clinical pathway: ct children’s ed and inpatient covid …...(see cap pathway), respiratory...

THIS PATHWAY SERVES AS A GUIDE AND DOES NOT REPLACE CLINICAL JUDGMENT.

CLINICAL PATHWAY: CT Children’s ED and InpatientCOVID-19 Algorithm

LAST UPDATED: 1.29.21

©2019 Connecticut Children’s Medical Center. All rights reserved. 19-004

Ensure patient wears surgical mask.

Is patient immunocompromised including but not limited to: 60 days old,

receiving immunomodulators or chronic steroids, sickle cell anemia,

neutropenia and/or oncology patient?Consult on-duty ED attending

for guidance.

If clinically stable: if possible, place in zone B

After rooming, follow care below1

Does patient have moderate to severe respiratory distress within the past 72 hours?

ANDWithin the past 14 days, does the patient have:

A positive COVID-19+ test orclose contact2 with a COVID-19

positive person?

If patient has any one of the following: fever, mild respiratory symptoms, travel to high risk area, chilblains, loss of smell/taste, positive COVID-19 test or close contact2 with COVID-19 positive person Place in any available private room

If no COVID-19 risk factorsabove place in any available bed

After rooming, follow care below1

Place in Rooms 3 or 5 if possible; otherwise, any available private room (see COVID-19 ED Surge Plan)

Isolate patient 6 feet away from staff, other patients, and visitors

1Is the patient likely to require hospitalization?

YES

NO2Close Contact Risk

Living in the samehouse or visiting someone with confirmed/suspected COVID-19

Being within 6 feet of someone with confirmed/suspected COVID-19 for 15 minutes over a 24 hour period, starting 2 days prior to the diagnosis

Direct contact with infectious secretions with someone with confirmed COVID-19

Send COVID-19 testing only if clinically indicated.

DISCHARGE HOMEIf suspicion of COVID-19 infection: Refer to CDC s Guidance on Home Care (Not Requiring

Hospitalization)• Refer to COVID-19 Cardiology Return to Play Algorithm• Can offer telemedicine visit with CT Children s Infectious

Disease and Immunology [call CT Children s One Call 833-226-2362]

• Ensure patient and family is quarantined at home per CDC/DPH recommendations • CDC s Guidance for Preventing Spread of

COVID-19• CDC s Guidance for Discontinuing Home

Quarantine• CDC s Guidance for Discontinuing Home

Quarantine for Immunocompromised Individuals

Send COVID-19 test3 [reserve respiratory BIOFIRE for critically ill patients] o Appendix A Instructions for Sending COVID-19

Specimen

If suspicion of COVID-19 Infection:Evaluation and Initial Treatment:

Obtain baseline labs: o CBC with differential, chem 10, liver function

panel , blood gas with lactate, cortisol, fibrinogen, D-dimer, CRP, ESR, procalcitonin, LDH, ferritin, trigerlycerides, Hgb A1C in diabetic patients

o If suspected cardiac involvement: add troponin, NT-proBNP, CKMB

o If unable to obtain sufficient sample, prioritize based on clinical picture

When clinically indicated: consider portable CXR, EKG, UA-micro, urine culture

If signs of sepsis: use Sepsis Clinical Pathway If clinical picture consistent with bacterial pneumonia:

use CAP Clinical Pathway

If COVID-19 infection is not suspected: Standard care

Admit to inpatient floors See COVID-19 Inpatient Care on page 2

NO YES

YES

3UNIVERAL COVID-19 PCR TESTING FOR ALL ADMISSIONS:

See Appendix B: COVID-19Screening and Retesting Guidelines

ALL patients requiringhospital admission need a COVID-19 PCR test (with routine q2week screening on Mondays if prolonged admit)

Exceptions to testing:o Already tested within

the prior 72 hours o Positive test in the

prior 90 days COVID-19 test to be

ordered and sent in ED If LIAT COVID-19 testing

available: Utilize AppendixC: COVID-19 LIAT TestingWorkflowo Patient to stay in the

ED until LIAT results

If there is a cl inical suspicion for Multi-System Inflammatory

Syndrome in Children (MIS-C), please follow the MIS-C Clinical

Pathway.

