COVID-19 Clinical Information

Modified on 2/15/2022 at 03:18pm

For confirmed COVID-19 cases, reported illnesses have ranged from mild symptoms to severe illness.

According to the Centers for Disease Control and Prevention (CDC), frequently reported signs and symptoms include:

• Fever (83–99%)
• Cough (59–82%)
• Fatigue (44-70%)
• Anorexia (40-84%)
• Shortness of breath (31-40%)
• Sputum production (28-33%)
• Myalgias (11–35%).

Sore throat has also been reported in some patients early in the clinical course.

Less commonly reported symptoms include: headache, confusion, rhinorrhea, sore throat, hemoptysis, vomiting, and diarrhea. Some patients have experienced gastrointestinal symptoms such as diarrhea and nausea prior to developing fever and lower respiratory tract signs and symptoms.

Anosmia or dysgeusia are frequently reported symptoms that are very unusual in non-COVID-19 viral illnesses.

Age is a strong risk factor for severe illness, complications, and death.  Heart disease, hypertension, prior stroke, diabetes, chronic lung disease, and chronic kidney disease have all been associated with increased illness severity and adverse outcomes.

The CDC believes at this time that symptoms of COVID-19 may appear in as few as 2 days or as long as 14 days after exposure.

• COVID-19 therapeutic guidance

• Paxlovid – provider guidance
• Molnupiravir – provider guidance

• Nirmatrelvir-Ritonavir (Paxlovid®) Fact Sheet for Healthcare Providers
• Nirmatrelvir-Ritonavir (Paxlovid®) Fact Sheet for Patients, Parents, and Caregivers
• Molnupiravir Fact Sheet for Healthcare Providers
• Molnupiravir Fact Sheet for Patients, Parents, and Caregivers

• NIH COVID-19 Treatment Guidelines
• IDSA Guidelines on the Treatment and Management of Patients with COVID-19
• Liverpool COVID-19 Drug Interactions Checker

Symptomatic Patient Testing Criteria (“NOVEL CORONAVIRUS COVID-19”)

• Any patient with symptoms of COVID-19.

 Screening test criteria (“NOVEL CORONAVIRUS COVID-19”)

• Asymptomatic patients exposed to COVID-19
  • Patient was in close contact (spending more than 15 minutes total over a 24-hour period within 6 feet) of a person with lab-confirmed COVID-19 infection
  • Recommended sample collection timeframe is 5 days after last exposure (day 0 is day of last exposure) to the person with COVID-19 during that person’s infectious period.
• Asymptomatic behavioral health unit patients before admission

RE-TESTING FOR COVID-19 in symptomatic patients who have not tested positive in the last 90 days.

Patients with COVID-19 typically have high titers of virus in the oro- and nasopharynx and therefore, the OP or NP swab is a sensitive test. However, over the course of the illness, the levels of virus in the upper airway decline – even in patients with progressive lower respiratory tract illness.  Most asymptomatic COVID-19 patients also have high viral titers, though the kinetics of viral load are not well understood very early in infection.

Therefore, there are two scenarios where retesting may be necessary:

1. The patient tested negative but was very early in their course of illness, and/or were asymptomatic, and/or did not have COVID-19 (these scenarios cannot be distinguished in most cases).  The patient later developed symptoms consistent with COVID-19, and met criteria for symptomatic testing.  Sample type for retesting in this case may be NP, OP or sputum.
2. The patient presented with a long course of illness (>=7 days) and an NP or OP swab was negative.  Repeating an NP or OP swab in this case is not recommended as it does not access the lower respiratory tract where virus is more likely to be found; sputum, tracheal aspirate or BAL is recommended for retesting in these cases.

Retesting will be screened for in Epic on an active basis, and cases not approved will have testing canceled. Page *4903 to discuss circumstances with the pathology resident on call to streamline approval if criteria are met.

RE-TESTING FOR COVID-19 in symptomatic or high-risk exposed asymptomatic patients who have previously tested positive within the last 90 days.

 Patients with a previous COVID-19 infection may test positive with the PCR test for weeks or months after an infection.  For this reason, a test-based strategy to return to work or discontinue isolation is not recommended.  A symptom-based strategy to discontinue transmission-based precautions is described below:

1. Patients with mild to moderate illness who are not severely immunocompromised:
   1. At least 10 days have passed since symptoms first appeared (or since positive test if asymptomatic) and
   2. At least 24 hours have passed since last fever without the use of fever-reducing medications and
   3. Symptoms (e.g., cough, shortness of breath) have improved/are improving
2. Patients with severe to critical illness or who are severely immunocompromised:
   1. 20 days have passed since symptoms first appeared (or since positive test if asymptomatic) and
   2. At least 24 hours have passed since last fever without the use of fever-reducing medications and
   3. Symptoms (e.g., cough, shortness of breath) have improved

Patients with symptoms and a high-risk exposure should be tested ASAP and, if first test is negative, again on day 7-10 of quarantine if they present on day 1-5 post exposure.  If a patient with symptoms and a high-risk exposure presents on day 6-14 post exposure, they should only be tested one time, ASAP.

Patients with a previous positive COVID test in the past 90 days who have had a high-risk exposure and are currently asymptomatic do not need to quarantine and retesting is not recommended.

Patients with a previous positive COVID test in the past 180days should not be retested prior to undergoing pre-procedure asymptomatic screening with a COVID PCR test. Similarly, hospitalized patients without a known high-risk COVID exposure who have had a previous positive COVID test in the past 180 days should not be retested upon admission or routinely throughout their hospital stay.

For COVID-19 PCR specimens originating from locations other than the UI Health Care main campus, results will typically be available by noon the day after the specimen is received in the Microbiology lab. (Pre-procedural specimen results will typically be available the evening prior to the procedure).

Providers can view all results in Epic once results have been verified. MyChart results are available less than 1 hour after availability in Epic.

Do not call the laboratory to ask about timing of results; this delays testing for all patients. Predicted turnaround times will not be provided for individual cases. Surgical subcommittee guidelines describe planning scheduled and unscheduled surgical cases around COVID-19 testing.

Random access (also known as “rapid” or “stat”) testing is automatically performed in cases approved by HICS. This type of testing is not orderable and is not available by request.

Effective on or before Thursday, July 1, 2021, COVID-19 Swab Kits will be available to most patient care units/clinics on the main UI Hospitals & Clinics campus via the Omnicells. As of that date, if you need a swab kit in order to collect a specimen from a patient for COVID-19 testing, first check your Omnicell for the kit. If you do not have Omnicells in your unit/clinic you can order the NP swab from Processed Stores at 6-1784 for PS#157252 NP Swab COVID-19 or PS#157253 OP Swab COVID-19.

After COVID-19 swab specimens are collected, the lids must be securely tightened, and they must be double bagged before being placed into a tube carrier. The specimens should be sent directly to the microbiology lab at tube station #160. If a clinical area doesn’t have access to the pneumatic tube system, please follow normal processes to request service from the pathology runners during daytime weekday hours. Outside of daytime weekday hours, specimens will need to be transported to the microbiology lab by the clinical area.

Kits will be placed in each Omnicell based on recent or anticipated testing needs. Staff from Processed Stores will replenish the kits, using products supplied by Pathology, as they replenish other Omnicell supplies.

Questions? Contact Heidi Nobiling (heidi-nobiling@uiowa.edu) if you have questions or concerns about this change.

