WikEM - User contributions [en]

Talk:Bezoar

2022-04-14T03:40:58Z

Jochickabee: Created page with "test"

test

Talk:Thiamine deficiency

2020-09-17T20:19:18Z

Jochickabee: Created page with "test"

test

Thiamine

2020-09-17T20:01:44Z

Jochickabee: /* Adult Dosing */

==Administration==
*Dosage Forms: 50,100,250,500mg
*Routes of Administration: IM, IV
**Im or IV routres require: Intradermal skin test before use if hypersensitivity risk
*Common Trade Names: Vitamin B1

==Adult Dosing==
*Beriberi
**10-20mg IM tid x 2wk
***Then 5-30mg PO QD x1mo

*Wet beriberi with CHF
**10-30mg IV tid

*Wernicke's encephalopathy
**High-dose parenteral regimen: 500mg IV TID x 2 days
***Then 250mg IM/IV QD x 5 days

==Pediatric Dosing==

==Special Populations==
*[[Drug Ratings in Pregnancy|Pregnancy Rating]]: A (according to dietary reference intake)
*[[Lactation risk categories|Lactation risk]]: Safe

===Renal Dosing===
Not defined
===Hepatic Dosing===
Not defined

==Contraindications==
*Allergy to class/drug

==Adverse Reactions==
===Serious===
*anaphylaxis
*angioedema
*cyanosis

===Common===
*injection site pain
*pruritus
*warmth sensation
*urticaria

==Pharmacology==
*Half-life: Unknown
*Metabolism: Liver, CYP450, Unknown
*Excretion: Urine

==Mechanism of Action==
Physiologic cofactor

==Comments==

==See Also==
{{Thiamine deficiency types}}

==References==
*[https://online.epocrates.com/drugs/188810/vitamin-B1-common-name/Monograph Epocrates: Vitamin B1]
<references/>
[[Category:Pharmacology]]
[[Category:FEN]]

WLAVA:COVID19 ED Operational Updates

2020-06-30T23:07:52Z

Jochickabee: /* FACULTY CME REIMBURSEMENT */

♦♦♦ = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 6/30/20♦♦♦==

===GLA UNIVERSAL MASKING POLICY===
* Please wear a mask at all times.
* Please remind staff and patients to wear a mask appropriately.
** It is for our own good to prevent spread of employee transmission.

===ED BREAKROOM===
* No eating at MD workstations.
* No more than 2 people in ED breakroom.
** Eat outside or in private area.
* No potlucks, parties, shared food/drinks.

== EMPLOYEE SYMPTOM SELF-REFERRAL TOOL ==
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

===SEROLOGICAL TESTING===
* '''Getting the test:'''
** Free serological testing will be available to all employees on a voluntary basis
** Blood draw occurs through the outpatient lab
*** [https://leaf.va.gov/VISN22/691/Clinical/?a=newform Submit LEAF request] (VA Intranet) PRIOR to blood draw
*** Expect 1-2 day delay in processing prior to being able to show up at outpatient lab

* '''Serological testing results:'''
** Serology results are now available online.
** Click this [https://vaww.fre.cdw.va.gov/sites/D05_BISLTeam/RCM/VISN22/Covid19Employee.rdl?Web=1 link] and you will be taken to this screen:

** Enter your DOB and click "apply"
** You will need both patient-level CPRS and your Network Username in VistA. Easiest way to do this would be at the VA.
** Contact Employee Health (310) 268-3522 if you do not see your results
** If you don't see the title "Covid-19 Employee Self-Lookup" after clicking the "Apply" button, please email VHAGLADataAnalysisHelp@va.gov with a screenshot of any other error message.

===REVISED CARDIOLOGY ADMISSION CRITERIA===
* '''Please note that the Cardiology team cannot care for ICU level patients.''' Patients requiring ICU level of care will be admitted by the MICU team with mandatory cardiology consult. This includes, but not limited to:
** Hemodynamically Unstable Arrhythmias:
*** Atrial fibrillation / flutter requiring titratable gtts for rate control
*** Ventricular tachycardia/VF electrical storm/multiple ICD shocks
*** High degree/complete heart block (with or without temporary pacing wire)
** Cardiogenic shock, with or without mechanical support (ie. Impella), or heart failure requiring frequent titration of vasoactive gtts
** Acute Coronary Syndrome
*** Unstable angina/NSTEMI that is hemodynamically unstable, requiring NTG gtt or other vasoactive gtts
*** STEMI

===ED IPAD PROGRAM===
* Kat Yip is spearheading our iPad deployment program (SOP pending).
* Aims of the program:
** Allow Veterans to stay connected to family using video technology.
** To decrease unnecessary face-to-face time (F2F) while evaluating a patient with symptoms of COVID.
* Apple ID p/w (case sensitive): Covid2019**
* Please clean, turn off after use (preserve battery), and return to locked cabinet.
* Key to locked cabinet is in red lock box inside the ED Provider Workstation area.
* Email Manny and Kat for feedback/issues.

===GOOGLE GROUPS EMAILS===
* You might not be receiving important emails and they could be going to your spam email if you don’t white-list google groups (hopefully somehow you're getting this one or Jonie's previous email)
* In case you don’t have it, here’s how.
** Please whitelist these addresses – best way is to create a filter in your email settings or adding them to your email’s contact list.
*** vaed-all-providers@googlegroups.com
*** vaed-fee-basis@googlegroups.com
*** vaem-faculty@googlegroups.com -- (for faculty)
** For Gmail
*** Click the gear icon on the top right and select see all settings
*** Click the Filters and Blocked addresses tab
*** Scroll down a little and click Create a New Filter
*** In the pop-up window enter @googlegroups.com
*** Click Create filter (it may look greyed out but you can click it)
*** Check “Never send it to spam”
*** Click “Create filter”

===BYTEBLOC===
* Annoyed by the DAILY bytebloc emails reminding you of your shifts? Here’s how to turn them off
* Log in to bytebloc
* Click on Staff
* Click User Options
* Go to Email notifications tab and edit your preferences

===SNF OUTBREAK===
* Low threshold to place SNF patients on enhanced isolation (please wear appropriate PPE!).
* Asymptomatic patients, not able to isolate in SNF, will be directly admitted to inpatient. Symptomatic patients will go through the ED.
* Expect that these patients will come to the ED and have a low threshold to admit.

===METFORMIN RECALL===
* There has been a recall of 500mg and 750mg Extended Release Metformin pills due to NDMA impurity.
* No adverse effects have been reported due to this to date
* Please see pdf: [[:File:AMENDMENT_Metformin ER Tablets USP 500mg and 750mg Recall Due to NDMA_National PBM Patient-Level Recall Communication_FINAL_061920 (1).pdf]]
* FDA recommends that we continue to prescribe metformin when clinically appropriate and that this does not affect the immediate release products
* "Continue to report adverse reactions by entering the information into CPRS Allergies/Adverse reactions field. Adverse events should also be reported, as appropriate, to the VA ADERS program and FDA MedWatch (1800FDA1088)."

===PSYCH ED PATIENTS===
* Order a CEPHEID for any patient that is placed in the psych ED regardless of whether or not you believe they are going to be discharged
* There was a incident where a patient was asymptomatic and exposed multiple patients in the psych ED and therefore we are allowing CEPHEID for these patients specifically

===ED PHARMACIST===
* We now have in house ED pharmacists: My "Phoung" Pham - program manager, Srjit "Surj" Singh, and William Duong
* They will be sitting next to Dexter (UR) for now
* They are available from 7a-7:30p (with 30 minute lunch)
* Please ask for any pharmacy/medication related issues
* They are also able to dispense naloxone from the ED and will help with patient education
* If questions or problems, ask Cindy Koh

===ED FELLOWS===
* We will be having rotating UCLA Fellows rotating through the ED as attendings a few shifts a month
* Max Berger - UCLA MedED Fellow
* Abdulkareem "Kareem" Agunbiade - UCLA Ultrasound Fellow
* They will be allowed to staff patients with residents

===CHAPERONE POLICY REMINDER===
* Chaperones must be present for sensitive exams
* Chaperones must be the same gender as the patient identifies
* Chaperones cannot be residents, who are considered an 'extension' of the attending
* Document the name of the chaperone in the chart
* Males must be offered a chaperone. If they decline, document this in the chart

===N95 8000S===
* We are no longer collecting the 8000s for reuse, you can discard them.
* We are still collecting 1860/1870 in brown paper bags and placing them in the bins
* We are not collecting the newer masks for now

===FIT TESTING DATES===
* Room 0413B is in the Sim Center.
* The Thursday sessions are still occurring but have been moved to 1pm-3pm in Room 3232
** June 30, Room 0413B (Sim Center) 6am-12pm
** July 1, Room 0413B (Sim Center) 6am-2pm
** July 2, Room 0413B (Sim Center) 6am-12pm
** July 2, Room 3232 1pm-3pm
* FIT testing by appointment otherwise, notify us if you have not been FIT tested for the 8000 series

===ED SHAREPOINT===
* As mentioned before, thanks to Jonie, the sharepoint has been revamped (linked below accessible via VA intranet only)
* There is now a [https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/Radiology/Home.aspx page with Radiology FAQs about consents, IV contrast, and uploading CDs]
* [https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/Transfers%20%20Trauma/Home.aspx Trauma/transfer page]
* [https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/Direct%20Scheduling%20%20Rapid%20Access/Home.aspx ED-PACT/Rapid access page]

===FACULTY CME REIMBURSEMENT===
* Jonie has put the procedure [https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/Physician%20Handbook/Faculty%20CME%20Reimbursement.aspxhttps:/dvagov.sharepoint.com/sites/VHAGLAMed/ed/Physician%20Handbook/Faculty%20CME%20Reimbursement.aspx here] (sharepoint only)
* Submit your educational stipend requests asap. Deadline is Sept 30, 2020
* You will need to place the LEAF request early prior to any start date
* Aim for August 15, 2020
* You can purchase the product and send receipt with form ; make sure the start date is after purchase
* No travel will be approved due to COVID-19
* If you have any other questions, please call Patricia Moonyeen Gamboa/Patricia Cruz x43512

==AIRWAY REMINDERS==
===AIRWAY COVERAGE===
* Expanded airway coverage by anesthesia (7a-11p DAILY) ends on 6/30 since elective surgeries will be restarting
* We will return to covering evenings and weekends
* We are opening up airway shifts for July
** 11p-7a M-F
** 7a-7p Sat/Sun
** 7p-7a Sat/Sun
* Please let Scott know if you can cover these shifts
** Please continue to drop off at 7a (5 North, Rm 5003), if ED is not covering airways.

==== HOW TO CONTACT ANESTHESIA====
* '''Daytime:''' Vocera "COVID AIRWAY" or the airway pager.
* '''After 11p:''' Use the call list on ED SharePoint (see below).
**'''To find the call list, follow these steps:'''
*** Go to GLA home page
*** Go to intranet on right side of page
*** Go to Patient care on the top of the page
*** Go to big red box "WLA VA on Call Schedule"
***Scroll down to anesthesia

====ED ATTENDING AIRWAYS====
*We are still responsible for non-covid airways and crash airways in the ED or after 11p (triple night coverage).
** You get first dibs on any airway you want.

===AEROSOLIZING PROCEDURES===
* Per Dr Goetz, '''aerosolizing procedures are okay in PUIs''' as long as patients are in a negative pressure room (all private rooms in the ED currently) and all staff entering the room is donning appropriate PPE. This means N95, eye protection, face shield, gown, and gloves. This includes:
** CPAP
** Nebulizer treatments
** High flow nasal cannula

===UNUSED MEDICATION BAGS===
* '''Please make sure all used med bags are discarded.'''
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
** If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

====GLIDESCOPE GO SHORTAGE====
* There is a national shortage of Glidescope S4 blades.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====SECURING ETT VIDEOS====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====AEROSOL BOXES====
* Moved to Jonie's office (code 1453).
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

=====SUGGESTED WORKFLOW FOR AEROSOL BOX=====
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attach the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95.
*** Please wear the recommended level of PPE for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-11p 7 days a week.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
====ED ATTENDING AIRWAY RESPONSIBILITIES====
* Write an '''Intubation Note''' in CPRS
* Please hand off the pager to the responsible Airway Attending.
* Airway Team should restock cart and medications after each use.
* Report anything missing to Derrick, Miguel and COVID champions.

====ED COVID AIRWAY TEAM====
* '''Overnight:'''
** '''Intubating COVID:''' 11p-7a
** '''Buddy:''' A) 12a-8a B) 11p-7a

====DAILY AIRWAY CART LOG====
* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top of the Airway Cart'''.
* Best practice is to refill the cart after intubation because you know what is missing.
* This daily log is a double check/insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

====RESTOCKING CARTR====
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

====AIRWAY RED BOX IN MED ROOM====
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===UPDATED GUIDANCE ON PPE===
* '''Summary of COS Guidance Document:'''
** Since in the ED we won’t necessarily know the COVID status of a patient prior to doing a potentially aerosol-generating procedure on a patient (including things like peri-coronal or peri-apical abscess drainage, PTA drainage, nasal packing):
*** '''Our best strategy in the ED is to wear PPE assuming that the patient is COVID+''' (face shield, N-95 respirator, gown, gloves)
**'''Other salient points:'''
*** All patients and staff should always wear a mask
*** All patients and staff should maintain 6 feet of distance when possible
*** Gloves should be worn in all patient encounters and changed in between encounters
*** Hands should be washed (for 20 seconds) or hand sanitizer used after all patient encounters

===USE OF DISINFECTANT WIPES===
* We are running low on Saniwipes and other disinfectant wipes
* '''Please use Saniwipes to clean medical equipment only – reusable PPE, ultrasound machine, etc.'''
* '''Do not use disinfectant wipes to clean work areas.'''
* For all work areas (areas not directly involved in patient care), EMS will be providing bottles of Virex Plus Disinfectant spray or a Glance General Purpose Cleaner along with disposable rags (white) or reusable rags (green) that can be deposited in the dirty linen bins. Please ask the charge where it is being kept.
*[[:File:Disinfecting Procedures.pdf]]

===3M 8000 N95 FIT TESTING===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out.
** EVERY Thursday Room 3232 12-2 is scheduled until end of July:
***Primary purpose of this FIT testing is for rotating residents so please set aside a time for them to go to this.
***Make sure you complete the questionnaire ahead of time.
*Please notify us if you have not been FIT tested for the 8000 series and cannot make one of these dates before your next shift! They are really flexible and will work with our schedules but we need to know ahead of time what works for you so they can be available.

*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR CLEANING===
* After intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Place PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team ASAP.

===PPE GENERAL INFORMATION===
* [[WLAVA:COVID-19_PPE#Airway.2FCode_Donning_.26_Doffing_Checklist|Donning/Doffing checklist and videos.]]

====MASK GUIDANCE====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

===SPS N95 COLLECTION===
* SPS Collecting ALL N95s.
* You will NOT be getting these masks back to you.
** The VA intends to stockpile these in case of an emergency.
** Therefore if you need to keep them for a certain reason (I.e. failed 8000 testing), please keep them yourselves. * Chief of Staff published another guidance document outlining collection of all N95 face masks (including the 8000 series)
** We ARE collecting the mask if used for intubation/buddy/aerosolizing procedure (if not visibly soiled or ruined).
** DO NOT SAVE N95 IF THE FOLLOWING CRITERIA ARE MET:
*** If the mask is visibly soiled or deformed/destroyed.
* Please '''label the mask''' with your '''name''' and '''date''', '''place in paper bag''' and '''again label your name and date''', then '''deposit in the red bin the dirty utility room.'''
** The care team is also responsible for providing necessary precautions to ensure safety of visitors, Veterans, and staff.

===PPE MAIN PAGE===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==
* Avoid having symptomatic patients enter Building 500 if they do not require emergency care.
** Try to accommodate their needs from the tent (i.e., page consult service if they came for appt, call pharmacy to prepare meds if came for refill, skype PCP, etc.)

===TENT COVERAGE===
* Tent hours are now 8a-4:30p M-F
* We will no longer be proctoring beyond 6/23 and tent will be staffed by other services
* Anticipate patients will be showing up to the ED (primarily FT) during off tour hours
* Please send out the Roche (LB) swab on these patients (do not send CEPHEID unless patient being admitted)
** If a patient doesn't meet criteria for testing, please educate him/her. If insistent, then go ahead and swab because we do not want them tested outside the system
* Make sure to use the ED PACT tool liberally for patients that have an assigned PMD to f/u on test
** Alternatively, if an employee, make sure that they make an appointment to f/u with employee health
* OP swabs are acceptable alternative if the patient is unable to tolerate the NP swab

===EST PROVIDER ORIENTATION CHECKLIST===
* For CORE faculty assigned to orient dental residents on the weekday mornings.
* [[File:Tent Orientation Checklist 5.27.20.pdf|thumb|center|EST Provider Orientation Checklist]]

=== TENT ORIENTATION/PROCTORING CLARIFICATION===
* Please take a look at the schedule. It has been attached to the Master schedule.
** [https://onedrive.live.com/edit.aspx?resid=4879B40AF988B29!12314&ithint=file%2cxlsx&authkey=!AKwmdarimU4_kdM Link to Orientation/Proctoring schedule.]

===TENT DISPO TOOL===
*Please see the [https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB EST Provider Disposition Tool] for EST workflow.
*This decision-making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

===EMPLOYEE SELF-REFERRAL TOOL===
* Please refer asymptomatic employees to Employee Health and NOT the tent
* We are trying not to co-mingle symptomatic and asymptomatic patients
** The Best time to test is 4-5 days after exposure so they can usually wait for an employee health appointment.
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

===PROPOSED WORKFLOW FOR PUIS IN TENT SEEKING TO ENTER MEDICAL CENTER===
* Many patients have been trying to re-enter the hospital after having been seen in the tent, especially if they are here for a scheduled appointment.
* '''Make sure that PUIs know they cannot enter the hospital unless they have a serious medical disease requiring the ED evaluation/stabilization.'''
* EST provider can help facilitate their outpatient care by doing the following:
** Have them skype the clerk to set up a follow up appointment.
** If the patient is insistent about being seen, you can set up a telehealth encounter with the clinic.
*** Page the desired service
*** They can see the patient in the EST.
*** They can arrange for outpatient VVC appointment.
*** If medications are ordered for the patient, have the service order the medications and call the pharmacy to prepare them. Then have the service call EST to notify that they are ready for pickup and EST can send a runner to the pharmacy.
* The purpose of this is to allow the patient to have his appointment but with a virtual encounter instead.
* We will be seeing more of this as clinics start re-opening.
* Please make sure you proctor the dental residents as such.

===SYMPTOMATIC EMPLOYEES IN EST===
* Please test all symptomatic employees in EST, do not refer to Employee Health (unless EST is overwhelmed with patients).
* Please test all asymptomatic employees presenting to the EST if they are within optimal testing window (4-6 days from known exposure).
** Ideally these employees are reaching out to EH to schedule their testing. Please, do not turn away walk-ins unless they are not at least 4 days from known exposure.
** In the rare event that you have to transfer a symptomatic patient to EH, please call in advance so that the employee remains outside the EH waiting room (it is a shared area for asymptomatic employees and job applicants).
** Employee Health Contact Information:
*** Mirasol Button X44325
*** Angella Burrell x40281
*** EH main line x53522

===NEW CPRS NOTE TEMPLATES===
* Search "Tent" in CPRS Note library:
** Enhanced Screening Tent Provider Note
** Employee Health Enhanced Screening Tent Note
* '''Please pay attention to the *** sections as they provide guidance to make the flow less redundant or clunky.'''

===TENT CONSULTS===
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===PRE-PROCEDURE TENT===
* The pre-procedure tent will be getting more volume as the hospital expands operations.
* If you haven't noticed, there are two sides to the tent - symptomatic tent and the pre-procedural tent for those needing surveillance screening prior to their operations, infusion, dialysis, etc.
* For patients to show up in the pre-procedure tent, they must have an appointment and order by the original provider.
* Some of these asymptomatic patients are being sent to the tent without orders or an appointment and then need to be seen in the symptomatic side because they need an order from the tent provider.
* If they end up being seen by the tent provider, please perform the test. Then try to locate the service/individual who sent them to provide directed feedback that they should be placing the order and having the patient make an appointment.
* If you are unable to locate the sending provider, email
[[vhawlaest@va.gov]] (or for any other tent issues) with the information so that the tent leadership can follow up.
* Our goal is to keep the pre-procedure patients (who are higher risk usually) separate from the symptomatic ones in the screening tent.

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

===COVID-19 TRIAGE SCREEN===
* Please make sure to review the COVID-19 Screen section of the ED RN Triage Note.
* ED Nurses are supposed to notify the Charge Nurse of any patient that screens positive (these patients should be placed in a private room with isolation orders).
* This information is supposed to be relayed to ED provider, but it may not be happening routinely (please let Manny know if it isn’t).
* If after you see the patient, you feel that their COVID-19 screen is actually negative (i.e., patient cough is chronic without acute change) please document that in your note.

===TESTING ASYMPTOMATIC PATIENTS===
* If a patient insists on being swabbed while being asymptomatic, please try your best to educate the patient about why it is not necessary.
* If the patient is still insistent and says they’ll get swabbed elsewhere (e.g. county), please just go ahead and swab them. We do not want our patients to be swabbed outside or system.
* Send the LB (Roche) tests on these people and NOT the CEPHEID

===CEPHEID TESTING===
*CEPHEID results are required prior to bed assignment, EXCEPT for high-risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

====NP SWABS====
* If the patient is unable to tolerate a nasopharyngeal swab (coughing, gagging, restlessness), it is fine to do an oropharyngeal swab. These are the same swabs, just inform the nurse that the sampling is different.

===COVID TESTING FOR TRANSFERS===
* GLA's unwritten policy is that COVID testing is not a prerequisite for transfer of a patient to WLA from another facility
** If the patient is stable for transfer, then the transfer should occur
**COVID testing can be done in the ED and the patient's destination determined as a results
* Please let Manny know when this happens as he is keeping track of the volume of these patients

===NEGATIVE PRESSURE ROOMS===
* All private rooms in the main ED are negative pressure rooms.
* Move patient to negative pressure room if plan to perform aerosolizing procedure.
====ISOLATION FOR PUIs====
* For high-risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

===CLARIFICATION ON NIPPV===
* There is no absolute contraindication for NIPPV in COVID unknown patients. We do not have an institutional policy against it.
* However, we must continue to be very judicious with its use.
* It is generally not recommended in COVID PUIs and decision should be made with consideration for HCW exposure (risk higher with BIPAP vs HFNC).
* If suspicion for COVID is low and patient may benefit from NIPPV, have a discussion with care team (RN and RT) to weigh risks/benefits.
* Obtain CEPHEID early on these patients.

==== HOW TO ORDER CEPHEID (RAPID) TEST ====
* CEPHEID order in ED Order Menu Screen
[[File:Image002.png|thumb|center|CEPHEID Order]]

===CEPHEID REPEAT TESTING===
* If a patient had a CEPHEID done for an anticipated admission, left AMA or eloped briefly and returned to the ED for admission, the COVID-19 test does not need to be repeated.
* COVID test is assumed good for 5 days provided that the patient is not newly symptomatic.
** We have not clarified other bouncebacks yet with the other services.

====COVID (LB) TESTING FOR HIGH-RISK PATIENTS ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high-risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions====
* Back to MICU

====DIRECT ADMISSIONS====
* Direct admissions will not require COVID results.
* They can be admitted as a PUI and have it done on the ward.
* Therefore, you should not be receiving patients in the ED just to get COVID testing before going upstairs if direct admit.

====PATIENTS REFUSING COVID19 TEST====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====POSSIBLE COVID-19 AFTERCARE====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

===HOME ISOLATION/QUARANTINE RECOMMENDATIONS===
* '''LA DPH home isolation handouts available in the wire rack.'''
** Please send all PUIs home with handout.
* Current advisement is to stay at home until at least 10 days after your symptoms first appeared AND 3 days after your symptoms have recovered.
** Recovery defined by:
** Resolution of fever for 72 hours without using antipyretics AND significant improvement in respiratory symptoms.
** This applies even if you had URI sx, were retested and had a negative COVID-19.

====WLA VA ID COVID-19 TESTING ALGORITHM 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====HOW TO PLACE ISOLATION PRECAUTIONS====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]

====COVID DEVICE CLEANING====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====CODING COVID-19 ENCOUNTERS====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

===OPENING OUTPATIENT SERVICES===
* Hospital is delaying opening outpatient services to 5/26 (was previously 5/18).

===INPATIENT VISITATION POLICY CHANGE===
* Check your email for the policy document, highlights include:
** Inpatient visitation under a public health emergency with social-distancing guidance
*** Visitation is prohibited with the exception of Veterans who are at the end-of-life, defined as having a prognosis of hours to short-term days.
*** Compassionate visitation exceptions will be considered on a case-by-case basis only with recommendation from the Attending Physician or Nurse Manager, and concurrence of the Chief of Staff.
** The Attending Physician, in consultation with the Nurse Manager/Charge Nurse, will make the final decision as to whether a veteran patient may have visitors if there is conflict or concerns between staff.

==EDUCATION/SIMULATION REMINDERS==

===MOCK CODE DRILLS REMINDER===
* Try to perform mock codes if clinical duties permit. DHS is expecting a second spike soon and nursing needs to be trained up in PPE and for these codes.
* In particular, make sure that the RNs are familiar with the donning/doffing procedure and practice it
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

=== PROCTORING DOCTORS-IN-TRAINING===
* Medical students returning, not allowed to see PUIs.
* Interns get oriented every Thursday at 10am of their new rotation.
* Please make sure that the interns are informed of COVID, where to get appropriate PPE, and how to don and doff.
** 8000 Masks are available from charge nurse
** 3D printed face shields are in the upper cabinets
** Hospital face shields are in the med room
** Goggles will be with nursing, although it is unclear if we have enough for everyone and this will be a shared resource between physicians and nurses.
* If the intern is not fit tested for the 8000 series, please tell them to coordinate with their chief resident.
* If the intern is not fitted for 8000 series, please advise him/her against seeing PUIs until tested.
**They would have to use the 1860/1870 masks and we have a limited number of those remaining and reserving those for staff that failed out of the 8000 masks.

====CODE GENERAL INFO====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM LAB TRAINING===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT TESTING===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

====UPCOMING FIT TESTING DATES====
* EVERY Thursday Room 3232 12-2
* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

===MEDICAL RECORDS===
* Try not to use the medical record to litigate administrative issues. Please try to make your documentation an objective record of the care you provided (including timestamps if appropriate), the consultants you spoke with, and their verbal recommendation (including name and timestamps if appropriate).
* If you encounter an administrative or interpersonal issue (i.e., the consultant did not page you back or was rude) try to keep that off the medical record. If you have issues with a consultant paging you back, please make sure to escalate up the chain of command in realtime. We should address any patient care delays in realtime, since documenting delays in care without going up the chain of command does not necessarily release anyone from liability. The escalation should be as follows:
# Resident on-call
# Attending on-call
# Service Chief
# ED Chief and MOD
# CoS
* If you come across any interpersonal issues or people making up fake policies, please email Manny a summary of the encounter and he will f/u with the corresponding service (use encryption if sending PHI).

===NALOXONE NOTE===
* When signing the Naloxone note, make sure you sign your ED Note FIRST.
* When you sign the Naloxone note first, it uses "Opioid Use Disorder" as a primary diagnosis and causes the encounter to fall out
* By signing the ED note first, you can fill out the encounter form appropriately and give the proper diagnosis.

===RAPID ACCESS/DIRECT===
* Please remember to have ED clerk obtain an appointment PRIOR to DC for any ED patient being sent to Endocrine for DM management for urgent/Rapid Access Follow-up.
* Please confirm that this actually happens before the patient leaves the ED. Our clerks must schedule an appointment prior to ED discharge for all Rapid Access/Direct Scheduling consults.
Mask Policy
* To mitigate exposure risk, please make sure that all ED patients (and staff) are complying with our universal masking policy. When evaluating any patient, at minimum wear eye protection and a face mask.
* Please see attached document that outlines indications and processes for prevention of COVID transmission in the outpatient setting.

===SEE ALL PATIENTS PRESENTING TO ED===
* Do Not Send Patients to the Tent from ED (EMTALA Violation).
* If patients present to the ED but should have been screened out to the tent or seen in the tent, please do not send patients back to tent from the ED.
* Our goal is to make sure to keep potential “walking well” COVID patients outside the hospital.
* However, once a patient has walked into the ED for one reason or another, please just see them. We do not want these patients moving around the hospital.
* This goes for all patients – once they have presented to the ED, we “own” them and should complete the encounter.
* This helps us as well in terms of increasing capture for the work we are doing.

===SENSITIVE EXAMINATIONS===
* Female patients must have a female chaperone
* Male patients must be offered to have a male chaperone, document if patient declines
* The chaperone must be the same gender as the patient identifies
* Physician must document the name of the chaperone in the chart
* Chaperone may not be your resident, who is considered an extension of the attending.
===SHIFT SWAPS===
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====AT RISK RESIDENTS====
* At-risk resident will be working on a WOW outside a room to socially isolate.

