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Covid-19 (Coronavirus) Clinical Alert

ACEP Clinical Warning Graphic-300px.jpg

This page is updated often to help keep emergency physicians prepared and save time.

 

For the latest federal announcements and guidance related to COVID-19, click here. For ACEP's current federal policy requests, click here

March 12, 2020

WHO classified COVID-19 as a pandemic during Situation Report - 51

WHO Director General remarks:

"In the past two weeks, the number of cases of COVID-19 outside China has increased 13-fold, and the number of affected countries has tripled.  ...WHO has been assessing this outbreak around the clock and we are deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction."

Global Case Map

View map of COVID-19 Global Cases - Johns Hopkins University. 

 

March 10, 2020

From the CDC:

Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed feverand/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing). Priorities for testing may include:

  1. Hospitalized patients who have signs and symptoms compatible with COVID-19 in order to inform decisions related to infection control.
  2. Other symptomatic individuals such as, older adults (age ≥ 65 years) and individuals with chronic medical conditions and/or an immunocompromised state that may put them at higher risk for poor outcomes (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease).
  3. Any persons including healthcare personnel2, who within 14 days of symptom onset had close contact3 with a suspect or laboratory-confirmed4 COVID-19 patient, or who have a history of travel from affected geographic areas5 within 14 days of their symptom onset.

Mildly ill patients should be encouraged to stay home and contact their healthcare provider by phone for guidance about clinical management. Patients who have severe symptoms, such as difficulty breathing, should seek care immediately. Older patients and individuals who have underlying medical conditions or are immunocompromised should contact their physician early in the course of even mild illness.

From CMS: EMTALA Requirements and Implications

CMS has issued guidance for hospitals on their EMTALA obligations when dealing with individuals with confirmed or suspected COVID-19 infections. This is not a waiver of EMTALA--the law sets a high threshold for issuing waivers such as issuance of a Presidential disaster declaration and a Secretary’s declaration of a public health emergency. Existing EMTALA requirements are still in place, including the requirement to screen and stabilize every individual who presents, and to accept transfers from hospitals that lack necessary capabilities to do so.

The guidance instead provides information for ensuring that new workflows and processes implemented by hospitals to address COVID-19 guidance are compliant with EMTALA, including alternative screening locations on campus, communications to encourage the public to go to alternative sites in the community, and signage directing individuals to other locations. For a more detailed summary, please click here.  

Hosting Mass Gatherings: CDC releases interim guidance "Get Your Mass Gatherings of Large Community Events Ready for Coronavirus Disease 2019"

New resource for patients: Stop the Spread: A Patient Guide to the Novel Coronavirus (COVID-19)

ACEP Now: COVID-19 for the Emergency Physician: What You Need to Know

Recent Updates


Check for the latest with the CDC here:
Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings.

Physician Personal Checklist

Strategic Plan for ED Management

Information for the Public

ACEP Clinical Warning Graphic-300px.jpg

This page is updated often to help keep emergency physicians prepared and save time.

 

March 5, 2020

On March 4, ACEP sent a letter to Congress outlining key policy changes to help ensure our health care system is prepared for an outbreak in the United States. Please share with local and state public policy stakeholders as appropriate, as this is an issue that needs attention at all levels of government.

ACEP has created a National Strategic Plan for Emergency Department Management of Outbreaks of COVID-19, which includes a checklist for facilities, as well as a personal preparation checklist for individual emergency physicians.

A new members-only community forum on engagED allows you to openly share thoughts about COVID-19 and offer suggestions.

A podcast released March 5 from JACEP Open disucsses "COVID-19 According to the Literature."

The U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) also released a COVID-19 Healthcare Planning Checklist.

CDC has announced that testing of patients for COVID-19 is no longer restricted but must be ordered by a physician.

A new multi-center study of 110 patients suggests that most patients with the COVID-19 associated pneumonia have ground glass opacities on chest CT or have a mixed picture of ground glass opacities with consolidation. CT findings were present both in patients with mild disease, as well as severe disease. However, the CT was considerably more severe in patients with severe disease. The authors suggested that CT can be used to grade the severity of the disease.

