WikEM - User contributions [en]

Harbor:Infectious Disease Threats

2020-04-06T19:40:12Z

Jtolles: /* Harbor Checklists */

==Coronavirus ([[COVID-19]])==
;See [[COVID-19]] for non-Harbor-specific information; please feel free to contribute to the further development of these pages''

===COVID physician leads===
*AED Flow/Discharges- Andrea
*Drug/Non-PPE Shortages - Andrea
*Non-Emergency Physicians in the Emergency Department - Mike
*Homeless Issues - Dennis
* Airway-Ryan
*Environmental Services/Cleaning Protocols- Moh
*Triage/Fast Track Tents - Brad
*Email Updates - Andrea
*Pediatric Schedule - Kelly
*PPE - Shira
*EMS - Shira
*Palliative Care/End-Of-Life Issues - Tim J.
*ACLS - Shira
*COVID Testing - Mike
*Transfers to Mercy Ship – Denise (Currently only for inpatients with non-respiratory issues and negative Covid test)
*Attending scheduling for Adult ED – Manny
*PED issues - Patricia

===COVID Terminology===
*“Pink”
**respiratory complaint/Not PUI
**Need droplet/contact PPE
**pink wrist bands = need mask.
*“PUI”
** Meet DHS Testing Criteria (See below)

*Disaster track categories
**The router will place initial category,
**Ask nurse to change as necessary (can use communication order)
***Categories
****COVID EXPOSURE – no symptoms but at risk
****COVID FT – ILI symptoms (Cough, fever or SOB)
****COVID AED – not PUI but too complicated for quick dispo
****COVID PUI – meet DHS testing criteria

===Latest Updates===
*A&B/RSV RT-PCR order is replaced with “COVID-19 Test Request” on 4/3/2020.

===Harbor Checklists===
* Bedside checklist: [[:File:Harbor COVID checklist v3-21-20.pdf]]
* Additional DPH Guidance: http://publichealth.lacounty.gov/acd/nCorona2019.htm
* HARBOR ID UPDATES https://lacounty.sharepoint.com/sites/dhs-harbor-inf_prev_ctrl/SitePages/Breaking-News-and-Other-Disease-Information.aspx
*DHS Covid Sharepoint https://lacounty.sharepoint.com/sites/DHS-COVID19/ExpectedPractices/Forms/Newest%20on%20Top.aspx
*Seattle ICU doctor's one page info on mgmt of COVID from ACEP website [[:File:COVID19 seattle one pager.pdf]]
*Harbor DEM COVID airway management guide [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
*Proper donning and doffing with reusable goggles and stethoscope [[:File:Procedure for Reuse of Faceshields and Goggles 3-19-2020.pdf]]
*Summary of Harbor consensus guidelines for COVID ARDS management [[File:Clinical Cheat sheet.pdf|thumb]]

===Triage===
*PUI going direct to room - do not order triage labs
*PINK wristband = mask + respiratory area if in waiting room

===DHS PUI Testing Criteria 3-23-20===
*Nurses will put everyone '''suspected''' of meeting PUI in a room in droplet precautions
*ED Attending will determine if patient meets definition
#Fever '''AND''' (cough '''OR''' shortness of breath '''''AND''''' NOT requiring hospitalization). Must be '''MEASURED''' fever in ED or at home (>100.4 F/38.0 C) '''''AND''''':
## healthcare worker '''''OR'''''
## works or lives in group environment (SNF/group home/rehab center/jail) '''''OR'''''
# Symptoms of Acute Respiratory Infection (New cough ''''OR'''' new Shortness of Breath. No fever required) '''''AND''''' REQUIRING HOSPITALIZATION '''''without an alternative diagnosis''''' (positive blood culture, cavitary lesion, chronic (>14d))
#'''''CONSIDER''''' testing ONLY if it will change management for:
## age>65 with chronic medical conditions (heart or lung disease)'''''OR'''''
## immunosuppression (includes prednisone>20mg daily)

** ID is available 24/7 if you are unclear if they meet PUI criteria

===Commercial testing (Quest or UCLA) for PUI criteria above===
'''NO LONGER NEED FLU TEST, flu season is over'''.
*PROCEDURE
**Order COVID-19 test from Covid Order Set.
**If Flu/RSV consider excluding COVID
**Complete both:
***"Harbor UCLA's Laboratory Miscellaneous Lab Form"[[:File:Laboratory Miscellaneous Request Form.pdf]]
***UCLA's lab request form [[:File:HARBOR UCLA UCLA BURL CUSTOM 032720.pdf]]
**Specimen must be walked up to the lab
*'''If Testing, Send out the batch text (p9699)'''. Please include:
** '''Patient Name''',
**'''MRUN'''
**'''Location''' (e.g. "AED Room A12")
**If "Consult to COVID Tracking" order Write "FYI" in callback field. Does not result in a callback.
==
*'''Follow Up of Test Results for Discharged Patients'''
*** AED patients: '''''Lab Follow-up - HAR''''' (like UCx and STI's)
****DHS empaneled patients: '''''message the provider'''''
*** PED patients: '''''Peds - HAR/USC''''' (the usual laboratory follow up procedure may be followed)
****DHS empaneled patients: '''''message the provider'''''
**Do not rely on Public Health to follow up test results

===Discharge===
*Homeless patient with mild symptoms that could be discharged,
**Placement
***Call SW early
***DPH call center (833-596-1009) 8a-6p every day
****Helps with transportation
****Need pending Covid test
****Must be able to perform ADLs

===Airway Management===
*'''Airway management''' [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
**Intubate early (consider if need 6L NC or more), use VL so you’re face is further away. Clean VL with grey wipes, observe 3 min wet time
**Location: negative room pressure preferred; if patient too unstable to move to negative pressure room, use single patient room
**Avoid BiPAP, high flow nasal cannula (HFNC), nebulizers
***Use MDI/spacer instead of nebs
***If needed HFNC with surgical mask over patient is preferred over BiPAP. Both require ''airborne precautions.''
***Viral filters should not be used with BVM or stocked in the airway carts, in order to preserve them for the transport ventilators
**Per CDC, do not treat with steroids (prolongs viral replication) unless for a secondary reason (ie, COPD)
**When intubating patients, for any unclear cases, wear N95, face shield, gown and gloves
***If using PAPR, then need pre-assigned RN outside the room to help decontaminate it by wiping it down with purple wipes before you take it off
**From Manny - We have an aerosol box approved and ready for us in trauma bay 1. Please remember to handle with care and more importantly, clean with bleach (orange) wipes after each use per infection control. This is a good tool to consider when you are intubating a PUI patient.
***Pre-oxygenate with NRB at 15L/min with surgical mask over vents and use apneic nasal cannula at 6L/min during intubation.
***Avoid using bag-valve-mask if possible
***If possible, directly attach patient to ventilator without BVM after cuff is inflated
***RSI to ensure paralysis. Consider higher range of dosing of paralytic to avoid patient coughing.
***Follow ARDSnet protocol, TV ~6ml/kg ideal body weight, high PEEP - http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

===Treatment Tips===
* Patient Presentation
**''Patient may have preceding GI symptoms prior to developing respiratory illness''
*'''Treatment'''
**Avoid steroids unless strong non-COVID indication
**Limited data on chloroquine or hydroxychloroquine
**Remdesivir via compassionate use for severely hypoxemic (Mechanical vent, high PEEP, FiO2 requirements >40%,).
*Any MDIs used in the ED to sent home with the patient instead of prescribing the patient another MDI and throwing the one used in the ED away. To do so, three simple steps needs to happen:
#Fill out a pre-printed rx sticker - available in English and Spanish with patient's name, the date, your name, patient's MRN. The stickers will be on the same clipboard as the logs (see #3 below) in each doc box.
#Put sticker on box for inhaler or inhaler itself and hand to patient
#Put patient sticker (or write patient name and MRN), your name, and circle drug given on the log. There will be a log in each doc box (purple, green, pediatrics).

==== Ventilator Management ====
* PRVC mode, initial tidal volume: 6-8 mL/kg of predicted body weight (link)
* If initial plateau pressure is persistently > 30 cm H2O, reduce the tidal volume by 1 mL/kg, until plateau pressure <30 H2O
* Goal: SpO2 88-96%: Adjust PEEP and FiO2 as per table below

{| class="wikitable"
|-
| '''FiO2''' || 0.3 || 0.4 || 0.5 || 0.6 || 0.7 || 0.8 || 0.9 || 1.0
|-
| '''PEEP''' || 12-14 || 14-16 || 18 || 18-20 || 18-20 || 22 || 22 || 22-24
|}

* If SpO2 <88% despite maximum FiO2 and PEEP on table above, intervene in the following order. If goal SpO2 is not achieved, proceed to the next step on the list.
** Prone the patient
** Observe for signs of dyssynchrony with the ventilator (e.g. initiating a new breath before full exhalation, coughing/auto-triggering). If present, first increase sedation to RASS of -4. If persistent, give single dose non-depolarizing paralytic (e.g. vecuronium 0.1mg/kg)
** Seek expert (MICU) consultation to place patient on APRV
** If above steps and MICU consultation fail to stabilize oxygenation of patient, V-V ECMO may be considered for select patients. Contact trauma attending to reach Dennis Kim.

====Antibiotics ====
* CAP treatment for intubated patients with ARDS per surviving sepsis guidelines

====Fluid resuscitation====
* For hemodynamically stable patients with ARDS, avoid fluid resuscitation
* For hemodynamically unstable patients with ARDS, consider small (500mL) fluid boluses and early norepinephrine

===PPE===
*“Special Precautions” are announced for an EMS patient and airway management pages, please ensure that all involved healthcare workers are wearing appropriate PPE.
*Recommendation for PPE [[:File:Guidance on precautions and masks for COVID-19_updated 3.25.20.pdf]]
**In general, wear surgical masks (ties) or procedure mask (ear loops) and eye protection (goggles or face shield) while working in the ED since we often deal with limited information when evaluating patients. Personal glasses or the traditional ED disposable plastic glasses are not sufficient.
**If a patient is getting a high-risk aerosol generating procedure (AGP) then airborne precautions are preferred in addition to contact and droplet precautions. AGP include intubation, NIPPV (BiPAP/CPAP), high flow oxygen, nebulizers, CPR, and suctioning, to name a few relevant in the ED. If need to do NIPPV, nebs, HFNC try your best to place surgical mask over.
**Once intubated, or after an AGP is completed, patient needs airborne precautions x 1 hr if vent is not being disconnected or if patient is not getting suction. Since an ETT connected to a vent is a closed circuit, after 1 hour the patient goes back onto droplet/contact precautions. If other AGP done again then 1 hr clock restarts needing airborne precautions. If patient was dispositioned out of the ED while still in airborne precautions, then will need terminal clean with 1-hour air exchange.
**If no AGP, then patient needs to wear a mask and have contact and droplet precautions with closed door. So for example, if a masked ‘pink’ patient is going to CT without an AGP, only need a wipe down as per usual contact/droplet cleaning, and does not need a terminal clean.
**After a Pink or PUI patient leaves the ED, the room may be cleaned immediately per droplet/contact precautions, unless there was an AGP was done in the previous 1 hour.
**Only need terminal clean if aerosol generating procedure (AGP) done, otherwise just droplet precaution cleaning with wipes
**Write your name into the log by patient room if sick suspected COVID patient getting admitted
** PAPR - get from Charge RN.
*** If using a PAPR - get a '''preassigned nurse''' outside the room '''decontaminate it''' for you before you take it off (Purple wipes)
**If patient brought in by EMS, let MICN know you suspect COVID so they can inform the EMS crew & decontaminate their rig

===Exposures===
* '''If you are exposed''' to a confirmed patient - whether in PPE or not - you should self-monitor for symptoms for 14 days. OK to work as long as you do not have symptoms. IPC and Employee Health will give recs for staff exposures based on CDC criteria.
** [[:File:Self Monitoring log .pdf]]
** [[:File:Guidance for WFM Call Offs .v2._3.24.2020.pdf]]
* Infection Prevention confirms the exposure and provides Employee Health with a list of affected departments. Employee Health then notifies all dept chairs or supervisors of exposure and request list of names of staff with potential exposure. Supervisor provides staff with a confidential notice to present to Employee Health
*Employee presents to Employee Health for evaluation
Based on CDC exposure risk either self-monitor with or without work restrictions are initiated

===Admissions===
*‘Consult to COVID Tracking’ in Quick Orders page, please write “FYI” in the required call back field. Do not expect a call back since this is just for tracking purchases. Send this tracking page for all PUIs getting admitted, even if known to be Covid+ already.
*Adult patient
**Covid hospitalist team p1325 - non-ICU level care
**If COVID PUI is requiring >6L of NC consider intubation or at least notifying MICU team.
**MICU - third call pager
**Any discrepancies if patient is PUI, consult ID

*PED
**Our PICU has no negative pressure rooms. The Pediatric ward has 5 rooms that are negative pressure. For children with URI/ILI symptoms that need to be admitted they will need to go into a negative pressure room upstairs. If they require SDU or PICU placement we will need to discuss with the PICU attending. The PICU has converted room 15 on the pediatric ward to be used for ICU level care and may turn a few more of the negative pressure rooms into ICU level care rooms.
**For all of PED patients being admitted, please ask about fever, cough, and/or SOB or any known exposure to Covid+ patient. This is important information to get on all of our traumas and patients who come in for other reasons as it does have an impact on our staff and the admitting team.
**For all adolescent psych patients, as part of your MSE, please ask each of them about recent fever, cough, sob and known exposure to Covid+ patient. Also remember that GI symptoms can also be caused by Covid. If there is a patient with any of these symptoms, they cannot go to the adolescent psych ED until we talk with ID to determine risk of Covid-19.
**Per ID, if a PED asthmatic patient is well enough to go home, we should not be doing COVID-19 testing on him or her. If he/she is being admitted we should discuss with ID the need for COVID-19 testing.

===Screening L&D Patients===
* If >14 weeks with fever or cough, keep in ED
* If febrile, immediately consult OB and place in AED 15, 16, 17, 21, Tra 1-7, or peds 4 for FetalLink monitoring capabilities

===Latest Numbers - Census, Positives, Supplies, Rx===
*Census
**AED Volume: 4/5= 99
**PED Volume: 4/5= 20
**UCC Volume: 4/3= 22
** Hospital 4/6= 193
***RED 4W PCU: 4/3= 18/27 (9 open)
***RED 3W SDU: 4/3= 19/20 (1 open)
***RED 5WICU: 4/6= 8/8 (zero open)
***ED RED ICU: 4/6= 0 (@11:00)
** DHS & LA County hospital/ICU beds, available ventilators, etc
*** http://file.lacounty.gov/SDSInter/dhs/1070348_DHSCOVID-19Dashboard.pdf
*** http://mlkioasashaw01.dhs.lacounty.gov/SASVisualAnalyticsViewer/VisualAnalyticsViewer.jsp?saspfs_request_backurl_list=http%3A%2F%2Fmlkioasashaw01.dhs.lacounty.gov%2FSASVisualAnalyticsHub&saspfs_request_backlabel_list=Home&saspfs_request_path_url=SBIP%3A%2F%2FMETASERVER%2FProd%2FDHS%2F_Shared%2FReports%2FCovid+04+05+20%28Report%29&saspfs_request_entitykey=A501L7HF.AX000487%2FTransformation&_vaSectionName=vi1051

*COVID Cases
** Harbor
*** POSITIVE 4/4= 20
*** PUI (pend) 4/4= 5
** LA County
*** COVID +ve= 4/4=5304
**** Predicted trajectory: 4/4=6918; 4/5=8578; 4/6=10,636; 4/7=13,189; 4/8=16,355; 4/9=20,280; 4/10=25,147; 4/11=31,182; 4/12=38,666; 4/13=47,946; 4/14=59,452; 4/15=73,721; 4/16=91,414; 4/17=113,353
**** Age <18= 48
**** Age 18-40= 1785
**** Age 41-65= 2160
**** Age >65= 1050
**** Deaths= 117
*** Mercy Transfers 4/2=10

*Supplies
** Viral swabs 4/4=1374
** Surgical masks 4/4= <30-day supply
** N-95 4/4= <30-day supply
** Face shields 4/4= 800
** PAPR + Dover (ED) 2+5
** CAPR (ED) 6 (~40 DLCs 3/30)
** Ventilators 3/31 23 available
** Gloves 3/26= enough
** Gowns 3/26= enough

*Drug shortages
** Morphine & Fentanyl
** IV fluids - use oral hydration whenever possible. Reserve IVF to those that cannot tolerate PO.
** Albuterol and ipratropium MDI - we have enough for now but in next few weeks we may be seeing surge in PUI's and their need, please conserve when you can. We have placed order for more but no definitive release date. Remember we can give patients same used MDI on discharge
** Chloroquine and hydroxychlorquine and azithromycin are on shortage list but they're not standard of care for PUIs. We'll see as situation unfolds.

===COVID ACTION PLAN (Phases 1-3)===
* Phase I: “COVID-19 Screening”
** Pre-router - mask patients with fever, cough, dyspnea
** Router - register on disaster track (“COVID Possible”)
*** “Routine” priority
**** COVID EXPOSURE – no symptoms but at risk
**** COVID FT – ILI symptoms
**** COVID ED – not PUI criteria but ILI with other medical issues that are too complex for FastTrack
*** “High” Priority
****COVID PUI – for patients meeting DPH criteria
*** Patients in respiratory isolation to AWR Alcove / back half of PWR
** Triage
*** Triage priority: Cardiac > High > COVID > Routine
*** Temporarily suspending CXR for RIPT scoring
** Ambulance Triage
*** All patient (including those going to Psych ED) must be screened per above
** Psych ED
*** EMS to Psych ED will receive screening at psych
**** If a patient meets PUI criteria, they should be immediately transferred to the AED and placed in a room
*** Patients arriving in Triage or AED for clearance to psych need MSE note
**** If no infectious or other medical concerns, the patient can go directly to the Psych ED after physician evaluation
*** Labor & Delivery
**** ED will perform infection screening on all patients presenting to the ED including L&D patients >14 weeks gestation
***** If negative, they will be directed to L&D
***** If positive with fever (subjective or recorded in past 24 hours), they will be triaged as usual and OB will be consulted
***** '''''If >24 weeks gestation, they will be prioritized to AED 15, 16, 17, 21, Tra 1-7, or PED 4 for Fetal Link monitoring, with the goal of door to monitoring in <20 minutes'''''
***** If the patient is in active labor, the patient will be moved to one of the trauma bays and the L&D team will decide the best location for impending delivery

* Triage Rapid DC
** '''''RN''''' completes portion of team triage and goes to open triage room for next patient after provider interview completed
** '''''Provider'''''
*** Completes MSE Note: “definitive treatment provider”; “please see chart for details”; tracking acuity “5”; no typing in History/Exam section
*** Completes paper chart or .phrase and pre-printed paper discharge (English/Spanish/Korean)
*** Give discharge paper work to registration and patient (provider to sign the discharge paperwork and state “patient verbally consents” to avoid fomite transmission)
*** Takes patient to registration windows A-C and hands paper forms (H&P and signed DC) to Patient Access Staff
*** Join RN in new room after discharge process from prior patient complete
** PAS will complete registration then sticker the paper forms, and place the chart in box to be scanned
** Patient leaves from registration
** RN wipes down exposed/touched surfaces per droplet protocol using Grey Cavi-wipe to clean all surfaces (door handle, chair, etc.)
** Discharge off the tracking board
*** DETAILED STEPS:
#1 - click pt recented seen x 6
#2 - "H" for home, "T" for today, "N" for now

*PED Rapid DC
** If the patient does not meet PUI criteria, send directly to PED 8-10 for immediate discharge
*** If >3 patients, send to the masked patient side of the Peds WR NP or resident in PED 8-10
*** Chart with “.edcovid” – include reference that patient given COVID ED instructions
*** Discharge with pre-printed paper discharge
*** Registration in PED 8-10
** If the patient meets PUI criteria, patient taken directly to a room and notify PED team
*** Change QuickReg to “COVID PUI”
*** If not eligible for FT but not a PUI, change QuickReg to “COVID PED”

*Phase 2
** '''''DHS/OOP ESI 4/5 can go to UCC'''''
** FT Team Rapid Dispo (ESI 3 or 4) - low risk, COVID suspected (but not meeting DHS PUI criteria), but still needs simple workup
*** Complete triage, rapid history & exam
*** Apply PINK wrist band to patient indicating COVID suspected/DHS PUI patients.
*** Provider & triage RN exit the room and initiates a new triage process in the open room for the next patient
*** Patient goes to COVID suspected/DHS PUI specific tasking rooms
**** RME 7 (internal waiting room)
**** RME 9 (phlebotomy)
**** These two rooms will be designated COVID suspected rooms and will have more frequent housekeeping cleaning
**** Tasking LVN to ensure droplet precautions are followed in these rooms and will escort patient to XR & EKGs
*** After tasking, patient will be escorted to Registration windows A-C
**** Registration sends patient to respiratory isolation area of the waiting room
*** FT team/NPs evaluates disposition from the Alcove if appropriate (use privacy screen)
** Non-FT Candidate
*** Notify RME charge nurse for available bed in ED

===.edcovid, paper charts, & discharge material===
*History:
*Chief complaint _
*HPI _
*Pertinent ROS:
*_ Fever
*_ Cough
*_ Rhinorrhea
*_ Headache
*_ Vomiting
*Other: _
*
*Past Medical History
*_ No significant Past Medical History
*_ High-risk Conditions: Age >65, Heart disease, Diabetes, Pregnant, Immunocompromised
*Other: _
*
*Allergies: _
*_ No known drug allergies

*Physical Exam:
*_Vital signs normal
*General: Patient is well nourished, well developed, awake and alert, in no acute distress
*Head: Normocephalic and atraumatic
*Eyes: Normal inspection, extraocular muscles intact
*_ Ears: normal external exam and tympanic membranes
*Nose & Throat: Normal external exam, moist mucosa
*Neck: Non-meningeal
*Cardiovascular: Patient is not tachycardic
* _ Regular rate and rhythm without appreciable murmur
* _ Heart rate appropriate for fever
*Respiratory:
* _ Patient is in no respiratory distress
* _ Lungs are clear to auscultation bilaterally
*Back: Normal inspection of the back with good range of motion
*Extremities: Normal strength, capillary refills <2 seconds
*Neuro: Normal mentation, alert and oriented, appropriately conversive, coordination appears to be adequate, ambulatory without assistance
*Skin: Warm, dry, and intact
*
*Medical Decision Making
*_ The patient appears well, is in no respiratory distress, and does not meet the clinical inclusion criteria for COVID-19 testing. The patient is not in the high-risk category for flu testing and treatment with anti-viral medication. The lung exam does not support a diagnosis of pneumonia. The history and physical are inconsistent with pulmonary embolism.
*
*Clinical Impression/Plan
*_ Influenza-like illness/viral syndrome: The patient was counseled on self care: rest, staying hydrated, taking acetaminophen/ibuprofen for fever, and avoiding close contact with others fever-free for >24 hours. We discussed returning to the emergency department if fevers persist more than 5 days, they develop difficulty breathing, they are unable to tolerate liquids, or they become confused or develop neck stiffness.

==
*Paper chart [[file:2 - Provider Paper Documentation v2.pdf]]
*Paper discharge instructions
**Hospital Copy
***[[file:3 - Paper DC Signature Adult English.pdf]]
***[[file:3 - Paper DC Signature Adult SPANISH.pdf]]
***[[file:3 - Paper DC Signature Adult Korean.pdf]]
***[[file:3 - Paper DC Signature Adult Mandarin.pdf]]
**Patient Copy
***[[file:4 - Paper Discharge Inst - ADULT English.pdf]]
***[[file:4 - Paper Discharge Inst - Adult SPANISH.pdf]]
***[[file:4 - Paper Discharge Inst - Adult Korean.pdf]]
***[[file:4 - Paper Discharge Inst - Adult Mandarin.pdf]]

==
* Orchid electronic discharge available under “Understanding 2019 Novel Coronavirus”

===COVID FAQ's===
*Carts in airborne precaution rooms only need to be wiped down - Zangwill 3/30
*Reasonable to clamp ET tube after cardiac arrest death - Zangwill 3/30
*Do NOT put patient info on pink armband - Martee 3/30
*No morgue viewings of COVID patients - Dr. Bolaris 3/30
** no Pt identifiers on outside pink tag - Nancy Blake 3/31
*Homeless patients
**If eligible for DC, need COVID test sent
**Consult SW - DPH intake center 8a-8p; 833-596-1009

==Flu/ILI==
*Influenza-like-illness (ILI) is defined as fever >100.0 F / 37.8 C AND cough or sore throat.
*Per our DHS policy, please consider treatment for high-risk populations.
**Antivirals for influenza are most effective when administered when symptoms have been present for <48 hours.
**May benefit for severely ill patients who have had >48 hours of symptoms.
*High risk patients for complications include:
# Age < 2 years or > 65 years
# Pregnancy
# Chronic disease. Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes)
# Immune suppression, including that caused by medications or HIV
# Persons younger than 19 years of age who are receiving long term aspirin therpay
*Don't send POC influenza test, due to low sensitivity (50-70%).
*Please send the Biofire / Respiratory Panel PCR for admitted ILI patients.
*Don't send POC RSV unless it will change your management.

