COVID-19 Clinical Update
April 6, 2020
UPDATE: Envision's newly updated COVID-19 website provides access to specialty-specific resources, wellness resources, COVID-19 Clinical Hot Topics webinars and other crucial clinical information and resources.
Key Take-Home Points
- The CDC now approves the use of facemasks for patient evaluation. N95s should still be used for aerosolized procedures.
- The CDC has updated quarantine guidelines for healthcare workers who have been exposed to patients with the virus.
- CMS has offered clarity to EMTALA rules, allowing qualified RNs to perform medical screen exams. Hospital bylaws still apply.
- Clinician wellness resources, including weekly peer support group meetings and a phone number for the Crisis Text Line.
- A COVID-19 email inbox (Coronavirus@EnvisionHealth.com) and a COVID-19 hotline (1.844.607.5824) have been established for non-emergent questions and concerns related to the virus.
- Recordings of the COVID-19 Webex for site clinical leaders and the Envision COVID-19 All Hands Meeting have been added to the Envision COVID-19 website.
On March 11, 2020, the World Health Organization declared COVID-19 a pandemic, and the United States has declared a national emergency in response to the virus.
Extreme caution should be used when evaluating patients with signs or symptoms of viral respiratory illness. We are closely monitoring developments to ensure we are keeping our patients and clinicians safe and informed with the most up-to-date information.
The complete clinical picture for COVID-19 remains unclear, including the incubation period, times of infectivity and methods of transmission. Early epidemiological articles indicate that the virus has a long incubation and period of infectivity when compared with the flu. Additionally, evidence exists that COVID-19 spreads more easily than the current influenza virus. Mortality rates have been shown to be around 1 to 2 percent, although the WHO has reported case fatality rates of 3.4 percent globally. Some countries, such as Italy, are experiencing mortality rates greater than 5 percent.
- Hospitals expect to see significant increases in patient volume over the next few weeks
- Testing for COVID-19 is extremely limited, but expansion efforts are underway
- No vaccines or antivirals are currently available
- Treatment recommendations are limited to supportive care measures
As the virus spreads, healthcare workers and hospital systems will need to frequently monitor their hospital’s infection control bulletins, CDC’s website, Envision communications and local health department recommendations.
Envision has convened a National COVID-19 Task Force, a multidisciplinary leadership team to address issues that arise from the virus. This team is developing web-based resources, education for hospitals and clinicians, workforce management strategies, and disaster protocols and planning. Further resources and communications will be released as available.
Identification, Testing, Treatment, Quarantine Protocols and Reporting
- Volume Surges: Hospitals should plan immediately for significant increases in patient volume in the emergency department and medical inpatient units. https://annals.org/aim/fullarticle/2763037/how-should-u-s-hospitals-prepare-coronavirus-disease-2019-covid
- Develop a strategy for patient volume and complexity
- Identify alternative locations for staffing and triage of respiratory illness patients
- Develop surge staffing plans for the entire institution
- Protect and support our healthcare workers on the frontlines
- Define a strategy for limited healthcare resources
- Develop clear chains of command and open communication policies
- Healthcare Worker Quarantine Recommendations: Review CDC guidelines for quarantine and scenario-based recommendations for monitoring and risk categories of viral exposure for healthcare workers. Those who fall into a HIGH or MEDIUM risk category must remain out of work for 14 days and must be afebrile before returning. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
- Quarantine Considerations for Healthcare Providers with Low Staffing: The CDC has recommended that “facilities could consider allowing asymptomatic HCP who have had an exposure to a COVID-19 patient to continue to work after options to improve staffing have been exhausted and in consultation with their occupational health program…Facilities could have exposed HCP wear a facemask while at work for 14 days after the exposure event.” https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
- Quarantine of an Envision Clinician: Site clinical leaders (or site medical directors or chiefs) should contact the Envision COVID-19 Hotline at 1.844.607.5824 if a physician or APP has mandated or self-directed quarantine.
- PPE: If a patient meets these patient under investigation (PUI) criteria, healthcare workers should use respiratory isolation precautions, facemasks and eye protection (defined as goggles and face shields). They should contact their hospital’s infection control and local/state health department immediately. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html
- Triage and Alternative Care Areas: Hospitals and clinicians should ensure rapid triage and isolation for patients who screen positive as a PUI. Facilities should consider alternative treatment areas and modify emergency department intake/triage protocols. Telehealth solutions for patient triage should be employed where available to protect healthcare workers from exposure and mitigate volume surges.
- Pre-Hospital Care: EMS workers or outpatient clinic providers should obtain a detailed travel history or exposure history for those patients with the complaint of acute respiratory illness and fever. If a patient is identified as a PUI, clinicians should use personal protective equipment as described above and immediately inform the healthcare facility to prepare. Facilities should maintain a well-ventilated space, separated by six or more feet from other patients for incoming patients who screen positive as a PUI. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html
- EMTALA: CMS has clarified its statement regarding EMTALA regulations for COVID-19. Qualified RNs can perform a medical screen exam; however, check your hospital bylaws to determine if RNs are considered qualified to perform a medical screening examination at your facility. https://www.cms.gov/files/document/qso-20-15-hospitalcahemtala.pdf
The CDC’s guidance for treatment and evaluation is rapidly evolving. Continue to follow the CDC guidelines at https://www.cdc.gov/coronavirus/2019-ncov/index.html