This guidance is for external POSITIVE COVID-19 tests.

*Antibody (serology) is not acceptable
^†Interim guidance, subject to change

If acceptable documentation from an outside entity cannot be obtained or the positive home test was before Dec. 1, 2021, then follow the approved processes below for testing at UI Health Care prior to procedure and on admission.

If a patient reports a positive test, regardless of symptoms:

• With the result ≤10 days ago (for inpatients and outpatients)
  • Consider the patient COVID-19 positive and isolate
  • No re-test is needed for isolation decisions

• With the result >10 days ago (for inpatients)
  • Test the patient using the appropriate COVID-19 test order (asymptomatic vs Novel Coronavirus) based on clinical status
    • Positive result: isolate (chart will flag as COVID-19, recently recovered will initiate when infection resolved)
    • Negative: no isolation (chart will not be flagged as COVID-19 and recently recovered banner will not initiate)

Verbal reports of a positive antigen or PCR test can be accepted:

• With the result ≤10 days ago (for inpatients and outpatients)
  • Consider the patient COVID-19 positive and isolate
  • Enter/Edit Result in EPIC to get the COVID-19 infection on the patient’s chart
  • No re-test is needed for isolation decisions
•  With the result 11-20 days ago (for inpatients and outpatients)
  • Consider isolation if the patient is immunocompromised &/or has severe and ongoing symptoms. If isolation is warranted, follow enter/edit result instructions above to get the COVID-19 infection on the patient’s chart.

Hospital Incident Command System (HICS) Directive: Jan. 30, 2023

The following revised guidelines are for all patients, regardless of vaccination status, undergoing procedures in any procedural location at UIHC scheduled on Feb. 6, 2023, and after.

The guidelines apply to all procedural locations at UIHC.

Universal pre-procedural testing for asymptomatic patients is discontinued.  This change is in accordance with updated guidance from the Society for Healthcare Epidemiology of America (SHEA) and the American Society of Anesthesiologists (ASA).

Process for patients with a previous COVID-19 positive test:

Documentation is needed for acceptance of outside entity or home tests. For information on documentation of a positive COVID-19 test from an outside entity or home test, see External positive COVID-19 test results.

The following are recommendations for patients with a previous COVID-19 infection:

• Elective surgery should be delayed for 7 weeks after a SARS-CoV-2 infection in unvaccinated patients that are asymptomatic at the time of surgery.
• The evidence is insufficient to make recommendations for those who become infected after COVID-19 vaccination.  Although there is evidence that, in general, vaccination reduces post-infection morbidity, the effect of vaccination on the appropriate length of time between infection and surgery/procedure is unknown.
• Any delay in surgery needs to be weighed against the time-sensitive needs of the individual patient.
• If surgery is deemed necessary during a period of likely increased risk, those potential risks should be included in the informed consent and shared decision-making with the patient.
• Extending the above delay should be considered if the patient continues to have symptoms.
• Any decision to proceed with surgery should consider:
• • The severity of the initial infection
  • The potential risk of ongoing symptoms
  • Comorbidities and frailty status
  • Complexity of surgery
• Because individuals are considered infectious for 5-10 days after the start of the infection, surgery should be delayed for at least 10 days after the diagnosis of COVID-19 infection unless scheduling surgery in this interval outweighs the risk to both the patient and care team.
• Individual units (e.g., SFCH) may have specific recommendations for the perioperative anesthetic management of patients with a recent history of upper respiratory infection, no matter the etiology.

A new guideline for code blue for patients with confirmed or suspected COVID-19 has been outlined for our UI Health Care staff to follow, effectively immediately.

Code Blue Guideline for COVID-19 patients or PUI

1. Cardiac arrest management for patients with either confirmed COVID-19 infection or PUI is a high-risk period for transmission to health care workers.
2. Providers should proactively address goals of care of COVID-19 patients. In the event of cardiac arrest, the evidence is showing that the probability of a good outcome is poor, especially in critically ill COVID-19 patients. This information should be shared with the patient (or surrogate decision-makers) as it relates to the specific patient’s condition.
3. If a patient enters cardiac arrest, follow current guidelines for your area (calling a code blue for inpatient and outpatient at main campus & calling 911 for offsite locations).
4. While you wait for the response team to arrive follow the current American Heart Association Guidance:

1. 1. Cover your own mouth and nose with a face mask.
   2. Cover the patient’s mouth and nose with a face mask.
   3. Perform hands-only CPR.
   4. Use an AED/Defibrillator if available.
   5. Once the response team arrives, let them assume care of the patient and leave the room.

5. The response team for COVID-19 cardiac arrest patients should be limited to only necessary personnel. Pharmacists will be available outside the room. Students are not to be allowed in to simply observe.
6. All code blue response team members, during cardiac arrest, should adhere to airborne and contact isolation precautions. No Code Blue team member should enter the patient’s room without these precautions. The door should remain closed.
7. Each member of the code team should carry his/her own properly-fit N95 mask.
8. Limited supply (2 of each size of N95 and 8 face shields) will be brought to the code as back up. One set will be brought by HOM/nursing supervisor and one set will be on the defibrillator/monitor that is brought to the code.
9. Appropriate donning and doffing procedures may delay routine cardiac arrest care. Providers will work expeditiously as best as they can, without compromising their safety. Isolation precautions and use of PPE are not different in COVID-19 confirmed patients or PUI.
10. No unnecessary equipment should be taken into the patient’s room during cardiac arrest. The emergency medicine tray should be left outside the room. A pharmacist will assist with preparing and mixing drugs. A dedicated team member outside the room will serve as the liaison between the team leader in the room and the pharmacist outside the room, using closed loop communication.
11. For intubated patients in ICUs who are being mechanically ventilated, respiratory therapists should expand alarm parameters and ventilation should continue with the standard mechanical ventilator (10 breaths/min). The ventilator circuit should not be broken unless evidence of equipment malfunction occurs. A viral/bacterial filter will be added to the expiratory arm by the respiratory therapist.
12. For patients who are being bag mask ventilated (whether intubated or not), a viral/bacterial filter will be added by the respiratory therapist.
13. After a cardiac arrest event, all equipment (such as defibrillator, etc.) should remain in the room for complete decontamination prior to placing back in service. Any patient who achieves ROSC should be transported to an ICU room using maximal contact and droplet precautions using standard institutional policy for COVID-19-positive patients (including use of security to clear hallways). The code team should discard their PPEs after the code and while in the room, and then wear new PPEs for patient transport.

The Show of Support Team consists of a hospital security officer, BHS nurse leader (M–F, 7 a.m.–3 p.m.), and BHS SWOT/HOM (off shifts). Please see table below as a guide on when to call each team. Staff will dial 192 (on the back of the badge) and request either the Show of Support Team or the Code Green Team (a similar model to medical emergencies).

The Code Green and Show of Support Teams are available to units/services at UI Hospitals & Clinics. Off-site areas should follow their emergency management plan.

Frequently asked questions

What if I don’t need the SOS/Code Green Team but just need a psychiatric consult?

• Psych Consult Services at pager #3322
• Psych nurse daytime consult pager #7689
• BHS SWOT nurse #3498

What if a visitor is having the behavioral emergency?

• Contact Safety and Security, dial 195

What if my patient needs twice as tough restraints?

