Home > All Topics > Practical Protocols for Managing Patients With SARS-CoV-2 Infection (COVID-19) in the Emergency Department

FREE PREVIEW
This article is available to subscribers.
Already have an account? Log in. Not a subscriber? Subscribe now.

1,337 views

Practical Protocols for Managing Patients With SARS-CoV-2 Infection (COVID-19) in the Emergency Department

Download PDF

Table of Contents

Abstract
Introduction
Section 1. Laboratory Testing and Imaging
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
Section 3. Cardiac Arrest Protocol
1. Table 6. Cardiac Arrest Protocol: Out-of-Hospital Cardiac Arrest
Section 4. Medication Treatment Guidelines
1. Table 7. Medication Treatment Guidelines for SARS-CoV-2 Infection (COVID-19) in the Emergency Department
Section 4a. Anticoagulation Protocol
Section 4b. Monoclonal Antibody Therapy
1. Table 8. Inclusion and Exclusion Criteria for Bamlanivimab Treatment Under Emergency Use Authorization
Section 5. Intubation Protocol
1. Table 9. Intubation Protocol
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
Section 7. Acute Dyspnea/Palliative Care Treatment/Goals of Care Discussions
1. Figure 1. Acute Dyspnea Palliation Algorithm
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
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
Section 9. Guidelines for Prone Positioning of Nonintubated Patients
1. Table 16. Proning of Nonintubated Patients
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
Section 11. Return-to-Work Criteria
1. Table 23. Return-to-Work Criteria
Selected Web Resources
References

Evan S. Leibner, MD, PhD^{1 2 3 4}

Sonya Stokes, MD, MPH ^{2 5}

Danish Ahmad, MD^{1 2 3 4}

Eric Legome, MD ^{2 5}

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

Corresponding Author:

Evan Leibner, MD PhD

One Gustave Levy Place, Box 1620

New York, NY 10029

Phone 212-241-8867

evan.leibner@mountsinai.org

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

Table 2. Imaging Diagnostics for COVID-19

Table 3. Different Testing Criteria for COVID-19

Table 4. Risk Factor Assessment for COVID-19

Table 5. Disposition Criteria Based on Risk Factors and Clinical Findings for Patients With Confirmed or Suspected COVID-19

Not a subscriber yet? We hope you enjoyed this preview. To receive the full PDF of this topic for free, enter your email address

References

Center for Science and Engineering at Johns Hopkins University. Covid-19 Dashboard. Accessed February 15, 2021.
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
Leibner E, Hyman J. Airway Management Policy for the Mount Sinai Health System. Mount Sinai Health System; 2020.
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
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
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
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
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
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
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

Enter your email to get the full list of 48 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

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

We hope you enjoyed this free preview.

To learn more about this topic and to earn CME credit,

Download Calculated Decisions PDF

Introduction

The ACEP ED COVID-19 Management Tool is an emergency department classification and management tool for adult patients (aged ≥18 years) with suspected or confirmed SARS-CoV-2 (v1.0, updated April 6, 2021).

Access Calculator

About the Score

The American College of Emergency Physicians (ACEP) Emergency Department COVID-19 Management Tool is intended to guide severity classification, risk stratification, and diagnostic and management decisions in adult patients (aged ≥18 years) with suspected or confirmed SARS-CoV-2 (COVID-19) infection in the emergency department.

There is no need to apply this tool to patients who are not being evaluated for COVID-19. If the patient is considered to have mild disease, this tool may help avoid further testing.

This algorithm is not intended to be a substitute for clinicians' clinical judgement. The algorithm is not exhaustive in regard to diagnostic and treatment recommendations for patients with COVID-19 and COVID-like illness. Presenting symptoms or conditions that may be manifestations of COVID-19 could also be manifestations of other serious disease (eg, myocardial infarction, pulmonary embolism, stroke), which may require additional specific diagnostic and therapeutic interventions not discussed in this tool.

Imaging, laboratory tests, treatment, and disposition should be considered based on disease severity and risk for disease progression. The United States Centers for Disease Control and Prevention (CDC) has more information on outcome risks associated with race, ethnicity, and access to health care resources. The American Journal of Obstetrics and Gynecology has published a guideline to assist with risk stratification of pregnant patients. The National Institutes of Health (NIH) maintains recommendations for appropriate diagnostic testing. Recommendations for respiratory support, intravenous fluids, and other interventions are also maintained by the NIH. Pharmacologic recommendations for patients with COVID-19 are evolving quickly; recommendations for pharmacologic management are maintained by the NIH and the Infectious Diseases Society of America.