==Measles==
* Report suspected measles immediately to DPH
** Weekdays 8:30 AM – 5 PM: call 888-397-3993
** After-hours: call 213-974-1234 and ask for the physician on call.

*Plan:
** Isolate pt - https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Measles-HCFacilityICRecs.pdf
** If advised to test for measles by DPH, submit a specimen for polymerase chain reaction (PCR) testing
*** Full clinical guidance from the California Department of Public Health https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Measles-ClinicalGuidance.pdf
*** Guidance from CDC for healthcare professionals:https://www.cdc.gov/measles/hcp/index.html

* Risk factors: international travel, never immunized of born after 1956
* Symptoms
** Fever, including subjective fever.
** Rash that starts on the head and descends.
** Usually 1 or 2 of the “3 Cs” – cough, coryza and conjunctivitis.

==Hepatitis A==
The County Department of Public Health has declared a Hepatitis A Outbreak in Los Angeles County and we are being asked in the emergency department to do our part to stem this outbreak.
　
In order to help we need to do the following things for all ADULTS (>18 years):
　
#Suspect: Consider acute viral hepatitis, especially in homeless patients or patients using illicit drugs.
#Test: If you suspect the patient may have acute viral hepatitis, order appropriate serologic studies (Hep A IgM, Hep B Core IgM, Hep B Surface Ag, Hep C Antibody Ab.) These are all available in the "AMB Hepatitis Workup" order set. STAT 45 minute turnarounds for the Hep A IgM is available, must be ordered as a standalone STAT test from the ED Quick Orders Page. If it is bundled with other Hepatitis tests, the machine runs all of them, delaying the turnaround time.
#Report: All suspected and confirmed cases of Hepatits A should be immediately reported to both the Dept of Health at (888) 397-3993 or after hours (213) 974-1234 AND Harbor Infection Control at x3838 While Patient Is Still in the Emergency Department
#Vaccinate: Anyone (regardless of why they are here) who is or has been homeless in the last two months, or uses illicit drugs (NOT JUST IV; except marijuana) should be offered the initial dose of Hep A vaccine while in the ED (the Cerner order is "Hepatitis A adult vaccine" on ED Quick Orders Page). They can be referred to the Department of Health for their second injection in six months. Check the "immunizations" area in Cerner to make sure they are not already immunized.
#Protect Yourself: If you haven't gotten the hepatitis A vaccine, it is recommended that you go to employee health to get vaccinated.

{{Harbor Ebola Precautions}}

==See Also==
*[[Harbor:Main]]

==References==
<references/>

[[Category:Admin]]

File:Clinical Cheat sheet.pdf

2020-04-06T19:38:22Z

Jtolles:

Summary of Harbor consensus recommendations for clinical management

Harbor:Infectious Disease Threats

2020-04-06T19:18:51Z

Jtolles: /* Airway Management */

==Coronavirus ([[COVID-19]])==
;See [[COVID-19]] for non-Harbor-specific information; please feel free to contribute to the further development of these pages''

===COVID physician leads===
*AED Flow/Discharges- Andrea
*Drug/Non-PPE Shortages - Andrea
*Non-Emergency Physicians in the Emergency Department - Mike
*Homeless Issues - Dennis
* Airway-Ryan
*Environmental Services/Cleaning Protocols- Moh
*Triage/Fast Track Tents - Brad
*Email Updates - Andrea
*Pediatric Schedule - Kelly
*PPE - Shira
*EMS - Shira
*Palliative Care/End-Of-Life Issues - Tim J.
*ACLS - Shira
*COVID Testing - Mike
*Transfers to Mercy Ship – Denise (Currently only for inpatients with non-respiratory issues and negative Covid test)
*Attending scheduling for Adult ED – Manny
*PED issues - Patricia

===COVID Terminology===
*“Pink”
**respiratory complaint/Not PUI
**Need droplet/contact PPE
**pink wrist bands = need mask.
*“PUI”
** Meet DHS Testing Criteria (See below)

*Disaster track categories
**The router will place initial category,
**Ask nurse to change as necessary (can use communication order)
***Categories
****COVID EXPOSURE – no symptoms but at risk
****COVID FT – ILI symptoms (Cough, fever or SOB)
****COVID AED – not PUI but too complicated for quick dispo
****COVID PUI – meet DHS testing criteria

===Latest Updates===
*A&B/RSV RT-PCR order is replaced with “COVID-19 Test Request” on 4/3/2020.

===Harbor Checklists===
* Bedside checklist: [[:File:Harbor COVID checklist v3-21-20.pdf]]
* Additional DPH Guidance: http://publichealth.lacounty.gov/acd/nCorona2019.htm
* HARBOR ID UPDATES https://lacounty.sharepoint.com/sites/dhs-harbor-inf_prev_ctrl/SitePages/Breaking-News-and-Other-Disease-Information.aspx
*DHS Covid Sharepoint https://lacounty.sharepoint.com/sites/DHS-COVID19/ExpectedPractices/Forms/Newest%20on%20Top.aspx
*Seattle ICU doctor's one page info on mgmt of COVID from ACEP website [[:File:COVID19 seattle one pager.pdf]]
*Harbor DEM COVID airway management guide [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
*Proper donning and doffing with reusable goggles and stethoscope [[:File:Procedure for Reuse of Faceshields and Goggles 3-19-2020.pdf]]

===Triage===
*PUI going direct to room - do not order triage labs
*PINK wristband = mask + respiratory area if in waiting room

===DHS PUI Testing Criteria 3-23-20===
*Nurses will put everyone '''suspected''' of meeting PUI in a room in droplet precautions
*ED Attending will determine if patient meets definition
#Fever '''AND''' (cough '''OR''' shortness of breath '''''AND''''' NOT requiring hospitalization). Must be '''MEASURED''' fever in ED or at home (>100.4 F/38.0 C) '''''AND''''':
## healthcare worker '''''OR'''''
## works or lives in group environment (SNF/group home/rehab center/jail) '''''OR'''''
# Symptoms of Acute Respiratory Infection (New cough ''''OR'''' new Shortness of Breath. No fever required) '''''AND''''' REQUIRING HOSPITALIZATION '''''without an alternative diagnosis''''' (positive blood culture, cavitary lesion, chronic (>14d))
#'''''CONSIDER''''' testing ONLY if it will change management for:
## age>65 with chronic medical conditions (heart or lung disease)'''''OR'''''
## immunosuppression (includes prednisone>20mg daily)

** ID is available 24/7 if you are unclear if they meet PUI criteria

===Commercial testing (Quest or UCLA) for PUI criteria above===
'''NO LONGER NEED FLU TEST, flu season is over'''.
*PROCEDURE
**Order COVID-19 test from Covid Order Set.
**If Flu/RSV consider excluding COVID
**Complete both:
***"Harbor UCLA's Laboratory Miscellaneous Lab Form"[[:File:Laboratory Miscellaneous Request Form.pdf]]
***UCLA's lab request form [[:File:HARBOR UCLA UCLA BURL CUSTOM 032720.pdf]]
**Specimen must be walked up to the lab
*'''If Testing, Send out the batch text (p9699)'''. Please include:
** '''Patient Name''',
**'''MRUN'''
**'''Location''' (e.g. "AED Room A12")
**If "Consult to COVID Tracking" order Write "FYI" in callback field. Does not result in a callback.
==
*'''Follow Up of Test Results for Discharged Patients'''
*** AED patients: '''''Lab Follow-up - HAR''''' (like UCx and STI's)
****DHS empaneled patients: '''''message the provider'''''
*** PED patients: '''''Peds - HAR/USC''''' (the usual laboratory follow up procedure may be followed)
****DHS empaneled patients: '''''message the provider'''''
**Do not rely on Public Health to follow up test results

===Discharge===
*Homeless patient with mild symptoms that could be discharged,
**Placement
***Call SW early
***DPH call center (833-596-1009) 8a-6p every day
****Helps with transportation
****Need pending Covid test
****Must be able to perform ADLs

===Airway Management===
*'''Airway management''' [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
**Intubate early (consider if need 6L NC or more), use VL so you’re face is further away. Clean VL with grey wipes, observe 3 min wet time
**Location: negative room pressure preferred; if patient too unstable to move to negative pressure room, use single patient room
**Avoid BiPAP, high flow nasal cannula (HFNC), nebulizers
***Use MDI/spacer instead of nebs
***If needed HFNC with surgical mask over patient is preferred over BiPAP. Both require ''airborne precautions.''
***Viral filters should not be used with BVM or stocked in the airway carts, in order to preserve them for the transport ventilators
**Per CDC, do not treat with steroids (prolongs viral replication) unless for a secondary reason (ie, COPD)
**When intubating patients, for any unclear cases, wear N95, face shield, gown and gloves
***If using PAPR, then need pre-assigned RN outside the room to help decontaminate it by wiping it down with purple wipes before you take it off
**From Manny - We have an aerosol box approved and ready for us in trauma bay 1. Please remember to handle with care and more importantly, clean with bleach (orange) wipes after each use per infection control. This is a good tool to consider when you are intubating a PUI patient.
***Pre-oxygenate with NRB at 15L/min with surgical mask over vents and use apneic nasal cannula at 6L/min during intubation.
***Avoid using bag-valve-mask if possible
***If possible, directly attach patient to ventilator without BVM after cuff is inflated
***RSI to ensure paralysis. Consider higher range of dosing of paralytic to avoid patient coughing.
***Follow ARDSnet protocol, TV ~6ml/kg ideal body weight, high PEEP - http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

===Treatment Tips===
* Patient Presentation
**''Patient may have preceding GI symptoms prior to developing respiratory illness''
*'''Treatment'''
**Avoid steroids unless strong non-COVID indication
**Limited data on chloroquine or hydroxychloroquine
**Remdesivir via compassionate use for severely hypoxemic (Mechanical vent, high PEEP, FiO2 requirements >40%,).
*Any MDIs used in the ED to sent home with the patient instead of prescribing the patient another MDI and throwing the one used in the ED away. To do so, three simple steps needs to happen:
#Fill out a pre-printed rx sticker - available in English and Spanish with patient's name, the date, your name, patient's MRN. The stickers will be on the same clipboard as the logs (see #3 below) in each doc box.
#Put sticker on box for inhaler or inhaler itself and hand to patient
#Put patient sticker (or write patient name and MRN), your name, and circle drug given on the log. There will be a log in each doc box (purple, green, pediatrics).

==== Ventilator Management ====
* PRVC mode, initial tidal volume: 6-8 mL/kg of predicted body weight (link)
* If initial plateau pressure is persistently > 30 cm H2O, reduce the tidal volume by 1 mL/kg, until plateau pressure <30 H2O
* Goal: SpO2 88-96%: Adjust PEEP and FiO2 as per table below

{| class="wikitable"
|-
| '''FiO2''' || 0.3 || 0.4 || 0.5 || 0.6 || 0.7 || 0.8 || 0.9 || 1.0
|-
| '''PEEP''' || 12-14 || 14-16 || 18 || 18-20 || 18-20 || 22 || 22 || 22-24
|}

* If SpO2 <88% despite maximum FiO2 and PEEP on table above, intervene in the following order. If goal SpO2 is not achieved, proceed to the next step on the list.
** Prone the patient
** Observe for signs of dyssynchrony with the ventilator (e.g. initiating a new breath before full exhalation, coughing/auto-triggering). If present, first increase sedation to RASS of -4. If persistent, give single dose non-depolarizing paralytic (e.g. vecuronium 0.1mg/kg)
** Seek expert (MICU) consultation to place patient on APRV
** If above steps and MICU consultation fail to stabilize oxygenation of patient, V-V ECMO may be considered for select patients. Contact trauma attending to reach Dennis Kim.

====Antibiotics ====
* CAP treatment for intubated patients with ARDS per surviving sepsis guidelines

====Fluid resuscitation====
* For hemodynamically stable patients with ARDS, avoid fluid resuscitation
* For hemodynamically unstable patients with ARDS, consider small (500mL) fluid boluses and early norepinephrine

===PPE===
*“Special Precautions” are announced for an EMS patient and airway management pages, please ensure that all involved healthcare workers are wearing appropriate PPE.
*Recommendation for PPE [[:File:Guidance on precautions and masks for COVID-19_updated 3.25.20.pdf]]
**In general, wear surgical masks (ties) or procedure mask (ear loops) and eye protection (goggles or face shield) while working in the ED since we often deal with limited information when evaluating patients. Personal glasses or the traditional ED disposable plastic glasses are not sufficient.
**If a patient is getting a high-risk aerosol generating procedure (AGP) then airborne precautions are preferred in addition to contact and droplet precautions. AGP include intubation, NIPPV (BiPAP/CPAP), high flow oxygen, nebulizers, CPR, and suctioning, to name a few relevant in the ED. If need to do NIPPV, nebs, HFNC try your best to place surgical mask over.
**Once intubated, or after an AGP is completed, patient needs airborne precautions x 1 hr if vent is not being disconnected or if patient is not getting suction. Since an ETT connected to a vent is a closed circuit, after 1 hour the patient goes back onto droplet/contact precautions. If other AGP done again then 1 hr clock restarts needing airborne precautions. If patient was dispositioned out of the ED while still in airborne precautions, then will need terminal clean with 1-hour air exchange.
**If no AGP, then patient needs to wear a mask and have contact and droplet precautions with closed door. So for example, if a masked ‘pink’ patient is going to CT without an AGP, only need a wipe down as per usual contact/droplet cleaning, and does not need a terminal clean.
**After a Pink or PUI patient leaves the ED, the room may be cleaned immediately per droplet/contact precautions, unless there was an AGP was done in the previous 1 hour.
**Only need terminal clean if aerosol generating procedure (AGP) done, otherwise just droplet precaution cleaning with wipes
**Write your name into the log by patient room if sick suspected COVID patient getting admitted
** PAPR - get from Charge RN.
*** If using a PAPR - get a '''preassigned nurse''' outside the room '''decontaminate it''' for you before you take it off (Purple wipes)
**If patient brought in by EMS, let MICN know you suspect COVID so they can inform the EMS crew & decontaminate their rig

===Exposures===
* '''If you are exposed''' to a confirmed patient - whether in PPE or not - you should self-monitor for symptoms for 14 days. OK to work as long as you do not have symptoms. IPC and Employee Health will give recs for staff exposures based on CDC criteria.
** [[:File:Self Monitoring log .pdf]]
** [[:File:Guidance for WFM Call Offs .v2._3.24.2020.pdf]]
* Infection Prevention confirms the exposure and provides Employee Health with a list of affected departments. Employee Health then notifies all dept chairs or supervisors of exposure and request list of names of staff with potential exposure. Supervisor provides staff with a confidential notice to present to Employee Health
*Employee presents to Employee Health for evaluation
Based on CDC exposure risk either self-monitor with or without work restrictions are initiated

===Admissions===
*‘Consult to COVID Tracking’ in Quick Orders page, please write “FYI” in the required call back field. Do not expect a call back since this is just for tracking purchases. Send this tracking page for all PUIs getting admitted, even if known to be Covid+ already.
*Adult patient
**Covid hospitalist team p1325 - non-ICU level care
**If COVID PUI is requiring >6L of NC consider intubation or at least notifying MICU team.
**MICU - third call pager
**Any discrepancies if patient is PUI, consult ID

*PED
**Our PICU has no negative pressure rooms. The Pediatric ward has 5 rooms that are negative pressure. For children with URI/ILI symptoms that need to be admitted they will need to go into a negative pressure room upstairs. If they require SDU or PICU placement we will need to discuss with the PICU attending. The PICU has converted room 15 on the pediatric ward to be used for ICU level care and may turn a few more of the negative pressure rooms into ICU level care rooms.
**For all of PED patients being admitted, please ask about fever, cough, and/or SOB or any known exposure to Covid+ patient. This is important information to get on all of our traumas and patients who come in for other reasons as it does have an impact on our staff and the admitting team.
**For all adolescent psych patients, as part of your MSE, please ask each of them about recent fever, cough, sob and known exposure to Covid+ patient. Also remember that GI symptoms can also be caused by Covid. If there is a patient with any of these symptoms, they cannot go to the adolescent psych ED until we talk with ID to determine risk of Covid-19.
**Per ID, if a PED asthmatic patient is well enough to go home, we should not be doing COVID-19 testing on him or her. If he/she is being admitted we should discuss with ID the need for COVID-19 testing.

===Screening L&D Patients===
* If >14 weeks with fever or cough, keep in ED
* If febrile, immediately consult OB and place in AED 15, 16, 17, 21, Tra 1-7, or peds 4 for FetalLink monitoring capabilities

===Latest Numbers - Census, Positives, Supplies, Rx===
*Census
**AED Volume: 4/5= 99
**PED Volume: 4/5= 20
**UCC Volume: 4/3= 22
** Hospital 4/6= 193
***RED 4W PCU: 4/3= 18/27 (9 open)
***RED 3W SDU: 4/3= 19/20 (1 open)
***RED 5WICU: 4/6= 8/8 (zero open)
***ED RED ICU: 4/6= 0 (@11:00)
** DHS & LA County hospital/ICU beds, available ventilators, etc
*** http://file.lacounty.gov/SDSInter/dhs/1070348_DHSCOVID-19Dashboard.pdf
*** http://mlkioasashaw01.dhs.lacounty.gov/SASVisualAnalyticsViewer/VisualAnalyticsViewer.jsp?saspfs_request_backurl_list=http%3A%2F%2Fmlkioasashaw01.dhs.lacounty.gov%2FSASVisualAnalyticsHub&saspfs_request_backlabel_list=Home&saspfs_request_path_url=SBIP%3A%2F%2FMETASERVER%2FProd%2FDHS%2F_Shared%2FReports%2FCovid+04+05+20%28Report%29&saspfs_request_entitykey=A501L7HF.AX000487%2FTransformation&_vaSectionName=vi1051

*COVID Cases
** Harbor
*** POSITIVE 4/4= 20
*** PUI (pend) 4/4= 5
** LA County
*** COVID +ve= 4/4=5304
**** Predicted trajectory: 4/4=6918; 4/5=8578; 4/6=10,636; 4/7=13,189; 4/8=16,355; 4/9=20,280; 4/10=25,147; 4/11=31,182; 4/12=38,666; 4/13=47,946; 4/14=59,452; 4/15=73,721; 4/16=91,414; 4/17=113,353
**** Age <18= 48
**** Age 18-40= 1785
**** Age 41-65= 2160
**** Age >65= 1050
**** Deaths= 117
*** Mercy Transfers 4/2=10

*Supplies
** Viral swabs 4/4=1374
** Surgical masks 4/4= <30-day supply
** N-95 4/4= <30-day supply
** Face shields 4/4= 800
** PAPR + Dover (ED) 2+5
** CAPR (ED) 6 (~40 DLCs 3/30)
** Ventilators 3/31 23 available
** Gloves 3/26= enough
** Gowns 3/26= enough

*Drug shortages
** Morphine & Fentanyl
** IV fluids - use oral hydration whenever possible. Reserve IVF to those that cannot tolerate PO.
** Albuterol and ipratropium MDI - we have enough for now but in next few weeks we may be seeing surge in PUI's and their need, please conserve when you can. We have placed order for more but no definitive release date. Remember we can give patients same used MDI on discharge
** Chloroquine and hydroxychlorquine and azithromycin are on shortage list but they're not standard of care for PUIs. We'll see as situation unfolds.

===COVID ACTION PLAN (Phases 1-3)===
* Phase I: “COVID-19 Screening”
** Pre-router - mask patients with fever, cough, dyspnea
** Router - register on disaster track (“COVID Possible”)
*** “Routine” priority
**** COVID EXPOSURE – no symptoms but at risk
**** COVID FT – ILI symptoms
**** COVID ED – not PUI criteria but ILI with other medical issues that are too complex for FastTrack
*** “High” Priority
****COVID PUI – for patients meeting DPH criteria
*** Patients in respiratory isolation to AWR Alcove / back half of PWR
** Triage
*** Triage priority: Cardiac > High > COVID > Routine
*** Temporarily suspending CXR for RIPT scoring
** Ambulance Triage
*** All patient (including those going to Psych ED) must be screened per above
** Psych ED
*** EMS to Psych ED will receive screening at psych
**** If a patient meets PUI criteria, they should be immediately transferred to the AED and placed in a room
*** Patients arriving in Triage or AED for clearance to psych need MSE note
**** If no infectious or other medical concerns, the patient can go directly to the Psych ED after physician evaluation
*** Labor & Delivery
**** ED will perform infection screening on all patients presenting to the ED including L&D patients >14 weeks gestation
***** If negative, they will be directed to L&D
***** If positive with fever (subjective or recorded in past 24 hours), they will be triaged as usual and OB will be consulted
***** '''''If >24 weeks gestation, they will be prioritized to AED 15, 16, 17, 21, Tra 1-7, or PED 4 for Fetal Link monitoring, with the goal of door to monitoring in <20 minutes'''''
***** If the patient is in active labor, the patient will be moved to one of the trauma bays and the L&D team will decide the best location for impending delivery

* Triage Rapid DC
** '''''RN''''' completes portion of team triage and goes to open triage room for next patient after provider interview completed
** '''''Provider'''''
*** Completes MSE Note: “definitive treatment provider”; “please see chart for details”; tracking acuity “5”; no typing in History/Exam section
*** Completes paper chart or .phrase and pre-printed paper discharge (English/Spanish/Korean)
*** Give discharge paper work to registration and patient (provider to sign the discharge paperwork and state “patient verbally consents” to avoid fomite transmission)
*** Takes patient to registration windows A-C and hands paper forms (H&P and signed DC) to Patient Access Staff
*** Join RN in new room after discharge process from prior patient complete
** PAS will complete registration then sticker the paper forms, and place the chart in box to be scanned
** Patient leaves from registration
** RN wipes down exposed/touched surfaces per droplet protocol using Grey Cavi-wipe to clean all surfaces (door handle, chair, etc.)
** Discharge off the tracking board
*** DETAILED STEPS:
#1 - click pt recented seen x 6
#2 - "H" for home, "T" for today, "N" for now

*PED Rapid DC
** If the patient does not meet PUI criteria, send directly to PED 8-10 for immediate discharge
*** If >3 patients, send to the masked patient side of the Peds WR NP or resident in PED 8-10
*** Chart with “.edcovid” – include reference that patient given COVID ED instructions
*** Discharge with pre-printed paper discharge
*** Registration in PED 8-10
** If the patient meets PUI criteria, patient taken directly to a room and notify PED team
*** Change QuickReg to “COVID PUI”
*** If not eligible for FT but not a PUI, change QuickReg to “COVID PED”

*Phase 2
** '''''DHS/OOP ESI 4/5 can go to UCC'''''
** FT Team Rapid Dispo (ESI 3 or 4) - low risk, COVID suspected (but not meeting DHS PUI criteria), but still needs simple workup
*** Complete triage, rapid history & exam
*** Apply PINK wrist band to patient indicating COVID suspected/DHS PUI patients.
*** Provider & triage RN exit the room and initiates a new triage process in the open room for the next patient
*** Patient goes to COVID suspected/DHS PUI specific tasking rooms
**** RME 7 (internal waiting room)
**** RME 9 (phlebotomy)
**** These two rooms will be designated COVID suspected rooms and will have more frequent housekeeping cleaning
**** Tasking LVN to ensure droplet precautions are followed in these rooms and will escort patient to XR & EKGs
*** After tasking, patient will be escorted to Registration windows A-C
**** Registration sends patient to respiratory isolation area of the waiting room
*** FT team/NPs evaluates disposition from the Alcove if appropriate (use privacy screen)
** Non-FT Candidate
*** Notify RME charge nurse for available bed in ED

===.edcovid, paper charts, & discharge material===
*History:
*Chief complaint _
*HPI _
*Pertinent ROS:
*_ Fever
*_ Cough
*_ Rhinorrhea
*_ Headache
*_ Vomiting
*Other: _
*
*Past Medical History
*_ No significant Past Medical History
*_ High-risk Conditions: Age >65, Heart disease, Diabetes, Pregnant, Immunocompromised
*Other: _
*
*Allergies: _
*_ No known drug allergies

*Physical Exam:
*_Vital signs normal
*General: Patient is well nourished, well developed, awake and alert, in no acute distress
*Head: Normocephalic and atraumatic
*Eyes: Normal inspection, extraocular muscles intact
*_ Ears: normal external exam and tympanic membranes
*Nose & Throat: Normal external exam, moist mucosa
*Neck: Non-meningeal
*Cardiovascular: Patient is not tachycardic
* _ Regular rate and rhythm without appreciable murmur
* _ Heart rate appropriate for fever
*Respiratory:
* _ Patient is in no respiratory distress
* _ Lungs are clear to auscultation bilaterally
*Back: Normal inspection of the back with good range of motion
*Extremities: Normal strength, capillary refills <2 seconds
*Neuro: Normal mentation, alert and oriented, appropriately conversive, coordination appears to be adequate, ambulatory without assistance
*Skin: Warm, dry, and intact
*
*Medical Decision Making
*_ The patient appears well, is in no respiratory distress, and does not meet the clinical inclusion criteria for COVID-19 testing. The patient is not in the high-risk category for flu testing and treatment with anti-viral medication. The lung exam does not support a diagnosis of pneumonia. The history and physical are inconsistent with pulmonary embolism.
*
*Clinical Impression/Plan
*_ Influenza-like illness/viral syndrome: The patient was counseled on self care: rest, staying hydrated, taking acetaminophen/ibuprofen for fever, and avoiding close contact with others fever-free for >24 hours. We discussed returning to the emergency department if fevers persist more than 5 days, they develop difficulty breathing, they are unable to tolerate liquids, or they become confused or develop neck stiffness.