• Call BHS units or HOM to have restraints sent to you:
  • 2JPW: 3-6155
  • 2JPE: 6-7736
  • HOM #3313

More information

• For additional information please visit: Code Green Committee SharePoint Site
• Download a flyer on responding to behavioral emergencies

1. Resuscitation efforts will be carried out using standard procedures and protocols

2. Care will be taken to minimize the number of staff members and equipment entering the patient’s room.

• Any provider and staff members (e.g., RT, RN) entering the room during a resuscitation will follow standard, contact and airborne precautions with eye protection given high likelihood of an aerosol-generating procedure. This means wearing a gown, gloves, N95 mask and face shield. Door will remain closed.
• PICU Charge RN will bring a special COVID-19 filter for resuscitation bag and bag of back up PPE (8 face shields and 2 of each size N95 mask) to all RRT and Code Blue events.
• Pediatric Senior Resident will bring a special COVID-19 filter for resuscitation bag and bag of back up PPE (8 face shields and 2 of each size N95 mask) to all RRT and Code Blue events. This will be stored in the Resident Workroom on Level 10. Resident must return this to L10 charge nurse who will should inventory, re-stock and replace bag in Resident Workroom on Level 10 after use (directions inside bag).
• Intubation should be performed by the most experienced provider available. Awake fiberoptic intubation should be avoided.  Perform a rapid sequence induction to avoid manual ventilation.  Laryngoscopes should be sheathed immediately post-intubation and all used airway equipment will be sealed in a zip-locked plastic bag.
• Medication tray should be left outside the room.

*Additional responders who are needed for a Code Blue but should not enter the patient’s room include:

• Floor / Charge RN to direct traffic
• RN to assist with preparing medications
• RT Supervisor and CWS House Operations Supervisor (HOM)
• All other typical Code Blue responders

PURPOSE: Description of workflow alterations in an effort to mitigate the spread of infection within the hyperbaric facility when caring for emergent cases and/or incidences involving two or more patients, in addition to suspected COVID-19 patients. This patient population includes those receiving emergency related treatment.

TARGET POPULATION: Hyperbaric staff, patients, physicians, and the physical facility

DEFINITIONS: None

CRITERIA:

CLINICAL ASSESSMENT/SCREENING:

1. Patients that meet the inclusion criteria to receive hyperbaric treatment will be assessed daily with the following methods.
2. Upon arrival to the facility and if able, each patient will be screened for new or worsening cough, fever, or sore throat. Clinical presentation will provide a secondary observation if the patient is displaying COVID-19 like symptoms and unable to verbally respond to these questions.
3. Patient temperatures will be taken daily and documented in EPIC.

DOCUMENTATION REQUIREMENTS:

• Covid-19 prescreening will be documented in EPIC in accordance with hospital guidelines.

PRECAUTIONS, CONSIDERATIONS, AND OBSERVATIONS:

A. Facility Preparedness

1. The chamber will be disinfected between each treatment by the hyperbaric staff with an approved disinfecting agent recommended by Perry Baromedical.
2. Hyperbaric equipment including recliners, chairs, pillows, IV poles, ventilators, and patient monitors will be cleaned with an approved disinfectant agent between each treatment.
3. The dressing rooms will be disinfected with a hospital supplied approved cleaning agent between each patient use.
4. Patient equipment in the form of hoods or masks will be disinfected between each treatment and stored separately in a sealed bag on a labeled shelf.

B. Patient requirements

1. All patients will don a surgical mask upon entering the facility and be asked to wash their hands and/or use hand sanitizer.
2. As required to participate in a hyperbaric treatment, the patient will change into approved 100% HBO cotton scrubs.
3. After changing clothes, patients will either wash their hands or use hand sanitizer.
4. Vital signs will be performed and documented in EPIC. Temperature, heart rate, respiratory rate, oxygen saturation, and blood pressure will be taken before the patient enters the chamber.
5. The patient will be allowed to use a surgical mask during the compression phase of the dive. This accommodation allows access to their nose to facilitate a Valsalva maneuver to prevent ear barotrauma.
6. If the patient is intubated, COVID-19 isolation guidelines established by the Respiratory Care department will be followed.
7. Once treatment depth has been reached, each patient will remove their surgical mask and don their HBO approved oxygen hood.
8. The hood will remain on the patient for the duration of the treatment including decompression. This action effectively isolates each patient from the chamber environment.
9. If a patient hood needs to be removed for any reason, the patient will immediately don their surgical mask. Hood breaches will be kept to a minimum.

C. Staff requirements

1. Each attendant will abide by the Respiratory isolation guidelines established by the hospital, CDC, and the Undersea & Hyperbaric Medical Society during this COVID-19crisis.
2. A surgical mask must be worn by the HBO attendant at all times.
3. Hand sanitizer will be used between each patient contact encounter and as per our hand hygiene policy.
4. Gloves will be donned and doffed between patients

D. Patient load

1. Up to six patients can be treated at the same time if from the same household.
2. In the event multiple emergent cases arrive simultaneously and the patients are not from the same household up to 2 patients will be treated at the same time in order to maintain social distancing provided both patients can be seated. If one or both patients require a bed for treatment, only 1 will be treated at a time.
3. Efforts will be made to triage patients based on clinical presentation.
4. A risk assessment to patient and attendant safety will be made on a case by case basis.

E. Safety

1. We will continue our regular practice and use of approved dive tables based on the presenting illness of each patient.

REFERENCES:

Dr. Merete Ibsen – Medical Director

Mike Holder – Safety Director

Clinical Care Guidance for Healthcare Professionals about Coronavirus (COVID-19). (2020, May 3). Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care.html

Guidelines for infection control, patient treatment, and staff safety considerations related to Hyperbaric Oxygen Therapy (HBO2) in monoplace and multiplace hyperbaric chambers during the novel coronavirus disease (COVID-19) outbreak. March 2020

APPROVED BY: Medical Director and Respiratory Care Director

Source: Department of Respiratory Care

Effective Date: 5/8/2020

Version Number: 1

View protocol for ordering COVID-19 testing and retesting for all inpatient admissions

Patients with COVID-19 who have a routine clinical visit and all visitors who are COVID-19 positive must complete the full 10-day isolation before coming to our facilities. Patients who are in this COVID-19 isolation period should have these routine visits rescheduled to after their isolation is complete.

If the patient has an urgent medical need during this 10-day isolation, a discussion should be held between the physician and the nurse to determine if the patient should have an on-site visit due to their medical urgency.

Rare exceptions may be granted for visitors in this 10-day isolation time, such as in situations of birth or impending death.

Please remember to remind the patient/visitor (deemed necessary to come UI Health Care during their 10-day isolation period), that they must wear a medical-grade mask at all times while on site.

For patients who are moderately or severely immunocompromised

The Centers for Disease Control (CDC) and Johnson County Public Health recommend individuals who are moderately or severely immunocompromised should isolate for 20 or more days after COVID-19 symptom onset. While UI Health Care recommends immunocompromised patients follow these isolation guidelines, patients who are in active treatment or who have new symptoms requiring urgent evaluation may be asked to come in for an appointment after 10 days of isolation.

PROTOCOL TEMPORARILY CREATED PURSUANT TO AUTHORITY OF HOSPITAL INCIDENT COMMANDER ACTIVATED IN RESPONSE TO COVID-19. EFFECTIVE UNTIL FURTHER NOTICE.

