Patient Care

Visitors


  • Visitors who were previously COVID-positive may visit if 20-day Screening Criteria for Resolution of COVID are met. The 20-day timeframe is being used because we do not know the clinical course of the visitor’s COVID illness or their immune status.
    • 20-Day Screening Criteria for Resolution of COVID
      • 24 hours afebrile without the use of fever-reducing medications, AND
      • Improving symptoms, AND
      • 20 days since onset symptoms or initial date of positive test (if asymptomatic)



Med-Surg/Intermediate Care

  • Admitted patients with a COVID-19 lab test confirmed or pending should be placed in a designated zone or unit per individual entity capacity and workflow.
  • Notify Infectious Disease Specialist or ID Medical Director at your facility (Appendix B).
  • Provide supportive care

Imaging

  • Baseline CXR, repeat if condition worsens

Oxygen (can apply to non-ventilated ICU patients, when applicable)

  • If FiO2 needs exceed 6 Liters nasal cannula, place on High Flow Nasal Cannula (HFNC) at maximum LPM and FiO2
  • CPAP or BiPAP as needed
  • Encourage/facilitate prone positioning 3-4 times a day while off CPAP/BiPAP
  • Instruct patient in self-administration of incentive spirometer and PEP/EZPAP every 2 hours while awake
  • Titrate oxygen on all delivery devices as tolerated to target SaO2 of 94%

Vital Signs

  • Every 4 hours with temperature and O2 sat, consider continuous pulse ox if available

Labs/Micro

  • Sputum culture, if not already done

Treatment

  • There are currently no FDA approved treatments for COVID-19; beyond supportive care, pharmacotherapy options at this point are off-label or investigative
  • See figure “Potential pharmacotherapy options for patient in high risk populations or with high acuity”
    • For patients requiring supplemental oxygen, begin corticosteroids as outlined in pharmacotherapy guidance
    • COVID-19 is associated with hypercoagulability. Initiate chemical VTE prophylaxis as outlined in the pharmacotherapy guidance
  • Initiate pneumonia order set when bacterial co-infection is suspected
  • Conservative use of IV fluids, absent septic shock
  • Convalescent plasma therapy is another investigative therapy for specialized cases meeting criteria

Discharge Planning

  • Early CTM consult for patients who may require post-acute placement

Discharge criteria

  • Afebrile x 24 hours without use of anti-pyretics
  • Clinical improvement in signs and symptoms
  • Sustainable home oxygen requirement

Post-discharge isolation instructions

  • Continue to self-isolate for a total of 10 days after evidence of first symptoms (i.e. cough, shortness of breath, etc.) AND no fever for at least 24 hours without anti-pyretics, AND improvement in symptoms (i.e., cough, shortness of breath, etc.)
  • **Patients who were critically ill or are severely immunosuppressed should consult with their physician prior to discontinuing home isolation.
  • Separate from other family members and pets




Potential Pharmacotherapy Options for COVID-19 Patients






Convalescent Plasma Therapy

Convalescent plasma therapy may be indicated for severely ill patients. The Mayo Clinic EAP protocol can be found at https://www.uscovidplasma.org/. Additional guidance is available from the FDA at https://www.fda.gov/media/136798/download.





Critical Care

Intubation/Extubation and Ventilator Management for COVID Positive or COVID PUI Patients

  1. Admitted patients with a COVID-19 lab test should be placed in a designated zone or unit
    1. Refer to the Surge Management of Emerging and Pandemic Respiratory Illness policy
  2. Apply Airborne Plus PPE before intubation
  3. Notify Infectious Disease Specialist or ID Medical Director (Appendix B)
  4. Manage respiratory failure, ARDS if present

    Consider dedicated intubation teams

    • Anesthesia provider, if available

    Have intubation kits pre-assembled

    • Self-inflating bag with Viral filter attached and keep closed seal, PEEP valve at zero all times.
    • (2) anesthesia masks with head straps on to tighten the seal.
    • LMA iGel size 4 and 5 (as backup airway if unable to obtain ET intubation)

    Follow airway management guidelines

    Minimize Aerosolization of Virus

    • Early Tracheal Intubation instead of Bi-PAP of HFNO
    • Intubate in a negative pressure room, if available, and avoid nebulization
    • HEPA filters for positive pressure ventilation
    • Rapid sequence intubation for apnea and lack of cough. Use high dose paralytics
    • PPV, high-flow oxygen and manual bagging only if clinically necessary
    • Immediate endotracheal tube cuff inflation before PPV
    • Limit ventilator disconnects. If needed, do so at end-expiration

    Maximize First Attempt Success

    • Use a checklist and closed loop communication
    • Most experienced clinician should intubate
    • Use video laryngoscopy (VL) if possible
    • Have all necessary equipment at the bedside
    • Robust preoxygenation with 100% O2 for 3-5 minutes
    • Early placement of a supraglottic airway instead of manual bagging for rescue oxygenation
    • Second clinician with personal protective equipment (PPE) outside of the room for immediate assistance

    Limiting Contamination

    • Use double-glove technique
    • Use VL for indirect tracheal intubation if available
    • Limit to a 3-person intubation team when possible (RN, RT and Intubator); Two staff on standby for CPR if needed
    • Placed soiled equipment in double seal biohazard bags

    ETT Clamping Procedure

    • 2 Respiratory Therapists will perform this procedure.
    • Therapist 1: clamp (non-serrated) will be applied across the ETT at the end of inspiration.
    • Therapist 2: circuit will be disconnected, and the new circuit applied.
    • Therapist 1: clamp will be removed, and ventilation continued. (This procedure should take no longer than a few seconds.)
    • Monitor patient for several minutes to verify effective ventilation on new device.

    Utilize lung protective strategies

    • Low tidal volumes

    Utilize prone positioning

    • Rotoprone bed or manual proning
    • See detailed manual proning procedure

    If ventilators in short supply, consider alternatives

    • NICU ventilators
    • Anesthesia machine

    Conservative approach to vent weaning

    • Minimize re-intubations

    General extubation guidance

    • Consider instillation of 5-10 ml of 2% lidocaine through the endotracheal tube saline instillation port to minimize cough
    • Extubate per usual procedure
    • Additional staff should not enter room until adequate air exchanges have occurred


  5. For patients with respiratory decompensation, steroids may be considered
  6. Manage septic shock per usual sepsis guidelines, if present
    1. Society of Critical Care Medicine suggests a conservative as opposed to liberal fluid strategy
  7. Transfer to non-ICU setting when ICU criteria no longer present




Manual Proning Procedure

Video from NEJM

Pronation Therapy: Retrieved 4/9/2020 from Elsevierperformancemanager.com

Prone positioning is contraindicated in patients who have increased intracranial pressure, hemodynamic instability, spinal cord injuries, maxillofacial injuries, or rib fractures, and in those who have had recent abdominal surgery.

  1. Perform hand hygiene and don appropriate personal protective equipment (PPE), Droplet Plus or Airborne Plus, as clinically indicated for the patient.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Assess the patient's respiratory status.
  5. Assess the patient's hemodynamic status to determine his or her ability to tolerate a position change.
  6. Obtain the patient's height and weight to determine the possibility of turning the patient within the confines of the bed frame and the risk of injury to the health care team members. Ensure that the height and weight do not exceed the manufacturer's recommended limits for commercial positioning systems.
  7. Assess the patient's level of sedation and level of pain.
  8. Ensure that an adequate number of experienced, knowledgeable health care team members are available to perform the procedure.
  9. If the patient is on a low air-loss surface, inflate it to the maximum level to make turning easier.
  10. Administer sedatives and analgesics as prescribed. Reassess the patient's pain and sedation status, allowing for sufficient onset of action per medication, route, and the patient's condition.
  11. Perform eye care, including lubricating the eyes and horizontal taping of the closed eyelids.
  12. Apply a protective barrier (hydrocolloid or foam dressing) to the face and all bony prominence areas (e.g., shoulders, chest, iliac crest, elbows, tibial areas) as needed.
  13. Ensure that the patient's tongue is inside his or her mouth. If the tongue is swollen or protruding, insert a bite block or an oropharyngeal airway.
  14. Ensure that all lines, tubes, and drains are secure. Consider using two suture-less securement devices for central lines.
    1. Reposition all lines, tubes, and drains that are located above the patient’s waist up toward the head of the bed.
    2. Reposition all lines, tubes, and drains that are located below the waist down toward the foot of the bed.
  15. Change dressings that are due to be changed during pronation therapy.
  16. Empty ileostomy or colostomy bags before positioning. Place a pad around the stoma to prevent direct pressure on it.
  17. Stop enteral feeding unless it is a post-pyloric feeding. Consider using bolus feedings when the patient is supine.
  18. Suction the patient’s artificial airway and oral cavity.