==
*Paper chart [[file:2 - Provider Paper Documentation v2.pdf]]
*Paper discharge instructions
**Hospital Copy
***[[file:3 - Paper DC Signature Adult English.pdf]]
***[[file:3 - Paper DC Signature Adult SPANISH.pdf]]
***[[file:3 - Paper DC Signature Adult Korean.pdf]]
***[[file:3 - Paper DC Signature Adult Mandarin.pdf]]
**Patient Copy
***[[file:4 - Paper Discharge Inst - ADULT English.pdf]]
***[[file:4 - Paper Discharge Inst - Adult SPANISH.pdf]]
***[[file:4 - Paper Discharge Inst - Adult Korean.pdf]]
***[[file:4 - Paper Discharge Inst - Adult Mandarin.pdf]]

==
* Orchid electronic discharge available under “Understanding 2019 Novel Coronavirus”

===COVID FAQ's===
*Carts in airborne precaution rooms only need to be wiped down - Zangwill 3/30
*Reasonable to clamp ET tube after cardiac arrest death - Zangwill 3/30
*Do NOT put patient info on pink armband - Martee 3/30
*No morgue viewings of COVID patients - Dr. Bolaris 3/30
** no Pt identifiers on outside pink tag - Nancy Blake 3/31
*Homeless patients
**If eligible for DC, need COVID test sent
**Consult SW - DPH intake center 8a-8p; 833-596-1009

==Flu/ILI==
*Influenza-like-illness (ILI) is defined as fever >100.0 F / 37.8 C AND cough or sore throat.
*Per our DHS policy, please consider treatment for high-risk populations.
**Antivirals for influenza are most effective when administered when symptoms have been present for <48 hours.
**May benefit for severely ill patients who have had >48 hours of symptoms.
*High risk patients for complications include:
# Age < 2 years or > 65 years
# Pregnancy
# Chronic disease. Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes)
# Immune suppression, including that caused by medications or HIV
# Persons younger than 19 years of age who are receiving long term aspirin therpay
*Don't send POC influenza test, due to low sensitivity (50-70%).
*Please send the Biofire / Respiratory Panel PCR for admitted ILI patients.
*Don't send POC RSV unless it will change your management.

==Measles==
* Report suspected measles immediately to DPH
** Weekdays 8:30 AM – 5 PM: call 888-397-3993
** After-hours: call 213-974-1234 and ask for the physician on call.

*Plan:
** Isolate pt - https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Measles-HCFacilityICRecs.pdf
** If advised to test for measles by DPH, submit a specimen for polymerase chain reaction (PCR) testing
*** Full clinical guidance from the California Department of Public Health https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Measles-ClinicalGuidance.pdf
*** Guidance from CDC for healthcare professionals:https://www.cdc.gov/measles/hcp/index.html

* Risk factors: international travel, never immunized of born after 1956
* Symptoms
** Fever, including subjective fever.
** Rash that starts on the head and descends.
** Usually 1 or 2 of the “3 Cs” – cough, coryza and conjunctivitis.

==Hepatitis A==
The County Department of Public Health has declared a Hepatitis A Outbreak in Los Angeles County and we are being asked in the emergency department to do our part to stem this outbreak.
　
In order to help we need to do the following things for all ADULTS (>18 years):
　
#Suspect: Consider acute viral hepatitis, especially in homeless patients or patients using illicit drugs.
#Test: If you suspect the patient may have acute viral hepatitis, order appropriate serologic studies (Hep A IgM, Hep B Core IgM, Hep B Surface Ag, Hep C Antibody Ab.) These are all available in the "AMB Hepatitis Workup" order set. STAT 45 minute turnarounds for the Hep A IgM is available, must be ordered as a standalone STAT test from the ED Quick Orders Page. If it is bundled with other Hepatitis tests, the machine runs all of them, delaying the turnaround time.
#Report: All suspected and confirmed cases of Hepatits A should be immediately reported to both the Dept of Health at (888) 397-3993 or after hours (213) 974-1234 AND Harbor Infection Control at x3838 While Patient Is Still in the Emergency Department
#Vaccinate: Anyone (regardless of why they are here) who is or has been homeless in the last two months, or uses illicit drugs (NOT JUST IV; except marijuana) should be offered the initial dose of Hep A vaccine while in the ED (the Cerner order is "Hepatitis A adult vaccine" on ED Quick Orders Page). They can be referred to the Department of Health for their second injection in six months. Check the "immunizations" area in Cerner to make sure they are not already immunized.
#Protect Yourself: If you haven't gotten the hepatitis A vaccine, it is recommended that you go to employee health to get vaccinated.

{{Harbor Ebola Precautions}}

==See Also==
*[[Harbor:Main]]

==References==
<references/>

[[Category:Admin]]

Harbor:Infectious Disease Threats

2020-04-06T19:14:48Z

Jtolles: /* Airway Management */

==Coronavirus ([[COVID-19]])==
;See [[COVID-19]] for non-Harbor-specific information; please feel free to contribute to the further development of these pages''

===COVID physician leads===
*AED Flow/Discharges- Andrea
*Drug/Non-PPE Shortages - Andrea
*Non-Emergency Physicians in the Emergency Department - Mike
*Homeless Issues - Dennis
* Airway-Ryan
*Environmental Services/Cleaning Protocols- Moh
*Triage/Fast Track Tents - Brad
*Email Updates - Andrea
*Pediatric Schedule - Kelly
*PPE - Shira
*EMS - Shira
*Palliative Care/End-Of-Life Issues - Tim J.
*ACLS - Shira
*COVID Testing - Mike
*Transfers to Mercy Ship – Denise (Currently only for inpatients with non-respiratory issues and negative Covid test)
*Attending scheduling for Adult ED – Manny
*PED issues - Patricia

===COVID Terminology===
*“Pink”
**respiratory complaint/Not PUI
**Need droplet/contact PPE
**pink wrist bands = need mask.
*“PUI”
** Meet DHS Testing Criteria (See below)

*Disaster track categories
**The router will place initial category,
**Ask nurse to change as necessary (can use communication order)
***Categories
****COVID EXPOSURE – no symptoms but at risk
****COVID FT – ILI symptoms (Cough, fever or SOB)
****COVID AED – not PUI but too complicated for quick dispo
****COVID PUI – meet DHS testing criteria

===Latest Updates===
*A&B/RSV RT-PCR order is replaced with “COVID-19 Test Request” on 4/3/2020.

===Harbor Checklists===
* Bedside checklist: [[:File:Harbor COVID checklist v3-21-20.pdf]]
* Additional DPH Guidance: http://publichealth.lacounty.gov/acd/nCorona2019.htm
* HARBOR ID UPDATES https://lacounty.sharepoint.com/sites/dhs-harbor-inf_prev_ctrl/SitePages/Breaking-News-and-Other-Disease-Information.aspx
*DHS Covid Sharepoint https://lacounty.sharepoint.com/sites/DHS-COVID19/ExpectedPractices/Forms/Newest%20on%20Top.aspx
*Seattle ICU doctor's one page info on mgmt of COVID from ACEP website [[:File:COVID19 seattle one pager.pdf]]
*Harbor DEM COVID airway management guide [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
*Proper donning and doffing with reusable goggles and stethoscope [[:File:Procedure for Reuse of Faceshields and Goggles 3-19-2020.pdf]]

===Triage===
*PUI going direct to room - do not order triage labs
*PINK wristband = mask + respiratory area if in waiting room

===DHS PUI Testing Criteria 3-23-20===
*Nurses will put everyone '''suspected''' of meeting PUI in a room in droplet precautions
*ED Attending will determine if patient meets definition
#Fever '''AND''' (cough '''OR''' shortness of breath '''''AND''''' NOT requiring hospitalization). Must be '''MEASURED''' fever in ED or at home (>100.4 F/38.0 C) '''''AND''''':
## healthcare worker '''''OR'''''
## works or lives in group environment (SNF/group home/rehab center/jail) '''''OR'''''
# Symptoms of Acute Respiratory Infection (New cough ''''OR'''' new Shortness of Breath. No fever required) '''''AND''''' REQUIRING HOSPITALIZATION '''''without an alternative diagnosis''''' (positive blood culture, cavitary lesion, chronic (>14d))
#'''''CONSIDER''''' testing ONLY if it will change management for:
## age>65 with chronic medical conditions (heart or lung disease)'''''OR'''''
## immunosuppression (includes prednisone>20mg daily)

** ID is available 24/7 if you are unclear if they meet PUI criteria

===Commercial testing (Quest or UCLA) for PUI criteria above===
'''NO LONGER NEED FLU TEST, flu season is over'''.
*PROCEDURE
**Order COVID-19 test from Covid Order Set.
**If Flu/RSV consider excluding COVID
**Complete both:
***"Harbor UCLA's Laboratory Miscellaneous Lab Form"[[:File:Laboratory Miscellaneous Request Form.pdf]]
***UCLA's lab request form [[:File:HARBOR UCLA UCLA BURL CUSTOM 032720.pdf]]
**Specimen must be walked up to the lab
*'''If Testing, Send out the batch text (p9699)'''. Please include:
** '''Patient Name''',
**'''MRUN'''
**'''Location''' (e.g. "AED Room A12")
**If "Consult to COVID Tracking" order Write "FYI" in callback field. Does not result in a callback.
==
*'''Follow Up of Test Results for Discharged Patients'''
*** AED patients: '''''Lab Follow-up - HAR''''' (like UCx and STI's)
****DHS empaneled patients: '''''message the provider'''''
*** PED patients: '''''Peds - HAR/USC''''' (the usual laboratory follow up procedure may be followed)
****DHS empaneled patients: '''''message the provider'''''
**Do not rely on Public Health to follow up test results

===Discharge===
*Homeless patient with mild symptoms that could be discharged,
**Placement
***Call SW early
***DPH call center (833-596-1009) 8a-6p every day
****Helps with transportation
****Need pending Covid test
****Must be able to perform ADLs

===Airway Management===
*'''Airway management''' [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
**Intubate early (consider if need 6L NC or more), use VL so you’re face is further away. Clean VL with grey wipes, observe 3 min wet time
**Location: negative room pressure preferred; if patient too unstable to move to negative pressure room, use single patient room
**Avoid BiPAP, high flow nasal cannula (HFNC), nebulizers
**If non-invasive ventilation is required (due to limited vents), HFNC with surgical mask is preferred over BiPAP. Both require ''airborne precautions.''
***Use MDI/spacer instead of nebs
***If needed HFNC with surgical mask over patient is preferred over BiPAP
***Viral filters should not be used with BVM or stocked in the airway carts, in order to preserve them for the transport ventilators
**Per CDC, do not treat with steroids (prolongs viral replication) unless for a secondary reason (ie, COPD)
**When intubating patients, for any unclear cases, wear N95, face shield, gown and gloves
***If using PAPR, then need pre-assigned RN outside the room to help decontaminate it by wiping it down with purple wipes before you take it off
**From Manny - We have an aerosol box approved and ready for us in trauma bay 1. Please remember to handle with care and more importantly, clean with bleach (orange) wipes after each use per infection control. This is a good tool to consider when you are intubating a PUI patient.
***Pre-oxygenate with NRB at 15L/min with surgical mask over vents and use apneic nasal cannula at 6L/min during intubation.
***Avoid using bag-valve-mask if possible
***If possible, directly attach patient to ventilator without BVM after cuff is inflated
***RSI to ensure paralysis. Consider higher range of dosing of paralytic to avoid patient coughing.
***Follow ARDSnet protocol, TV ~6ml/kg ideal body weight, high PEEP - http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

===Treatment Tips===
* Patient Presentation
**''Patient may have preceding GI symptoms prior to developing respiratory illness''
*'''Treatment'''
**Avoid steroids unless strong non-COVID indication
**Limited data on chloroquine or hydroxychloroquine
**Remdesivir via compassionate use for severely hypoxemic (Mechanical vent, high PEEP, FiO2 requirements >40%,).
*Any MDIs used in the ED to sent home with the patient instead of prescribing the patient another MDI and throwing the one used in the ED away. To do so, three simple steps needs to happen:
#Fill out a pre-printed rx sticker - available in English and Spanish with patient's name, the date, your name, patient's MRN. The stickers will be on the same clipboard as the logs (see #3 below) in each doc box.
#Put sticker on box for inhaler or inhaler itself and hand to patient
#Put patient sticker (or write patient name and MRN), your name, and circle drug given on the log. There will be a log in each doc box (purple, green, pediatrics).

==== Ventilator Management ====
* PRVC mode, initial tidal volume: 6-8 mL/kg of predicted body weight (link)
* If initial plateau pressure is persistently > 30 cm H2O, reduce the tidal volume by 1 mL/kg, until plateau pressure <30 H2O
* Goal: SpO2 88-96%: Adjust PEEP and FiO2 as per table below

{| class="wikitable"
|-
| '''FiO2''' || 0.3 || 0.4 || 0.5 || 0.6 || 0.7 || 0.8 || 0.9 || 1.0
|-
| '''PEEP''' || 12-14 || 14-16 || 18 || 18-20 || 18-20 || 22 || 22 || 22-24
|}

* If SpO2 <88% despite maximum FiO2 and PEEP on table above, intervene in the following order. If goal SpO2 is not achieved, proceed to the next step on the list.
** Prone the patient
** Observe for signs of dyssynchrony with the ventilator (e.g. initiating a new breath before full exhalation, coughing/auto-triggering). If present, first increase sedation to RASS of -4. If persistent, give single dose non-depolarizing paralytic (e.g. vecuronium 0.1mg/kg)
** Seek expert (MICU) consultation to place patient on APRV
** If above steps and MICU consultation fail to stabilize oxygenation of patient, V-V ECMO may be considered for select patients. Contact trauma attending to reach Dennis Kim.

====Antibiotics ====
* CAP treatment for intubated patients with ARDS per surviving sepsis guidelines

====Fluid resuscitation====
* For hemodynamically stable patients with ARDS, avoid fluid resuscitation
* For hemodynamically unstable patients with ARDS, consider small (500mL) fluid boluses and early norepinephrine

===PPE===
*“Special Precautions” are announced for an EMS patient and airway management pages, please ensure that all involved healthcare workers are wearing appropriate PPE.
*Recommendation for PPE [[:File:Guidance on precautions and masks for COVID-19_updated 3.25.20.pdf]]
**In general, wear surgical masks (ties) or procedure mask (ear loops) and eye protection (goggles or face shield) while working in the ED since we often deal with limited information when evaluating patients. Personal glasses or the traditional ED disposable plastic glasses are not sufficient.
**If a patient is getting a high-risk aerosol generating procedure (AGP) then airborne precautions are preferred in addition to contact and droplet precautions. AGP include intubation, NIPPV (BiPAP/CPAP), high flow oxygen, nebulizers, CPR, and suctioning, to name a few relevant in the ED. If need to do NIPPV, nebs, HFNC try your best to place surgical mask over.
**Once intubated, or after an AGP is completed, patient needs airborne precautions x 1 hr if vent is not being disconnected or if patient is not getting suction. Since an ETT connected to a vent is a closed circuit, after 1 hour the patient goes back onto droplet/contact precautions. If other AGP done again then 1 hr clock restarts needing airborne precautions. If patient was dispositioned out of the ED while still in airborne precautions, then will need terminal clean with 1-hour air exchange.
**If no AGP, then patient needs to wear a mask and have contact and droplet precautions with closed door. So for example, if a masked ‘pink’ patient is going to CT without an AGP, only need a wipe down as per usual contact/droplet cleaning, and does not need a terminal clean.
**After a Pink or PUI patient leaves the ED, the room may be cleaned immediately per droplet/contact precautions, unless there was an AGP was done in the previous 1 hour.
**Only need terminal clean if aerosol generating procedure (AGP) done, otherwise just droplet precaution cleaning with wipes
**Write your name into the log by patient room if sick suspected COVID patient getting admitted
** PAPR - get from Charge RN.
*** If using a PAPR - get a '''preassigned nurse''' outside the room '''decontaminate it''' for you before you take it off (Purple wipes)
**If patient brought in by EMS, let MICN know you suspect COVID so they can inform the EMS crew & decontaminate their rig

===Exposures===
* '''If you are exposed''' to a confirmed patient - whether in PPE or not - you should self-monitor for symptoms for 14 days. OK to work as long as you do not have symptoms. IPC and Employee Health will give recs for staff exposures based on CDC criteria.
** [[:File:Self Monitoring log .pdf]]
** [[:File:Guidance for WFM Call Offs .v2._3.24.2020.pdf]]
* Infection Prevention confirms the exposure and provides Employee Health with a list of affected departments. Employee Health then notifies all dept chairs or supervisors of exposure and request list of names of staff with potential exposure. Supervisor provides staff with a confidential notice to present to Employee Health
*Employee presents to Employee Health for evaluation
Based on CDC exposure risk either self-monitor with or without work restrictions are initiated

===Admissions===
*‘Consult to COVID Tracking’ in Quick Orders page, please write “FYI” in the required call back field. Do not expect a call back since this is just for tracking purchases. Send this tracking page for all PUIs getting admitted, even if known to be Covid+ already.
*Adult patient
**Covid hospitalist team p1325 - non-ICU level care
**If COVID PUI is requiring >6L of NC consider intubation or at least notifying MICU team.
**MICU - third call pager
**Any discrepancies if patient is PUI, consult ID

*PED
**Our PICU has no negative pressure rooms. The Pediatric ward has 5 rooms that are negative pressure. For children with URI/ILI symptoms that need to be admitted they will need to go into a negative pressure room upstairs. If they require SDU or PICU placement we will need to discuss with the PICU attending. The PICU has converted room 15 on the pediatric ward to be used for ICU level care and may turn a few more of the negative pressure rooms into ICU level care rooms.
**For all of PED patients being admitted, please ask about fever, cough, and/or SOB or any known exposure to Covid+ patient. This is important information to get on all of our traumas and patients who come in for other reasons as it does have an impact on our staff and the admitting team.
**For all adolescent psych patients, as part of your MSE, please ask each of them about recent fever, cough, sob and known exposure to Covid+ patient. Also remember that GI symptoms can also be caused by Covid. If there is a patient with any of these symptoms, they cannot go to the adolescent psych ED until we talk with ID to determine risk of Covid-19.
**Per ID, if a PED asthmatic patient is well enough to go home, we should not be doing COVID-19 testing on him or her. If he/she is being admitted we should discuss with ID the need for COVID-19 testing.

===Screening L&D Patients===
* If >14 weeks with fever or cough, keep in ED
* If febrile, immediately consult OB and place in AED 15, 16, 17, 21, Tra 1-7, or peds 4 for FetalLink monitoring capabilities

===Latest Numbers - Census, Positives, Supplies, Rx===
*Census
**AED Volume: 4/5= 99
**PED Volume: 4/5= 20
**UCC Volume: 4/3= 22
** Hospital 4/6= 193
***RED 4W PCU: 4/3= 18/27 (9 open)
***RED 3W SDU: 4/3= 19/20 (1 open)
***RED 5WICU: 4/6= 8/8 (zero open)
***ED RED ICU: 4/6= 0 (@11:00)
** DHS & LA County hospital/ICU beds, available ventilators, etc
*** http://file.lacounty.gov/SDSInter/dhs/1070348_DHSCOVID-19Dashboard.pdf
*** http://mlkioasashaw01.dhs.lacounty.gov/SASVisualAnalyticsViewer/VisualAnalyticsViewer.jsp?saspfs_request_backurl_list=http%3A%2F%2Fmlkioasashaw01.dhs.lacounty.gov%2FSASVisualAnalyticsHub&saspfs_request_backlabel_list=Home&saspfs_request_path_url=SBIP%3A%2F%2FMETASERVER%2FProd%2FDHS%2F_Shared%2FReports%2FCovid+04+05+20%28Report%29&saspfs_request_entitykey=A501L7HF.AX000487%2FTransformation&_vaSectionName=vi1051

*COVID Cases
** Harbor
*** POSITIVE 4/4= 20
*** PUI (pend) 4/4= 5
** LA County
*** COVID +ve= 4/4=5304
**** Predicted trajectory: 4/4=6918; 4/5=8578; 4/6=10,636; 4/7=13,189; 4/8=16,355; 4/9=20,280; 4/10=25,147; 4/11=31,182; 4/12=38,666; 4/13=47,946; 4/14=59,452; 4/15=73,721; 4/16=91,414; 4/17=113,353
**** Age <18= 48
**** Age 18-40= 1785
**** Age 41-65= 2160
**** Age >65= 1050
**** Deaths= 117
*** Mercy Transfers 4/2=10

*Supplies
** Viral swabs 4/4=1374
** Surgical masks 4/4= <30-day supply
** N-95 4/4= <30-day supply
** Face shields 4/4= 800
** PAPR + Dover (ED) 2+5
** CAPR (ED) 6 (~40 DLCs 3/30)
** Ventilators 3/31 23 available
** Gloves 3/26= enough
** Gowns 3/26= enough

*Drug shortages
** Morphine & Fentanyl
** IV fluids - use oral hydration whenever possible. Reserve IVF to those that cannot tolerate PO.
** Albuterol and ipratropium MDI - we have enough for now but in next few weeks we may be seeing surge in PUI's and their need, please conserve when you can. We have placed order for more but no definitive release date. Remember we can give patients same used MDI on discharge
** Chloroquine and hydroxychlorquine and azithromycin are on shortage list but they're not standard of care for PUIs. We'll see as situation unfolds.