Date Created Per HICS: 4/02/2020                                                             Date Amended Per HICS: (4/16/2020)

Purpose: To minimize personal protective equipment (PPE) utilization, decrease PPE doffing risks and maintain medication infusion safety. The decision to implement this policy will be made by the unit leadership (Nurse Manager and Medical Director) on a unit by unit basis due to staff education requirements and unique circumstances on each patient care unit.

Policy: For patients with a confirmed COVID-19 infection, an Alaris IV infusion pump located outside the patient’s room may be utilized for administration of continuous infusions or intravenous fluids. The decision to use this plan shall be made in conjunction with the treatment team and nursing.

General procedures for inpatient care units and the ILI Clinic:

A. Inpatients should be able to be easily visualized if this process is utilized. This can include glass doors or use of the Video Monitoring Unit (Note- the VMU is to be used as a supplemental monitoring resource dedicated to ensuring the nursing staff is aware of any activity by the patient that may affect the IV infusion, such as ‘picking’ at the lines.)

B. Direct visualization or VMU is not required for patients receiving IV fluids (D5, NS etc…) in the ILI clinic.

C. An Alaris IV infusion pump located outside of the patient’s room may be utilized for peripheral or central administration of continuous infusions or intravenous fluids

D. Extension tubing shall be attached to the Alaris IV infusion pump

1. If utilizing tubing sets instead of or in addition to extension tubing, ports on tubing sets should not be used to administer medications
2. IV extension tubing may be used for the same amount of time as other IV tubing
3. Position patient in the room so that the least amount of IV extension tubing is used
4. Keep IV tubing off the floor
5. Care should be taken to secure IV tubing and connection sites

E. Nursing staff shall verify the IV line to be used for a given infusion prior to initiating medication administration

1. Frequency of site checks (N-07.001)
   • Peripheral IV and Midline Catheter, non-infusing: every 24 hours
   • Peripheral IV and Midline Catheter, infusing: every 4 hours
   • Central Venous Devices, non-infusing: every 24 hours
   • Central Venous Devices, infusing: every 12 hours

F. A patient specific barcode shall be attached to the Alaris IV infusion pump located outside the patient’s room

G. A dark-colored bag shall be placed over any IV medication hung outside a patient room to protect patient information

H. Care should be taken to ensure that power cords are secured and not a trip hazard and not on the floor

I. The correct electrical connection outlet devices are located on the IV poles used for the Alaris pumps. Extension cords are temporarily authorized for this use and will be extended for the duration of the HICS COVID-19 event.

J. No restrictions regarding which continuous infusions or intravenous fluids may be run by nursing staff using an Alaris IV infusion pump located outside the patient’s room. This including but not limited to:

1. High-alert medications (MM.7-1)
2. Titratable continuous infusions

K. IV push medications will be done inside the patient’s room

L. Intermittent infusion will be infused via an Alaris Infusion Device located inside the patient’s room

M. Ensure that when connected to a central line, that lumens are either infusing or saline locked to avoid occlusion. Don’t shut off the pump and forget to saline lock when you are done with the lumen.

Mechanically ventilated patients who cannot be directly visualized from outside the patient room when the door is closed and are not on video monitoring:

A.Nursing staff may not administer any continuous infusions or intravenous fluids using an Alaris IV infusion pump located outside the patient’s room

B. All IV medications shall be administered using an Alaris IV infusion pump located inside the patient’s room

 Considerations during patient transport

A. Limit the number of disconnections/reconnections of IV extension tubing

B. Check that all medical devices are secure

C. Consider use of a clean disposable chux or clean pillowcase to place IV tubing in patient bed

The process outlined below is to be used for the discharge of all COVID-19 positive patients.  This process has been developed with collaboration from a multi-disciplinary team and approved through the HICS structure.

• Once decision to discharge the patient has been confirmed, nursing will work with the patient and/or the responsible party picking up the patient to identify an approximate discharge time.
  • Note: COVID-19 positive patients may have one designated visitor during their admission unless an exception is made. COVID-19 positive patients are not to be waiting for rides outside of their room. All efforts should be made to prioritize any possible discharge barriers and to complete paperwork in a timely manner to make identified discharge time. Nursing’s intent is to limit the wait time of the patient’s ride and to limit the time the COVID-19 positive patient spends in public areas.
  • It is strongly recommended that patients fill their discharge prescriptions at the UI Health Care Discharge Pharmacy to minimize community spread. Prescriptions should be sent electronically to the Discharge Pharmacy. Pharmacy staff will call the patient’s room to counsel the patient, and the prescriptions will be sent up to the patient’s room.

• Nursing staff will perform discharge and documentation per usual method, ensuring patient receives and verbalizes understanding of COVID-19 discharge instructions.
• Nursing will request “patient transport” via EPIC. Nursing will include “COVID-19 positive”, or similar language in comment section of request to alert transporter to take appropriate precautions.
  • Note: Patient transport request will be placed only after it is determined patient’s ride is on hospital grounds and waiting at designated pickup location.

• Nursing staff will take wheelchair into patient’s room, prepare patient for discharge (e.g. transfer them into the wheelchair with belongings) while wearing Modified Airborne, Contact and eye protection PPE.
• When transportation staff arrives to unit, nursing will cover the patient with a clean sheet, place surgical mask on patient, clean handles of wheelchair with approved disinfectant per manufacturer’s guidelines* and communicate to transportation staff that patient is COVID-19 positive.
• Transporter needs to wear a surgical face mask and eye protection; clean gloves should be stored in transporter’s pocket.  Additional PPE is not required unless other medical assistance resulting in physical contact (i.e., assist in patient transfer) is required.
  • For infants / young toddlers, the parent / guardian may sit in the wheelchair and hold onto their child for the transport off the unit.
  • For older children / adolescents, the patient should be in the wheelchair but there may be a parent / guardian present for transport off the unit as well.
• If assistance or physical contact will be needed, two transporters will accompany the patient.  One transporter will wear a surgical face mask and eye-protection and does not wear gloves.  This person will open doors, activate elevator buttons, etc.  The second transporter will wear ; this person will provide assistance to the patient.
• Under no circumstances should anyone wearing gloves touch door handles, doors, elevator buttons, etc.
• Patient will be transported to designated exit via mode-of-transportation as identified by Guest Services. If applicable, Guest Services will contact Safety and Security at #6-2658 for access to designated exit.
  • Adult patients – W194 near Ramp 1
  • Adult patients – 1940X near South JPP
  • Pediatric patients – UI Stead Family Children’s Hospital Main Entrance
  • NICU/NNSY patients – 1940X near South JPP
  • MBCU patients- 1940X near South JPP and/or Ramp 4
  • When family members pick up the patient or the patient drives their own vehicle, staff transport the patient to their vehicle using less frequently populated routes.
• Once transport is complete, transporter will put on gloves and:
  • Place sheet in routine linen hamper
  • Thoroughly wipe wheelchair down with approved disinfectant per the manufacturer’s guidelines*
  • Remove PPE except surgical face mask and perform hand hygiene
  • Return the wheelchair for patient use
  • PPE, linen hamper, and disinfectant will be stored in the Guest Services area near West GH entrance for adult patients
  • PPE, linen hamper, and disinfectant will be stored in the Guest Services area near UI Stead Family Children’s Hospital Main Entrance for pediatric patients

Note: If transport must hand patient off to valet staff, valet staff need to wear a surgical face mask and eye protection. If providing medical assistance or making physical contact with the patient (i.e., assist patient to transfer), D. Valet staff will follow same disposal and cleaning instructions as described above.