Calculator Review Authors

Peter A. D. Steel, MA, MBBS

Department of Emergency Medicine, New York- Presbyterian/Weill Cornell Medical Center, New York, NY

Brian Fengler, MD

Department of Emergency Medicine, University of Tennessee Medical Center, Murfreesboro, TN

Christopher R. Carpenter, MD, MSc

Department of Emergency Medicine, Washington University School of Medicine in St. Louis, Saint Louis, MO

Stephen Cantrill, MD

Department of Emergency Medicine, Denver Health, Denver, CO

Sandy Schneider, MD

Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY

Evidence Appraisal

Step 1 - Severity Classification

The disease severity classification categories utilized by this tool (mild, moderate, severe, critical) are based on the classification categories adopted by the NIH COVID-19 Treatment Guidelines Panel, which were developed based on an early consensus of the literature describing the disease entity initially pre-senting in Wuhan, China, and subsequently identified as SARS-CoV-2.

Step 2 - Risk Prognostication

This section utilizes the PRIEST COVID-19 clinical severity score as a validated tool to predict a patient’s risk for end organ failure and/or mortality. The PRIEST study was a mixed prospective and retrospective observational cohort study undertaken in 70 emergency departments across the United Kingdom. A total of 22,445 patients were included; all were suspected to have COVID-19 and presented between March 26, 2020 and May 28, 2020. This tool was included because it did not require diagnostic testing (ie, laboratory tests, imaging) as part of the evaluation of the patient.

Step 3 - Risk Assessment

In this section, the user is asked if the patient has any additional risk factors that could increase the risk of severe disease, organ failure, and/or mortality. The CDC maintains consistently updated data on the outcome risks associated with race/ethnicity, socioeconomic status, and access to health care resources. Additional references (Bellou et al 2020; Ebinger et al 2020; Lokken et al 2021; Strausz et al 2021; Williamson et al 2020; Tartof et al 2020) are provided to summarize evidence for other risk factors.

Step 4 - Diagnostic Testing

This section follows the NIH guidelines for testing recommendations. Recommendations within this section will be updated as the NIH updates its guidelines. Evidence for exertional O₂measurement is included from additional references (Greenhalgh et al 2020; Goodacre et al 2020; Paglia et al 2020).

Step 5 - Diagnostic Interpretation

Laboratory values that have been associated with risk of disease progression, severe disease, and/or mortality are included in this section. Abnormal value cutoffs were heterogenous across the studies, so the working group determined the most pragmatic values to display within this summary tool. The following references were included: Bellou et al (2020), Guan et al (2021), Hahm et al (2021), and Payán-Pernía et al (2020). Clinicians are advised in this section to check with their own facility's laboratory to determine the abnormal cutoff values that are used there.

Step 6 - Disposition

This section presents an approach to disposition of the patient based on severity classification. Most of the section was developed by consensus among the working group. Supplemental evidence was included from Banerjee et al (2021), patient educational materials produced by the CDC, and resources for patients from JAMA.

Step 7a - Nonpharmacologic Treatment

This section cites 8 references that include recommendations for nonpharmacologic treatment of respiratory infections in general (eg, Patchett et al 2021), as well as for COVID-19 specifically (eg, Banerjee et al 2021). The recommendations are organized based on clinician assessment of disease severity. Some of the recommendations are consensus based.

Step 7b - Pharmacologic Treatment

This section is abstracted directly from the NIH COVID-19 treatment guidelines, the majority of which are evidence based. The entries are listed by severity of disease. When provided in the NIH guidelines, the strength of the recommendation and level of evidence for the recommendation are specified. (See Table 1 for definitions.) For example, the following recommendation is provided for moderate, severe, or critical COVID-19:

Remdesivir: For hospitalized patients who require minimal supplemental oxygen (BIIa).

National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021.

Instructions

This tool is intended for use in patients aged ≥18 years. The evidence for management of COVID-19 is evolving quickly and recommendations may change.