===COVID ACTION PLAN (Phases 1-3)===
* Phase I: “COVID-19 Screening”
** Pre-router - mask patients with fever, cough, dyspnea
** Router - register on disaster track (“COVID Possible”)
*** “Routine” priority
**** COVID EXPOSURE – no symptoms but at risk
**** COVID FT – ILI symptoms
**** COVID ED – not PUI criteria but ILI with other medical issues that are too complex for FastTrack
*** “High” Priority
****COVID PUI – for patients meeting DPH criteria
*** Patients in respiratory isolation to AWR Alcove / back half of PWR
** Triage
*** Triage priority: Cardiac > High > COVID > Routine
*** Temporarily suspending CXR for RIPT scoring
** Ambulance Triage
*** All patient (including those going to Psych ED) must be screened per above
** Psych ED
*** EMS to Psych ED will receive screening at psych
**** If a patient meets PUI criteria, they should be immediately transferred to the AED and placed in a room
*** Patients arriving in Triage or AED for clearance to psych need MSE note
**** If no infectious or other medical concerns, the patient can go directly to the Psych ED after physician evaluation
*** Labor & Delivery
**** ED will perform infection screening on all patients presenting to the ED including L&D patients >14 weeks gestation
***** If negative, they will be directed to L&D
***** If positive with fever (subjective or recorded in past 24 hours), they will be triaged as usual and OB will be consulted
***** '''''If >24 weeks gestation, they will be prioritized to AED 15, 16, 17, 21, Tra 1-7, or PED 4 for Fetal Link monitoring, with the goal of door to monitoring in <20 minutes'''''
***** If the patient is in active labor, the patient will be moved to one of the trauma bays and the L&D team will decide the best location for impending delivery

* Triage Rapid DC
** '''''RN''''' completes portion of team triage and goes to open triage room for next patient after provider interview completed
** '''''Provider'''''
*** Completes MSE Note: “definitive treatment provider”; “please see chart for details”; tracking acuity “5”; no typing in History/Exam section
*** Completes paper chart or .phrase and pre-printed paper discharge (English/Spanish/Korean)
*** Give discharge paper work to registration and patient (provider to sign the discharge paperwork and state “patient verbally consents” to avoid fomite transmission)
*** Takes patient to registration windows A-C and hands paper forms (H&P and signed DC) to Patient Access Staff
*** Join RN in new room after discharge process from prior patient complete
** PAS will complete registration then sticker the paper forms, and place the chart in box to be scanned
** Patient leaves from registration
** RN wipes down exposed/touched surfaces per droplet protocol using Grey Cavi-wipe to clean all surfaces (door handle, chair, etc.)
** Discharge off the tracking board
*** DETAILED STEPS:
#1 - click pt recented seen x 6
#2 - "H" for home, "T" for today, "N" for now

*PED Rapid DC
** If the patient does not meet PUI criteria, send directly to PED 8-10 for immediate discharge
*** If >3 patients, send to the masked patient side of the Peds WR NP or resident in PED 8-10
*** Chart with “.edcovid” – include reference that patient given COVID ED instructions
*** Discharge with pre-printed paper discharge
*** Registration in PED 8-10
** If the patient meets PUI criteria, patient taken directly to a room and notify PED team
*** Change QuickReg to “COVID PUI”
*** If not eligible for FT but not a PUI, change QuickReg to “COVID PED”

*Phase 2
** '''''DHS/OOP ESI 4/5 can go to UCC'''''
** FT Team Rapid Dispo (ESI 3 or 4) - low risk, COVID suspected (but not meeting DHS PUI criteria), but still needs simple workup
*** Complete triage, rapid history & exam
*** Apply PINK wrist band to patient indicating COVID suspected/DHS PUI patients.
*** Provider & triage RN exit the room and initiates a new triage process in the open room for the next patient
*** Patient goes to COVID suspected/DHS PUI specific tasking rooms
**** RME 7 (internal waiting room)
**** RME 9 (phlebotomy)
**** These two rooms will be designated COVID suspected rooms and will have more frequent housekeeping cleaning
**** Tasking LVN to ensure droplet precautions are followed in these rooms and will escort patient to XR & EKGs
*** After tasking, patient will be escorted to Registration windows A-C
**** Registration sends patient to respiratory isolation area of the waiting room
*** FT team/NPs evaluates disposition from the Alcove if appropriate (use privacy screen)
** Non-FT Candidate
*** Notify RME charge nurse for available bed in ED

===.edcovid, paper charts, & discharge material===
*History:
*Chief complaint _
*HPI _
*Pertinent ROS:
*_ Fever
*_ Cough
*_ Rhinorrhea
*_ Headache
*_ Vomiting
*Other: _
*
*Past Medical History
*_ No significant Past Medical History
*_ High-risk Conditions: Age >65, Heart disease, Diabetes, Pregnant, Immunocompromised
*Other: _
*
*Allergies: _
*_ No known drug allergies

*Physical Exam:
*_Vital signs normal
*General: Patient is well nourished, well developed, awake and alert, in no acute distress
*Head: Normocephalic and atraumatic
*Eyes: Normal inspection, extraocular muscles intact
*_ Ears: normal external exam and tympanic membranes
*Nose & Throat: Normal external exam, moist mucosa
*Neck: Non-meningeal
*Cardiovascular: Patient is not tachycardic
* _ Regular rate and rhythm without appreciable murmur
* _ Heart rate appropriate for fever
*Respiratory:
* _ Patient is in no respiratory distress
* _ Lungs are clear to auscultation bilaterally
*Back: Normal inspection of the back with good range of motion
*Extremities: Normal strength, capillary refills <2 seconds
*Neuro: Normal mentation, alert and oriented, appropriately conversive, coordination appears to be adequate, ambulatory without assistance
*Skin: Warm, dry, and intact
*
*Medical Decision Making
*_ The patient appears well, is in no respiratory distress, and does not meet the clinical inclusion criteria for COVID-19 testing. The patient is not in the high-risk category for flu testing and treatment with anti-viral medication. The lung exam does not support a diagnosis of pneumonia. The history and physical are inconsistent with pulmonary embolism.
*
*Clinical Impression/Plan
*_ Influenza-like illness/viral syndrome: The patient was counseled on self care: rest, staying hydrated, taking acetaminophen/ibuprofen for fever, and avoiding close contact with others fever-free for >24 hours. We discussed returning to the emergency department if fevers persist more than 5 days, they develop difficulty breathing, they are unable to tolerate liquids, or they become confused or develop neck stiffness.

==
*Paper chart [[file:2 - Provider Paper Documentation v2.pdf]]
*Paper discharge instructions
**Hospital Copy
***[[file:3 - Paper DC Signature Adult English.pdf]]
***[[file:3 - Paper DC Signature Adult SPANISH.pdf]]
***[[file:3 - Paper DC Signature Adult Korean.pdf]]
***[[file:3 - Paper DC Signature Adult Mandarin.pdf]]
**Patient Copy
***[[file:4 - Paper Discharge Inst - ADULT English.pdf]]
***[[file:4 - Paper Discharge Inst - Adult SPANISH.pdf]]
***[[file:4 - Paper Discharge Inst - Adult Korean.pdf]]
***[[file:4 - Paper Discharge Inst - Adult Mandarin.pdf]]

==
* Orchid electronic discharge available under “Understanding 2019 Novel Coronavirus”

===COVID FAQ's===
*Carts in airborne precaution rooms only need to be wiped down - Zangwill 3/30
*Reasonable to clamp ET tube after cardiac arrest death - Zangwill 3/30
*Do NOT put patient info on pink armband - Martee 3/30
*No morgue viewings of COVID patients - Dr. Bolaris 3/30
** no Pt identifiers on outside pink tag - Nancy Blake 3/31
*Homeless patients
**If eligible for DC, need COVID test sent
**Consult SW - DPH intake center 8a-8p; 833-596-1009

==Flu/ILI==
*Influenza-like-illness (ILI) is defined as fever >100.0 F / 37.8 C AND cough or sore throat.
*Per our DHS policy, please consider treatment for high-risk populations.
**Antivirals for influenza are most effective when administered when symptoms have been present for <48 hours.
**May benefit for severely ill patients who have had >48 hours of symptoms.
*High risk patients for complications include:
# Age < 2 years or > 65 years
# Pregnancy
# Chronic disease. Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes)
# Immune suppression, including that caused by medications or HIV
# Persons younger than 19 years of age who are receiving long term aspirin therpay
*Don't send POC influenza test, due to low sensitivity (50-70%).
*Please send the Biofire / Respiratory Panel PCR for admitted ILI patients.
*Don't send POC RSV unless it will change your management.

==Measles==
* Report suspected measles immediately to DPH
** Weekdays 8:30 AM – 5 PM: call 888-397-3993
** After-hours: call 213-974-1234 and ask for the physician on call.

*Plan:
** Isolate pt - https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Measles-HCFacilityICRecs.pdf
** If advised to test for measles by DPH, submit a specimen for polymerase chain reaction (PCR) testing
*** Full clinical guidance from the California Department of Public Health https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Measles-ClinicalGuidance.pdf
*** Guidance from CDC for healthcare professionals:https://www.cdc.gov/measles/hcp/index.html

* Risk factors: international travel, never immunized of born after 1956
* Symptoms
** Fever, including subjective fever.
** Rash that starts on the head and descends.
** Usually 1 or 2 of the “3 Cs” – cough, coryza and conjunctivitis.

==Hepatitis A==
The County Department of Public Health has declared a Hepatitis A Outbreak in Los Angeles County and we are being asked in the emergency department to do our part to stem this outbreak.
　
In order to help we need to do the following things for all ADULTS (>18 years):
　
#Suspect: Consider acute viral hepatitis, especially in homeless patients or patients using illicit drugs.
#Test: If you suspect the patient may have acute viral hepatitis, order appropriate serologic studies (Hep A IgM, Hep B Core IgM, Hep B Surface Ag, Hep C Antibody Ab.) These are all available in the "AMB Hepatitis Workup" order set. STAT 45 minute turnarounds for the Hep A IgM is available, must be ordered as a standalone STAT test from the ED Quick Orders Page. If it is bundled with other Hepatitis tests, the machine runs all of them, delaying the turnaround time.
#Report: All suspected and confirmed cases of Hepatits A should be immediately reported to both the Dept of Health at (888) 397-3993 or after hours (213) 974-1234 AND Harbor Infection Control at x3838 While Patient Is Still in the Emergency Department
#Vaccinate: Anyone (regardless of why they are here) who is or has been homeless in the last two months, or uses illicit drugs (NOT JUST IV; except marijuana) should be offered the initial dose of Hep A vaccine while in the ED (the Cerner order is "Hepatitis A adult vaccine" on ED Quick Orders Page). They can be referred to the Department of Health for their second injection in six months. Check the "immunizations" area in Cerner to make sure they are not already immunized.
#Protect Yourself: If you haven't gotten the hepatitis A vaccine, it is recommended that you go to employee health to get vaccinated.

{{Harbor Ebola Precautions}}

==See Also==
*[[Harbor:Main]]

==References==
<references/>

[[Category:Admin]]

Harbor:Infectious Disease Threats

2020-04-06T19:01:06Z

Jtolles: /* Airway Management */

==Coronavirus ([[COVID-19]])==
;See [[COVID-19]] for non-Harbor-specific information; please feel free to contribute to the further development of these pages''

===COVID physician leads===
*AED Flow/Discharges- Andrea
*Drug/Non-PPE Shortages - Andrea
*Non-Emergency Physicians in the Emergency Department - Mike
*Homeless Issues - Dennis
* Airway-Ryan
*Environmental Services/Cleaning Protocols- Moh
*Triage/Fast Track Tents - Brad
*Email Updates - Andrea
*Pediatric Schedule - Kelly
*PPE - Shira
*EMS - Shira
*Palliative Care/End-Of-Life Issues - Tim J.
*ACLS - Shira
*COVID Testing - Mike
*Transfers to Mercy Ship – Denise (Currently only for inpatients with non-respiratory issues and negative Covid test)
*Attending scheduling for Adult ED – Manny
*PED issues - Patricia

===COVID Terminology===
*“Pink”
**respiratory complaint/Not PUI
**Need droplet/contact PPE
**pink wrist bands = need mask.
*“PUI”
** Meet DHS Testing Criteria (See below)

*Disaster track categories
**The router will place initial category,
**Ask nurse to change as necessary (can use communication order)
***Categories
****COVID EXPOSURE – no symptoms but at risk
****COVID FT – ILI symptoms (Cough, fever or SOB)
****COVID AED – not PUI but too complicated for quick dispo
****COVID PUI – meet DHS testing criteria

===Latest Updates===
*A&B/RSV RT-PCR order is replaced with “COVID-19 Test Request” on 4/3/2020.

===Harbor Checklists===
* Bedside checklist: [[:File:Harbor COVID checklist v3-21-20.pdf]]
* Additional DPH Guidance: http://publichealth.lacounty.gov/acd/nCorona2019.htm
* HARBOR ID UPDATES https://lacounty.sharepoint.com/sites/dhs-harbor-inf_prev_ctrl/SitePages/Breaking-News-and-Other-Disease-Information.aspx
*DHS Covid Sharepoint https://lacounty.sharepoint.com/sites/DHS-COVID19/ExpectedPractices/Forms/Newest%20on%20Top.aspx
*Seattle ICU doctor's one page info on mgmt of COVID from ACEP website [[:File:COVID19 seattle one pager.pdf]]
*Harbor DEM COVID airway management guide [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
*Proper donning and doffing with reusable goggles and stethoscope [[:File:Procedure for Reuse of Faceshields and Goggles 3-19-2020.pdf]]

===Triage===
*PUI going direct to room - do not order triage labs
*PINK wristband = mask + respiratory area if in waiting room

===DHS PUI Testing Criteria 3-23-20===
*Nurses will put everyone '''suspected''' of meeting PUI in a room in droplet precautions
*ED Attending will determine if patient meets definition
#Fever '''AND''' (cough '''OR''' shortness of breath '''''AND''''' NOT requiring hospitalization). Must be '''MEASURED''' fever in ED or at home (>100.4 F/38.0 C) '''''AND''''':
## healthcare worker '''''OR'''''
## works or lives in group environment (SNF/group home/rehab center/jail) '''''OR'''''
# Symptoms of Acute Respiratory Infection (New cough ''''OR'''' new Shortness of Breath. No fever required) '''''AND''''' REQUIRING HOSPITALIZATION '''''without an alternative diagnosis''''' (positive blood culture, cavitary lesion, chronic (>14d))
#'''''CONSIDER''''' testing ONLY if it will change management for:
## age>65 with chronic medical conditions (heart or lung disease)'''''OR'''''
## immunosuppression (includes prednisone>20mg daily)

** ID is available 24/7 if you are unclear if they meet PUI criteria

===Commercial testing (Quest or UCLA) for PUI criteria above===
'''NO LONGER NEED FLU TEST, flu season is over'''.
*PROCEDURE
**Order COVID-19 test from Covid Order Set.
**If Flu/RSV consider excluding COVID
**Complete both:
***"Harbor UCLA's Laboratory Miscellaneous Lab Form"[[:File:Laboratory Miscellaneous Request Form.pdf]]
***UCLA's lab request form [[:File:HARBOR UCLA UCLA BURL CUSTOM 032720.pdf]]
**Specimen must be walked up to the lab
*'''If Testing, Send out the batch text (p9699)'''. Please include:
** '''Patient Name''',
**'''MRUN'''
**'''Location''' (e.g. "AED Room A12")
**If "Consult to COVID Tracking" order Write "FYI" in callback field. Does not result in a callback.
==
*'''Follow Up of Test Results for Discharged Patients'''
*** AED patients: '''''Lab Follow-up - HAR''''' (like UCx and STI's)
****DHS empaneled patients: '''''message the provider'''''
*** PED patients: '''''Peds - HAR/USC''''' (the usual laboratory follow up procedure may be followed)
****DHS empaneled patients: '''''message the provider'''''
**Do not rely on Public Health to follow up test results

===Discharge===
*Homeless patient with mild symptoms that could be discharged,
**Placement
***Call SW early
***DPH call center (833-596-1009) 8a-6p every day
****Helps with transportation
****Need pending Covid test
****Must be able to perform ADLs

===Airway Management===
*'''Airway management''' [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
**Intubate early (consider if need 6L NC or more), use VL so you’re face is further away. Clean VL with grey wipes, observe 3 min wet time
**Avoid BiPAP, high flow nasal cannula (HFNC), nebulizers
***Use MDI/spacer instead of nebs
***If needed HFNC with surgical mask over patient is preferred over BiPAP
***Viral filters should not be used with BVM or stocked in the airway carts, in order to preserve them for the transport ventilators
**Per CDC, do not treat with steroids (prolongs viral replication) unless for a secondary reason (ie, COPD)
**When intubating patients, for any unclear cases, wear N95, face shield, gown and gloves
***If using PAPR, then need pre-assigned RN outside the room to help decontaminate it by wiping it down with purple wipes before you take it off
**From Manny - We have an aerosol box approved and ready for us in trauma bay 1. Please remember to handle with care and more importantly, clean with bleach (orange) wipes after each use per infection control. This is a good tool to consider when you are intubating a PUI patient.
***Pre-oxygenate with NRB and use apneic nasal cannula during intubation.
***Avoid using bag-valve-mask if possible
***If possible, directly attach patient to ventilator without BVM after cuff is inflated
***RSI to ensure paralysis. Consider higher range of dosing of paralytic to avoid patient coughing.
***Follow ARDSnet protocol, TV ~6ml/kg ideal body weight, high PEEP - http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

===Treatment Tips===
* Patient Presentation
**''Patient may have preceding GI symptoms prior to developing respiratory illness''
*'''Treatment'''
**Avoid steroids unless strong non-COVID indication
**Limited data on chloroquine or hydroxychloroquine
**Remdesivir via compassionate use for severely hypoxemic (Mechanical vent, high PEEP, FiO2 requirements >40%,).
*Any MDIs used in the ED to sent home with the patient instead of prescribing the patient another MDI and throwing the one used in the ED away. To do so, three simple steps needs to happen:
#Fill out a pre-printed rx sticker - available in English and Spanish with patient's name, the date, your name, patient's MRN. The stickers will be on the same clipboard as the logs (see #3 below) in each doc box.
#Put sticker on box for inhaler or inhaler itself and hand to patient
#Put patient sticker (or write patient name and MRN), your name, and circle drug given on the log. There will be a log in each doc box (purple, green, pediatrics).

==== Ventilator Management ====
* PRVC mode, initial tidal volume: 6-8 mL/kg of predicted body weight (link)
* If initial plateau pressure is persistently > 30 cm H2O, reduce the tidal volume by 1 mL/kg, until plateau pressure <30 H2O
* Goal: SpO2 88-96%: Adjust PEEP and FiO2 as per table below

{| class="wikitable"
|-
| '''FiO2''' || 0.3 || 0.4 || 0.5 || 0.6 || 0.7 || 0.8 || 0.9 || 1.0
|-
| '''PEEP''' || 12-14 || 14-16 || 18 || 18-20 || 18-20 || 22 || 22 || 22-24
|}

* If SpO2 <88% despite maximum FiO2 and PEEP on table above, intervene in the following order. If goal SpO2 is not achieved, proceed to the next step on the list.
** Prone the patient
** Observe for signs of dyssynchrony with the ventilator (e.g. initiating a new breath before full exhalation, coughing/auto-triggering). If present, first increase sedation to RASS of -4. If persistent, give single dose non-depolarizing paralytic (e.g. vecuronium 0.1mg/kg)
** Seek expert (MICU) consultation to place patient on APRV
** If above steps and MICU consultation fail to stabilize oxygenation of patient, V-V ECMO may be considered for select patients. Contact trauma attending to reach Dennis Kim.

====Antibiotics ====
* CAP treatment for intubated patients with ARDS per surviving sepsis guidelines

====Fluid resuscitation====
* For hemodynamically stable patients with ARDS, avoid fluid resuscitation
* For hemodynamically unstable patients with ARDS, consider small (500mL) fluid boluses and early norepinephrine

===PPE===
*“Special Precautions” are announced for an EMS patient and airway management pages, please ensure that all involved healthcare workers are wearing appropriate PPE.
*Recommendation for PPE [[:File:Guidance on precautions and masks for COVID-19_updated 3.25.20.pdf]]
**In general, wear surgical masks (ties) or procedure mask (ear loops) and eye protection (goggles or face shield) while working in the ED since we often deal with limited information when evaluating patients. Personal glasses or the traditional ED disposable plastic glasses are not sufficient.
**If a patient is getting a high-risk aerosol generating procedure (AGP) then airborne precautions are preferred in addition to contact and droplet precautions. AGP include intubation, NIPPV (BiPAP/CPAP), high flow oxygen, nebulizers, CPR, and suctioning, to name a few relevant in the ED. If need to do NIPPV, nebs, HFNC try your best to place surgical mask over.
**Once intubated, or after an AGP is completed, patient needs airborne precautions x 1 hr if vent is not being disconnected or if patient is not getting suction. Since an ETT connected to a vent is a closed circuit, after 1 hour the patient goes back onto droplet/contact precautions. If other AGP done again then 1 hr clock restarts needing airborne precautions. If patient was dispositioned out of the ED while still in airborne precautions, then will need terminal clean with 1-hour air exchange.
**If no AGP, then patient needs to wear a mask and have contact and droplet precautions with closed door. So for example, if a masked ‘pink’ patient is going to CT without an AGP, only need a wipe down as per usual contact/droplet cleaning, and does not need a terminal clean.
**After a Pink or PUI patient leaves the ED, the room may be cleaned immediately per droplet/contact precautions, unless there was an AGP was done in the previous 1 hour.
**Only need terminal clean if aerosol generating procedure (AGP) done, otherwise just droplet precaution cleaning with wipes
**Write your name into the log by patient room if sick suspected COVID patient getting admitted
** PAPR - get from Charge RN.
*** If using a PAPR - get a '''preassigned nurse''' outside the room '''decontaminate it''' for you before you take it off (Purple wipes)
**If patient brought in by EMS, let MICN know you suspect COVID so they can inform the EMS crew & decontaminate their rig

===Exposures===
* '''If you are exposed''' to a confirmed patient - whether in PPE or not - you should self-monitor for symptoms for 14 days. OK to work as long as you do not have symptoms. IPC and Employee Health will give recs for staff exposures based on CDC criteria.
** [[:File:Self Monitoring log .pdf]]
** [[:File:Guidance for WFM Call Offs .v2._3.24.2020.pdf]]
* Infection Prevention confirms the exposure and provides Employee Health with a list of affected departments. Employee Health then notifies all dept chairs or supervisors of exposure and request list of names of staff with potential exposure. Supervisor provides staff with a confidential notice to present to Employee Health
*Employee presents to Employee Health for evaluation
Based on CDC exposure risk either self-monitor with or without work restrictions are initiated

===Admissions===
*‘Consult to COVID Tracking’ in Quick Orders page, please write “FYI” in the required call back field. Do not expect a call back since this is just for tracking purchases. Send this tracking page for all PUIs getting admitted, even if known to be Covid+ already.
*Adult patient
**Covid hospitalist team p1325 - non-ICU level care
**If COVID PUI is requiring >6L of NC consider intubation or at least notifying MICU team.
**MICU - third call pager
**Any discrepancies if patient is PUI, consult ID

*PED
**Our PICU has no negative pressure rooms. The Pediatric ward has 5 rooms that are negative pressure. For children with URI/ILI symptoms that need to be admitted they will need to go into a negative pressure room upstairs. If they require SDU or PICU placement we will need to discuss with the PICU attending. The PICU has converted room 15 on the pediatric ward to be used for ICU level care and may turn a few more of the negative pressure rooms into ICU level care rooms.
**For all of PED patients being admitted, please ask about fever, cough, and/or SOB or any known exposure to Covid+ patient. This is important information to get on all of our traumas and patients who come in for other reasons as it does have an impact on our staff and the admitting team.
**For all adolescent psych patients, as part of your MSE, please ask each of them about recent fever, cough, sob and known exposure to Covid+ patient. Also remember that GI symptoms can also be caused by Covid. If there is a patient with any of these symptoms, they cannot go to the adolescent psych ED until we talk with ID to determine risk of Covid-19.
**Per ID, if a PED asthmatic patient is well enough to go home, we should not be doing COVID-19 testing on him or her. If he/she is being admitted we should discuss with ID the need for COVID-19 testing.

===Screening L&D Patients===
* If >14 weeks with fever or cough, keep in ED
* If febrile, immediately consult OB and place in AED 15, 16, 17, 21, Tra 1-7, or peds 4 for FetalLink monitoring capabilities

===Latest Numbers - Census, Positives, Supplies, Rx===
*Census
**AED Volume: 4/5= 99
**PED Volume: 4/5= 20
**UCC Volume: 4/3= 22
** Hospital 4/6= 193
***RED 4W PCU: 4/3= 18/27 (9 open)
***RED 3W SDU: 4/3= 19/20 (1 open)
***RED 5WICU: 4/6= 8/8 (zero open)
***ED RED ICU: 4/6= 0 (@11:00)
** DHS & LA County hospital/ICU beds, available ventilators, etc
*** http://file.lacounty.gov/SDSInter/dhs/1070348_DHSCOVID-19Dashboard.pdf
*** http://mlkioasashaw01.dhs.lacounty.gov/SASVisualAnalyticsViewer/VisualAnalyticsViewer.jsp?saspfs_request_backurl_list=http%3A%2F%2Fmlkioasashaw01.dhs.lacounty.gov%2FSASVisualAnalyticsHub&saspfs_request_backlabel_list=Home&saspfs_request_path_url=SBIP%3A%2F%2FMETASERVER%2FProd%2FDHS%2F_Shared%2FReports%2FCovid+04+05+20%28Report%29&saspfs_request_entitykey=A501L7HF.AX000487%2FTransformation&_vaSectionName=vi1051

*COVID Cases
** Harbor
*** POSITIVE 4/4= 20
*** PUI (pend) 4/4= 5
** LA County
*** COVID +ve= 4/4=5304
**** Predicted trajectory: 4/4=6918; 4/5=8578; 4/6=10,636; 4/7=13,189; 4/8=16,355; 4/9=20,280; 4/10=25,147; 4/11=31,182; 4/12=38,666; 4/13=47,946; 4/14=59,452; 4/15=73,721; 4/16=91,414; 4/17=113,353
**** Age <18= 48
**** Age 18-40= 1785
**** Age 41-65= 2160
**** Age >65= 1050
**** Deaths= 117
*** Mercy Transfers 4/2=10

*Supplies
** Viral swabs 4/4=1374
** Surgical masks 4/4= <30-day supply
** N-95 4/4= <30-day supply
** Face shields 4/4= 800
** PAPR + Dover (ED) 2+5
** CAPR (ED) 6 (~40 DLCs 3/30)
** Ventilators 3/31 23 available
** Gloves 3/26= enough
** Gowns 3/26= enough

*Drug shortages
** Morphine & Fentanyl
** IV fluids - use oral hydration whenever possible. Reserve IVF to those that cannot tolerate PO.
** Albuterol and ipratropium MDI - we have enough for now but in next few weeks we may be seeing surge in PUI's and their need, please conserve when you can. We have placed order for more but no definitive release date. Remember we can give patients same used MDI on discharge
** Chloroquine and hydroxychlorquine and azithromycin are on shortage list but they're not standard of care for PUIs. We'll see as situation unfolds.