*Per Manufacturer’s guidelines, thoroughly wipe the surface with approved disinfectant and ensure the area is wet and allowed to air dry.

**Droplet Precautions PPE: surgical face mask

**Modified Airborne Precautions PPE: N95 respirator or CAPR

**Contact Precautions PPE: isolation gown, gloves

**Eye Protection: face shield, goggles, or mask with fluid shield

**Note: Staff can choose to wear a N95 respirator in place of a surgical face mask but it is not required

Patients who have previously tested positive for COVID-19 in the past 90 days should not be routinely re-tested if new symptoms develop. Re-testing could be considered if symptoms are highly specific for COVID-19 (loss of taste or smell with fever or respiratory symptoms) AND the patient had a recent high-risk exposure (within 6 feet of a person with lab confirmed COVID-19 for more than 15 minutes without the source person wearing a face covering during the source person’s infectious period). Patients with symptoms and a high-risk exposure should be tested ASAP and again on day 7-10 of quarantine if they present on day 1-5 post exposure.  If a patient with symptoms and a high-risk exposure presents on day 6-14 post exposure, they should only be tested one time, ASAP.

Patients with a previous positive COVID-19 test in the past 90 days who have had a high-risk exposure and are currently asymptomatic do not need to quarantine and retesting is not recommended.

Patients with a previous positive COVID-19 test in the past 180 days (counted from the first positive test) should not be retested prior to undergoing pre-procedure asymptomatic screening with a COVID-19 PCR test. Similarly, hospitalized patients without a known high-risk COVID-19 exposure who do not have COVID-19 symptoms and have had a previous positive COVID-19 test in the past 180 days (counted from the first positive test) should not be retested upon admission or routinely throughout their hospital stay.

At this time, notaries will continue in-person visits to UIHC patients as needed.  The current process for notaries in non-COVID rooms will remain unchanged.  The proposed process (below) will go into effect only for COVID positive patients or patients awaiting COVID test results who require notary services.

1. Notary (or two witnesses) will wear proper PPE to access unit. Notary will sign appropriate form outside the patient room and use window or open door to view patient.
2. RN staff working with patient will take the signed paperwork from notary and a Voalte phone with Haiku access into the patient’s room.
3. Patient will sign the paperwork while notary/witnesses observe from doorway.  Paperwork will remain in the patient room and accompany patient when transferred or discharged.
4. RN staff will take a picture of each page of the signed document using the Voalte phone and Haiku application.
5. Social Work staff will send email to Health Information Management at brooke-zittergruen@uiowa.edu and karen-r-kelly@uiowa.edu. HIM will ensure all document photos are combined into a single PDF and uploaded into the patient’s file in Epic (in media tab).

Unit Voalte phones are the primary technology for this process.  Any requests for additional applications or usage must go through HICS.

Criteria and workflow to administer COVID post-exposure prophylaxis with monoclonal antibodies

You can show proof of COVID-19 vaccination in either of the two ways listed below. Verbal report of COVID-19 vaccination is not accepted.

1. Upload photo via Mychart
2. Bring documentation in-person

Vaccination documentation can be a photo of your COVID-19 vaccination card or documented proof of vaccination from a pharmacy or health care provider.

Note that when a patient checks into an encounter, IRIS is queried and updated COVID-19 vaccination information will be available under both Health Maintenance and Immunizations. Staff can manually query IRIS without an encounter by opening the patient’s chart either by using Patient Station or the Open button, choosing the Immunizations tab and selecting Imm Registry to trigger a query.

Please see the following links for step-by-step instructions in Epic for validating COVID-19 vaccination status, entering historical immunization records, and reconciling outside immunizations.

Patients diagnosed with COVID-19 who are undergoing telemedicine home monitoring by the QuickCare Telemedicine team deemed to need in person evaluation (see Ambulatory Monitoring of COVID Patients) will be seen via this workflow and under these clinical practice guidelines.

ILI Respiratory Clinic Treatment Visit Clinical Workflow and Clinical Practice Guidelines

• Schedulers give patients instructions about location of appointment and who to contact upon arrival.
• Workflow at Management Check in:
  • Patients will call the number listed on the parking spot sign when they arrive
  • Get the patient’s name and DOB. Ask them where they are parked.
  • The nurse or paramedic will exit the clinic to pick up the patient from their vehicle.
• Workflow for Providerswith Clinical Practice Guidelines:
  • Vitals obtained and physical exam conducted by nursing staff and provider. Use clinical judgement, but consider these guidelines:
    • If patient is in respiratory distress (RR > 24 or inability to speak in full sentences or persistent O2 sat < 92% on 3 Liters NC) or with unstable vitals (hypotensive) —> ED transfer for stabilization, triage, and disposition decision
    • If 02 on room air is <92% —> Administer O2 via nasal cannula to keep SpO2 > 92% —> If O2 requirement is stable with < 3L O2 NC, and no respiratory distress or tachypnea > 24 RPM —> Direct admission
    • If concern for fluid overload on auscultation —> Consider CXR
    • If wheezing on lung exam or history of asthma/COPD —> albuterol MDI (preferably with patient’s home MDI)
  • Assess for history of heart failure or QTc prolongation
  • IV placed and blood drawn and sent for BMP (Utilize ILI: RESPIRATORY ILLNESS CLINIC ORDERS Smart Set —> Treatment —> IV Fluids)
  • Assess for nausea
    • Zofran 4 mg ODT or IV push
    • Obtain EKG if history of QTc prolongation.  Ensure QTc is <470 ms before administering Zofran
  • Review labs
    • If Cr > 1.8 mg/dL with no history of CKD —> Admission
    • If Cr > 0.5 mg/dL above baseline Cr if history of CKD —> Admission
    • If Na < 125 mEq/L or > 148 mEq/L —> Admission
    • If K < 2.5 mEq/L —> Admission
  • Replace potassium if needed
    • If K 2.5 – 3.4 mEq/L —> 40 mEq KCl liquid
  • Administer IV Fluids (LR or NS) – caution if later in course of illness (Day 7+) and concern for respiratory distress
    • 1000 cc bolus
    • 500 cc and re-evaluate for consideration of another 500 cc if history of CHF or concerns of fluid overload on CXR
  • If patient previously unable to keep down fluids secondary to nausea, can PO challenge with water or clear liquids.  If patient fails PO challenge and has intractable vomiting/nausea precluding adequate home hydration —> Direct admission
  • If patient continues to show signs/symptoms of dehydration after 1 L of IV fluids —> Direct admission

Contact General Medicine Triage Officer (pager 5025) or Family Medicine Resident on call (pager 4070) to discuss direct admission. If direct admission is accepted, provider will place admission bed request order.

Transportation to Main Hospital from ILI Respiratory Clinic

• Patient is a direct admit to UIHC (determine unit location from ATC)
  • Call Johnson County non-emergency dispatch number (319-356-6800)
• Patient needs to be transferred to ED non-emergently (319-356-6800)
  • Call Johnson County non-emergency dispatch number
• Patient is unstable and needing transferred to the ED
  • Call 911
• If patient declines ambulance transfer and chooses to go by private vehicle then the admitting floor and the Emergency Department both need to be notified prior to the patient leaving the clinic.
  • The patient will check-in through the Emergency Department. The admitting floor staff will be responsible for transporting the patient from the Emergency Department to the admitting floor.

