COVID-19 UPDATESHEALTHCARE POLIC IES & PROCEDURESTransforming Emergency Medicine

FROM THE FOUNDERIn our efforts to better serve and support our physicians andAPPs, we would like to present our second IES COVID-19newsletter. In this publication, there is a lot of clinical information,as well as some early data points by campus. We are trying topresent information that is pertinent to our practices as well aslet you know ways that we are trying to support you betterpersonally. We received overwhelmingly positive feedbackafter the first newsletter last week and have attempted to answersome of the questions as well as give updates on progresswith regard to some of the other initiatives discussed in thisversion. Your IES team has been relentless in their work tobetter support you. Knowing that we have your back hopefullyhas allowed you some comfort as you fully focus on our presentand future challenges. We appreciate all that you do andwelcome any suggestions. Feel free to contact us 24/7 withany comments, questions, or concerns. I want to give a specialthanks to Drs. Risch and Shahani, Clare Graca, and CrystalHawkins for staying on top of this very fluid situation but alsoorchestrating our communications. Best regards,Nick Zenarosa, MD, FACEP214.763.6165 | nzenarosa@ies.healthcare 1

Updated Tuesday, March 24, 2020

INSIDE THIS ISSUE:PPE RecommendationsCOVID-19 Critical CareGuidelinesManagementConverting BIPAP Machineinto VentilatorCOVID-19 in PregnancyScripting for Test ResultsSensitivity of TestingEnd of Life PerspectiveCOVID-19 ED ManagementProvider Healthy & SafetyBasicsEpidemiologyClinical PresentationDiagnosticTreatment

PERSONAL PROTECTIVE EQUIPMENT UPDATE

N95 EXTENDED USE AND REUSE RECOMMENDATIONS Supplies of N95 Respirators are depleted during this pandemic. CDC guidelineshave been instituted to conserve supplies while protecting health care workersin such circumstances. • Minimize number of individuals who need to use respiratory protection • Use alternatives when feasible (ie. surgical mask for non-aersolizing procedures, PAPR, etc.) • Extend use (same mask for several pts in a row without taking off in same day) • Reuse (use same mask after taking it off between patient encounters or days) • Do not discard N95 or surgical masks, as they can be reused after 7 days, after placing in a paper bag with the date of placement/name. In theory the fomites on the surface of the mask will die over time and themask can be reused. Based on surface studies, we estimate that reuse canprobably be safe after 7 days. In an ideal situation we would be able to havea new mask per patient and per day, but in a crisis we have to become creativeto protect ourselves and our patients.

PROVIDERS MUST BE FIT TESTED FOR PROPER N95 USE.CONTACT YOUR DIRECTOR IF YOU ARE NOT.

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Extended use is preferred over reuse as less touching of mask (taking on andoff) and therefore less contact transmission. Reuse should avoid contact insiderespirator. Perform hand hygiene before touching or adjusting respirator. Use cleangloves when donning used respirator and performing seal check, discardgloves. N95 should be discarded if soiled/contaminated or damaged. Consider a faceshield or mask over N95 respirator to reduce surface contamination. Click Here for CDC Recommended Guidance for Extended Use and LimitedReuse of N95 Filtering Facepiece Respirators in Healthcare Settings. Click Here for JAMA Editorial for call for unique ideas on conserving personalprotective equipment. Evaluation (CDC and WHO Guidelines): Droplet Protection Only- SurgicalMask on patient and on self, eye protection advisable, and gloves. If patientis wearing a mask, technically eye protection is optional. If patient is unableto keep a mask on, eye protection is mandatory for the exposure to remainlow risk. Supported by N95 vs Mask Study. Click Here for more details. Aerosolizing Procedures: N95 or Powered Air Purifying Respiratory (PAPR)with Gown, Gloves, Eye Protection (For BIPAP, High-Flow Nasal Cannula, Nebs,CPR, Intubation, Bronchoscopy, etc.) Hand Hygiene: Purell or Ethanol based hand sanitizer on non-soiled handshave shown to be effective against viruses. Click Here for more details. Surface Cleaning: Solutions like 70% ethanol or 0.5% sodium hypochloritesolutions have shown to be extremely effective. Click Here for more details. Avoid Unnecessary Equipment: stethoscopes, ultrasounds, pens, etc. whenevaluating patient Click Here for CDC Guidelines for PPE (Facemasks, Respirators, Gowns, EyeProtection).Click Here to find out how to Put ON and Take OFF PPE.Click Here for the COVID N95 vs Medical Mask image.