====JONIE/BABY CHIEF OFFICE====
* As a reminder, please do not eat in Jonie’s office or use it for clinical work. There was an open mug of coffee with spoiled milk on Jonie’s desk that spilled. It was gross and a pain to clean, and nearly destroyed a bunch of valuable PPE and the viral filters.
* If you need to finish charting, please use the 3rd-floor office
===REMOTE ACCESS AND CHECKING VA EMAIL===
* Detailed instructions on Slack (email Manuel for access).
* Please check your VA email while you are on shift.
* If you need remote access, apply through this [https://vaww.ramp.vansoc.va.gov/SelfService/Pages/RAUserDetails.aspx?val=API+SkW607t6VC7a4uScig%3d%3d link]
** Click on “request access” and choose the “Rescute/CAG/GFE Mobile” option.
** You will need the CAG access (using personal computers to remotely log in).
===PIV EXEMPTIONS===
* There may be some problems with the mass PIV exemption. If you run into issues, you can try one of these avenues
call *14 - Enterprise Service Desk
* Dwight.Brown2@va.gov
*Shawn.Arnold@va.gov
* Incident/Ticket number is IVC1043797

====UCLA BADGE & MEDNET EMAIL ACCOUNT====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS OFFICE & FREE APPS====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Administrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:Administrative Handbook

2020-06-03T23:35:32Z

Jochickabee: /* CPRS NOTES */

==Tech Basics==
====CPRS CONFIGURATION====
* To configure an automated list of patients checked into ED:
** Select "'''Clinics'''" in upper left hand, type in and select:
*** "'''WLA-Emergency Department'''"
** Under "List Appointments for" select: "'''Today'''"
** Click "'''Save Patient List Settings'''" & set it up for "'''All Days of Week'''"
[[File:Appointment List.jpg|thumb|center|Appointment List Example]]

=====CPRS NOTES=====
* To add notes to your home screen for easy access:
** Toolbar click Tools -> Options -> Notes -> Document Titles.
**Type in then ADD:
*** "'''Emergency Dept Attending Note'''"
*** Any other Emergency Dept notes
*You can move this group of notes to TOP of your list using shift and “^” arrow
[[File:Note Fav.jpg|thumb|center|Note Favorites]]
*As of '''6/2/2020''', these are all the Document Titles you need:

# Emergency Dept Note (10-10)
# Emergency Dept Fast Track Physician Note
# Emergency Dept Attending Note
# Emergency Dept After Care Instructions
# Emergency Dept: Rapid Medical Evaluation Note <RME>
# Emergency Dept Patient Handoff Note
# Emergency Dept Observation Progress Note
# Naloxone Note
# CURE <State Prescription DMP>
# Emergency Dept AMA
# Emergency Dept Transfer Request Note
# Emergency Dept Critical Lab/Imaging/Follow-up
# Procedure Note
# Emergency Dept Procedural Sedation Note
# Intubation Note
# Cardiac Arrest Note
# Death Pronouncement Note
# Emergency Dept Airway Response Note
# Emergency Dept Physician Telephone Note
# Employee Health Note (note becomes blinded in chart; use for needlestick etc.)
# Beneficiary Travel
# Interfacility Transfer Note 10-2649A
# Emergency Dept VA Video Connect
# Emergency Dept Telehealth Note


=====PRINTER SETUP=====
* Click Search Icon (magnifying glass) and Run script to find the computer "'''\\vhawlaprt003\GLA-PTX______"
*See end list for common printer names
OR
* Search for "'''Printer'''" and select "'''Printer & scanners'''"
[[File:Print Search.png|thumb|center|Print Search]]
* Select "'''Add a printer or scanner'''"
[[File:Print Add.png|thumb|center|Add a Printer]]
* Select "'''The printer that I want isn't listed'''
[[File:Print Add2.png|thumb|center|Printer Not Listed]]
* Select "'''Stop'''" then type in '''GLA-PT______''' in "'''Name:'''" search bar and hit enter.
* Under "'''Search results:'''" select the Tent printer listed and click "'''OK'''"
[[File:Print Add3.png|thumb|center|Add Tent Printer GLA-186586]]
*Commonly Used Printers
**GLA-PTX164697 - RM A-M
**GLA-PTX164574 - next to main ED clerk
**GLA-PTX164684 - in Fast Track
**GLA-PTX165531 - color prints to Medical Media in their 6th floor North office

==Access==
*PIV replacement
**1)Contact PIV sponsor to submit a replacement request
***Patricia "Pat" Preyer: Patricia.Preyer@va.gov
**2)Book photo appointment with PIV office https://app.waitwhile.com/book/vhaglavapivoffi
***Bring 2 forms of ID with matching name
**3)Return to PIV office for pickup.
***Call in advance x48778

*PIV Card/Proxy card (med room)/404 key
**Contact: Thomas Blair, Manuel Celedon, Kian Preston-Suni for form
**Provider should call Warren Richards in advance x54016 or 310-268-4016 and bring signed forms over to key shop
***Form authorizer:
****Write the persons’ name in the blank space
****Add the 3 dates in the corresponding sections (prepared/required/sign)
****Sign as the Initiator BLUE INK
****Sign as the Authorizer (print your name legibly next to it) BLUE INK

==Tech Advanced==
=====CPRS Changes=====
*vhaglaclin@va.gov (Jeff Balsam and Hyun-Sung Son)
*Most changes will require “approval” of chiefs (cc)
*Around June they stop taking requests to work on new housestaff set-up
*If pharmacy related also include
**Vhawlapharminformatics@va.gov
*If Radiology related include
**Jon.hall@va.gov

=====Tech Equipment Issues=====
*YourIT (icon on homepage)
*Can add Keivan Zafari or Reza P to expedite

==Policies==
*Critical labs: ER responds overnight (8p-8a), weekends, and holidays
**Write note: "'''Emergency Dept Critical Lab/Imaging Follow-Up"

*Chest pain pathway guidelines (always use clinical judgement)
**Low risk: HEART score 0-3 AND Negative trop/ECG @ 0& 3 hrs
***Discharge with PCP follow up
**Moderate risk: HEART score 4-6
***Admit to ED Cardiology Observation for Cardiology consult OR
***Consider serial trop/EKG +- outpatient stress testing
**High Risk HEART score 7-10
***Admit to Cardiology for inpatient evaluation

*Direct admissions:
**Clinics are able to directly admit stable patients that do not need urgent diagnostics/treatment
**They should contact UM admission screener.
***If any issue with UM they can contact MOD (hospitalist)

*Psych Diversion:
** 4+ patients requiring psychiatric care

==Who's Who==
*Emergency Department
**Manager: Tuesday Majors
**Asst Nurse Manager: Angelica "Angie" Baltazar
**Asst Nurse Manager: Colleen Ferguson

*SW
**ED Supervisor: Lisa Penny
**Lead: Takinia Jones

*HAS (administration/clerk)
**Chief (all of GLA): Linda Surapruik
**ED: Keon Pierce (primarily) and Jeremy Ni
**Lead MSA: Shanae Lee

*OTS (covers entire hospital)
**Lead: Bernard Miller
**Sam Kaufman and Rich Flores were our former ED RN managers

*Supplies (Logistics)- formerly called SPD (formerly, Sterile Processing Dept)
**Restituto “Resti” Corpus
**Ken Hill (supervisor)

*SPS (Sterile Processing Service)
**Grace Richmonds
**Lisa Baldenegro

*Lab/Path
**Chief: John Vallone
**GLA Supervisor: Salem Toney

*Emergency Management/ Disaster/Occupational Health
**Ben Spivey
***FIT Testing:
****Ben Spivey, Jasvinder Singh, Mitra Ansari

==Reporting==
*Joint Patient Safety Event Reporting Form
**CPRS-->Tools-->Admin Applications/Reporting Tools-->JSPR-->Fill in form as prompted

==Miscellaneous==
=====Medical Media Print (posters)=====
*VHAGLAMedicalMedia@va.gov
**To use color printer add “GLA-PTX165531"
**Prints to their 6N office
**The computer in this room is super slow, so print from another VA computer

=====Booklet/handout mass printing=====
*VHAGLAReproduction@va.gov

WLAVA:Administrative Handbook

2020-06-02T05:15:45Z

Jochickabee: /* PRINTER SETUP */

==Tech Basics==
====CPRS CONFIGURATION====
* To configure an automated list of patients checked into ED:
** Select "'''Clinics'''" in upper left hand, type in and select:
*** "'''WLA-Emergency Department'''"
** Under "List Appointments for" select: "'''Today'''"
** Click "'''Save Patient List Settings'''" & set it up for "'''All Days of Week'''"
[[File:Appointment List.jpg|thumb|center|Appointment List Example]]

=====CPRS NOTES=====
* To add notes to your home screen for easy access:
** Toolbar click Tools -> Options -> Notes -> Document Titles.
**Type in then ADD:
*** "'''Emergency Dept Attending Note'''"
*** Any other Emergency Dept notes
*You can move this group of notes to TOP of your list using shift and “^” arrow
[[File:Note Fav.jpg|thumb|center|Note Favorites]]
*As of '''6/2/2020''', these are all the Document Titles you need:

# Emergency Dept Note (10-10)
# Emergency Dept Fast Track Physician Note
# Emergency Dept Attending Note
# Emergency Dept After Care Instructions
# Emergency Dept: Rapid Medical Evaluation Note <RME>
# Emergency Dept Patient Handoff Note
# Emergency Dept Observation Progress Note
# Naloxone Note
# CURE <State Prescription DMP>
# Emergency Dept AMA
# Emergency Dept Transfer Request Note
# Emergency Dept Critical Lab/Imaging/Follow-up
# Procedure Note
# Emergency Dept Procedural Sedation Note
# Intubation Note
# Cardiac Arrest Note
# Death Pronouncement Note
# Emergency Dept Airway Response Note
# Emergency Dept Physician Telephone Note
# Beneficiary Travel
# Interfacility Transfer Note 10-2649A
# Emergency Dept VA Video Connect
# Emergency Dept Telehealth Note


=====PRINTER SETUP=====
* Click Search Icon (magnifying glass) and Run script to find the computer "'''\\vhawlaprt003\GLA-PTX______"
*See end list for common printer names
OR
* Search for "'''Printer'''" and select "'''Printer & scanners'''"
[[File:Print Search.png|thumb|center|Print Search]]
* Select "'''Add a printer or scanner'''"
[[File:Print Add.png|thumb|center|Add a Printer]]
* Select "'''The printer that I want isn't listed'''
[[File:Print Add2.png|thumb|center|Printer Not Listed]]
* Select "'''Stop'''" then type in '''GLA-PT______''' in "'''Name:'''" search bar and hit enter.
* Under "'''Search results:'''" select the Tent printer listed and click "'''OK'''"
[[File:Print Add3.png|thumb|center|Add Tent Printer GLA-186586]]
*Commonly Used Printers
**GLA-PTX164697 - RM A-M
**GLA-PTX164574 - next to main ED clerk
**GLA-PTX164684 - in Fast Track
**GLA-PTX165531 - color prints to Medical Media in their 6th floor North office

==Access==
*PIV replacement
**1)Contact PIV sponsor to submit a replacement request
***Patricia "Pat" Preyer: Patricia.Preyer@va.gov
**2)Book photo appointment with PIV office https://app.waitwhile.com/book/vhaglavapivoffi
***Bring 2 forms of ID with matching name
**3)Return to PIV office for pickup.
***Call in advance x48778

*PIV Card/Proxy card (med room)/404 key
**Contact: Thomas Blair, Manuel Celedon, Kian Preston-Suni for form
**Provider should call Warren Richards in advance x54016 or 310-268-4016 and bring signed forms over to key shop
***Form authorizer:
****Write the persons’ name in the blank space
****Add the 3 dates in the corresponding sections (prepared/required/sign)
****Sign as the Initiator BLUE INK
****Sign as the Authorizer (print your name legibly next to it) BLUE INK

==Tech Advanced==
=====CPRS Changes=====
*vhaglaclin@va.gov (Jeff Balsam and Hyun-Sung Son)
*Most changes will require “approval” of chiefs (cc)
*Around June they stop taking requests to work on new housestaff set-up
*If pharmacy related also include
**Vhawlapharminformatics@va.gov
*If Radiology related include
**Jon.hall@va.gov

=====Tech Equipment Issues=====
*YourIT (icon on homepage)
*Can add Keivan Zafari or Reza P to expedite

==Policies==
*Critical labs: ER responds overnight (8p-8a), weekends, and holidays
**Write note: "'''Emergency Dept Critical Lab/Imaging Follow-Up"

*Chest pain pathway guidelines (always use clinical judgement)
**Low risk: HEART score 0-3 AND Negative trop/ECG @ 0& 3 hrs
***Discharge with PCP follow up
**Moderate risk: HEART score 4-6
***Admit to ED Cardiology Observation for Cardiology consult OR
***Consider serial trop/EKG +- outpatient stress testing
**High Risk HEART score 7-10
***Admit to Cardiology for inpatient evaluation

*Direct admissions:
**Clinics are able to directly admit stable patients that do not need urgent diagnostics/treatment
**They should contact UM admission screener.
***If any issue with UM they can contact MOD (hospitalist)

*Psych Diversion:
** 4+ patients requiring psychiatric care

==Who's Who==
*Emergency Department
**Manager: Tuesday Majors
**Asst Nurse Manager: Angelica "Angie" Baltazar
**Asst Nurse Manager: Colleen Ferguson

*SW
**ED Supervisor: Lisa Penny
**Lead: Takinia Jones

*HAS (administration/clerk)
**Chief (all of GLA): Linda Surapruik
**ED: Keon Pierce (primarily) and Jeremy Ni
**Lead MSA: Shanae Lee

*OTS (covers entire hospital)
**Lead: Bernard Miller
**Sam Kaufman and Rich Flores were our former ED RN managers

*Supplies (Logistics)- formerly called SPD (formerly, Sterile Processing Dept)
**Restituto “Resti” Corpus
**Ken Hill (supervisor)

*SPS (Sterile Processing Service)
**Grace Richmonds
**Lisa Baldenegro

*Lab/Path
**Chief: John Vallone
**GLA Supervisor: Salem Toney

*Emergency Management/ Disaster/Occupational Health
**Ben Spivey
***FIT Testing:
****Ben Spivey, Jasvinder Singh, Mitra Ansari

==Reporting==
*Joint Patient Safety Event Reporting Form
**CPRS-->Tools-->Admin Applications/Reporting Tools-->JSPR-->Fill in form as prompted

==Miscellaneous==
=====Medical Media Print (posters)=====
*VHAGLAMedicalMedia@va.gov
**To use color printer add “GLA-PTX165531"
**Prints to their 6N office
**The computer in this room is super slow, so print from another VA computer

=====Booklet/handout mass printing=====
*VHAGLAReproduction@va.gov

WLAVA:Administrative Handbook

2020-06-02T04:58:38Z

Jochickabee: /* CPRS NOTES */

==Tech Basics==
====CPRS CONFIGURATION====
* To configure an automated list of patients checked into ED:
** Select "'''Clinics'''" in upper left hand, type in and select:
*** "'''WLA-Emergency Department'''"
** Under "List Appointments for" select: "'''Today'''"
** Click "'''Save Patient List Settings'''" & set it up for "'''All Days of Week'''"
[[File:Appointment List.jpg|thumb|center|Appointment List Example]]

=====CPRS NOTES=====
* To add notes to your home screen for easy access:
** Toolbar click Tools -> Options -> Notes -> Document Titles.
**Type in then ADD:
*** "'''Emergency Dept Attending Note'''"
*** Any other Emergency Dept notes
*You can move this group of notes to TOP of your list using shift and “^” arrow
[[File:Note Fav.jpg|thumb|center|Note Favorites]]
*As of '''6/2/2020''', these are all the Document Titles you need:

# Emergency Dept Note (10-10)
# Emergency Dept Fast Track Physician Note
# Emergency Dept Attending Note
# Emergency Dept After Care Instructions
# Emergency Dept: Rapid Medical Evaluation Note <RME>
# Emergency Dept Patient Handoff Note
# Emergency Dept Observation Progress Note
# Naloxone Note
# CURE <State Prescription DMP>
# Emergency Dept AMA
# Emergency Dept Transfer Request Note
# Emergency Dept Critical Lab/Imaging/Follow-up
# Procedure Note
# Emergency Dept Procedural Sedation Note
# Intubation Note
# Cardiac Arrest Note
# Death Pronouncement Note
# Emergency Dept Airway Response Note
# Emergency Dept Physician Telephone Note
# Beneficiary Travel
# Interfacility Transfer Note 10-2649A
# Emergency Dept VA Video Connect
# Emergency Dept Telehealth Note


=====PRINTER SETUP=====
* Search for "'''Printer'''" and select "'''Printer & scanners'''"
[[File:Print Search.png|thumb|center|Print Search]]
* Select "'''Add a printer or scanner'''"
[[File:Print Add.png|thumb|center|Add a Printer]]
* Select "'''The printer that I want isn't listed'''
[[File:Print Add2.png|thumb|center|Printer Not Listed]]
* Select "'''Stop'''" then type in '''GLA-PT______''' in "'''Name:'''" search bar and hit enter.
* Under "'''Search results:'''" select the Tent printer listed and click "'''OK'''"
[[File:Print Add3.png|thumb|center|Add Tent Printer GLA-186586]]

==Access==
*PIV replacement
**1)Contact PIV sponsor to submit a replacement request
***Patricia "Pat" Preyer: Patricia.Preyer@va.gov
**2)Book photo appointment with PIV office https://app.waitwhile.com/book/vhaglavapivoffi
***Bring 2 forms of ID with matching name
**3)Return to PIV office for pickup.
***Call in advance x48778

*PIV Card/Proxy card (med room)/404 key
**Contact: Thomas Blair, Manuel Celedon, Kian Preston-Suni for form
**Provider should call Warren Richards in advance x54016 or 310-268-4016 and bring signed forms over to key shop
***Form authorizer:
****Write the persons’ name in the blank space
****Add the 3 dates in the corresponding sections (prepared/required/sign)
****Sign as the Initiator BLUE INK
****Sign as the Authorizer (print your name legibly next to it) BLUE INK

==Tech Advanced==
=====CPRS Changes=====
*vhaglaclin@va.gov (Jeff Balsam and Hyun-Sung Son)
*Most changes will require “approval” of chiefs (cc)
*Around June they stop taking requests to work on new housestaff set-up
*If pharmacy related also include
**Vhawlapharminformatics@va.gov
*If Radiology related include
**Jon.hall@va.gov

=====Tech Equipment Issues=====
*YourIT (icon on homepage)
*Can add Keivan Zafari or Reza P to expedite

==Policies==
*Critical labs: ER responds overnight (8p-8a), weekends, and holidays
**Write note: "'''Emergency Dept Critical Lab/Imaging Follow-Up"

*Chest pain pathway guidelines (always use clinical judgement)
**Low risk: HEART score 0-3 AND Negative trop/ECG @ 0& 3 hrs
***Discharge with PCP follow up
**Moderate risk: HEART score 4-6
***Admit to ED Cardiology Observation for Cardiology consult OR
***Consider serial trop/EKG +- outpatient stress testing
**High Risk HEART score 7-10
***Admit to Cardiology for inpatient evaluation

*Direct admissions:
**Clinics are able to directly admit stable patients that do not need urgent diagnostics/treatment
**They should contact UM admission screener.
***If any issue with UM they can contact MOD (hospitalist)

*Psych Diversion:
** 4+ patients requiring psychiatric care

==Who's Who==
*Emergency Department
**Manager: Tuesday Majors
**Asst Nurse Manager: Angelica "Angie" Baltazar
**Asst Nurse Manager: Colleen Ferguson

*SW
**ED Supervisor: Lisa Penny
**Lead: Takinia Jones

*HAS (administration/clerk)
**Chief (all of GLA): Linda Surapruik
**ED: Keon Pierce (primarily) and Jeremy Ni
**Lead MSA: Shanae Lee

*OTS (covers entire hospital)
**Lead: Bernard Miller
**Sam Kaufman and Rich Flores were our former ED RN managers

*Supplies (Logistics)- formerly called SPD (formerly, Sterile Processing Dept)
**Restituto “Resti” Corpus
**Ken Hill (supervisor)

*SPS (Sterile Processing Service)
**Grace Richmonds
**Lisa Baldenegro

*Lab/Path
**Chief: John Vallone
**GLA Supervisor: Salem Toney

*Emergency Management/ Disaster/Occupational Health
**Ben Spivey
***FIT Testing:
****Ben Spivey, Jasvinder Singh, Mitra Ansari

==Reporting==
*Joint Patient Safety Event Reporting Form
**CPRS-->Tools-->Admin Applications/Reporting Tools-->JSPR-->Fill in form as prompted

==Miscellaneous==
=====Medical Media Print (posters)=====
*VHAGLAMedicalMedia@va.gov
**To use color printer add “GLA-PTX165531"
**Prints to their 6N office
**The computer in this room is super slow, so print from another VA computer

=====Booklet/handout mass printing=====
*VHAGLAReproduction@va.gov

WLAVA:COVID19 ED Operational Updates

2020-05-28T08:22:56Z

Jochickabee: /* NO CARDIAC SURGERY */

♦♦♦ = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 5/24/20♦♦♦==

===ED WORKFLOW UPDATES===
* Do Not Send Patients to the Tent from ED (EMTALA Violation).
* If patients present to the ED but should have been screened out to the tent or seen in the tent, please do not send patients back to tent from the ED.
* Our goal is to make sure to keep potential “walking well” COVID patients outside the hospital.
* However, once a patient has walked into the ED for one reason or another, please just see them. We do not want these patients moving around the hospital.
* This goes for all patients – once they have presented to the ED, we “own” them and should complete the encounter.
* This helps us as well in terms of increasing capture for the work we are doing.

===AIRWAY UPDATES===
* We are continuing to honor the airway shifts through May even though anesthesia has expanded their coverage
* '''If you are scheduled for a weekend 7a-7p shift and would like to give it up''', please notify Scott and we can take you off
* '''If you are scheduled for a weekend 7p-7a shift and would like it shortened to 11p-7a''', please notify Scott to have this changed

===UPDATED GUIDANCE ON PPE===
* '''Summary of COS Guidance Document:'''
** Since in the ED we won’t necessarily know the COVID status of a patient prior to doing a potentially aerosol-generating procedure on a patient (including things like peri-coronal or peri-apical abscess drainage, PTA drainage, nasal packing):
*** '''Our best strategy in the ED is to wear PPE assuming that the patient is COVID+''' (face shield, N-95 respirator, gown, gloves)
**'''Other salient points:'''
*** All patients and staff should always wear a mask
*** All patients and staff should maintain 6 feet of distance when possible
*** Gloves should be worn in all patient encounters and changed in between encounters
*** Hands should be washed (for 20 seconds) or hand sanitizer used after all patient encounters

===USE OF DISINFECTANT WIPES===
* We are running low on Saniwipes and other disinfectant wipes
* '''Please use Saniwipes to clean medical equipment only – reusable PPE, ultrasound machine, etc.'''
* '''Do not use disinfectant wipes to clean work areas.'''
* For all work areas (areas not directly involved in patient care), EMS will be providing bottles of Virex Plus Disinfectant spray or a Glance General Purpose Cleaner along with disposable rags (white) or reusable rags (green) that can be deposited in the dirty linen bins. Please ask the charge where it is being kept.
*[[:File:Disinfecting Procedures.pdf]]

===AEROSOLIZING PROCEDURES===
* Per Dr Goetz, '''aerosolizing procedures are okay in PUIs''' as long as patients are in a negative pressure room (all private rooms in the ED currently) and all staff entering the room is donning appropriate PPE. This means N95, eye protection, face shield, gown, and gloves. This includes:
** CPAP
** Nebulizer treatments
** High flow nasal cannula

===CEPHEID ORDER===
* CEPHEID order in ED Order Menu Screen
[[File:Image002.png|thumb|center|CEPHEID Order]]

===CEPHEID REPEAT TESTING===
* If a patient had a CEPHEID done for an anticipated admission, left AMA or eloped briefly and returned to the ED for admission, the COVID-19 test does not need to be repeated.
* COVID test is assumed good for 5 days provided that the patient is not newly symptomatic.
** We have not clarified other bouncebacks yet with the other services.

===ASYMPTOMATIC TESTING IN PATIENTS===
* If a patient insists on being swabbed while being asymptomatic, please try your best to educate the patient about why it is not necessary.
* If the patient is still insistent and says they’ll get swabbed elsewhere (e.g. county), please just go ahead and swab them. We do not want our patients to be swabbed outside or system.
* Send the LB (Roche) tests on these people and NOT the CEPHEID

===AUGUST SCHEDULE DELAYED===
* August schedule will be delayed due to issues with Bytebloc and we may need to revert to the old system for this month.

===FIT TESTING DATES===
* ALL FIT Testing will be in Rm 3232
* EVERY Thursday Room 3232 12-2 is scheduled until June (would be perfect for intern orientation):
** Wednesday 05-27-2020 6am-2pm
** Thursday 05-28-2020 12m-2pm
** Thursday 06-04-2020 12pm-2pm
*Please notify us if you have not been FIT tested for the 8000 series and cannot make one of these dates before your next shift! They are really flexible and will work with our schedules but we need to know ahead of time what works for you so they can be available.

===PROPOSED WORKFLOW FOR PUIS IN TENT SEEKING TO ENTER MEDICAL CENTER===
* Many patients have been trying to re-enter the hospital after having been seen in the tent, especially if they are here for a scheduled appointment.
* '''Make sure that PUIs know they cannot enter the hospital unless they have a serious medical disease requiring the ED evaluation/stabilization.'''
* EST provider can help facilitate their outpatient care by doing the following:
** Have them skype the clerk to set up a follow up appointment.
** If the patient is insistent about being seen, you can set up a telehealth encounter with the clinic.
*** Page the desired service
*** They can see the patient in the EST.
*** They can arrange for outpatient VVC appointment.
*** If medications are ordered for the patient, have the service order the medications and call the pharmacy to prepare them. Then have the service call EST to notify that they are ready for pickup and EST can send a runner to the pharmacy.
* The purpose of this is to allow the patient to have his appointment but with a virtual encounter instead.
* We will be seeing more of this as clinics start re-opening.
* Please make sure you proctor the dental residents as such.

==AIRWAY REMINDERS==
===ANESTHESIA AIRWAY COVERAGE===
* '''Anesthesia in-house for COVID airway coverage 7a-11p DAILY (7 days a week).'''
** They will drop off the pager at 11p daily.
** Please drop off pager at 7a (5 North, Rm 5003).
* After 11p, Anesthesia can be called for impending COVID airways if 2 hours notice can be given.
** If you have any issues, please notify one of us.

==== HOW TO CONTACT ANESTHESIA====
* '''Daytime:''' Vocera "COVID AIRWAY" or the airway pager.
* '''After 11p:''' Use the call list on ED SharePoint (see below).
**'''To find the call list, follow these steps:'''
*** Go to GLA home page
*** Go to intranet on right side of page
*** Go to Patient care on the top of the page
*** Go to big red box "WLA VA on Call Schedule"
***Scroll down to anesthesia

====ED ATTENDING AIRWAYS====
*We are still responsible for non-covid airways and crash airways in the ED or after 11p (triple night coverage).
** You get first dibs on any airway you want.
===UNUSED MEDICATION BAGS===
* '''Please make sure all used med bags are discarded.'''
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
** If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

====GLIDESCOPE GO SHORTAGE====
* There is a national shortage of Glidescope S4 blades.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====SECURING ETT VIDEOS====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====AEROSOL BOXES====
* Moved to Rm 3220 (code 1453).
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

=====SUGGESTED WORKFLOW FOR AEROSOL BOX=====
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attach the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95.
*** Please wear the recommended level of PPE for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-11p 7 days a week.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
====ED ATTENDING AIRWAY RESPONSIBILITIES====
* Write an '''Intubation Note''' in CPRS
* Please hand off the pager to the responsible Airway Attending.
* Airway Team should restock cart and medications after each use.
* Report anything missing to Derrick, Miguel and COVID champions.

====ED COVID AIRWAY TEAM====
* '''Overnight:'''
** '''Intubating COVID:''' 11p-7a
** '''Buddy:''' A) 12a-8a B) 11p-7a

====DAILY AIRWAY CART LOG====
* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top of the Airway Cart'''.
* Best practice is to refill the cart after intubation because you know what is missing.
* This daily log is a double check/insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

====RESTOCKING CARTR====
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

====AIRWAY RED BOX IN MED ROOM====
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===3M 8000 N95 FIT TESTING===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out.
* ALL FIT Testing will be in Rm 3232
* EVERY Thursday Room 3232 12-2 is scheduled until June (would be perfect for intern orientation):
** Wednesday 05-27-2020 6am-2pm
** Thursday 05-28-2020 12m-2pm
** Thursday 06-04-2020 12pm-2pm
*Please notify us if you have not been FIT tested for the 8000 series and cannot make one of these dates before your next shift! They are really flexible and will work with our schedules but we need to know ahead of time what works for you so they can be available.

*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR CLEANING===
* After intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Place PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team ASAP.

===PPE GENERAL INFORMATION===
* [[WLAVA:COVID-19_PPE#Airway.2FCode_Donning_.26_Doffing_Checklist|Donning/Doffing checklist and videos.]]

====MASK GUIDANCE====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

===SPS N95 COLLECTION===
* SPS Collecting ALL N95s.
* You will NOT be getting these masks back to you.
** The VA intends to stockpile these in case of an emergency.
** Therefore if you need to keep them for a certain reason (I.e. failed 8000 testing), please keep them yourselves. * Chief of Staff published another guidance document outlining collection of all N95 face masks (including the 8000 series)
** We ARE collecting the mask if used for intubation/buddy/aerosolizing procedure (if not visibly soiled or ruined).
** DO NOT SAVE N95 IF THE FOLLOWING CRITERIA ARE MET:
*** If the mask is visibly soiled or deformed/destroyed.
* Please '''label the mask''' with your '''name''' and '''date''', '''place in paper bag''' and '''again label your name and date''', then '''deposit in the red bin the dirty utility room.'''
** The care team is also responsible for providing necessary precautions to ensure safety of visitors, Veterans, and staff.

===PPE MAIN PAGE===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==
* Avoid having symptomatic patients enter Building 500 if they do not require emergency care.
** Try to accommodate their needs from the tent (i.e., page consult service if they came for appt, call pharmacy to prepare meds if came for refill, skype PCP, etc.)

