I have interjected some notes as well, they are marked in brackets. This is a mix of transcription, shorthand, etc for a one-hour talk and Q&A session. Hopefully summarizing it here will be helpful for those who may not have a whole hour to chill with a podcast-style discussion.
And as always, check the megathread for helpful links. I especially recommend the EMcrit page on COVID-19, though i'm not sure how up to date it is right now (esp. regarding the late-onset myocarditis being described by others, and possibly causing the reports from China of patients being d/c home and dying the next day). Regardless it's a good starting point.
Situation update and initial comments
Nathan Furukawa, MD, MPH Epidemic Intelligence Service Officer Centers for Disease Control and Prevention
Michael Bell, MD Deputy Director, Division of Healthcare Quality Promotion Centers for Disease Control and Prevention
CAPT Lisa Delaney, MS, CIH (USPHS) COVID-19 Response Worker Health and Safety Team Centers for Disease Control and Prevention
Clinical aspects of COVID-19
80% will have mild illness. Comordities/age put at higher risk (esp snf/ltnf). Less likely to cause severe illness in children, and some very minimal data that pregnant women are not higher risk
Mean incubation is 4-5d but can be from 2-14d. Fever, cough, myalgia, fatigue, SOB. Some pts are getting diarrhea/nausea prior to fever/resp. Not all adults present with fever, esp elderly; could simply be change in mental status and nonspecific malaise. Some pts skate along for a week when sick inpatient then suddenly nosedive
r/medicine post by a purported ICU physician in Washington, this might be related to the apparent myocarditis that is causing many late-stage deaths, even after pts appeared to be out of the woods from sepsis>
Regarding diagnostics, lymphopenia most common finding. Sometimes there is elevated alt/ast and it can be sign of more severe illness. Procalc normal
Transmission and infection control
Close range transmission, about 6 ft. radius for sneeze/cough. Also surface to hands to mucous membranes. Use soap or etoh handwash, whichever is quickest/available. Airborne transmission is also suspected. But airborne precautions are not currently recommended because it is not proven to transmit the virus in this way. No need for neg-pressure isolation rooms, unless doing aerosol generating procedures (i.e. induced sputum obtaining).
Supply limitations dictate reservation of respirators for high risk procedures or very high risk pts. Surgical masks provide some protection and it may be that respirators are not any better than surgical masks for routine assessment of patients. Masks on patients are most effective on person who is coughing. Even better than other ppl or providers wearing masks/ppe in terms of spread prevention
PPE is not the most important factor; it is better to ensure you don’t need PPE. As in, remote evaluation by phone or telehealth. Can also use plexiglass-type partitions for triage.
Building ventilation should flow from clean to contaminated. Keep patients home whenever possible. Don’t use actual respirator for training. If supplies low can use alternatives such as reusable respirators, and PAPRs. If needed can reuse n95s (i.e. leave on between encounters). IF crisis, can use beyond shelf life.
Q & A session
If short on PPE?
CDC recommends notifying state health care dept. to address local shortages.
Surface contamination in healthcare settings?
EPA-registered hospital disinfectants seem to be effective at killing covid.
Empiric abx for covid pts?
If fever/resp and infiltrates, consider empiric abx. Should be made on clinical suspicion and antimicrobial stewardship, just as with bact pna superimposed on flu.
How long shut down room after covid pt leaves?
If building ventilation does 12 exchanges per hour, then 30-40min is usually enough time. If building older, may need to wait longer. Mainly important so that the room can later be surface/terminal cleaned without having to use valuable resp gear for workers. Less important towards risk for the future patient (i.e. the risk is going to be highest for whoever goes into the room first).
Extended use of respirators?
Can reuse between several rooms, but don’t touch resp/eye protection. These have low risk of transmitting to the next patient. DO replace gown/gloves. If cohorting occurs, can use less overall PPE (cohorting must be only confirmed cases cohorted together).
Full reuse of respirators?
Only in extreme cases. Use hand hygiene when don/doffing the respirator if you use it for the whole day. Store properly between uses.
How obtain remdesevir?