PPE CONTINUED

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A panel of 36 experts from 12 countries made recommendations based onconsensus and literature review. Click Here for Surviving Sepsis Campaign:Guidelines on the Management of Critically Ill Adults with Coronavirus Disease2019 (COVID-19). For healthcare workers performing aerosolizing-generating procedures theyrecommended using fitted respiratory masks (N95, PAPR, etc ). Respiratormasks block 95-99% of aerosol particles. Aersolizing Generating Procedures should ideally be performed in NegativePressure Room with a minimum of 12 air changes per hour or at least 160 L/second/patient. Where this is not feasible, a portable HEPA filter, should beused in the room wherever possible. For healthcare workers providing usual care for non-ventilated COVID-19patients, we suggest using surgical masks as opposed to respirator masks inaddition to gloves, gowns, eye protection. For healthcare workers performing endotracheal intubation on patients withCOVID-19, we suggest using video-guided laryngoscopy over directlaryngoscopy. We recommend that intubation be performed by the healthcareworker who is most experienced with airway management in order to minimizeattempts and risk of transmission.

SSC COVID-19 CRITICAL CARE GUIDELINES

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SSC COVID-19 CRITICAL CARE GUIDELINESCONTINUEDIn adults with COVID-19 and SHOCK, we suggest using dynamic skintemperature, capillary refill time, and/or serum lactate measurement over staticmeasures to assess fluid responsiveness. For the acute resuscitation wesuggest using a conservative fluid strategy over a liberal fluid strategy.Recommend using Crystalloids over colloids fluids. Recommend usingnorepinephrine over other pressors first. Suggest supplemental oxygen if peripheral oxygen saturation (SPO2) is <90% and recommend that SPO2 be maintained no higher than 96%. For adults with COVID-19 andacute hypoxemic respiratory failure espiteconventional oxygen therapy, we suggest using HFNC over conventionaloxygen therapy. Which has low risk for contamination risk compared toconventional oxygen, page 19 of the below document.

In mechanically ventilated adults with COVID19 and ARDS, we recommend using low tidal volume ventilation (Vt 4-8 ml/kg of predicted body weight).With recommended target plateau pressures < 30 cm H20. Also suggestHigher PEEP strategy over lower PEEP strategy. Also suggest ProneVentilation for 12 to 16 hours over no prone ventilation. Click Here for the recommendations and further ICU management guidelines.

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MANAGEMENTPPE: Proper PPE (mask for patient, mask for healthcare workers, eyeprotection, gloves) Supportive Care: Oxygen, Cautious IV Fluid Administration • Albuterol: Avoid nebulizers as these are aerosolizing • Albuterol MDI Inhaler: with spacer, 2 puff q 20 min until relief, then q 4-6 hours, Onset 5-10 min • Albuterol PO: 4 mg TID-QID , Onset 30 min • Terbutaline SC: 0.25 mg q 20 min x 3 (max 0.75 mg/hr), Onset 6-15 min • Terbutaline PO: 5 mg TID, Onset 30-45 min • Epinephrine: 0.1 to 0.3 mg subcutaneous injection, q 20-30 min for total 1 mg, Onset • Click Here for Alternatives to Albuterol. Oxygen: Nasal Cannula (NC), place surgical mask over nasal prongs High Flow Nasal Cannula: NC providing more than 6L/min, this with a maskover it, is preferred over CPAP/BIPAP BiPAP: Consider avoiding as it is aerosolizing, unless appropriate PPE in place Intubation: If respiratory status deteriorating, early intubation should beconsidered, have a back up plan. • PPE: Don PAPR or N95 Mask, Gown, Gloves, Hair Cover • Most Skilled Person for Intubation • Pre-Oxygenate: NC with mask covering patient or BVM with minimal bagging, HOB elevated, airway adjuncts, HEPA Viral Filter • Suction: closed suction system • Rapid Sequence Intubation to avoid BVM - Rocuronium 1.5 – 2 mg/kg IV, longer half life to succinylcholine • Video Laryngoscopy: avoids face close to patient’s mouth 6

Vent Settings: ARDS protective settings, use VENT BundleAC Volume, TV 6cc/kg of Ideal Body Weight, IFR 60-80 lpm, PEEP 5, FIO2100%, weaning down as tolerated to SpO2 to 88-95%, RR 18 Click Here for WHO Guidelines Respiratory COVID-19. CPR: Must wear PPE. At this time given the community spread, we recommendwearing airborne level PPE for all CPR. The Covid-19 CPR policy for BSWHactually states "Health care professionals (HCP) attempting cardiopulmonaryresuscitation (CPR) and related events (rapid response and intubation) onpatients under investigation (PUI) of COVID-19 or known COVID-19 infectionMUST don personal protective equipment (PPE) before entering the room." STEMI and NSTEMI: In high risk patients to have COVID19 for STEMI andNSTEMI we are trying to avoid emergent cath and exposure. We should considerthrombolysis. Click Here for BSW Protocol. Dosing: Alteplase (TPA):