Clinical suspicion would include:Fever 100.4 F for 24 hours AND any one of the following: GI: abdominal pain,

diarrhea, vomiting CV: chest pain, arrhythmia,

signs of shock, hypotension Mucocutaneous: rash, oral

changes, conjunctivit is, extremity swelling/peeling

Resp: cough, shortness of breath, difficulty breathing

Neuro: al tered mental status, headache, irr itabil ity

(Bolded symptoms are most common presenting symptoms)

NO

Is patient clinically unstable? Place in Room 1YES

NO

CONTACTS: MICHELE MCKEE, MD | CARLA PRUDEN, MD | ANAND SEKARAN, MD | JOHN SCHREIBER, MDThis pathway is subject to change, based on evolving recommendations from the CDC and CT DPH.

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CLINICAL PATHWAY: CT Children’s ED and InpatientCOVID-19 Algorithm

DISCHARGE CRITERIA/INSTRUCTIONS

• Clinically stable without supplemental O2 requirement, well hydrated without need for IVF• Offer telemedicine visit with CT Children s Infectious Disease and Immunology [call CT Children s One Call 833-226-2362] • Ensure appropriate follow up with PCP arranged• Refer to COVID-19 Cardiology Return to Play Algorithm• Ensure patient and family is quarantined at home per CDC/DPH recommendations

CDC s Guidance for Preventing Spread of COVID-19 CDC s Guidance for Discontinuing Home Quarantine CDC s Guidance for Discontinuing Home Quarantine for Immunocompromised Individuals

If patient requires CODE or MET: Use designated code cart Keep door closed if possible Use electronic communication devices as

able (code cart RN and Recorder RN) Only key personnel in room All personnel in room must wear COVID-

19 PPE

Initial Management(If not already completed in ED)

COVID testing: Send COVID-19 test4 (reserve respiratory BIOFIRE for critically ill patients)

o See Appendix A Instructions for Sending COVID-19 Specimeno See Appendix B: COVID-19 Screening and Retesting Guidelines for

screening (and retesting) guidelines If COVID-19 positive:

o If not already, move patient to Special Isolation Unito Providers to notify DPH (even if completed by lab): submit DPH

form onlineo Consult Infectious Diseaseo Inform primary attending

If initial COVID-19 test negative: see Appendix B: COVID-19 Screening and Retesting Guidelines for recommendations for repeat testing

Labs: If unable to obtain sufficient sample, prioritize based on clinical picture. Obtain baseline labs on admission:

o CBC with differential, chem 10, liver function panel , blood gas with lactate, cortisol, fibrinogen, D-dimer, CRP, ESR, procalcitonin, LDH, ferritin, trigerlycerides, Hgb A1C in diabetic patients

If suspected cardiac involvement: add troponin, NT-proBNP, CKMB If ferritin >500 mcg/ml: obtain cytokine panel (IL-6, IL-1, NK cell activity) Trend labs per primary team discretion

Studies: If clinically indicated, consider the following: portable CXR, EKG

Consults: Infectious Disease (required) Rheumatology, if suspected clinical/laboratory evidence of cytokine

storm syndrome (e.g. high fever, worsening coagulopathy, ARDS, elevated ferritin)

Cardiology, if suspected cardiac involvementNote: In order to conserve PPE, consultants will strongly consider waiving the physical examination. Nevertheless, a formal consult should be placed.

Treatment Considerations: Primarily supportive in nature with a focus on treatment of pneumonia

(see CAP Pathway), respiratory failure, ARDS, sepsis and septic shock(see Septic Shock Pathway)

Please utilize COVID-19 VTE algorithm to determine interventions toprevent or treat for thrombosis

If clinical suspicion of Multi-System Inflammatory Syndrome in Children (MIS-C), follow MIS-C Clinical Pathway

See Therapies for COVID-19 Pathway for medication considerations

Admit to Inpatient Units

Transfer and Admission of Patient Room based on Inpatient Med-Surg

COVID-19 Surge Guideline (Appendix D) or COVID-19 PICU Surge Plan

Refer to Transferring a COVID-19Patient (Appendix E)o Ensure receiving unit is ready

for patient arrival prior to transfer

o Transport patient in empty elevator

Visitor Guidelines Follow Visitor Guideline for

Inpatient Areas

General Considerations PPE and Respiratory Considerations

COVID-19 PPE• Please follow specific PPE

recommendations for specialized areaso See COVID-19 PPE policy on Intraneto If patient in PICU, see PICU specific