Calculator Creator

Stephen Cantrill, MD, FACEP
Brian Fengler, MD
Shannon Brown
Christopher R. Carpenter, MD, MSc, FACEP, AGSF
Brenna Farmer, MD, MBA, MS
Kent C. Grimes
Tara Khan, DO, MS
Dan Mayer, MD
Laura Melville, MD, MS
David Ng, MD, MS, FACEP
Christopher Sampson, MD, FACEP
Sandy Schneider, MD, FACEP
Saman Shahid, MBBS
Bradley Shy, MD, FACEP
Peter A. D. Steel, MA, MBBS
Edward H. Suh, MD

References

All current citations are listed on page 7 of the ACEP Emergency Department COVID-19 Management Tool.

Original/Primary Reference

American College of Emergency Physicians. Emergency department COVID-19 management tool. May 27, 2021. Accessed June 28, 2021.

Validation Reference

COVID-19 Treatment Guidelines Panel Members. Coronavirus disease 2019 (COVID-19) treatment guidelines. National Institutes of Health. 2021. Accessed June 28, 2021.

Additional References

American College of Emergency Physicians. COVID-19. Accessed June 28, 2021.
Arjona A, Sarkar DK. Evidence supporting a circadian control of natural killer cell function. Brain Behav Immun. 2006;20(5):469-476. DOI: 10.1016/j.bbi.2005.10.002
Banerjee J, Canamar CP, Voyageur C, et al. Mortality and readmission rates among patients with COVID-19 after discharge from acute care setting with supplemental oxygen. JAMA Netw Open. 2021;4(4):e213990. DOI: 10.1001/jamanetworkopen.2021.3990
Bellou V, Tzoulaki I, van Smeden M, et al. Prognostic factors for adverse outcomes in patients with COVID-19: a field-wide systematic review and meta-analysis. Eur Respir J. 2021:2002964. DOI: 10.1183/13993003.02964-2020
Bhimraj A, Morgan RL, Shumaker AH, et al. Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19. Infectious Diseases Society of America. 2021. Accessed June 28, 2021.
Campbell JP, Turner JE. Debunking the myth of exercise-induced immune suppression: redefining the impact of exercise on immunological health across the lifespan. Front Immunol. 2018;9:648. DOI: 10.3389/fimmu.2018.00648
Chow DS, Glavis-Bloom J, Soun JE, et al. Development and external validation of a prognostic tool for COVID-19 critical disease. PLoS One. 2020;15(12):e0242953. DOI: 10.1371/journal.pone.0242953
Clift AK, Coupland CAC, Keogh RH, et al. COVID-19 mortality risk in Down syndrome: results from a cohort study of 8 million adults. Ann Intern Med. 2021;174(4):572-576. DOI: 10.7326/M20-4986
Ebinger JE, Achamallah N, Ji H, et al. Pre-existing traits associated with Covid-19 illness severity. PLoS One. 2020;15(7):e0236240. DOI: 10.1371/journal.pone.0236240
Ghosh S, Deshwal H, Bin Saeedan M, et al. Imaging algorithm for COVID-19: a practical approach. Clin Imaging. 2021;72:22-30. DOI: 10.1016/j.clinimag.2020.11.022
Giannakoulis VG, Papoutsi E, Siempos II. Effect of cancer on clinical outcomes of patients with COVID-19: a meta-analysis of patient data. JCO Glob Oncol. 2020;6:799-808. DOI: 10.1200/GO.20.00225
Goodacre S, Thomas B, Lee E, et al. Post-exertion oxygen saturation as a prognostic factor for adverse outcome in patients attending the emergency department with suspected COVID-19: a substudy of the PRIEST observational cohort study. Emerg Med J. 2020;38(2):88–93. DOI: 10.1136/emermed-2020-210528
Goodacre S, Thomas B, Sutton L, et al. Derivation and validation of a clinical severity score for acutely ill adults with suspected COVID-19: The PRIEST observational cohort study. PLoS One. 2021;16(1):e0245840. DOI: 10.1371/journal.pone.0245840
Greenhalgh T, Javid B, Knight M, et al. What is the efficacy and safety of rapid exercise tests for exertional desaturation in covid-19? Centre for Evidence-Based Medicine. April 21, 2020. Accessed June 28, 2021.