Dosing based on patient weight: • 67kg: Infuse 15mg IV over 1-2min; then 50mg over 30min; then 35mg over next 60min (i.e. 100mg over 1.5hr) • ≤67kg: Infuse 15mg IV over 1-2min; then 0.75 mg/kg (max 50mg) over 30 min; then 0.5 mg/kg over 60min (max 35 mg) Tenecteplase (TNKase): • 50 mg vial in 10 mL sterile water (5 mg/mL) • < 60 kg = 30 mg IV push over 5 seconds • 60-69 kg = 35 mg IV push over 5 seconds • 70-79 kg = 40 mg IV push over 5 seconds • 80-89 kg = 45 mg IV push over 5 seconds • 90 kg = 50 mg IV push over 5 seconds Disposition: • Not all persons under investigation (PUI) need admission • Mild Symptoms may qualify for home isolation if able to comply with health department monitoring

MANAGEMENT CONTINUED

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MANAGEMENT CONTINUEDModifying a BiPAP into a Ventilator

Phillips Respironics V60 Ventilator

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At this time very little is known about COVID-19, particularly to its effect onpregnant women and infants, and there are currently no specificrecommendations regarding evaluation and management. Retrospective Review of Potential Vertical Transmission of COVID-19 Infectionin Nine Pregnant Women. Click Here for more details. • 9 pregnant patients with lab confirmed COVID-19 Pneumonia admitted in Wuhan • Vertical transmission was assessed by testing for the presence of SARS- CoV2 in amniotic fluid, cord blood, and neonatal throat swab samples • Breastmilk samples were also collected and tested from patients after the first lactation • All 9 mothers had Caesarean section in their 3rd trimester • No mother acquired severe pneumonia or death • Premature rupture of membranes: 2/9 • C-Section Delivery for 9/9 • Neonatal Asphyxia 0/9 • Fetal distress: 2/9 • All 9 births had 1-min Apgar score of 8 -9 and a 5 min Apgar score of 9 – 10 • Fetal death: 0/9 • Amniotic fluid, cord blood, neonatal throat swab, and breastmilk samples tested from 6 patients and all samples tested negative for the virus BreastfeedingIn limited studies on women with COVID-19 and another coronavirusinfection, Severe Acute Respiratory Syndrome (SARS-CoV), the virus has notbeen detected in breast milk; however we do not know whether motherswith COVID-19 can transmit the virus via breast milk. Recommendations toinclude washing hands and wearing face mask before touching infant. Click Here for ACOG COVID-19 Pregnant Patient Evaluation PDF. Click Here for ACOG Pregnancy Guideline. Click Here for CDC Pregnancy Guidelines.

COVID-19 IN PREGNANCY

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SCRIPTING FOR TEST RESULTSNotifying your Patient of a NEGATIVE Result or Sending Home without aResult: Your test result is presumed negative (or pending). We believe it issafe for you to be at home, however your illness still has a chance of spreading.There is still a chance that you have COVID (even with a negative result). Werecommend: • Continue home isolation for at least 7 days from onset of symptoms, assuming symptom improvement, and minimum of 72 hours of not needing fever reducing medications • Avoid close contact with people who live in your home, using separate bathroom, if available • Wash your hands often with soap and water for at least 20 seconds • Clean and disinfect objects and surfaces touched frequently • If your symptoms worsen (eg. Shortness of breath) call your healthcare provider and tell them you have been evaluated for COVID-19 BEFORE seeking care. Put facemask before you enter facility where you are seeking treatment • If you have a medical emergency and need to call 911, notify dispatch that you are being evaluated for COVID-19. Put facemask on before EMS arrives

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SCRIPTING FOR TEST RESULTS CONTINUEDNotifying your Patient of a POSITIVE Result: Your COVID-19 test result is apresumed positive. Most people do really well and do not suffer withrespiratory distress with this disease. The biggest symptom to look out for isdifficulty breathing. Please wear a mask and practice good hygiene whennear other people. We have a few recommendations to help prevent spreadand warnings to look out for: • Continue home isolation for at least 7 days from onset of symptoms, assuming symptom improvement, and minimum of 72 hours of not needing fever reducing medications • Avoid close contact with people who live in your home, using separate bathroom, if available • Wash your hands often with soap and water for at least 20 seconds • Clean and disinfect objects and surfaces touched frequently • If your symptoms worsen (eg. Shortness of breath) call your healthcare provider and tell them you have been evaluated for COVID-19 BEFORE seeking care. Put facemask on before you enter facility where you are seeking treatment • If you have a medical emergency and need to call 911, if possible notify dispatch that you are being evaluated for COVID-19. Put facemask before EMS arrives

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SENSITIVITY OF TESTING: RT-PCR VS. CT VSRT-PCR Nasopharyngeal Testing: Sensitivity of RT-PCR Testing Ranges from66-80%, with some studies suggesting CT. Take Home: Single RT-PCR does not exclude COVID-19, poor testing can leadto false negatives Click Here for more details. According to the CDC: What does it mean if the specimen tests negative for the virus thatcauses COVID-19? A negative test result for this test means that SARSCoV-2 RNA was not presentin the specimen above the limit of detection. However, a negative result doesnot rule out COVID-19 and should not be used as the sole basis for treatmentor patient management decisions. A negative result does not exclude thepossibility of COVID-19. When diagnostic testing is negative, the possibility ofa false negative result should be considered in the context of a patient’s recentexposures and the presence of clinical signs and symptoms consistent withCOVID-19.