COVID-19 policy• Caregivers must mask when leaving patient

room, or when team member enters room • For quarantined patients (COVID negative,

exposed): special precautions x14 days; consider discontinuing if asymptomatic and no new risk factors

• For COVID positive patients: consider discontinuing special precautions (while continuing surgical mask, eye protection, gloves per COVID-19 PPE policy) when following criteria met:o If never symptomatic (and remains

asymptomatic): 10 days from first positive test (20 days if immunocompromised)

o If symptomatic: afebrile for 24 hours without fever-reducing medications, AND symptom improvement AND 10 days since symptoms first appeared (20 days if immunocompromised or was severely ill with COVID-19)

Evaluation and Treatment

Respiratory Considerations Must don N95 when caring for a patient

with a trach, unless COVID-19 PCR negative in prior 2 weeks with no new symptoms/risk factors - see AerosolizedProcedures (Appendix F)

See specific instructions for Respiratory Treatments

4COVID-19 PCR Screening See Appendix B: COVID-19

Screening and Retesting Guidelinesfor specific recommendations

ALL patients requiring hospital admission need a COVID-19 PCR test (with routine q2week screening on Mondays, if prolonged admission)

Exceptions to testing:o Already tested within the

prior 72 hours o Positive test in the prior 90

days Patients transferred, or admitted

directly to inpatient units will have COVID-19 test sent by inpatient floor staff (patient to be on SpecialPrecautions until result returns)

Patient and caregivers must remainconfined to room until COVID-19 PCR test results negative (caregivers may leave the hospital but must avoid use of shared spaces until test negative)

If screening COVID-19 PCR test is positive (or test is negative but with high clinical suspicion of COVID-19), patient will require transfer to the inpatient Special Isolation Unit (SIU)

CONTACTS: MICHELE MCKEE, MD | CARLA PRUDEN, MD | ANAND SEKARAN, MD | JOHN SCHREIBER, MD This pathway is subject to change, based on evolving recommendations from the CDC and CT DPH.LAST UPDATED: 1.29.21

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CLINICAL PATHWAY: CT Children’s ED and InpatientCOVID-19 AlgorithmAppendix A: Instructions for Sending COVID-19 Specimen





INSTRUCTIONS FOR SENDING COVID-19 SPECIMEN

Hartford Hospital Specimen

• Specimens must be collected in a viral transport tubeo Both BIOFIRE and COVID-19 specimens may be sent with 1 single swab

(reserve respiratory BIOFIRE for critically ill patients)• Place COVID-19 sample in a green irreplaceable biohazard bag• Patient’s COVID-19 test requisition form (will have printed when COVID-19 test was

ordered)• Must hand carry sample to the HH Lab; DO NOT use the tube system• When walking samples to Hartford Hospital, the staff member will only need to wear

gloves for PPE. There is no need to don full PPE for sample transport.

LIAT Specimen

• Specimen must be collected in viral transport medium• Label sample with barcoded patient demographic label that includes: the initials of the

person collecting the sample, date and time of collection• Patient sample should be placed in a green irreplaceable biohazard bag• Must hand carry sample to COVID-19 specimen drop-off room (1C, room #1693) and fill

out the log• When walking samples to COVID-19 specimen drop-off room, the staff member will only

need to wear gloves for PPE. There is no need to don full PPE for sample transport.


CLINICAL PATHWAY: CT Children’s ED and InpatientCOVID-19 AlgorithmAppendix B: Screening and Re-testing Guidelines





Screening for Admissions, Inpatients, and direct-to-OR from ED/Inpatient Units:

• ALL patients requiring hospital admission and urgent surgical procedures need ascreening COVID-19 PCR test

o If LIAT is available, utilize Appendix C: COVID-19 LIAT Testing Workflow• Exceptions to testing:

o Patient already tested within the prior 72 hours▪ EXCEPTION: if patient is newly symptomatic since the test, must retest

o Positive test result in the patient in the prior 90 days to admission▪ Patient is no longer infectious (standard precautions; does not need SIU

placement) when the following timelines are met:• If never symptomatic: 10 days from first positive test (20 days if

immunocompromised)• If initially symptomatic: afebrile for 24 hours without fever-reducing

medications, AND symptom improvement, AND 10 days sincesymptoms first appeared (20 days if immunocompromised or wasseverely ill with COVID-19)