Turning the Patient Prone Manually Using a Sheet – Arm Tuck Method

  1. Perform hand hygiene and don gloves and appropriate PPE based on the patient’s signs and symptoms and indications for isolation precautions.
  2. Verify the correct patient using two identifiers.
  3. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  4. Verify that three to five health care team members are available to assist with the procedure.
    1. One health care team member is dedicated to the management of the head of the patient, the endotracheal (ET) tube, and the ventilator lines and coordinates the steps of the procedure.
    2. Those health care team members stationed on each side of the bed maintain body contact with the bed at all times, serving as side rails to ensure a safe environment.
    3. Additional health care team members may be needed if the patient is large or has numerous tubes and drains.
  5. Roll the patient on his or her side and tuck a flat sheet under him or her.
  6. Attach electrocardiogram (ECG) electrodes to the patient's back (Figure 1).
  7. Place the patient flat and pull the sheet through so that it is under him or her.
  8. Using the sheet under the patient, move him or her to the edge of the bed opposite the direction of the turn (Figure 2A).
  9. Prepare the patient for the turn.
    1. Turn the patient’s head so that it is facing away from the direction of the turn.
    2. Loop the ventilator tubing above the patient’s head.
    3. Cross the patient’s leg closer to the edge of the bed over the opposite leg at the ankle.
    4. Remove the ECG electrodes from the patient’s chest.
    5. Tuck the flat sheet around the arm that will be pulled underneath the patient when the turn is executed (Figure 2B).
    6. Position one arm up and one arm alongside the body while turning the patient’s head in the direction of the upper arm.
    7. Place a second flat sheet on the bed and tuck it under the patient (Figure 2C). This sheet will be pulled through as the patient is turned.
  10. On a three count, roll the patient over into the prone position, using the sheet (Figure 2D). The arm and sheet will pull across the bed. If the abdomen-unrestricted position is required, insert pillows under the head, chest, and pelvic region when the patient is tilted fully onto his or her side.
  11. Pull and center the patient (Figure 2E) in the bed. Discard the sheet that was used to place the patient in the supine position.
  12. Correctly position all tubes, drains, and lines.
  13. Attach the ECG leads to the electrodes on the patient’s back.
  14. Rotate the patient’s arms parallel to the body and then place them in a position of comfort. The arms may be positioned by the head, aligned with the body, or one up and one down (Figure 3).
  15. When the arm is in the up position, keep the shoulder in neutral position and the elbow at 90 degrees.
  16. Place pillows under the patient’s shins to raise the patient’s ankles off the bed and to maintain the patient’s feet in a dorsiflexed position.
  17. If the patient is on a low air-loss surface, adjust the inflation as appropriate.
  18. Adjust the bed to place the patient in reverse Trendelenburg position.
  19. Resume the tube feeding.
  20. Assess, treat, and reassess pain.
  21. Discard supplies, remove PPE, and perform hand hygiene.
  22. Document the procedure in the patient’s record.




Resuscitation

General Principles for All Code Blues

Pre-Arrest Interventions

  1. All patients with suspected COVID-19 infection requiring admission should be asked about advance directives and informed about the difficulty of performing CPR in patients with this disease. The goal of these initial conversations (in ED and on the ICU or medical floor) is to identify COVID positive or COVID PUI Do Not Resuscitate patients and enable preparation for those requesting CPR. Identify next of kin for medical decision making: if possible start Medical Power of Attorney paperwork.
  2. Ensure that prepackaged appropriate airborne plus PPE kits (2 for each patient) are available on the medical floor and ICU.
  3. Consider if it would be appropriate to place IV pump outside patient room.

Cardiac Arrest Non-Critical Care

  1. Code Blue PPE consists of Airborne Plus PPE (N95 or PAPR, Gown, Gloves, and Face shield). PAPR should only be used if unable to be fit-tested for N95. All providers entering the Code Blue room should be appropriately trained in use of the appropriate PPE. All appropriate PPE must be in place prior to entry.
  2. As patient’s condition deteriorates, staff is required to don Airborne Plus PPE and initiate emergency notification for Code Blue or RRT.
  3. All staff must be in Airborne plus PPE prior to Bag Valve Mask ventilation or intubation)
  4. First line responders may need to allow patient’s pulse oxygen saturation to drop prior to initiating Ambu bag respirations to allow time for donning of appropriate PPE and/or arrival of Code Blue team. All staff must be in Airborne Plus PPE prior to Bag Valve Mask ventilation or intubation.
  5. If patient’s pulse ox drops to an unacceptable level, Airborne Plus PPE must be donned prior to beginning respirations/ compressions.
  6. In a non-trauma code, begin chest compressions (or apply external compression device) after donning Airborne Plus PPE. All responding healthcare providers must don Airborne Plus PPE prior to entering the room.
  7. Leave Crash cart at door. Only bring defibrillator in room, along with Airway Kit/Bag/Roll. Pass crash cart trays and supplies, and additional medications from doorway into room from code cart. The drug tray from the crash cart should not be brought into the room. Place first line drugs (i.e. epinephrine, atropine, bicarbonate, etc.) in a plastic bag and pass into the room as needed.
  8. Information will be relayed to the documenter outside the room by verbal escalation of the team lead. (VOCERA will not be used during this event to relay information to the documenter and may be used for other needs deemed necessary).
  9. The patient should be initially ventilated with a bag-valve mask by a healthcare provider wearing Airborne Plus PPE. Do not begin intubation until all personnel are wearing Airborne Plus PPE.
  10. During intubation, all persons present in the room should wear Airborne Plus PPE. If possible, Intubation should be done in negative air flow room, by special COVID intubation team.
  11. If patient’s FIO2 reaches 80% initiate transfer to ICU.
  12. Prior to any transfer, the patient should receive new sheet and blanket.
  13. If intubated, the patient is to be placed on a ventilator, so that there is a HEPA filter contained circuit.
  14. If not ventilated, patient should wear facemask during transport.
  15. If transfer of the patient is required after intubation, all persons in the room should doff and degerm prior to moving the patient. Then, if in close contact with the patient during transfer, each person should don new Airborne Plus PPE. One person not in close contact with the patient to don NEW facemask in order to push elevator buttons etc. during transport.
  16. All equipment will remain in room after code event to be cleaned.
  17. All equipment will be cleaned in room with direction from Infection Preventionist/ manufacturers recommendations.
  18. Patients should be transferred to a negative pressure room if immediately available. If a negative pressure room is not available, the patient can be placed in a private room with closed door

Cardiac Arrest Critical Care

  1. Code Blue PPE consists of Airborne Plus PPE (N95 or PAPR, Gown, Gloves, and Face shield). PAPR should only be used if unable to be fit-tested for N95. All providers entering the Code Blue room should be appropriately trained in use of the appropriate PPE. All appropriate PPE must be donned prior to entry.
  2. Respiratory therapy and nursing will don Airborne Plus PPE and enter room.
  3. Respiratory will evaluate ventilator and endotracheal tube for dislodgement, occlusion, or malfunction. Breath sounds will be assessed for equality. If tension pneumothorax is suspected, physician will don PPE and enter room to perform needle decompression.
  4. The automatic compression device will be applied, and chest compressions begun, if available.
  5. At this point, if patient is not on a ventilator, patient should be intubated
  6. ACLS protocols shall be utilized until patient is resuscitated or efforts deemed futile per Code Blue Team Leader.