The CDC this week issued guidelines for reuse of PPE. Emergency personnel may want to adopt these early.

Actions are being taken to increase the production of N95 masks as well as attempts to curtail the use of N95 masks outside of medical use.

There is also pressure to increase the availability of testing kits. At this time, testing guidelines are posted on the CDC site and are likely to change shortly as kits become more available. At this time testing should be limited to those with severe unexplained respiratory disease.

The CDC will be issuing addition guidance for special groups including, but not limited to, law enforcement, residential care centers, dialysis center, and communities with large amounts of homeless in the near future.

Facilities should consider diverting patients with respiratory disease to a different, specialized evaluation unit if feasible. Signs should be posted and patients with respiratory disease should be given a mask at entry.

Patients should be placed in a negative pressure or similar room if available.

Check for the latest with the CDC here: Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings.

For patient-facing information about Covid-19, visit emergencyphysicians.org.

Reporting Updates

As of March 5, there were more than 96,888 confirmed cases in more than five dozen countries, including more than 80,422 in Mainland China and more than 162 in the United States. There have been more than 3,305 deaths, including more than 2,902 in China and 11 in the United States (10 in Washington state, 1 in California). 

It should be noted that the CDC reports that the number of flu cases and flu-related hospitalizations in the United States this season totaled 29 million and 280,000, respectively, as of the week ending Feb. 15. CDC officials also report that there have been 16,000 flu-related fatalities, including 105 pediatric deaths, so far this season.

Risk & Evaluation Criteria

The CDC website has a chart to guide evaluation of patients under investigation.

Cases should be reported to the hospital’s infection control department and to the local or state health department.

Epidemiology

Epidemiological modeling suggests that cases will double every 6-7 days. 

Exposure to disease about 5 days (2-14 range). Patients present with fever cough and shortness of breath. Older patients, those with chronic illness and possibly pregnant women are at potentially higher risk.

Reports suggest an equal distribution of male and female. 

Deaths continue to occur primarily in patients with co-morbidities. 

Patients with severe disease have multilobar pneumonia and often leukopenia (though leukocytosis has been seen). Hepatic enzymes are elevated in some patients. About 1/3 - 1/2 of patients with underlying disease. Pneumonia appears around the 2nd week of symptoms.

Travel Information

South Korea has a level 3 travel warning, as previously issued for China. Iran and Italy now have a level 2 travel alert — joining Japan. The CDC recommends that people with chronic medical conditions and older adults consider postponing non-essential travel to countries with a level 2 alert.
In addition, CDC has posted information for travelers regarding apparent community transmission in Singapore, Taiwan, Thailand, and Vietnam, and recommendations for persons to reconsider cruise ship voyages in Asia.

Workplace Information

It has been recommended that all employers review or create an epidemic response plan delineating who must report to work and who can work from home. In addition, they should review their sick time and compensation plan if workers are quarantined.

While created for H1N1, this plan may be useful as you review your facilities’ pandemic response plans - National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza


  1. IDENTIFY: Screening must be implemented. See the CDC site for screening criteria.

    The first step of controlling the disease is identify. Patients should be screened for travel to mainland China within the past 14 days and for the presence of respiratory disease and/or fever. In addition patients who have had exposure to patients with Covid-19 with symptoms should be identified.

    The CDC website updates screening criteria often so if there is any question, consult their website -Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings.

    ALL facilities need to be screening (hospitals, clinics, urgent cares, ambulatory surgery centers, etc.).

    The CDC released interim guidance for EMS professionals.
      
  2. ISOLATE: Review your isolation plans. 

    The CDC issued guidelines for optimizing the supply of N95 respirators, including -

    • minimizing the number of healthcare personnel who need to use respiratory protection
    • using alternatives to N95 respirators when feasible
    • implementing practices to allow extended use and/or limited reuse of N95 respirators when possible, and
    • prioritizing the use of N95 respirators for those personnel at highest risk of acquiring infection or experiencing complications of infection.

