Table of Contents

 

1. Abstract
2. Introduction
3. Section 1. Laboratory Testing and Imaging
   1. Table 1. Basic Laboratory Testing for COVID-19
   2. Table 2. Imaging Diagnostics for COVID-19
   3. Table 3. Different Testing Criteria
4. Section 2. Disposition/Admission Criteria
   1. Table 4. Risk Factor Assessment for COVID-19
   2. Table 5. Disposition Criteria Based on Risk Factors and Clinical Findings for Patients With Confirmed or Suspected COVID-19
5. Section 3. Cardiac Arrest Protocol
   1. Table 6. Cardiac Arrest Protocol: Out-of-Hospital Cardiac Arrest
6. Section 4. Medication Treatment Guidelines
   1. Table 7. Medication Treatment Guidelines for SARS-CoV-2 Infection (COVID-19) in the Emergency Department
7. Section 4a. Anticoagulation Protocol
8. Section 4b. Monoclonal Antibody Therapy
   1. Table 8. Inclusion and Exclusion Criteria for Bamlanivimab Treatment Under Emergency Use Authorization
9. Section 5. Intubation Protocol
   1. Table 9. Intubation Protocol
10. Section 6. Nonaerosolized Asthma Protocol
    1. Table 10. Asthma Protocol for the Stable Patient With Moderate to Severe Symptoms
    2. Table 11. Asthma Protocol for the Crashing Decompensated Patient
11. Section 7. Acute Dyspnea/Palliative Care Treatment/Goals of Care Discussions
    1. Figure 1. Acute Dyspnea Palliation Algorithm
12. Section 7a. Death Management Talking Points
    1. Table 12. Talking Points for Death Conversations
    2. Table 13. Strategies for Making Patient-Centered Recommendations About Intubation and Code Status for Patients Who Are at High Risk for Poor Outcomes
13. Section 8. COVID-19 Smart Phrase/ Discharge Plan for Likely COVID-19 Patients
    1. Table 14. COVID-19 Smart Phrases
    2. Table 15. Discharge Instructions for Likely COVID-19 Patients
14. Section 9. Guidelines for Prone Positioning of Nonintubated Patients
    1. Table 16. Proning of Nonintubated Patients
15. Section 10. Critical Care for ED COVID-19 Patients
    1. Table 17. Troubleshooting for Intubated Patients
    2. Table 18. Acute Respiratory Distress Syndrome Management in COVID-19 Patients
    3. Table 19. Shock Management in COVID-19 Patients
    4. Table 20. Ventilator Management for COVID-19 Patients
    5. Table 21. Diagnostics in Critical Care of COVID-19 Patients
    6. Table 22. Respiratory Management in COVID-19 Patients
16. Section 11. Return-to-Work Criteria
    1. Table 23. Return-to-Work Criteria
17. Selected Web Resources
18. References

1. Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
2. Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
3. Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY
4. Mount Sinai Hospital, New York, NY
5. Mount Sinai West and Mount Sinai Morningside Hospitals, New York, NY

Abstract

Coronavirus disease (COVID-19), caused by the SARS-CoV-2 virus, originated in Wuhan, Hubei Province, China in late 2019 and grew rapidly into a pandemic. As of the writing of this monograph, there are over 100 million confirmed cases worldwide and 2.3 million deaths.¹ New York City, with over 630,000 COVID-19-positive patients and over 27,000 deaths, became the infection epicenter in the United States. The Mount Sinai Health System, with 8 hospitals spread across New York City and Long Island, has been on the forefront of the pandemic. This compendium summarizes the lessons learned through interdisciplinary collaborations to meet the varied challenges created by the explosive appearance of the infection in our community, and will be updated continuously as new research and best practices emerge. It is our hope is that the collaborations and lessons learned that went into creating these guidelines and protocols can serve as a useful template for other systems to adapt to their fight against COVID-19.

Introduction

This monograph summarizes the evaluation, treatment, and disposition tactics the Mount Sinai Health System created and implemented to help manage a new disease that posed an unprecedented volume of critical patients and had no known treatment. While by no means all-encompassing, the methods outlined here are focused on the front-line emergency clinician. We provide a rubric of how to think about major decisions regarding workup, treatment, and disposition. There is a focus on providing fundamental care in a way that maximizes safety for both patients and clinicians. Discussions regarding personal protective equipment (PPE), operational flow, and nonmedical resources are beyond the scope of this monograph. Although not discussed in detail, many of the nodal points in clinical decision-making can likely be performed by both telemedicine and advanced practice providers.

Table 1. Basic Laboratory Testing for COVID-19

References

1. Center for Science and Engineering at Johns Hopkins University. Covid-19 Dashboard. Accessed February 15, 2021.
2. Li Y, Xia L. Coronavirus disease 2019 (COVID-19): role of chest CT in diagnosis and management. AJR Am J Roentgenol. 2020:1-7. DOI: 10.2214/AJR.20.22954
3. Leibner E, Hyman J. Airway Management Policy for the Mount Sinai Health System. Mount Sinai Health System; 2020.
4. Hansen G, Marino J, Wang ZX, et al. Clinical performance of the point-of-care cobas Liat for detection of SARS-CoV-2 in 20 minutes: a multicenter study. J Clin Microbiol. 2021;59(2). DOI: 10.1128/jcm.02811-20
5. Mostafa HH, Carroll KC, Hicken R, et al. Multi-center evaluation of the Cepheid Xpert® Xpress SARS-CoV-2/flu/RSV test. J Clin Microbiol. 2020. DOI: 10.1128/jcm.02955-20
6. Pujadas E, Ibeh N, Hernandez MM, et al. Comparison of SARS-CoV-2 detection from nasopharyngeal swab samples by the Roche cobas 6800 SARS-CoV-2 test and a laboratory-developed real-time RT-PCR test. J Med Virol. 2020;92(9):1695-1698. DOI: 10.1002/jmv.25988
7. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020;8(5):475-481. DOI: 10.1016/S2213-2600(20)30079-5
8. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;323(11):1061-1069. DOI: 10.1001/jama.2020.1585
9. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-1062. DOI: 10.1016/S0140-6736(20)30566-3
10. Donnelly JP, Wang XQ, Iwashyna TJ, et al. Readmission and death after initial hospital discharge among patients with COVID-19 in a large multihospital system. JAMA. 2021;325(3):304-306. DOI: 10.1001/jama.2020.21465

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Keywords: coronavirus disease 2019, COVID-19, SARS-CoV-2, patient flow, testing, PPE, Mount Sinai, protocols, testing, diagnostics, disposition, cardiac arrest, medication, monoclonal, intubation, asthma, dyspnea, death, smart phrase, discharge, proning, ARDS, shock, ventilator, return to work