Equipment

Each unit or response team should have a cart kit with the following standard equipment:

  1. Airborne Plus PPE for 4 people
    1. Gown
    2. Face Shield
    3. Gloves
    4. N95
  2. Ambu bag attached ETCO2 detector and PEEP Valve
  3. HEPA Filter for Ambu bag and vent circuit
  4. ETCO2 sampling line + adapter (If available for capnography in ICU)
  5. Bougie
  6. Nasal Cannula (based on recommendation <6L/min for apneic phase)
  7. Intubation tray (ETTs various sizes, nasal/oral airways)
  8. LMA sizes 3,4,5, if available and used in the facility (based on recommendation as alternate way to oxygenate between attempts instead of BVM)
  9. Designated video-assisted laryngoscope with blade and stylet (based on recommendation for video laryngoscopy for first pass success and more distance from airway)
  10. 2 Large Ziplock bags (Double bag for used laryngoscope blade and stylet)
  11. Medium/large BIPAP/CPAP mask
  12. ETT securement device
  13. Clamp (To decrease atelectasis and prevent environmental contamination for when circuit disconnected)

Additional supplies:

Medications for intubation and for sedation post intubation.

Plastic bag for passing first line drugs into the room as needed

CPR Compression Device

Code Blue Cart IF REQUESTED FROM Team Leader

Staff recommended:

  1. INSIDE THE ROOM (Goal is to limit to 4 staff members or less)
    1. Airway management
    2. Chest compression staff (if no compression device)
    3. Code leader
    4. Registered Nurse (medication/defibrillation management)
  2. OUTSIDE THE ROOM
    1. Runner
    2. Documenter
    3. Pharmacist, if available

The need to increase core Code Blue Team during special circumstances will be allowed using the clinical judgement of the team lead.

(ex: OB Delivery CODE, morbidly obese requiring additional support, etc.)

*Always include the support of our chaplain services when available.





Adult Discharge and Care Transitions

Discharge considerations: It should be recognized the guidance below may evolve as experiences and data for the hospitalized patients continues to accumulate. Adjustments may be necessary when resources and health system capacity is limited.

  1. Although may vary between different facilities, below are guiding principles.
  2. In order to decrease readmissions, effort should be made to discharge to home, and to place clinical, social and pharmacy f/u for patient prior to discharge.

COVID-19 Clinical Criteria

Discharge criteria (clinical)

  • Afebrile x 24 hours without use of anti-pyretics
  • Clinical improvement in signs and symptoms

Post-discharge isolation instructions

  • Continue to self-isolate for a total of 10 days after evidence of first symptoms (i.e. cough, shortness of breath, etc.) AND no fever for at least 24 hours without fever-reducing medications AND improvement in other symptoms (i.e., cough, shortness of breath, etc.). This includes quarantine from other family members and pets.
  • **Patients who were critically ill or are severely immunosuppressed should consult with their physician prior to discontinuing home isolation.


  1. Engage care transition managers (CTM) early in the care of the COVID-19 patients to facilitate placement with in the most appropriate level of post-acute care.
  2. Interdisciplinary teams to discuss and reinforce importance of timely discharge home with patients and families throughout admission, recommend discharge home, as opposed to facility, whenever safe and reasonable.
  3. Engage social services/social workers early to begin facilitating at home social needs for these patients assuming most will remain quarantined at home. This would include at home services and durable medical equipment, including Home Oxygen.
    1. If patient cannot return home safely, coordination with local public health department is warranted.
  4. Particular high-risk COVID-19 patients (e.g. immunosuppressed, transplant, HIV-positive, and pregnant patients), close communication with specialists is critical to clarify post-discharge clinical care (e.g. immunosuppressive medication management, special precautions) and appointment follow up.
  5. Confirm telehealth or other appointment with patient’s PCP and/or specialist and instructions given to the patient prior to discharge.
  6. Pending Test Results: Patients who are discharged from a wholly owned or JV hospital on CareConnect with COVID-19 test results still pending will receive a phone call from a Texas Health nurse informing the patient of test results
    1. This will include both ED or inpatients whose results are received after discharge.
    2. Both positive and negative results will be called to the patient.

Department of Public Health and Infection Control Coordination

  1. Entity-based Infection Prevention reports positive COVID-19 patients to public health. It’s public health’s responsibility to conduct contact tracing in community.
  2. Patients need to understand their infectious risk to household contacts and necessary precautions. Refer to After Visit Summary.

Discharge to Post Acute Facilities

  1. Please consider new waiver from Texas Health and Human Services (THHS) for patients needing post-acute facilities.




Operating Rooms and Invasive Procedural Areas

General resource for COVID-19 guidance: https://www.facs.org/covid-19/clinical-guidance

COVID-19 Testing Prior to Elective Procedures

  1. Refer to Appendix D - Summary Information on Elective Procedures/Services and COVID Testing for a list of procedures requiring COVID-19 testing prior to scheduling.
  2. Approximately 3 days prior to planned procedures, screen patient for presence of COVID-19 symptoms or risk factors (contact with known or suspected COVID-19). This screening can be completed telephonically.
  3. Approximately 2-3 days prior to planned procedure complete COVID-19 test.
    1. Texas Health will accept COVID-19 molecular testing results performed by an external entity, provided the result is within the appropriate time frame. THPG also has testing centers if patient testing is not done during pre-assessment testing (PAT) at the hospital. Likewise, patients can go to neighboring Texas Health entities who offer testing.
    2. Testing two to three days before the procedure is the recommended timeframe. Longer than that interval could be acceptable, for example, a Friday test for a case on the subsequent Tuesday. In special situations, such as a nursing home patient with a send out test, or a staged procedure with multiple hospital visits over a short time span, results as old as seven days will be accepted. Any interval beyond seven days necessitates a repeat test.

**Patients who were COVID-positive in the previous 90 days and are asymptomatic do not need COVID-19 testing.

Prior to Inpatient Urgent Procedures

  1. Screen patient for COVID-19 symptoms.
    1. If symptomatic, follow the COVID-19 Testing Algorithm to Inform Classification for Symptomatic Patients on Admission or During Admission
    2. If asymptomatic, follow the COVID-19 Testing Algorithm to Inform Classification for Asymptomatic Specialty Patient Populations
  2. If patient is COVID-19 Presumptive Negative with no Clinical Risk Factors, follow routine Procedural area PPE practices. Droplet Plus or Airborne Plus PPE is not necessary.
  3. Patients who are undergoing multiple procedures during their stay should have a COVID-19 test every 7 days.

Preparation (For COVID-19 Positive, Presumptive Positive (PUI), or Presumptive Negative (PUI) with Clinical Risk Factors)

  1. OR should remain in POSITIVE pressure airflow
    1. Place a blanket at the bottom of all doorways to prevent OR air from exiting
    2. Consider performing these procedures as the last case of the day
  2. Remove all non-essential items
    1. Furniture, equipment, documents, glove boxes (keep minimal supply in the OR), containers, etc.
  3. Verify cabinets and drawers are closed and do not open or use during case.
  4. Keep hold items in sub-sterile area.
  5. Designate 1 or 2 runners to stay in sub-sterile area and outside of the OR to run/pass supplies needed.
  6. Patient will be transported by unit, directly to the OR, so that staff will be in PPE upon patient arrival. Follow suspected/known COVID-19 patient transport guidelines. Consider notifying security to clear the path before patient transport.

Intraoperative (For COVID-19 Positive, Presumptive Positive (PUI), or Presumptive Negative (PUI) with Clinical Risk Factors)

  1. Minimize personnel present in room during intubation and extubation.
    1. All staff in room should utilize Airborne Plus precautions during intubation and extubation. LMA can be used as a bridge to intubation or in select cases where benefit outweighs risk of aerosol generation (e.g. ability to perform deep extubation, ability to ventilate spontaneously, avoidance of airway irritation). LMA should be switched for ETT anesthesia if an adequate seal cannot be attained.
    2. Airborne plus precautions are continued until appropriate number of air exchanges have occurred following intubation and extubation.
    3. All staff entering the OR during this time must utilize airborne plus precautions.
    4. A filter should be added to all respiratory connections where possible (vent, Ambu bag, ET tube)
  2. The OR door should not open and no one should enter or leave during this time.
  3. If there is an emergency, any staff entering the room before the air exchanges have occurred are required to wear a N95 respirator.
  4. Pharmacy will be stationed outside the room during an emergency to provide medications
    1. Reduces N95 respirator usage, unless directed to come into the room
  5. The smoke evacuator is the first line of defense when using electrocautery. When it is not available, N95 masks should be used for personnel in the operating room or procedural area, particularly those in the surgical field. Where possible, electrocautery and restricting the number of people in the OR should be minimized. Laparoscopic cases should use a filter on a port.
  6. In cases where the surgical procedure is not high-risk for aerosol generation, surgical mask with face shields will be worn by staff who are not present during intubation and extubation windows to reduce N95 respirator usage.
  7. Communicate intubation and extubation times so that staff outside the room know when the required wait times have been met.
    1. Room RN will document the intubation time and document the time (Intubation time +time required for air exchanges) that other team members can enter the room in appropriate attire post intubation.
    2. A staff member outside the room documents this time on a sign outside the room.
    3. Just before extubation, all staff in the OR who are not essential in the extubation and recovery of the patient will leave the OR.
    4. Room RN will document the time that the team will leave the room with the patient (extubation time + time required for air exchanges) and call the front desk to have the exterior sign changed to reflect the post-extubation wait time.
  8. For COVID-19 Positive, Presumptive Positive (PUI), or Presumptive Negative (PUI) with Clinical Risk Factors, label specimens as “PUI for COVID” or “COVID positive”
  9. Document infection status under notes on the Pathology requisition