▪ EXCEPTION: if patient is newly symptomatic within this 90 day period,must retest

• For ED patients requiring admission:o Screening test to be ordered and sent in the ED prior to transfer to floors or

surgeryo If LIAT is available, utilize Appendix C: COVID-19 LIAT Testing Workflow

▪ Patient to stay in the ED until LIAT results• For patients transferred or admitted directly to inpatient units:

o Screening test to be sent by inpatient floor staffo Patient will be on Special Precautions Isolation until COVID-19 PCR test results

negativeo Patients and caregivers must remain confined in room until COVID-19 PCR test

results negative (caregivers may leave the hospital but must avoid use of sharedspaces until test is negative)

• If requiring surgical procedure:o Screening test sent by ED or inpatient floor staff prior to procedure

• For long-term patients requiring prolonged hospitalization:o Send repeat COVID-19 PCR screening every other Mondayo See Appendix F: Aerosol Generating Procedures

• If initial COVID-19 PCR screen is POSITIVE (or test is negative but with high clinicalsuspicion of COVID-19):

o Patient will require transfer to the inpatient Special Isolation Unit (SIU)o Will require full utilization of COVID-19 PPE


CLINICAL PATHWAY: CT Children’s ED and InpatientCOVID-19 AlgorithmAppendix B: Screening and Re-testing Guidelines





Recommendations for repeat COVID-19 testing:

• If initial COVID-19 screening test is positive:o There is no indication to retest within the following 90 days from first positive test

unless the patient becomes newly symptomatic▪ Patient is no longer infectious (standard precautions; does not need SIU

placement) when the following timelines are met:• If never symptomatic: 10 days from first positive test (20 days if

immunocompromised or was severely ill with COVID-19)• If symptomatic: afebrile for 24 hours without fever-reducing

medications, AND symptom improvement, AND 10 days sincesymptoms first appeared (20 days if immunocompromised or wasseverely ill with COVID-19)

• If initial COVID-19 screening test is negative:o If symptomatic with high clinical suspicion for COVID-19:

▪ Consider repeat COVID-19 testing (must have ≥24 hours between initialand repeat test)

▪ Continue isolation/COVID-19 PPE until repeat testing returns▪ If repeat testing is negative, patient likely negative for COVID-19 and no

further testing is required. Consider sending respiratory BIOFIREo If asymptomatic/respiratory BIOFIRE is negative, with low clinical suspicion for

COVID-19:▪ Likely negative for COVID-19 infection; repeat testing is not indicated

• For long-term patients requiring prolonged hospitalization:o Send repeat COVID-19 PCR screening every other Monday

• Special Circumstances:o May consider sending repeat COVID-19 PCR if:

▪ Needing transfer to another facility that requires a COVID-19 test within acertain time frame

▪ Patient is transferred to inpatient units without a prior COVID-19 test▪ Patient is needing COVID-19 testing pre-procedure▪ *Consider use of more rapid LIAT COVID-19 test when faster turn around

time is necessary


CLINICAL PATHWAY: CT Children’s ED and InpatientCOVID-19 AlgorithmAppendix C: COVID-19 Liat Testing Workflow





Arrival to ED

Admit as Inpatient OR sent directly to OR

OR imminent inpatient psych admission?

Discharge to home

A COVID‐19 LIAT test may be ordered from the inpatient units in unique situations (e.g., patient transferred without prior COVID‐19 test, for psychiatric hospital placement, pre‐procedure)

Order:Rapid COVID/Flu (LIAT)

If clinically indicated:Rapid Flu/RSV (LIAT)

*select whom to route the result in the LIAT testorder

YES

Patient has COVID‐19 symptoms?

If clinically indicated, order:COVID/Flu (HHC)YES

Is the patient to return to the OR within 48 hours?

