145000 confirmed cases, Asia and Europe are hotspots
Attack rate way higher than flu, mortality on population level at least 0.3% compared to 0.01% for the flu. Factor 30!
Half of IC patients with COVID-19 die, equal to ARDS patient mortality.
Immunocompromised patients are the most vulnerable, just like 70+ers.
Measures for oncological patients: no colleagues with respiratory tract infections (RTI) are allowed near them. Patients with RTI’s in separate rooms.
Diagnosis: PCR of respiratory material in 12 labs in the Netherlands -> now to 50 labs.
Advice is to perform viral diagnostics in ALL patients admitted due to RTI’s.
Source of material is important: deeper is better. It can be negative in throat swabs, but then the sputum might be positive. Clinical suspicion remains important, even with negative tests.
Shortages of molecular diagnostics, less tested by the GGD (=CDC) and fewer hospital staff being tested. Now only “critical” personal are being tested, and those with high risk contacts.
Is reinfection possible? Unclear, but does seem VERY unlikely. Not safe to let positive staff work without PPE.
Unclear how much viral load says something about recovery.
Serology, can this say something about experienced infection, and is risk of new infection low? Erasmus University Medical Centre is looking into it.
Situation in Brabant hospitals and region/Intensive Care treatments:
- Breda now has 33 patients (200 in the region). 11 on the ICU, 3 died (10%).
- Most cases quickly isolated and swiftly diagnosed.
- Dutch presentation is diverse, seems to have multiple introductions and all these introductions are giving outbreaks. Suspicion that Carnival
led to outbreaks.
- Male > female incidence.
- Patients on ICU: circa 50% <50 years, and circa 50% >50 years. So also young people are affected.
- ARDS treatment, prone position, high PEEP and prostacyclin.
- People with comorbidity are admitted to ICU quicker after first symptoms, young people typically 1-5 days of mild symptoms, then or better or quickly a lot worse and bad ARDS, CT imaging with severe abnormalities.
- Performing CT-scanning with intubated patients possibly not very risky, because few aerosols with well-sealed tube.
- Breda: o Of 22 beds to 26 on Sunday to 28, now 15 for COVID patients. o Three categories of patients: negative, suspected and positive. Separated care. o Whole hospitals unruly and worried. Still sufficient capacity and materials.
- Quicker intubations than otherwise, long Optiflow or NIV makes outcomes of ARDS worse. This is also ensures more safety for staff.
- Patients are intubated approx. 3 weeks, two weeks with poor outcomes and only then slow recovery. First two weeks also a lot of virus present. ICU treatment is treating the ARDS, not so much the virus. It’s a long-stay illness. Particularly a lot of pulmonary insufficiency.
- High PEEP and low-normal driving pressure.
- People who die usually develop after 4-7 days post-intubation/respiration an acute worsening.
- Data from Italy and China: do not give steroids, it increases viral load.
- Amount of people with a lot of abdominal pain suspect for pancreatitis ended up being positive (for COVID) and did not have abdominal pathology.
- Threatening shortages: swabs and reagents and mouth masks. Be thrifty! FFP2 masks only to be used with aerosol-forming interventions. FFP2 masks are to be centrally controlled. On the wards these won’t always be necessary, only with risk for aerosols. Stores are only going to last several days. On the ICU per patient 20 masks a day as a triaged amount is doable.
- Through the army: 70 respiratory machines are being delivered where they are necessary.
- Reuse of masks: lots of hospitals looking for gassing/radiation/washing. Land-wide research follows. Save all your masks (surgical, FFP1 and FFP2). Possibly use hydrogen peroxide.
Separate regular and COVID care.
Regulation of supplies needs to increase.
Supplies for COVID patients need standardisation and treatment needs standardisation.
We need to optimalise respiratory machines and regular machines on the ICU.
Make a flexpool of staff. Use university hospitals to find best triage flow.
Central coordination of staff so that care-givers can mail and get more staff.
Schedules need to be made for all phases (orange, red, black). Inventarise all personnel with ICU experienced. Anaesthesiologists to be included in scheduling. Use peri-operative rooms.
EPD: ensure personnel can work with it. Dashboards need to be made to supply data. Make ICT optimalise the EPD.
Triage needs to be made in the black (=worst) phase, suggestions will follow. Form triagist teams on de ER/A&E.
We need to account for a significant increase in respirated patients.
Diagnostics take time. First isolate patients, if they are positive take them to a designated COVID area, that way fewer isolation rooms are necessary.
Multidisciplinary conversations over suspected and positive patients are crucial, if needed digitally.
Health and Youth Care Inspectorate is allowing ways of working, deviation of standards; that inspection would otherwise not approve.
Ensure staff stays involved and safe!
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