===EST PROVIDER ORIENTATION CHECKLIST===
* For CORE faculty assigned to orient dental residents on the weekday mornings.
* [[:File:Tent Orientation Checklist 4.29.20.pdf]]

=== TENT ORIENTATION/PROCTORING CLARIFICATION===
* Please take a look at the schedule. It has been attached to the Master schedule.
** [https://onedrive.live.com/edit.aspx?resid=4879B40AF988B29!12314&ithint=file%2cxlsx&authkey=!AKwmdarimU4_kdM Link to Orientation/Proctoring schedule.]

====TENT COVERAGE====

{| class="wikitable"
|-
! !! '''Orient''' !! '''Proctor'''
|-
| 5/25 || Grock (10a) || Grock (until 2p)
|-
| 5/26 || No Orientation|| Zhao*
|-
| 5/27 || Celedon || Celedon
|-
| 5/28 || No Orientation || Zhao*
|-
| 5/29 || No Orientation || Lemus*
|}
# Call tent at 7a to check in 310-268-3333
# *7-8:15(ish) Orient, 8:15-3 FT/Proctor
# **7-8:15 Orient, proctor until tent provider feels comfortable. Then move to main ED afterward and proctor remotely.
# ***7a-3p Proctor, Tent resident has been previously oriented so no orientation needed.
** Proctoring providers:
*** Extra/double noon or evening providers moved to orient/proctor; if none THEN
*** 8-4 FT provider moved to 7-3 so that you can orient then proctor; if not FTEE THEN
*** Backup provider
* If the Tent provider has already been oriented, the schedule reflect purple on the date and only proctoring needs to take place.
* 8-4 main ED or FT attending may be late if orienting (orientation will usually take 75-90 min).

===TENT DISPO TOOL===
*Please see the [https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB EST Provider Disposition Tool] for EST workflow.
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

===EMPLOYEE SELF-REFERRAL TOOL===
* Please refer asymptomatic employees to Employee Health and NOT the tent
* We are trying not to co-mingle symptomatic and asymptomatic patients
** Best time to test is 4-5 days after exposure so they can usually wait for an employee health appointment.
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

===NEW CPRS NOTE TEMPLATES===
* Search "Tent" in CPRS Note library:
** Enhanced Screening Tent Provider Note
** Employee Health Enhanced Screening Tent Note
* '''Please pay attention to the *** sections as they provide guidance to make the flow less redundant or clunky.'''

===TENT CONSULTS===
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

===CEPHEID TESTING===
*CEPHEID results are required prior to bed assignment, EXCEPT for high-risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

===NEGATIVE PRESSURE ROOMS===
* All private rooms in the main ED are negative pressure rooms.
* Move patient to negative pressure room if plan to perform aerosolizing procedure.
====ISOLATION FOR PUIs====
* For high-risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== HOW TO ORDER CEPHEID (RAPID) TEST ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

====COVID (LB) TESTING FOR HIGH-RISK PATIENTS ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions====
* Back to MICU

====DIRECT ADMISSIONS====
* Direct admissions will not require COVID results.
* They can be admitted as a PUI and have it done on the ward.
* Therefore, you should not be receiving patients in the ED just to get COVID testing before going upstairs if direct admit.

====PATIENTS REFUSING COVID19 TEST====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====POSSIBLE COVID-19 AFTERCARE====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

===HOME ISOLATION/QUARANTINE RECOMMENDATIONS===
* '''LA DPH home isolation handouts available in the wire rack.'''
** Please send all PUIs home with handout.
* Current advisement is to stay at home until at least 10 days after your symptoms first appeared AND 3 days after your symptoms have recovered.
** Recovery defined by:
** Resolution of fever for 72 hours without using antipyretics AND significant improvement in respiratory symptoms.
** This applies even if you had URI sx, were retested and had a negative COVID-19.

====WLA VA ID COVID-19 TESTING ALGORITHM 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====HOW TO PLACE ISOLATION PRECAUTIONS====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]

====COVID DEVICE CLEANING====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====CODING COVID-19 ENCOUNTERS====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

===OPENING OUTPATIENT SERVICES===
* Hospital is delaying opening outpatient services to 5/26 (was previously 5/18).

===INPATIENT VISITATION POLICY CHANGE===
* Check your email for the policy document, highlights include:
** Inpatient visitation under a public health emergency with social-distancing guidance
*** Visitation is prohibited with the exception of Veterans who are at the end-of-life, defined as having a prognosis of hours to short-term days.
*** Compassionate visitation exceptions will be considered on a case-by-case basis only with recommendation from the Attending Physician or Nurse Manager, and concurrence of the Chief of Staff.
** The Attending Physician, in consultation with the Nurse Manager/Charge Nurse, will make the final decision as to whether a veteran patient may have visitors if there is conflict or concerns between staff.

==EDUCATION/SIMULATION REMINDERS==
=== PROCTORING DOCTORS-IN-TRAINING===
* Medical students returning, not allowed to see PUIs.
* Interns get oriented every Thursday at 10am of their new rotation.
* Please make sure that the interns are informed of COVID, where to get appropriate PPE, and how to don and doff.
** 8000 Masks are available from charge nurse
** 3D printed face shields are in the upper cabinets
** Hospital face shields are in the med room
** Goggles will be with nursing, although it is unclear if we have enough for everyone and this will be a shared resource between physicians and nurses.
* If the intern is not fit tested for the 8000 series, please tell them to coordinate with their chief resident.
* If the intern is not fitted for 8000 series, please advise him/her against seeing PUIs until tested.
**They would have to use the 1860/1870 masks and we have a limited number of those remaining and reserving those for staff that failed out of the 8000 masks.

===MOCK CODE DRILLS===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE GENERAL INFO====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM LAB TRAINING===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT TESTING===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

====UPCOMING FIT TESTING DATES====
* EVERY Thursday Room 3232 12-2
* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

===SENSITIVE EXAMINATIONS===
* Female patients must have a female chaperone
* Male patients must be offered to have a male chaperone, document if patient declines
* The chaperone must be the same gender as the patient identifies
* Physician must document the name of the chaperone in the chart
* Chaperone may not be your resident, who is considered an extension of the attending.
===SHIFT SWAPS===
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

===REMOTE ACCESS AND CHECKING VA EMAIL===
* Detailed instructions on Slack (email Manuel for access).
* Please check your VA email while you are on shift.
* If you need remote access, apply through this [https://vaww.ramp.vansoc.va.gov/SelfService/Pages/RAUserDetails.aspx?val=API+SkW607t6VC7a4uScig%3d%3d link]
** Click on “request access” and choose the “Rescute/CAG/GFE Mobile” option.
** You will need the CAG access (using personal computers to remotely log in).
===PIV EXEMPTIONS===
* There may be some problems with the mass PIV exemption. If you run into issues, you can try one of these avenues
call *14 - Enterprise Service Desk
* Dwight.Brown2@va.gov
*Shawn.Arnold@va.gov
* Incident/Ticket number is IVC1043797

====UCLA BADGE & MEDNET EMAIL ACCOUNT====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS OFFICE & FREE APPS====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Administrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-05-01T21:01:06Z

Jochickabee: /* ♦♦♦BREAKING NEWS 4/30/20 */

♦♦♦XXX = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 4/30/20==

'''ANESTHESIA AIRWAY COVERAGE'''
* '''Effective 5/4''', Anesthesia is expanding their COVID airway coverage until 11pm DAILY!!! That means they will be in house until 11pm.
** This includes weekends.
** This includes ED COVID airways.
* After 11pm, they can still do airways given that they have a 2 hour lead in time because they have to be called in from home.
** They will drop off the pager at 11pm daily
** During the daytime, they can be contacted via Vocera "COVID AIRWAY" or the airway pager
* After 11p, use the call list. To find the call list, follow these steps (thanks Scott for pointing this out):
** Go to GLA home page
** Go to intranet on right side of page
** Go to Patient care on the top of the page
**Go to big red box "WLA VA on Call Schedule"
**Scroll down to anesthesia
*We are still responsible for these airways
** Crash airways after 11pm (thus the triple overnight coverage)
** If it’s your airway in the ED and you would like to do it
* Bear with us as this is a new process. Let’s be thankful to our Anesthesia colleagues for stepping up to this. If you have any problems, please notify one of us.

'''DRECT ADMISSIONS DON’T NEED COVID RESULTS'''
* Direct admissions will not require COVID results. They can be admitted as a PUI and have it done on the ward.
* Therefore, you should not be receiving patients in the ED just to get COVID testing before going upstairs if direct admit.

'''TESTING CRITERIA'''
* We still have a limited amount of tests.
* If a patient does not meet our testing criteria, please try to counsel him/her about self-isolation and why we are not testing.
* However if the patient is persistent about wanting testing, please perform the LB test (not CEPHEID) on them. This is to avoid patients seeking outside sources for testing (e.g. County system). We prefer that our patients be tested within the VA system if possible.
*We are not advertising this to other services (such as primary care) because we don’t want to be flooded with requests.

'''UNUSED MED BAGS'''
*Please make sure all used med bags are discarded.
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
*If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attach the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Starting 5/4/20 Anesthesia covers all inpatient airways including ED COVID airways from 7a-11p all days of the week.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR Cleaning===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===Tent Dispo Tool===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

====COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Possible COVID-19 Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-05-01T20:59:41Z

Jochickabee: /* Aerosol/Airway/Intubation Box */

♦♦♦XXX = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 4/30/20==

'''ANESTHESIA AIRWAY COVERAGE'''
* Anesthesia is expanding their COVID airway coverage until 11pm DAILY effective 5/4!!! That means they will be in house until 11pm.
** This includes weekends.
** This includes ED COVID airways.
* After 11pm, they can still do airways given that they have a 2 hour lead in time because they have to be called in from home.
** They will drop off the pager at 11pm daily
** During the daytime, they can be contacted via Vocera "COVID AIRWAY" or the airway pager
* After 11p, use the call list. To find the call list, follow these steps (thanks Scott for pointing this out):
** Go to GLA home page
** Go to intranet on right side of page
** Go to Patient care on the top of the page
**Go to big red box "WLA VA on Call Schedule"
**Scroll down to anesthesia
*We are still responsible for these airways
** Crash airways after 11pm (thus the triple overnight coverage)
** If it’s your airway in the ED and you would like to do it
* Bear with us as this is a new process. Let’s be thankful to our Anesthesia colleagues for stepping up to this. If you have any problems, please notify one of us.

'''DRECT ADMISSIONS DON’T NEED COVID RESULTS'''
* Direct admissions will not require COVID results. They can be admitted as a PUI and have it done on the ward.
* Therefore, you should not be receiving patients in the ED just to get COVID testing before going upstairs if direct admit.

'''TESTING CRITERIA'''
* We still have a limited amount of tests.
* If a patient does not meet our testing criteria, please try to counsel him/her about self-isolation and why we are not testing.
* However if the patient is persistent about wanting testing, please perform the LB test (not CEPHEID) on them. This is to avoid patients seeking outside sources for testing (e.g. County system). We prefer that our patients be tested within the VA system if possible.
*We are not advertising this to other services (such as primary care) because we don’t want to be flooded with requests.

'''UNUSED MED BAGS'''
*Please make sure all used med bags are discarded.
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
*If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attach the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Starting 5/4/20 Anesthesia covers all inpatient airways including ED COVID airways from 7a-11p all days of the week.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR Cleaning===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===Tent Dispo Tool===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

====COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Possible COVID-19 Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-05-01T20:59:01Z

Jochickabee: /* AIRWAY GENERAL INFORMATION */

♦♦♦XXX = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 4/30/20==

'''ANESTHESIA AIRWAY COVERAGE'''
* Anesthesia is expanding their COVID airway coverage until 11pm DAILY effective 5/4!!! That means they will be in house until 11pm.
** This includes weekends.
** This includes ED COVID airways.
* After 11pm, they can still do airways given that they have a 2 hour lead in time because they have to be called in from home.
** They will drop off the pager at 11pm daily
** During the daytime, they can be contacted via Vocera "COVID AIRWAY" or the airway pager
* After 11p, use the call list. To find the call list, follow these steps (thanks Scott for pointing this out):
** Go to GLA home page
** Go to intranet on right side of page
** Go to Patient care on the top of the page
**Go to big red box "WLA VA on Call Schedule"
**Scroll down to anesthesia
*We are still responsible for these airways
** Crash airways after 11pm (thus the triple overnight coverage)
** If it’s your airway in the ED and you would like to do it
* Bear with us as this is a new process. Let’s be thankful to our Anesthesia colleagues for stepping up to this. If you have any problems, please notify one of us.

'''DRECT ADMISSIONS DON’T NEED COVID RESULTS'''
* Direct admissions will not require COVID results. They can be admitted as a PUI and have it done on the ward.
* Therefore, you should not be receiving patients in the ED just to get COVID testing before going upstairs if direct admit.

'''TESTING CRITERIA'''
* We still have a limited amount of tests.
* If a patient does not meet our testing criteria, please try to counsel him/her about self-isolation and why we are not testing.
* However if the patient is persistent about wanting testing, please perform the LB test (not CEPHEID) on them. This is to avoid patients seeking outside sources for testing (e.g. County system). We prefer that our patients be tested within the VA system if possible.
*We are not advertising this to other services (such as primary care) because we don’t want to be flooded with requests.

'''UNUSED MED BAGS'''
*Please make sure all used med bags are discarded.
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
*If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Starting 5/4/20 Anesthesia covers all inpatient airways including ED COVID airways from 7a-11p all days of the week.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR Cleaning===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===Tent Dispo Tool===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

====COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Possible COVID-19 Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-05-01T20:57:55Z

Jochickabee: /* ♦♦♦BREAKING NEWS 4/30/20 */

♦♦♦XXX = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 4/30/20==

'''ANESTHESIA AIRWAY COVERAGE'''
* Anesthesia is expanding their COVID airway coverage until 11pm DAILY effective 5/4!!! That means they will be in house until 11pm.
** This includes weekends.
** This includes ED COVID airways.
* After 11pm, they can still do airways given that they have a 2 hour lead in time because they have to be called in from home.
** They will drop off the pager at 11pm daily
** During the daytime, they can be contacted via Vocera "COVID AIRWAY" or the airway pager
* After 11p, use the call list. To find the call list, follow these steps (thanks Scott for pointing this out):
** Go to GLA home page
** Go to intranet on right side of page
** Go to Patient care on the top of the page
**Go to big red box "WLA VA on Call Schedule"
**Scroll down to anesthesia
*We are still responsible for these airways
** Crash airways after 11pm (thus the triple overnight coverage)
** If it’s your airway in the ED and you would like to do it
* Bear with us as this is a new process. Let’s be thankful to our Anesthesia colleagues for stepping up to this. If you have any problems, please notify one of us.

'''DRECT ADMISSIONS DON’T NEED COVID RESULTS'''
* Direct admissions will not require COVID results. They can be admitted as a PUI and have it done on the ward.
* Therefore, you should not be receiving patients in the ED just to get COVID testing before going upstairs if direct admit.

'''TESTING CRITERIA'''
* We still have a limited amount of tests.
* If a patient does not meet our testing criteria, please try to counsel him/her about self-isolation and why we are not testing.
* However if the patient is persistent about wanting testing, please perform the LB test (not CEPHEID) on them. This is to avoid patients seeking outside sources for testing (e.g. County system). We prefer that our patients be tested within the VA system if possible.
*We are not advertising this to other services (such as primary care) because we don’t want to be flooded with requests.

'''UNUSED MED BAGS'''
*Please make sure all used med bags are discarded.
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
*If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR Cleaning===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===Tent Dispo Tool===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

====COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Possible COVID-19 Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-05-01T20:57:17Z

Jochickabee: /* ♦♦♦BREAKING NEWS 4/28/20 */

♦♦♦XXX = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 4/30/20==

'''ANESTHESIA AIRWAY COVERAGE
'''
* Anesthesia is expanding their COVID airway coverage until 11pm DAILY effective 5/4!!! That means they will be in house until 11pm.
** This includes weekends.
** This includes ED COVID airways.
* After 11pm, they can still do airways given that they have a 2 hour lead in time because they have to be called in from home.
** They will drop off the pager at 11pm daily
** During the daytime, they can be contacted via Vocera "COVID AIRWAY" or the airway pager
* After 11p, use the call list. To find the call list, follow these steps (thanks Scott for pointing this out):
**Go to GLA home page
**Go to intranet on right side of page
** Go to Patient care on the top of the page
**Go to big red box "WLA VA on Call Schedule"
**Scroll down to anesthesia
* We are still responsible for these airways
**Crash airways after 11pm (thus the triple overnight coverage)
**If it’s your airway in the ED and you would like to do it
* Bear with us as this is a new process. Let’s be thankful to our Anesthesia colleagues for stepping up to this. If you have any problems, please notify one of us.

'''DRECT ADMISSIONS DON’T NEED COVID RESULTS'''
* Direct admissions will not require COVID results. They can be admitted as a PUI and have it done on the ward.
* Therefore, you should not be receiving patients in the ED just to get COVID testing before going upstairs if direct admit.

'''TESTING CRITERIA'''
* We still have a limited amount of tests.
* If a patient does not meet our testing criteria, please try to counsel him/her about self-isolation and why we are not testing.
* However if the patient is persistent about wanting testing, please perform the LB test (not CEPHEID) on them. This is to avoid patients seeking outside sources for testing (e.g. County system). We prefer that our patients be tested within the VA system if possible.
*We are not advertising this to other services (such as primary care) because we don’t want to be flooded with requests.

'''UNUSED MED BAGS'''
*Please make sure all used med bags are discarded.
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
*If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR Cleaning===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===Tent Dispo Tool===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

====COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Possible COVID-19 Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-05-01T20:53:54Z

Jochickabee: /* COVID WORKFLOW GENERAL INFORMATION */

♦♦♦XXX = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 4/28/20==
'''UNUSED MED BAGS'''
*Please make sure all used med bags are discarded.
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
*If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR Cleaning===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===Tent Dispo Tool===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

====COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Possible COVID-19 Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-05-01T20:53:41Z

Jochickabee: /* ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 */

♦♦♦XXX = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 4/28/20==
'''UNUSED MED BAGS'''
*Please make sure all used med bags are discarded.
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
*If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR Cleaning===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===Tent Dispo Tool===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

====COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Possible COVID-19 Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-05-01T20:53:26Z

Jochickabee: /* ♦♦♦Tent Dispo Tool 4/26/20 */

♦♦♦XXX = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 4/28/20==
'''UNUSED MED BAGS'''
*Please make sure all used med bags are discarded.
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
*If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR Cleaning===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===Tent Dispo Tool===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Possible COVID-19 Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:Enhanced Screening Tent

2020-04-29T04:44:36Z

Jochickabee: /* Tent Remote SKYPE */

'''Last Updated: 4/16/20'''
==Mission of EST==
* The mission of the tent is to rapidly triage ambulatory patients presenting to WLA VA MC that failed primary COVID-19 screen when attempting to enter the medical center or who presented directly to EST.
* This is not a clinic that provides a comprehensive evaluation but we can facilitate coordination of urgent telehealth visits.

== EST Provider Disposition Tool ==
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB

== EST Provider Schedule ==
[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Provider Schedule (VA Intranet Only)]

==EST Telehealth (No EST Provider Scheduled)==
[[WLAVA:Enhanced_Screening_Tent_Telehealth]]

===TENT SKYPE LINK (Remote Accessible)===
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==EST Phone Extensions==
* 310-478-3711
** EST Main '''x53333''' (310-268-3333)
** RN Tent screener 1 '''x41034'''
** RN Tent screener 2 '''x41035'''
** EST Provider '''x41075'''

==Direct Admissions or Admissions from EST==
* '''Last Updated: 4/4/20'''
* Stable patients can be admitted from the EST if there is no need for an acute medical intervention.
# Call MOD VA pager 99511
# '''GMED admissions:''' UCLA pager p89082
# '''MICU admissions:''' UCLA pager p89081

===Direct Admissions to 214-DOM (Undomiciled Veterans)===
*''Think of this as a homeless shelter for PUIs with pending COVID test or COVID+. Patients do not need to have substance use issues.''
** COVID DOM Checklist ([[:File:COVID-19 B214 ADM-ED.INPT.PACT 04.10.2020.pdf]])
* Call ED SW x 40976 for help coordinating with 214-DOM
# Consult social worker
# Make sure patient ruled out for TB with cxr or quant ifn within the past 12 months.
## pCXR an be done in the tent if needed.
### Have it read by ED provider if unable to read own CXR)
# Fill out CERS <ATTENDING ATTESTATION-INDEPENDENCE/ELIGIBILITY-CERS PROGRAM>
# Social worker will contact DOM for bed between 8am -10pm. If overnight, will need to be observed

==Patient & Staff Safety==
* All persons inside of the tent must be wearing at least a Level 1 surgical mask (may not enter tent without a surgical mask).
* We want to minimize the time that patients spend inside the EST so that we minimize their exposure to persons that may have COVID-19.
* Staff safety is a priority and we must help/remind each other maintain proper precautions when involved in direct patient care.
** Also important to ensure that staff break area is clean (do not bring soiled PPE to break area).

===How To Keep Yourself Protected===
* The virus (SARS-CoV-2) cannot jump on you or go through your intact skin. If you keep a distance and do not touch your eyes, nose, or mouth (mucosa) you will be safe.
* The EST Team has built in multiple lines of defense to keep you safe:
** The 1st line of defense is ensuring that patients are wearing surgical mask appropriately.
** The 2nd line of defense is good/frequent hand washing AND maintaining a safe distance (at least 3 feet) from the patient.
** The 3rd line of defense is wearing a surgical mask and face shield.
** The 4th line of defense is wearing gloves.
** The purpose of gown, bouffant, and shoe covers is to keep your clothes from becoming contaminated. We suggest bringing an extra pair of clothes to change into prior to getting into car (or using disposable scrubs provided by EST Team).

===Staff PPE for All Suspected COVID-19 Patients Seen in EST===
* Standard
* Droplet
* Contact precautions (with eye protection)
* Eye protection (face shield or goggles)

===Close Contact Definition===
* Being within approximately 6 feet (3 feet if person is wearing a mask) of a confirmed COVID-19 case for a prolonged period (5 minutes)
* Having unprotected direct contact with infectious secretions of a COVID-19 case.
**NOTE: Examples of Brief Interactions include:
*** Briefly entering the patient room without having direct contact with the patient or their secretions/excretions.

===NOT Close Contact Definition===
* Brief conversation at a triage desk with a patient who was not wearing a face mask.
* These encounters are NOT close contacts, except when an aerosol-generating procedure is or has been recently performed.

===Aerosol-generating procedures===
* Endotracheal intubation or extubation
* Cardiopulmonary resuscitation
* Non-invasive positive pressure ventilation (BiPAP)
* Bronchoscopy
* Open oropharyngeal or nasopharyngeal suctioning (closed circuit suctioning is considered non-aerosol generating)
* Nebulizer therapy. Use of metered dose inhalers with spacers is strongly preferred for patients being tested for or diagnosed with COVID-19.
**NOTE: The number of healthcare workers present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure.

===COVID-19 Specimen Collection (Nasopharyngeal Swabs)===
* Standard/Contact/Droplet precautions are recommended.
* The number of persons present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for specimen collection.

===Patient Transport to the Hospital/ED===
* If transport personnel must prepare the patient for transport (e.g., transfer them to the wheelchair or gurney), transport personnel should wear all recommended PPE (surgical mask and face shield at least).
* Patients should wear a face mask to contain secretions during transport. If patients cannot tolerate a face mask or one is not available, they should use tissues to cover their mouth and nose.

===General PPE Training===
* PPE training 3/17 to 4/17 @ 8:30a - 4:00p Bldg 500, Rm 6043 (no reservation required)

===Doffing PPE UCLA Video===
[https://vimeo.com/401663016/040bfd3727 UCLA PPE Doffing ]

==Primary Screen==
* Occurs at the entrance to Building 500.

[[File:Primary screening2.png|thumb|center|Primary Screening WLA VA MC]]

==Secondary Screen==
* '''Last Updated: 3/27/20'''
* Occurs in the first stage tent, completed by RN.

[[File:Screen Shot 2020-03-28 at 4.00.34 PM.png|thumb|center|EST RN Secondary Screen]]

==You Will Always Be Supported==
* Providers working the tent always have the option to phone a friend:
** '''ID is on call 24/7 for discussions regarding COVID-19 testing.'''
*** Please review the GLA ID COVID-19 Testing Algorithm prior to discussion with ID
*** UCLA Pager 89324 (Call 310-206-8477)
** '''ED is on call 24/7 for help with disposition of patients if you think you need an ED consult prior to disposition.'''
*** Please have go to Telehealth WOW for ED consult
*** x53169 or 310-268-3169
*** ED provider would be added as a co-signer on your EST note, if ED provider agrees with disposition decision.
*** If ED provider does not agree with your disposition, then send to ED for further evaluation.

===TENT SKYPE MEETING LINK (Remote Accessible)===
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==Minimize Close Contact With Patient==
* Staff safety is our primary priority.
* We are a triaging tent, not a comprehensive primary care or urgent care clinic.
* Our job is to ensure that patients are stable enough to wait a few days for a telehealth appointment.

===Focus On What Will Change Patient Management===
* '''We are here to rapidly triage and reassure patients/employees.'''
* '''We are NOT here to provide a definitive diagnosis.'''
* The majority of patients can be triaged at a distance using the "eyeball" test (i.e., sick versus non-sick).
* If you are about to touch the patient, always STOP to think "is what I am about to do going to change my management?"
** '''We encourage empiric treatment/management in the EST.'''
** '''For example:'''
*** Patients reported mild dyspnea but they are speaking in full sentences, are afebrile, are not tachypneic, and have unremarkable oxygen saturation on room air.
**** The lung auscultation exam is unlikely to change your management, so why expose yourself?
**** This patient is likely stable to wait a few days for a formal telehealth evaluation after recommending empiric treatment in EST.
***** If you are worried that the patient is wheezing, treat them empirically and discharge them with albuterol.
***** If you are worried that the patient has a pneumonia (unlikely if they are afebrile and have unremarkable respiratory vitals) you have the option to treat empirically with antibiotics (dispensed in the tent).

==Help Coordinate Urgent Telehealth F/U==
* For assigned patients we use the '''ED PACT Tool''' to notify their PCP.
* For unassigned patients we will place a '''Primary Care Consult''' AND '''add lead for the clinic as a cosigner.'''

==Testing for COVID-19==
* '''We are not testing ANY asymptomatic patients presenting to the tent.'''
** We at screening for patients with symptoms of an acute respiratory illness.
* You always have the option of '''discussing a case with ID (UCLA Pager 89324) to decide on COVID-19 testing''' as the criteria change day-to-day.
* We perform testing for COVID-19 in '''symptomatic''' patients meeting PUI criteria, if knowing their COVID-19 status will change our management:
** '''Symptomatic GLA Employees with direct patient care.'''
*** It guides our return to work instructions.
** '''Symptomatic resident of a long-term care facility (i.e., CLC, CalVet).'''
*** Patient may require admission to avoid outbreak at their living facility.
** '''Symptomatic patient in congregate living setting (i.e., DOM, senior assisted-living facility, homeless shelter).'''
*** Patient may require admission to avoid outbreak at their living facility.
** '''Symptomatic patient requiring HD or entrance to GLA for chemo/infusions.'''
*** Patient may require admission to avoid outbreak at their treatment facility.
** On a case-by-case basis we are testing '''Symptomatic patients that are at high risk for severe disease (age > 65, h/o lung or heart disease, immunocompromised, active cancer treatment, severe obesity, uncontrolled DM, HTN).'''
*** They do not require admission if otherwise well, but will require close f/u.
** '''We are not testing asymptomatic patients.'''
*** If patient is at high-risk for severe disease, please ensure patients obtain pcp f/u upon discharge using ED PACT tool or urgent Primary Care consult (see [[WLAVA:Enhanced_Screening_Tent#Help_Coordinate_Urgent_Telehealth_F.2FU|Urgent PCP F/u]] for details on this process)

* '''All asymptomatic patients or mildly symptomatic patients that do not meet the above criteria will not receive COVID-19 testing at this time.'''

===WLA VA ID COVID-19 Testing Algorithm===
*'''Last Updated 4/23/20'''
[[File:Screen Shot 2020-04-24 at 10.23.05 AM.png|thumb|center|WLA VA Tent Testing Algorithm]]
* '''Reference file (for printing):'''
** [[:File:COVID19 WLA EST algorithm updated 4.23.20.pdf]]

===LADPH PUI Criteria===
[[File:PUI Criteria.png|thumb|center|LADPH PUI Criteria]]

==Employee Health (EH) Mission==
* We are testing '''symptomatic employees''' (and a select few asymptomatic) with a history of exposure to COVID19 for COVID19 if they are involved in '''direct patient care''' as it will guide our return to work instructions.
* '''Please provide all employees with EH handout at discharge.'''
** If '''employee was tested for COVID-19 in EST''' they must be '''instructed to not go back to work''' until they are cleared by EH.
** If '''employee was not tested for COVID-19''', they must '''speak to EH and their supervisor''' to discuss sick leave and return to work timeline.
* Employee Health (x53522).