Order:COVID‐19 (HHC)

Order:Rapid COVID/Flu (LIAT)

*select whom to route the result in the LIAT test order

YESNO

YES

NO


CLINICAL PATHWAY: CT Children’s ED and InpatientCOVID-19 AlgorithmAppendix D: Inpatient Med-Surg COVID-19 Surge Guideline




COVID-19 Inpatient Med-Surg COVID-19 Surge Plan 1

Inpatient Medical Surgical COVID-19 Surge Plan Last edit: 12/9/20

• The SIU will remain on MS6 (6A) and will vary in size based on demand, with overflow to MS7 as outlined below• COVID positive patients, high risk PUIs* (only when LIAT test not available), and patients with probable diagnosis of MIS-C (see MIS-C Clinical Pathway)

will be placed in SIU • For patients who have known COVID-19 exposure but a negative initial COVID-19 PCR test, consider SIU placement or place on Special Precautions

o Consider repeat COVID-19 testing ≥24 hrs after initial testo If repeat testing is negative, patient likely negative for COVID-19

• Special Precautions for all patients in SIU• All patients to remain in room until COVID PCR results negative. Families to avoid public spaces until patient COVID PCR negative• Order of room use for non-COVID patients during inpatient surge: St. Mary’s (if meets clinical criteria), GSD, ED, PICU, treatment rooms, then playrooms

COVID-19 Surge Level Green [≤ 5 patients requiring SIU]

COVID-19 Surge Level Orange [6-10 patients requiring SIU]

COVID-19 Surge Level Red [>10 patients requiring SIU]

Rooms in order of use • [601-605]

o reserve negative pressure rooms 604 & 605 for aerosol generating procedures

Rooms in order of use • add 606-610

Rooms in order of use • flex to MS7, 7C (rooms 724-728)

Action Items • 604 & 605 PPE placed in anteroom• All other rooms place bedside table in hall

with PPE (gown, goggles/face shields)• Place trash can in hall• Place SIU signs in hall and special precaution

signs on patient doors • Extra Code Cart located in Pod A

Action Items • All other rooms place bedside table in hall

with PPE (gown, goggles/face shields)• Place trash can in halls• Ensure SIU and PPE signs are in

appropriate locations

Action Items • Open Command Center, if not already open

Communication • Visitor restrictions per protocol• Med Surg Directors update administration

on COVID volumes

Communication • Visitor restrictions per protocol• Med-Surg Directors update administration on

COVID volumes

Communication • Visitor restrictions per protocol• Med-Surg Directors update administration on

COVID volumes


http://intranet.connecticutchildrens.org/visitorspatient-guidelines-and-resourceshttp://intranet.connecticutchildrens.org/visitorspatient-guidelines-and-resourceshttp://intranet.connecticutchildrens.org/visitorspatient-guidelines-and-resources


CLINICAL PATHWAY: CT Children’s ED and InpatientCOVID-19 AlgorithmAppendix D: Inpatient Med-Surg COVID-19 Surge Guideline




COVID-19 Inpatient Med-Surg COVID-19 Surge Plan 2

Staffing • RN/PCA cohort in SIU• Standard MS6 Attending Coverage• Standard Resident coverage

Staffing • RN/PCA: cohort care in SIU• Standard MS6 Attending Coverage• Standard Resident coverage• RT: may need enhanced staffing

Staffing • RN/PCA: cohort care in SIU• Standard MS7 Attending Coverage• Standard Resident coverage• RT: may need enhanced staffing

•Supplies

• Ensure adequate PPE supply and storage• Utilize designated SIU PPE storage cabinet• Reprocess N95s per protocol

Supplies • Inform Supply Chain about heightened

need for PPE

Supplies • Inform Supply Chain about heightened

need for PPE

Testing • Universal testing for all patients admitted

to hospital and for patients going to the Operating Room

• No LIAT testing available:o High Risk PUI /COVID +/probable

MIS-C to SIU • LIAT testing available:

o COVID +/probable MIS-C patients in SIU


to hospital and for patients going to the Operating Room





to hospital and for patients going to theOperating Room




* PUI Definitions: • Person Under Investigation (PUI): An individual with symptoms of COVID-19 Infection or exposure to COVID-19 in the last 14 days

o Symptoms suggestive of COVID-19 infection: ▪ Fever without other probable cause, or ▪ Cough/shortness of breath, or ▪ New loss of taste or smell

o Exposure to COVID-19 in the prior 14 days, defined as one of the following: ▪ Close contact with a known positive case of COVID