Guan X, Zhang B, Fu M, et al. Clinical and inflammatory features based machine learning model for fatal risk prediction of hospitalized COVID-19 patients: results from a retrospective cohort study. Ann Med. 2021;53(1):257-266. DOI: 10.1080/07853890.2020.1868564
Hahm CR, Lee YK, Oh DH, et al. Factors associated with worsening oxygenation in patient with non-severe COVID-19 pneumonia. Tuberc Respir Dis (Seoul). 2021;84(2):115-124. DOI: 10.4046/trd.2020.0139
Haimovich AD, Ravindra NG, Stoytchev S, et al. Development and validation of the quick COVID-19 severity index: a prognostic tool for early clinical decompensation. Ann Emerg Med. 2020;76(4):442-453. DOI: 10.1016/j.annemergmed.2020.07.022
Kameda T, Mizuma Y, Taniguchi H, et al. Point-of-care lung ultrasound for the assessment of pneumonia: a narrative review in the COVID-19 era. J Med Ultrason (2001). 2021;48(1):31-43. DOI: 10.1007/s10396-020-01074-y
Lokken EM, Huebner EM, Taylor GG, et al. Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State. Am J Obstet Gynecol. 2021;225(1):77.e1-77.e14. DOI: 10.1016/j.ajog.2020.12.1221
Meira E Cruz M, Miyazawa M, Gozal D. Putative contributions of circadian clock and sleep in the context of SARS-CoV-2 infection. Eur Respir J. 2020;55(6):2001023. DOI: 10.1183/13993003.01023-2020
Paglia S, Nattino G, Occhipinti F, et al. The quick walk test: a noninvasive test to assess the risk of mechanical ventilation during COVID-19 outbreaks. Acad Emerg Med. 2021;28(2):244-247. DOI: 10.1111/acem.14180
Patchett D, Yang J, Northern J, et al. Viral respiratory infections: an ounce of prevention is worth a pound of cure. Mayo Clin Proc Innov Qual Outcomes. 2021;5(2):480-485. DOI: 10.1016/j.mayocpiqo.2020.12.008
Payán-Pernía S, Gómez Pérez L, Remacha Sevilla ÁF, et al. Absolute lymphocytes, ferritin, C-reactive protein, and lactate dehydrogenase predict early invasive ventilation in patients with COVID-19. Lab Med. 2020;52(2):141-145. DOI: 10.1093/labmed/lmaa105
Pecora F, Persico F, Argentiero A, et al. The role of micronutrients in support of the immune response against viral infections. Nutrients. 2020;12(10):3198. DOI: 10.3390/nu12103198
Rubin GD, Ryerson CJ, Haramati LB, et al. The role of chest imaging in patient management during the COVID-19 pandemic: a multinational consensus statement from the Fleischner Society. Radiology. 2020;296:1. DOI: 10.1148/radiol.2020201365
Sjoding MW, Dickson RP, Iwashyna TJ, et al. Racial bias in pulse oximetry measurement. N Engl J Med. 2020;383(25):2477-2478. DOI: 10.1056/NEJMc2029240
Strausz S, Kiiskinen T, Broberg M, et al. Sleep apnoea is risk factor for severe COVID-19. BMJ Open Respir Res. 2021;8(1):e000845. DOI: 10.1136/bmjresp-2020-000845
Tjendra Y, Al Mana AF, Espejo AP, et al. Predicting disease severity and outcome in COVID-19 patients: a review of multiple biomarkers. Arch Pathol Lab Med. 2020;144(12):1465- 1474. DOI: 10.5858/arpa.2020-0471-SA
Tartof SY, Qian L, Hong V, et al. Obesity and mortality among patients diagnosed with COVID-19: results from an integrated health care organization. Ann Intern Med. 2020;173(10):773- 781. DOI: 10.7326/M20-3742
Toussie D, Voutsinas N, Finkelstein M, et al. Clinical and chest radiography features determine patient outcomes in young and middle-aged adults with COVID-19. Radiology. 2020;297(1):E197-E206. DOI: 10.1148/radiol.2020201754
United States Centers for Disease Control and Prevention. COVID-19 hospitalization and death by race/ethnicity. CDC. June 17, 2021. Accessed June 28, 2021.
United States Food and Drug Administration. Pulse oximeter accuracy and limitations: FDA safety communication. FDA. February 19, 2021. Accessed June 28, 2021.
Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature. 2020;584(7821):430-436. DOI: 10.1038/s41586-020-2521-4