuals.
  6. Identify and treat any reversible causes 
  7. Post-CPR
    • Dispose of, or clean, all equipment used during CPR
    • Remove PPE safely to avoid self-contamination
    • Hand hygiene has an important role in decreasing transmission.
    • Post resuscitation debrief is important and should be planned.

FULL Resus Council – GUIDE HERE

 

Covid-19 Destination Wards

 HRICRH
CPAP/NIVAcute FloorRespiratory Floor
Oxygen ONLY (FOR Escalation)Acute FloorRespiratory/Acute Floor
Oxygen ONLY (NOT FOR Escalation)Acute Floor/Ward 17Respiratory/Acute Floor/Ward 6CD
PalliativeWard 6Ward 6AB

Pathways out of ED

Pathways out of ED

During the COVID-19 Pandemic the pathways to stream patients out of ED are changing to allow for better flow through the ED’s and prevent congestion at the front door.

ENT

If the patient is suitable for outpatient treatment – M-F call ENT clinic 01422 222336, Out of hours: If COVID is not suspected book a clinic appointment directly via ED reception, if COVID is suspected ask the patient to phone the clinic the next working day.

Full Pathway – ENT pathway.docx

Gynae

If the patient is stable and no suspicison of COVID contact the Gynae SPR bleep no. 2409 and then send the patient to 4c 7.00-19.00 or 8c OOH, if unstable or COVID is suspected contact the Gynae SPR and they will attend ED at CRH. IF at HRI the patient must be seen by ED and stablised for transfer.

If at HRI 9.00-17.00 contact the Gynae SPR on bleep 565 for review in the ED

If the Gynae SPR is not available please contact the Gyane consultant on 01422 22 5330 8.30-20.30 or via switchboard out of hours.

Full Pathway –Gynae pathway

Maxillofacial

Monday-Friday 9.00-17.00 for facial trauma and injuries contact the HRI Max fac team on 01484 342336, out of hours contact the on-call maxillofacial team at BRI. For acute dental problems (toothache/ mild swelling/ borken teeth) patient to contact their own dentist if registered or 111 if not registered with a dentist.

Maxillofacial Pathway

Oncology

Phone the helpline 01422 222999 and they will advice where to send the patient for assessment – wither Ward 12 or Ward 14 at HRI depending on capacity.

Opthalmology

8.30-17.30 M-F and 8.30-12.00 Sat. contact Eye clinic on 01422 222539 out of hours contact the on-call opthalmologist via switchboard who will advise where to send the patient and when.

Opthalmology pathway

Orthopaedics

Orthopaedic Consultants are available in the Minor Injuries Unit at HRI 10.00-22.00  – direct as many patients to them as possible. If unable to sit e.g. # NOF call the on-call Orthopaedic Registrar bleep no. 062 at HRI.

Patients requiring admission e.g. #NOF still require ECG/bloods/CXR/FNB prior to sending to the ward.

Paediatrics

There is a Paediatric Consultant based in ED at CRH 9.00-21.30 to review children and aid decision making. Any child under 3 months old with a fever and a PAWS <10 and no clinical concern can go to PAU directly for assessment.

Febrile under 3mth

Surgical Patients

Contact the 2nd on call Surgical Consultant on 07741363257 who will either come and review the patient or advise where to send them. Urology and Vascular patients need to be referred to the on-call middle grade or consultant for the speciality.

COVID-19 (40 Step Desaturation Test)

April 12, 2020

NHS England has introduced the use of a “40 step desaturation test” into discharge planning from the ED. You will have heard Covid -19 patients complaining of increasing SOB on exercise, and it’s important that we test this prior to discharge. Method: Is this appropriate? – Could the patient walk… Read more

COVID-19 (Awake Self-Proning)

April 8, 2020

There is increasing evidence that Awake Self-Proning of our Covid-19 patients can improve oxygenation. Proning the patient can has several effects which can dramatically improve their SaO2 Improves Ventilation to back of the lung (the back of the lung contains more alveoli than the anterior lung) Improves Perfusion – as blood supply… Read more

COVID-19 (CPAP)

March 19, 2020

NIV/CPAP  is an Aerosol Generating Proceedure (AGP)

Staff must wear full APG PPE
In Side room with a door
Door Marked with APG sign –HERE

CPAP/EPAP levels of 8-15cmH2O is suggested to work well by the Italian society of Emergency medicine
BTS has released the guidance – HERE  Read more

COVID-19 (CPR)

March 19, 2020

Deteriorating Patients

Early senior decision making around DNACPR, is vital for both staff, patients, and families.
Document decsion making and communications clearly
There will be regular updates in “handover” about ICU admission criteria – as these may change over time

CPR (Aerosol Generation Procedure)

Read more

COVID-19 (Death Certification)

April 4, 2020

The rules have changed since 25th march 2020 on death certification, below is a brief summary of how this might affect us. We are aiming to keep a death certification box in both ED’s so that these can be completed in a timely fashion.
MCCD
Any doctor can complete a death certificate (MCCD) even if they haven’t seen the patient providing: Read more