===COVID ACTION PLAN (Phases 1-3)===
* Phase I: “COVID-19 Screening”
** Pre-router - mask patients with fever, cough, dyspnea
** Router - register on disaster track (“COVID Possible”)
*** “Routine” priority
**** COVID EXPOSURE – no symptoms but at risk
**** COVID FT – ILI symptoms
**** COVID ED – not PUI criteria but ILI with other medical issues that are too complex for FastTrack
*** “High” Priority
****COVID PUI – for patients meeting DPH criteria
*** Patients in respiratory isolation to AWR Alcove / back half of PWR
** Triage
*** Triage priority: Cardiac > High > COVID > Routine
*** Temporarily suspending CXR for RIPT scoring
** Ambulance Triage
*** All patient (including those going to Psych ED) must be screened per above
** Psych ED
*** EMS to Psych ED will receive screening at psych
**** If a patient meets PUI criteria, they should be immediately transferred to the AED and placed in a room
*** Patients arriving in Triage or AED for clearance to psych need MSE note
**** If no infectious or other medical concerns, the patient can go directly to the Psych ED after physician evaluation
*** Labor & Delivery
**** ED will perform infection screening on all patients presenting to the ED including L&D patients >14 weeks gestation
***** If negative, they will be directed to L&D
***** If positive with fever (subjective or recorded in past 24 hours), they will be triaged as usual and OB will be consulted
***** '''''If >24 weeks gestation, they will be prioritized to AED 15, 16, 17, 21, Tra 1-7, or PED 4 for Fetal Link monitoring, with the goal of door to monitoring in <20 minutes'''''
***** If the patient is in active labor, the patient will be moved to one of the trauma bays and the L&D team will decide the best location for impending delivery

* Triage Rapid DC
** '''''RN''''' completes portion of team triage and goes to open triage room for next patient after provider interview completed
** '''''Provider'''''
*** Completes MSE Note: “definitive treatment provider”; “please see chart for details”; tracking acuity “5”; no typing in History/Exam section
*** Completes paper chart or .phrase and pre-printed paper discharge (English/Spanish/Korean)
*** Give discharge paper work to registration and patient (provider to sign the discharge paperwork and state “patient verbally consents” to avoid fomite transmission)
*** Takes patient to registration windows A-C and hands paper forms (H&P and signed DC) to Patient Access Staff
*** Join RN in new room after discharge process from prior patient complete
** PAS will complete registration then sticker the paper forms, and place the chart in box to be scanned
** Patient leaves from registration
** RN wipes down exposed/touched surfaces per droplet protocol using Grey Cavi-wipe to clean all surfaces (door handle, chair, etc.)
** Discharge off the tracking board
*** DETAILED STEPS:
#1 - click pt recented seen x 6
#2 - "H" for home, "T" for today, "N" for now

*PED Rapid DC
** If the patient does not meet PUI criteria, send directly to PED 8-10 for immediate discharge
*** If >3 patients, send to the masked patient side of the Peds WR NP or resident in PED 8-10
*** Chart with “.edcovid” – include reference that patient given COVID ED instructions
*** Discharge with pre-printed paper discharge
*** Registration in PED 8-10
** If the patient meets PUI criteria, patient taken directly to a room and notify PED team
*** Change QuickReg to “COVID PUI”
*** If not eligible for FT but not a PUI, change QuickReg to “COVID PED”

*Phase 2
** '''''DHS/OOP ESI 4/5 can go to UCC'''''
** FT Team Rapid Dispo (ESI 3 or 4) - low risk, COVID suspected (but not meeting DHS PUI criteria), but still needs simple workup
*** Complete triage, rapid history & exam
*** Apply PINK wrist band to patient indicating COVID suspected/DHS PUI patients.
*** Provider & triage RN exit the room and initiates a new triage process in the open room for the next patient
*** Patient goes to COVID suspected/DHS PUI specific tasking rooms
**** RME 7 (internal waiting room)
**** RME 9 (phlebotomy)
**** These two rooms will be designated COVID suspected rooms and will have more frequent housekeeping cleaning
**** Tasking LVN to ensure droplet precautions are followed in these rooms and will escort patient to XR & EKGs
*** After tasking, patient will be escorted to Registration windows A-C
**** Registration sends patient to respiratory isolation area of the waiting room
*** FT team/NPs evaluates disposition from the Alcove if appropriate (use privacy screen)
** Non-FT Candidate
*** Notify RME charge nurse for available bed in ED

===.edcovid, paper charts, & discharge material===
*History:
*Chief complaint _
*HPI _
*Pertinent ROS:
*_ Fever
*_ Cough
*_ Rhinorrhea
*_ Headache
*_ Vomiting
*Other: _
*
*Past Medical History
*_ No significant Past Medical History
*_ High-risk Conditions: Age >65, Heart disease, Diabetes, Pregnant, Immunocompromised
*Other: _
*
*Allergies: _
*_ No known drug allergies

*Physical Exam:
*_Vital signs normal
*General: Patient is well nourished, well developed, awake and alert, in no acute distress
*Head: Normocephalic and atraumatic
*Eyes: Normal inspection, extraocular muscles intact
*_ Ears: normal external exam and tympanic membranes
*Nose & Throat: Normal external exam, moist mucosa
*Neck: Non-meningeal
*Cardiovascular: Patient is not tachycardic
* _ Regular rate and rhythm without appreciable murmur
* _ Heart rate appropriate for fever
*Respiratory:
* _ Patient is in no respiratory distress
* _ Lungs are clear to auscultation bilaterally
*Back: Normal inspection of the back with good range of motion
*Extremities: Normal strength, capillary refills <2 seconds
*Neuro: Normal mentation, alert and oriented, appropriately conversive, coordination appears to be adequate, ambulatory without assistance
*Skin: Warm, dry, and intact
*
*Medical Decision Making
*_ The patient appears well, is in no respiratory distress, and does not meet the clinical inclusion criteria for COVID-19 testing. The patient is not in the high-risk category for flu testing and treatment with anti-viral medication. The lung exam does not support a diagnosis of pneumonia. The history and physical are inconsistent with pulmonary embolism.
*
*Clinical Impression/Plan
*_ Influenza-like illness/viral syndrome: The patient was counseled on self care: rest, staying hydrated, taking acetaminophen/ibuprofen for fever, and avoiding close contact with others fever-free for >24 hours. We discussed returning to the emergency department if fevers persist more than 5 days, they develop difficulty breathing, they are unable to tolerate liquids, or they become confused or develop neck stiffness.

==
*Paper chart [[file:2 - Provider Paper Documentation v2.pdf]]
*Paper discharge instructions
**Hospital Copy
***[[file:3 - Paper DC Signature Adult English.pdf]]
***[[file:3 - Paper DC Signature Adult SPANISH.pdf]]
***[[file:3 - Paper DC Signature Adult Korean.pdf]]
***[[file:3 - Paper DC Signature Adult Mandarin.pdf]]
**Patient Copy
***[[file:4 - Paper Discharge Inst - ADULT English.pdf]]
***[[file:4 - Paper Discharge Inst - Adult SPANISH.pdf]]
***[[file:4 - Paper Discharge Inst - Adult Korean.pdf]]
***[[file:4 - Paper Discharge Inst - Adult Mandarin.pdf]]

==
* Orchid electronic discharge available under “Understanding 2019 Novel Coronavirus”

===COVID FAQ's===
*Carts in airborne precaution rooms only need to be wiped down - Zangwill 3/30
*Reasonable to clamp ET tube after cardiac arrest death - Zangwill 3/30
*Do NOT put patient info on pink armband - Martee 3/30
*No morgue viewings of COVID patients - Dr. Bolaris 3/30
** no Pt identifiers on outside pink tag - Nancy Blake 3/31
*Homeless patients
**If eligible for DC, need COVID test sent
**Consult SW - DPH intake center 8a-8p; 833-596-1009

==Flu/ILI==
*Influenza-like-illness (ILI) is defined as fever >100.0 F / 37.8 C AND cough or sore throat.
*Per our DHS policy, please consider treatment for high-risk populations.
**Antivirals for influenza are most effective when administered when symptoms have been present for <48 hours.
**May benefit for severely ill patients who have had >48 hours of symptoms.
*High risk patients for complications include:
# Age < 2 years or > 65 years
# Pregnancy
# Chronic disease. Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes)
# Immune suppression, including that caused by medications or HIV
# Persons younger than 19 years of age who are receiving long term aspirin therpay
*Don't send POC influenza test, due to low sensitivity (50-70%).
*Please send the Biofire / Respiratory Panel PCR for admitted ILI patients.
*Don't send POC RSV unless it will change your management.

==Measles==
* Report suspected measles immediately to DPH
** Weekdays 8:30 AM – 5 PM: call 888-397-3993
** After-hours: call 213-974-1234 and ask for the physician on call.

*Plan:
** Isolate pt - https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Measles-HCFacilityICRecs.pdf
** If advised to test for measles by DPH, submit a specimen for polymerase chain reaction (PCR) testing
*** Full clinical guidance from the California Department of Public Health https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Measles-ClinicalGuidance.pdf
*** Guidance from CDC for healthcare professionals:https://www.cdc.gov/measles/hcp/index.html

* Risk factors: international travel, never immunized of born after 1956
* Symptoms
** Fever, including subjective fever.
** Rash that starts on the head and descends.
** Usually 1 or 2 of the “3 Cs” – cough, coryza and conjunctivitis.

==Hepatitis A==
The County Department of Public Health has declared a Hepatitis A Outbreak in Los Angeles County and we are being asked in the emergency department to do our part to stem this outbreak.
　
In order to help we need to do the following things for all ADULTS (>18 years):
　
#Suspect: Consider acute viral hepatitis, especially in homeless patients or patients using illicit drugs.
#Test: If you suspect the patient may have acute viral hepatitis, order appropriate serologic studies (Hep A IgM, Hep B Core IgM, Hep B Surface Ag, Hep C Antibody Ab.) These are all available in the "AMB Hepatitis Workup" order set. STAT 45 minute turnarounds for the Hep A IgM is available, must be ordered as a standalone STAT test from the ED Quick Orders Page. If it is bundled with other Hepatitis tests, the machine runs all of them, delaying the turnaround time.
#Report: All suspected and confirmed cases of Hepatits A should be immediately reported to both the Dept of Health at (888) 397-3993 or after hours (213) 974-1234 AND Harbor Infection Control at x3838 While Patient Is Still in the Emergency Department
#Vaccinate: Anyone (regardless of why they are here) who is or has been homeless in the last two months, or uses illicit drugs (NOT JUST IV; except marijuana) should be offered the initial dose of Hep A vaccine while in the ED (the Cerner order is "Hepatitis A adult vaccine" on ED Quick Orders Page). They can be referred to the Department of Health for their second injection in six months. Check the "immunizations" area in Cerner to make sure they are not already immunized.
#Protect Yourself: If you haven't gotten the hepatitis A vaccine, it is recommended that you go to employee health to get vaccinated.

{{Harbor Ebola Precautions}}

==See Also==
*[[Harbor:Main]]

==References==
<references/>

[[Category:Admin]]

Harbor:Infectious Disease Threats

2020-04-06T18:55:03Z

Jtolles: /* Treatment Tips */

==Coronavirus ([[COVID-19]])==
;See [[COVID-19]] for non-Harbor-specific information; please feel free to contribute to the further development of these pages''

===COVID physician leads===
*AED Flow/Discharges- Andrea
*Drug/Non-PPE Shortages - Andrea
*Non-Emergency Physicians in the Emergency Department - Mike
*Homeless Issues - Dennis
* Airway-Ryan
*Environmental Services/Cleaning Protocols- Moh
*Triage/Fast Track Tents - Brad
*Email Updates - Andrea
*Pediatric Schedule - Kelly
*PPE - Shira
*EMS - Shira
*Palliative Care/End-Of-Life Issues - Tim J.
*ACLS - Shira
*COVID Testing - Mike
*Transfers to Mercy Ship – Denise (Currently only for inpatients with non-respiratory issues and negative Covid test)
*Attending scheduling for Adult ED – Manny
*PED issues - Patricia

===COVID Terminology===
*“Pink”
**respiratory complaint/Not PUI
**Need droplet/contact PPE
**pink wrist bands = need mask.
*“PUI”
** Meet DHS Testing Criteria (See below)

*Disaster track categories
**The router will place initial category,
**Ask nurse to change as necessary (can use communication order)
***Categories
****COVID EXPOSURE – no symptoms but at risk
****COVID FT – ILI symptoms (Cough, fever or SOB)
****COVID AED – not PUI but too complicated for quick dispo
****COVID PUI – meet DHS testing criteria

===Latest Updates===
*A&B/RSV RT-PCR order is replaced with “COVID-19 Test Request” on 4/3/2020.

===Harbor Checklists===
* Bedside checklist: [[:File:Harbor COVID checklist v3-21-20.pdf]]
* Additional DPH Guidance: http://publichealth.lacounty.gov/acd/nCorona2019.htm
* HARBOR ID UPDATES https://lacounty.sharepoint.com/sites/dhs-harbor-inf_prev_ctrl/SitePages/Breaking-News-and-Other-Disease-Information.aspx
*DHS Covid Sharepoint https://lacounty.sharepoint.com/sites/DHS-COVID19/ExpectedPractices/Forms/Newest%20on%20Top.aspx
*Seattle ICU doctor's one page info on mgmt of COVID from ACEP website [[:File:COVID19 seattle one pager.pdf]]
*Harbor DEM COVID airway management guide [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
*Proper donning and doffing with reusable goggles and stethoscope [[:File:Procedure for Reuse of Faceshields and Goggles 3-19-2020.pdf]]

===Triage===
*PUI going direct to room - do not order triage labs
*PINK wristband = mask + respiratory area if in waiting room

===DHS PUI Testing Criteria 3-23-20===
*Nurses will put everyone '''suspected''' of meeting PUI in a room in droplet precautions
*ED Attending will determine if patient meets definition
#Fever '''AND''' (cough '''OR''' shortness of breath '''''AND''''' NOT requiring hospitalization). Must be '''MEASURED''' fever in ED or at home (>100.4 F/38.0 C) '''''AND''''':
## healthcare worker '''''OR'''''
## works or lives in group environment (SNF/group home/rehab center/jail) '''''OR'''''
# Symptoms of Acute Respiratory Infection (New cough ''''OR'''' new Shortness of Breath. No fever required) '''''AND''''' REQUIRING HOSPITALIZATION '''''without an alternative diagnosis''''' (positive blood culture, cavitary lesion, chronic (>14d))
#'''''CONSIDER''''' testing ONLY if it will change management for:
## age>65 with chronic medical conditions (heart or lung disease)'''''OR'''''
## immunosuppression (includes prednisone>20mg daily)

** ID is available 24/7 if you are unclear if they meet PUI criteria

===Commercial testing (Quest or UCLA) for PUI criteria above===
'''NO LONGER NEED FLU TEST, flu season is over'''.
*PROCEDURE
**Order COVID-19 test from Covid Order Set.
**If Flu/RSV consider excluding COVID
**Complete both:
***"Harbor UCLA's Laboratory Miscellaneous Lab Form"[[:File:Laboratory Miscellaneous Request Form.pdf]]
***UCLA's lab request form [[:File:HARBOR UCLA UCLA BURL CUSTOM 032720.pdf]]
**Specimen must be walked up to the lab
*'''If Testing, Send out the batch text (p9699)'''. Please include:
** '''Patient Name''',
**'''MRUN'''
**'''Location''' (e.g. "AED Room A12")
**If "Consult to COVID Tracking" order Write "FYI" in callback field. Does not result in a callback.
==
*'''Follow Up of Test Results for Discharged Patients'''
*** AED patients: '''''Lab Follow-up - HAR''''' (like UCx and STI's)
****DHS empaneled patients: '''''message the provider'''''
*** PED patients: '''''Peds - HAR/USC''''' (the usual laboratory follow up procedure may be followed)
****DHS empaneled patients: '''''message the provider'''''
**Do not rely on Public Health to follow up test results

===Discharge===
*Homeless patient with mild symptoms that could be discharged,
**Placement
***Call SW early
***DPH call center (833-596-1009) 8a-6p every day
****Helps with transportation
****Need pending Covid test
****Must be able to perform ADLs

===Airway Management===
*'''Airway management''' [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
**Intubate early (consider if need 6L NC or more), use VL so you’re face is further away. Clean VL with grey wipes, observe 3 min wet time
**Avoid BiPAP, high flow nasal cannula (HFNC), nebulizers
***Use MDI/spacer instead of nebs
***If needed HFNC with surgical mask over patient is preferred over BiPAP
***Viral filters should not be used with BVM or stocked in the airway carts, in order to preserve them for the transport ventilators
**Per CDC, do not treat with steroids (prolongs viral replication) unless for a secondary reason (ie, COPD)
**When intubating patients, for any unclear cases, wear N95, face shield, gown and gloves
***If using PAPR, then need pre-assigned RN outside the room to help decontaminate it by wiping it down with purple wipes before you take it off
**From Manny - We have an aerosol box approved and ready for us in trauma bay 1. Please remember to handle with care and more importantly, clean with bleach (orange) wipes after each use per infection control. This is a good tool to consider when you are intubating a PUI patient.
***Pre-oxygenate with NRB and use apneic nasal cannula during intubation.
***Avoid using bag-valve-mask if possible
****Only bag patient after cuff on ETT is inflated
***RSI to ensure paralysis. Consider higher range of dosing of paralytic to avoid patient coughing.
***Follow ARDSnet protocol, TV ~6ml/kg ideal body weight, high PEEP - http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf
===Treatment Tips===
* Patient Presentation
**''Patient may have preceding GI symptoms prior to developing respiratory illness''
*'''Treatment'''
**Avoid steroids unless strong non-COVID indication
**Limited data on chloroquine or hydroxychloroquine
**Remdesivir via compassionate use for severely hypoxemic (Mechanical vent, high PEEP, FiO2 requirements >40%,).
*Any MDIs used in the ED to sent home with the patient instead of prescribing the patient another MDI and throwing the one used in the ED away. To do so, three simple steps needs to happen:
#Fill out a pre-printed rx sticker - available in English and Spanish with patient's name, the date, your name, patient's MRN. The stickers will be on the same clipboard as the logs (see #3 below) in each doc box.
#Put sticker on box for inhaler or inhaler itself and hand to patient
#Put patient sticker (or write patient name and MRN), your name, and circle drug given on the log. There will be a log in each doc box (purple, green, pediatrics).

==== Ventilator Management ====
* PRVC mode, initial tidal volume: 6-8 mL/kg of predicted body weight (link)
* If initial plateau pressure is persistently > 30 cm H2O, reduce the tidal volume by 1 mL/kg, until plateau pressure <30 H2O
* Goal: SpO2 88-96%: Adjust PEEP and FiO2 as per table below

{| class="wikitable"
|-
| '''FiO2''' || 0.3 || 0.4 || 0.5 || 0.6 || 0.7 || 0.8 || 0.9 || 1.0
|-
| '''PEEP''' || 12-14 || 14-16 || 18 || 18-20 || 18-20 || 22 || 22 || 22-24
|}

* If SpO2 <88% despite maximum FiO2 and PEEP on table above, intervene in the following order. If goal SpO2 is not achieved, proceed to the next step on the list.
** Prone the patient
** Observe for signs of dyssynchrony with the ventilator (e.g. initiating a new breath before full exhalation, coughing/auto-triggering). If present, first increase sedation to RASS of -4. If persistent, give single dose non-depolarizing paralytic (e.g. vecuronium 0.1mg/kg)
** Seek expert (MICU) consultation to place patient on APRV
** If above steps and MICU consultation fail to stabilize oxygenation of patient, V-V ECMO may be considered for select patients. Contact trauma attending to reach Dennis Kim.

====Antibiotics ====
* CAP treatment for intubated patients with ARDS per surviving sepsis guidelines

====Fluid resuscitation====
* For hemodynamically stable patients with ARDS, avoid fluid resuscitation
* For hemodynamically unstable patients with ARDS, consider small (500mL) fluid boluses and early norepinephrine

===PPE===
*“Special Precautions” are announced for an EMS patient and airway management pages, please ensure that all involved healthcare workers are wearing appropriate PPE.
*Recommendation for PPE [[:File:Guidance on precautions and masks for COVID-19_updated 3.25.20.pdf]]
**In general, wear surgical masks (ties) or procedure mask (ear loops) and eye protection (goggles or face shield) while working in the ED since we often deal with limited information when evaluating patients. Personal glasses or the traditional ED disposable plastic glasses are not sufficient.
**If a patient is getting a high-risk aerosol generating procedure (AGP) then airborne precautions are preferred in addition to contact and droplet precautions. AGP include intubation, NIPPV (BiPAP/CPAP), high flow oxygen, nebulizers, CPR, and suctioning, to name a few relevant in the ED. If need to do NIPPV, nebs, HFNC try your best to place surgical mask over.
**Once intubated, or after an AGP is completed, patient needs airborne precautions x 1 hr if vent is not being disconnected or if patient is not getting suction. Since an ETT connected to a vent is a closed circuit, after 1 hour the patient goes back onto droplet/contact precautions. If other AGP done again then 1 hr clock restarts needing airborne precautions. If patient was dispositioned out of the ED while still in airborne precautions, then will need terminal clean with 1-hour air exchange.
**If no AGP, then patient needs to wear a mask and have contact and droplet precautions with closed door. So for example, if a masked ‘pink’ patient is going to CT without an AGP, only need a wipe down as per usual contact/droplet cleaning, and does not need a terminal clean.
**After a Pink or PUI patient leaves the ED, the room may be cleaned immediately per droplet/contact precautions, unless there was an AGP was done in the previous 1 hour.
**Only need terminal clean if aerosol generating procedure (AGP) done, otherwise just droplet precaution cleaning with wipes
**Write your name into the log by patient room if sick suspected COVID patient getting admitted
** PAPR - get from Charge RN.
*** If using a PAPR - get a '''preassigned nurse''' outside the room '''decontaminate it''' for you before you take it off (Purple wipes)
**If patient brought in by EMS, let MICN know you suspect COVID so they can inform the EMS crew & decontaminate their rig

===Exposures===
* '''If you are exposed''' to a confirmed patient - whether in PPE or not - you should self-monitor for symptoms for 14 days. OK to work as long as you do not have symptoms. IPC and Employee Health will give recs for staff exposures based on CDC criteria.
** [[:File:Self Monitoring log .pdf]]
** [[:File:Guidance for WFM Call Offs .v2._3.24.2020.pdf]]
* Infection Prevention confirms the exposure and provides Employee Health with a list of affected departments. Employee Health then notifies all dept chairs or supervisors of exposure and request list of names of staff with potential exposure. Supervisor provides staff with a confidential notice to present to Employee Health
*Employee presents to Employee Health for evaluation
Based on CDC exposure risk either self-monitor with or without work restrictions are initiated

===Admissions===
*‘Consult to COVID Tracking’ in Quick Orders page, please write “FYI” in the required call back field. Do not expect a call back since this is just for tracking purchases. Send this tracking page for all PUIs getting admitted, even if known to be Covid+ already.
*Adult patient
**Covid hospitalist team p1325 - non-ICU level care
**If COVID PUI is requiring >6L of NC consider intubation or at least notifying MICU team.
**MICU - third call pager
**Any discrepancies if patient is PUI, consult ID

*PED
**Our PICU has no negative pressure rooms. The Pediatric ward has 5 rooms that are negative pressure. For children with URI/ILI symptoms that need to be admitted they will need to go into a negative pressure room upstairs. If they require SDU or PICU placement we will need to discuss with the PICU attending. The PICU has converted room 15 on the pediatric ward to be used for ICU level care and may turn a few more of the negative pressure rooms into ICU level care rooms.
**For all of PED patients being admitted, please ask about fever, cough, and/or SOB or any known exposure to Covid+ patient. This is important information to get on all of our traumas and patients who come in for other reasons as it does have an impact on our staff and the admitting team.
**For all adolescent psych patients, as part of your MSE, please ask each of them about recent fever, cough, sob and known exposure to Covid+ patient. Also remember that GI symptoms can also be caused by Covid. If there is a patient with any of these symptoms, they cannot go to the adolescent psych ED until we talk with ID to determine risk of Covid-19.
**Per ID, if a PED asthmatic patient is well enough to go home, we should not be doing COVID-19 testing on him or her. If he/she is being admitted we should discuss with ID the need for COVID-19 testing.

