Evaluation of a COVID-19 emergency department observation protocol.

OBJECTIVES: Caring for patients with COVID-19 has resulted in a considerable strain on hospital capacity. One strategy to mitigate crowding is the use of ED-based observation units to care for patients who may have otherwise required hospitalization. We sought to create a COVID-19 Observation Protocol for our ED Observation Unit (EDOU) for patients with mild to moderate COVID-19 to allow emergency physicians (EP) to gather more data for or against admission and intervene in a timely manner to prevent clinical deterioration. METHODS: This was a retrospective cohort study which included all patients who were positive for SARS-CoV-2 at the time of EDOU placement for the primary purpose of monitoring COVID-19 disease. Our institution updated the ED Observation protocol partway into the study period. Descriptive statistics were used to characterize demographics. We assessed for differences in demographics, clinical characteristics, and outcomes between admitted and discharged patients. Multivariate logistic regression models were used to assess whether meeting criteria for the ED observation protocols predicted disposition. RESULTS: During the time period studied, 120 patients positive for SARS-CoV-2 were placed in the EDOU for the primary purpose of monitoring COVID-19 disease. The admission rate for patients in the EDOU during the study period was 35%. When limited to patients who met criteria for version 1 or version 2 of the protocol, this dropped to 21% and 25% respectively. Adherence to the observation protocol was 62% and 60% during the time of version 1 and version 2 implementation, respectively. Using a multivariate logistic regression, meeting criteria for either version 1 (OR = 3.17, 95% CI 1.34-7.53, p < 0.01) or version 2 (OR = 3.18, 95% CI 1.39-7.30, p < 0.01) of the protocol resulted in a higher likelihood of discharge. There was no difference in EDOU LOS between admitted and discharged patients. CONCLUSION: An ED observation protocol can be successfully created and implemented for COVID-19 which allows the EP to determine which patients warrant hospitalization. Meeting protocol criteria results in an acceptable admission rate.

A Case of Bleeding During Infection With COVID-19.

Dr. Patrick Lowe: Our case today is that of a 47-year-old woman who was referred to our emergency department (ED) due to bloody urine, dark tarry stools, red spots on her skin, and bruising throughout her body. Fourteen days prior to presentation, she began exhibiting intermittent fevers, headache, shortness of breath, and a dry cough, and she tested positive for SARS-CoV-2 (the virus that causes COVID-19 pneumonia). Over the 3 days prior to her ED presentation, she experienced a headache that was more intense than the headaches she had been having in the preceding 2 weeks. She reported episodes of both dark urine as well as bright red blood in her urine. In addition, she had multiple dark stools described as tar-like when asked. On the day of her ED presentation, the patient noted a red rash throughout her body. In addition, earlier in the day, she had atraumatic self-limited epistaxis. She denied any falls or head strikes, vision changes, focal weakness or numbness, shortness of breath, chest pain, abdominal pain, or peripheral swelling.

Clinical Policies and Procedures for Critical Care Transport during a Respiratory Pandemic.

The severe acute respiratory syndrome coronavirus disease-2 (SARS-CoV-2) pandemic of 2020-2021 created unprecedented challenges for clinicians in critical care transport (CCT). These CCT services had to rapidly adjust their clinical approaches to evolving patient demographics, a preponderance of respiratory failure, and transport utilization stratagem. Organizations had to develop and implement new protocols and guidelines in rapid succession, often without the education and training that would have been involved pre-coronavirus disease 2019 (COVID-19). These changes were complicated by the need to protect crew members as well as to optimize patient care. Clinical initiatives included developing an awake proning transport protocol and a protocol to transport intubated proned patients. One service developed a protocol for helmet ventilation to minimize aerosolization risks for patients on noninvasive positive pressure ventilation (NIPPV). While these clinical protocols were developed specifically for COVID-19, the growth in practice will enhance the care of patients with other causes of respiratory failure. Additionally, these processes will apply to future respiratory epidemics and pandemics.

Critical Care Transport of Patients With COVID-19.

PURPOSE: Critical care transport is associated with a high rate of adverse events, and the risks and outcomes of transporting critically ill patients during the COVID-19 pandemic have not been previously described. MATERIALS AND METHODS: We performed a retrospective review of transports of subjects with suspected or confirmed COVID-19 from sending hospitals to tertiary care hospitals in Boston. Follow-up data were obtained for patients transported between March 1st and April 20th, 2020. RESULTS: Of 254 charts identified, 250 patients were transported. Nine patients (3.5%) had cardiac arrest prior to transport. Twenty-nine (11.6%) had hypotension, 22 (8.8%) had a critical desaturation, and 4 (1.6%) had both en route. Hospital follow-up data were available for 189 patients. Of those intubated during their hospitalization, 44 (25.0%) had died, 59 (33.5%) had been extubated, and 13 (17.6%) had been discharged alive. For the subgroup with prior cardiac arrest, follow-up data available for 6. Of these 6, 2 died and 4 (66.7%) have been discharged alive. CONCLUSIONS: Few patients with COVID-19 had an adverse event in transport. The in-hospital mortality rate was 25%, with a 33.5% extubation rate. Patients resuscitated from cardiac arrest prior to transport had a 66.7% discharge rate among those transported to consortium hospitals.