COVID-19 (DKA/HHS)

April 15, 2020

Experience is showing that those with diabetic patients with COVID-19 are more likely to develop DKA/HSS. However, treating them with the traditional large amount of fluid is detrimental to their chest, if they have Covid-19

Hence the following has been developed from the Guy & Thomas’ guidance – CLICK HERE
High Clinical Suspicion of Covid-19

Clinical: Fever ≥37.8°C plus any of; cough, short of breath, myalgia, headache, sore throat
CXR: consistent with Covid-19

Read more

COVID-19 (Doning/Doffing Video)

March 10, 2020

2 video links to PHE how to Don and Doff your PPE Read more

COVID-19 (Donning/Doffing-LOCAL)

March 25, 2020

Local instructional videos for donning/doffing Non-Aerosol Generating Procedures Aerosol Generating Procedures Disponible FFP3 (Leeds) Read more

COVID-19 (Escalation-Arrhythmia Clinic)

March 26, 2020

Due to the limited capacity when referring patients to the “New Arrhythmia Clinic” we MUST Send a BNP We don’t need to wait for the result in ED prior to referral and discharge BNP Result (clinic will review) >400, we will arrange an urgent echo and face-to-face clinic. <400, we will book a remote… Read more

COVID-19 (Escalation-Ophthalmology Referral)

March 27, 2020

Any patient presenting to ED with ONLY Ophthalmic symptoms should be referred directly by the ED triage team to Ophthalmology: Referral 08:30 – 17:30 Mon-Fri, and 09:00 – 12:00 Sat all referrals are to be made directly to dedicated phone Out is these times refers to Ophthalmology on-call Minimum dataset:… Read more

COVID-19 (Escalation-Primary PCI)

April 10, 2020

Eligibility

Symptoms suggestive of Acute Myocardial Infarction
Chest Pain within 12 hours
ECG showing acute myocardial infarction

ST elevation >1mm in limb leads
ST elevation >2mm in precordial leads
New LBBB with appropriate clinical history

Read more

COVID-19 (optimal use of oxygen)

April 16, 2020

As you are aware during the Covid-19 pandemic our use of oxygen has increased. However, supply is limited and most hospitals can only generate 3000-5000l/min of oxygen (i.e. enough to treat 300-500 patients on 10l/min). If you exceed this capacity the oxygen valves can freeze and the whole oxygen supply… Read more

COVID-19 (Paediatric multisystem inflammatory syndrome)

May 13, 2020

AKA: Paediatric Inflammatory Multi-system Syndrome – Temporally associated with SARS-CoV 2 

Although COVID-19 seems a benign disease in almost all children there are increasing evidence (however rare) of a “Paediatric multisystem inflammatory syndrome”. This is a RARE and newly emerging condition and there are many questions still e.g. It is currently unclear if it is directly related to the COVID-19 pandemic.
Case definition (RCPCH)

A child presenting with persistent fever, inflammation (neutrophilia, elevated CRP and lymphopaenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder). This may include children fulfilling full or partial criteria for Kawasaki disease. 
Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, infections associated with myocarditis such as enterovirus (waiting for results of these investigations should not delay seeking expert advice).
SARS-CoV-2 PCR testing may be positive or negative

Read more

COVID-19 (Palliative Care)

April 8, 2020

Some patients who present with COVID-19 infection will be not suitable for escalation and actively dying when they attend the ED, for these patients the best management may be palliative care. The primary symptom that causes distress is breathlessness. Palliative Care of COVID-19 patients will ideally be provided with a… Read more

COVID-19 (RespED)

March 19, 2020

To improve management and maintain protection for staff and patients we have created a RespED at both sites, much of the flow chart is based on information from the Italian society of emergency medicine As time more information becomes avalible this will inevitably change   Read more

COVID-19 (Respiratory Flow Chart)

March 27, 2020

As we know COVID-19 is putting an incredible burden on resources, especially for higher level respiratory support. It is important to target those resourses in the most effect way, hence the development of the “Respiratory Flow Chart”

 

Read more

COVID-19 (Talking to Relatives)

April 12, 2020

During the current Covid-19 pandemic relatives are not attending the hospital with patients, which means we are increasingly having to have difficult conversations over the phone. Chelsea and Westminster have published this helpful guide. Remember: Keep your language simple  Avoid jargon/euphemism Be honest Pauses can be helpful Don’t rush Talk… Read more

COVID-19 (VTE prophylaxis in Lower Limb Injury)

April 20, 2020

During the Covid-19 pandemic alternatives to LMWH have been agreed – [For those who can’t inject themselves]
Read more

COVID-19 (X-Ray learning resource)

March 15, 2020

British Society of Thoracic Imaging (BSTI) have released a free learning resource containing CXR and CT of confirmed Covid-19 cases, will short history including time image was taken from onset of symptoms. From the China experience CXR/CT doesn’t seem to be a rule out strategy in ED at the moment… Read more