• Close contact is defined as being within 6 feet of a COVID-19 infected person for a cumulative total of ≥15 minutes over a 24 hour period, starting from 2 days before diagnosis, or

▪ Recent travel to a location with a high level of SARS-CoV2 transmission (CT DPH Travel Advisory and CDC Travel), or ▪ Residence in an institution with an active cluster of COVID-like illness

• High Risk PUI: o Patients with current COVID-19 symptoms AND a known COVID-19 exposure

• Low Risk PUI: o Patients with current COVID-19 symptoms (NO known COVID-19 exposures)


https://portal.ct.gov/Coronavirus/travelhttps://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html


CLINICAL PATHWAY: CT Children’s ED and InpatientCOVID-19 AlgorithmAppendix E: Transferring a COVID-19 Patient




1

Process for Transferring a COVID-19 Patient

Patients with known or suspected COVID-19 can be transported safely between patient units by adhering to the following steps:

1. The receiving unit will indicate to the sending unit when the room andstaff are ready to accept the patient.

2. ED RN will give report to the receiving unit by phone.

3. ED RN will sanitize stretcher handrails and any other area with visiblesoil, with disinfectant wipes prior to leaving the ED.

4. Upon leaving the room, the patient will don a surgical mask and aclean sheet will be placed over the patient (to the chin) for transport.

5. If the ED RN is accompanying the patient to the new location, theymust remove their gloves and gown, wash their hands, and don cleangown and gloves. They may leave their N95 and eye protection onwithout change. If another team member is transporting the patientthey must wear appropriate PPE.

6. The patient must be transported directly to the receiving unit. Do notallow any visitors or other staff in the elevator with the patient. Onlyfamily members may accompany.

7. Receiving unit will be ready with PPE donned to receive the patient ina negative pressure room, or a standard room if no negative pressureroom is available.

8. A Special Precautions isolation sign must be placed on the door ofthe negative pressure room.

9. Once the patient is moved from the stretcher to the bed, remove thelinens from the ED stretcher and place in the linen hamper in theroom. The stretcher should be moved to the anteroom or hallway.

10. The team member will remove gown, gloves, and eye protection inthe room. The respirator/mask must be removed in the ante room orthe hallway if there is no ante room. Perform hand hygiene.

11. A new pair of clean gloves will be donned. Wipe the mattress andhandrails with a disinfectant wipe. Then transport the stretcher backto the original room in the ED for terminal cleaning of the entire room.



CLINICAL PATHWAY: CT Children’s ED and InpatientCOVID-19 AlgorithmAppendix F: Aerosol-Generating Procedures




Aerosol Generating Procedures:

Updated 9/25/2020

Some procedures performed on patients who are potential or known positive for COVID-19 could generate infectious aerosols. In particular, procedures that are likely to induce coughing (e.g., sputum induction, open suctioning of airways) should be performed cautiously and avoided if possible.

Respiratory modalities in this category would include:

- IPPB- IPV- Cough assist- Vest- Nebulized medications- High flow nasal cannula (HFNC)- Non-invasive ventilation (BiPAP/CPAP) devices- Tracheostomy tube changes, floor patient with tracheostomy and open airway, etc (see PPE –

High Risk Scenarios) – Exception: if a patient with a tracheostomy has been admitted and hashad a negative COVID-19 PCR test in the prior 2 weeks with no new symptoms or other COVID-19risk factors, an N-95 mask is not required

Though higher risk, health care providers may still need to perform these procedures if it is clinically required. It is imperative to take the necessary PPE precautions when performing these aerosolizing procedures (PPE policy High Risk Scenarios). In addition:

- If performed, these procedures should take place in a negative pressure room when possible- Limit the number of health care providers present during these aerosol generating procedures

to only those essential for patient care and procedural support- Clean and disinfect procedure room surfaces promptly per CDC recommendations

Reference: CDC Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings.


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clinical pathway: ct children’s ed and inpatient covid …...(see cap pathway), respiratory...

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