Recovery

  1. For COVID-19 Positive, Presumptive Positive (PUI), or Presumptive Negative (PUI) with Clinical Risk Factors, patients will be recovered in the OR by anesthesia and OR staff, and PACU, as appropriate.
    1. COVID negative or non-tested patients may be recovered in PACU after adequate air-exchange has been completed post extubation.

Cleaning

  1. All items should remain in the OR until appropriate number of air exchanges have occurred.
  2. After the designated wait time, room should be terminally cleaned per cleaning guidelines.
  3. Return case cart and notify SPD of patient infection status.
  4. If available, use an ultra-violet machine as part of the room cleaning process.




Obstetrical Care

Mode of transmission of COVID-19/SaRs-CoV-2

At this time, the primary mode of transmission appears to be from respiratory droplets formed by coughing and sneezing from an infected individual as well as through close personal contact. This does not appear to spread through airborne transmission. Vertical transplacental transmission seems rare but may occur. The virus does not appear to be in amniotic fluid, cord blood, or breastmilk from infected mothers.

Pregnancy-specific risks from infection

A systemic review of 19 studies examined 79 women affected by COVID-19, MERS, and SARS. Complications cited included miscarriage, preterm delivery, premature rupture of membranes, preeclampsia, and fetal growth restriction. Specific to COVID-19, there was a higher rate of preterm delivery (about 41%). Although the initial data has been encouraging for COVID-19 with a lower maternal morbidity/mortality than observed with similar coronavirus infections, the data remains sparse. Therefore, until more comprehensive studies of COVID-19 outcomes become available, it is prudent to consider the pregnant population high-risk.

* Attempt to limit the exposure of pregnant personnel (especially those in the third trimester) and other at-risk persons from caring for these patients 

Initial Evaluation

  1. Screen for symptoms upon arrival and proceed with indicated COVID-19 Testing algorithm as appropriate depending on presence or absence of symptoms (see Obstetrical Care Process Flow Diagram)
  2. Notification of charge nurse once PUI suspected
  3. Patient placed on droplet plus precautions or airborne plus precautions as clinically indicated.
  4. Refer to Specimen Collection Procedure section for detailed information about procedure and PPE requirements.
  5. Consult infectious disease physician on all PUI or COVID positive patients
    1. Candidates for outpatient monitoring should be capable of breathing without significant discomfort, maintaining normal oxygenation (>94% on room air), and tolerating PO intake
    2. If admission deemed necessary, notify house supervisor and NICU charge nurse (if preterm or NICU care anticipated). Admit either to L&D (negative pressure room, if available) or a COVID-19-specific unit (as designated by the individual hospital) based on clinical needs.

Antenatal Management

  1. Perform COVID-19 test on all antepartum patients who were not COVID-positive in the previous 90 days and are asymptomatic on admission.
  2. Does not require continuous external fetal monitoring for COVID-19 alone. Should be considered if maternal instability.
  3. Continuous pulse oximetry is recommended with respiratory symptoms
  4. Antenatal corticosteroids may worsen the maternal clearance of the virus. Late pre-term corticosteroids (>34 weeks) is not recommended for COVID positive, Presumptive Positive (PUI), or Presumptive Negative (PUI) with clinical risk factors patients at this time. This may be individualized to the clinical circumstance.
  5. If respiratory distress, early escalation of respiratory support recommended. In the case of significant ARDS requiring mechanical ventilation and prone positioning, take care to provide adequate cushioning for the gravid abdomen to avoid placing body weight on the abdomen.
  6. At this time, iatrogenic preterm delivery is not recommended as a treatment for COVID-19.
  7. CT Chest (abdominal shielding preferable) may be used to evaluate severity of illness and potentially confirm diagnosis
  8. Consider assigning the same care teams to the patient to limit the transmission risk and thus risk of needing to quarantine multiple staff members
  9. Bedside ultrasound preferred
  10. Consultation of Maternal-Fetal Medicine, particularly if ICU admission

Labor and Delivery Room Management of COVID-19 Positive, Presumptive Positive (PUI), OR Presumptive Negative (PUI) with Clinical Risk Factors Obstetrical Patient

L&D Visitation for COVID-Positive Mom

  • Symptomatic partner – no visitation
  • Known COVID-positive partner:
    • Visitation for delivery only if 10-day Screening Criteria for Resolution of COVID are not met
      • Partner must wear hospital-provided mask at all times
      • Partner must stay in mother’s room at all times
      • After delivery, partner should be escorted out by staff and not allowed to visit until Screening Criteria for Resolution of COVID are met
    • Normal visitation if 10-day Screening Criteria for Resolution of COVID are met
  • Partner with unknown COVID status:
    • Partner must wear hospital-provided mask at all times
    • Partner must stay in mother’s room at all times
    • If partner leaves mother’s room, they should be escorted out by staff and not allowed to return

L&D Visitation for COVID-Negative Mom

  • Symptomatic partner – no visitation
  • Known COVID-positive partner:
    • Visitation for delivery only if 10-day Screening Criteria for Resolution of COVID are not met
      • Partner must wear hospital-provided mask at all times
      • Partner must stay in mother’s room at all times
      • After delivery, partner must be escorted out by staff and not allowed to visit until Screening Criteria for Resolution of COVID are met
    • Normal visitation if 10-day Screening Criteria for Resolution of COVID are met
  • Partner with unknown COVID status – normal visitation

L&D General COVID Guidance

  1. Reserve induction of labor for standard obstetrical indications
  2. Water birth is contraindicated
  3. Droplet Plus or Airborne Plus precautions when Clinically Indicated for all healthcare providers while in room. It is particularly important to use proper PPE upon room entry, even when urgent patient evaluation is needed.
  4. Airborne Plus precautions are recommended for personnel present during aerosolizing procedures including intubation
  5. Airborne Plus precautions should be used during the second stage of labor. This is also true for Non-COVID (not -tested) patients. (Facemask and standard precautions are adequate for asymptomatic patients that test negative for COVID-19).
  6. Patient to wear face mask, if possible, in the second stage to reduce the risk of droplet transmission
  7. Recommend early epidural placement in an attempt to avoid intubation for emergent procedures, which are aerosolizing
  8. Recommend oxygen mask instead of nasal cannula to avoid inadvertent aerosolization of infection
  9. Reserve supplemental oxygen for maternal indications
  10. Avoid inhaled nitrous oxide in COVID-19 positive or COVID-19 unknown patients, due to risk of contaminating equipment and risk of inadequate sterilization. For patients with a diagnostic test confirmed negative, nitrous oxide may continue to be offered as an option for analgesia.
  11. If NICU staff needed at delivery, preferable for them to remain outside of the delivery room until delivery imminent
    1. NICU staff should utilize Airborne Plus precautions
  12. Infant warmer should be placed at least 6 feet from bedside
  13. If the placenta/membranes are sent to pathology, these should be marked as from a COVID Positive or COVID PUI patient, though they do not need to be sent for this indication alone
  14. If possible, keep patient in delivery room until discharge.
    1. If transferring to postpartum, this should be performed by L&D staff and not hospital transportation. Elevator should be empty during transportation between floors
    2. Patient to wear face mask during transport

Operating Room Management

  1. Cesarean delivery should be reserved for standard obstetrical indications
  2. Entity leadership discretion as to who may be in delivery suite (support person). These individuals to don appropriate PPE prior to entering the operating room
  3. Patient to wear face mask for transport to and from operating room
  4. Infant warmer should be placed at least 6 feet from OR table
  5. Recommend early epidural placement to achieve adequate anesthesia instead of requiring intubation
  6. Staff and providers present should utilize Airborne Plus precautions. This is also true for Non-COVID (not tested) patients. (Facemask and standard precautions are adequate for asymptomatic patients that test negative on the COVID-19 test).