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The possibility of a false negative result should especially be considered if thepatient’s recent exposures or clinical presentation indicate that COVID19 islikely, and diagnostic tests for other causes of illness (e.g., other respiratoryillness) are negative. If COVID-19 is still suspected based on exposure historytogether with other clinical findings, re-testing should be considered byhealthcare providers in consultation with public health authorities. Click Here for CDC Fact Sheet. CT Scan • Estimated sensitivities for CT to be with presumed COVID-19 pneumonia estimated to be 86-97% • CT scans may be less sensitive for those without respiratory symptoms ~50% • Difficult to assess sensitivity as a +CT scan with a negative RT-PCR could be a false positive CT scan. • What defines a positive CT scan for COVID 19? • Is it worth contaminating a CT scanner to diagnose this disease andrisk spread to others? Chest XR • In Guan et al sensitivity of x-ray was 59% compared to 86% for CT scan • Variety of different findings found: bilateral reticular nodular opacities, focal consolidation, pulmonary edema, and ground glass opacities. Click Here for Clinical Characteristics of Coronavirus Disease 2019 in China Click Here for Essentials for Radiologists on COVID-19: An Update -Radiology Scientific Expert Panel Click Here for Correlation of Chest CT and RT-PCR Testing in CoronavirusDisease 2019 (COVID-19) in China: A Report of 1014 Cases

SENSITIVITY OF TESTING: RT-PCR VS CT VS. XRCONTINUED

Provided by: Lauren Fine, MD There are other things we can consider besides "doing everything" foreveryone. First, I wanted to share some guidance from the AHA's guidelines on theethical aspects of CPR. "In the hospital the decision to terminate resuscitativeefforts rests with the treating physician. Healthcare professionals mustunderstand the patient, the arrest features, and the system factors that haveprognostic importance for resuscitation.” This is a reminder that we call thecodes. A patient may come in "full code" with CPR in progress but you maydetermine that ongoing CPR is unlikely to beneficial to the patient. This mightbe the patient with terminal metastatic cancer or the bed-bound nursing homepatient with a trach and peg. You are the physician. You are empowered tomake these decisions about who is most likely to benefit from ongoingresuscitation. I appreciate that this ethical guidance includes "system factors" for prognostic importance for resuscitation because as we fill up with moreand more COVID-19 patients the ventilator we use for one patient may be theventilator we don't have for another patient.

END OF LIFE CARE PERSPECTIVE

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END OF LIFE CARE PERSPECTIVE CONTINUEDSecond, I suspect there is considerable variability about how we handle severeillness at the end of life in the ER. Some cases that come to mind are thepatient with the massive ICH who is obtunded with a GCS of 3. The elderlypatient with a massive ischemic stroke. The immobile dementia nursing homepatient with septic shock. This is obviously not an exhaustive list, but examples.I want to remind you all that it is OK to recommend things like comfort careoff the bat. Tell families when you think an illness is going to be irreversibledespite maximal medical therapies or interventions. You know these things.You have good judgment and experience. Take the burden off the familyand patient’s hands, tell them that their loved one is dying and that the bestthing you can do for them is to make them comfortable. Offer fentanyl dripsor other IV narcotics. Suggest language like "I want to do everything I can tohelp your loved one, but I don't want to do anything to hurt them or prolongtheir suffering." Use your chaplains. Show families that even though you maynot be putting a tube in their loved one's throat or offering CPR, that you care.That you care about limiting the suffering of your dying patients. Make surethey are comfortable. Use language like "We are not going to do CPR if yourloved one's heart stops beating or they stop breathing because it will not helpthem." If a family argues with this statement and pushes for CPR you may need toadjust, but you can lead with this recommendation based on your knowledgeand expertise. Most will understand. Also, some patients are religious. Myfather is a big fan of the phrase "it is time to let go and let god" and manyfamilies appreciate this sort of language. If I have had a chance to ask thefamily about the patient's spirituality or religion I may often frame thesediscussions as "there are things I can do here, but I am not more powerfulthan God." Families appreciate hearing this. Trying times are ahead. Please take care of yourselves. On the CPRs you doperform, remember to protect yourself. You are a scarce resource, you areneeded.

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COVID-19 ED MANAGEMENT

We are in the process of gathering BSW site data for the development of aCOVID-19 dashboard. The above table reflects data as of March 23, 2020.If you would like to share suggestions pertaining to the content of the data,please email Dr. Bob Risch at rrisch@ies.healthcare and update your site dataeach Wednesday.