1. All COVID-PCR test results will be released to MyChart immediately.

• Includes positive and negative results for LAB8963, LAB9023, LAB8978

2. Positive results-Symptomatic or High-Risk Exposed Patients

• Discuss release from isolation guidelines: Fever free x 24 hours without the use of fever reducing meds PLUS symptoms improving PLUS at least 10 days since onset of symptoms.
• ILI Respiratory Clinic nurse reviews result in EPIC Results Inbasket and contacts patient via telephone. Discuss the following and document in EPIC using .COVIDRESULTSPHONECALL:
  • Self-isolation (see .COVIDPTINSTSUSPECTEDORCONFIRMED).
  • Quarantine and post exposure testing for high-risk close contacts.
  • Verify address and delivery instructions for home monitoring kit if applicable (apartment number, floor, access code, preferred door to drop off kit).

3. Positive results – Pre-operative/procedure testing for Asymptomatic Patients

• Surgical/procedure team to contact patient with next steps regarding upcoming procedure.
• ILI Respiratory Clinic nurse will contact patient to review self-isolation, quarantine, and telemedicine follow-up information.

4. Negative results- Symptomatic Patients without high risk exposure

• Recommend self-isolation until fever free x 24 hours without the use of fever reducing medications.
• ILI Respiratory Clinic nurse reviews results in EPIC Results Inbasket
• If patient has MyChart, nurse sends patient a letter via MyChart using smartphrase.
• If patient does not have MyChart, nurse sends a result note to the P ILI RESPIRATORY ILLNESS NURSE pool and documents specific instructions to be communicated.
  • Clinical staff members will make 1 attempt to provide results.  If no answer, will send UIHC: INFLUENZA LIKE ILLNESS RESULTS LETTER COVID Negative (Symptomatic)

5. Negative Results – Symptomatic Patients with high risk exposure

• Patients with symptoms and a high-risk exposure should be tested ASAP and again on day 7-10 of quarantine if they present on day 1-5 post exposure.  If a patient with symptoms and a high-risk exposure presents on day 6-14 post exposure, they should only be tested one time, ASAP.
• Recommend self-isolation until fever free x 24 hours without the use of fever reducing medications.
• ILI respiratory clinic nurse reviews result in EIPC Results Inbasket
  • If patient has MyChart, nurse sends patient a letter via MyChart using smartphrase.
• If patient does not have MyChart, nurse sends a result note to the P ILI RESPIRATORY ILLNESS NURSE pool and documents specific instructions to be communicated.
  • Clinical staff members will make 1 attempt to provide results.  If no answer, will send UIHC: INFLUENA LIKE ILLNESS RESULTS LETTER àCOVID Negative (Symptomatic) – Exposed Healthcare personnel, Non-Essential/critical worker OR COVID Negative (Symptomatic) – Exposed; Essential/Critical Worker.
  • If patient answers and is still having symptoms, clinical staff can Order Follow-Up Appointment if needed
  • If symptoms still present, schedule patient follow up video visit depending on severity of symptoms and whether additional work-up is needed.
  • Use FOL159 (FOLLOW UP- ILI Telemedicine).  Return Reason: COVID negative, follow up for symptom resolution or FOL145 (FOLLOW UP PCP), or arrange follow-up in QuickCare or Urgent Care.
  • Instruct patient that if they wish to cancel their appointment to contact scheduling at 1-319-384-9010.
  • If patient answers and symptoms have resolved or are significantly improved, no additional follow up needed

6. Negative Results – Exposed Asymptomatic Patients

• The Iowa Department of Public Health recommends that persons with a high-risk exposure to a person with COVID-19 complete a 14-day in-home quarantine if possible.  However, if a 14-day quarantine cannot be completed, there are options for early release from in-home quarantine:
  • Early release after 7 days of in-home quarantine may be considered if a person remains without symptoms and has a negative test on or just before the 7^th. However, during the remaining 7 days of quarantine, the person must:
    • Continue to monitor for symptoms of COVID-19
    • Wear a face mask at all times
    • Maintain social distance
    • Follow all other safety measures recommended by public health
  • Early release after 10 days of in-home quarantine may be considered if a person remains without symptoms without any testing.  However, during the remaining 4 days of quarantine, the person must:
    • Continue to monitor for symptoms of COVID-19
    • Wear a face mask at all times
    • Maintain social distance
    • Follow all other safety measures recommended by public health
  • ILI Respiratory Clinic nurse reviews results in EPIC Results Inbasket
• If patient has MyChart, nurse sends patient a letter via MyChart using smartphrase.
• If patient does not have MyChart, nurse sends a result note to the P ILI RESPIRATORY ILLNESS NURSE pool and documents specific instructions to be communicated.
• Clinical staff members will make 1 attempt to provide results. If no answer, will send UIHC: INFLUENZA LIKE ILLNESS RESULTS LETTER COVID Negative High-Risk Exposure.
  • If patient develops symptoms during COVID quarantine, they should schedule another telemedicine appointment to determine if symptomatic COVID testing is needed.

7. Negative results – Pre-operative/procedure testing for Asymptomatic Patients

• Review to MyChart and done result.  Will not communicate result to patient via telephone.

8. Indeterminate Results – Indeterminate results from UIHC lab have been run twice and come back as a “low positive.” Patients with an indeterminate COVID-19 result will be treated as positive and instructed to isolate like any other COVID-19 positive patient. These patients will not be routinely retested.

• The Iowa Department of Public Health does not consider these results to be positive and will not contact trace.

View ILI Respiratory Clinic/telemedicine contacts

1. Definition of services

• Ambulatory and home monitoring of COVID positive patients, managed by:
  • Respiratory Telemedicine – home treatment team staffed by Quick Care and Urgent Care providers

2. Determination of appropriateness for direct admission

• See document Criteria for Escalation of Care from Home Monitoring of COVID Positive or Suspected Patients

3. Protocol for direct admission to hospitalist COVID team via a telemedicine encounter

• Telemedicine provider will page the general medicine triage officer or Family Medicine resident on-call (patient >18 yo) or appropriate pediatric service to admit the patient to discuss the patient and the indications for admission
  • If both providers agree a direct admission is appropriate:
    • Referring provider places an admission bed request.
      • This can be done by going to Meds & Orders and entering “admission bed request”
        • Select the inpatient bed request
        • Referring clinic: ILI
        • Contact information: Enter your name and pager
        • Isolation: droplet, contact and eye protection
        • Admitting service: internal medicine (patient >18 yo) or appropriate pediatric service to admit the patient (patient <= 18 yo)
        • Attending service contacted: Select “yes” and then enter the accepting provider’s name. This allows ATC to skip the triage process.
        • Complete the rest of the questions
      • This will trigger the admission transfer center (ATC) to find a bed for the patient.
      • ATC will contact the requesting provider for more information and to inform them when a bed is available.
    • If the medicine triage officer or contacted pediatric service provider recommends ED evaluation:
      • Telemedicine provider will then call the ED, identify themselves and ask to speak to one of the ED staff about the patient.
      • The charge nurse will often answer first and take information about the patient to pass along to the ED staff
      • Discuss the patient with the ED staff, indicating why the hospitalist is concerned about admitting to the floor.
    • Protocol for patients arriving by private vehicle to the ED for either admission or evaluation:
      • Patient (and parent/legal guardian(s) if applicable) should be instructed to present to the main ED entrance.
      • Adult patients are not allowed visitors.
      • Instruct patient to arrive wearing a mask if patient is >2 yo. If they don’t have a mask, they should IMMEDIATELY notify screener or security that a mask is needed by calling the ED once they arrive at the main ED entrance.
      • If patient presenting for direct admission:
        • Screener will notify the ED Charge nurse that a patient has arrived for direct admission
        • ED Charge nurse will notify via Voalte the Med/Surg HOM for adult patients or the CWS HOM for pediatric patients
        • HOM will arrange for an escort to meet the patient at the ED an accompany them to the appropriate ward. This escort is responsible to be sure masks are kept on and in place.