===Screening L&D Patients===
* If >14 weeks with fever or cough, keep in ED
* If febrile, immediately consult OB and place in AED 15, 16, 17, 21, Tra 1-7, or peds 4 for FetalLink monitoring capabilities

===Latest Numbers - Census, Positives, Supplies, Rx===
*Census
**AED Volume: 4/5= 99
**PED Volume: 4/5= 20
**UCC Volume: 4/3= 22
** Hospital 4/6= 193
***RED 4W PCU: 4/3= 18/27 (9 open)
***RED 3W SDU: 4/3= 19/20 (1 open)
***RED 5WICU: 4/6= 8/8 (zero open)
***ED RED ICU: 4/6= 0 (@11:00)
** DHS & LA County hospital/ICU beds, available ventilators, etc
*** http://file.lacounty.gov/SDSInter/dhs/1070348_DHSCOVID-19Dashboard.pdf
*** http://mlkioasashaw01.dhs.lacounty.gov/SASVisualAnalyticsViewer/VisualAnalyticsViewer.jsp?saspfs_request_backurl_list=http%3A%2F%2Fmlkioasashaw01.dhs.lacounty.gov%2FSASVisualAnalyticsHub&saspfs_request_backlabel_list=Home&saspfs_request_path_url=SBIP%3A%2F%2FMETASERVER%2FProd%2FDHS%2F_Shared%2FReports%2FCovid+04+05+20%28Report%29&saspfs_request_entitykey=A501L7HF.AX000487%2FTransformation&_vaSectionName=vi1051

*COVID Cases
** Harbor
*** POSITIVE 4/4= 20
*** PUI (pend) 4/4= 5
** LA County
*** COVID +ve= 4/4=5304
**** Predicted trajectory: 4/4=6918; 4/5=8578; 4/6=10,636; 4/7=13,189; 4/8=16,355; 4/9=20,280; 4/10=25,147; 4/11=31,182; 4/12=38,666; 4/13=47,946; 4/14=59,452; 4/15=73,721; 4/16=91,414; 4/17=113,353
**** Age <18= 48
**** Age 18-40= 1785
**** Age 41-65= 2160
**** Age >65= 1050
**** Deaths= 117
*** Mercy Transfers 4/2=10

*Supplies
** Viral swabs 4/4=1374
** Surgical masks 4/4= <30-day supply
** N-95 4/4= <30-day supply
** Face shields 4/4= 800
** PAPR + Dover (ED) 2+5
** CAPR (ED) 6 (~40 DLCs 3/30)
** Ventilators 3/31 23 available
** Gloves 3/26= enough
** Gowns 3/26= enough

*Drug shortages
** Morphine & Fentanyl
** IV fluids - use oral hydration whenever possible. Reserve IVF to those that cannot tolerate PO.
** Albuterol and ipratropium MDI - we have enough for now but in next few weeks we may be seeing surge in PUI's and their need, please conserve when you can. We have placed order for more but no definitive release date. Remember we can give patients same used MDI on discharge
** Chloroquine and hydroxychlorquine and azithromycin are on shortage list but they're not standard of care for PUIs. We'll see as situation unfolds.

===COVID ACTION PLAN (Phases 1-3)===
* Phase I: “COVID-19 Screening”
** Pre-router - mask patients with fever, cough, dyspnea
** Router - register on disaster track (“COVID Possible”)
*** “Routine” priority
**** COVID EXPOSURE – no symptoms but at risk
**** COVID FT – ILI symptoms
**** COVID ED – not PUI criteria but ILI with other medical issues that are too complex for FastTrack
*** “High” Priority
****COVID PUI – for patients meeting DPH criteria
*** Patients in respiratory isolation to AWR Alcove / back half of PWR
** Triage
*** Triage priority: Cardiac > High > COVID > Routine
*** Temporarily suspending CXR for RIPT scoring
** Ambulance Triage
*** All patient (including those going to Psych ED) must be screened per above
** Psych ED
*** EMS to Psych ED will receive screening at psych
**** If a patient meets PUI criteria, they should be immediately transferred to the AED and placed in a room
*** Patients arriving in Triage or AED for clearance to psych need MSE note
**** If no infectious or other medical concerns, the patient can go directly to the Psych ED after physician evaluation
*** Labor & Delivery
**** ED will perform infection screening on all patients presenting to the ED including L&D patients >14 weeks gestation
***** If negative, they will be directed to L&D
***** If positive with fever (subjective or recorded in past 24 hours), they will be triaged as usual and OB will be consulted
***** '''''If >24 weeks gestation, they will be prioritized to AED 15, 16, 17, 21, Tra 1-7, or PED 4 for Fetal Link monitoring, with the goal of door to monitoring in <20 minutes'''''
***** If the patient is in active labor, the patient will be moved to one of the trauma bays and the L&D team will decide the best location for impending delivery

* Triage Rapid DC
** '''''RN''''' completes portion of team triage and goes to open triage room for next patient after provider interview completed
** '''''Provider'''''
*** Completes MSE Note: “definitive treatment provider”; “please see chart for details”; tracking acuity “5”; no typing in History/Exam section
*** Completes paper chart or .phrase and pre-printed paper discharge (English/Spanish/Korean)
*** Give discharge paper work to registration and patient (provider to sign the discharge paperwork and state “patient verbally consents” to avoid fomite transmission)
*** Takes patient to registration windows A-C and hands paper forms (H&P and signed DC) to Patient Access Staff
*** Join RN in new room after discharge process from prior patient complete
** PAS will complete registration then sticker the paper forms, and place the chart in box to be scanned
** Patient leaves from registration
** RN wipes down exposed/touched surfaces per droplet protocol using Grey Cavi-wipe to clean all surfaces (door handle, chair, etc.)
** Discharge off the tracking board
*** DETAILED STEPS:
#1 - click pt recented seen x 6
#2 - "H" for home, "T" for today, "N" for now

*PED Rapid DC
** If the patient does not meet PUI criteria, send directly to PED 8-10 for immediate discharge
*** If >3 patients, send to the masked patient side of the Peds WR NP or resident in PED 8-10
*** Chart with “.edcovid” – include reference that patient given COVID ED instructions
*** Discharge with pre-printed paper discharge
*** Registration in PED 8-10
** If the patient meets PUI criteria, patient taken directly to a room and notify PED team
*** Change QuickReg to “COVID PUI”
*** If not eligible for FT but not a PUI, change QuickReg to “COVID PED”

*Phase 2
** '''''DHS/OOP ESI 4/5 can go to UCC'''''
** FT Team Rapid Dispo (ESI 3 or 4) - low risk, COVID suspected (but not meeting DHS PUI criteria), but still needs simple workup
*** Complete triage, rapid history & exam
*** Apply PINK wrist band to patient indicating COVID suspected/DHS PUI patients.
*** Provider & triage RN exit the room and initiates a new triage process in the open room for the next patient
*** Patient goes to COVID suspected/DHS PUI specific tasking rooms
**** RME 7 (internal waiting room)
**** RME 9 (phlebotomy)
**** These two rooms will be designated COVID suspected rooms and will have more frequent housekeeping cleaning
**** Tasking LVN to ensure droplet precautions are followed in these rooms and will escort patient to XR & EKGs
*** After tasking, patient will be escorted to Registration windows A-C
**** Registration sends patient to respiratory isolation area of the waiting room
*** FT team/NPs evaluates disposition from the Alcove if appropriate (use privacy screen)
** Non-FT Candidate
*** Notify RME charge nurse for available bed in ED

===.edcovid, paper charts, & discharge material===
*History:
*Chief complaint _
*HPI _
*Pertinent ROS:
*_ Fever
*_ Cough
*_ Rhinorrhea
*_ Headache
*_ Vomiting
*Other: _
*
*Past Medical History
*_ No significant Past Medical History
*_ High-risk Conditions: Age >65, Heart disease, Diabetes, Pregnant, Immunocompromised
*Other: _
*
*Allergies: _
*_ No known drug allergies

*Physical Exam:
*_Vital signs normal
*General: Patient is well nourished, well developed, awake and alert, in no acute distress
*Head: Normocephalic and atraumatic
*Eyes: Normal inspection, extraocular muscles intact
*_ Ears: normal external exam and tympanic membranes
*Nose & Throat: Normal external exam, moist mucosa
*Neck: Non-meningeal
*Cardiovascular: Patient is not tachycardic
* _ Regular rate and rhythm without appreciable murmur
* _ Heart rate appropriate for fever
*Respiratory:
* _ Patient is in no respiratory distress
* _ Lungs are clear to auscultation bilaterally
*Back: Normal inspection of the back with good range of motion
*Extremities: Normal strength, capillary refills <2 seconds
*Neuro: Normal mentation, alert and oriented, appropriately conversive, coordination appears to be adequate, ambulatory without assistance
*Skin: Warm, dry, and intact
*
*Medical Decision Making
*_ The patient appears well, is in no respiratory distress, and does not meet the clinical inclusion criteria for COVID-19 testing. The patient is not in the high-risk category for flu testing and treatment with anti-viral medication. The lung exam does not support a diagnosis of pneumonia. The history and physical are inconsistent with pulmonary embolism.
*
*Clinical Impression/Plan
*_ Influenza-like illness/viral syndrome: The patient was counseled on self care: rest, staying hydrated, taking acetaminophen/ibuprofen for fever, and avoiding close contact with others fever-free for >24 hours. We discussed returning to the emergency department if fevers persist more than 5 days, they develop difficulty breathing, they are unable to tolerate liquids, or they become confused or develop neck stiffness.

==
*Paper chart [[file:2 - Provider Paper Documentation v2.pdf]]
*Paper discharge instructions
**Hospital Copy
***[[file:3 - Paper DC Signature Adult English.pdf]]
***[[file:3 - Paper DC Signature Adult SPANISH.pdf]]
***[[file:3 - Paper DC Signature Adult Korean.pdf]]
***[[file:3 - Paper DC Signature Adult Mandarin.pdf]]
**Patient Copy
***[[file:4 - Paper Discharge Inst - ADULT English.pdf]]
***[[file:4 - Paper Discharge Inst - Adult SPANISH.pdf]]
***[[file:4 - Paper Discharge Inst - Adult Korean.pdf]]
***[[file:4 - Paper Discharge Inst - Adult Mandarin.pdf]]

==
* Orchid electronic discharge available under “Understanding 2019 Novel Coronavirus”

===COVID FAQ's===
*Carts in airborne precaution rooms only need to be wiped down - Zangwill 3/30
*Reasonable to clamp ET tube after cardiac arrest death - Zangwill 3/30
*Do NOT put patient info on pink armband - Martee 3/30
*No morgue viewings of COVID patients - Dr. Bolaris 3/30
** no Pt identifiers on outside pink tag - Nancy Blake 3/31
*Homeless patients
**If eligible for DC, need COVID test sent
**Consult SW - DPH intake center 8a-8p; 833-596-1009

==Flu/ILI==
*Influenza-like-illness (ILI) is defined as fever >100.0 F / 37.8 C AND cough or sore throat.
*Per our DHS policy, please consider treatment for high-risk populations.
**Antivirals for influenza are most effective when administered when symptoms have been present for <48 hours.
**May benefit for severely ill patients who have had >48 hours of symptoms.
*High risk patients for complications include:
# Age < 2 years or > 65 years
# Pregnancy
# Chronic disease. Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes)
# Immune suppression, including that caused by medications or HIV
# Persons younger than 19 years of age who are receiving long term aspirin therpay
*Don't send POC influenza test, due to low sensitivity (50-70%).
*Please send the Biofire / Respiratory Panel PCR for admitted ILI patients.
*Don't send POC RSV unless it will change your management.

==Measles==
* Report suspected measles immediately to DPH
** Weekdays 8:30 AM – 5 PM: call 888-397-3993
** After-hours: call 213-974-1234 and ask for the physician on call.

*Plan:
** Isolate pt - https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Measles-HCFacilityICRecs.pdf
** If advised to test for measles by DPH, submit a specimen for polymerase chain reaction (PCR) testing
*** Full clinical guidance from the California Department of Public Health https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Measles-ClinicalGuidance.pdf
*** Guidance from CDC for healthcare professionals:https://www.cdc.gov/measles/hcp/index.html

* Risk factors: international travel, never immunized of born after 1956
* Symptoms
** Fever, including subjective fever.
** Rash that starts on the head and descends.
** Usually 1 or 2 of the “3 Cs” – cough, coryza and conjunctivitis.

==Hepatitis A==
The County Department of Public Health has declared a Hepatitis A Outbreak in Los Angeles County and we are being asked in the emergency department to do our part to stem this outbreak.
　
In order to help we need to do the following things for all ADULTS (>18 years):
　
#Suspect: Consider acute viral hepatitis, especially in homeless patients or patients using illicit drugs.
#Test: If you suspect the patient may have acute viral hepatitis, order appropriate serologic studies (Hep A IgM, Hep B Core IgM, Hep B Surface Ag, Hep C Antibody Ab.) These are all available in the "AMB Hepatitis Workup" order set. STAT 45 minute turnarounds for the Hep A IgM is available, must be ordered as a standalone STAT test from the ED Quick Orders Page. If it is bundled with other Hepatitis tests, the machine runs all of them, delaying the turnaround time.
#Report: All suspected and confirmed cases of Hepatits A should be immediately reported to both the Dept of Health at (888) 397-3993 or after hours (213) 974-1234 AND Harbor Infection Control at x3838 While Patient Is Still in the Emergency Department
#Vaccinate: Anyone (regardless of why they are here) who is or has been homeless in the last two months, or uses illicit drugs (NOT JUST IV; except marijuana) should be offered the initial dose of Hep A vaccine while in the ED (the Cerner order is "Hepatitis A adult vaccine" on ED Quick Orders Page). They can be referred to the Department of Health for their second injection in six months. Check the "immunizations" area in Cerner to make sure they are not already immunized.
#Protect Yourself: If you haven't gotten the hepatitis A vaccine, it is recommended that you go to employee health to get vaccinated.

{{Harbor Ebola Precautions}}

==See Also==
*[[Harbor:Main]]

==References==
<references/>

[[Category:Admin]]

Harbor:How to get started in research at Harbor

2018-07-11T04:14:33Z

Jtolles: /* Get an iMedRIS account */

==Do your CITI training==
''Forewarned: this will take a long time – probably several days''
*Go to https://www.citiprogram.org and create an account
*Use Los Angeles Biomedical Research Institute as your organization affiliation
*We must do: HIPAA, Responsible conduct of research basic course, Conflicts of interest, Export controls, Biomedical researcher – basic/refresher, and Good clinical practices
*When you complete each module, download a copy of the certificate for your files
*For questions contact Tina Yiadom at eyiadom@labiomed.org, 222-3624

==Complete the patent/copyright agreement form==
''This only needs to be completed once''
*Bring this with you and turn it in during Step 3
*Not yet available online, but available from Luz or in PEM fellowship dropbox

==Request project number from the Office of Research Administration (ORA) in RB-1 (Walter P. Martin Research Center)==
*Luz Garcia for government/non-profit funded projects, including CTSI activities and institutional/internal projects (lgarcia@labiomed.org, x3621)
*Barbara Lee for industry funded projects (blee@labiomed.org, x3621)
*Step 3 and 4 may be reversed – ie do the institutional research project form, scan it, and email it to Luz/Barbara to obtain a number

==Complete the Institutional Research Project application==
*Either abbreviated or full (not yet available online, ask Luz for these forms, or they are available in PEM fellowship dropbox), AND an investigator protocol (use the template) http://intranet.labiomed.org/group/4/forms

===Abbreviated Institutional Research Project (Accelerated Review)===
*For projects that would fall under the Institutional Review Board’s (Human Subjects Committee’s) Expedited, Exempt categories, or Not Human Research determination. Examples of studies that would be proposed using the *Abbreviated application form include retrospective chart reviews, surveys, basic science research using previously collected de-identified samples, etc. Please see iRIS, Operating Procedures, HRP-319 and HRP-320 for the Exempt and Expedited review categories.

*If you are doing chart review, will need Medical Records Director’s signature: Nanette Jackson. Go to MFI suite 100 with a copy of the completed institutional research project form and protocol template to get her signature.

===Institutional Research Project (Full Review)===
*For research projects that: (1) propose to use funds from any institutional source including Departmental Funds, PI unrestricted funds, etc. or projects will be conducted without funds; (2) prospective studies proposing to conduct Human Subjects research that is neither Exempt nor Expedited; (3) studies that include animal research.
*Additionally, a PRACC form must be filled out if the research is externally funded
http://intranet.labiomed.org/group/10/forms
*Submit these forms to Luz Garcia in N-14

==Get an iMedRIS account==
contact Tina Yiadom (eyiadom@labiomed.org, x 3624) to request an iMedRIS account.

==Fill out the IRB forms on the iMedRIS account==
===Checklist===
*Protocol number (that you obtained from Luz Garcia)
*Investigator protocol (that you did in step 4)
*Brief summary of your project written for a lay person
*Institutional Research Project Application
*CV’s of all investigators
*PRACC if applicable
*Consent forms: Need consent, for children 8-17yo assent, PHI authorization
**Templates are available on iMedRIS under My Assistant, Operating Procedures, 2. HRPP - For Investigators, and online http://intranet.labiomed.org/group/4/forms
*Data collection forms
*Any recruitment materials you plan to use (flyers, etc.)
**(There are additional forms if using an investigational drug or device, or CTSI services, or using animals in research – we are unlikely to be using these)

===Submit through IMedRIS and await review by compliance===
*You will likely need to change some things after they review it; often there are multiple back and forth cycles of you changing things. Submit all responses / changes through Imedris.
*Once your project is approved, you must download Stamped forms and use only those (consent, data collection, etc) from iMedRIS. Do not use unstamped forms and do not use forms beyond their expiration date. Doing either of these things will trigger an audit.
**If you need consent forms translated into Spanish, request that through the compliance office. For PEM fellows: the fellowship funds will be used to pay for the translation.
**Note: consent forms must be signed by the PI within 14 days of execution. Not doing so will trigger an audit.
**Also, once your project is approved, if it involves a clinical patient care unit, you must submit it to Nursing. They will review it and keep it in a binder in the ED for nurses to review.
**Write cover letter briefly describing your study and nursing’s role (if any), and submit it along with a copy of the protocol, consents, IRB approval letter, to Joy Lagrone jlagrone@dhs.lacounty.gov and Dawna Wilsey DWilsey@dhs.lacounty.gov.

===Note===
*RB1 = Walter P. Martin Research Center
*RB2 = St. John’s Cardiovascular Research Center
*RB3 = Liu Research Center

==Documents that will be needed if you are audited==
===Make a “Regulatory Binder” with the following===
*A note to file (see template at http://intranet.labiomed.org/group/4/forms) that says all of the following are available (if they are applicable) on Imedris: IRB Protocol, IRB Protocol amendments, IRB correspondence, PI correspondence, Site Standard Operating Procedures, All versions of IRB approved consent forms, Data Collection Forms, IRB approved recruitment materials. Also determine which Human Subjects Committee (HSC) reviewed your project and add to your Note to File which one it was, and the fact that the membership roster is available on Imedris.
*Collect a copy of the medical (or NP) licenses of all the study investigators. Write a note to file that their CVs are available on Imedris. Make a note to file listing which CITI modules they have completed (they can log onto CITI www.citiprogram.org, click My Reports, and print that out). Make a Staff Designation Signature Log, which lists each investigator, their role in the project, their specific tasks, their start date and stop date (can be left blank until study over) in the project, and their signature AND initials.
*Make and keep a subject screening log and a subject enrollment log. The difference is that the screening log includes patients that were screened but did not enroll.

Also, for each patient’s research folder / documents:
#Make sure there is an inclusion/exclusion eligibility checklist for each patient, either as part of the data collection forms or as a separate sheet of paper in each patient’s research folder.
#There is also supposed to be a statement that says “The subject was given ample time (30-45 minutes) to read the consent form including the bill of rights form, all questions and concerns of the subject were answered, the subject signed the consent form prior to any study related procedures being performed and the subject was given a copy of the signed and dated consent form.” in each research chart.

==Other Information==
*Here is additional information http://intranet.labiomed.org/node/512
*You need to be on the LA Biomed network to access the LA Biomed intranet for these links to work (except for the citiprogram link).

==See Also==
*[[Harbor:Main]]

[[Category:Admin]]

EBQ:High Dose Steroids in Cord Injury

2014-10-10T18:47:44Z

Jtolles: /* Clinical Question */

{{JC info
| title= Effects of the Second National Acute Spinal Cord Injury Study of high-dose methylprednisolone therapy on acute cervical spinal cord injury-results in spinal injuries center.
| abbreviation= High Dose Steroids in Cord Injury
| expansion=
| published=
| author= Tsutsumi S. et al.
| journal= Spine
| year= 2006 Dec 15
| volume= 31
| issue=26
| pages= 2992-6
| pmid= 17172994
| fulltexturl= http://journals.lww.com/spinejournal/pages/articleviewer.aspx?year=2006&issue=12150&article=00003&type=abstract
| pdfurl=http://theddx.org/papers/High%20Dose%20Steroids%20and%20Spinal%20Injury.pdf
}}
==Clinical Question==
Does high-dose methylprednisolone treatment of acute cervical spinal cord injury improve neurologic motor function outcomes?

==Conclusion==

==Major Points==

==Study Design==

==Population==
===Patient Demographics===
===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:Neuro]]
[[Category:Trauma]]

EBQ:A national evaluation of the effect of trauma-center care on mortality

2014-10-10T18:43:46Z

Jtolles: /* Subgroup analysis */

{{JC info
| title= A national evaluation of the effect of trauma-center care on mortality
| abbreviation= A national evaluation of the effect of trauma-center care on mortality
| expansion=
| published= 2006 Jan 2
| author= MacKenzie E. et el.
| journal=NEJM
| year= 2006
| volume= 354
| issue=4
| pages= 366-78
| pmid= 16436768
| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMsa052049
| pdfurl=http://www.nejm.org/doi/pdf/10.1056/NEJMsa052049
}}
==Clinical Question==
Is there a difference in mortality between trauma patients treated at level 1 trauma centers vs non-trauma centers?

==Conclusion==
The risk of death is significantly lower for patients treated at a trauma center than at non-trauma center.

==Major Points==

==Study Design==
Prospective cohort study.

==Population==
===Patient Demographics===
===Inclusion Criteria===
*Age 18-84
*Arrived alive at the hospital
*At least one injury with a score ≥3 on the Abbreviated Injury Scale

===Exclusion Criteria===
*Arrived at hospital without vital signs and pronounced dead within 30 min of arrival
*Sought treatment >24 hr after injury
*Age ≥65 years with first listed diagnosis as hip fracture
*Neither English- nor Spanish-speaking
*Non-US residents
*Incarcerated or homeless at the time of injury

==Interventions==

==Outcomes==

===Primary Outcome===
Mortality

===Secondary Outcomes===
None

===Subgroup analysis===
None

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:Trauma]]

EBQ:A national evaluation of the effect of trauma-center care on mortality

2014-10-10T18:43:37Z

Jtolles: /* Secondary Outcomes */

{{JC info
| title= A national evaluation of the effect of trauma-center care on mortality
| abbreviation= A national evaluation of the effect of trauma-center care on mortality
| expansion=
| published= 2006 Jan 2
| author= MacKenzie E. et el.
| journal=NEJM
| year= 2006
| volume= 354
| issue=4
| pages= 366-78
| pmid= 16436768
| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMsa052049
| pdfurl=http://www.nejm.org/doi/pdf/10.1056/NEJMsa052049
}}
==Clinical Question==
Is there a difference in mortality between trauma patients treated at level 1 trauma centers vs non-trauma centers?

==Conclusion==
The risk of death is significantly lower for patients treated at a trauma center than at non-trauma center.

==Major Points==

==Study Design==
Prospective cohort study.

==Population==
===Patient Demographics===
===Inclusion Criteria===
*Age 18-84
*Arrived alive at the hospital
*At least one injury with a score ≥3 on the Abbreviated Injury Scale

===Exclusion Criteria===
*Arrived at hospital without vital signs and pronounced dead within 30 min of arrival
*Sought treatment >24 hr after injury
*Age ≥65 years with first listed diagnosis as hip fracture
*Neither English- nor Spanish-speaking
*Non-US residents
*Incarcerated or homeless at the time of injury

==Interventions==

==Outcomes==

===Primary Outcome===
Mortality

===Secondary Outcomes===
None

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:Trauma]]

EBQ:A national evaluation of the effect of trauma-center care on mortality

2014-10-10T18:43:29Z

Jtolles: /* Primary Outcome */

{{JC info
| title= A national evaluation of the effect of trauma-center care on mortality
| abbreviation= A national evaluation of the effect of trauma-center care on mortality
| expansion=
| published= 2006 Jan 2
| author= MacKenzie E. et el.
| journal=NEJM
| year= 2006
| volume= 354
| issue=4
| pages= 366-78
| pmid= 16436768
| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMsa052049
| pdfurl=http://www.nejm.org/doi/pdf/10.1056/NEJMsa052049
}}
==Clinical Question==
Is there a difference in mortality between trauma patients treated at level 1 trauma centers vs non-trauma centers?