OR Room Cleaning

  1. All items should remain in the OR until appropriate number of air exchanges have occurred.
  2. After the designated wait time, room should be terminally cleaned. EVS staff should wear face mask and other routine PPE if the room is empty.
  3. EVS Staff should wear Airborne Plus PPE if cleaning within one hour of aerosol-generating procedure.
  4. Return case cart and notify SPD of patient COVID-19 infection status.
  5. If available, use ultra-violet light as part of room cleaning process.

Postnatal Management

COVID-positive mom and well newborn rooming-in:

  • There is no clinical evidence, thus far, that well newborns who room-in with a COVID positive mom have a worse outcome, therefore COVID-positive moms and well newborns may room-in.
  • During the birth hospitalization, the mother should maintain a reasonable distance from her infant when possible. When mother provides hands-on care to her newborn, she should wear a mask and perform hand-hygiene. Use of an isolette may facilitate distancing and provide the infant an added measure of protection from respiratory droplets.
  • If non-infected partners or other family members are present during the birth hospitalization, they should use masks and hand hygiene when providing hands-on care to the infant.
  • If the mother is acutely ill with COVID-19 and unable to care for her infant in a safe way, it may be appropriate to temporarily separate mother and newborn or to have the newborn cared for by non-infected caregivers in mother’s room.

Breastfeeding:

  • Breastfeeding is not contraindicated.
  • Mothers should perform hand hygiene before breastfeeding and wear a mask during breastfeeding.
  • If an infected mother chooses not to nurse her newborn, she may express breast milk after appropriate hand hygiene, and this may be fed to the infant by other uninfected caregivers.
  • Mothers of NICU infants may express breast milk for their infants during any time that their infection status prohibits their presence in the NICU.

See Neonatal Care guidelines for care of infant





Obstetrical Care Process Flow Diagram

*Refer to General Infection Control Guidelines for patient transport information





Neonatal Care of Infant born to mother who is COVID-19 Positive, Presumptive Positive (PUI), or Presumptive Negative (PUI) with Clinical Risk Factors

Newborn Risk

  1. It remains unclear if COVID-19 is vertically transmitted from mother to fetus antenatally via maternal viremia and transplacental transfer. Prior published experience with respiratory viruses would suggest this is unlikely.
  2. Perinatal exposure may be possible at the time of vaginal delivery based on the detection of virus in stool and urine.
  3. Newborns are at risk of infection from a symptomatic mother’s respiratory secretions after birth, regardless of delivery mode

Delivery room management

  1. Neonatal Clinician should attend deliveries based on their normal center-specific policies-Maternal COVID-19 alone is not an indication for neonatal team delivery attendance
  2. Hospitals and physicians may reevaluate the appropriateness of institutional traditions for mandatory attendance by the neonatal team at low risk deliveries and instead allow the neonatal team to “standby” to conserve PPE
  3. Newborn resuscitation should not be compromised to facilitate maternal/infant separation however, resuscitation should occur at the infant warmer at least 6 feet from mom if possible
  4. All providers in the delivery room during the delivery process should practice Airborne Plus precautions.
  5. Avoid Skin to Skin Care
  6. Delayed Cord Clamping can be considered, especially in infants less than 30 weeks gestation. Decision should be made on a case by case basis in discussion with OB provider

Well Newborn Admission

  1. Infant should be bathed as soon as is reasonably possible after birth
  2. Refer to Appendix E for additional guidance for handling milk of COVID-19 positive mother or PUI. All providers/caregivers should practice Droplet Plus precautions or Airborne Plus precautions, as clinically indicated. Follow Texas Health visitation guidelines. 
  3. Testing should be reserved for infants whose mothers test positive or presumptive positive for COVID-19 (see below for further guidance on testing infants with a COVID Positive mother). When the mother’s initial status is presumptive negative, a repeat test is performed on mothers with clinical risk factors for COVID-19 at 24 hours. If both of the mother’s tests are negative, testing of the infant is not indicated.
  4. Well newborns should receive all indicated care including circumcision if requested.
  5. Well newborns should be discharged from the birth hospital based on the center’s normal criteria with the following specific considerations
    1. Infants having positive COVID testing but with no symptoms of COVID-19 may be discharged home with appropriate precautions and plans for frequent outpatient follow-up contacts via phone, telemedicine, or in-office through 14 days after birth. Specific guidance regarding precautions for caretakers should be provided. See http://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.html. Uninfected individuals >60 years of age or with comorbid conditions should not provide care if possible.
    2. Infants born to COVID-19 positive moms with negative infant testing should be optimally discharged to a designated healthy caregiver. If the mother is in the same household, she should maintain a distance of at least 6 feet from infant as much as possible and use a mask and perform frequent hand hygiene if closer contact is required until EITHER of following criteria have been met
      1. she has been afebrile for 24 hours without antipyretics, symptoms are improving (cough, shortness of breath) AND at least 10 days have passed since symptoms first appeared
      2. she has had negative COVID testing from two consecutive nasopharyngeal swab specimens collected at least 24 hours apart

NICU Admission for infant born to PUI, COVID Positive, Presumptive Positive (PUI) or Presumptive Negative (PUI) with clinical risk factors mother

  1. Isolation Precautions for NICU
    1. Airborne Plus for patients on CPAP, ventilator, or on oxygen at a flow of greater than 2 LPM. This is increased from the previous greater than 1 LPM.
    2. Droplet Plus for patients on Nasal Cannula less than 2 LPM
  2. Infants should be admitted to a single patient room, preferably with negative pressure capabilities if available. Infants requiring Airborne Plus isolation must ALWAYS be housed in a single patient room. Infants requiring Droplet Plus isolation should be ideally housed in a single patient room but if one is not available, these infants could be housed in a shared patient area with a minimum of 6 feet and a physical barrier between patients.
  3. Infant should be bathed as soon as reasonably possible after birth
  4. Refer to Appendix E for additional guidance for handling milk of COVID-19 positive mother or PUI
  5. The respiratory therapy manager, charge nurse, nurse manager, and the medical director for the NICU/SCN should be notified on admission
  6. Attempt to limit the exposure of pregnant personnel (especially those in the third trimester) and other at-risk persons from caring for these infants
  7. In the absence of evidence, routine care including CPAP management is indicated. The evidence for early intubation exists only for adults and older pediatric patients and there is data that early intubation for preterm infants may be harmful
  8. Testing should be reserved for infants whose mothers test positive or presumptive positive for COVID-19. When the mother’s initial status is presumptive negative, a repeat test is performed on mothers with clinical risk factors for COVID-19 at 24 hours. If both of the mother’s tests are negative, testing of the infant is not indicated.
  9. Maternal visitation-Maternal PUI, COVID Positive or Presumed Positive (PUI), or Presumptive Negative (PUI) with clinical risk factors mom may not visit until cleared from requiring any isolation precautions by Infectious Disease and hospital infection prevention. Maternal visitation if PUI tests COVID-19 negative depends on maternal symptomatology and diagnosis and should be evaluated on a case by case basis with NICU manager and hospital infection prevention team.
  10. Support persons exposed to PUI/COVID-19 positive mom may not visit until completion of 14 days of quarantine if maternal testing is positive, or until mother’s COVID testing results are confirmed negative.
  11. Availability of Angel Eye webcams will be encouraged

COVID Testing for Infants born to COVID-positive Moms

  • Bathe after birth to remove virus potentially present on skin surfaces.
  • Obtain either a single swab of the nasopharynx; or a single swab of the throat followed by the nasopharynx; or two separate swabs from each of these sites and submit for a single test. Refer to Laboratory for Specimen Collection Guidelines.
  • Test at approximately 24 hours of age and again at approximately 48 hours of age.
  • If it is planned that a healthy newborn will be discharged prior to 48 hours of age, clinicians may choose to order a single test at 24-48 hours of age.
  • For infants who are positive on their initial testing, perform follow-up testing every 72 hours intervals until two consecutive negative tests are obtained to establish that the infant has cleared the virus from mucosal sites.
  • For positive infants needing ongoing hospital care, caregivers should continue to use appropriate personal protective equipment until discharge, or until the infant has two consecutive negative tests collected greater than or equal to 24 hours apart. This stringent PCR test-based approach may be optimal for sick and premature newborns as the duration of shedding infectious virus has not been established for such infants.