PROTECTING YOURSELF AND YOUR FAMILYWe all understand and accept increased risk in our profession. This risk doesnot come without worry and we should not be cavalier about the possibility ofbringing it home. • Avoid wearing jewelry (consider silicone rings) • Bring Clean Scrubs and Jacket to Work in Bag • Wipe down your cell phone • Wash hands and arms with soap after shift • Place Scrubs and clothes in plastic bag, change into clean clothes • Sanitize Badge and Phone when leaving • Take off shoes, work bag, jewelry in garage • Wash both sets of clothes (hot water and detergent) • Have discussions at home about separate living spaces and bathrooms to hopefully minimize risk • Prioritize your family as testing and vaccinations becomes available 1 6

FEELING SICK • Do NOT go into work. • Contact your Medical Director and your PA immediately. They will assist you in obtaining appropriate testing and guiding you through potential next steps. EXPOSURE TO CONFIRMED COVID-19 CASES:If you cared for a patient who has confirmed COVID-19, please contact: • BEST providers - site Medical Director • IES Carrollton providers - Trent Stephenson, DO trents@ies.healthcare • IES Houston providers - site Medical Director • JPS providers - Chet Schrader, MD cschrader@ies.healthcare Please contact your HR Generalist immediately for any of the following: • If you have been notified that you will need to be quarantined and unable to work shifts (temporarily furloughed) • If you will be required to be tested for COVID-19 testing Michelle Dippel - Direct: 469.420.5569, mdippel@ies.healthcare • BSWH Central - Waco, Brenham, Llano, Marble Falls • BEST EMS • JPS • CHI St. Luke’s • Boone County Emergency Medicine • Key Medical Sarah Dawson - Direct: 469.420.5575, sdawson@ies.healthcare • BSWH North - BUMC, Fort Worth, McKinney, Plano, Lake Pointe, Forney, Wylie, Grapevine, Irving, Waxahachie, Heart Denton, Heart Plano • URSA / NTCC • IES Carrollton, PLLC FURLOUGHIf you are not allowed to work as a result of potential exposure, notify yourHR Generalist immediately. He or she will support you by guiding youthrough the process and assisting you in accessing available resources. Weare working diligently with the Medical Directors to identify ways that we cansupport you and your family if you are pulled off shifts. We are also looking atprograms that are currently available and assessing all proposed legislationthat could apply to our providers. We will share that information as itbecomes available. 1 7

PROVIDER HEALTH

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PROVIDER HEALTH CONTINUEDWORKER’S COMPENSATIONShould you test positive for COVID-19 due to a documented patient orworkplace exposure, you may be eligible for Worker’s Compensation. YourHR Generalist can discuss your potential eligibility. SHORT-TERM DISABILITY/LONG-TERM DISABILITYShort-term disability covers non-occupational illness and injury and is excludedin instances where workers compensation applies. If you elected short-termdisability during annual enrollment, your HR generalist can help answer anyquestions about your coverage. Long-term disability covers one’s own illnessor injury. All full-time IES employees automatically receive Long-Term disabilitycoverage as a part of their employment. If you have questions about qualifyingevents and/or corresponding benefits, please contact your HR generalist. EMPLOYEE ASSISTANCE PROGRAMWe understand that during this time, you and your family may be faced withmany different challenges. IES currently offers an Employee AssistanceProgram to all full-time employees, which is available 24/7 to help developsolutions and to connect you with various tool and resources. EAP can bereached at 800.538.3543 or www.cignalap.com

PERSONAL PROTECTIVE EQUIPMENT (PPE)In the face of a global PPE shortage, IES is actively working to acquire equipmentand develop innovative solutions where alternatives are necessary. We haveconnected with John McWhorter at Baylor Scott & White Health System, LauraThomas at JPS Health System, and Doug Lawson at Baylor St. Luke’s HealthSystem to assist any way we can. In addition, we are activating our globalcontacts to develop pipelines and establish business and communitypartnerships that will enable us to support your needs Our goal is to equipyou as quickly as possible while, at the same time, establish ongoing resourcesto support you through the weeks and months to come. Here are a few thingsalready underway:

PROVIDER SAFETY

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PROVIDER SAFETY CONTINUEDMASKSDr. Zenarosa and the entire IES Leadership Team have provided funds tosource 20K (twenty thousand) KN-95 Masks, which are the same masks usedby the Veterans Administration. The masks were located overseas on Friday.The order was secured over the weekend and were shipped to the US. Theyare currently being inspected by a third-party. Once that inspection iscompleted, they will be released and then shipped to Dallas. We anticipatethe masks will arrive in Dallas within the next week.FACE SHIELDSWe are developing innovative solutions ininstances where products are inaccessible. Dr.Steve Arze and several of our clinical leadershave developed a first-generation prototypefor a face shield out of a 2-Litre Soda Bottleand weather stripping. These faces shieldscould potentially provide additional protectionand prolong the usage of the KN95 masks.Stay tuned for more information and save those2-Liter bottles.