==Conclusion==
The risk of death is significantly lower for patients treated at a trauma center than at non-trauma center.

==Major Points==

==Study Design==
Prospective cohort study.

==Population==
===Patient Demographics===
===Inclusion Criteria===
*Age 18-84
*Arrived alive at the hospital
*At least one injury with a score ≥3 on the Abbreviated Injury Scale

===Exclusion Criteria===
*Arrived at hospital without vital signs and pronounced dead within 30 min of arrival
*Sought treatment >24 hr after injury
*Age ≥65 years with first listed diagnosis as hip fracture
*Neither English- nor Spanish-speaking
*Non-US residents
*Incarcerated or homeless at the time of injury

==Interventions==

==Outcomes==

===Primary Outcome===
Mortality

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:Trauma]]

EBQ:A national evaluation of the effect of trauma-center care on mortality

2014-10-10T18:42:34Z

Jtolles: /* Exclusion Criteria */

{{JC info
| title= A national evaluation of the effect of trauma-center care on mortality
| abbreviation= A national evaluation of the effect of trauma-center care on mortality
| expansion=
| published= 2006 Jan 2
| author= MacKenzie E. et el.
| journal=NEJM
| year= 2006
| volume= 354
| issue=4
| pages= 366-78
| pmid= 16436768
| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMsa052049
| pdfurl=http://www.nejm.org/doi/pdf/10.1056/NEJMsa052049
}}
==Clinical Question==
Is there a difference in mortality between trauma patients treated at level 1 trauma centers vs non-trauma centers?

==Conclusion==
The risk of death is significantly lower for patients treated at a trauma center than at non-trauma center.

==Major Points==

==Study Design==
Prospective cohort study.

==Population==
===Patient Demographics===
===Inclusion Criteria===
*Age 18-84
*Arrived alive at the hospital
*At least one injury with a score ≥3 on the Abbreviated Injury Scale

===Exclusion Criteria===
*Arrived at hospital without vital signs and pronounced dead within 30 min of arrival
*Sought treatment >24 hr after injury
*Age ≥65 years with first listed diagnosis as hip fracture
*Neither English- nor Spanish-speaking
*Non-US residents
*Incarcerated or homeless at the time of injury

==Interventions==

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:Trauma]]

EBQ:A national evaluation of the effect of trauma-center care on mortality

2014-10-10T18:39:40Z

Jtolles: /* Study Design */

{{JC info
| title= A national evaluation of the effect of trauma-center care on mortality
| abbreviation= A national evaluation of the effect of trauma-center care on mortality
| expansion=
| published= 2006 Jan 2
| author= MacKenzie E. et el.
| journal=NEJM
| year= 2006
| volume= 354
| issue=4
| pages= 366-78
| pmid= 16436768
| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMsa052049
| pdfurl=http://www.nejm.org/doi/pdf/10.1056/NEJMsa052049
}}
==Clinical Question==
Is there a difference in mortality between trauma patients treated at level 1 trauma centers vs non-trauma centers?

==Conclusion==
The risk of death is significantly lower for patients treated at a trauma center than at non-trauma center.

==Major Points==

==Study Design==
Prospective cohort study.

==Population==
===Patient Demographics===
===Inclusion Criteria===
*Age 18-84
*Arrived alive at the hospital
*At least one injury with a score ≥3 on the Abbreviated Injury Scale

===Exclusion Criteria===

==Interventions==

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:Trauma]]

EBQ:A national evaluation of the effect of trauma-center care on mortality

2014-10-10T18:38:56Z

Jtolles: /* Inclusion Criteria */

{{JC info
| title= A national evaluation of the effect of trauma-center care on mortality
| abbreviation= A national evaluation of the effect of trauma-center care on mortality
| expansion=
| published= 2006 Jan 2
| author= MacKenzie E. et el.
| journal=NEJM
| year= 2006
| volume= 354
| issue=4
| pages= 366-78
| pmid= 16436768
| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMsa052049
| pdfurl=http://www.nejm.org/doi/pdf/10.1056/NEJMsa052049
}}
==Clinical Question==
Is there a difference in mortality between trauma patients treated at level 1 trauma centers vs non-trauma centers?

==Conclusion==
The risk of death is significantly lower for patients treated at a trauma center than at non-trauma center.

==Major Points==

==Study Design==

==Population==
===Patient Demographics===
===Inclusion Criteria===
*Age 18-84
*Arrived alive at the hospital
*At least one injury with a score ≥3 on the Abbreviated Injury Scale

===Exclusion Criteria===

==Interventions==

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:Trauma]]

EBQ:A national evaluation of the effect of trauma-center care on mortality

2014-10-10T18:35:40Z

Jtolles: /* Conclusion */

{{JC info
| title= A national evaluation of the effect of trauma-center care on mortality
| abbreviation= A national evaluation of the effect of trauma-center care on mortality
| expansion=
| published= 2006 Jan 2
| author= MacKenzie E. et el.
| journal=NEJM
| year= 2006
| volume= 354
| issue=4
| pages= 366-78
| pmid= 16436768
| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMsa052049
| pdfurl=http://www.nejm.org/doi/pdf/10.1056/NEJMsa052049
}}
==Clinical Question==
Is there a difference in mortality between trauma patients treated at level 1 trauma centers vs non-trauma centers?

==Conclusion==
The risk of death is significantly lower for patients treated at a trauma center than at non-trauma center.

==Major Points==

==Study Design==

==Population==
===Patient Demographics===
===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:Trauma]]

EBQ:Catheter related infections

2014-10-10T18:32:48Z

Jtolles: /* Clinical Question */

{{JC info
| title= The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.
| abbreviation=The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis
| expansion=The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.
| published= 2012
| author= Marik PE et al
| journal= Critical Care Medicine
| year= 2012
| volume= 40
| issue= 8
| pages= 2479-85
| pmid= 22809915
| fulltexturl= http://www.intensivo.sochipe.cl/subidos/catalogo3/ITS%20por%20CVC%20femoral%20vs%20subclavia%20y%20yugular%20CCM%202012.pdf
| pdfurl=http://www.intensivo.sochipe.cl/subidos/catalogo3/ITS%20por%20CVC%20femoral%20vs%20subclavia%20y%20yugular%20CCM%202012.pdf
|
}}

==Clinical Question==
What is the rate of catheter-related infections of non-tunneled catheters placed at the femoral vein site as compared with subclavian and internal jugular sites?

==Conclusion==

==Major Points==

==Guidelines==

==Design==
Systematic Review and meta-analysis

==Population==
===Inclusion Criteria===

===Exclusion Criteria===

===Baseline Characteristics===

==Interventions==

==Outcomes==

===Primary Outcomes===

===Secondary Outcomes===

==Subgroup Analysis==

==Criticisms==

==Funding==

==CME==

==Sources==
<references/>

[[Category:EBQ]]

EBQ:Catheter related infections

2014-10-10T18:30:38Z

Jtolles: /* Design */

{{JC info
| title= The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.
| abbreviation=The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis
| expansion=The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.
| published= 2012
| author= Marik PE et al
| journal= Critical Care Medicine
| year= 2012
| volume= 40
| issue= 8
| pages= 2479-85
| pmid= 22809915
| fulltexturl= http://www.intensivo.sochipe.cl/subidos/catalogo3/ITS%20por%20CVC%20femoral%20vs%20subclavia%20y%20yugular%20CCM%202012.pdf
| pdfurl=http://www.intensivo.sochipe.cl/subidos/catalogo3/ITS%20por%20CVC%20femoral%20vs%20subclavia%20y%20yugular%20CCM%202012.pdf
|
}}

==Clinical Question==

==Conclusion==

==Major Points==

==Guidelines==

==Design==
Systematic Review and meta-analysis

==Population==
===Inclusion Criteria===

===Exclusion Criteria===

===Baseline Characteristics===

==Interventions==

==Outcomes==

===Primary Outcomes===

===Secondary Outcomes===

==Subgroup Analysis==

==Criticisms==

==Funding==

==CME==

==Sources==
<references/>

[[Category:EBQ]]

EBQ:Omeprazole in Bleeding Peptic Ulcers

2014-10-10T18:28:16Z

Jtolles: /* Clinical Question */

{{JC info
| title=Effect of Intravenous Omeprazole on Recurrent Bleeding after Endoscopic Treatment of Bleeding Peptic Ulcer
| published=2000-08-03
| author=Lau JYW, et al
| journal=NEJM
| year=2000
| volume=343
| issue=5
| pages=310-316
| pmid=10922420
| fulltexturl=http://www.nejm.org/doi/full/10.1056/NEJM200008033430501
| pdfurl=http://www.nejm.org/doi/pdf/10.1056/NEJM200008033430501
}}

==Clinical Question==
Does high dose intravenous omeprazole reduce the incidence of recurrent bleeding in patients who have undergone endoscopic intervention for bleeding peptic ulcers?

==Conclusion==

==Major Points==

==Study Design==

==Population==
===Patient Demographics===
===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:GI]]

EBQ:A national evaluation of the effect of trauma-center care on mortality

2014-10-10T18:22:27Z

Jtolles: /* Clinical Question */

EBQ:Single Dose Dexamethasone in Asthma

2014-10-10T18:19:10Z

Jtolles: /* Clinical Question */

{{JC info
| title= Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma
| abbreviation= Dex in Peds Asthma
| expansion=Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma
| published= 2006
| author= Altamimi S. et al
| journal= Pediatric Emergency Care
| year= 2006
| volume= 786-793
| issue= 22
| pages= 12
| pmid= 17198210
| fulltexturl= http://journals.lww.com/pec-online/Abstract/2006/12000/Single_Dose_Oral_Dexamethasone_in_the_Emergency.3.aspx
| pdfurl=
}}
==Clinical Question==
What is the efficacy of a single dose of oral dexamethasone as compared with 5 days of twice-daily prednisolone in the treatment of mild to moderate asthma exacerbations in children seen in the emergency department?

==Conclusion==

==Major Points==

==Study Design==

==Population==
===Patient Demographics===
===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]

[[Category:Peds]]

EBQ:Incidence and predictors of difficult and impossible mask ventilation

2014-10-10T18:16:51Z

Jtolles: /* Clinical Question */

{{JC info
| title=Incidence and predictors of difficult and impossible mask ventilation.
| abbreviation= Incidence and predictors of difficult and impossible mask ventilation.
| expansion=Incidence and predictors of difficult and impossible mask ventilation.
| published=2006
| author=Kheterpal S. et al
| journal= Anesthesiology
| year=2006
| volume=105
| issue=5
| pages=885-891
| pmid= 17065880
| fulltexturl=http://journals.lww.com/anesthesiology/Fulltext/2006/11000/Incidence_and_Predictors_of_Difficult_and.7.aspx
| pdfurl=http://pdfs.journals.lww.com/anesthesiology/2006/11000/Incidence_and_Predictors_of_Difficult_and.7.pdf
}}

==Clinical Question==
What patient characteristics are associated with difficult mask ventilation?

==Conclusion==

==Major Points==

==Study Design==

==Population==
===Patient Demographics===
===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>
[[Category:EBQ]][[Category:Airway/Resus]][[Category:Pulm]]

EBQ:Effect of video laryngoscopy on trauma patient survival

2014-10-10T18:09:45Z

Jtolles: /* Criticisms */

{{JC info
| title=Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial
| abbreviation=
| expansion=
| published=2013
| author=Yeatts et al
| journal=The Journal of Trauma and Acute Care Surgery
| year=2013
| volume=75
| issue=2
| pages=212-219
| pmid=23823612
| fulltexturl=
| pdfurl=http://mycedars-sinai.com/Patients/Programs-and-Services/Surgery/Surgical-Educational-Programs/Documents/SICU-Articles/Effect-of-video-laryngoscopy-on-trauma-patient-survival-09-18-13.pdf
| status = Complete
}}
==Clinical Question==
'''Does the use of GlideScope video laryngoscopy affect survival to hospital discharge in adult patients requiring emergency airway management?'''

==Conclusion==
'''No mortality benefit was found with the use of GlideScope vs Direct Laryngoscopy(DL) in trauma patient intubation. Use of the GlideScope in patients with severe head injury had a greater incidence of hypoxia and mortality on subgroup analysis.
'''

==Study Design==
*Prospective randomized controlled trial
*Single Center: University of Maryland Shock Trauma Center

==Population==
*Adult patients in trauma resuscitation unit at requiring emergency intubation.
*N=623
===Patient Demographics===
*Age: 42.5
*Male: 73%
*Mechanism of Injury:
**Blunt: 71.6%
**Penetrating: 12%
**Other: 6.1%
*Injury Severity Score: 19 (Direct Laryngoscopy); 17 (GlideScope)

===Inclusion Criteria===
All adult patients requiring intubation according to the Eastern Association for the Surgery of Trauma guidelines:
#Airway obstruction
#Hypoventilation
#Severe Hypoxemia
#GCS≤8
#Hemorrhagic Shock
#Combativeness
#Extreme pain

===Exclusion Criteria===
#Minors
#Patients with suspected laryngeal trauma or extensive maxillofacial injury
#Need for immediate surgical airway
#Spinal cord injury requiring fiber-optic intubation
#Cardiac arrest on arrival
#Death on arrival

==Interventions==
All patients received [[Rapid Sequence Intubation|RSI]] with either thiopental or etomidate and succinlcholine followed by preoxygenation and inline cervical spine immobilization. Intubation was performed by an attending anesthesiologist or a EM or anesthesia resident with 1 year intubating experience. All intubations were recorded on video with digital capture of vital signs every 6 seconds. Time to intubation was defined as difference between mouth insertion of blade and removal with confirmation via continuous capnography and physical exam. Multiple attempts were added together for cumulative time.

==Outcome==

===Primary Outcomes===
*Mortality rate: 7.5% (DL) vs 9.2% (GlideScope)
::p = 0.43

===Secondary Outcomes===
*First-pass Success: 81% (DL) vs. 80%(GlideScope)
::p=0.46

===Subgroup analysis===
*Intubation Duration(seconds): 40 (DL) vs. 56 (GlideScope)
*Mortality in Head Injury: 16% (DL) vs 22% (GlideScope)

==Criticisms==
Although patients were randomized, the attending physician could choose to remove a patient from the study due to preference for DL or GlideScope. 210 of 898 eligible patients were excluded for this reason. Also, this study only uses the GlideScope video laryngoscope with the hyper-angulated blade, so abstraction to all videolaryngoscopy is not possible.

==Review Questions==
<quiz display=simple>
{Was there a difference to mortality between those intubated with GlideScope vs DL?
|type="[]"}
-Yes
+No

{Did the use of GlideScope increase the duration of intubation attempt?
|type="[]"}
+Yes
-No

{In what subgroup did the authors find a higher mortality in post hoc analysis?
|type="[]"}
-Those intubated by anesthesiology residents
+Severe head injury patients
-Those with blunt chest trauma
-Those with penetrating chest trauma

</quiz>

<references/>

[[Category:EBQ]] [[Category:Trauma]]

EBQ:Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma

2014-10-10T18:03:38Z

Jtolles: /* Major Points */

{{JC info
| title= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| abbreviation= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| expansion=Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| published= 2009
| author= Holmes J. et al
| journal= Annals of Emergency Medicine
| year= 2009
| volume= 54
| issue= 4
| pages= 528-33
| pmid= 19250706
| fulltexturl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/1.html?issn=01960644&_returnURL=http%3A//linkinghub.elsevier.com/retrieve/pii/S0196064409000535%3Fshowall%3Dtrue
| pdfurl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/s0196064409000535.pdf?issn=0196-0644
}}

==Clinical Question==
What is the accuracy of the prediction rule derived in the publication [http://www.ncbi.nlm.nih.gov.journals.labiomed.org/pubmed/11973557 ''Holmes, JF et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Medicine. 2002;39:500-509.''] for detecting intra-abdominal injury in children after blunt torso trauma?

==Conclusion==
The clinical decision rule defined by Holmes et al. for ruling out intra-abdominal injury in children with blunt torso trauma would substantially reduce unnecessary abdominal CT in pediatric trauma patients. 
Because the rule yielded a false negative in one patient, who underwent diagnostic laparotomy without surgical intervention, it may need further refinement before widespread application.

==Major Points==
6-variable clinical rule test characteristics: 
Sensitivity 94.5% 
Specificity 37.1% 
33% reduction in unnecessary abdominal CT scans

==Inclusion Criteria==
* <18 yr old
* Blunt torso trauma
* Underwent definitive testing for intra-abdominal injury: CT, diagnostic peritoneal lavage, diagnostic laparotomy or laparoscopy.

==Exclusion Criteria==
* Penetrating trauma
* Pregnant patients
* Presentation >24hr after injury
* Patients who did not undergo definitive testing because of low suspicion for intra-abdominal injury

==Interventions==

==Outcome==

===Primary Outcomes===
# The presence of intra-abdominal injury 
# Intra-abdominal injury requiring acute intervention, defined as: blood transfusion for intra-abdominal hemorrhage, angiographic embolization of vessel or organ, or therapeutic intervention at laparotomy.

===Secondary Outcomes===
Reduction in abdominal CT scans if the rule were to be strictly applied to rule-out intra-abdomninal injury.

===Subgroup analysis===
Children who had intra-abdominal injury missed by the decision rule.

==Criticisms==
The clinical decision rule failed to identify 8 children with an intra-abdominal injury that was ultimately detected on definitive testing. However, none of these subjects required acute intervention for their injury.

==Funding==
UC Davis Children's Miracle Network Research Grant 
SAEM Research Training Grant

==Sources==

<references/>

[[Category:EBQ]]

EBQ:Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma

2014-10-10T18:01:47Z

Jtolles: /* Conclusion */

{{JC info
| title= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| abbreviation= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| expansion=Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| published= 2009
| author= Holmes J. et al
| journal= Annals of Emergency Medicine
| year= 2009
| volume= 54
| issue= 4
| pages= 528-33
| pmid= 19250706
| fulltexturl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/1.html?issn=01960644&_returnURL=http%3A//linkinghub.elsevier.com/retrieve/pii/S0196064409000535%3Fshowall%3Dtrue
| pdfurl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/s0196064409000535.pdf?issn=0196-0644
}}

==Clinical Question==
What is the accuracy of the prediction rule derived in the publication [http://www.ncbi.nlm.nih.gov.journals.labiomed.org/pubmed/11973557 ''Holmes, JF et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Medicine. 2002;39:500-509.''] for detecting intra-abdominal injury in children after blunt torso trauma?

==Conclusion==
The clinical decision rule defined by Holmes et al. for ruling out intra-abdominal injury in children with blunt torso trauma would substantially reduce unnecessary abdominal CT in pediatric trauma patients. 
Because the rule yielded a false negative in one patient, who underwent diagnostic laparotomy without surgical intervention, it may need further refinement before widespread application.

==Major Points==

==Inclusion Criteria==
* <18 yr old
* Blunt torso trauma
* Underwent definitive testing for intra-abdominal injury: CT, diagnostic peritoneal lavage, diagnostic laparotomy or laparoscopy.

==Exclusion Criteria==
* Penetrating trauma
* Pregnant patients
* Presentation >24hr after injury
* Patients who did not undergo definitive testing because of low suspicion for intra-abdominal injury

==Interventions==

==Outcome==

===Primary Outcomes===
# The presence of intra-abdominal injury 
# Intra-abdominal injury requiring acute intervention, defined as: blood transfusion for intra-abdominal hemorrhage, angiographic embolization of vessel or organ, or therapeutic intervention at laparotomy.

===Secondary Outcomes===
Reduction in abdominal CT scans if the rule were to be strictly applied to rule-out intra-abdomninal injury.

===Subgroup analysis===
Children who had intra-abdominal injury missed by the decision rule.

==Criticisms==
The clinical decision rule failed to identify 8 children with an intra-abdominal injury that was ultimately detected on definitive testing. However, none of these subjects required acute intervention for their injury.

==Funding==
UC Davis Children's Miracle Network Research Grant 
SAEM Research Training Grant

==Sources==

<references/>

[[Category:EBQ]]

EBQ:Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma

2014-10-10T17:55:48Z

Jtolles: /* Criticisms */

{{JC info
| title= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| abbreviation= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| expansion=Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| published= 2009
| author= Holmes J. et al
| journal= Annals of Emergency Medicine
| year= 2009
| volume= 54
| issue= 4
| pages= 528-33
| pmid= 19250706
| fulltexturl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/1.html?issn=01960644&_returnURL=http%3A//linkinghub.elsevier.com/retrieve/pii/S0196064409000535%3Fshowall%3Dtrue
| pdfurl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/s0196064409000535.pdf?issn=0196-0644
}}

==Clinical Question==
What is the accuracy of the prediction rule derived in the publication [http://www.ncbi.nlm.nih.gov.journals.labiomed.org/pubmed/11973557 ''Holmes, JF et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Medicine. 2002;39:500-509.''] for detecting intra-abdominal injury in children after blunt torso trauma?

==Conclusion==

==Major Points==

==Inclusion Criteria==
* <18 yr old
* Blunt torso trauma
* Underwent definitive testing for intra-abdominal injury: CT, diagnostic peritoneal lavage, diagnostic laparotomy or laparoscopy.

==Exclusion Criteria==
* Penetrating trauma
* Pregnant patients
* Presentation >24hr after injury
* Patients who did not undergo definitive testing because of low suspicion for intra-abdominal injury

==Interventions==

==Outcome==

===Primary Outcomes===
# The presence of intra-abdominal injury 
# Intra-abdominal injury requiring acute intervention, defined as: blood transfusion for intra-abdominal hemorrhage, angiographic embolization of vessel or organ, or therapeutic intervention at laparotomy.

===Secondary Outcomes===
Reduction in abdominal CT scans if the rule were to be strictly applied to rule-out intra-abdomninal injury.

===Subgroup analysis===
Children who had intra-abdominal injury missed by the decision rule.

==Criticisms==
The clinical decision rule failed to identify 8 children with an intra-abdominal injury that was ultimately detected on definitive testing. However, none of these subjects required acute intervention for their injury.

==Funding==
UC Davis Children's Miracle Network Research Grant 
SAEM Research Training Grant

==Sources==

<references/>

[[Category:EBQ]]

EBQ:Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma

2014-10-10T17:51:50Z

Jtolles: /* Subgroup analysis */

{{JC info
| title= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| abbreviation= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| expansion=Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| published= 2009
| author= Holmes J. et al
| journal= Annals of Emergency Medicine
| year= 2009
| volume= 54
| issue= 4
| pages= 528-33
| pmid= 19250706
| fulltexturl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/1.html?issn=01960644&_returnURL=http%3A//linkinghub.elsevier.com/retrieve/pii/S0196064409000535%3Fshowall%3Dtrue
| pdfurl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/s0196064409000535.pdf?issn=0196-0644
}}

==Clinical Question==
What is the accuracy of the prediction rule derived in the publication [http://www.ncbi.nlm.nih.gov.journals.labiomed.org/pubmed/11973557 ''Holmes, JF et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Medicine. 2002;39:500-509.''] for detecting intra-abdominal injury in children after blunt torso trauma?

==Conclusion==

==Major Points==

==Inclusion Criteria==
* <18 yr old
* Blunt torso trauma
* Underwent definitive testing for intra-abdominal injury: CT, diagnostic peritoneal lavage, diagnostic laparotomy or laparoscopy.

==Exclusion Criteria==
* Penetrating trauma
* Pregnant patients
* Presentation >24hr after injury
* Patients who did not undergo definitive testing because of low suspicion for intra-abdominal injury

==Interventions==

==Outcome==

===Primary Outcomes===
# The presence of intra-abdominal injury 
# Intra-abdominal injury requiring acute intervention, defined as: blood transfusion for intra-abdominal hemorrhage, angiographic embolization of vessel or organ, or therapeutic intervention at laparotomy.

===Secondary Outcomes===
Reduction in abdominal CT scans if the rule were to be strictly applied to rule-out intra-abdomninal injury.

===Subgroup analysis===
Children who had intra-abdominal injury missed by the decision rule.