COVID-19 Precautions for the NICU/SCN for ALL VISITORS

  1. Visitation is limited to 2 primary care givers of infants (typically the mother and father). No grandparents or visitors less than 18 years old will be allowed entry. Exceptions must be discussed with NICU manager, SCN manager, and medical director.
  2. Out of an abundance of caution, all visitors entering the NICU will be asked to submit to temperature taking and COVID screening questionnaire.
  3. Suggested Questions for COVID questionnaire:
    1. Have you had any viral symptoms, including: unexplained fever, muscle aches, cough, sore throat, sneezing, breathing problems, stomach aches, or diarrhea in the past 5 days
    2. Have you been exposed to anyone with COVID-19 disease or anyone being tested for COVID-19 disease?
  4. All visitors will be asked to comply with THR’s universal masking policy
  5. Exceptions to visitation by COVID-positive mother and partner should be considered for special situations, such as infant end-of-life
  6. Mother and partner must wear hospital-provided masks
  7. If both mom and partner are unable to visit, they may designate a single visitor who has no COVID symptoms and no exposure to confirmed/suspected COVID persons.
  8. NICU Visitation by mother/partner exposed to confirmed/suspected COVID-positive person:
    1. No visitation for 14 days after exposure to confirmed/suspected COVID-positive person. Exposure is defined as being within 6 feet of a confirmed/suspected COVID-positive person for ≥15 minutes
    2. Mother and partner must wear hospital-provided masks
    3. If both mom and partner are unable to visit, they may designate a single visitor who has no COVID symptoms and no exposure to confirmed/suspected COVID persons

NICU Visitation by COVID-positive mother and partner

  • Positive mother and her partner are allowed to visit NICU infant if:
    • 24 hours have passed without symptoms AND without the use of fever-reducing medication
      AND
    • 10 days have passed since first symptom or initial positive test date (if asymptomatic)
  • Exceptions to visitation by COVID-positive mother and partner should be considered for special situations, such as infant end-of-life
  • Mother and partner must wear hospital-provided masks.
  • If both mom and partner are unable to visit, they may designate a single visitor who has no COVID symptoms and no exposure to confirmed/suspected COVID persons.




Neonatal Care Process Flow Diagram




Cardiovascular Care

The Heart & Vascular Council has assembled the below COVID-19 guidance for cardiovascular services based on American College of Cardiology and American Society of Echocardiography recommendations. The intent is to provide guidance during an inpatient COVID surge state where hospital resources, including clinical staff and appropriate PPE, are constrained relative to the volume of COVID-19 patients requiring cardiovascular care. 

  1. Echocardiograms (TTEs, stress echoes and TEEs) should be performed only when the benefit to patient care outweighs risk (from the procedure or from potential staff exposure). Repeat echocardiograms should not be performed unless there has been a clear change in clinical status.

    TEEs carry a risk of COVID-19 spread since they can provoke aerosolization. TEEs therefore deserve consideration in determining when and whether they should be performed. https://www.asecho.org/ase-statement-covid-19/
  2. Cath/PCI: should be performed in accordance with best practices and evidence-based medicine as with the non-COVID patient. However, special consideration should be given to the COVID patient who requires a cath lab procedure in terms of clinical benefit versus staff exposure risk. Consider when noninvasive or clinical parameters (STEMI, ongoing ACS, high risk NSTEMI) place the patient in a high cardiovascular risk group that would likely benefit from invasive testing/intervention compared to aggressive medical therapy.
  3. STEMI patients are at high risk for instability and developing situations during their intervention leading to aerosolization; the caregiver team should anticipate this prior to starting the case and utilize Airborne Plus PPE precautions.
    1. In the setting of “field activation” of the Cardiac Cath lab for STEMI, patients should undergo a screening evaluation in the ED with cardiology consultation before moving forward to the cath lab. This screening evaluation should include a rapid COVID test if feasible.
    2. For those patients being transferred from an outside facility, where the transferring physician has already consulted with the cardiology/cath lab attending, patient may go straight to the cardiac cath lab without entering the ED. THR STEMI receiving facilities will now accept STEMI transfers that have been clinically screened by outlying THR community hospitals directly to the Cath Lab.
    3. Transfer to Cardiac Cath Lab should not be delayed for pending COVID test results (if a test result is unavailable, use Airborne Plus PPE precautions).
  4. ACE/ARB recommendation: The HFSA, ACC, and AHA recommend continuation of RAAS antagonists for those patients who are currently prescribed such agents for indications for which these agents are known to be beneficial, such as heart failure, hypertension, or ischemic heart disease. In the event patients with cardiovascular disease are diagnosed with COVID-19, individualized treatment decisions should be made according to each patient's hemodynamic status and clinical presentation. Therefore, be advised not to add or remove any RAAS-related treatments, beyond actions based on standard clinical practice.
  5. Any CV case requiring deep sedation (as defined by the guidelines below), intubation, or would be reasonably expected to generate aerosol (TEE) should have pre-procedural COVID testing.

    https://www.asahq.org/standards-and-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedationanalgesia

    From a practical standpoint, clinical judgment for any individual case still holds-if the care team felt that moderate sedation in an untested patient created an aerosol risk, wearing N95s during the procedure would be reasonable. Likewise, any patient can also be referred for pre-procedural testing based on physician discretion.
  6. PPE recommendations: Cardiac procedures should follow the guidance provided in the current version of the PPE rubric

Cardiac Rehab: Clinical Guidance for Service Resumption During COVID-19

  1. Patient prioritization: Given current testing capacity and clinical workflow changes driven by the COVID 19 pandemic, re-opening of cardiac rehab (CR) should be executed in a phased approach. Although all patients enrolled in CR are known to gain benefit from the program, prioritization should be given to those patients who might garner the greatest benefit/risk ratio. This includes initially those patients:
    • Post myocardial infarction (generally within 2-4 weeks post event)
    • Post cardiac surgery (CABG) (generally within 4-6 weeks post procedure)

      Patients with these qualifying diagnoses who were in an active course of therapy prior to suspension of CR services or whom did not initiate therapy during the CR downtime are also eligible to resume or begin a rehabilitation course.
  2. Duration of CR: A “short course” strategy (4-6 weeks) of CR may be considered in those patients who achieve appropriate fitness goals, show no evidence of significant arrhythmias, recurrent ischemia or abnormal blood pressure responses to supervised, monitored exercise, and demonstrate understanding of rehabilitation objectives. A strong relationship with the CR team, as well as clear contact information for these patients should questions arise will facilitate progression of CR to a home-based strategy and should be mandatory.
  3. Testing and screening recommendations: To ensure a safe environment for our staff and all patients while providing the best evidence-based care to our patients, the following recommendations pertain to testing and screening patient for CR:
    • All patients, not positive for COVID in the previous 90 days, should be tested for COVID-19 prior to initiating CR.
    • All patients and involved family members should be given clear and thorough education regarding social distancing and high awareness of social isolation throughout their course of CR.