PROTECTIVE EYEWEAROn Monday, March 23rd a survey was sent to all providers to identify thosewho wear prescriptive lenses. If you wear prescription glasses to work routinelyand have not completed the survey , please Click Here to submit your responseno later than Wednesday, March 25th at 12pm. Dr. Kara Norvell, Dr. John Garrett and Dr. Liz Fagan are actively working tosecure protective eyewear. Approximately 500 safety glasses were secured.Once these items are delivered, we will work to disburse those as needed. DAILY STORAGE OF PPEGiven the unknown impact of the current global shortages for PPE, our clinicalleaders are also working on solutions for storing existing PPE in a way that willprolong its usability. More information to come. ADDITIONAL PPE NEEDSIf you have a PPE needs that have not been addressed, please notify yourMedical Director. Your Medical Director is meeting regularly with the IES clinicaland non-clinical leadership to make needs known. We will continue to advocatefor our providers and work to provide solutions as quickly as possible.

Specific travel restrictions have been enacted by the various groups and hospitalsystems. Be sure to check with your Medical Directors about potential travelrestrictions and any corresponding requirements that may impact your abilityto work. To access the most recent travel-related communications disseminated by IES: • JPS providers Click Here for email sent 3/21/20 • BEST providers Click Here for email sent 3/20/20 • Houston providers Please follow guidelines made by the hospital

TRAVEL RESTRICTIONS

Physical and emotional wellbeing are important in your ability to care for others.IES offers several resources to support you through this complex andoverwhelming time. PEER SUPPORTIn coordination with the Baylor Scott & White SWADDLE program, IES has anactive network of emergency medicine providers trained in providingconfidential peer support. All interactions are privileged and will remainconfidential. Many of our trained peers are themselves experienced inhealthcare adversity. This resource is available to all clinicians at any IES-affiliated site. We strive to have a peer of your choice contact you within 24hours. Click Here to connect to the INSPIRE form. VOLUNTEER PSYCHOLOGISTSACEP members have access to 3 FREE, CONFIDENTIAL counseling or wellnesscoaching sessions. Click Here for more details. Separately, discussions arecurrently underway with clinical psychologists who may be willing to volunteertheir time. More information will be forthcoming.

PROVIDER WELLNESS (INSPIRE)

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CONCERNED ABOUT LIABILITY? We have resources in place.Click Here to See FAQs from MedPro. LATEST IN MED MALAll trials and hearings in Dallas and Tarrant County have been postponed.Med Pro, our professional liability carrier, is still processing claims. If aprovider receives a subpoena, notice of claim letter, petition, or othercorrespondence, please contact your medical director or Matt Innes at minnes@ies.healthcare.

RISK CONCERNS

FAMILY SUPPORTWith societal challenges such as school closings and, more recently, statemandated “shelter-in-place” orders, we are trying to better understand theday-to-day needs of you and your family. A work-in-progress, we have reachedout to several organizations who are navigating unchartered territory to fill theneeds of frontline health care providers who need childcare. Initially, we have established partnerships with our immediate contacts herein Dallas. We are very mindful that our providers are also located in Fort Worthas well as Houston. We ask your patience as we develop relationships andwork with businesses and non-profits to quickly develop initiatives that we canoffer to all our providers. CHILDCAREWe have established a partnership with the YMCA who has quickly mobilizedto provide childcare to first responders within North Texas. While the YMCAis offering this service to all first responders in North Texas, we have establisheda personal relationship with the Executive Director of School Age Serviceswho has worked with us to tailor and expand their offerings for IES providers.In addition, we are working with the YMCA to expand these offerings to FortWorth and Houston.

FAMILY SUPPORT

FAMILY SUPPORT - CONTINUEDIf you have children ages 5-12, the YMCA has established childcare at 11locations spanning Waxahachie to Anna and Rockwall to Mid-Cities. Childcareis available between 7am and 5:30pm, Monday – Friday at all locations. Inaddition, the YMCA has agreed to extend hours at the T. Boone Pickens YMCAin downtown Dallas from 6am – 7:30am. The YMCA has worked with government agencies to secure specialdispensation in order to provide childcare during the “shelter in place” andsocial-distancing mandates. Care is only available to healthcare professionalswhile working. Care is limited as each facility and capacity may not exceed50 (including children and staff) at any one location. In consultation with theCDC, daily protocols will include daily health screens at drop-off and beforelunch, stringent handwashing routines and facility sanitizing. A special code: GRP_IES has been established for all IES providers. Pleaseuse this code when signing up through the YMCA. It allows us to monitor theIES demand for childcare and to provide you access to a subsidized rate. Thiscode is for IES providers only, and we ask that this code not be sharedoutside IES. The cost will be $45 per day per child (normally $60 per day). This currentlyincludes daily snacks. Initiatives are underway to potentially provide lunchesas well. Cost should not be a barrier for anyone. In partnership with the YMCA,financial aid will be available for anyone who needs it. Drop-in childcare is not available at this time. Childcare is by registration only.Registration must be completed NO LATER than 3 PM the day before careis needed.