===Employee COVID-19 Triage Algorithm===
'''Last Updated: 4/16/20'''
[[File:68497152-DD2F-46F8-8D54-14057FB8CFAB.png|thumb|center|Employee COVID-19 Triage]]

===Employee Exposure Risk Determination Algorithm===
'''Last Updated: 4/17/20'''
* Reviewing the exposure risk algorithm shows that this simple intervention keeps exposure risk low to medium.
** Second layer of defense is ensuring that you wear a face mask (NOT N95).
[[File:Screen Shot 2020-04-17 at 8.20.52 PM.png|thumb|center|nterim Guidance at GLA during regular staffing mode for ASYMPTOMATIC employees WITH PROLONGED CLOSE CONTACT with a COVID-19 patient]]
[[File:08B718CA-9CB2-48A8-9633-8BDA4F095449.jpg|thumb|center|Supplementary Appendix]]

===EMPLOYEE RETURN TO WORK GUIDANCE===
'''Last Updated: 4/17/20'''
[[File:Screen Shot 2020-04-17 at 8.21.13 PM.png|thumb|center|eturn to Work Guidance for Staff with Direct Patient Contact]]

==Suggested Management Algorithm for Patients Presenting to EST==
* '''Is patient ambulatory?'''
** YES -> Go to next step
** NO -> Go to ED
* '''Is patient obviously sick appearing (i.e., in severe pain, visibly tachypneic, somnolent, diaphoretic, etc.)?'''
** YES -> Go to ED
** NO -> Go to next step
* '''Check focused vital signs:'''
** ''HR >110, SBP < 100, RR> 25 SaO2 < 94%''
*** YES -> Send to ED with warm handoff
*** NO -> Go to next step
* '''Does patient have a fever AND...?'''
** YOU CAN ALWAYS CONSULT ED PROVIDER REGARDING THESE PATIENTS
** ''Fever alone is not a reason for ED evaluation if the patient is well appearing, is able to care for self and has no obvious finding suggestive of serious bacterial illness or SIRS criteria.''
** Does patient have a fever AND:
*** ''Meet SIRS criteria or acute/new significant dyspnea or chest pain or productive cough or unable to care for self or obvious signs of serious bacterial illness (abdominal pain, pyelo, cellulitis, etc).''
**** YES -> Send to ED with warm handoff or consider ED consult
**** No --> go to next step
* '''Does patient meet "Wild Card" criteria?'''
** ''Wild Card = Patient with a high-risk co-morbidity (Immunocompromised, Age > 65 years, significant lung or heart disease history, active malignancy, severe obesity, uncontrolled DM)''
*** YES -> consider ED or ID consult (if patient has URI sx and concern for COVID19).
*** NO -> Go to Step 6
* '''Significant ''acute/new'' shortness of breath that affects activities of daily living?'''
** No -> Treat empirically and discharge home with urgent f/u
** Yes -> consider ED consult

==Clinical Syndromes Associated with Mild COVID-19==
* Patients with uncomplicated upper respiratory infection may have non-specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache, GI symptoms (n/v/diarrhea), or muscle pain. These patients do not have signs of dehydration (tachycardia, orthostasis), sepsis (2 or more SIRS criteria), or significant dyspnea.

==Further Triage of Patients with Dyspnea==
* '''Assessing dyspnea in EST patients:'''
** Ask the patient to ''describe the problem with their breathing in their own words,'' and assess the ease and comfort of their speech. Ask open-ended questions and listen to ''whether the patient can complete their sentences.''
*** '''Ask the following questions:'''
**** ''Are you so breathless that you are unable to speak more than a few words?''
**** ''Are you breathing harder or faster than usual when doing nothing at all?''
**** ''Are you so ill that you’ve stopped doing all of your usual daily activities?''
*** '''Focus on change. A clear story of deterioration''' is more important than whether the patient currently feels short of breath. '''Ask questions like:'''
**** ''Is your breathing faster, slower or the same as normal?''
**** ''What could you do yesterday that you can’t do today?''
**** ''What makes you breathless now that didn’t make you breathless yesterday?''
*** '''Interpret the breathlessness in the context of the wider history and physical signs.''' Does the patient have normal vital signs and normal appearance OR do they have abnormal respiratory vital signs and look breathless?

[[File:PNG image.png|thumb|center|Triaging Dyspneic Patients]]

==Direct Admissions or Admissions from EST==
* '''Last Updated: 4/2/20'''
* Stable patients can be admitted from the EST if there is no need for an acute medical intervention.
# Call MOD VA pager 99511
# '''GMED admissions:''' UCLA pager p89082
# '''MICU admissions:''' UCLA pager p89081

===Direct Admission Scenarios===
* Provider making admission disposition is in charge of coordinating with OTS and MOD to notify the admission team and give sign out.
* Stable COVID19 patient coming from home should go directly to inpatient bed, but can go to tent if there is no open bed available upon patient arrival.
* Stable COVID19 patient that is being admitted from outpatient clinic, should wait in private room in clinic until they are assigned a bed. If the clinic ends and patient not assigned a bed, then patient is sent to tent as a holding area.
* Stable COVID19 patient seen in the EST that requires admission, EST provider will call MOD to coordinate admission process.

==Detailed Provider Orientation==
[[WLAVA:Enhanced_Screening_Tent_LIP_Orientation#Printer_Setup|Provider Orientation]]

==EST Handouts==
* '''Employee Health EST Discharge Instructions'''
** [[:File:Employee Instructions - Triage Tent.pdf]]
* '''No COVID-19 Testing LADPH Discharge Instructions for People with Respiratory Symptoms'''
**[[:File:COVHomeCare(2).pdf]]
* '''Pending COVID-19 LADPH Discharge Instructions for Home Isolation'''
**[[:File:HomeisolationenCoV.pdf]]
* '''LADPH Home Quaratine Guidance for Close Contacts to COVID-19'''
**[[:File:COVHomeQuarantine.pdf]]
* '''LADPH Home Cleaning Instructions'''
**[[:File:CleaningInfographic.pdf]]
* '''LADPH Group Living Home Cleaning Instructions'''
**[[:File:Guidance Cleaning English.pdf]]
* '''Physician Work Note'''
**[[:File:WLA Physician Work Note.pdf]]

==Educational Materials==
* [https://www.blog.numose.com/emed-basics/sick-not-sick Medical Screening Exam (Sick vs Non-sick)]
* [[:File:Back Pain EST.pdf]]

==EST Provider Orientation Videos==
[[WLAVA:Enhanced_Screening_Tent_LIP_Orientation#EST_Provider_Orientation_Video|EST Provider Orientation Videos]]

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Operational_Updates|WLAVA: COVID19 ED Operational Updates]]
* [[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

{{Special:Prefixindex/WLA VA: |hideredirects=1}}

WLAVA:Enhanced Screening Tent Telehealth

2020-04-29T04:44:26Z

Jochickabee: /* TENT SKYPE LINK (Remote Accessible) */

'''Last Updated: 4/4/20'''
==Background==
* Walkthrough of ED provider telehealth alternatives when there is no dedicated EST provider.
===Important EST Extensions===
* Main Tent: '''x53333'''
* RN Tent screener 1: '''x41034'''
* RN Tent screener 2 '''x41035'''
* Tent Provider: '''x41075'''

===Designated ED Provider for EST After Hours (No EST Provider Present)===
*'''If possible, visit TENT, introduce yourself to the Tent staff, leave your name so that the staff know to reach you.'''
*'''Monday-Friday:'''
**Fast Track Provider 4p-mn shift
* '''Weekends/Holidays:'''
**Fast Track 9a-5 shift AND
**Main ED 3p-11p shift

===Skype Video Chat===
*'''Please log on to Skype at the start of every shift'''
**Open Skype application using Windows search:[[File:Screen Shot 2020-04-05 at 3.44.01 PM.png|thumb|center|Search for Skype]]
**Type Tent staff name in Skype, double click the name:[[File:Screen Shot 2020-04-05 at 4.31.45 PM.png|thumb|center|Search for Tent Staff or Provider]]
**Click the "Camera" button to make or receive video call:
** Make a call with Skype: [[File:Screen Shot 2020-04-05 at 4.31.51 PM.png|thumb|center|Click "Camera" Button for Video Chat]]
** Receive a call with Skype:
[[File:Skypecall.png|thumb|center|Receiving Skype Video Call]]
**'''Use the Dragon Dictation Handset as your microphone/speaker''' (do not need to press the red button to use the microphone).

===FaceTime Video Chat===
* ''For ED Providers:''
# Sign iPad log book and obtain cabinet key from ED MSA.
# Get Provider iPad or iPhone from locked cabinet.
# iPad/iPhone password = 112233
# Open FaceTime app
# Call Tent

'''PLEASE RETURN IPAD TO LOCKED CABINET AT THE END OF YOUR SHIFT AND HAVE ED MSA UPDATE LOG BOOK.'''

===TENT SKYPE MEETING LINK (Remote Accessible)===
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==Other WLA Pages==
* [[WLAVA:COVID19_ED_Operational_Updates|WLAVA: COVID19 ED Operational Updates]]
* [[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]

{{Special:Prefixindex/WLA VA: |hideredirects=1}}

WLAVA:Enhanced Screening Tent

2020-04-29T04:43:49Z

Jochickabee: /* You Will Always Be Supported */

'''Last Updated: 4/16/20'''
==Mission of EST==
* The mission of the tent is to rapidly triage ambulatory patients presenting to WLA VA MC that failed primary COVID-19 screen when attempting to enter the medical center or who presented directly to EST.
* This is not a clinic that provides a comprehensive evaluation but we can facilitate coordination of urgent telehealth visits.

== EST Provider Disposition Tool ==
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB

== EST Provider Schedule ==
[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Provider Schedule (VA Intranet Only)]

==EST Telehealth (No EST Provider Scheduled)==
[[WLAVA:Enhanced_Screening_Tent_Telehealth]]

===TENT SKYPE LINK (Remote Accessible)===
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==EST Phone Extensions==
* 310-478-3711
** EST Main '''x53333''' (310-268-3333)
** RN Tent screener 1 '''x41034'''
** RN Tent screener 2 '''x41035'''
** EST Provider '''x41075'''

==Direct Admissions or Admissions from EST==
* '''Last Updated: 4/4/20'''
* Stable patients can be admitted from the EST if there is no need for an acute medical intervention.
# Call MOD VA pager 99511
# '''GMED admissions:''' UCLA pager p89082
# '''MICU admissions:''' UCLA pager p89081

===Direct Admissions to 214-DOM (Undomiciled Veterans)===
*''Think of this as a homeless shelter for PUIs with pending COVID test or COVID+. Patients do not need to have substance use issues.''
** COVID DOM Checklist ([[:File:COVID-19 B214 ADM-ED.INPT.PACT 04.10.2020.pdf]])
* Call ED SW x 40976 for help coordinating with 214-DOM
# Consult social worker
# Make sure patient ruled out for TB with cxr or quant ifn within the past 12 months.
## pCXR an be done in the tent if needed.
### Have it read by ED provider if unable to read own CXR)
# Fill out CERS <ATTENDING ATTESTATION-INDEPENDENCE/ELIGIBILITY-CERS PROGRAM>
# Social worker will contact DOM for bed between 8am -10pm. If overnight, will need to be observed

==Patient & Staff Safety==
* All persons inside of the tent must be wearing at least a Level 1 surgical mask (may not enter tent without a surgical mask).
* We want to minimize the time that patients spend inside the EST so that we minimize their exposure to persons that may have COVID-19.
* Staff safety is a priority and we must help/remind each other maintain proper precautions when involved in direct patient care.
** Also important to ensure that staff break area is clean (do not bring soiled PPE to break area).

===How To Keep Yourself Protected===
* The virus (SARS-CoV-2) cannot jump on you or go through your intact skin. If you keep a distance and do not touch your eyes, nose, or mouth (mucosa) you will be safe.
* The EST Team has built in multiple lines of defense to keep you safe:
** The 1st line of defense is ensuring that patients are wearing surgical mask appropriately.
** The 2nd line of defense is good/frequent hand washing AND maintaining a safe distance (at least 3 feet) from the patient.
** The 3rd line of defense is wearing a surgical mask and face shield.
** The 4th line of defense is wearing gloves.
** The purpose of gown, bouffant, and shoe covers is to keep your clothes from becoming contaminated. We suggest bringing an extra pair of clothes to change into prior to getting into car (or using disposable scrubs provided by EST Team).

===Staff PPE for All Suspected COVID-19 Patients Seen in EST===
* Standard
* Droplet
* Contact precautions (with eye protection)
* Eye protection (face shield or goggles)

===Close Contact Definition===
* Being within approximately 6 feet (3 feet if person is wearing a mask) of a confirmed COVID-19 case for a prolonged period (5 minutes)
* Having unprotected direct contact with infectious secretions of a COVID-19 case.
**NOTE: Examples of Brief Interactions include:
*** Briefly entering the patient room without having direct contact with the patient or their secretions/excretions.

===NOT Close Contact Definition===
* Brief conversation at a triage desk with a patient who was not wearing a face mask.
* These encounters are NOT close contacts, except when an aerosol-generating procedure is or has been recently performed.

===Aerosol-generating procedures===
* Endotracheal intubation or extubation
* Cardiopulmonary resuscitation
* Non-invasive positive pressure ventilation (BiPAP)
* Bronchoscopy
* Open oropharyngeal or nasopharyngeal suctioning (closed circuit suctioning is considered non-aerosol generating)
* Nebulizer therapy. Use of metered dose inhalers with spacers is strongly preferred for patients being tested for or diagnosed with COVID-19.
**NOTE: The number of healthcare workers present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure.

===COVID-19 Specimen Collection (Nasopharyngeal Swabs)===
* Standard/Contact/Droplet precautions are recommended.
* The number of persons present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for specimen collection.

===Patient Transport to the Hospital/ED===
* If transport personnel must prepare the patient for transport (e.g., transfer them to the wheelchair or gurney), transport personnel should wear all recommended PPE (surgical mask and face shield at least).
* Patients should wear a face mask to contain secretions during transport. If patients cannot tolerate a face mask or one is not available, they should use tissues to cover their mouth and nose.

===General PPE Training===
* PPE training 3/17 to 4/17 @ 8:30a - 4:00p Bldg 500, Rm 6043 (no reservation required)

===Doffing PPE UCLA Video===
[https://vimeo.com/401663016/040bfd3727 UCLA PPE Doffing ]

==Primary Screen==
* Occurs at the entrance to Building 500.

[[File:Primary screening2.png|thumb|center|Primary Screening WLA VA MC]]

==Secondary Screen==
* '''Last Updated: 3/27/20'''
* Occurs in the first stage tent, completed by RN.

[[File:Screen Shot 2020-03-28 at 4.00.34 PM.png|thumb|center|EST RN Secondary Screen]]

==You Will Always Be Supported==
* Providers working the tent always have the option to phone a friend:
** '''ID is on call 24/7 for discussions regarding COVID-19 testing.'''
*** Please review the GLA ID COVID-19 Testing Algorithm prior to discussion with ID
*** UCLA Pager 89324 (Call 310-206-8477)
** '''ED is on call 24/7 for help with disposition of patients if you think you need an ED consult prior to disposition.'''
*** Please have go to Telehealth WOW for ED consult
*** x53169 or 310-268-3169
*** ED provider would be added as a co-signer on your EST note, if ED provider agrees with disposition decision.
*** If ED provider does not agree with your disposition, then send to ED for further evaluation.

===Tent Remote SKYPE ===
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==Minimize Close Contact With Patient==
* Staff safety is our primary priority.
* We are a triaging tent, not a comprehensive primary care or urgent care clinic.
* Our job is to ensure that patients are stable enough to wait a few days for a telehealth appointment.

===Focus On What Will Change Patient Management===
* '''We are here to rapidly triage and reassure patients/employees.'''
* '''We are NOT here to provide a definitive diagnosis.'''
* The majority of patients can be triaged at a distance using the "eyeball" test (i.e., sick versus non-sick).
* If you are about to touch the patient, always STOP to think "is what I am about to do going to change my management?"
** '''We encourage empiric treatment/management in the EST.'''
** '''For example:'''
*** Patients reported mild dyspnea but they are speaking in full sentences, are afebrile, are not tachypneic, and have unremarkable oxygen saturation on room air.
**** The lung auscultation exam is unlikely to change your management, so why expose yourself?
**** This patient is likely stable to wait a few days for a formal telehealth evaluation after recommending empiric treatment in EST.
***** If you are worried that the patient is wheezing, treat them empirically and discharge them with albuterol.
***** If you are worried that the patient has a pneumonia (unlikely if they are afebrile and have unremarkable respiratory vitals) you have the option to treat empirically with antibiotics (dispensed in the tent).

==Help Coordinate Urgent Telehealth F/U==
* For assigned patients we use the '''ED PACT Tool''' to notify their PCP.
* For unassigned patients we will place a '''Primary Care Consult''' AND '''add lead for the clinic as a cosigner.'''

==Testing for COVID-19==
* '''We are not testing ANY asymptomatic patients presenting to the tent.'''
** We at screening for patients with symptoms of an acute respiratory illness.
* You always have the option of '''discussing a case with ID (UCLA Pager 89324) to decide on COVID-19 testing''' as the criteria change day-to-day.
* We perform testing for COVID-19 in '''symptomatic''' patients meeting PUI criteria, if knowing their COVID-19 status will change our management:
** '''Symptomatic GLA Employees with direct patient care.'''
*** It guides our return to work instructions.
** '''Symptomatic resident of a long-term care facility (i.e., CLC, CalVet).'''
*** Patient may require admission to avoid outbreak at their living facility.
** '''Symptomatic patient in congregate living setting (i.e., DOM, senior assisted-living facility, homeless shelter).'''
*** Patient may require admission to avoid outbreak at their living facility.
** '''Symptomatic patient requiring HD or entrance to GLA for chemo/infusions.'''
*** Patient may require admission to avoid outbreak at their treatment facility.
** On a case-by-case basis we are testing '''Symptomatic patients that are at high risk for severe disease (age > 65, h/o lung or heart disease, immunocompromised, active cancer treatment, severe obesity, uncontrolled DM, HTN).'''
*** They do not require admission if otherwise well, but will require close f/u.
** '''We are not testing asymptomatic patients.'''
*** If patient is at high-risk for severe disease, please ensure patients obtain pcp f/u upon discharge using ED PACT tool or urgent Primary Care consult (see [[WLAVA:Enhanced_Screening_Tent#Help_Coordinate_Urgent_Telehealth_F.2FU|Urgent PCP F/u]] for details on this process)

* '''All asymptomatic patients or mildly symptomatic patients that do not meet the above criteria will not receive COVID-19 testing at this time.'''

===WLA VA ID COVID-19 Testing Algorithm===
*'''Last Updated 4/23/20'''
[[File:Screen Shot 2020-04-24 at 10.23.05 AM.png|thumb|center|WLA VA Tent Testing Algorithm]]
* '''Reference file (for printing):'''
** [[:File:COVID19 WLA EST algorithm updated 4.23.20.pdf]]

===LADPH PUI Criteria===
[[File:PUI Criteria.png|thumb|center|LADPH PUI Criteria]]

==Employee Health (EH) Mission==
* We are testing '''symptomatic employees''' (and a select few asymptomatic) with a history of exposure to COVID19 for COVID19 if they are involved in '''direct patient care''' as it will guide our return to work instructions.
* '''Please provide all employees with EH handout at discharge.'''
** If '''employee was tested for COVID-19 in EST''' they must be '''instructed to not go back to work''' until they are cleared by EH.
** If '''employee was not tested for COVID-19''', they must '''speak to EH and their supervisor''' to discuss sick leave and return to work timeline.
* Employee Health (x53522).

===Employee COVID-19 Triage Algorithm===
'''Last Updated: 4/16/20'''
[[File:68497152-DD2F-46F8-8D54-14057FB8CFAB.png|thumb|center|Employee COVID-19 Triage]]

===Employee Exposure Risk Determination Algorithm===
'''Last Updated: 4/17/20'''
* Reviewing the exposure risk algorithm shows that this simple intervention keeps exposure risk low to medium.
** Second layer of defense is ensuring that you wear a face mask (NOT N95).
[[File:Screen Shot 2020-04-17 at 8.20.52 PM.png|thumb|center|nterim Guidance at GLA during regular staffing mode for ASYMPTOMATIC employees WITH PROLONGED CLOSE CONTACT with a COVID-19 patient]]
[[File:08B718CA-9CB2-48A8-9633-8BDA4F095449.jpg|thumb|center|Supplementary Appendix]]

===EMPLOYEE RETURN TO WORK GUIDANCE===
'''Last Updated: 4/17/20'''
[[File:Screen Shot 2020-04-17 at 8.21.13 PM.png|thumb|center|eturn to Work Guidance for Staff with Direct Patient Contact]]

==Suggested Management Algorithm for Patients Presenting to EST==
* '''Is patient ambulatory?'''
** YES -> Go to next step
** NO -> Go to ED
* '''Is patient obviously sick appearing (i.e., in severe pain, visibly tachypneic, somnolent, diaphoretic, etc.)?'''
** YES -> Go to ED
** NO -> Go to next step
* '''Check focused vital signs:'''
** ''HR >110, SBP < 100, RR> 25 SaO2 < 94%''
*** YES -> Send to ED with warm handoff
*** NO -> Go to next step
* '''Does patient have a fever AND...?'''
** YOU CAN ALWAYS CONSULT ED PROVIDER REGARDING THESE PATIENTS
** ''Fever alone is not a reason for ED evaluation if the patient is well appearing, is able to care for self and has no obvious finding suggestive of serious bacterial illness or SIRS criteria.''
** Does patient have a fever AND:
*** ''Meet SIRS criteria or acute/new significant dyspnea or chest pain or productive cough or unable to care for self or obvious signs of serious bacterial illness (abdominal pain, pyelo, cellulitis, etc).''
**** YES -> Send to ED with warm handoff or consider ED consult
**** No --> go to next step
* '''Does patient meet "Wild Card" criteria?'''
** ''Wild Card = Patient with a high-risk co-morbidity (Immunocompromised, Age > 65 years, significant lung or heart disease history, active malignancy, severe obesity, uncontrolled DM)''
*** YES -> consider ED or ID consult (if patient has URI sx and concern for COVID19).
*** NO -> Go to Step 6
* '''Significant ''acute/new'' shortness of breath that affects activities of daily living?'''
** No -> Treat empirically and discharge home with urgent f/u
** Yes -> consider ED consult

==Clinical Syndromes Associated with Mild COVID-19==
* Patients with uncomplicated upper respiratory infection may have non-specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache, GI symptoms (n/v/diarrhea), or muscle pain. These patients do not have signs of dehydration (tachycardia, orthostasis), sepsis (2 or more SIRS criteria), or significant dyspnea.

==Further Triage of Patients with Dyspnea==
* '''Assessing dyspnea in EST patients:'''
** Ask the patient to ''describe the problem with their breathing in their own words,'' and assess the ease and comfort of their speech. Ask open-ended questions and listen to ''whether the patient can complete their sentences.''
*** '''Ask the following questions:'''
**** ''Are you so breathless that you are unable to speak more than a few words?''
**** ''Are you breathing harder or faster than usual when doing nothing at all?''
**** ''Are you so ill that you’ve stopped doing all of your usual daily activities?''
*** '''Focus on change. A clear story of deterioration''' is more important than whether the patient currently feels short of breath. '''Ask questions like:'''
**** ''Is your breathing faster, slower or the same as normal?''
**** ''What could you do yesterday that you can’t do today?''
**** ''What makes you breathless now that didn’t make you breathless yesterday?''
*** '''Interpret the breathlessness in the context of the wider history and physical signs.''' Does the patient have normal vital signs and normal appearance OR do they have abnormal respiratory vital signs and look breathless?

[[File:PNG image.png|thumb|center|Triaging Dyspneic Patients]]

==Direct Admissions or Admissions from EST==
* '''Last Updated: 4/2/20'''
* Stable patients can be admitted from the EST if there is no need for an acute medical intervention.
# Call MOD VA pager 99511
# '''GMED admissions:''' UCLA pager p89082
# '''MICU admissions:''' UCLA pager p89081

===Direct Admission Scenarios===
* Provider making admission disposition is in charge of coordinating with OTS and MOD to notify the admission team and give sign out.
* Stable COVID19 patient coming from home should go directly to inpatient bed, but can go to tent if there is no open bed available upon patient arrival.
* Stable COVID19 patient that is being admitted from outpatient clinic, should wait in private room in clinic until they are assigned a bed. If the clinic ends and patient not assigned a bed, then patient is sent to tent as a holding area.
* Stable COVID19 patient seen in the EST that requires admission, EST provider will call MOD to coordinate admission process.

==Detailed Provider Orientation==
[[WLAVA:Enhanced_Screening_Tent_LIP_Orientation#Printer_Setup|Provider Orientation]]

==EST Handouts==
* '''Employee Health EST Discharge Instructions'''
** [[:File:Employee Instructions - Triage Tent.pdf]]
* '''No COVID-19 Testing LADPH Discharge Instructions for People with Respiratory Symptoms'''
**[[:File:COVHomeCare(2).pdf]]
* '''Pending COVID-19 LADPH Discharge Instructions for Home Isolation'''
**[[:File:HomeisolationenCoV.pdf]]
* '''LADPH Home Quaratine Guidance for Close Contacts to COVID-19'''
**[[:File:COVHomeQuarantine.pdf]]
* '''LADPH Home Cleaning Instructions'''
**[[:File:CleaningInfographic.pdf]]
* '''LADPH Group Living Home Cleaning Instructions'''
**[[:File:Guidance Cleaning English.pdf]]
* '''Physician Work Note'''
**[[:File:WLA Physician Work Note.pdf]]

==Educational Materials==
* [https://www.blog.numose.com/emed-basics/sick-not-sick Medical Screening Exam (Sick vs Non-sick)]
* [[:File:Back Pain EST.pdf]]

==EST Provider Orientation Videos==
[[WLAVA:Enhanced_Screening_Tent_LIP_Orientation#EST_Provider_Orientation_Video|EST Provider Orientation Videos]]

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Operational_Updates|WLAVA: COVID19 ED Operational Updates]]
* [[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

{{Special:Prefixindex/WLA VA: |hideredirects=1}}

WLAVA:COVID19 ED Operational Updates

2020-04-29T04:41:54Z

Jochickabee: /* Patients with Possible COVID-19 Home Aftercare */

♦♦♦XXX = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 4/28/20==
'''UNUSED MED BAGS'''
*Please make sure all used med bags are discarded.
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
*If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR Cleaning===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent Dispo Tool 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Possible COVID-19 Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-29T04:41:04Z

Jochickabee:

♦♦♦XXX = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 4/28/20==
'''UNUSED MED BAGS'''
*Please make sure all used med bags are discarded.
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
*If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR Cleaning===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent Dispo Tool 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-29T04:40:19Z

Jochickabee:

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in ~3 days) with Update Date
==♦♦♦BREAKING NEWS 4/28/20==
'''UNUSED MED BAGS'''
*Please make sure all used med bags are discarded.
* Request a new bag from pharmacy.
* It's a violation of policy to leave medications in an undesignated location (this is why the intubation meds are stocked separately in a locked room).
*If you are concerned about waste and intubating in the ED, consider asking the nurse to grab the meds from the omnicell instead.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===PAPR Cleaning===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent Dispo Tool 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:Enhanced Screening Tent LIP Orientation

2020-04-28T06:52:12Z

Jochickabee: /* EST PROVIDER TEMPLATES */

'''Last Updated: 4/19/20'''
==PROVIDER START GUIDE==
===EST PROVIDER ORIENTATION VIDEO===
====EST PROVIDER ORIENTATION #1====
{{#widget:YouTube|id=Z8m0jiI-WAY}}
====EST PROVIDER ORIENTATION #2====
{{#widget:YouTube|id=8FoLue3cAOU}}
====EST PROVIDER ORIENTATION #3====
{{#widget:YouTube|id=DgK7l8mOG6I}}
====EST PROVIDER ORIENTATION #4 (Q&A)====
{{#widget:YouTube|id=WCaDOGkHS04}}

===EST PHONE EXTENSIONS===
* 310-478-3711
** EST provider '''x53333''' (310-268-3333)
** RN Tent screener 1 '''x41034'''
** RN Tent screener 2 '''x41035'''

===COMPUTER SETUP===
====WINDOWS DESKTOP CONFIGURATION====
* Search (click on magnifying glass) for and load the following programs and 'pin' to your taskbar (right click over icon and select "pin to taskbar"):
** Skype (to communicate with RNs in EST and other providers in VA)
** CPRS
** Outlook
** Internet Explorer
** Chrome
** Impax

[[File:Screen Shot 2020-03-24 at 11.58.34 AM.png|thumb|center|Search & Taskbar Set up]]

=====PRINTER SETUP=====
* Search for "'''Printer'''" and select "'''Printer & scanners'''"
[[File:Print Search.png|thumb|center|Print Search]]
* Select "'''Add a printer or scanner'''"
[[File:Print Add.png|thumb|center|Add a Printer]]
* Select "'''The printer that I want isn't listed'''
[[File:Print Add2.png|thumb|center|Printer Not Listed]]
* Select "'''Stop'''" then type in '''GLA-PT186586''' in "'''Name:'''" search bar and hit enter.
* Under "'''Search results:'''" select the Tent printer listed and click "'''OK'''"
[[File:Print Add3.png|thumb|center|Add Tent Printer GLA-186586]]

====ED SHAREPOINT====
* Contains VA extensions and UCLA/VA on-call pager numbers
* [https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx GLA VA ED Sharepoint]
* Can copy and paste the URL if above link does not work
** https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx GLA VA ED Sharepoint
** Also found in CPRS -> Tools -> GLA/VA Links -> Other Links -> ED Sharepoint
** Add to favorites

===CPRS SETUP===
====CPRS CONFIGURATION====

* To configure an automated list of patients checked into EST:
** Select "'''Clinics'''" in upper left hand, type in and select:
*** "'''WLA-Screening Tent'''"
** Under "List Appointments for" select: "'''Today'''"
** Click "'''Save Patient List Settings'''" & set it up for "'''All Days of Week'''" if you are working multiple days OR "'''Current Day Only'''" if working one day.
[[File:Appointment List.jpg|thumb|center|Appointment List Example]]

=====CPRS NOTES=====
* To add notes to your home screen for easy access:
** Toolbar click Tools -> Options -> Notes -> Document Titles.
**Type in then ADD:
*** “'''Enhanced Screening Tent (EST) Provider Note'''”
*** “'''Employee Health Note'''”
*You can move this group of notes to TOP of your list using shift and “^” arrow
[[File:Note Fav.jpg|thumb|center|Note Favorites]]