      Screening Criteria for Resolution of COVID (excluding NICU, refer to NICU section):

      • 24 hours afebrile without the use of fever-reducing medications, AND
      • Improving symptoms, AND
        • 10 days since onset symptoms or date of positive test (if asymptomatic) for mild to moderate illness
          OR
        • 20 days since onset symptoms or date of positive test (if asymptomatic) for severe/critical illness (see below) or severely immunocompromised (see below)

      Criteria for Severe/Critical Illness:

      • ICU admission
      • Greater than 3 LPM oxygen
      • On COVID therapy (Remdesivir, plasma, Tocilizumab, steroids)

      Criteria for Severely Immunosuppressed:

      • Cancer/on chemotherapy
      • Bone marrow transplant
      • Solid organ transplant
      • Stem cells for cancer treatment
      • Genetic immune deficiencies (ex: common variable immune deficiency, selective IgA deficiency, severe combined immunodeficiency, chronic granulomatous disease, and complement deficiencies.
      • HIV (CD4 Less than 200 and/or not on effective highly active anti-retroviral therapy)
      • Use of oral or intravenous corticosteroids or other medicines called immunosuppressants that lower the body’s ability to fight some infections (e.g., mycophenolate, sirolimus, cyclosporine, tacrolimus, etanercept, rituximab)
      • HIV diagnosis
      • On HIV medications
      • Over the age 70??
      • Type 2 Diabetes mellitus on Problem List
      • ESRD on Problem List
      • Receipt of prednisone greater than 20mg/day for greater than 14 days
      • Neutropenia (two separate days with ANC and/or WBC values less than 500)
      • DMARDs (Disease-modifying anti-Rheumatic drugs)

  4. PPE, patient masking and social distancing in the CR setting:
    • All patients must undergo a temperature check and recommended COVID-19 symptom questionnaire prior to entering the facility. It is recommended that anyone with a fever of 100.0 or above, or with recent contact with a COVID 19 positive person should not be allowed to exercise.
    • Studies have shown that due to the increased ventilation associated with exercise there is a farther degree of aerosolization. Therefore, it is recommended that patients are 12 feet away from each other as well as staff while exercising. This requirement may require creative placement of exercise equipment or staggering of patients throughout the day.
    • It is recommended that all staff wear gloves and eye protectino at all times;
    • For staff who are required to be less than 12 ft. to a patient during active exercise, it is recommended that staff wear a N95 mask, face shield, and gloves during those times.
    • Diligent wipe down with appropriate disinfectant of equipment and space around equipment after every use is mandatory.
    • Patients should wear masks upon entry to the facility and during warm up/stretching. However, it is not recommended that patients wear mask during exercise. This is to inhibit any unwanted rebreathing of CO2, breakdown of mask integrity due to humidified air, as well as false perception of increased work of breathing.
    • All patients should wear exercise gear upon entrance to the facility to avoid the need to change in locker rooms. Gym bags should be kept 6 feet apart and patient water bottle should be brought in from home rather than the use of water fountains. Alternative consideration is to supply a water bottle from the facility to lessen any from home exposure.
    • If possible, provide Therabands to each patient to take home rather than re-use in the facility.
    • Facility rooms should be well ventilated and air conditioned. Avoiding the use of fans; both ceiling and close to patient.
    • To the extent possible, CR operations should be consistent with a “no touch experience” for the patient. Elimination of the use of clipboards, sign in sheets, and other such items is strongly recommended.




Hemodialysis

Patients with AKI and ESRD in the ICU:

  1. Nephrologist will follow THR Policy and CDC recommended PPE and safety guidelines during their interactions with the patients.
  2. Nephrologist should consider minimizing/avoiding daily patient contact by collaborating with the ICU team and relying on ICU personnel assessment to convey relevant physical exam and ultrasound finding such as volume status.
  3. Established RRT practices and equipment should be used to manage COVID-19/PUI patients with AKI and ESRD.
  4. CRRT should be the preferred modality of renal replacement therapy in critically ill patients.
  5. If patient surge overwhelms the CRRT capacity, consideration should be given to using available hemodialysis machines for prolonged intermittent treatments in SLED mode, and then using the machine for another patient, after terminal cleaning.

Patients with AKI and ESRD in the General Hospital Floors:

  1. Nephrologist will follow THR Policy and CDC recommended PPE and safety guidelines during their interactions with the patient.
  2. Nephrologist should consider minimizing/avoiding daily patient contact by collaborating with primary physician and relying on them to convey relevant physical exam and ultrasound finding such as volume status.
  3. Transferring active or suspected COVID-19 patients to the dialysis unit for treatment is not recommended. The recommendation is to use available portable hemodialysis equipment at the bedside. Placing the patient in a room large enough to accommodate portable equipment is advised.

Patient Care:

  1. Perform COVID-19 test on any patient who has received a transplant due to the immunosuppressed state.
  2. Suspected or confirmed COVID-19 patients should be co-located or cohorted in the dedicated COVID-19 units
  3. If available, non-acute care and non-dialysis nurses may be recruited to monitor patients undergoing renal replacement therapy, with the supervision of an ICU nurse or dialysis nurse.
  4. ESRD PUI do not need to be hospitalized for dialysis, awaiting resulting COVID-19 results. The respective outpatient units do have policy in place for care of PUIs.

Vascular Access:

  1. If patients develop indications to start renal replacement therapy (of if an ESRD patient needs a dialysis catheter for vascular access), this will be placed by an ICU provider or nephrologist with significant expertise in placement of central venous catheters.
  2. For patients with ESRD who have AVF or AVG, CRRT and PIRRT using AVF/AVG could be considered if 1:1 ICU nursing is available and careful monitoring of the patient is possible. Needle dislodgment and exsanguination is a major concern, and we emphasize the need for close monitoring if PIRRT and CRRT are performed using AVF or AVG.

Care and Disinfection of the Renal Replacement Equipment:

  1. CRRT filter changes can be performed every 72 hours or extended beyond this if necessary.
  2. After treatment, dialysis equipment should be cleaned with a disinfectant from the EPA List N per CDC and manufacturers recommendations. The equipment should be disinfected before being removed from the room.
  3. All disposable CRRT machine equipment (tubing/filter set, CRRT solution bag, etc.) should be discarded according to routine practices.
  4. Further guidance regarding RRT Machine disinfection AND approved disinfection cleaning products for COVID-19 can be found at the CDC and EPA (List N) website noted below:
    https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/dialysis.html




Wound Care Clinics

Clinical Guidance on Resumption of Services

  1. Prior to first clinic appointment, COVID Testing should be performed on patients referred from or residing in post-acute care facilities (SNFs, NH, IRFs, LTACHs) who were not COVID-positive in the previous 90 days and are asymptomatic at the time of treatment. Patient from these facilities receiving recurrent treatments should be tested prior to their first appointment and at least every 7 days during their course of care. Patients currently residing in a SNF, NH, IRF, or LTAC should be tested through that facility.
  2. New referrals or established patients in the clinic who reside at home do not require COVID testing, provided that they are asymptomatic and have had no known exposures to a patient with COVID.
  3. All patients should be screened clinically for symptoms or known exposures to a patient with COVID on arrival to every clinic visit. If a patient screens positive, unless emergent care is needed, the wound care visit should be postponed, and the patient referred to their PCP.
  4. PPE should be determined by patient and procedure specific factors:
    • Symptomatic, COVID test positive patient
      -Care should be postponed
      -If clinically emergent, schedule at end of day and follow Airborne Plus precautions for all procedures
    • Asymptomatic, COVID test positive patient
      -Care should be postponed
      -If clinically emergent, schedule at end of day and follow Airborne Plus precautions for all procedures
    • Post-acute care resident (regardless of test result)
      -Airborne Plus precautions for aerosol generating procedures
    • Post-acute care resident, COVID test negative
      -Standard precautions for non-aerosol generating procedures
    • Home residing, untested patient
      -Airborne Plus precautions for aerosol generating procedures
      -Standard precautions for non-aerosol generating procedures




Pulmonary Rehab

  1. Patient prioritization: Given current testing capacity and clinical workflow changes driven by the COVID 19 pandemic, re-opening of pulmonary rehab (PR) should be executed in a phased approach. Although all patients enrolled in PR are known to gain benefit from the program, prioritization should be given to those patients who might garner the greatest benefit/risk ratio (e.g., COPD, pulmonary hypertension, restrictive lung disease). This decision should be made by the referring physician with consultation of the Pulmonary Rehab Medical Director if necessary.
    1. For patients who were previously enrolled in PR prior to the COVID-19 pandemic, confirm with the prescribing physician whether patient should be scheduled for resumption of therapy.
  2. Duration of PR: A “short course” strategy of PR may be considered in those patients who achieve appropriate therapy goals and demonstrate understanding of rehabilitation objectives. A strong relationship with the PR team, as well as clear PR contact information for these patients, should questions arise, will facilitate progression of PR to a home-based strategy and should be mandatory.
  3. Testing and screening recommendations: To ensure a safe environment for our staff and all patients while providing the best evidence-based care to our patients, the following recommendations pertain to testing and screening patient for PR:

    Guiding principles
    • All patients should be tested for COVID-19 prior to initiating PR if they were not COVID-positive in the previous 90 days and are asymptomatic at the time of therapy.
    • All patients and involved family members should be given clear and thorough education regarding social distancing and high awareness of social isolation throughout their course of PR.
    • Based on current clinical evidence pertaining to transmissible viral shedding and CDC guidelines, it is not necessary to re-test an asymptomatic patient with a COVID Positive test result within 90 days of their initial positive result prior to initiating a course of therapy.