    The CDC has recommendations around the annual ‘fit’ testing, including -

    • Where possible an airborne infection isolation room should be used for patients potentially infected.
    • This type of room can reduce the exposure of personnel.
    • Barriers such as glass/plastic window between patients and intake desks, information booths, pharmacy pick-up can reduce airborne spread.
       
  3. INFORM: Bottom line - notify your institution’s Infection Control and call your local health office (LHO). The CDC links to this directory of local health departments.

    Isolate and call your local health office (LHO) BEFORE testing to confirm true patient under investigation (PUI) status.

  4. TESTING: CDC has a very detailed explanation of what testing to obtain, how to ship, who to contact. The local health office (LHO) and department of health (DOH), with the CDC, will guide clinicians as what type of testing is needed. The CDC site has a directory of local health departments

    The CDC recommends nasopharyngeal and oropharyngeal swabs as well as sputum be collected. They may also recommend blood, urine and stool.

    Healthcare providers who need to test patients for Coronavirus using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill for that test using the newly created HCPCS code (U0001).

    The Medicare claims processing system will be able to accept this code on April 1, 2020 for dates of service on or after February 4, 2020.

  5. TREATMENT: Treatment is symptomatic. There is no antiviral known to be effective. Of the cases with pneumonia in China, most have been older men with comorbidities. Pneumonia appears around day 7. ARDS appears in about 17-29%. Secondary infection appears in about 10%.

    About 25-30% require ICU with some receiving mechanical ventilation and a few have been treated with ECMO. Some patients have had acute cardiac or kidney injury during the course of the disease.

    The commercial panel that screens for coronavirus and other respiratory viruses such as RSV do not detect coronavirus.

    It is unclear how long patients may shed the virus and may be infectious. That should be known as the disease is further studied.

    Media reports about a "cure" or "treatment" are not correct. There was one patient that received a combination of anti-virals and did recover, however that is not evidence in favor of any treatment. Treatment remains supportive.

In short, screen patients to IDENTIFY potential patients with novel coronavirus. ISOLATE them within your department. INFORM your health department as early as possible. Consult the CDC website for further information.

For more information:

Relation Between Chest CT Findings and Clinical Conditions of Coronavirus Disease (COVID-19) Pneumonia: A Multicenter Study. Zhao W, Zhong Z, Xie X, Yu O, and Liu J. American Journal of Roentgenology. Published online March 3, 2020.

JACEP Open published two studies:

Positive RT-PCR Test Results in Patients Recovered From COVID-19. Lan L, Xu D, Ye G, et al. JAMA. Published online February 27, 2020.

Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. Wu Z, McGoogan J. JAMA. Published online February 24, 2020.

What Healthcare Providers Need to Know About Novel Coronavirus Webinar
The National Ebola Training and Education Center discusses the nature and impact of the virus, plus suggestions for containment and treatment. Representatives from the HHS, CDC, ASPR and HPP were on this Feb 18 webinar.

Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. Wang D, Hu B, Hu C, et al. JAMA. Published online February 7, 2020.

National Ebola Training and Education Center has information and PPE recommendations - https://repository.netecweb.org/exhibits/show/ncov/ncov 

Initial Public Health Response and Interim Clinical Guidance for the 2019 Novel Coronavirus Outbreak — United States, December 31, 2019–February 4, 2020 - CDC Morbidity and Mortality Weekly Report (MMWR)

2019-nCoV: The Identify-Isolate-Inform (3I) Tool Applied to a Novel Emerging Coronavirus - Kristi L. Koenig, MD; Christian K. Beÿ, BS; Eric C. McDonald, MD, MPH; Western Journal of Emergency Medicine, articles in press

CDC Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-nCoV) in Wuhan, China

Webinars and Podcasts

ACEP COVID-19 Update webinar
March 5

COVID-19 According to the Literature
JACEP Open podcast - March 5 

What Healthcare Providers Need to Know About Novel Coronavirus Webinar
National Ebola Training and Education Center - Feb. 18

Reports and Research

LIVE CHAT
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