=====EST PROVIDER TEMPLATES=====
* Create new Template in CPRS Shared Templates:
** Copy/Paste page below
***[[WLAVA:Enhanced_Screening_Tent_Template]]
** Printable page
***[[:File:EST Provider Note Template 4.19.20.pdf]]

* Employee Template:
* Create new Template in CPRS Shared Templates:
** Copy/Paste page below
***[[WLAVA:Enhanced Screening Tent Employee Template]]
** Printable page
***[[:File:EST Employee Health Note Template 4.19.20.pdf]]

======EST EXAMPLE NORMAL PHYSICAL EXAMINATION======
* '''GEN:''' Well-appearing, No apparent distress
* '''Resp:''' Normal work of breathing, speaking in complete sentences
* '''Neuro:''' A&Ox3, normal speech, no facial droop, moving all extremities, no gross focal deficits
* '''Gait:''' Steady

=====CPRS VISIT & ENCOUNTER=====
======WLA SCREENING TENT VISIT======
* Please make sure you link your EST note to the correct encounter
** The visit is "'''WLA-Screening Tent'''" or "'''STENT'''"
[[File:Encounter.png|thumb|center|Selecting Correct Visit]]

======EST ENCOUNTER======
* When signing your note please complete the encounter information
* Click on '''Encounter''' bar on the bottom left of CPRS.
[[File:Encoutner.PNG|thumb|center|Encounter Tab]]
** Make sure you are added as primary provider
** Type of Visit "'''Emergency Dept Visit'''"
** Section Name "'''Expanded Problem Focus Low'''"
[[File:Encounter Main.png|thumb|center|Encounter Main Screen]]

* Must add a diagnosis
** Can select from "'''Diagnosis Section'''" OR select "'''Other Diagnosis...'''"
** If select "Other Diagnosis" open this link as the CPRS search engine for ICD10 codes is horrendous.
***[https://www.icd10data.com/ Best ICD10 Search Engine]
** Please make sure that the diagnosis you selected is the primary diagnosis

*'''Suggested ICD10 codes include (but not limited to):'''
**Acute Upper Respiratory Infection, J06.9
**Cough, R05
**Viral Infection unspecified, B34.9
**Fever unspecified, R50.9
* '''Coding COVID19 Encounters'''
** For exposure to COVID19, or suspected COVID19 cases: Z20.828
***If asymptomatic no other diagnosis code needed
***If symptomatic, use appropriate diagnosis code above
** For confirmed COVID19 cases: B97.29

[[File:Encounter Dx.png|thumb|center|Insert Encounter Diagnosis]]

==EST WORKFLOW==
* Overview of Enhanced Screening Tent Operations:
[[File:WLA VA EST SOP.jpg|thumb|center|WLA VA EST Overview]]
* General RN & provider workflow for Enhanced Screening Tent:
[[File:WLA COVID-19 EST Flow.jpg|thumb|center|WLA COVID19 EST Workflow]]

===ORDERS===
* The order menu is located in the "'''ENHANCED SCREENING TENT'''" section of "'''Orders'''" tab
[[File:Find EST order menu.png|thumb|center|EST Main Order Menu]]
[[File:EST main order screen.png|thumb|center|EST Main Order Screen]]

====DISCHARGE MEDICATIONS====
* '''Medications for discharged must be processed by EST Provider (not RN or LVN).'''
* See SOP for details ([[:File:ER Triage Tent Outpatient Med Ordering and Dispensing SOP_v4 3.20.20.pdf]])
* Please call Pharmacy at the end of the day to refill EST medication supply.
** Please call Pharmacy to troubleshoot pharmacy-related issues:
*** '''Outpatient Pharmacy''' – ext. 48294
**** Monday through Friday: 8am – 7pm
**** Saturday: 8am – 4:30pm
*** '''Inpatient Pharmacy''' – ext. 53244
**** May be reached at any time outside of those listed for Outpatient Pharmacy
* Step-by-Step Process:
** Order medication in CPRS from EST discharge medication menu[[File:EST DC Med Menu.png|thumb|center|EST DC Medication Menu]]
** Find correct medication in cart and check that '''medication label''' AND '''overlay label''' match[[File:Pre-label Stock Item.png|thumb|center|Pre-label Example]][[File:Screen Shot 2020-04-10 at 2.06.55 PM.png|thumb|center|Overlay Label Example]]
** Fill out overlay label with patient name, your name, and date
** Apply overlay label to medication bottle ('''do not cover product Lot and Expiration Number''')
** Use Prison-style tally marks to record dispensed medications in '''Ward Stock Request''' form inside of white binder located on top of discharge medication cart
** Provide patient with medication information handout included in manila folder

===URGENT PRIMARY CARE F/U FOR EST===
* We are temporarily borrowing the ED PACT Tool in order to ensure urgent primary care f/u
* The ED-PACT Tool is an order that directly alerts PACT RN Care Managers to address urgent or specific needs of patients who are sent home from the ED.
**It assures that patients post-ED follow-up care needs are addressed by bringing the PACT RN Care Manager into the communication loop.
**The PACT RN Care Manager will work with the PACT Team to let (Primary Care Provider, LVN, Clerk) to address the Veteran’s care need(s).

====HOW DOES PACT TOOL WORK?====
* The flow depends on if patient is assigned or unassigned

=====ASSIGNED PATIENTS=====
* Identify Patient’s PACT Team by looking at top banner in CPRS
[[File:Assigned patient.png|thumb|center|Finding WLA Clinic Assignment]]
* Providers enter a CPRS order indicating urgent or specific needs for post-EST follow-up care using link on EST order menu
[[File:Ed pact tool main.png|thumb|center|ED-Pact Tool Order]]
* Choose PACT Clinic AND then the team
[[File:ED PACT GOLD 2.png|thumb|center|Select Appropriate PACT Clinic]]
* '''Fill in and Sign Templated Order'''
** Under reason for request:
*** ''Check “Seen in COVID- 19 Enhanced Screening Tent (EST)”''
*** '''If you have clinical concern for potential COVID-19 (regardless of whether you sent test), check “Clinical concern for potential COVID-19”'''
*** Check other boxes to indicate follow-up care need
[[File:Order Template.jpg|thumb|center|Order Template]]

=====UNASSIGNED PATIENTS=====
* For patients without a GLA PACT assignment, with urgent or specific needs, use link “No PACT assigned at any VA location/no local PACT at bottom of ED-PACT Tool Menu.
* This link will direct you to the Primary Care Consult Menu.
** '''Select the clinic location closest to the Veteran’s residence.'''
**'''Place the primary care consult''' AND add the points of contacts for each clinic (listed on the primary care consult menu) as additional signers on your EST note.
[[File:Additonal signer PC.png|thumb|center|Unassigned Patients, PC Consult, and Adding Additional Signer]]
[[File:PC Consult.png|thumb|center|Primary Care (PC) Consult]]

===MANAGEMENT ALGORITHMS===

====SUGGESTED MANAGEMENT ALGORITHM FOR PATIENTS PRESENTING TO EST====
* '''Is patient ambulatory?'''
** YES -> Go to next step
** NO -> Go to ED
* '''Is patient obviously sick appearing (i.e., in severe pain, visibly tachypneic, somnolent, diaphoretic, etc.)?'''
** YES -> Go to ED
** NO -> Go to next step
* '''Check focused vital signs:'''
** ''HR >110, SBP < 100, RR> 25 SaO2 < 94%''
*** YES -> Send to ED with warm handoff
*** NO -> Go to next step
* '''Does patient have a fever AND...?'''
** ''Fever alone is not a reason for ED evaluation if the patient is well appearing, is able to care for self and has no obvious finding suggestive of serious bacterial illness or SIRS criteria.''
** ''Does patient has a fever AND:''
*** ''meets SIRS criteria or has acute/new significant dyspnea or has chest pain or is unable to care for self or has obvious signs of serious bacterial illness (abdominal pain, pyelo, cellulitis, etc).''
**** YES -> Send to ED with warm handoff or consider ED consult
**** No --> go to next step
* '''Does patient meet "Wild Card" criteria?'''
** ''Wild Card = Patient with a high-risk co-morbidity (Immunocompromised, Age > 75 years, significant lung or heart disease history, active malignancy)''
*** YES -> consider ED consult
*** NO -> Go to Step 6
* '''Significant ''acute/new'' shortness of breath that affects activities of daily living?'''
** No -> Treat empirically and discharge home with urgent f/u
** Yes -> consider ED consult

===EMPLOYEE HEALTH ALGORITHM===
* We are testing '''symptomatic employees''' (and a select few asymptomatic) with a history of exposure to COVID19 for COVID19 if they are involved in '''direct patient care''' as it will guide our return to work instructions.
* '''Please provide all employees with EH handout at discharge.'''
** If '''employee was tested for COVID-19 in EST''' they must be '''instructed to not go back to work''' until they are cleared by EH.
** If '''employee was not tested for COVID-19''', they must '''speak to EH and their supervisor''' to discuss sick leave and return to work timeline.
* Employee Health (x53522).

====EMPLOYEE COVID-19 TRIAGE ALGORITHM====
'''Last Updated: 4/16/20'''
[[File:68497152-DD2F-46F8-8D54-14057FB8CFAB.png|thumb|center|Employee COVID-19 Triage]]

====EMPLOYEE EXPOSURE RISK DETERMINATION ALGORITHM====
'''Last Updated: 4/17/20'''
* Reviewing the exposure risk algorithm shows that this simple intervention keeps exposure risk low to medium.
** Second layer of defense is ensuring that you wear a face mask (NOT N95).
[[File:Screen Shot 2020-04-17 at 8.20.52 PM.png|thumb|center|nterim Guidance at GLA during regular staffing mode for ASYMPTOMATIC employees WITH PROLONGED CLOSE CONTACT with a COVID-19 patient]]
[[File:08B718CA-9CB2-48A8-9633-8BDA4F095449.jpg|thumb|center|Supplementary Appendix]]

===EMPLOYEE RETURN TO WORK GUIDANCE===
'''Last Updated: 4/17/20'''
[[File:Screen Shot 2020-04-17 at 8.21.13 PM.png|thumb|center|Return to Work Guidance for Staff with Direct Patient Contact]]

==EDUCATIONAL MATERIALS==
* [https://www.blog.numose.com/emed-basics/sick-not-sick Medical Screening Exam (Sick vs Non-sick)]
* [[:File:Back Pain EST.pdf]]

==OTHER WLA VA PAGES==
* [[WLAVA:COVID19_ED_Operational_Updates|WLAVA: COVID19 ED Operational Updates]]
* [[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

{{Special:Prefixindex/WLA VA: |hideredirects=1}}

WLAVA:Enhanced Screening Tent Template

2020-04-28T06:51:10Z

Jochickabee:

CC: |PATIENT AGE|
 
HPI: 
 
REFERRED BY: 
[ ] Self 
[ ] Failed primary screen 
[ ] Primary care provider 
[ ] Other: (free text box) 
 
SYMPTOM SCREEN (select all that apply): 
[ ] Subjective fevers/chills or T > 99.9F 
[ ] Cough (new or worse than usual) 
[ ] Sore throat (new or worse than usual) 
[ ] Shortness of breath or trouble breathing (new or worse than usual) 
[ ] Body or muscle aches (new or worse than usual) 
[ ] Diarrhea (new or worse than usual) 
[ ] Severe fatigue 
[ ] Other: (free text box) 
 
EXPOSURE SCREEN: 
[ ] Close contact with CONFIRMED COVID19 case (within 14 days of Sx onset) 
[ ] Close contact with patients of a respiratory illness outbreak in last 3 days 
[ ] Healthcare worker (including EMT, paramedic, etc) 
[ ] Lives in a long-term care facility (CLC, CalVet, New Vista, community SNF, etc) 
[ ] Lives in a group living facility (homeless shelter, board & care, DOM, New Directions, US Vets, etc) 
[ ] Patient gets chronic care in healthcare facility (i.e., dialysis or chemotherapy patient) 
 
SOCIAL HISTORY: 
[ ] Domiciled in private residence 
[ ] Undomiciled (includes living in tent, car, etc) 
[ ] Domiciled in long-term care facility (auto populate if selected above in exposure screen?) 
[ ] Domiciled in group living facility (auto populate if selected above in exposure screen?) 
 
PMHx: 
ACTIVE PROBLEMS 
|ACTIVE PROB LIST-SHORT| 
 
ALLERGIES: 
|ALLERGIES| 
 
VITALS: 
T: |TEMPERATURE| 
P: |PULSE| 
R: |RESPIRATION| 
BP:|BLOOD PRESSURE| 
Pain: |PAIN| 
Pulse Ox: |PULSE OXIMETRY| 
 
PHYSICAL EXAM: 
GEN: Well-appearing, No apparent distress 
Resp: Normal work of breathing, speaking in complete sentences 
Neuro: A&Ox3, Gait: steady, moving all extremities, no gross focal deficits 
 
ASSESSMENT: 
Patient is afebrile and with unremarkable respiratory vital signs. Patient at baseline ambulatory status, 
non-toxic appearing, and speaking in full sentences. Based on the limited examination there is a low 
suspicion for serious bacterial infection or systemic illness. 
[ ] COVID-19 suspected, met testing criteria. 
[ ] COVID-19 suspected, did not meet testing criteria. 
[ ] COVID-19 suspected, testing refused. 
[ ] COVID-19 not suspected. 
[ ] Other: (free text box) 
 
PLAN:
[ ] Encouraged patient to continue with symptom alleviation. 
[ ] Encouraged to return if has significant worsening of symptoms including chest pain, shortness of 
breath, or inability to care for self. 
 
DISPOSITION: 
[ ] If no concern for COVID, allowed to enter medical center 
[ ] Home 
[ ] Long-term care facility (i.e., CLC, CalVet, New Vista, community SNF, etc) 
[ ] Building 214 “COVID” DOM 
[ ] VA Homeless Housing Program (i.e., Grant Per Diem, DOM, New Directions, etc.) 
[ ] Other group living facility (i.e., shelter, board & care, assisted living facility etc.) 
[ ] ED attending consult for help with disposition: (text box for name) 
[ ] Escorted to ED (critically ill) 
[ ] Directly Admitted 
[ ] Other: (free text box)

Wlava:Enhanced Screening Tent Employee Template

2020-04-28T06:46:33Z

Jochickabee: Blanked the page

WLAVA:Enhanced Screening Tent Employee Template

2020-04-28T06:45:37Z

Jochickabee: Created page with "CC: |PATIENT AGE| HPI: REFERRED BY: [ ] Self [ ] Failed primary screen [ ] GLA Employee Symptom Self-Referral Tool [ ] Supervisor ..."

CC: |PATIENT AGE|
 
HPI: 
 
REFERRED BY: 
[ ] Self 
[ ] Failed primary screen 
[ ] GLA Employee Symptom Self-Referral Tool 
[ ] Supervisor 
[ ] Employee Health 
[ ] Other: (free text box) 
 
SYMPTOM SCREEN (select all that apply): 
[ ] Subjective fevers/chills or T > 99.9F 
[ ] Cough (new or worse than usual) 
[ ] Sore throat (new or worse than usual) 
[ ] Shortness of breath or trouble breathing (new or worse than usual) 
[ ] Body or muscle aches (new or worse than usual) 
[ ] Diarrhea (new or worse than usual) 
[ ] Severe fatigue 
[ ] Other: (free text box) 
 
EXPOSURE SCREEN: 
[ ] Close contact with CONFIRMED COVID19 case (within 14 days of Sx onset) 
[ ] Healthcare worker (including EMT, paramedic, etc) 
[ ] Works in a long-term care facility (CLC, CalVet, New Vista, community SNF, etc) 
[ ] Works in a group living facility (homeless shelter, board & care, DOM, New Directions, US Vets, etc) 
[ ] Works in HD clinic or infusion center 
 
EMPLOYEE PATIENT DETAILS: 
[ ] Job description: 
[ ] Physician 
[ ] Nurse 
[ ] Respiratory Therapist 
[ ] Intermediate Care Technician 
[ ] Other: (free text box) 
[ ] Job location: (free text box) 
 
EMPLOYEE PATIENT EXPOSURE: 
[ ] Date of Suspected Exposure: (free text box for date) 
[ ] Patient was wearing a mask (if unsure leave unchecked) 
[ ] Aerosol generating procedure being performed at time of exposure (intubation, CPR, bronchoscopy, 
BiPAP, nebulizer treatment, etc) 
 
PPE Worn By Employee Patient (select all that apply): 
[ ] Surgical mask 
[ ] N95 respirator or equivalent (PAPR, elastomeric respirator) 
[ ] Eye protection 
[ ] Face shield 
[ ] Gloves 
[ ] Gown 
 
How long was exposure: 
[ ] Less than 5 minutes 
[ ] Greater than 5 minutes 
Proximity to the Patient during exposure: 
[ ] Less than 6 feet 
[ ] Greater than 6 feet 
 
SOCIAL HISTORY: 
[ ] Domiciled in private residence 
[ ] Undomiciled (includes living in tent, car, etc) 
 
PMHx: 
ACTIVE PROBLEMS 
|ACTIVE PROB LIST-SHORT| 
 
ALLERGIES: 
|ALLERGIES| 
 
VITALS: 
T: |TEMPERATURE| 
P: |PULSE| 
R: |RESPIRATION| 
BP:|BLOOD PRESSURE| 
Pain: |PAIN| 
Pulse Ox: |PULSE OXIMETRY| 
 
PHYSICAL EXAM: 
GEN: Well-appearing, No apparent distress 
Resp: Normal work of breathing, speaking in complete sentences 
Neuro: A&Ox3, Gait: steady, moving all extremities, no gross focal deficits 
 
ASSESSMENT: 
Patient is afebrile and with unremarkable respiratory vital signs. Patient at baseline ambulatory status, 
non-toxic appearing, and speaking in full sentences. Based on the limited examination there is a low 
suspicion for serious bacterial infection or systemic illness. 
[ ] COVID-19 suspected, met testing criteria. 
[ ] COVID-19 suspected, did not meet testing criteria. 
[ ] COVID-19 suspected, testing refused. 
[ ] COVID-19 not suspected. 
[ ] Other: (free text box) 
 
PLAN: 
[ ] Encouraged patient to continue with symptom alleviation. 
[ ] Encouraged to return if has significant worsening of symptoms including chest pain, shortness of 
breath, or inability to care for self. 
 
DISPOSITION: 
[ ] No concern for COVID, allowed to enter medical center 
[ ] Home 
[ ] ED, handoff given to ED attending: (text box for name) 
 
EMPLOYEE RETURN TO WORK GUIDANCE: 
[ ] Employees with pending COVID-19 who ARE ASYMPTOMATIC: 
- If this employee was tested following an exposure, employee should remain on duty but must 
wear a mask for 14 days. If employee has no known exposure, employee can return to work and 
should follow current GLA masking policy. 
- Encourage they take their temperature twice per day and report T> 99.9F. 
- If they become symptomatic they must report to Employee Health (310-268-3522) 
 
[ ] Employees pending COVID-19 test results who HAVE ANY SYMPTOMS OF COVID-19: 
- Off duty minimum of 7 days from onset of symptoms. 
- Return to work when all of the following criteria are met: 
o Must be afebrile (T <100.0F) without the use of fever-reducing medications. 
o Improvement in respiratory symptoms (i.e., cough, shortness of breath) 
o Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 
from at least two consecutive nasopharyngeal swab specimens collected > 24 hours 
apart (total of two negative specimens) 
 
[ ] Employees with a POSITIVE COVID-19 test who HAVE ANY SYMPTOMS OF COVID-19: 
- Off duty minimum of 7 days from onset of symptoms. 
- Return to work when all of the following criteria are met: 
o Resolution of fever (T <100.0F) without the use of fever-reducing medications. 
o Improvement in respiratory symptoms (i.e., cough, shortness of breath) 
o Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 
from at least two consecutive nasopharyngeal swab specimens collected > 24 hours 
apart (total of two negative specimens) 
 
[ ] Employees with a POSITIVE COVID-19 test who ARE ASYMPTOMATIC: 
- Exclude from work until 10 days have passed since the date of their first positive COVID-19 
diagnostic test and criteria below is met. If the patient develops symptoms at any time, they 
should report to Employee Health (310-268-3522). 
- Return to work criteria: 
o Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 
from at least two consecutive nasopharyngeal swab specimens collected > 24 hours 
apart (total of two negative specimens) 
 
[ ] Employees with a negative COVID-19 test who HAVE ANY SYMPTOMS OF COVID-19: 
- If an alternative diagnosis has been made (i.e., tested positive for influenza), criteria for return 
to work should be based on that diagnosis. 
Otherwise, follow criteria below: 
o IF patient has had objective fever at ANY point (T >99.9F): 
▪ Off duty minimum of 7 days from onset of symptoms. 
▪ Return to work criteria (must meet all): 
• Must be afebrile off antipyretic and have improving symptoms for 3 days. 
• Must wear mask for 14 days from onset of symptoms. 
o IF patient has never had objective fever (T > 99.9F): 
▪ Off duty while symptomatic. 
▪ Return to work criteria (must meet all): 
• May return 24 hours after improvement in respiratory symptoms. 
• Must wear mask if persistently coughing.

WLAVA:Enhanced Screening Tent LIP Orientation

2020-04-28T06:45:04Z

Jochickabee: /* EST PROVIDER TEMPLATES */

'''Last Updated: 4/19/20'''
==PROVIDER START GUIDE==
===EST PROVIDER ORIENTATION VIDEO===
====EST PROVIDER ORIENTATION #1====
{{#widget:YouTube|id=Z8m0jiI-WAY}}
====EST PROVIDER ORIENTATION #2====
{{#widget:YouTube|id=8FoLue3cAOU}}
====EST PROVIDER ORIENTATION #3====
{{#widget:YouTube|id=DgK7l8mOG6I}}
====EST PROVIDER ORIENTATION #4 (Q&A)====
{{#widget:YouTube|id=WCaDOGkHS04}}

===EST PHONE EXTENSIONS===
* 310-478-3711
** EST provider '''x53333''' (310-268-3333)
** RN Tent screener 1 '''x41034'''
** RN Tent screener 2 '''x41035'''

===COMPUTER SETUP===
====WINDOWS DESKTOP CONFIGURATION====
* Search (click on magnifying glass) for and load the following programs and 'pin' to your taskbar (right click over icon and select "pin to taskbar"):
** Skype (to communicate with RNs in EST and other providers in VA)
** CPRS
** Outlook
** Internet Explorer
** Chrome
** Impax

[[File:Screen Shot 2020-03-24 at 11.58.34 AM.png|thumb|center|Search & Taskbar Set up]]

=====PRINTER SETUP=====
* Search for "'''Printer'''" and select "'''Printer & scanners'''"
[[File:Print Search.png|thumb|center|Print Search]]
* Select "'''Add a printer or scanner'''"
[[File:Print Add.png|thumb|center|Add a Printer]]
* Select "'''The printer that I want isn't listed'''
[[File:Print Add2.png|thumb|center|Printer Not Listed]]
* Select "'''Stop'''" then type in '''GLA-PT186586''' in "'''Name:'''" search bar and hit enter.
* Under "'''Search results:'''" select the Tent printer listed and click "'''OK'''"
[[File:Print Add3.png|thumb|center|Add Tent Printer GLA-186586]]

====ED SHAREPOINT====
* Contains VA extensions and UCLA/VA on-call pager numbers
* [https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx GLA VA ED Sharepoint]
* Can copy and paste the URL if above link does not work
** https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx GLA VA ED Sharepoint
** Also found in CPRS -> Tools -> GLA/VA Links -> Other Links -> ED Sharepoint
** Add to favorites

===CPRS SETUP===
====CPRS CONFIGURATION====

* To configure an automated list of patients checked into EST:
** Select "'''Clinics'''" in upper left hand, type in and select:
*** "'''WLA-Screening Tent'''"
** Under "List Appointments for" select: "'''Today'''"
** Click "'''Save Patient List Settings'''" & set it up for "'''All Days of Week'''" if you are working multiple days OR "'''Current Day Only'''" if working one day.
[[File:Appointment List.jpg|thumb|center|Appointment List Example]]

=====CPRS NOTES=====
* To add notes to your home screen for easy access:
** Toolbar click Tools -> Options -> Notes -> Document Titles.
**Type in then ADD:
*** “'''Enhanced Screening Tent (EST) Provider Note'''”
*** “'''Employee Health Note'''”
*You can move this group of notes to TOP of your list using shift and “^” arrow
[[File:Note Fav.jpg|thumb|center|Note Favorites]]

=====EST PROVIDER TEMPLATES=====
* Create new Template in CPRS Shared Templates:
** Copy/Paste page below
[[WLAVA:Enhanced_Screening_Tent_Template]]
** Printable page
[[:File:EST Provider Note Template 4.19.20.pdf]]

* Employee Template:
* Create new Template in CPRS Shared Templates:
** Copy/Paste page below
[[WLAVA:Enhanced Screening Tent Employee Template]]
** Printable page
[[:File:EST Employee Health Note Template 4.19.20.pdf]]

======EST EXAMPLE NORMAL PHYSICAL EXAMINATION======
* '''GEN:''' Well-appearing, No apparent distress
* '''Resp:''' Normal work of breathing, speaking in complete sentences
* '''Neuro:''' A&Ox3, normal speech, no facial droop, moving all extremities, no gross focal deficits
* '''Gait:''' Steady

=====CPRS VISIT & ENCOUNTER=====
======WLA SCREENING TENT VISIT======
* Please make sure you link your EST note to the correct encounter
** The visit is "'''WLA-Screening Tent'''" or "'''STENT'''"
[[File:Encounter.png|thumb|center|Selecting Correct Visit]]

======EST ENCOUNTER======
* When signing your note please complete the encounter information
* Click on '''Encounter''' bar on the bottom left of CPRS.
[[File:Encoutner.PNG|thumb|center|Encounter Tab]]
** Make sure you are added as primary provider
** Type of Visit "'''Emergency Dept Visit'''"
** Section Name "'''Expanded Problem Focus Low'''"
[[File:Encounter Main.png|thumb|center|Encounter Main Screen]]

* Must add a diagnosis
** Can select from "'''Diagnosis Section'''" OR select "'''Other Diagnosis...'''"
** If select "Other Diagnosis" open this link as the CPRS search engine for ICD10 codes is horrendous.
***[https://www.icd10data.com/ Best ICD10 Search Engine]
** Please make sure that the diagnosis you selected is the primary diagnosis

*'''Suggested ICD10 codes include (but not limited to):'''
**Acute Upper Respiratory Infection, J06.9
**Cough, R05
**Viral Infection unspecified, B34.9
**Fever unspecified, R50.9
* '''Coding COVID19 Encounters'''
** For exposure to COVID19, or suspected COVID19 cases: Z20.828
***If asymptomatic no other diagnosis code needed
***If symptomatic, use appropriate diagnosis code above
** For confirmed COVID19 cases: B97.29

[[File:Encounter Dx.png|thumb|center|Insert Encounter Diagnosis]]

==EST WORKFLOW==
* Overview of Enhanced Screening Tent Operations:
[[File:WLA VA EST SOP.jpg|thumb|center|WLA VA EST Overview]]
* General RN & provider workflow for Enhanced Screening Tent:
[[File:WLA COVID-19 EST Flow.jpg|thumb|center|WLA COVID19 EST Workflow]]

===ORDERS===
* The order menu is located in the "'''ENHANCED SCREENING TENT'''" section of "'''Orders'''" tab
[[File:Find EST order menu.png|thumb|center|EST Main Order Menu]]
[[File:EST main order screen.png|thumb|center|EST Main Order Screen]]

====DISCHARGE MEDICATIONS====
* '''Medications for discharged must be processed by EST Provider (not RN or LVN).'''
* See SOP for details ([[:File:ER Triage Tent Outpatient Med Ordering and Dispensing SOP_v4 3.20.20.pdf]])
* Please call Pharmacy at the end of the day to refill EST medication supply.
** Please call Pharmacy to troubleshoot pharmacy-related issues:
*** '''Outpatient Pharmacy''' – ext. 48294
**** Monday through Friday: 8am – 7pm
**** Saturday: 8am – 4:30pm
*** '''Inpatient Pharmacy''' – ext. 53244
**** May be reached at any time outside of those listed for Outpatient Pharmacy
* Step-by-Step Process:
** Order medication in CPRS from EST discharge medication menu[[File:EST DC Med Menu.png|thumb|center|EST DC Medication Menu]]
** Find correct medication in cart and check that '''medication label''' AND '''overlay label''' match[[File:Pre-label Stock Item.png|thumb|center|Pre-label Example]][[File:Screen Shot 2020-04-10 at 2.06.55 PM.png|thumb|center|Overlay Label Example]]
** Fill out overlay label with patient name, your name, and date
** Apply overlay label to medication bottle ('''do not cover product Lot and Expiration Number''')
** Use Prison-style tally marks to record dispensed medications in '''Ward Stock Request''' form inside of white binder located on top of discharge medication cart
** Provide patient with medication information handout included in manila folder

===URGENT PRIMARY CARE F/U FOR EST===
* We are temporarily borrowing the ED PACT Tool in order to ensure urgent primary care f/u
* The ED-PACT Tool is an order that directly alerts PACT RN Care Managers to address urgent or specific needs of patients who are sent home from the ED.
**It assures that patients post-ED follow-up care needs are addressed by bringing the PACT RN Care Manager into the communication loop.
**The PACT RN Care Manager will work with the PACT Team to let (Primary Care Provider, LVN, Clerk) to address the Veteran’s care need(s).