Clinicaltrials.gov, or compassionate access at gilead.com
Any other trials?
Some with HIV meds. Unpublished so far. Anecdotal reports of using chloroquine or hydroxychloroquine. Chinese have use interferon-alpha, ribavirin, ??? inhibitors.
What point would you recommend outpatient clinics cancel routine visits?
Depends on extent of community effect. Timing therefore will vary based on location. Now is the time to think through larger script refills, text/telephone followup as well. Postpone visits when able at least 3 months. Give no more than a few more days before this starts, for most locations in the US.
Which clinical samples are best for testing for covid?
Right now for initial dx testing, CDC recommends collecting upper resp tract specimens, both nasal and oral. Get one nasopharyngeal one oropharyngeal, can put in same tube and send for single test. Lower respiratory tract specimens can be collected in hospital, but do NOT induce sputum for testing because this will produce large amounts of droplets and aerosol and not worth the risk. Intubated patients, can send bronchoalveolar lavage or tracheal aspirate. More info at CDC website. OCCUPATIONAL EXPOSURE: wear a respirator as much as possible, but save them for high aerosol procedures such as intubation, BiPAP/CPAP placement, giving nebs, airway suction, bronchoscopy, or chest physiotherapy.
If resources are available, is it sensible to isolate patients in private room if they have unexplained fever and resp symptoms regardless of travel history?
Yes, if you have the space. Be sure to rule out other causes including influenza first. But spread is large enough now that isolation is reasonable if you have the room space.
Can you explain donning and doffing?
See CDC website for full instructions
Do you have recommendations for how I should prepare my clinic for patients with covid symptoms?
Same as above with outpatient clinics. EXPLORE use of telehealth modality. Nurse information lines, other triage lines. Do anything possible to decrease time spent in waiting room; if not possible, maximize distance between patients inside (6ft). can call them from cars using cellphones instead of waiting in lobby.
Can we use expired respirators?
Can be used with caution, in context of lack of local supply. N95 filter seems good after time but straps may decay. Use for non-patient care first (i.e. training).
Do we have data on how long the virus survives on surfaces?
Prelim of persistence on surfaces (in the lab) exist. Stainless steel, can persist 2-3hrs. But they aren’t covered in protein like a natural viral load would be, which alters timing (unstated which way). Bottom line, can exist at least a couple hours.
Recommendations for cleaning surfaces in clinics?
Environmental cleaning/disinfection important for control. Recommend routine daily cleaning, cleaning between uses of patient care rooms and surfaces and any shared equipment. Cleaning is necessary to remove any protein/matter/etc protecting virus before any chemical disinfectant use. Disinfectant is assessed by EPA to be effective against particular microbes. Be sure disinfectants are used according to labels. If using wipes, be sure to note how long the surface must stay wet for that particular cleaner to be effective.
Collected tips and some ideas for urgent care/primary care. Any feedback on these are very welcome.
–Start rescheduling non-sick visits ASAP
–Implement phone check-in if at all possible, to limit time spent in any shared airspace
–Might be reasonable to provide a basic mask for every patient with cough, regardless of suspicion for covid
–get everyone on board with how to don/doff
–initially can limit pt contact to two or three people (i.e. one person checkin/triage, one person conduct exam/swabs, or perhaps a provider exam then lab technician does swab). However as COVID becomes endemic this will probably not be practical anymore
–COVID swabs should be one NP, one OP, and then place in same tube
–Importantly, negative pressure rooms are NOT recommended unless doing aerosol generating procedures…which means for urgent care/primary it should be safe to simply have the patient in a private room.
–Also, it doesn't appear that anything stronger than standard PPE (gown/glove/face shield/surgical mask) is necessary for routine swabs/testing in the outpatient setting.
–Establish a chain of contact/followup for every single covid test. The CDC "person under investigation" sheets are cumbersome but ultimately may be the best way to do this, especially for clinics that are seeing less than 50pts a day (any more might be too difficult to manage with a smaller staff).
Hopefully this can help those of us outside the hospital to do our part too.
Source: Original link