Click Here for full details.Please register using the following code:

GRP_IES 2 2

Active discussions are underway with major hotel chains as well as universitiesthat may be capable of supplying rooms to IES providers who need to besegregated from their families. We ask for you patience as this is a particularlychallenging time for the hospitality industry which has been hit particularlyhard given the economic shut-down. While we are doing our best to provideresources for providers throughout DFW and Houston, the following resourceis immediately available: For the next two weeks, the Wyndham Garden North location (I-35 & LBJ-635)is offering complimentary rooms to first responders only (no family members).Room are located on special floors and are accessed through speciallydesignated elevator banks. Interested providers may contact Wyndhamdirectly at 972.243.3363. Space is limited and based upon availability. Wyndham Garden North 2645 LBJ Freeway, Dallas, TX 75234 972.243.3363

LODGING

Behind the scenes we are working tirelessly to support you through theevolving challenges surrounding COVID-19. To better assist the frontline withnon-clinical needs, a COVID Help Desk has been established to field questionsand to connect providers with resources. Please submit your questions,concerns, suggestions, or ideas to the COVID HELP DESK at:

COVID@ies.healthcare 469.420.5590

We will respond to all emails and/or phone calls within 24 hours.

COMMUNICATION

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COMMUNICATION - CONTINUEDINFORMATION DISSEMINATIONWe are working hard to streamline communications through enhancedcoordination and consolidation. Currently we are utilizing the followingchannels to disseminate information:

You should have received a text message from IES on Thursday, March 19th.These text messages are anticipated to be very infrequent and will includecritical information. If you inadvertently opted out and would like to continueto receive messages, please contact Crystal Hawkins at chawkins@ies.healthcare. TEXAS STATE SOCIAL SERVICES HOTLINE • Local community resources, healthcare, utilities, food, housing and more. • Dial 2-1-1 • Option 6 is for information on COVID-19

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THE BASICS

Pathophysiology: Virus binds with high affinity to the Angiotensin-ConvertingEnzyme 2 (ACE2) Receptor, which is expressed in Alveolar cells of the Lungs.The virus seems to cause direct diffuse alveolar damage. Click Here for Pathological findings of COVID-19 associated with acuterespiratory distress syndrome. Types: • COVID19 is potentially mutating as there are two main types • L-Type (70%) More Common in Wuhan, More Severe • S-Type (30%) More Common Outside Wuhan, Less Severe • Phenotype Mapping: Click Here

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2019 Novel Coronavirus, known as SARS-COV-2COVID-19 (Coronavirus Disease 2019)Wuhan, China (Hubei Province)Likely from BatsBetacoronavirus, diameter of 60-140nm, positivesense RNA virus

Virus Name:Disease Name:Ground Zero: Origin Source:Virus Characteristics:

EPIDEMIOLOGY

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UPDATED DAILY STATISTICS (CASES, DEATHS,Click Here for John Hopkins CSSEClick Here for WorldoMeter Stats Transmission: • Droplet: Primary Transmission Person-to-Person for “prolonged period of time” within 6 feet • Direct Contact: Contact with Infectious Secretions (Sputum, Serum, Blood, Respiratory Droplets) • Depending on Surface, Virus may persist for roughly four days Click Here for more details. • Airborne: There is no evidence to support this outside of aerosolizing procedures in healthcare. Contagious-ness: In epidemiology, the R-naught (R0) is a number used byscientists to describe the intensity of an infectious disease outbreak. Thevalue describes the number of cases an infectious person will cause duringtheir infectious period. An R0 < 1 epidemic will stop, R0 = 1, epidemic will growsteadily, R0 > 1, epidemic will grow exponentially. The R0 can be reduced byisolation, quarantine, vaccination and definitive treatment. The R0 for COVID-19 is estimated to be 2.2. Click Here for more details.

Case Fatality Rate: 0.2% to 8%, with a reportedworldwide average of about 3.9%. This widerange varies from country to country. Wesuspect that this number is actually overinflateddue to limitations in testing and the high numberof asymptomatic patients. Click Here for John Hopkins CSSE Dashboard. Click Here for Mortality Data from China CDC.