====HOW DOES PACT TOOL WORK?====
* The flow depends on if patient is assigned or unassigned

=====ASSIGNED PATIENTS=====
* Identify Patient’s PACT Team by looking at top banner in CPRS
[[File:Assigned patient.png|thumb|center|Finding WLA Clinic Assignment]]
* Providers enter a CPRS order indicating urgent or specific needs for post-EST follow-up care using link on EST order menu
[[File:Ed pact tool main.png|thumb|center|ED-Pact Tool Order]]
* Choose PACT Clinic AND then the team
[[File:ED PACT GOLD 2.png|thumb|center|Select Appropriate PACT Clinic]]
* '''Fill in and Sign Templated Order'''
** Under reason for request:
*** ''Check “Seen in COVID- 19 Enhanced Screening Tent (EST)”''
*** '''If you have clinical concern for potential COVID-19 (regardless of whether you sent test), check “Clinical concern for potential COVID-19”'''
*** Check other boxes to indicate follow-up care need
[[File:Order Template.jpg|thumb|center|Order Template]]

=====UNASSIGNED PATIENTS=====
* For patients without a GLA PACT assignment, with urgent or specific needs, use link “No PACT assigned at any VA location/no local PACT at bottom of ED-PACT Tool Menu.
* This link will direct you to the Primary Care Consult Menu.
** '''Select the clinic location closest to the Veteran’s residence.'''
**'''Place the primary care consult''' AND add the points of contacts for each clinic (listed on the primary care consult menu) as additional signers on your EST note.
[[File:Additonal signer PC.png|thumb|center|Unassigned Patients, PC Consult, and Adding Additional Signer]]
[[File:PC Consult.png|thumb|center|Primary Care (PC) Consult]]

===MANAGEMENT ALGORITHMS===

====SUGGESTED MANAGEMENT ALGORITHM FOR PATIENTS PRESENTING TO EST====
* '''Is patient ambulatory?'''
** YES -> Go to next step
** NO -> Go to ED
* '''Is patient obviously sick appearing (i.e., in severe pain, visibly tachypneic, somnolent, diaphoretic, etc.)?'''
** YES -> Go to ED
** NO -> Go to next step
* '''Check focused vital signs:'''
** ''HR >110, SBP < 100, RR> 25 SaO2 < 94%''
*** YES -> Send to ED with warm handoff
*** NO -> Go to next step
* '''Does patient have a fever AND...?'''
** ''Fever alone is not a reason for ED evaluation if the patient is well appearing, is able to care for self and has no obvious finding suggestive of serious bacterial illness or SIRS criteria.''
** ''Does patient has a fever AND:''
*** ''meets SIRS criteria or has acute/new significant dyspnea or has chest pain or is unable to care for self or has obvious signs of serious bacterial illness (abdominal pain, pyelo, cellulitis, etc).''
**** YES -> Send to ED with warm handoff or consider ED consult
**** No --> go to next step
* '''Does patient meet "Wild Card" criteria?'''
** ''Wild Card = Patient with a high-risk co-morbidity (Immunocompromised, Age > 75 years, significant lung or heart disease history, active malignancy)''
*** YES -> consider ED consult
*** NO -> Go to Step 6
* '''Significant ''acute/new'' shortness of breath that affects activities of daily living?'''
** No -> Treat empirically and discharge home with urgent f/u
** Yes -> consider ED consult

===EMPLOYEE HEALTH ALGORITHM===
* We are testing '''symptomatic employees''' (and a select few asymptomatic) with a history of exposure to COVID19 for COVID19 if they are involved in '''direct patient care''' as it will guide our return to work instructions.
* '''Please provide all employees with EH handout at discharge.'''
** If '''employee was tested for COVID-19 in EST''' they must be '''instructed to not go back to work''' until they are cleared by EH.
** If '''employee was not tested for COVID-19''', they must '''speak to EH and their supervisor''' to discuss sick leave and return to work timeline.
* Employee Health (x53522).

====EMPLOYEE COVID-19 TRIAGE ALGORITHM====
'''Last Updated: 4/16/20'''
[[File:68497152-DD2F-46F8-8D54-14057FB8CFAB.png|thumb|center|Employee COVID-19 Triage]]

====EMPLOYEE EXPOSURE RISK DETERMINATION ALGORITHM====
'''Last Updated: 4/17/20'''
* Reviewing the exposure risk algorithm shows that this simple intervention keeps exposure risk low to medium.
** Second layer of defense is ensuring that you wear a face mask (NOT N95).
[[File:Screen Shot 2020-04-17 at 8.20.52 PM.png|thumb|center|nterim Guidance at GLA during regular staffing mode for ASYMPTOMATIC employees WITH PROLONGED CLOSE CONTACT with a COVID-19 patient]]
[[File:08B718CA-9CB2-48A8-9633-8BDA4F095449.jpg|thumb|center|Supplementary Appendix]]

===EMPLOYEE RETURN TO WORK GUIDANCE===
'''Last Updated: 4/17/20'''
[[File:Screen Shot 2020-04-17 at 8.21.13 PM.png|thumb|center|Return to Work Guidance for Staff with Direct Patient Contact]]

==EDUCATIONAL MATERIALS==
* [https://www.blog.numose.com/emed-basics/sick-not-sick Medical Screening Exam (Sick vs Non-sick)]
* [[:File:Back Pain EST.pdf]]

==OTHER WLA VA PAGES==
* [[WLAVA:COVID19_ED_Operational_Updates|WLAVA: COVID19 ED Operational Updates]]
* [[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

{{Special:Prefixindex/WLA VA: |hideredirects=1}}

WLAVA:Enhanced Screening Tent LIP Orientation

2020-04-28T06:44:00Z

Jochickabee: /* EST PROVIDER TEMPLATES */

'''Last Updated: 4/19/20'''
==PROVIDER START GUIDE==
===EST PROVIDER ORIENTATION VIDEO===
====EST PROVIDER ORIENTATION #1====
{{#widget:YouTube|id=Z8m0jiI-WAY}}
====EST PROVIDER ORIENTATION #2====
{{#widget:YouTube|id=8FoLue3cAOU}}
====EST PROVIDER ORIENTATION #3====
{{#widget:YouTube|id=DgK7l8mOG6I}}
====EST PROVIDER ORIENTATION #4 (Q&A)====
{{#widget:YouTube|id=WCaDOGkHS04}}

===EST PHONE EXTENSIONS===
* 310-478-3711
** EST provider '''x53333''' (310-268-3333)
** RN Tent screener 1 '''x41034'''
** RN Tent screener 2 '''x41035'''

===COMPUTER SETUP===
====WINDOWS DESKTOP CONFIGURATION====
* Search (click on magnifying glass) for and load the following programs and 'pin' to your taskbar (right click over icon and select "pin to taskbar"):
** Skype (to communicate with RNs in EST and other providers in VA)
** CPRS
** Outlook
** Internet Explorer
** Chrome
** Impax

[[File:Screen Shot 2020-03-24 at 11.58.34 AM.png|thumb|center|Search & Taskbar Set up]]

=====PRINTER SETUP=====
* Search for "'''Printer'''" and select "'''Printer & scanners'''"
[[File:Print Search.png|thumb|center|Print Search]]
* Select "'''Add a printer or scanner'''"
[[File:Print Add.png|thumb|center|Add a Printer]]
* Select "'''The printer that I want isn't listed'''
[[File:Print Add2.png|thumb|center|Printer Not Listed]]
* Select "'''Stop'''" then type in '''GLA-PT186586''' in "'''Name:'''" search bar and hit enter.
* Under "'''Search results:'''" select the Tent printer listed and click "'''OK'''"
[[File:Print Add3.png|thumb|center|Add Tent Printer GLA-186586]]

====ED SHAREPOINT====
* Contains VA extensions and UCLA/VA on-call pager numbers
* [https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx GLA VA ED Sharepoint]
* Can copy and paste the URL if above link does not work
** https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx GLA VA ED Sharepoint
** Also found in CPRS -> Tools -> GLA/VA Links -> Other Links -> ED Sharepoint
** Add to favorites

===CPRS SETUP===
====CPRS CONFIGURATION====

* To configure an automated list of patients checked into EST:
** Select "'''Clinics'''" in upper left hand, type in and select:
*** "'''WLA-Screening Tent'''"
** Under "List Appointments for" select: "'''Today'''"
** Click "'''Save Patient List Settings'''" & set it up for "'''All Days of Week'''" if you are working multiple days OR "'''Current Day Only'''" if working one day.
[[File:Appointment List.jpg|thumb|center|Appointment List Example]]

=====CPRS NOTES=====
* To add notes to your home screen for easy access:
** Toolbar click Tools -> Options -> Notes -> Document Titles.
**Type in then ADD:
*** “'''Enhanced Screening Tent (EST) Provider Note'''”
*** “'''Employee Health Note'''”
*You can move this group of notes to TOP of your list using shift and “^” arrow
[[File:Note Fav.jpg|thumb|center|Note Favorites]]

=====EST PROVIDER TEMPLATES=====
* Create new Template in CPRS Shared Templates:
** Copy/Paste page below
[[WLAVA:Enhanced_Screening_Tent_Template]]
** Printable page
[[:File:EST Provider Note Template 4.19.20.pdf]]

* Employee Template:
* Create new Template in CPRS Shared Templates:
** Copy/Paste page below
[[https://www.wikem.org/wiki/Wlava:Enhanced_Screening_Tent_Employee_Template]]
** Printable page
[[:File:EST Employee Health Note Template 4.19.20.pdf]]

======EST EXAMPLE NORMAL PHYSICAL EXAMINATION======
* '''GEN:''' Well-appearing, No apparent distress
* '''Resp:''' Normal work of breathing, speaking in complete sentences
* '''Neuro:''' A&Ox3, normal speech, no facial droop, moving all extremities, no gross focal deficits
* '''Gait:''' Steady

=====CPRS VISIT & ENCOUNTER=====
======WLA SCREENING TENT VISIT======
* Please make sure you link your EST note to the correct encounter
** The visit is "'''WLA-Screening Tent'''" or "'''STENT'''"
[[File:Encounter.png|thumb|center|Selecting Correct Visit]]

======EST ENCOUNTER======
* When signing your note please complete the encounter information
* Click on '''Encounter''' bar on the bottom left of CPRS.
[[File:Encoutner.PNG|thumb|center|Encounter Tab]]
** Make sure you are added as primary provider
** Type of Visit "'''Emergency Dept Visit'''"
** Section Name "'''Expanded Problem Focus Low'''"
[[File:Encounter Main.png|thumb|center|Encounter Main Screen]]

* Must add a diagnosis
** Can select from "'''Diagnosis Section'''" OR select "'''Other Diagnosis...'''"
** If select "Other Diagnosis" open this link as the CPRS search engine for ICD10 codes is horrendous.
***[https://www.icd10data.com/ Best ICD10 Search Engine]
** Please make sure that the diagnosis you selected is the primary diagnosis

*'''Suggested ICD10 codes include (but not limited to):'''
**Acute Upper Respiratory Infection, J06.9
**Cough, R05
**Viral Infection unspecified, B34.9
**Fever unspecified, R50.9
* '''Coding COVID19 Encounters'''
** For exposure to COVID19, or suspected COVID19 cases: Z20.828
***If asymptomatic no other diagnosis code needed
***If symptomatic, use appropriate diagnosis code above
** For confirmed COVID19 cases: B97.29

[[File:Encounter Dx.png|thumb|center|Insert Encounter Diagnosis]]

==EST WORKFLOW==
* Overview of Enhanced Screening Tent Operations:
[[File:WLA VA EST SOP.jpg|thumb|center|WLA VA EST Overview]]
* General RN & provider workflow for Enhanced Screening Tent:
[[File:WLA COVID-19 EST Flow.jpg|thumb|center|WLA COVID19 EST Workflow]]

===ORDERS===
* The order menu is located in the "'''ENHANCED SCREENING TENT'''" section of "'''Orders'''" tab
[[File:Find EST order menu.png|thumb|center|EST Main Order Menu]]
[[File:EST main order screen.png|thumb|center|EST Main Order Screen]]

====DISCHARGE MEDICATIONS====
* '''Medications for discharged must be processed by EST Provider (not RN or LVN).'''
* See SOP for details ([[:File:ER Triage Tent Outpatient Med Ordering and Dispensing SOP_v4 3.20.20.pdf]])
* Please call Pharmacy at the end of the day to refill EST medication supply.
** Please call Pharmacy to troubleshoot pharmacy-related issues:
*** '''Outpatient Pharmacy''' – ext. 48294
**** Monday through Friday: 8am – 7pm
**** Saturday: 8am – 4:30pm
*** '''Inpatient Pharmacy''' – ext. 53244
**** May be reached at any time outside of those listed for Outpatient Pharmacy
* Step-by-Step Process:
** Order medication in CPRS from EST discharge medication menu[[File:EST DC Med Menu.png|thumb|center|EST DC Medication Menu]]
** Find correct medication in cart and check that '''medication label''' AND '''overlay label''' match[[File:Pre-label Stock Item.png|thumb|center|Pre-label Example]][[File:Screen Shot 2020-04-10 at 2.06.55 PM.png|thumb|center|Overlay Label Example]]
** Fill out overlay label with patient name, your name, and date
** Apply overlay label to medication bottle ('''do not cover product Lot and Expiration Number''')
** Use Prison-style tally marks to record dispensed medications in '''Ward Stock Request''' form inside of white binder located on top of discharge medication cart
** Provide patient with medication information handout included in manila folder

===URGENT PRIMARY CARE F/U FOR EST===
* We are temporarily borrowing the ED PACT Tool in order to ensure urgent primary care f/u
* The ED-PACT Tool is an order that directly alerts PACT RN Care Managers to address urgent or specific needs of patients who are sent home from the ED.
**It assures that patients post-ED follow-up care needs are addressed by bringing the PACT RN Care Manager into the communication loop.
**The PACT RN Care Manager will work with the PACT Team to let (Primary Care Provider, LVN, Clerk) to address the Veteran’s care need(s).

====HOW DOES PACT TOOL WORK?====
* The flow depends on if patient is assigned or unassigned

=====ASSIGNED PATIENTS=====
* Identify Patient’s PACT Team by looking at top banner in CPRS
[[File:Assigned patient.png|thumb|center|Finding WLA Clinic Assignment]]
* Providers enter a CPRS order indicating urgent or specific needs for post-EST follow-up care using link on EST order menu
[[File:Ed pact tool main.png|thumb|center|ED-Pact Tool Order]]
* Choose PACT Clinic AND then the team
[[File:ED PACT GOLD 2.png|thumb|center|Select Appropriate PACT Clinic]]
* '''Fill in and Sign Templated Order'''
** Under reason for request:
*** ''Check “Seen in COVID- 19 Enhanced Screening Tent (EST)”''
*** '''If you have clinical concern for potential COVID-19 (regardless of whether you sent test), check “Clinical concern for potential COVID-19”'''
*** Check other boxes to indicate follow-up care need
[[File:Order Template.jpg|thumb|center|Order Template]]

=====UNASSIGNED PATIENTS=====
* For patients without a GLA PACT assignment, with urgent or specific needs, use link “No PACT assigned at any VA location/no local PACT at bottom of ED-PACT Tool Menu.
* This link will direct you to the Primary Care Consult Menu.
** '''Select the clinic location closest to the Veteran’s residence.'''
**'''Place the primary care consult''' AND add the points of contacts for each clinic (listed on the primary care consult menu) as additional signers on your EST note.
[[File:Additonal signer PC.png|thumb|center|Unassigned Patients, PC Consult, and Adding Additional Signer]]
[[File:PC Consult.png|thumb|center|Primary Care (PC) Consult]]

===MANAGEMENT ALGORITHMS===

====SUGGESTED MANAGEMENT ALGORITHM FOR PATIENTS PRESENTING TO EST====
* '''Is patient ambulatory?'''
** YES -> Go to next step
** NO -> Go to ED
* '''Is patient obviously sick appearing (i.e., in severe pain, visibly tachypneic, somnolent, diaphoretic, etc.)?'''
** YES -> Go to ED
** NO -> Go to next step
* '''Check focused vital signs:'''
** ''HR >110, SBP < 100, RR> 25 SaO2 < 94%''
*** YES -> Send to ED with warm handoff
*** NO -> Go to next step
* '''Does patient have a fever AND...?'''
** ''Fever alone is not a reason for ED evaluation if the patient is well appearing, is able to care for self and has no obvious finding suggestive of serious bacterial illness or SIRS criteria.''
** ''Does patient has a fever AND:''
*** ''meets SIRS criteria or has acute/new significant dyspnea or has chest pain or is unable to care for self or has obvious signs of serious bacterial illness (abdominal pain, pyelo, cellulitis, etc).''
**** YES -> Send to ED with warm handoff or consider ED consult
**** No --> go to next step
* '''Does patient meet "Wild Card" criteria?'''
** ''Wild Card = Patient with a high-risk co-morbidity (Immunocompromised, Age > 75 years, significant lung or heart disease history, active malignancy)''
*** YES -> consider ED consult
*** NO -> Go to Step 6
* '''Significant ''acute/new'' shortness of breath that affects activities of daily living?'''
** No -> Treat empirically and discharge home with urgent f/u
** Yes -> consider ED consult

===EMPLOYEE HEALTH ALGORITHM===
* We are testing '''symptomatic employees''' (and a select few asymptomatic) with a history of exposure to COVID19 for COVID19 if they are involved in '''direct patient care''' as it will guide our return to work instructions.
* '''Please provide all employees with EH handout at discharge.'''
** If '''employee was tested for COVID-19 in EST''' they must be '''instructed to not go back to work''' until they are cleared by EH.
** If '''employee was not tested for COVID-19''', they must '''speak to EH and their supervisor''' to discuss sick leave and return to work timeline.
* Employee Health (x53522).

====EMPLOYEE COVID-19 TRIAGE ALGORITHM====
'''Last Updated: 4/16/20'''
[[File:68497152-DD2F-46F8-8D54-14057FB8CFAB.png|thumb|center|Employee COVID-19 Triage]]

====EMPLOYEE EXPOSURE RISK DETERMINATION ALGORITHM====
'''Last Updated: 4/17/20'''
* Reviewing the exposure risk algorithm shows that this simple intervention keeps exposure risk low to medium.
** Second layer of defense is ensuring that you wear a face mask (NOT N95).
[[File:Screen Shot 2020-04-17 at 8.20.52 PM.png|thumb|center|nterim Guidance at GLA during regular staffing mode for ASYMPTOMATIC employees WITH PROLONGED CLOSE CONTACT with a COVID-19 patient]]
[[File:08B718CA-9CB2-48A8-9633-8BDA4F095449.jpg|thumb|center|Supplementary Appendix]]

===EMPLOYEE RETURN TO WORK GUIDANCE===
'''Last Updated: 4/17/20'''
[[File:Screen Shot 2020-04-17 at 8.21.13 PM.png|thumb|center|Return to Work Guidance for Staff with Direct Patient Contact]]

==EDUCATIONAL MATERIALS==
* [https://www.blog.numose.com/emed-basics/sick-not-sick Medical Screening Exam (Sick vs Non-sick)]
* [[:File:Back Pain EST.pdf]]

==OTHER WLA VA PAGES==
* [[WLAVA:COVID19_ED_Operational_Updates|WLAVA: COVID19 ED Operational Updates]]
* [[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

{{Special:Prefixindex/WLA VA: |hideredirects=1}}

Wlava:Enhanced Screening Tent Employee Template

2020-04-28T06:42:48Z

WLAVA:Enhanced Screening Tent Template

2020-04-28T06:41:39Z

Jochickabee:

CC: |PATIENT AGE|
 
HPI: 
 
REFERRED BY: 
[ ] Self 
[ ] Failed primary screen 
[ ] Primary care provider 
[ ] Other: (free text box) 
 
SYMPTOM SCREEN (select all that apply): 
[ ] Subjective fevers/chills or T > 99.9F 
[ ] Cough (new or worse than usual) 
[ ] Sore throat (new or worse than usual) 
[ ] Shortness of breath or trouble breathing (new or worse than usual) 
[ ] Body or muscle aches (new or worse than usual) 
[ ] Diarrhea (new or worse than usual) 
[ ] Severe fatigue 
[ ] Other: (free text box) 
 
EXPOSURE SCREEN: 
[ ] Close contact with CONFIRMED COVID19 case (within 14 days of Sx onset) 
[ ] Close contact with patients of a respiratory illness outbreak in last 3 days 
[ ] Healthcare worker (including EMT, paramedic, etc) 
[ ] Lives in a long-term care facility (CLC, CalVet, New Vista, community SNF, etc) 
[ ] Lives in a group living facility (homeless shelter, board & care, DOM, New Directions, US Vets, etc) 
[ ] Patient gets chronic care in healthcare facility (i.e., dialysis or chemotherapy patient) 
 
SOCIAL HISTORY: 
[ ] Domiciled in private residence 
[ ] Undomiciled (includes living in tent, car, etc) 
[ ] Domiciled in long-term care facility (auto populate if selected above in exposure screen?) 
[ ] Domiciled in group living facility (auto populate if selected above in exposure screen?) 
 
PMHx: 
ACTIVE PROBLEMS 
|ACTIVE PROB LIST-SHORT| 
 
ALLERGIES: 
|ALLERGIES| 
 
VITALS: 
T: |TEMPERATURE| 
P: |PULSE| 
R: |RESPIRATION| 
BP:|BLOOD PRESSURE| 
Pain: |PAIN| 
Pulse Ox: |PULSE OXIMETRY| 
 
PHYSICAL EXAM: 
GEN: Well-appearing, No apparent distress 
Resp: Normal work of breathing, speaking in complete sentences 
Neuro: A&Ox3, Gait: steady, moving all extremities, no gross focal deficits 
 
ASSESSMENT: 
Patient is afebrile and with unremarkable respiratory vital signs. Patient at baseline ambulatory status, 
non-toxic appearing, and speaking in full sentences. Based on the limited examination there is a low 
suspicion for serious bacterial infection or systemic illness. 
[ ] COVID-19 suspected, met testing criteria. 
[ ] COVID-19 suspected, did not meet testing criteria. 
[ ] COVID-19 suspected, testing refused. 
[ ] COVID-19 not suspected. 
[ ] Other: (free text box) 
 
PLAN:
[ ] Encouraged patient to continue with symptom alleviation. 
[ ] Encouraged to return if has significant worsening of symptoms including chest pain, shortness of 
breath, or inability to care for self. 
 
DISPOSITION: 
[ ] Allowed to enter medical center 
[ ] Home 
[ ] Long-term care facility (i.e., CLC, CalVet, New Vista, community SNF, etc) 
[ ] Building 214 “COVID” DOM 
[ ] VA Homeless Housing Program (i.e., Grant Per Diem, DOM, New Directions, etc.) 
[ ] Other group living facility (i.e., shelter, board & care, assisted living facility etc.) 
[ ] ED attending consult for help with disposition: (text box for name) 
[ ] Escorted to ED (critically ill) 
[ ] Directly Admitted 
[ ] Other: (free text box)

WLAVA:Enhanced Screening Tent LIP Orientation

2020-04-28T06:37:32Z

Jochickabee: /* EST PROVIDER TEMPLATES */

'''Last Updated: 4/19/20'''
==PROVIDER START GUIDE==
===EST PROVIDER ORIENTATION VIDEO===
====EST PROVIDER ORIENTATION #1====
{{#widget:YouTube|id=Z8m0jiI-WAY}}
====EST PROVIDER ORIENTATION #2====
{{#widget:YouTube|id=8FoLue3cAOU}}
====EST PROVIDER ORIENTATION #3====
{{#widget:YouTube|id=DgK7l8mOG6I}}
====EST PROVIDER ORIENTATION #4 (Q&A)====
{{#widget:YouTube|id=WCaDOGkHS04}}

===EST PHONE EXTENSIONS===
* 310-478-3711
** EST provider '''x53333''' (310-268-3333)
** RN Tent screener 1 '''x41034'''
** RN Tent screener 2 '''x41035'''

===COMPUTER SETUP===
====WINDOWS DESKTOP CONFIGURATION====
* Search (click on magnifying glass) for and load the following programs and 'pin' to your taskbar (right click over icon and select "pin to taskbar"):
** Skype (to communicate with RNs in EST and other providers in VA)
** CPRS
** Outlook
** Internet Explorer
** Chrome
** Impax

[[File:Screen Shot 2020-03-24 at 11.58.34 AM.png|thumb|center|Search & Taskbar Set up]]

=====PRINTER SETUP=====
* Search for "'''Printer'''" and select "'''Printer & scanners'''"
[[File:Print Search.png|thumb|center|Print Search]]
* Select "'''Add a printer or scanner'''"
[[File:Print Add.png|thumb|center|Add a Printer]]
* Select "'''The printer that I want isn't listed'''
[[File:Print Add2.png|thumb|center|Printer Not Listed]]
* Select "'''Stop'''" then type in '''GLA-PT186586''' in "'''Name:'''" search bar and hit enter.
* Under "'''Search results:'''" select the Tent printer listed and click "'''OK'''"
[[File:Print Add3.png|thumb|center|Add Tent Printer GLA-186586]]

====ED SHAREPOINT====
* Contains VA extensions and UCLA/VA on-call pager numbers
* [https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx GLA VA ED Sharepoint]
* Can copy and paste the URL if above link does not work
** https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx GLA VA ED Sharepoint
** Also found in CPRS -> Tools -> GLA/VA Links -> Other Links -> ED Sharepoint
** Add to favorites

===CPRS SETUP===
====CPRS CONFIGURATION====

* To configure an automated list of patients checked into EST:
** Select "'''Clinics'''" in upper left hand, type in and select:
*** "'''WLA-Screening Tent'''"
** Under "List Appointments for" select: "'''Today'''"
** Click "'''Save Patient List Settings'''" & set it up for "'''All Days of Week'''" if you are working multiple days OR "'''Current Day Only'''" if working one day.
[[File:Appointment List.jpg|thumb|center|Appointment List Example]]

=====CPRS NOTES=====
* To add notes to your home screen for easy access:
** Toolbar click Tools -> Options -> Notes -> Document Titles.
**Type in then ADD:
*** “'''Enhanced Screening Tent (EST) Provider Note'''”
*** “'''Employee Health Note'''”
*You can move this group of notes to TOP of your list using shift and “^” arrow
[[File:Note Fav.jpg|thumb|center|Note Favorites]]

=====EST PROVIDER TEMPLATES=====
* Create new Template in CPRS Shared Templates:
** Copy/Paste page below
[[WLAVA:Enhanced_Screening_Tent_Template]]
** Printable page
[[:File:EST Provider Note Template 4.19.20.pdf]]

* Employee Template:
[[:File:EST Employee Health Note Template 4.19.20.pdf]]

======EST EXAMPLE NORMAL PHYSICAL EXAMINATION======
* '''GEN:''' Well-appearing, No apparent distress
* '''Resp:''' Normal work of breathing, speaking in complete sentences
* '''Neuro:''' A&Ox3, normal speech, no facial droop, moving all extremities, no gross focal deficits
* '''Gait:''' Steady

=====CPRS VISIT & ENCOUNTER=====
======WLA SCREENING TENT VISIT======
* Please make sure you link your EST note to the correct encounter
** The visit is "'''WLA-Screening Tent'''" or "'''STENT'''"
[[File:Encounter.png|thumb|center|Selecting Correct Visit]]

======EST ENCOUNTER======
* When signing your note please complete the encounter information
* Click on '''Encounter''' bar on the bottom left of CPRS.
[[File:Encoutner.PNG|thumb|center|Encounter Tab]]
** Make sure you are added as primary provider
** Type of Visit "'''Emergency Dept Visit'''"
** Section Name "'''Expanded Problem Focus Low'''"
[[File:Encounter Main.png|thumb|center|Encounter Main Screen]]

* Must add a diagnosis
** Can select from "'''Diagnosis Section'''" OR select "'''Other Diagnosis...'''"
** If select "Other Diagnosis" open this link as the CPRS search engine for ICD10 codes is horrendous.
***[https://www.icd10data.com/ Best ICD10 Search Engine]
** Please make sure that the diagnosis you selected is the primary diagnosis

*'''Suggested ICD10 codes include (but not limited to):'''
**Acute Upper Respiratory Infection, J06.9
**Cough, R05
**Viral Infection unspecified, B34.9
**Fever unspecified, R50.9
* '''Coding COVID19 Encounters'''
** For exposure to COVID19, or suspected COVID19 cases: Z20.828
***If asymptomatic no other diagnosis code needed
***If symptomatic, use appropriate diagnosis code above
** For confirmed COVID19 cases: B97.29

[[File:Encounter Dx.png|thumb|center|Insert Encounter Diagnosis]]

==EST WORKFLOW==
* Overview of Enhanced Screening Tent Operations:
[[File:WLA VA EST SOP.jpg|thumb|center|WLA VA EST Overview]]
* General RN & provider workflow for Enhanced Screening Tent:
[[File:WLA COVID-19 EST Flow.jpg|thumb|center|WLA COVID19 EST Workflow]]

===ORDERS===
* The order menu is located in the "'''ENHANCED SCREENING TENT'''" section of "'''Orders'''" tab
[[File:Find EST order menu.png|thumb|center|EST Main Order Menu]]
[[File:EST main order screen.png|thumb|center|EST Main Order Screen]]

====DISCHARGE MEDICATIONS====
* '''Medications for discharged must be processed by EST Provider (not RN or LVN).'''
* See SOP for details ([[:File:ER Triage Tent Outpatient Med Ordering and Dispensing SOP_v4 3.20.20.pdf]])
* Please call Pharmacy at the end of the day to refill EST medication supply.
** Please call Pharmacy to troubleshoot pharmacy-related issues:
*** '''Outpatient Pharmacy''' – ext. 48294
**** Monday through Friday: 8am – 7pm
**** Saturday: 8am – 4:30pm
*** '''Inpatient Pharmacy''' – ext. 53244
**** May be reached at any time outside of those listed for Outpatient Pharmacy
* Step-by-Step Process:
** Order medication in CPRS from EST discharge medication menu[[File:EST DC Med Menu.png|thumb|center|EST DC Medication Menu]]
** Find correct medication in cart and check that '''medication label''' AND '''overlay label''' match[[File:Pre-label Stock Item.png|thumb|center|Pre-label Example]][[File:Screen Shot 2020-04-10 at 2.06.55 PM.png|thumb|center|Overlay Label Example]]
** Fill out overlay label with patient name, your name, and date
** Apply overlay label to medication bottle ('''do not cover product Lot and Expiration Number''')
** Use Prison-style tally marks to record dispensed medications in '''Ward Stock Request''' form inside of white binder located on top of discharge medication cart
** Provide patient with medication information handout included in manila folder

===URGENT PRIMARY CARE F/U FOR EST===
* We are temporarily borrowing the ED PACT Tool in order to ensure urgent primary care f/u
* The ED-PACT Tool is an order that directly alerts PACT RN Care Managers to address urgent or specific needs of patients who are sent home from the ED.
**It assures that patients post-ED follow-up care needs are addressed by bringing the PACT RN Care Manager into the communication loop.
**The PACT RN Care Manager will work with the PACT Team to let (Primary Care Provider, LVN, Clerk) to address the Veteran’s care need(s).

