COVID Pro-Tips, Direct from the Emergency Department

During a virtual meeting last month, emergency physicians had some pro tips for treating COVID-19 patients. Perhaps the most surprising among them: consider telling patients with COVID-19 to lie on their side -- not on their stomach.

Other tips included assigning physicians to screen incoming emergency patients at the door in no more than 5 minutes, and embracing nasal cannulas instead of non-invasive respiration.

In interviews with MedPage Today, ED physicians from coast to coast offered these and other pearls about treating patients with COVID-19, expanding on presentations from last month's virtual meeting of the American College of Emergency Physicians.

Prone to 'Proning'? Think Sideways

"Proning" became a buzzword of COVID treatment in the early days of the pandemic. Research suggested that patients may do better if they lie prone in hospital beds, although reports have noted that proning could also cause injury. Proning has become so common that some medical providers, including Emory Healthcare and Nebraska Medicine, have developed protocols for patients with COVID.

"A lot of people have this idea that these patients have to turn over onto their stomachs – 'adult tummy time,'" said Salim Rezaie, MD, a San Antonio emergency physician and Editor-in-Chief of Emergency Physicians Monthly. In fact, he said, patients may be more comfortable yet still gain a benefit if they rotate onto their sides.

"The key strategy is not to let them continue to lie on their backs. The virus, at least when it attacks initially, seems to like the posterior segments of the lung. With gravity, [in bed] the blood will go to the posterior. By having them shift onto their sides and stomachs, you're using gravity to shift where the blood flows," Rezaie said in an interview.

Heavier patients will benefit from lying on their sides, he added. "Proning puts a lot of strain on your back," he said, while patients can lay on their sides indefinitely.

At New York City's Elmhurst Hospital, medical staff made an announcement every hour to remind patients with COVID who were on oxygen to change position from resting on their backs to laying on their stomachs, emergency physician Colleen Smith, MD, said in an interview with MedPage Today.

Assign Physicians to Screen Patients in 5 Minutes

The coronavirus pandemic overwhelmed New York City last spring, and Elmhurst Hospital in the borough of Queens became "the center of this crisis," health officials said at the time. The public hospital faced "apocalyptic" conditions, a resident physician told the New York Times. The newspaper reported that 13 patients died in a single day.

The ED became so swamped that there was no room for incoming patients to sit and the line stretched outside, Smith said. "We didn't have the capacity to test all the patients with COVID, and many of those who did have it were really not that sick," she said. Meanwhile, "we'd have a person with a laceration or broken toe sitting in a waiting room full of people with COVID. But we can't turn people away and say, 'Don't come here.'"

As Smith and colleagues reported in a presentation at the ACEP annual meeting, the hospital adopted an unusual strategy. It assigned attending, board-certified physicians to triage all incoming ED patients via 5-minute screenings. The physicians replaced the nurses who normally handle triage.

Patients have a right to be examined by a physician at the ED, Smith said, and the screening system allowed this process to happen quickly. Also, she said, "we wanted people who had more experience in determining 'sick' from 'not-sick' to be making the decision to send someone home. One of the most difficult tasks in medicine is to tell 'sick' from 'not-sick.' Particularly with COVID, we were starting to see that may people looked OK but had really low oxygen levels. We started calling it 'silent hypoxemia.'"

The physicians examined patients at the front door of the ED, where they took vitals and asked questions, Smith said. The physicians determined whether patients likely to have COVID could safely go home, taking into account factors such as vital signs, age, appearance (do they look sick?) and comorbidities.

Patients who agreed to go home would receive discharge papers with information about aspects of COVID care such as safe quarantining. But the hospital didn't boot patients who appeared well enough to avoid an ED stay. "If a person said 'I really want to get checked out,'" Smith said, "we'd never force them to leave. If they were seriously worried and wanted a chest x-ray or whatever it was, and I couldn't reassure them, I'd let them come in."

ED physicians also made sure to allow patients with urgent conditions such as chest pain or vaginal bleeding to bypass the line to be screened by a physician, Smith said. They'd be taken into a part of the department that was intended to be kept COVID-free.