CLINICAL PRESENTATION

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Common Symptoms: Fever (77-98%), Dry Cough (46-82%), Fatigue (11-52%),Myalgias, Dyspnea (3-31%)Less Common Symptoms: Sore throat, headache, productive cough, diarrhea The Onset and Duration of Viral Shedding and period of Infectiousness isNot Known Yet. Incubation Phase: 2-14 days Asymptomatic: Most recent literature suggests that asymptomatic peoplecan be infectious and may be a key vector of disease. Click Here for moredetails. Mild Symptoms: Minor URI symptoms, well appearing, no distressSevere Symptoms: Hypoxia, Respiratory DistressShortness of Breath: Presents on Day 5-13 of IllnessHospital Admission: Mean time 6-9 daysICU Admission: 20-30% of hospitalized need ICU, 44-71% receivedmechanical ventilation, 3-12% ECMOARDS: 17-29% of Hospitalized Patients Click Here for Interim Clinical Guidance for Management of Patients withConfirmed Coronavirus Disease (COVID-19)

DIAGNOSTICSLab Findings: Leukopenia (9-25%), Leukocytosis (24-30%), Lymphopenia(63%), Elevated LFTs (37%), Normal Procalcitonin on Admission. Radiologic Findings: Chest CT and CXR bilateral areas of consolidation andground glass opacities. Click Here for CDC Laboratory and Radiographic Findings Real-Time PCR (RT-PCR SARS-COV2) Nasopharyngeal Swab: Insert swab into the nostril parallel to the palate,leave swab in place for few seconds to absorb secretions. Plastic withSynthetic Fiver Swabs, place swab in 2-3 ml of viral transport media. Storeat 35 to 46 degrees Fahrenheit if transport < 72 hours. Click Here for CDCClinical Guidelines and Specimens For BSW Sites, current testing done at BSW Temple, Texas, (approximately400 specimens per day) with plans to have testing available at BUMC in thenext week. • Testing Time: Approximately 2 hours 45 minutes + Travel Time

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There are Currently NO Approved Treatments for Coronavirus and NOApproved Vaccine at this Time. Avoid:Corticosteroids: Avoid because of potential for prolonging viral replication,unless COPD/Asthma Exacerbation, Click Here for more details. NSAIDs: Use has been associated with worse outcomes. Mechanism:,Ibuprofen up-regulates the expression of ACE2, a binding site of SARS-COV2. Click Here for more details.

Who to Test: Consider testing patients with fever, Lower Resp Infection (Cough,SOB), Domestic Travel to High Risk Areas, Older Adults or People who haveChronic Medical Conditions, No clear Other Source, Contact with SuspectCOVID. Caveat: Current testing capacity is limited. While limited, strongly considerdischarging everyone who could have COVID-19 that is well appearing andstable for discharge without testing and give them instructions on homequarantine. Encourage these patients to obtain outpatient testing as soon aspossible. It is advantageous for patients to ultimately come back to the ERwhen sick with a known COVID-19 status. Still, at this exact point in time, weare unable to test everyone presenting with consistent symptoms, who arewell appearing. At BUMC, we are not testing the worried well, we are discharging patientshome to self quarantine. Drive Through Testing Available:Drive through testing is available at the BSW Urgent Care on Lovers LaneDownload the MyBSWHealth App, complete the COVID screen, this will createa free E-visit and order if you qualify for testing (not all patients will qualifybased on symptoms; they must have a positive screen). Click Here for iPhone Application. Click Here for Android Application.

DIAGNOSTICS CONTINUED

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TREATMENTS

ACE Inhibitors / ARBs: Studies Regarding ACEi/ARBs suggest that they canincrease ACE2 expression AHA, American College of Cardiology, and HeartFailure Society recommend continuation of ACEi or ARB for all patients withCHF, HTN, or CAD. The removal of these medications should be done by theirphysician. Click Here for more details. Potential Treatments Requiring Further Study: Remdesivir: showed activity against Ebola, MERS, and SARS, highlyeffective in one vitro studyDosing: 200 mg IV x 1 day, then 100 mg IV daily for 9 day. This trial isenrolling at several BSW sites.Click Here for source. Lopinavir/Ritonavir (Kaletra): has been suggested by small case reportsbut there is insufficient evidence to make a recommendation for use as thistherapy remains investigational. If lopinavir/ritonavir is to be used, it shouldbe limited to patients with severe symptoms (e.g. ICU admission, requiringmechanical ventilation/ECMO).Dosing: 200/50 mg 2 tablets PO BID for 7 days. There is limited availabilitysince ABBVIE is only releasing product for the treatment of HIV.Click Here for source. Hydroxychloroquine: was found to be more potent than Chloroquine atinhibiting SARS-CoV-2 in VitroDosing: 400 mg BID x 1 day, then 200 mg PO BID x 4 daysClick Here for source. Chloroquine: highly effective in one study, > 100 pateints with COVID 19showed superior control to improving respiratory symptoms and course inpatients with COVID19 pneumoniaDosing: 500 mg PO BID x 10 daysClick Here for source. 3 0

TREATMENTS CONTINUED

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