====HOW DOES PACT TOOL WORK?====
* The flow depends on if patient is assigned or unassigned

=====ASSIGNED PATIENTS=====
* Identify Patient’s PACT Team by looking at top banner in CPRS
[[File:Assigned patient.png|thumb|center|Finding WLA Clinic Assignment]]
* Providers enter a CPRS order indicating urgent or specific needs for post-EST follow-up care using link on EST order menu
[[File:Ed pact tool main.png|thumb|center|ED-Pact Tool Order]]
* Choose PACT Clinic AND then the team
[[File:ED PACT GOLD 2.png|thumb|center|Select Appropriate PACT Clinic]]
* '''Fill in and Sign Templated Order'''
** Under reason for request:
*** ''Check “Seen in COVID- 19 Enhanced Screening Tent (EST)”''
*** '''If you have clinical concern for potential COVID-19 (regardless of whether you sent test), check “Clinical concern for potential COVID-19”'''
*** Check other boxes to indicate follow-up care need
[[File:Order Template.jpg|thumb|center|Order Template]]

=====UNASSIGNED PATIENTS=====
* For patients without a GLA PACT assignment, with urgent or specific needs, use link “No PACT assigned at any VA location/no local PACT at bottom of ED-PACT Tool Menu.
* This link will direct you to the Primary Care Consult Menu.
** '''Select the clinic location closest to the Veteran’s residence.'''
**'''Place the primary care consult''' AND add the points of contacts for each clinic (listed on the primary care consult menu) as additional signers on your EST note.
[[File:Additonal signer PC.png|thumb|center|Unassigned Patients, PC Consult, and Adding Additional Signer]]
[[File:PC Consult.png|thumb|center|Primary Care (PC) Consult]]

===MANAGEMENT ALGORITHMS===

====SUGGESTED MANAGEMENT ALGORITHM FOR PATIENTS PRESENTING TO EST====
* '''Is patient ambulatory?'''
** YES -> Go to next step
** NO -> Go to ED
* '''Is patient obviously sick appearing (i.e., in severe pain, visibly tachypneic, somnolent, diaphoretic, etc.)?'''
** YES -> Go to ED
** NO -> Go to next step
* '''Check focused vital signs:'''
** ''HR >110, SBP < 100, RR> 25 SaO2 < 94%''
*** YES -> Send to ED with warm handoff
*** NO -> Go to next step
* '''Does patient have a fever AND...?'''
** ''Fever alone is not a reason for ED evaluation if the patient is well appearing, is able to care for self and has no obvious finding suggestive of serious bacterial illness or SIRS criteria.''
** ''Does patient has a fever AND:''
*** ''meets SIRS criteria or has acute/new significant dyspnea or has chest pain or is unable to care for self or has obvious signs of serious bacterial illness (abdominal pain, pyelo, cellulitis, etc).''
**** YES -> Send to ED with warm handoff or consider ED consult
**** No --> go to next step
* '''Does patient meet "Wild Card" criteria?'''
** ''Wild Card = Patient with a high-risk co-morbidity (Immunocompromised, Age > 75 years, significant lung or heart disease history, active malignancy)''
*** YES -> consider ED consult
*** NO -> Go to Step 6
* '''Significant ''acute/new'' shortness of breath that affects activities of daily living?'''
** No -> Treat empirically and discharge home with urgent f/u
** Yes -> consider ED consult

===EMPLOYEE HEALTH ALGORITHM===
* We are testing '''symptomatic employees''' (and a select few asymptomatic) with a history of exposure to COVID19 for COVID19 if they are involved in '''direct patient care''' as it will guide our return to work instructions.
* '''Please provide all employees with EH handout at discharge.'''
** If '''employee was tested for COVID-19 in EST''' they must be '''instructed to not go back to work''' until they are cleared by EH.
** If '''employee was not tested for COVID-19''', they must '''speak to EH and their supervisor''' to discuss sick leave and return to work timeline.
* Employee Health (x53522).

====EMPLOYEE COVID-19 TRIAGE ALGORITHM====
'''Last Updated: 4/16/20'''
[[File:68497152-DD2F-46F8-8D54-14057FB8CFAB.png|thumb|center|Employee COVID-19 Triage]]

====EMPLOYEE EXPOSURE RISK DETERMINATION ALGORITHM====
'''Last Updated: 4/17/20'''
* Reviewing the exposure risk algorithm shows that this simple intervention keeps exposure risk low to medium.
** Second layer of defense is ensuring that you wear a face mask (NOT N95).
[[File:Screen Shot 2020-04-17 at 8.20.52 PM.png|thumb|center|nterim Guidance at GLA during regular staffing mode for ASYMPTOMATIC employees WITH PROLONGED CLOSE CONTACT with a COVID-19 patient]]
[[File:08B718CA-9CB2-48A8-9633-8BDA4F095449.jpg|thumb|center|Supplementary Appendix]]

===EMPLOYEE RETURN TO WORK GUIDANCE===
'''Last Updated: 4/17/20'''
[[File:Screen Shot 2020-04-17 at 8.21.13 PM.png|thumb|center|Return to Work Guidance for Staff with Direct Patient Contact]]

==EDUCATIONAL MATERIALS==
* [https://www.blog.numose.com/emed-basics/sick-not-sick Medical Screening Exam (Sick vs Non-sick)]
* [[:File:Back Pain EST.pdf]]

==OTHER WLA VA PAGES==
* [[WLAVA:COVID19_ED_Operational_Updates|WLAVA: COVID19 ED Operational Updates]]
* [[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

{{Special:Prefixindex/WLA VA: |hideredirects=1}}

WLAVA:Enhanced Screening Tent Template

2020-04-28T06:30:32Z

Jochickabee:

CC: |PATIENT AGE| 
 
HPI:
 
REFERRED BY: 
[ ] Self 
[ ] Failed primary screen 
[ ] Primary care provider 
[ ] Other: (free text box) 
 
SYMPTOM SCREEN (select all that apply): 
[ ] Subjective fevers/chills or T > 99.9F 
[ ] Cough (new or worse than usual) 
[ ] Sore throat (new or worse than usual) 
[ ] Shortness of breath or trouble breathing (new or worse than usual) 
[ ] Body or muscle aches (new or worse than usual) 
[ ] Diarrhea (new or worse than usual) 
[ ] Severe fatigue 
[ ] Other: (free text box) 
 
EXPOSURE SCREEN: 
[ ] Close contact with CONFIRMED COVID19 case (within 14 days of Sx onset) 
[ ] Close contact with patients of a respiratory illness outbreak in last 3 days 
[ ] Healthcare worker (including EMT, paramedic, etc) 
[ ] Lives in a long-term care facility (CLC, CalVet, New Vista, community SNF, etc) 
[ ] Lives in a group living facility (homeless shelter, board & care, DOM, New Directions, US Vets, etc) 
[ ] Patient gets chronic care in healthcare facility (i.e., dialysis or chemotherapy patient) 
 
SOCIAL HISTORY: 
[ ] Domiciled in private residence 
[ ] Undomiciled (includes living in tent, car, etc) 
[ ] Domiciled in long-term care facility (auto populate if selected above in exposure screen?) 
[ ] Domiciled in group living facility (auto populate if selected above in exposure screen?) 
 
PMHx: 
ACTIVE PROBLEMS 
|ACTIVE PROB LIST-SHORT| 
 
ALLERGIES: 
|ALLERGIES| 
 
VITALS: 
T: |TEMPERATURE| 
P: |PULSE| 
R: |RESPIRATION| 
BP:|BLOOD PRESSURE| 
Pain: |PAIN| 
Pulse Ox: |PULSE OXIMETRY| 
 
PHYSICAL EXAM: 
GEN: Well-appearing, No apparent distress 
Resp: Normal work of breathing, speaking in complete sentences 
Neuro: A&Ox3, Gait: steady, moving all extremities, no gross focal deficits 
 
ASSESSMENT: 
Patient is afebrile and with unremarkable respiratory vital signs. Patient at baseline ambulatory status, 
non-toxic appearing, and speaking in full sentences. Based on the limited examination there is a low 
suspicion for serious bacterial infection or systemic illness. 
[ ] COVID-19 suspected, met testing criteria. 
[ ] COVID-19 suspected, did not meet testing criteria. 
[ ] COVID-19 suspected, testing refused. 
[ ] COVID-19 not suspected. 
[ ] Other: (free text box) 
 
PLAN:
[ ] Encouraged patient to continue with symptom alleviation. 
[ ] Encouraged to return if has significant worsening of symptoms including chest pain, shortness of 
breath, or inability to care for self. 
 
DISPOSITION: 
[ ] Allowed to enter medical center 
[ ] Home 
[ ] Long-term care facility (i.e., CLC, CalVet, New Vista, community SNF, etc) 
[ ] Building 214 “COVID” DOM 
[ ] VA Homeless Housing Program (i.e., Grant Per Diem, DOM, New Directions, etc.) 
[ ] Other group living facility (i.e., shelter, board & care, assisted living facility etc.) 
[ ] ED attending consult for help with disposition: (text box for name) 
[ ] Escorted to ED (critically ill) 
[ ] Directly Admitted 
[ ] Other: (free text box)

WLAVA:Enhanced Screening Tent Template

2020-04-28T06:28:00Z

Jochickabee:

== EST Provider Note==
CC: |PATIENT AGE| 
 
HPI:
 
REFERRED BY: 
[ ] Self 
[ ] Failed primary screen 
[ ] Primary care provider 
[ ] Other: (free text box) 
 
SYMPTOM SCREEN (select all that apply): 
[ ] Subjective fevers/chills or T > 99.9F 
[ ] Cough (new or worse than usual) 
[ ] Sore throat (new or worse than usual) 
[ ] Shortness of breath or trouble breathing (new or worse than usual) 
[ ] Body or muscle aches (new or worse than usual) 
[ ] Diarrhea (new or worse than usual) 
[ ] Severe fatigue 
[ ] Other: (free text box) 
 
EXPOSURE SCREEN: 
[ ] Close contact with CONFIRMED COVID19 case (within 14 days of Sx onset) 
[ ] Close contact with patients of a respiratory illness outbreak in last 3 days 
[ ] Healthcare worker (including EMT, paramedic, etc) 
[ ] Lives in a long-term care facility (CLC, CalVet, New Vista, community SNF, etc) 
[ ] Lives in a group living facility (homeless shelter, board & care, DOM, New Directions, US Vets, etc) 
[ ] Patient gets chronic care in healthcare facility (i.e., dialysis or chemotherapy patient) 
 
SOCIAL HISTORY: 
[ ] Domiciled in private residence 
[ ] Undomiciled (includes living in tent, car, etc) 
[ ] Domiciled in long-term care facility (auto populate if selected above in exposure screen?) 
[ ] Domiciled in group living facility (auto populate if selected above in exposure screen?) 
 
PMHx: 
ACTIVE PROBLEMS 
|ACTIVE PROB LIST-SHORT| 
 
ALLERGIES: 
|ALLERGIES| 
 
VITALS: 
T: |TEMPERATURE| 
P: |PULSE| 
R: |RESPIRATION| 
BP:|BLOOD PRESSURE| 
Pain: |PAIN| 
Pulse Ox: |PULSE OXIMETRY| 
 
PHYSICAL EXAM: 
GEN: Well-appearing, No apparent distress 
Resp: Normal work of breathing, speaking in complete sentences 
Neuro: A&Ox3, Gait: steady, moving all extremities, no gross focal deficits 
 
ASSESSMENT: 
Patient is afebrile and with unremarkable respiratory vital signs. Patient at baseline ambulatory status, 
non-toxic appearing, and speaking in full sentences. Based on the limited examination there is a low 
suspicion for serious bacterial infection or systemic illness. 
[ ] COVID-19 suspected, met testing criteria. 
[ ] COVID-19 suspected, did not meet testing criteria. 
[ ] COVID-19 suspected, testing refused. 
[ ] COVID-19 not suspected. 
[ ] Other: (free text box) 
 
PLAN:
[ ] Encouraged patient to continue with symptom alleviation. 
[ ] Encouraged to return if has significant worsening of symptoms including chest pain, shortness of 
breath, or inability to care for self. 
 
DISPOSITION: 
[ ] Allowed to enter medical center 
[ ] Home 
[ ] Long-term care facility (i.e., CLC, CalVet, New Vista, community SNF, etc) 
[ ] Building 214 “COVID” DOM 
[ ] VA Homeless Housing Program (i.e., Grant Per Diem, DOM, New Directions, etc.) 
[ ] Other group living facility (i.e., shelter, board & care, assisted living facility etc.) 
[ ] ED attending consult for help with disposition: (text box for name) 
[ ] Escorted to ED (critically ill) 
[ ] Directly Admitted 
[ ] Other: (free text box)

WLAVA:Enhanced Screening Tent Template

2020-04-28T06:24:53Z

Jochickabee: Created page with "== EST Provider Note== CC: |PATIENT AGE| HPI: REFERRED BY: [ ] Self [ ] Failed primary screen [ ] Primary care provider [ ] Other: (free..."

== EST Provider Note==
CC: |PATIENT AGE| 
 
HPI:
 
REFERRED BY: 
[ ] Self 
[ ] Failed primary screen 
[ ] Primary care provider 
[ ] Other: (free text box) 
 
SYMPTOM SCREEN (select all that apply): 
[ ] Subjective fevers/chills or T > 99.9F 
[ ] Cough (new or worse than usual) 
[ ] Sore throat (new or worse than usual) 
[ ] Shortness of breath or trouble breathing (new or worse than usual) 
[ ] Body or muscle aches (new or worse than usual) 
[ ] Diarrhea (new or worse than usual) 
[ ] Severe fatigue 
[ ] Other: (free text box) 
 
EXPOSURE SCREEN: 
[ ] Close contact with CONFIRMED COVID19 case (within 14 days of Sx onset) 
[ ] Close contact with patients of a respiratory illness outbreak in last 3 days 
[ ] Healthcare worker (including EMT, paramedic, etc) 
[ ] Lives in a long-term care facility (CLC, CalVet, New Vista, community SNF, etc) 
[ ] Lives in a group living facility (homeless shelter, board & care, DOM, New Directions, US Vets, etc) 
[ ] Patient gets chronic care in healthcare facility (i.e., dialysis or chemotherapy patient) 
 
SOCIAL HISTORY: 
[ ] Domiciled in private residence 
[ ] Undomiciled (includes living in tent, car, etc) 
[ ] Domiciled in long-term care facility (auto populate if selected above in exposure screen?) 
[ ] Domiciled in group living facility (auto populate if selected above in exposure screen?) 
 
PMHx: 
ACTIVE PROBLEMS 
|ACTIVE PROB LIST-SHORT| 
 
ALLERGIES: 
|ALLERGIES| 
 
VITALS: 
T: |TEMPERATURE| 
P: |PULSE| 
R: |RESPIRATION| 
BP:|BLOOD PRESSURE| 
Pain: |PAIN| 
Pulse Ox: |PULSE OXIMETRY| 
 
PHYSICAL EXAM: 
GEN: Well-appearing, No apparent distress 
Resp: Normal work of breathing, speaking in complete sentences 
Neuro: A&Ox3, Gait: steady, moving all extremities, no gross focal deficits 
 
ASSESSMENT: 
Patient is afebrile and with unremarkable respiratory vital signs. Patient at baseline ambulatory status, 
non-toxic appearing, and speaking in full sentences. Based on the limited examination there is a low 
suspicion for serious bacterial infection or systemic illness. 
[ ] COVID-19 suspected, met testing criteria. 
[ ] COVID-19 suspected, did not meet testing criteria. 
[ ] COVID-19 suspected, testing refused. 
[ ] COVID-19 not suspected. 
[ ] Other: (free text box) 
 
PLAN:
[ ] Encouraged patient to continue with symptom alleviation. 
[ ] Encouraged to return if has significant worsening of symptoms including chest pain, shortness of 
breath, or inability to care for self. 
 
DISPOSITION: 
[ ] Allowed to enter medical center 
[ ] Home 
[ ] Long-term care facility (i.e., CLC, CalVet, New Vista, community SNF, etc) 
[ ] Building 214 “COVID” DOM 
[ ] VA Homeless Housing Program (i.e., Grant Per Diem, DOM, New Directions, etc.) 
[ ] Other group living facility (i.e., shelter, board & care, assisted living facility etc.) 
[ ] ED attending consult for help with disposition: (text box for name) 
[ ] Escorted to ED (critically ill) 
[ ] Directly Admitted 
[ ] Other: (free text box)

WLAVA:Enhanced Screening Tent LIP Orientation

2020-04-28T06:15:57Z

Jochickabee: /* EMPLOYEE RETURN TO WORK GUIDANCE */

'''Last Updated: 4/19/20'''
==PROVIDER START GUIDE==
===EST PROVIDER ORIENTATION VIDEO===
====EST PROVIDER ORIENTATION #1====
{{#widget:YouTube|id=Z8m0jiI-WAY}}
====EST PROVIDER ORIENTATION #2====
{{#widget:YouTube|id=8FoLue3cAOU}}
====EST PROVIDER ORIENTATION #3====
{{#widget:YouTube|id=DgK7l8mOG6I}}
====EST PROVIDER ORIENTATION #4 (Q&A)====
{{#widget:YouTube|id=WCaDOGkHS04}}

===EST PHONE EXTENSIONS===
* 310-478-3711
** EST provider '''x53333''' (310-268-3333)
** RN Tent screener 1 '''x41034'''
** RN Tent screener 2 '''x41035'''

===COMPUTER SETUP===
====WINDOWS DESKTOP CONFIGURATION====
* Search (click on magnifying glass) for and load the following programs and 'pin' to your taskbar (right click over icon and select "pin to taskbar"):
** Skype (to communicate with RNs in EST and other providers in VA)
** CPRS
** Outlook
** Internet Explorer
** Chrome
** Impax

[[File:Screen Shot 2020-03-24 at 11.58.34 AM.png|thumb|center|Search & Taskbar Set up]]

=====PRINTER SETUP=====
* Search for "'''Printer'''" and select "'''Printer & scanners'''"
[[File:Print Search.png|thumb|center|Print Search]]
* Select "'''Add a printer or scanner'''"
[[File:Print Add.png|thumb|center|Add a Printer]]
* Select "'''The printer that I want isn't listed'''
[[File:Print Add2.png|thumb|center|Printer Not Listed]]
* Select "'''Stop'''" then type in '''GLA-PT186586''' in "'''Name:'''" search bar and hit enter.
* Under "'''Search results:'''" select the Tent printer listed and click "'''OK'''"
[[File:Print Add3.png|thumb|center|Add Tent Printer GLA-186586]]

====ED SHAREPOINT====
* Contains VA extensions and UCLA/VA on-call pager numbers
* [https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx GLA VA ED Sharepoint]
* Can copy and paste the URL if above link does not work
** https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx GLA VA ED Sharepoint
** Also found in CPRS -> Tools -> GLA/VA Links -> Other Links -> ED Sharepoint
** Add to favorites

===CPRS SETUP===
====CPRS CONFIGURATION====

* To configure an automated list of patients checked into EST:
** Select "'''Clinics'''" in upper left hand, type in and select:
*** "'''WLA-Screening Tent'''"
** Under "List Appointments for" select: "'''Today'''"
** Click "'''Save Patient List Settings'''" & set it up for "'''All Days of Week'''" if you are working multiple days OR "'''Current Day Only'''" if working one day.
[[File:Appointment List.jpg|thumb|center|Appointment List Example]]

=====CPRS NOTES=====
* To add notes to your home screen for easy access:
** Toolbar click Tools -> Options -> Notes -> Document Titles.
**Type in then ADD:
*** “'''Enhanced Screening Tent (EST) Provider Note'''”
*** “'''Employee Health Note'''”
*You can move this group of notes to TOP of your list using shift and “^” arrow
[[File:Note Fav.jpg|thumb|center|Note Favorites]]

=====EST PROVIDER TEMPLATES=====
* Patient Template:
[[:File:EST Provider Note Template 4.19.20.pdf]]
* Employee Template:
[[:File:EST Employee Health Note Template 4.19.20.pdf]]

======EST EXAMPLE NORMAL PHYSICAL EXAMINATION======
* '''GEN:''' Well-appearing, No apparent distress
* '''Resp:''' Normal work of breathing, speaking in complete sentences
* '''Neuro:''' A&Ox3, normal speech, no facial droop, moving all extremities, no gross focal deficits
* '''Gait:''' Steady

=====CPRS VISIT & ENCOUNTER=====
======WLA SCREENING TENT VISIT======
* Please make sure you link your EST note to the correct encounter
** The visit is "'''WLA-Screening Tent'''" or "'''STENT'''"
[[File:Encounter.png|thumb|center|Selecting Correct Visit]]

======EST ENCOUNTER======
* When signing your note please complete the encounter information
* Click on '''Encounter''' bar on the bottom left of CPRS.
[[File:Encoutner.PNG|thumb|center|Encounter Tab]]
** Make sure you are added as primary provider
** Type of Visit "'''Emergency Dept Visit'''"
** Section Name "'''Expanded Problem Focus Low'''"
[[File:Encounter Main.png|thumb|center|Encounter Main Screen]]

* Must add a diagnosis
** Can select from "'''Diagnosis Section'''" OR select "'''Other Diagnosis...'''"
** If select "Other Diagnosis" open this link as the CPRS search engine for ICD10 codes is horrendous.
***[https://www.icd10data.com/ Best ICD10 Search Engine]
** Please make sure that the diagnosis you selected is the primary diagnosis

*'''Suggested ICD10 codes include (but not limited to):'''
**Acute Upper Respiratory Infection, J06.9
**Cough, R05
**Viral Infection unspecified, B34.9
**Fever unspecified, R50.9
* '''Coding COVID19 Encounters'''
** For exposure to COVID19, or suspected COVID19 cases: Z20.828
***If asymptomatic no other diagnosis code needed
***If symptomatic, use appropriate diagnosis code above
** For confirmed COVID19 cases: B97.29

[[File:Encounter Dx.png|thumb|center|Insert Encounter Diagnosis]]

==EST WORKFLOW==
* Overview of Enhanced Screening Tent Operations:
[[File:WLA VA EST SOP.jpg|thumb|center|WLA VA EST Overview]]
* General RN & provider workflow for Enhanced Screening Tent:
[[File:WLA COVID-19 EST Flow.jpg|thumb|center|WLA COVID19 EST Workflow]]

===ORDERS===
* The order menu is located in the "'''ENHANCED SCREENING TENT'''" section of "'''Orders'''" tab
[[File:Find EST order menu.png|thumb|center|EST Main Order Menu]]
[[File:EST main order screen.png|thumb|center|EST Main Order Screen]]

====DISCHARGE MEDICATIONS====
* '''Medications for discharged must be processed by EST Provider (not RN or LVN).'''
* See SOP for details ([[:File:ER Triage Tent Outpatient Med Ordering and Dispensing SOP_v4 3.20.20.pdf]])
* Please call Pharmacy at the end of the day to refill EST medication supply.
** Please call Pharmacy to troubleshoot pharmacy-related issues:
*** '''Outpatient Pharmacy''' – ext. 48294
**** Monday through Friday: 8am – 7pm
**** Saturday: 8am – 4:30pm
*** '''Inpatient Pharmacy''' – ext. 53244
**** May be reached at any time outside of those listed for Outpatient Pharmacy
* Step-by-Step Process:
** Order medication in CPRS from EST discharge medication menu[[File:EST DC Med Menu.png|thumb|center|EST DC Medication Menu]]
** Find correct medication in cart and check that '''medication label''' AND '''overlay label''' match[[File:Pre-label Stock Item.png|thumb|center|Pre-label Example]][[File:Screen Shot 2020-04-10 at 2.06.55 PM.png|thumb|center|Overlay Label Example]]
** Fill out overlay label with patient name, your name, and date
** Apply overlay label to medication bottle ('''do not cover product Lot and Expiration Number''')
** Use Prison-style tally marks to record dispensed medications in '''Ward Stock Request''' form inside of white binder located on top of discharge medication cart
** Provide patient with medication information handout included in manila folder

===URGENT PRIMARY CARE F/U FOR EST===
* We are temporarily borrowing the ED PACT Tool in order to ensure urgent primary care f/u
* The ED-PACT Tool is an order that directly alerts PACT RN Care Managers to address urgent or specific needs of patients who are sent home from the ED.
**It assures that patients post-ED follow-up care needs are addressed by bringing the PACT RN Care Manager into the communication loop.
**The PACT RN Care Manager will work with the PACT Team to let (Primary Care Provider, LVN, Clerk) to address the Veteran’s care need(s).

====HOW DOES PACT TOOL WORK?====
* The flow depends on if patient is assigned or unassigned

=====ASSIGNED PATIENTS=====
* Identify Patient’s PACT Team by looking at top banner in CPRS
[[File:Assigned patient.png|thumb|center|Finding WLA Clinic Assignment]]
* Providers enter a CPRS order indicating urgent or specific needs for post-EST follow-up care using link on EST order menu
[[File:Ed pact tool main.png|thumb|center|ED-Pact Tool Order]]
* Choose PACT Clinic AND then the team
[[File:ED PACT GOLD 2.png|thumb|center|Select Appropriate PACT Clinic]]
* '''Fill in and Sign Templated Order'''
** Under reason for request:
*** ''Check “Seen in COVID- 19 Enhanced Screening Tent (EST)”''
*** '''If you have clinical concern for potential COVID-19 (regardless of whether you sent test), check “Clinical concern for potential COVID-19”'''
*** Check other boxes to indicate follow-up care need
[[File:Order Template.jpg|thumb|center|Order Template]]

=====UNASSIGNED PATIENTS=====
* For patients without a GLA PACT assignment, with urgent or specific needs, use link “No PACT assigned at any VA location/no local PACT at bottom of ED-PACT Tool Menu.
* This link will direct you to the Primary Care Consult Menu.
** '''Select the clinic location closest to the Veteran’s residence.'''
**'''Place the primary care consult''' AND add the points of contacts for each clinic (listed on the primary care consult menu) as additional signers on your EST note.
[[File:Additonal signer PC.png|thumb|center|Unassigned Patients, PC Consult, and Adding Additional Signer]]
[[File:PC Consult.png|thumb|center|Primary Care (PC) Consult]]

===MANAGEMENT ALGORITHMS===

====SUGGESTED MANAGEMENT ALGORITHM FOR PATIENTS PRESENTING TO EST====
* '''Is patient ambulatory?'''
** YES -> Go to next step
** NO -> Go to ED
* '''Is patient obviously sick appearing (i.e., in severe pain, visibly tachypneic, somnolent, diaphoretic, etc.)?'''
** YES -> Go to ED
** NO -> Go to next step
* '''Check focused vital signs:'''
** ''HR >110, SBP < 100, RR> 25 SaO2 < 94%''
*** YES -> Send to ED with warm handoff
*** NO -> Go to next step
* '''Does patient have a fever AND...?'''
** ''Fever alone is not a reason for ED evaluation if the patient is well appearing, is able to care for self and has no obvious finding suggestive of serious bacterial illness or SIRS criteria.''
** ''Does patient has a fever AND:''
*** ''meets SIRS criteria or has acute/new significant dyspnea or has chest pain or is unable to care for self or has obvious signs of serious bacterial illness (abdominal pain, pyelo, cellulitis, etc).''
**** YES -> Send to ED with warm handoff or consider ED consult
**** No --> go to next step
* '''Does patient meet "Wild Card" criteria?'''
** ''Wild Card = Patient with a high-risk co-morbidity (Immunocompromised, Age > 75 years, significant lung or heart disease history, active malignancy)''
*** YES -> consider ED consult
*** NO -> Go to Step 6
* '''Significant ''acute/new'' shortness of breath that affects activities of daily living?'''
** No -> Treat empirically and discharge home with urgent f/u
** Yes -> consider ED consult

===EMPLOYEE HEALTH ALGORITHM===
* We are testing '''symptomatic employees''' (and a select few asymptomatic) with a history of exposure to COVID19 for COVID19 if they are involved in '''direct patient care''' as it will guide our return to work instructions.
* '''Please provide all employees with EH handout at discharge.'''
** If '''employee was tested for COVID-19 in EST''' they must be '''instructed to not go back to work''' until they are cleared by EH.
** If '''employee was not tested for COVID-19''', they must '''speak to EH and their supervisor''' to discuss sick leave and return to work timeline.
* Employee Health (x53522).