==Criticisms==

==Funding==
UC Davis Children's Miracle Network Research Grant 
SAEM Research Training Grant

==Sources==

<references/>

[[Category:EBQ]]

EBQ:Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma

2014-10-10T17:50:55Z

Jtolles: /* Secondary Outcomes */

{{JC info
| title= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| abbreviation= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| expansion=Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| published= 2009
| author= Holmes J. et al
| journal= Annals of Emergency Medicine
| year= 2009
| volume= 54
| issue= 4
| pages= 528-33
| pmid= 19250706
| fulltexturl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/1.html?issn=01960644&_returnURL=http%3A//linkinghub.elsevier.com/retrieve/pii/S0196064409000535%3Fshowall%3Dtrue
| pdfurl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/s0196064409000535.pdf?issn=0196-0644
}}

==Clinical Question==
What is the accuracy of the prediction rule derived in the publication [http://www.ncbi.nlm.nih.gov.journals.labiomed.org/pubmed/11973557 ''Holmes, JF et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Medicine. 2002;39:500-509.''] for detecting intra-abdominal injury in children after blunt torso trauma?

==Conclusion==

==Major Points==

==Inclusion Criteria==
* <18 yr old
* Blunt torso trauma
* Underwent definitive testing for intra-abdominal injury: CT, diagnostic peritoneal lavage, diagnostic laparotomy or laparoscopy.

==Exclusion Criteria==
* Penetrating trauma
* Pregnant patients
* Presentation >24hr after injury
* Patients who did not undergo definitive testing because of low suspicion for intra-abdominal injury

==Interventions==

==Outcome==

===Primary Outcomes===
# The presence of intra-abdominal injury 
# Intra-abdominal injury requiring acute intervention, defined as: blood transfusion for intra-abdominal hemorrhage, angiographic embolization of vessel or organ, or therapeutic intervention at laparotomy.

===Secondary Outcomes===
Reduction in abdominal CT scans if the rule were to be strictly applied to rule-out intra-abdomninal injury.

===Subgroup analysis===

==Criticisms==

==Funding==
UC Davis Children's Miracle Network Research Grant 
SAEM Research Training Grant

==Sources==

<references/>

[[Category:EBQ]]

EBQ:Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma

2014-10-10T17:45:26Z

Jtolles: /* Primary Outcomes */

{{JC info
| title= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| abbreviation= Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| expansion=Validation of a Prediction Rule for the Identification of Children With Intra-abdominal Injuries After Blunt Torso Trauma
| published= 2009
| author= Holmes J. et al
| journal= Annals of Emergency Medicine
| year= 2009
| volume= 54
| issue= 4
| pages= 528-33
| pmid= 19250706
| fulltexturl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/1.html?issn=01960644&_returnURL=http%3A//linkinghub.elsevier.com/retrieve/pii/S0196064409000535%3Fshowall%3Dtrue
| pdfurl= http://www.mdconsult.com/das/article/body/432541073-2/jorg=journal&source=&sp=22527614&sid=0/N/713637/s0196064409000535.pdf?issn=0196-0644
}}

==Clinical Question==
What is the accuracy of the prediction rule derived in the publication [http://www.ncbi.nlm.nih.gov.journals.labiomed.org/pubmed/11973557 ''Holmes, JF et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Medicine. 2002;39:500-509.''] for detecting intra-abdominal injury in children after blunt torso trauma?

==Conclusion==

==Major Points==

==Inclusion Criteria==
* <18 yr old
* Blunt torso trauma
* Underwent definitive testing for intra-abdominal injury: CT, diagnostic peritoneal lavage, diagnostic laparotomy or laparoscopy.

==Exclusion Criteria==
* Penetrating trauma
* Pregnant patients
* Presentation >24hr after injury
* Patients who did not undergo definitive testing because of low suspicion for intra-abdominal injury

==Interventions==

==Outcome==

===Primary Outcomes===
# The presence of intra-abdominal injury 
# Intra-abdominal injury requiring acute intervention, defined as: blood transfusion for intra-abdominal hemorrhage, angiographic embolization of vessel or organ, or therapeutic intervention at laparotomy.

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms==

==Funding==
UC Davis Children's Miracle Network Research Grant 
SAEM Research Training Grant

==Sources==

<references/>

[[Category:EBQ]]

EBQ:Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma

2014-10-10T17:22:29Z

Jtolles: /* Inclusion Criteria */

EBQ:Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma

2014-10-10T17:17:11Z

Jtolles: /* Exclusion Criteria */

EBQ:Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma

2014-10-10T17:04:23Z

Jtolles: /* Funding */

EBQ:Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma

2014-10-10T17:01:08Z

Jtolles: /* Clinical Question */

EBQ:Hematuria in Renal Colic

2014-10-10T16:51:36Z

Jtolles: /* Secondary Outcomes */

{{JC info
| title= Utility of hematuria testing in patients with suspected renal colic: correlation with unenhanced helical CT results
| abbreviation=
| expansion=
| published= 2002 Jun
| author= Luchs J. et al.
| journal= Urology
| year= 2002
| volume= 59
| issue=6
| pages= 839-42
| pmid= 12031364
| fulltexturl=
| pdfurl=
}}
==Clinical Question==
How accurate is urinalysis for detecting ureteral stones?

==Conclusion==
The presence or absence of blood on urinalysis cannot be used to reliably determine which patients have ureteral stones.

==Major Points==
Urinalysis compared to noncontrast CT (gold standard): 
Sensitivity 84% 
Specificity 48%

==Study Design==
Retrospective chart review of 950 patients who had a formal microscopic urinalysis within 24 hours of undergoing a non-contrast helical CT.

==Population==
===Patient Demographics===
===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==
Workup and treatment according to treating physician (retrospective review).

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===
None.

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:GU]]

EBQ:Hematuria in Renal Colic

2014-10-10T16:49:19Z

Jtolles: /* Interventions */

{{JC info
| title= Utility of hematuria testing in patients with suspected renal colic: correlation with unenhanced helical CT results
| abbreviation=
| expansion=
| published= 2002 Jun
| author= Luchs J. et al.
| journal= Urology
| year= 2002
| volume= 59
| issue=6
| pages= 839-42
| pmid= 12031364
| fulltexturl=
| pdfurl=
}}
==Clinical Question==
How accurate is urinalysis for detecting ureteral stones?

==Conclusion==
The presence or absence of blood on urinalysis cannot be used to reliably determine which patients have ureteral stones.

==Major Points==
Urinalysis compared to noncontrast CT (gold standard): 
Sensitivity 84% 
Specificity 48%

==Study Design==
Retrospective chart review of 950 patients who had a formal microscopic urinalysis within 24 hours of undergoing a non-contrast helical CT.

==Population==
===Patient Demographics===
===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==
Workup and treatment according to treating physician (retrospective review).

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:GU]]

EBQ:Hematuria in Renal Colic

2014-10-10T16:48:53Z

Jtolles: /* Interventions */

{{JC info
| title= Utility of hematuria testing in patients with suspected renal colic: correlation with unenhanced helical CT results
| abbreviation=
| expansion=
| published= 2002 Jun
| author= Luchs J. et al.
| journal= Urology
| year= 2002
| volume= 59
| issue=6
| pages= 839-42
| pmid= 12031364
| fulltexturl=
| pdfurl=
}}
==Clinical Question==
How accurate is urinalysis for detecting ureteral stones?

==Conclusion==
The presence or absence of blood on urinalysis cannot be used to reliably determine which patients have ureteral stones.

==Major Points==
Urinalysis compared to noncontrast CT (gold standard): 
Sensitivity 84% 
Specificity 48%

==Study Design==
Retrospective chart review of 950 patients who had a formal microscopic urinalysis within 24 hours of undergoing a non-contrast helical CT.

==Population==
===Patient Demographics===
===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==
None (retrospective review).

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:GU]]

EBQ:Hematuria in Renal Colic

2014-10-10T16:46:29Z

Jtolles: /* Major Points */

{{JC info
| title= Utility of hematuria testing in patients with suspected renal colic: correlation with unenhanced helical CT results
| abbreviation=
| expansion=
| published= 2002 Jun
| author= Luchs J. et al.
| journal= Urology
| year= 2002
| volume= 59
| issue=6
| pages= 839-42
| pmid= 12031364
| fulltexturl=
| pdfurl=
}}
==Clinical Question==
How accurate is urinalysis for detecting ureteral stones?

==Conclusion==
The presence or absence of blood on urinalysis cannot be used to reliably determine which patients have ureteral stones.

==Major Points==
Urinalysis compared to noncontrast CT (gold standard): 
Sensitivity 84% 
Specificity 48%

==Study Design==
Retrospective chart review of 950 patients who had a formal microscopic urinalysis within 24 hours of undergoing a non-contrast helical CT.

==Population==
===Patient Demographics===
===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:GU]]

EBQ:Hematuria in Renal Colic

2014-10-10T16:44:59Z

Jtolles: /* Clinical Question */

{{JC info
| title= Utility of hematuria testing in patients with suspected renal colic: correlation with unenhanced helical CT results
| abbreviation=
| expansion=
| published= 2002 Jun
| author= Luchs J. et al.
| journal= Urology
| year= 2002
| volume= 59
| issue=6
| pages= 839-42
| pmid= 12031364
| fulltexturl=
| pdfurl=
}}
==Clinical Question==
How accurate is urinalysis for detecting ureteral stones?

==Conclusion==
The presence or absence of blood on urinalysis cannot be used to reliably determine which patients have ureteral stones.

==Major Points==

==Study Design==
Retrospective chart review of 950 patients who had a formal microscopic urinalysis within 24 hours of undergoing a non-contrast helical CT.

==Population==
===Patient Demographics===
===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:GU]]

EBQ:Hematuria in Renal Colic

2014-10-10T16:39:23Z

Jtolles: /* Study Design */

{{JC info
| title= Utility of hematuria testing in patients with suspected renal colic: correlation with unenhanced helical CT results
| abbreviation=
| expansion=
| published= 2002 Jun
| author= Luchs J. et al.
| journal= Urology
| year= 2002
| volume= 59
| issue=6
| pages= 839-42
| pmid= 12031364
| fulltexturl=
| pdfurl=
}}
==Clinical Question==

==Conclusion==
The presence or absence of blood on urinalysis cannot be used to reliably determine which patients have ureteral stones.

==Major Points==

==Study Design==
Retrospective chart review of 950 patients who had a formal microscopic urinalysis within 24 hours of undergoing a non-contrast helical CT.

==Population==
===Patient Demographics===
===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==

==Outcomes==

===Primary Outcome===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms & Further Discussion==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]
[[Category:GU]]

EBQ:Hematuria in Renal Colic

2014-10-10T16:35:53Z

Jtolles: /* Conclusion */

EBQ:Perry Subarachnoid Haemorrhage Study

2014-10-07T00:57:47Z

Jtolles: /* Subgroup analysis */

{{JC info
| title= High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study
| abbreviation= Perry Subarachnoid Haemorrhage
| expansion=Perry Subarachnoid Haemorrhage
| published= 2010
| author= Perry JJ et al
| journal= BMJ
| year= 2010
| volume=28
| issue= 341
| pages= c5204
| pmid= 21030443
| fulltexturl= http://www.bmj.com/content/341/bmj.c5204?view=long&pmid=21030443
| pdfurl= http://www.bmj.com/content/341/bmj.c5204.pdf
}}

==Clinical Question==
What is the sensitivity of non-contrast head CT for detecting spontaneous subarachnoid hemorrhage (SAH), when performed on a third-generation CT scanner within 6 hours of headache onset?

==Conclusion==
Third-generation non-contrast head CT is highly sensitive for detecting spontaneous SAH when performed within 6 hours of headache onset and interpreted by a radiologist experienced in reading head CT.

==Major Points==
Within 6 hours of headache onset, CT had: 

Sens = 100% (95% confidence interval: 97%-100%) 

Spec = 100% (99.5%-100%) 

For all patients studied, CT had: 

Sens = 92.9% (89%-95.5%) 

Spec = 100% (99.9%-100%) 

==Population==
ED patients in 11 tertiary care centers

===Patient Demographics===
*Mean age = 45
*60% women

===Inclusion Criteria===
*>15 years old
*Acute headache reaching peak intensity within one hour
*Normal neurologic exam
*CT ordered by the treating physician to rule out SAH

===Exclusion Criteria===
*Focal neurologic deficits
*Papilledema
*History of SAH
*History aneurysm
*Previous VP shunt
*Brain neoplasm
*Onset of headache >14 days ago
*Recurrent headache (≥3 similar)
*Transfer from outside hospital with confirmed diagnosis of SAH

==Interventions==
Treating physicians worked up study subjects for SAH and initiated treatment per their usual clinical practice.

==Outcome==

===Primary Outcomes===
* To diagnose SAH based on CT, xanthochromia in CSF, or RBCs >5x106/L in final tube of CSF collected and aneurysm identified on cerebral angiography (digital subtraction, CT, or MR angiography)

===Secondary Outcomes===
None

===Subgroup analysis===
Subjects who underwent head CT within 6 hours of headache onset
* Increased sensitivity for head CT (see above) when compared to study group as a whole 

Subjects who did not undergo lumbar puncture vs those who did
* No significant difference in sex, loss of consciousness, arrival by ambulance, exertional onset, vomiting, BP, HR
* Higher mean age: 47.1 vs 43
* Shorter time to headache maximum intensity
* Higher incidence of neck pain
* Higher incidence of "worst headache ever"

==Criticisms==
Not all study subjects underwent lumbar puncture, possibly resulting in an underestimation of the rate of false-negative CT. However, investigators endeavored to follow up all subjects at 6 months using medical records and phone calls; no patients contacted received a subsequent diagnosis of SAH. Only 50 patients could not be followed up by these methods. For these 50, review of referrals to neurosurgical centers and coroner reports failed to suggest that any had had a missed SAH.

==Funding==

==Sources==

<references/>

[[Category:EBQ]]

EBQ:Perry Subarachnoid Haemorrhage Study

2014-10-07T00:44:10Z

Jtolles: /* Secondary Outcomes */

{{JC info
| title= High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study
| abbreviation= Perry Subarachnoid Haemorrhage
| expansion=Perry Subarachnoid Haemorrhage
| published= 2010
| author= Perry JJ et al
| journal= BMJ
| year= 2010
| volume=28
| issue= 341
| pages= c5204
| pmid= 21030443
| fulltexturl= http://www.bmj.com/content/341/bmj.c5204?view=long&pmid=21030443
| pdfurl= http://www.bmj.com/content/341/bmj.c5204.pdf
}}

==Clinical Question==
What is the sensitivity of non-contrast head CT for detecting spontaneous subarachnoid hemorrhage (SAH), when performed on a third-generation CT scanner within 6 hours of headache onset?

==Conclusion==
Third-generation non-contrast head CT is highly sensitive for detecting spontaneous SAH when performed within 6 hours of headache onset and interpreted by a radiologist experienced in reading head CT.

==Major Points==
Within 6 hours of headache onset, CT had: 

Sens = 100% (95% confidence interval: 97%-100%) 

Spec = 100% (99.5%-100%) 

For all patients studied, CT had: 

Sens = 92.9% (89%-95.5%) 

Spec = 100% (99.9%-100%) 

==Population==
ED patients in 11 tertiary care centers

===Patient Demographics===
*Mean age = 45
*60% women

===Inclusion Criteria===
*>15 years old
*Acute headache reaching peak intensity within one hour
*Normal neurologic exam
*CT ordered by the treating physician to rule out SAH

===Exclusion Criteria===
*Focal neurologic deficits
*Papilledema
*History of SAH
*History aneurysm
*Previous VP shunt
*Brain neoplasm
*Onset of headache >14 days ago
*Recurrent headache (≥3 similar)
*Transfer from outside hospital with confirmed diagnosis of SAH

==Interventions==
Treating physicians worked up study subjects for SAH and initiated treatment per their usual clinical practice.

==Outcome==

===Primary Outcomes===
* To diagnose SAH based on CT, xanthochromia in CSF, or RBCs >5x106/L in final tube of CSF collected and aneurysm identified on cerebral angiography (digital subtraction, CT, or MR angiography)

===Secondary Outcomes===
None

===Subgroup analysis===

==Criticisms==
Not all study subjects underwent lumbar puncture, possibly resulting in an underestimation of the rate of false-negative CT. However, investigators endeavored to follow up all subjects at 6 months using medical records and phone calls; no patients contacted received a subsequent diagnosis of SAH. Only 50 patients could not be followed up by these methods. For these 50, review of referrals to neurosurgical centers and coroner reports failed to suggest that any had had a missed SAH.

==Funding==

==Sources==

<references/>

[[Category:EBQ]]

EBQ:Perry Subarachnoid Haemorrhage Study

2014-10-07T00:43:41Z

Jtolles: /* Primary Outcomes */

{{JC info
| title= High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study
| abbreviation= Perry Subarachnoid Haemorrhage
| expansion=Perry Subarachnoid Haemorrhage
| published= 2010
| author= Perry JJ et al
| journal= BMJ
| year= 2010
| volume=28
| issue= 341
| pages= c5204
| pmid= 21030443
| fulltexturl= http://www.bmj.com/content/341/bmj.c5204?view=long&pmid=21030443
| pdfurl= http://www.bmj.com/content/341/bmj.c5204.pdf
}}

==Clinical Question==
What is the sensitivity of non-contrast head CT for detecting spontaneous subarachnoid hemorrhage (SAH), when performed on a third-generation CT scanner within 6 hours of headache onset?

==Conclusion==
Third-generation non-contrast head CT is highly sensitive for detecting spontaneous SAH when performed within 6 hours of headache onset and interpreted by a radiologist experienced in reading head CT.

==Major Points==
Within 6 hours of headache onset, CT had: 

Sens = 100% (95% confidence interval: 97%-100%) 

Spec = 100% (99.5%-100%) 

For all patients studied, CT had: 

Sens = 92.9% (89%-95.5%) 

Spec = 100% (99.9%-100%) 

==Population==
ED patients in 11 tertiary care centers

===Patient Demographics===
*Mean age = 45
*60% women

===Inclusion Criteria===
*>15 years old
*Acute headache reaching peak intensity within one hour
*Normal neurologic exam
*CT ordered by the treating physician to rule out SAH

===Exclusion Criteria===
*Focal neurologic deficits
*Papilledema
*History of SAH
*History aneurysm
*Previous VP shunt
*Brain neoplasm
*Onset of headache >14 days ago
*Recurrent headache (≥3 similar)
*Transfer from outside hospital with confirmed diagnosis of SAH

==Interventions==
Treating physicians worked up study subjects for SAH and initiated treatment per their usual clinical practice.

==Outcome==

===Primary Outcomes===
* To diagnose SAH based on CT, xanthochromia in CSF, or RBCs >5x106/L in final tube of CSF collected and aneurysm identified on cerebral angiography (digital subtraction, CT, or MR angiography)

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms==
Not all study subjects underwent lumbar puncture, possibly resulting in an underestimation of the rate of false-negative CT. However, investigators endeavored to follow up all subjects at 6 months using medical records and phone calls; no patients contacted received a subsequent diagnosis of SAH. Only 50 patients could not be followed up by these methods. For these 50, review of referrals to neurosurgical centers and coroner reports failed to suggest that any had had a missed SAH.

==Funding==

==Sources==

<references/>

[[Category:EBQ]]

EBQ:Perry Subarachnoid Haemorrhage Study

2014-10-07T00:31:31Z

Jtolles: /* Interventions */

{{JC info
| title= High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study
| abbreviation= Perry Subarachnoid Haemorrhage
| expansion=Perry Subarachnoid Haemorrhage
| published= 2010
| author= Perry JJ et al
| journal= BMJ
| year= 2010
| volume=28
| issue= 341
| pages= c5204
| pmid= 21030443
| fulltexturl= http://www.bmj.com/content/341/bmj.c5204?view=long&pmid=21030443
| pdfurl= http://www.bmj.com/content/341/bmj.c5204.pdf
}}

==Clinical Question==
What is the sensitivity of non-contrast head CT for detecting spontaneous subarachnoid hemorrhage (SAH), when performed on a third-generation CT scanner within 6 hours of headache onset?

==Conclusion==
Third-generation non-contrast head CT is highly sensitive for detecting spontaneous SAH when performed within 6 hours of headache onset and interpreted by a radiologist experienced in reading head CT.

==Major Points==
Within 6 hours of headache onset, CT had: 

Sens = 100% (95% confidence interval: 97%-100%) 

Spec = 100% (99.5%-100%) 

For all patients studied, CT had: 

Sens = 92.9% (89%-95.5%) 

Spec = 100% (99.9%-100%) 

==Population==
ED patients in 11 tertiary care centers

===Patient Demographics===
*Mean age = 45
*60% women

===Inclusion Criteria===
*>15 years old
*Acute headache reaching peak intensity within one hour
*Normal neurologic exam
*CT ordered by the treating physician to rule out SAH

===Exclusion Criteria===
*Focal neurologic deficits
*Papilledema
*History of SAH
*History aneurysm
*Previous VP shunt
*Brain neoplasm
*Onset of headache >14 days ago
*Recurrent headache (≥3 similar)
*Transfer from outside hospital with confirmed diagnosis of SAH

==Interventions==
Treating physicians worked up study subjects for SAH and initiated treatment per their usual clinical practice.

==Outcome==

===Primary Outcomes===
* To diagnose SAH based on CT, xanthochromia in CSF, or any RBCs in final tube of CSF collected with positive results on cerebral angiography (digital subtraction, CT, or MR angiography)

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms==
Not all study subjects underwent lumbar puncture, possibly resulting in an underestimation of the rate of false-negative CT. However, investigators endeavored to follow up all subjects at 6 months using medical records and phone calls; no patients contacted received a subsequent diagnosis of SAH. Only 50 patients could not be followed up by these methods. For these 50, review of referrals to neurosurgical centers and coroner reports failed to suggest that any had had a missed SAH.

==Funding==

==Sources==

<references/>

[[Category:EBQ]]

EBQ:Perry Subarachnoid Haemorrhage Study

2014-10-07T00:28:03Z

Jtolles: /* Criticisms */

{{JC info
| title= High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study
| abbreviation= Perry Subarachnoid Haemorrhage
| expansion=Perry Subarachnoid Haemorrhage
| published= 2010
| author= Perry JJ et al
| journal= BMJ
| year= 2010
| volume=28
| issue= 341
| pages= c5204
| pmid= 21030443
| fulltexturl= http://www.bmj.com/content/341/bmj.c5204?view=long&pmid=21030443
| pdfurl= http://www.bmj.com/content/341/bmj.c5204.pdf
}}

==Clinical Question==
What is the sensitivity of non-contrast head CT for detecting spontaneous subarachnoid hemorrhage (SAH), when performed on a third-generation CT scanner within 6 hours of headache onset?

==Conclusion==
Third-generation non-contrast head CT is highly sensitive for detecting spontaneous SAH when performed within 6 hours of headache onset and interpreted by a radiologist experienced in reading head CT.

==Major Points==
Within 6 hours of headache onset, CT had: 

Sens = 100% (95% confidence interval: 97%-100%) 

Spec = 100% (99.5%-100%) 

For all patients studied, CT had: 

Sens = 92.9% (89%-95.5%) 

Spec = 100% (99.9%-100%) 

==Population==
ED patients in 11 tertiary care centers

===Patient Demographics===
*Mean age = 45
*60% women

===Inclusion Criteria===
*>15 years old
*Acute headache reaching peak intensity within one hour
*Normal neurologic exam
*CT ordered by the treating physician to rule out SAH

===Exclusion Criteria===
*Focal neurologic deficits
*Papilledema
*History of SAH
*History aneurysm
*Previous VP shunt
*Brain neoplasm
*Onset of headache >14 days ago
*Recurrent headache (≥3 similar)
*Transfer from outside hospital with confirmed diagnosis of SAH

==Interventions==

==Outcome==

===Primary Outcomes===
* To diagnose SAH based on CT, xanthochromia in CSF, or any RBCs in final tube of CSF collected with positive results on cerebral angiography (digital subtraction, CT, or MR angiography)

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms==
Not all study subjects underwent lumbar puncture, possibly resulting in an underestimation of the rate of false-negative CT. However, investigators endeavored to follow up all subjects at 6 months using medical records and phone calls; no patients contacted received a subsequent diagnosis of SAH. Only 50 patients could not be followed up by these methods. For these 50, review of referrals to neurosurgical centers and coroner reports failed to suggest that any had had a missed SAH.

==Funding==

==Sources==

<references/>

[[Category:EBQ]]

EBQ:Perry Subarachnoid Haemorrhage Study

2014-10-07T00:07:35Z

Jtolles: /* Population */

EBQ:Perry Subarachnoid Haemorrhage Study

2014-10-07T00:06:46Z

Jtolles: /* Exclusion Criteria */

EBQ:Perry Subarachnoid Haemorrhage Study

2014-10-07T00:05:33Z

Jtolles: /* Patient Demographics */

EBQ:Perry Subarachnoid Haemorrhage Study

2014-10-06T20:42:35Z

Jtolles: /* Major Points */

EBQ:Perry Subarachnoid Haemorrhage Study

2014-10-06T20:24:38Z

Jtolles: /* Conclusion */

EBQ:Perry Subarachnoid Haemorrhage Study

2014-10-06T17:20:38Z

Jtolles: /* Conclusion */