Patients who came in via ambulance went directly into the ED and bypassed the physician screening process – at least much of the time. "If people were very well, we'd take them out and put them in [the screening line]," she said.

About 2,000 patients went through the 5-minute screenings, and about 500 were admitted, Smith said. A preliminary analysis of 219 patients found that 74% (158) were sent home because they appeared to be well, lacked major comorbidities, and had oxygen saturations above 95%. Of those, 14 (9% of the total) returned to Elmhurst Hospital or a sister facility. Three of those were admitted, and 1 died.

Elmhurst Hospital returned to normal screening procedures after the worst of the pandemic passed, Smith said, and several sister hospitals in New York City successfully used similar strategies.

Put High-Flow Cannulas to Work

Rezaie, the San Antonio emergency physician, urged colleagues to deliver oxygen to patients through high-flow nasal cannulas (HFNC) instead of non-invasive respiration via masks. "It's just more comfortable for the patients and less likely that they'll get disconnected from the device. The last thing we want to do is get people disconnected," he said.

The move toward HFNC represents a significant evolution for ED physicians, he said. "We have had more comfort with the masks than we did with these bigger, pillowed nasal cannulas. However, this pandemic has shown that the nasal cannulas are a lot better for the patients."

A French study of 379 patients with COVID suggests that HFNCs reduce intubation and the need for mechanical ventilation but don't lower mortality. However, a November 2020 report in the journal Chest said this strategy has been "very controversial," with guidelines differing over whether it would be routinely used in hypoxemic patients with COVID.

The authors, based in the U.S. and Italy, recommend "the prior dictum of progressing from nasal cannula to non-rebreather face mask and then to invasive mechanical ventilation" in most patients. But they write that about 20% to 25% of patients may stabilize and avoid intubation thanks to "high-flow nasal cannula therapy, noninvasive ventilation, and awake proning."

Rezaie cautioned that patients who are struggling to breathe may be better off with masks. Look for signs of trouble such as sweating, he suggested, in addition to monitoring oxygenation and respiration levels.

Assign Physicians to 'Oxygen Rounds'

Emergency physician Elaine Rabin, MD, of Icahn School of Medicine at Mount Sinai, highlighted the use of "oxygen rounds" in a presentation at the ACEP meeting. Early on in the pandemic, she said, HFNC seemed like it might be a "panacea" to avoid intubation. But, she said, HFNC has a downside: It's an oxygen hog.

"If you're at all concerned about oxygen supply, you're gonna have to worry about it," she said. "There are a limited number of wall hookups to oxygen. And when all of your patients need them, you can run out pretty quickly. When you run out of wall units, you just have to rely on old technology and start using oxygen tanks."

But the oxygen in the tanks will run out, she said. "This is really dangerous when things get really overwhelmed. We heard many stories from all over the city of patients who seem to be in distress only to have it recognized that their oxygen tank can run out."

The solution, she said, is "oxygen rounds" – assigning workers to regularly check on oxygen tanks. "We had residents from other services -- dermatology, neurology, radiation oncology -- redeployed to us, and in our hospitals it was often them we assigned to this task," Rabin said in an interview with MedPage Today. "They would check the tanks every hour or two. We also reviewed the signs of increasing respiratory distress with them so the rounds served as an extra check on the clinical status of the patients as well."

Smith, the Elmhurst Hospital physician, said the residents who conducted oxygen rounds tracked the progress of patients on forms that were attached to beds or to the patients themselves. "They would write down the patient's level and how much oxygen they were getting. If somebody was really sick, their job was to bring it to the attention of the attendings," she said.

The forms allowed physicians to track the trends of oxygen use and adjust levels as needed without needing to check a screen, she said. "It was quicker and easier since the information was with the patient all the time."

In an August 2020 report about residency lessons from the pandemic, Rabin and colleagues noted that resident physicians who took part in oxygen rounds were also helpful in communicating with family members and discussing goals of care.

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