Emergency Department Management of Severe Hypoxemic Respiratory Failure in Adults With COVID-19.

BACKGROUND: While emergency physicians are familiar with the management of hypoxemic respiratory failure, management of mechanical ventilation and advanced therapies for oxygenation in the emergency department have become essential during the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: We review the current evidence on hypoxemia in COVID-19 and place it in the context of known evidence-based management of hypoxemic respiratory failure in the emergency department. DISCUSSION: COVID-19 causes mortality primarily through the development of acute respiratory distress syndrome (ARDS), with hypoxemia arising from shunt, a mismatch of ventilation and perfusion. Management of patients developing ARDS should focus on mitigating derecruitment and avoiding volutrauma or barotrauma. CONCLUSIONS: High flow nasal cannula and noninvasive positive pressure ventilation have a more limited role in COVID-19 because of the risk of aerosolization and minimal benefit in severe cases, but can be considered. Stable patients who can tolerate repositioning should be placed in a prone position while awake. Once intubated, patients should be managed with ventilation strategies appropriate for ARDS, including targeting lung-protective volumes and low pressures. Increasing positive end-expiratory pressure can be beneficial. Inhaled pulmonary vasodilators do not decrease mortality but may be given to improve refractory hypoxemia. Prone positioning of intubated patients is associated with a mortality reduction in ARDS and can be considered for patients with persistent hypoxemia. Neuromuscular blockade should also be administered in patients who remain dyssynchronous with the ventilator despite adequate sedation. Finally, patients with refractory severe hypoxemic respiratory failure in COVID-19 should be considered for venovenous extracorporeal membrane oxygenation.

Is novel coronavirus 2019 reinfection possible? Interpreting dynamic SARS-CoV-2 test results.

Since December 2019, COVID-19, the clinical syndrome associated with SARS-CoV-2 infection, has infected more than 6.2 million people and brought the function of the global community to a halt. As the number of patients recovered from COVID-19 rises and the world transitions toward reopening, the question of acquired immunity versus the possibility of reinfection are critical to anticipating future viral spread. Here, we present a case of a patient previously recovered from COVID-19 who re-presents with new respiratory, radiographical, laboratory, and real-time reverse transcriptase-polymerase chain reaction (RT-PCR) findings concerning for possible re-infection. We review this case in the context of the evolving discussion and theories surrounding dynamic RT-PCR results, prolonged viral shedding, and the possibility of developed immunity. Understanding how to interpret dynamic and late-positive SARS-CoV-2 RT-PCR results after primary infection will be critical for understanding disease prevalence and spread among communities worldwide.

Feasibility and Safety of Prone Position Transport for Severe Hypoxemic Respiratory Failure Due to Coronavirus Disease 2019.

OBJECTIVES: To assess the safety and feasibility of a new protocol for interhospital critical care transport of mechanically ventilated patients in the prone position during the coronavirus disease 2019 pandemic by nurse and paramedic critical care transport teams. DESIGN: Retrospective observational study. SETTING: Single critical care transport agency serving multiple centers in the greater Boston area. PATIENTS: All transports of intubated patients in the prone position with severe hypoxemic respiratory failure secondary to coronavirus disease 2019. INTERVENTIONS: Records were reviewed for patients transported in the prone position. Major adverse events in transport, defined as severe hypoxemia (oxygen saturation < 80% or an absolute decrease in oxygen saturation > 10%), hypotension (mean arterial pressure < 65 mm Hg) not responsive to vasopressors or inotropes, endotracheal tube or vascular catheter dislodgement, and cardiac arrest, were recorded. MEASUREMENTS AND MAIN RESULTS: A total of 25 patients were transported in prone position. The mean Pao2:Fio2 ratio in the group was 101.3 mm Hg, and 76% (n = 19) were on vasopressors. Fourteen patients (56%) had hypotension with at least one episode of mean arterial pressure less than 65 mm Hg en route, and seven (28%) had an episode of oxygen desaturation less than 88%. Only one major adverse event of severe hypoxemia (oxygen saturation < 80%) was noted. CONCLUSIONS: Critical care transport of severe hypoxemic respiratory failure patients with coronavirus disease 2019 in the prone position is safe when performed by a dedicated team of critical care nurse and paramedics with an established protocol.

Transport of a Nonintubated Prone Patient with Severe Hypoxemic Respiratory Failure Due to COVID-19.

With the COVID-19 pandemic, healthcare systems have been facing an unprecedented, large-scale respiratory disaster. Prone positioning improves mortality in severe hypoxemic respiratory failure, including COVID-19. While this is effective for intubated patients with moderate-to-severe ARDS, it has also been shown to be beneficial for non-intubated patients. Critical care transport (CCT) has become an essential component of combating COVID-19, frequently transporting patients to receive advanced respiratory therapies and distribute patients in concert with available resources. With increasing awake proning, CCT teams may encounter patients supported in the prone position. Historically, transporting in the prone position has not been embraced due to substantial risks of desaturation during transport. In this case report, we describe the first known report of transporting a non-intubated, critically ill COVID-19 patient in the prone position.