      Recommend the following approaches based on pre-therapy initiation test results:

      COVID Positive / Asymptomatic: Patient should undergo clear and thorough education on self-isolation and begin at home quarantine for at least 10 days from the date of the positive test result. No further COVID testing required to begin therapy within 90 days following the initial positiveresult. Refer to Criteria for Resolution of COVID

      COVID Positive / Symptomatic: Patient should undergo clear and thorough education on self-isolation and begin at home quarantine. Per CDC recommendations, patient must continue self-quarantine until asymptomatic and afebrile x 24 hours without fever-reducing medications, and they are at least 10 days post-first symptoms. Refer to Criteria for Resolution of COVID. No further COVID testing required to begin therapy within 90 days following the initial positive result.

      COVID Negative: Patient may start PR with strict adherence to temperature checks and symptom screener prior to each session. Patients should be retested after 30 days to confirm negative COVID status.

      Prior testing: In alignment with other Texas Health procedural and service testing algorithms, it is reasonable to initiate PR on those asymptomatic patients with a negative COVID 19 test documented less than 7 days prior to therapy initiation. For those tests with results 7 days or older, it is recommended they undergo a new COVID-19 test prior to initiating the PR course.
  4. PPE, patient masking and social distancing in the PR setting:
    • All patients must undergo a temperature check and recommended COVID-19 symptom questionnaire prior to entering the facility. It is recommended that anyone with a fever of 100.0 or above or a positive symptom screen should have therapy cancelled/postponed until safe to resume, per physician and PR team judgment.
    • Patients should wear masks upon entry to the facility and during warm up/stretching. It is not recommended that patients wear a mask during exercise. This is to inhibit any unwanted rebreathing of CO2, breakdown of mask integrity due to humidified air, as well as false perception of increased work of breathing. However, the patient may be allowed to wear amask, if he/she desires to do so.
      • Studies have shown that due to the increased ventilation associated with exercise there is a farther degree of aerosolization. Therefore, it is recommended that patients are 12 feet away from each other as well as staff while This requirement may require creative placement of exercise equipment or staggering of patients throughout the day.
      • It is recommended that all staff wear gloves and eye protection at all times.
      • For staff who are required to be less than12 ft. to an unmasked patient during active exercise, it is recommended that staff wear a N95 mask, face shield, and gloves during those times. If the patient is wearing a mask, an N-95 mask is not required for staff within 12 feet.
    • Diligent wipe down with appropriate disinfectant of equipment and space around equipment after every use is mandatory.
    • All patients should wear exercise gear upon entrance to the facility to avoid the need to change in locker rooms. Gym bags should be kept 6 feet apart and patient water bottle should be brought in from home rather than the use of water fountains. Alternative consideration is to supply a water bottle from the facility to lessen any from home exposure.
    • If used as part of the PR program, provide Therabands to each patient to take home rather than re-use in the facility.
    • Facility rooms should be well ventilated and air conditioned. Avoiding the use of fans; both ceiling and close to patient.
    • To the extent possible, PR operations should be consistent with a “no touch experience” for the patient. Elimination of the use of clipboards, sign in sheets, and other such items is strongly recommended.
  5. Cleaning of Equipment:
    • Diligent wipe down with appropriate disinfectant of equipment and space around equipment after every use is mandatory.

Pulmonary Function Tests (PFT):

  1. All patients should be tested for COVID-19 prior to performing PFT
  2. Follow appropriate PPE guidance (see Appendix A)
  3. Utilize MDI when possible; if nebulizers are necessary, utilize appropriate PPE for aerosol generating procedure




Post-mortem Care and Autopsy

Droplet Plus PPE should be worn when performing post-mortem care. Body should be double bagged. After patient has been placed in bags, wipe down outer bag with disinfectant wipes. If patient has been delivered to the morgue, wipe down transport morgue cart with disinfectant wipes per usual protocol.

If an autopsy is performed, collection of the following postmortem specimens is recommended:

  1. Postmortem clinical specimens for testing for SARS-CoV-2, the virus that causes COVID-19:
    1. Upper respiratory tract swab: Nasopharyngeal Swab (NP swab)
    2. Lower respiratory tract swab: Lung swab from each lung
  2. Separate clinical specimens for testing of other respiratory pathogens and other postmortem testing as indicated
  3. Formalin-fixed autopsy tissues from lung, upper airway, and other major organs

If an autopsy is NOT performed, collection of the following postmortem specimens is recommended:Ad

  1. Postmortem swab specimens for testing of other respiratory pathogens,
  2. Other postmortem microbiologic and infectious disease testing, as indicated
  3. Formalin-fixed autopsy tissues from lung, upper airway, and other major organism addition to postmortem specimens, any remaining specimens (e.g., NP swab, sputum, serum, stool) that may have been collected prior to death should be retained.

Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19) for more information.

Detailed guidance for postmortem specimen collection can be found in the section: 

Collection of Postmortem Clinical and Pathologic Specimens

Collection of Postmortem Upper Respiratory Tract Swab Specimens

  1. Individuals in the room during the procedure should be limited to healthcare personnel (HCP) obtaining the specimen. If HCP are not performing an autopsy or conducting aerosol generating procedures (AGPs), follow Droplet Plus Precautions.

Engineering Control Recommendations

  1. Since collection of nasopharyngeal swab specimens from deceased persons will not induce coughing or sneezing, a negative pressure room is not required if only a NP swab is being collected from the decedent. Personnel should adhere to Droplet Plus Precautions as described above.

Autopsy Procedures

Airborne Plus precautions should be followed during autopsy. Many of the following procedures are consistent with existing guidelines for safe work practices in the autopsy setting; see Guidelines for Safe Work Practices in Human and Animal Medical Diagnostic Laboratories.

  1. AGPs such as use of an oscillating bone saw should be avoided for confirmed or suspected cases of COVID-19. Consider using hand shears as an alternative cutting tool. If an oscillating saw is used, attach a vacuum shroud to contain aerosols.
  2. Allow only one person to cut at a given time.
  3. Limit the number of personnel working in the autopsy suite at any given time to the minimum number of people necessary to safely conduct the autopsy.
  4. Limit the number of personnel working on the human body at any given time.
  5. Use a biosafety cabinet for the handling and examination of smaller specimens and other containment equipment whenever possible.
  6. Use caution when handling needles or other sharps, and dispose of contaminated sharps in puncture-proof, labeled, closable sharps containers.
  7. A logbook including names, dates, and activities of all workers participating in the postmortem and cleaning of the autopsy suite should be kept to assist in future follow up, if necessary. Include custodian staff entering after hours or during the day.

Engineering Control Recommendations

Autopsies on decedents with known or suspected COVID-19 should be conducted in Airborne Infection Isolation Rooms (AIIRs). PPE Recommendations:

The following PPE should be worn during autopsy procedures:

  1. Double surgical gloves interposed with a layer of cut-proof synthetic mesh gloves
  2. Fluid-resistant or impermeable gown
  3. Waterproof apron
  4. Face shield
  5. N-95 respirator or higher
    1. Powered, air-purifying respirators (PAPRs) with HEPA filters may provide increased worker comfort during extended autopsy procedures.

Surgical scrubs, shoe covers, and surgical cap should be used per routine protocols. Doff (take off) PPE carefully to avoid contaminating yourself and before leaving the autopsy suite or adjacent anteroom (https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf).

After removing PPE, discard the PPE in the appropriate laundry or waste receptacle. Reusable PPE (e.g., goggles, face shields, and PAPRs) must be cleaned and disinfected according to the manufacturer’s recommendations before reuse. Immediately after doffing PPE, wash hands with soap and water for 20 seconds. If hands are not visibly dirty and soap and water are not available, an alcohol-based hand sanitizer that contains 60%-95% alcohol may be used. However, if hands are visibly dirty, always wash hands with soap and water before using alcohol-based hand sanitizer. Avoid touching the face with gloved or unwashed hands.