4. Protocol for direct admission to adult hospitalist COVID team or appropriate pediatric service via in-person visit at off-site Walk-in Clinics

• Provider will page the general medicine triage officer or family medicine on-call resident (patient >18 yo) OR appropriate pediatric service to admit the patient to discuss the patient and the indications for admission. See ILI Respiratory Clinic – Treatment Visit.
• If both providers agree a direct admission is appropriate:
  • Referring provider places an admission bed request.
    • This can be done by going to Meds & Orders and entering “admission bed request”
      • Select the inpatient bed request
      • Referring clinic: ILI
      • Contact information: Enter your name and pager
      • Isolation: droplet, contact and eye protection
      • Admitting service: internal medicine (patient >18 yo) or appropriate pediatric service to admit the patient (<= 18 yo)
      • Attending service contacted: Select “yes” and then enter the medicine triage officer’s name or Pediatric COVID Hospitalist. This allows ATC to skip the triage process.
      • Complete the rest of the questions
    • This will trigger the admission transfer center (ATC) to find a bed for the patient.
    • ATC will contact the requesting provider for more information and to inform them when a bed is available.

See ILI Respiratory Clinic Treatment Visit Clinical Workflow and Clinical Practice Guidelines for patient transportation guidelines.

• If the medicine triage officer or contacted pediatric service provider recommends ED evaluation
  • ILI Respiratory Clinic or HTT provider will then call the ED, identify themselves and ask to speak to one of the ED staff about the patient.
  • The charge nurse will often answer first and take information about the patient to pass along to the ED staff
  • Discuss the patient with the ED staff, indicating why the hospitalist is concerned about admitting to the floor.
  • See ILI Respiratory Clinic Treatment Visit Clinical Workflow and Clinical Practice Guidelines for patient transportation guidelines.

View telehealth visits and COVID-19 testing workflows

AMBULATORY PATIENTS (INCLUDING THOSE SEEN IN ED AND DISCHARGED TO HOME)

1. COVID Risk 0-2 Peds and Adults
2. • ILI (FOL159)
   • Asymptomatic or previously symptomatic but now asymptomatic
     • Patient seen in ILI Telemedicine/Respiratory Clinic
       • Encourage patient to call 319-384-9010 if they would like to schedule follow-up. If patient requesting follow-up, schedule them for last day of quarantine.
     • Patient seen in ED
     • Encourage patient to call 319-384-9010 if they would like to schedule follow-up. If patient requesting follow-up, schedule them for last day of quarantine. No kit
   • Mildly symptomatic
     • Definition
       • ILI Results Pool RN/Provider/ED Team judgment, but generally no more than 1-2 relatively benign symptoms (cough, URI sx). No dyspnea, fever, poor PO intake, etc
     • Patient seen in ILI Telemedicine
       • ILI Result Pool RN to place order for 3-5 day follow up depending on symptoms and risk factors.
     • Patient seen in ED
       • ED team member communicating results to place order for 3-5 day follow up depending on symptoms and risk factors.
     • No kit

• • Symptomatic
    • Definition
      • More serious symptoms (fever, dyspnea, diarrhea, poor PO intake, etc)
    • Patient seen in ILI Telemedicine/Respiratory Clinic
      • ILI Results Pool RN to place order for 2 day follow up.
    • Patient seen in ED
    • ED team member communicating results to place order for 2 day follow up.
    • Message pharmacy via email (HomeMonitoringKits@healthcare.uiowa.edu) to send limited kit*:
      1. Name/Initials
      2. MRN
      3. COVID Risk Score
      4. Specify limited kit
      5. Address
      6. Phone
      7. Special Delivery Instructions (such as leave at front door on black bench)
      8. Preferred language

2. COVID Risk 3+ Peds

• • ILI (FOL159)
  • Asymptomatic
    • Patient seen in ILI Telemedicine/Respiratory Clinic
      • ILI Results Pool RN to place order for 5 days post-positive test.
    • Patient seen in ED
      • ED team member communicating results to place order for 5 days post-positive test.
  • Mildly symptomatic or symptomatic
    • Patient seen in ILI Telemedicine/Respiratory Clinic
      • ILI Results Pool RN to place order for 1-day post-positive test.
    • Patient seen in ED
      • ED team member communicating results to place order for 1-day post-positive test.
  • Providers/ILI Results Pool RN/ED Team will determine if kit is necessary on case-by-case basis. (Full kits can only be sent to patients > 5 years old.)
    • If kit is necessary, message pharmacy via email (HomeMonitoringKits@healthcare.uiowa.edu) to send kit:
      1. Name/Initials
      2. MRN
      3. COVID Risk Score
      4. Specify full or limited kit**
      5. Address
      6. Phone
      7. Special Delivery Instructions (such as leave at front door on black bench)
      8. Preferred language

3. COVID Risk 4+ Adults

• • HTT (FOL161)
  •  Asymptomatic
    • Patient seen in ILI Telemedicine/Respiratory Clinic
      • ILI Results Pool RN to place order for 5 days post-positive test. If possible, avoid scheduling follow-up on Saturday/Sunday.
    • Patient seen in ED
      • ED team member communicating results to place order for 5 days post-positive test. If possible, avoid scheduling follow-up on Saturday/Sunday. If possible, avoid scheduling follow-up on Saturday/Sunday and tell patient to call 319-384-9010 to schedule an earlier test.
    • Message pharmacy via email (HomeMonitoringKits@healthcare.uiowa.edu) to send full kit**
      1. Name/Initials
      2. MRN
      3. COVID Risk Score
      4. Specify Full Kit
      5. Address
      6. Phone
      7. Special Delivery instructions (such as leave at front door on black bench)
      8. Preferred language

• • Mildly symptomatic or symptomatic
    • Patient seen in ILI Telemedicine/Respiratory Clinic
      • ILI Results Pool RN to place order for 2 day follow up (if next day follow-up needed, page 7576 to discuss). If possible, avoid scheduling follow-up on Saturday/Sunday and tell patient to call 319-384-9010 to schedule an earlier test.
    • Patient seen in ED
      • ED team member communicating results to place order for 2 day follow up.
    • Message pharmacy via email (Brenda Carmody, Courtney Gent, Lisa Mascardo) to send full kit**
      1. Name/Initials
      2. MRN
      3. COVID Risk Score
      4. Specify Full Kit
      5. Address
      6. Phone
      7. Special Delivery Instructions (such as leave at front door on black bench)
      8. Preferred language
  • Severely symptomatic or worsening
    • Page HTT team (7576) immediately to discuss a plan.