====EMPLOYEE COVID-19 TRIAGE ALGORITHM====
'''Last Updated: 4/16/20'''
[[File:68497152-DD2F-46F8-8D54-14057FB8CFAB.png|thumb|center|Employee COVID-19 Triage]]

====EMPLOYEE EXPOSURE RISK DETERMINATION ALGORITHM====
'''Last Updated: 4/17/20'''
* Reviewing the exposure risk algorithm shows that this simple intervention keeps exposure risk low to medium.
** Second layer of defense is ensuring that you wear a face mask (NOT N95).
[[File:Screen Shot 2020-04-17 at 8.20.52 PM.png|thumb|center|nterim Guidance at GLA during regular staffing mode for ASYMPTOMATIC employees WITH PROLONGED CLOSE CONTACT with a COVID-19 patient]]
[[File:08B718CA-9CB2-48A8-9633-8BDA4F095449.jpg|thumb|center|Supplementary Appendix]]

===EMPLOYEE RETURN TO WORK GUIDANCE===
'''Last Updated: 4/17/20'''
[[File:Screen Shot 2020-04-17 at 8.21.13 PM.png|thumb|center|Return to Work Guidance for Staff with Direct Patient Contact]]

==EDUCATIONAL MATERIALS==
* [https://www.blog.numose.com/emed-basics/sick-not-sick Medical Screening Exam (Sick vs Non-sick)]
* [[:File:Back Pain EST.pdf]]

==OTHER WLA VA PAGES==
* [[WLAVA:COVID19_ED_Operational_Updates|WLAVA: COVID19 ED Operational Updates]]
* [[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

{{Special:Prefixindex/WLA VA: |hideredirects=1}}

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:19:28Z

Jochickabee: /* COVID WORKFLOWS GENERAL INFORMATION */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===♦♦♦UV Sterilization 4/24/20===
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

===♦♦♦PAPR Cleaning 4/24/20===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent Dispo Tool 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOW GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:17:59Z

Jochickabee: /* ENHANCED SCREENING TENT (EST) REMINDERS */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===♦♦♦UV Sterilization 4/24/20===
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

===♦♦♦PAPR Cleaning 4/24/20===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent Dispo Tool 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Tent Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:17:17Z

Jochickabee: /* ♦♦♦Tent Dispo Tool (UPDATED) 4/26/20 */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===♦♦♦UV Sterilization 4/24/20===
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

===♦♦♦PAPR Cleaning 4/24/20===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent Dispo Tool 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Ten Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE Link ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:16:50Z

Jochickabee: /* ENHANCED SCREENING TENT (EST) REMINDERS */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===♦♦♦UV Sterilization 4/24/20===
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

===♦♦♦PAPR Cleaning 4/24/20===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent Dispo Tool (UPDATED) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====Ten Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent Remote SKYPE Link ====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:15:38Z

Jochickabee: /* PPE REMINDERS */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

===3M 8000 N95 Fit Testing===
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

===♦♦♦UV Sterilization 4/24/20===
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

===♦♦♦PAPR Cleaning 4/24/20===
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

====Mask Guidance====
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Symptoms Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====TENT (EST) Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT (EST) GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT (EST) MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent SKYPE Link (Remote Accessible)====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:14:45Z

Jochickabee: /* COVID WORKFLOW REMINDERS */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

====3M 8000 N95 Fit Testing====
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

====♦♦♦UV Sterilization 4/24/20====
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

====♦♦♦PAPR Cleaning 4/24/20====
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

===Mask Guidance===
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Symptoms Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====TENT (EST) Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT (EST) GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT (EST) MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent SKYPE Link (Remote Accessible)====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====COVID Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:13:48Z

Jochickabee: /* PPE REMINDERS */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

====3M 8000 N95 Fit Testing====
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

====♦♦♦UV Sterilization 4/24/20====
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

====♦♦♦PAPR Cleaning 4/24/20====
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

===Mask Guidance===
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Symptoms Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====TENT (EST) Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT (EST) GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT (EST) MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent SKYPE Link (Remote Accessible)====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:13:14Z

Jochickabee: /* PPE REMINDERS */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

====3M 8000 N95 Fit Testing====
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

====♦♦♦UV Sterilization 4/24/20====
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

====♦♦♦PAPR Cleaning 4/24/20====
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

===Mask Guidance===
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

====Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Symptoms Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====TENT (EST) Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT (EST) GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT (EST) MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent SKYPE Link (Remote Accessible)====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:12:46Z

Jochickabee: /* PPE REMINDERS */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

====3M 8000 N95 Fit Testing====
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

====Mask Decon & ♦♦♦UV Sterilization 4/24/20====
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

====♦♦♦PAPR Cleaning 4/24/20====
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

===Mask Guidance===
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

====Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Symptoms Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====TENT (EST) Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT (EST) GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT (EST) MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent SKYPE Link (Remote Accessible)====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:12:02Z

Jochickabee: /* AIRWAY REMINDERS */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Videos====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol/Airway/Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

====3M 8000 N95 Fit Testing====
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

====Mask Decontamination & ♦♦♦UV Sterilization Technique 4/24/20====
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

====♦♦♦PAPR Cleaning 4/24/20====
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

===Mask Guidance===
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

====Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Symptoms Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====TENT (EST) Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT (EST) GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT (EST) MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent SKYPE Link (Remote Accessible)====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:11:19Z

Jochickabee: /* Mask Guidance */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage 4/22/20====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Video 4/22/20====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol aka Airway or Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

====3M 8000 N95 Fit Testing====
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

====Mask Decontamination & ♦♦♦UV Sterilization Technique 4/24/20====
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

====♦♦♦PAPR Cleaning 4/24/20====
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

===Mask Guidance===
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

'''Patient Encounter Scenarios & Recommended PPE'''
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

====Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Symptoms Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====TENT (EST) Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT (EST) GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT (EST) MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent SKYPE Link (Remote Accessible)====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:10:18Z

Jochickabee: /* AIRWAY REMINDERS */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage 4/22/20====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Video 4/22/20====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Aerosol aka Airway or Intubation Box====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

'''Daily Airway Cart Log
'''* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

====3M 8000 N95 Fit Testing====
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

====Mask Decontamination & ♦♦♦UV Sterilization Technique 4/24/20====
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

====♦♦♦PAPR Cleaning 4/24/20====
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

===Mask Guidance===
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

====Patient Encounter Scenarios & Recommended PPE====
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

====Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Symptoms Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====TENT (EST) Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT (EST) GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT (EST) MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent SKYPE Link (Remote Accessible)====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:08:59Z

Jochickabee: /* GLA WEBSITES */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage 4/22/20====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Video 4/22/20====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Daily Airway Cart Log====
* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

====Aerosol aka Airway or Intubation or Plexi-BOX====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

====3M 8000 N95 Fit Testing====
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

====Mask Decontamination & ♦♦♦UV Sterilization Technique 4/24/20====
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

====♦♦♦PAPR Cleaning 4/24/20====
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

===Mask Guidance===
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

====Patient Encounter Scenarios & Recommended PPE====
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

====Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Symptoms Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====TENT (EST) Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT (EST) GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT (EST) MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent SKYPE Link (Remote Accessible)====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

'''Emergency Alerting & Accountability System (EAAS)'''
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:08:27Z

Jochickabee: /* Other WLA VA Pages */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage 4/22/20====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Video 4/22/20====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Daily Airway Cart Log====
* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

====Aerosol aka Airway or Intubation or Plexi-BOX====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

====3M 8000 N95 Fit Testing====
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

====Mask Decontamination & ♦♦♦UV Sterilization Technique 4/24/20====
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

====♦♦♦PAPR Cleaning 4/24/20====
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

===Mask Guidance===
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

====Patient Encounter Scenarios & Recommended PPE====
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

====Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Symptoms Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====TENT (EST) Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT (EST) GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT (EST) MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent SKYPE Link (Remote Accessible)====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

===Emergency Alerting & Accountability System (EAAS)===
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

'''WLA VA COVID19 Page Listing'''
{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]

WLAVA:COVID19 ED Operational Updates

2020-04-27T03:07:26Z

Jochickabee: /* Other WLA VA Pages */

*'''Last Updated 4/26/20'''

♦♦♦XXX = New Information (w/in 3 days) with Update Date
==♦♦♦BREAKING NEWS 4/26/20==
'''CEPHEID SHORTAGE'''
* We are running low on CEPHEID swabs
* Be very conservative on usage until we receive our next shipment.

'''COMPELLED TESTING'''
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
* After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.

'''CEPHEID ORDERING CRITERIA'''
* YES
** All admissions provided there are beds available (If likely to be boarding >24 hrs, order LB test instead)
** Disposition problems e.g. Transfers to another facility, holding up dispo to SNF. Please use your judgement with this and only if it will truly affect disposition. If this is used too liberally, we may have to scale back since we still have limited tests.
* NO (NOT YET)
** ED observation patients
* CEPHEID results are required prior to bed assignment, EXCEPT for high risk PUIs,
* Order the test as early as possible for timely results
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

'''HOW TO ORDER THE CEPHEID (Rapid)'''
* Go to COVID WORKFLOW section below.

'''COVID (LB) TESTING FOR HIGH-RISK PATIENTS'''
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
*[http://publichealth.lacounty.gov/acd/nCorona2019/test.htm LA County Testing Recommendation 4.22.20]
** Symptomatic Patients 65 years and Older
** Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

==AIRWAY REMINDERS==
====Glidescope Go '''S4 Blade''' Shortage 4/22/20====
* There is a shortage of Glidescope S4 blades.
*We only have 4 left in Jonie's office and a few in the airway cart and glidescope go bag.
* Please use the S3 blades instead so we can preserve the S4s for those who need them.

====Securing Airway Tube Video 4/22/20====
* Zahir and Derrick created a video on how to secure the airway tube
* If you have not done it, it's very difficult to do by yourself- so try it and please review videos.
* BASIC TECHNIQUE TO TEMPORARILY SECURING AN ET TUBE
{{#widget:YouTube|id=dMARECkwt7s}}

* SECURING AN ET TUBE WHILE USING AN AIRWAY BOX
{{#widget:YouTube|id=_CBRZfse9Hs}}

* DEMONSTRATION OF USING A PONCHO WHILE INTUBATING
{{#widget:YouTube|id=JP7V6pb9new}}

====Daily Airway Cart Log====
* The COVID Airway Shift Attending must check the Airway Carts x2 and new red Airway Box in the med room every day.
* The DAILY “Sign-off Log” and the “Item Checklist” are on separate clipboards on '''top the Airway Cart'''.
* Best practice is to refill the cart after an intubation because you know what is missing.
* This daily log is a double check / insurance.
* You also need to check that the COVID medication bags medications are NOT expired.
[[File:clipboard.jpg|100px]]
[[:File:Airway Cart Box Item Checklist_042020.pdf|COVID Airway Item Checklist]]

'''Restocking Cart'''
* If you need to restock the airway cart, most of the items should be available in the med room (bunny suits, hoods, etc.)
* However, if we are out (because Derrick and Miguel have been primarily stocking these), they would be in the med room or Jonie’s office (requires 404 key, which the majority of the nurses should have).

'''Airway Red Box in Med Room'''
* Stored in Med Room
* Check Daily (3 essential items)
** Glidescope Go ('''CHECK BATTERY''')
** Grab and Go Bag (gather items from the Yellow duffel bag)
** COVID Medication Bag
[[File:red box.jpg|100px]]

====Aerosol aka Airway or Intubation or Plexi-BOX====
* Stored in the Doctor's station.
* This is available for use and is not mandatory.
** Added layer of protection (giant splash guard).
* We recommend you practice using it on simulation dummy before deploying for COVID19 airway.
* Bed 4 has intubating manakin for you to practice.

'''Suggested Workflow for Airway Box'''
*Remember to put what you need inside the box before intubating:
** BVM with HEPA filter, suction, vent tubing, glidescope, tube, tape to secure tube.
* You have the option of draping the other end (extra drapes available on the counter along with tape)
* After securing tube, attache the viral filter/BVM OR continuous capnometry if you have that set up.
* 2nd person (likely RN) will need to bag the patient with viral filter or connect directly to vent.
* Lift the box from the patient and leave it in the room for at least 30 minutes over sink (to allow aerosols to clear) then retrieve for cleaning.
[[File:box sink.jpg|100px]]
* Sterilize after use with germicidal wipes thoroughly and allow it to dry.
** Buddy can clean this along with glidescope. Should wear full PPE.

===AIRWAY GENERAL INFORMATION===
* '''Treat All Intubations as PUIs:'''
** It is up to your discretion if you want to PAPR vs N95
*** please wear the recommended level of PPE GLA ID recommends for aerosolizing procedures.
** Please remember to document your PPE in CPRS note.

*'''See [[WLAVA:COVID19 ED Airway|Airway Page]] for detailed ED attending airway duties:'''
** '''Anesthesia covers all inpatient airways including ED COVID airways from 7a-7p.'''
** '''Anesthesia can be called for impending COVID airways if 2 hours notice can be given.'''
** '''ED Attending Airway Responsibilities:'''
*** Write an '''Intubation Note''' in CPRS
*** Please hand off the pager to the responsible Intubating attending as below
*** Airway Team should restock cart and medications after each use
*** Report anything missing to Derrick, Miguel and COVID champions

* '''ED COVID Airway Team:'''
*** '''Afternoons:''' Intubating 4P-MN Main ED; Buddy 4P-MN FT
*** '''Overnight:''' Intubating COVID 11P-7A; Buddy MN-8A (11p-7A ok)
*** '''Weekends:''' Intubating COVID 7a-7p and 7p-7a; Buddy ANY available attending (for continuity MN-8A preferred)

===AIRWAY MAIN PAGE===
[[WLAVA:COVID19_ED_Airway|WLAVA: COVID-19 ED Airway Main]]

==PPE REMINDERS==

====3M 8000 N95 Fit Testing====
* EVERYONE needs to be fit tested for the N95 8000s as these will be the ones handed out. Next fit test dates are:
** Monday 4/27/20 6:30-11:30, building 500 Rm 3232
*** Please complete questionnaire online if you have not done it within the past year.
*** URL: http://respiratormedicalevaluation.com

====Mask Decontamination & ♦♦♦UV Sterilization Technique 4/24/20====
* SPS is no longer collecting masks. Discard the 8000 N95 respirators.
* Save 1860s/1870s for future use as long as they weren't used for code/intubation.
** Use paper bag method x wait 5 days, 5x max.
* UV Sterilization Technique 4/24/20
** Not institutionally advised and use at your own risk.
** The UVC machine on the top shelf in the med room would require '''9 min 30 secs''' to sterilize anything that is put inside if you choose to use it. (Thanks to Miguel for figuring this out)

====♦♦♦PAPR Cleaning 4/24/20====
* After an intubation or CODE with PAPR use, '''remind the charge nurse to call SPS to pick it up for cleaning.'''
* Placing PAPR in the dirty utility room, on the cart instead of the floor. It may be assumed to be trash if on the ground.
* If SPS is not called, PAPR may not be cleaned for days and has a high chance of getting lost.
* If restocking Airway carts and there are no more PAPRs left in the Med Room, notify the ED Nurse Managers or COVID Team.

===PPE GENERAL INFORMATION===

===Mask Guidance===
** 1860 and 1870 N95 respirators are being distributed only to the OR and Procedure Center.
** ED is receiving only 3M 8000 N95 respirators.
** We have very very few 1860/1870 left for the entire ED (MDs, RNs, ICTs, etc).
*** We will not be resupplied with 1860/1870s.
** Remind consultants that 8000s are N95 respirators and this is an ID guideline.
*** They can request an 1860s/1870s is if they failed formal fit test for 8000s.

'''What Mask Should I Wear?'''
*'''PAPR:'''
** Provider intubating. Nursing as per their leadership recommendations.
* '''3M 8000 N95 Respirator:'''
** All providers working in the ED who passed fit testing.
*** Airway buddy.
*** Personnel seeing PUIs.
*** Nurse performing NP swab.
*** CODES or intubations.
** No need to wear a surgical mask over these.
*** Can discard with every PUI. Can continue to wear between non-PUI to non-PUI.
* '''3M 1860/1870 N95 Respirator:'''
** Providers that failed formal 8000 N95 fit testing.
** Wear a surgical mask over this and discard surgical mask with every PUI.
** If used for a CODE or Intubation, discard the N95.
** If used daily because you failed 8000 N95 fit test, consider saving these using paper bag method.

====Patient Encounter Scenarios & Recommended PPE====
[[File:06B68CDD-1AD2-4390-8044-22D7FC1A4DEB.jpg|thumb|center|Patient Encounter Scenarios and Detailed PPE]]

'''For Patients '''WITH''' COVID-19 Isolation Precautions'''
[[File:DBB5C750-02D7-4CA3-B085-80ECD361D51C.png|thumb|center|Donning and Doffing Guidance for Patients w/COVID-19 Isolation Precautions]]

'''For Patients '''WITHOUT''' COVID-19 Isolation Precautions'''
[[File:ABDFBBCB-FADB-4295-9CA0-3A5BD6EC916D.png|thumb|center|Donning and Doffing Guidance for Patients w/o COVID-19 Isolation Precautions]]

====Device Cleaning====
* If you cannot find Sani Cloth AF3 (grey top), here are alternate ways to clean devices
**'''Glidescope:'''
*** Super Sani-cloth (Purple top)
*** Contact time: 2 minutes
** '''Ultrasound (new): Sonosite EDGE II:'''
*** Monitor: Alcohol
*** Transducer: Bleach wipes (leaves residue)
** '''Ultrasound (old): Turbo:'''
*** Monitor: Alcohol
*** Transducer: Super Sani-cloth (purple top)
** '''Reference document on approved disinfectants:'''
*** [[:File:APPROVED_20200408.1200_Disinfectants.pdf]]

===PPE Main Page===
*Check out Page below for PPE including PAPR Donning/Doffing Protocols and Videos
[[WLAVA:COVID-19_PPE|WLA VA PPE Main Information Page]]

==ENHANCED SCREENING TENT (EST) REMINDERS==

===♦♦♦Tent (EST) Dispo Tool (UPDATED!) 4/26/20===
*Please see the EST Provider Disposition Tool that Manny created
https://uclahs.az1.qualtrics.com/jfe/form/SV_6WFnqOMheo6QakB
*This decision making tool helps the Tent provider decide on patient disposition and follow up. Please disseminate to tent providers.

====Employee Symptoms Self-Referral Tool====
* Employee self-referral tool helps employees decide how to best manage their symptoms, when they can return to work, and when to get tested for COVID-19.
* We can use this tool, but mainly to assist other employees.
** Please use and distribute this so that people can present to the correct location (Employee Health, Tent, or ED) and so they know how to correctly self-triage their symptoms/exposures.
*[https://uclahs.az1.qualtrics.com/jfe/form/SV_2o7OzYIPa2HRpE9 GLA VA Employee Symptom Self-Referral Tool]

====TENT (EST) Consults====
* '''When the tent calls you in the ED it is NOT a curbside.'''
** You are responsible for this patient moving forward.
** Your options are to see the person virtually (Skype Video) or go to the Tent.
** You can write an addendum to the EST note OR a new note e.g. EST Provider note or ED Attending note
* For the the EST Provider Note you can cancel out of template and port over your own template.
* Your name will be added as co-signer to the note written by the Provider in the Tent (for QI tracking purposes).
* Verify COVID Screen for patients referred from the Tent
** Testing is still limited; many COVID possible patients will NOT receive testing

'''Screening & Testing for COVID (Tent EST Referrals)'''
*The Tent is being staffed primarily by Non-EM providers including dental residents.
*For patients referred from the Tent to the ED, please double check if the patient meets criteria for COVID testing.
*The Tent providers, esp. dental residents, are really trying their best!
*In addition, please consider that patients who screen positive for COVID symptoms in the Tent, may not receive testing- but they may still have COVID, e.g. healthy patients with URI
*Please review GLA testing guidelines for COVID located on WiKEM below.

===TENT (EST) GENERAL INFORMATION===
* '''EST open M-F 7a-11p''' &'''Sa-Su 10a-10p'''
**[https://dvagov.sharepoint.com/sites/VHAGLACOS/Lists/COVID19%20Staff%20Redeployment%20Calendar/calendar.aspx EST Schedule (WLA Intranet Only)]
**'''Weekday 4p-mn FT''' (covers 4p-11p) and '''weekend FT''' (covers 10a-5p)
**'''Weekend main ED 7p-7a''' attending (covers from 5p-10p)
* Please check in with the EST nurses at the start of your shift and leave them your name (so they can reach you by Vocera).
* Refer to Telehealth Page about how to use SKYPE to speak to Tent Staff
*** [[WLAVA:Enhanced Screening Tent Telehealth]]

===TENT (EST) MAIN PAGES===
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth]]

====Tent SKYPE Link (Remote Accessible)====
https://meet.rtc.va.gov/jonie.hsiao/3MOQ53I5

==COVID WORKFLOW REMINDERS==

=== CEPHEID Testing ===
*CEPHEID results are required prior to be d assignment, EXCEPT for high risk PUIs.
* Order the test as early as possible for timely results.
* If not available, likely revert back to previous routine test (surveillance( practice. Discuss with ED charge OTS/ MOD decide on isolation status. Contact COVID champion if needed.

==== Isolation for PUIs ====
* For high risk PUIs, isolate the patients even if COVID is negative. Let the admission team decide if isolation should be removed.

==== How to Order CEPHEID (Rapid) Test ====
* The CEPHEID test is a "secret order" in the ID Menu
* Click the asterisks x 3 *** (see below)
** WLA Outpatient Clinic Order Menu
** Infectious Disease Clinic
** Left hand side-- Scroll Down find and Click " *** "
** Unnamed.png

==== ♦♦♦COVID (LB) Testing for High-Risk Patients 4/23 ====
* Can consider ordering LB (Long Beach/routine) testing (not CEPHEID) in high risk patients you are discharging home. As per LA DPH Guidelines.
* LA County Testing Recommendation 4.22.20
* Symptomatic Patients 65 years and Older
* Symptomatic Patients with high risk underlying conditions such as chronic lung disease, serious heart conditions, immunocompromised, severe obesity (BMI>40), diabetes, dialysis, liver disease
* Make sure you use the ED-PACT tool to request PCP follow up on test results.

====COVID Admissions 4/20/20====
* Back to MICU 4/20- and on

====Patients Refusing COVID19 Test====
* If a psych patient is refusing a swab, DO NOT try to force them to get it done.
** This could endanger the staff.
* Medical Director (Dr. Braverman) believes that compelled testing is necessary in patients who are refusing swabs.
** After doing everything you can (de-escalation, etc) with patient, please notify one of us for further action.
** May need to admit to medicine, w/ isolation precautions, until a swab can be obtained.

===COVID WORKFLOWS GENERAL INFORMATION===
====♦♦♦COVID-19 Quick Guide 4/24/20====
*[[:File:COVID-19 Quick Guide.022420.pdf]]

*'''Last Updated: 4/24/20'''
[[File:Screen Shot 2020-04-24 at 12.53.02 AM.png|thumb|center|COVID Quick Guide Approach to Stable Patients]]

====Patients with Possible COVID-19 Home Aftercare====
* For patients discharged with possible COVID:
** Please clearly inform them that regardless of the decision to test for COVID, they could still have the disease. Therefore, they will need home isolation instructions.
** Printouts of the LA County handout: "Home Care Instructions for People with Respiratory Instructions" are available in the wire rack next to the residents.
** A copy is uploaded on the Sharepoint under "ED Common Resources"
[[File:COVID POSS-1.png|thumb|center|LA County URI / Possible COVID Handout]]
** Please distribute this and document you did so in the chart.
** Use the ED PACT tool for f/u for these patients
[[File:Ed-pact covid.png|thumb|center|ED-PACT Tool: Checkbox Clinical Concern for Covid]]

====WLA VA ID COVID-19 Testing Algorithm 4/23/20====
* '''Please review algorithm below to determine if your patient meets criteria for COVID-19 testing.'''
[[File:Screen Shot 2020-04-24 at 12.50.10 AM.png|thumb|center|WLA VA ED & Tent Testing Algorithm]]
* Reference file ('''for printing'''):
[[:File:COVID19 WLA Tent algorithm updated 4.23.20.pdf]]

====How to Place Patients on Isolation Precautions====
* '''Please have a low threshold to place patients on isolation for COVID-19.'''
# '''Start a new note:'''
[[File:Start new note.jpg|thumb|center|Start New Note]]
# '''Type in 'Isolation Note:''''
[[File:Isolation note.jpg|thumb|center|Isolation Note]]
# '''Select Enhanced Droplet Precautions for COVID-19 patients:'''
[[File:EDP.jpg|thumb|center|Enhanced Droplet Precautions]]
# '''Once you finish the isolation note template, go to 'Orders' menu and sign the isolation order:'''
[[File:Iso order.jpg|thumb|center|Isolation Order]]

====Coding COVID-19 Encounters====
* '''For Suspected or Exposure to COVID19 or Exposure:''' Z20.828
* '''For Confirmed COVID19:''' B97.29
* Other suggested ICD10 codes include (but not limited to):
** Acute Upper Respiratory Infection, J06.9
** Cough, R05
** Viral Infection unspecified, B34.9
**Fever unspecified, R50.9

==EDUCATION/SIMULATION REMINDERS==
===Mock CODE Drills===
* If you are having a slow shift, please use the time to run a mock code drills to ensure our all staff are well prepared.
* COMMUNICATION is the most challenging part of these scenarios:
** "Quiet voices" within INSIDE team while RN1 is the main communicator with charge RN (just need to practice this)
** Baby monitor or Vocera seem to be best
* Practice doing each role: MD1, MD2, Leading drill/observer; have the nurses also practice roles they haven't tried yet as well
* Be very familiar with Airway COVID cart/and box.

====CODE General Info====
* NRB hanging in front of beds 6& 7 (please replenish if used)
* LUCAS now available-->RN1 and RN2 in room while ICT/NA fully DONNED outside
* RN2 to PAPR if preferred (will be more available to assist MD with intubation/give meds)
* Will add EPI laminated sign to COVID cart
* If patient coming through EMS-MD fully donned meet them at the entrance to assess situation (if time allows)
* '''Reference Documents:'''
** [[:File:ED COVID CODE Protocol_033020.pdf]]
** [[:File:COVID Practice Drills 4.0.pptx]]

===SIM Lab Training===
* Email Cindy Koh, Carol Lee or Sabrina Tom if you have not been signed off on airway PPE donning and doffing simulation.

===FIT Testing===
* To clarify, you need to be FIT tested yearly at each facility you work because the brand and type of mask may be different. Your face may change shape with age/weight/pregnancy etc...

* FIT Testing Sessions:
** Please complete online form prior to testing:
***URL: http://respiratormedicalevaluation.com
***Organization Code: vala

==ADMINISTRATIVE REMINDERS==

====Shift Swaps====
* Scott Jacobs is managing all scheduling edits through June.
** Please email him directly with any proposed swaps.

====UCLA Badges & Mednet E-mail Account====
* For Full-time faculty: How to apply for UCLA badge and mednet email address
** Slack: [http://gla-va-em.slack.com gla-va-em.slack.com]
***Under the left sidebar, you will see ucla-va-faculty-appointment-faq

====MS Office and Free Apps====
*We get discounted Microsoft Office from the VA. Follow the link and an email will be sent to your work VA email.
**[https://www.microsoft.com/en-us/home-use-program?culture=en-US&rtc=1 Microsoft Home Use Program (HUP)]

*For full time faculty with a mednet email, we can get free zoom, box, Qualtrics, and office 2016.
**[https://it.uclahealth.org/article/services-available-all-mednet-users UCLA IT Mednet Applications]

[[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA:COVID19 ADMINISTRATIVE]]

==MISCELLANEOUS REMINDERS==
===VA Scrubs===
* Please see COVID-19 Update #15 email 'Scrubs' MS Word document for details on how to access ScrubEX.
* It took some effort but we finally secured '''enough scrubs to cover all ED/FT provider shifts each day.'''
* However, we have to make sure to '''return them at the end of each shift.''' If you do not return it then that means the provider coming in after you will not have scrubs.

===GLA Showers===
* No Lockers - Bring your own towel/clothes
** [https://thewirecutter.com/reviews/best-packable-camp-towels/ Wirecutter best packable camp towel]
* Ground Floor (Basement):
** Women’s Locker Room: Rm 0435 passcode 2169
** Men’s Locker Room: Rm 0403 passcode 2168
* 5th Floor (OR Showers):
**Women’s Locker Room: Rm 5076 passcode 5324
**Men’s Locker Room: Rm 5075 passcode 5321

===Alternative Housing for Staff===
* The Fisher house is available for those who are interested and need housing options away from family.
* Please contact Neil if interested and include exact dates and details.
**Preference to Distance > DEMPS > Risk at home > # Consecutive shifts.

===UM Review===
* Use ‘UM Review’ label on EDIS to communicate with UM.
** Here are ways to contact UM if you have questions:
*** VA cell: 626 314 9774
*** VA Pager *11 p73284

===Donations (PPE/Food Etc.)===
* Please contact Alexia Lunningham, Chief of Voluntary Services at (310) 268-4350 or alexia.lunningham@va.gov to coordinate.
[[:File:VA COVID-19 Donation Form 4-2020.pdf]]

==GLA WEBSITES==
===COVID-19 ED Sharepoint===
*Links to GLA COVID19 documents and resources (https://dvagov.sharepoint.com/sites/VHAGLAMed/ed/default.aspx)

===COVID-19 VA Cases Nationally===
https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

===Emergency Alerting & Accountability System (EAAS)===
* If you wish to receive alerts from the VA EAAS (https://alerts7.athoc.com/SelfService/VAEAAS)
* Any issue please contact Lonnie Miller at x40863

==Other WLA VA Pages==
* [[WLAVA:COVID19_ED_Airway|WLAVA: COVID19 ED Airway Main]]
* [[WLAVA:COVID-19_PPE|WLAVA: COVID19 PPE Main Information Page]]
* [[WLAVA:Enhanced_Screening_Tent|WLAVA: Enhanced Screening Tent]]
* [[WLAVA:Enhanced_Screening_Tent_LIP_Orientation|WLAVA: EST Provider Orientation]]
* [[WLAVA:Enhanced Screening Tent Telehealth|WLAVA: Enhanced Screening Tent Telehealth]]
* [[WLAVA:_COVID19_ADMINISTRATIVE|WLAVA: COVID19 Adminastrative]]

{{Special:Prefixindex/WLA VA: |hideredirects=1}}

[[Category:Admin]]