DISCHARGING INPATIENTS

• Continued symptomatology OR <10 days since initial symptoms or positive test.
  • HTT (FOL161)
  • Discharging provider places order for 1 day follow up.
• Bedside RN will arrange home monitoring kit to be delivered to the patient’s room prior to discharge.

*Limited kit= pulse ox, masks, nurse education packet

**Full kit= blood pressure monitor, pulse ox, masks, nurse education packet

ADULT (18+) COVID RISK SCORE CRITERIA AND STRATIFICATION

Medical history

• Immunosuppression (2 points)
• Currently receiving chemotherapy, history of bone marrow or solid-organ transplant, HIV
• Active cancer/malignancy (1 point)
• Cognitive Impairment or Developmental Disability (1 point)
• Age (2 points possible)
  • <25 (-1 point)
  • 25-55 (0 points)
  • 55-69 (1 point)
  • >70 (2 points)
• Congestive heart failure (1 point)
• Coronary artery disease (1 point)
• Hypertension (1 point)
• Nursing home resident (1 point)
• Chronic kidney disease (CKD) (2 points)
• Chronic liver disease (1 point)
• Pregnancy (2 point)
• Chronic pulmonary disease (2 points possible)
  • Asthma (1 point)
  • Chronic obstructive pulmonary disease, Interstitial lung disease, cystic fibrosis, other chronic pulmonary diseases (2 points)
• Diabetes (1 point)
• Active tobacco use disorder (1 point)
• Congenital hematologic disorders (2 points possible)
  • Sickle cell disease (2 points)
  • Thalassemia and others (1 point)
• Cerebrovascular disease (1 point)
• Overweight/obesity with a BMI (body mass index) >25 (2 points possible)
  • BMI 25-29.9 (overweight) = 1pt
  • BMI 30+ (obesity) = 2 pts
• Race/Ethnicity = Hispanic or Latino, Black or African American, American Indian or Alaskan Native, and Native Hawaiian and other Pacific Islander people (1 point)

Score 0-2: ILI Respiratory Telemedicine Team

Score 4+: Home Treatment Team (HTT)

Disposition options available:

1. Call EMS (911).

• Use clinical judgement, but generally should be called with:
  • Unable to speak in full sentences.
  • Having concerning chest pain (particularly if non-pleuritic, exertional & relieved with rest, pressure-like).
  • Symptomatic hypotension: systolic BP <90 or a drop of 30 mmHg or more from baseline.
  • Syncope.
  • Cyanosis per family members.
  • Encephalopathy per family members.
  • Hypoxia: SaO2 <88%.

2. Same day appointment with ILI Respiratory Clinic for in-person evaluation. Patient can receive IV fluids, electrolytes, labs, imaging. Does not need direct admission or ED visit.

• Use clinical judgement, but generally consider with:
  • SaO2 >92, but decreasing over the last few days (ex 98% —> 95% —> 93%).
  • Asymptomatic hypotension, pre-syncope, lightheadedness.
  • Inability to tolerate PO.
  • Profuse loose stools.
• Place: FOL160 FOLLOWUP RESPIRATORY ILLNESS CLINIC à
  • PAC schedules patient to be seen same day for a 120min appointment .

3. Direct admission to the floor. If concern a patient requires ICU care, call EMS.

• Use clinical judgement, but consider with:
  • Similar to criteria in 2a, but in clinical judgement warrants admission. The patient must be stable enough to facilitate admission over a few hours time frame.
  • Worsening dyspnea on exertion, but still able to speak full sentences.
  • Mildly increased O2 requirements (if on baseline O2), but again able to speak full sentences.
  • SaO2 88-92% and able to speak full sentences without respiratory discomfort.
  • Hypotension, but not having syncope.

Spanish | French | Swahili

Spanish | French | Arabic | Chinese

Newborn Going Home with COVID-19 or with a Mom who has COVID-19

• Babies infected or whose status is not known due to lack of testing, but with no symptoms of COVID-19, may be go home on a case-by-case basis. Your babies care team will teach you precautions to take. Follow-up contacts (either by phone, telemedicine, or in-office) will be scheduled through 14 days after birth.

Be sure to teach all people who will care for your baby about wearing a mask and gloves, and washing their hands.

People over the age of 60 and those with health conditions should not care for your baby if possible.

• Babies with a negative COVID-19 test or who have never been exposed can go home when ready. A healthy (non-infected) person should care for baby.

If an exposed or positive mom is in the same house, she should try to stay at least 6 feet away from baby. When mom must be near baby, she needs to wash her hands with soap and water for at least 20 seconds. If possible, she should also put on a face mask before caring for baby.

She should do this until:

• At least 10 days have passed since symptoms first started and
• She does not have a temperature of greater than or equal to 38.0° C (100.4° F) for at least 24 hours without the use of medicine that lowers fevers
• Other people who are being tested or have symptoms, should wash their hands with soap and water for at least 20 seconds and should also wear a mask if they can whenever they are within 6 feet of the baby.

Breastfeeding

Studies have not found the virus in breastmilk.

We strongly suggest mom pump breastmilk. First, they should wash their hands and breast. Then a healthy person can feed baby the milk.

Moms who want to breastfeed should wash their hands and breasts well and wear a mask. An infected mom could give baby the virus by contact when they are close during nursing but not through the breast milk.

When you get home:

• Do not take your baby outside, except for health care
• Do not take your baby to businesses, places of worship, or other public places
• Do not use public transportation, ride sharing, or taxis

People: Keep baby in one room and away from other people in your home.  Do not have visitors.

Animals: Keep your baby away from pets while they are sick. Have someone else in your home care for your animals.

Cover your coughs and sneezes

Cover your mouth and nose with a tissue when coughing or sneezing. Throw used tissues in a lined trash can. Clean your hands right away.

If you do not have a tissue, hold your arm in front of your face. Cough or sneeze into your elbow. Coughing into your elbow instead of your hand is safer. When you cough into your hand, the virus gets on your hand and is easier to spread.

Clean your hands often

• Wash with soap and water for at least 20 seconds.
• If you do not have soap and water, clean your hands with an alcohol-based hand sanitizer with at least 60% alcohol. Cover all parts of your or older sibling’s hands and rub them together until they feel dry.
• Soap and water are best if hands are visibly dirty.
• Do not to touch eyes, nose, or mouth with unwashed hands.

Do not share items in the home

Do not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home. After using these items, they should be washed well with soap and water.

Clean all “high-touch” surfaces each day

High-touch surfaces are counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Clean any surfaces that may have blood, stool, or body fluids on them. Use a household cleaning spray or wipe. Follow the label instructions for safe use.

Watch for symptoms

Get health care right away if your baby:

• Has trouble breathing
• Will not drink or breast feed
• Does not have wet diapers often
• Does not wake up
• Has a fever

Call your baby’s doctor’s office and tell them your baby has been exposed to COVID-19 but can still be ill from other reasons. Keep a light sheet over your baby before going into the building and you should wear a mask. This will help the doctor’s office to keep other people in the office or waiting room from getting sick.

View a how-to guide on talking to your patients about the COVID-19 vaccine here.

Spanish | French | Swahili | Arabic | Mandarin