View source for COVID-19: Example hospital protocols

''All protocols are hospital dependent, please check with your hospital administration for existing protocols''
==Background==
This page is for sharing hospital protocols from various institutions. Please add from your institution.

==Labs/Imaging==
* COVID-19 PCR
* Viral panel for alternative diagnosis
** Co-infection with COVID-19 possible
* CBC
* Chem
* LFT
* Sepsis specific labs
** Blood & urine C&S
** Procalcitonin
** Lactate
* Cardiac markers
* D-dimer
* Coagulation panel
* COVID specific panel:
** Ferritin
** LDH
** CRP
** IL-6
* CXR
* POCUS
* CT not recommended for routine evaluation

==Intubation==
* Pre-oxygenation
** NC @ 6 L/min
** HFNC controversial
*** Consider facemask or other facial covering to prevent aerosolization
** CPAP mask modified with bio-filter
[[File:CPAP with Bio Filter.jpg|thumb|CPAP mask with viral filter]]
*** If not available, use [https://www.youtube.com/watch?v=c9h2I8n9Ptk&feature=youtu.be BVM with bio-filter]
*** Apneic oxygenation
* Personnel in room
** Intubating physician (most experienced)
*** Physician administers meds
*** Nurse may enter room once circuit is closed to minimize exposure
** Respiratory therapist
* Personnel outside
** Nurse to enter room once circuit closed
** Personnel to record/obtain unanticipated supplies
** Personnel to enter electronic orders if needed
* PPE
** CAPR/PAPR preferred
** Otherwise
*** N95 with surgical mask cover recommended
*** Eye goggles with side shielding
*** Hair cover
** Body suit preferred, otherwise surgical gown
** Double gloves recommended
** Doffing
*** All doffing in anteroom preferred
*** All PPE except facial covering doffed inside room
*** CAPR/PAPR/mask should be doffed immediately outside
*** Assign personnel to guide doffing process
* Equipment
** Video laryngoscopy (only bring into room what’s required)
*** Direct laryngoscopy NOT recommended
** ETT tube with backup unopened from packet
** CPAP mask or BVM with bio-filter
** Bougie (unopened from packet)
** RSI meds pre-drawn (sedation should be pre-ordered)
** Have other equipment ready for central & arterial lines outside
* Nursing
** Set up monitor outside door with extension tubings
** Minimize need for mult room entry 
* Technique
** Consider using [https://intubationbox.com/ face hood]
[[File:Using Intubation Box.jpg|thumb|Demonstration of an intubation box]]
** RSI by most experienced personnel
** Meds:
*** Paralytic: succinylcholine/rocuronium
*** Induction: etomidate/ketamine
** Video laryngoscope
*** Direct laryngoscopy NOT recommended
** Minimize suction
** Confirm placement with EtCO2 or calorimetric device 
*** Auscultating for BS not recommended
** Maintain bio-filter inline with ETT at all times
* Ventilation
** Set up pre-intubation
** Lung protective ventilation
*** Use ARDSnet
*** Vt: 8 ml/kg initially - use predicted body weight
*** Target 6 ml/kg
*** Goal PaO2 55-80 mm Hg, or SpO2 ≥ 88%
*** Plateau pressure ≤ 30 cm H2O
*** PEEP: start at 10; be ready to increase
*** Use PEEP table to adjust FiO2/PEEP
** Sedation: fentanyl/propofol or ketamine/propofol
** Albuterol: if needed, administer via inline adapter
* HEPA filter as close to patient as possible
* Consider establishing an area for incoming crash intubation from EMS
** It may be more efficient to bring patient to ED room for RSI
*** Cover patient's face with mask and/or sheet to minimize aerosolization
*** Consider apneic oxygenation during transport to room
*** Have pre-designated route to minimize exposure to staff and ED environment
*** Receiving team should be transporting patient

==CPR==
[[File:Resuscitation tent.jpg|thumb|Outdoor resuscitation tent]]
* Use auto CPR device if available
* Cover face with plastic or bed sheet to minimize aerosolization
* Minimal personnel
** RT
** 2 providers to switch if manual CPR
*** If physician needed for RSI then physician/nurse
*** Otherwise nurse/nurse
* Preselected resuscitative meds in bag
* Consider terminating code if no response after pre-planned number of rounds
* Consider establishing an area for incoming codes from EMS
** Decontamination room if available
** Outdoor tent with proper resuscitative equipment

==Asthma==
[[File:CPAP with filter and T-extender.jpg|thumb|CPAP mask with bio-filter and T-extender]]
* Minimize aerosolization
* Supplemental O2 as needed
* Beta agonist
** Albuterol HFA with spacer mask/chamber
** If needed, nebulized via modified CPAP mask with bio-filter
*** Administer through inline T-extensor
*** Provider in PPE for aerosolization precautions
*** Should be done in negative pressure environment
* Steroid may be given as per usual protocol
** Prednisone 60 mg PO
** Dexamethasone 10 mg or methylprednisolone 60 mg IM/IV
* Adjunctive therapy for severe symptoms
** Magnesium 2 gm IV
** Epinephrine 0.3 mg SQ/IM q20min
** Terbutaline 0.25 mg SQ q20min
** Ketamine 0.5 mg/kg IV and/or 0.1 mg/kg/hr titrated to effect
* Prepare for RSI per COVID-19 protocol if worsening

==CV procedures==

==Disposition==

==Shared Protocols==
*ASPR TRACIE COVID-19 Hospital Triage/Screening Resources <ref>https://asprtracie.hhs.gov/technical-resources/119/covid-19-hospital-triage-screening-resources/99</ref>
*Brigham & Women's Hospital Protocols- <ref>COVID-19 Protocols. Brigham and Women’s Hospital COVID-19 Clinical Guidelines. https://covidprotocols.org/protocols/02-ed-inpatient-floor-management-triage-transfers. Published 2020. Accessed April 8, 2020.</ref>
*Massachusets General Hospital protocols- <ref>Massachusetts General Hospital COVID-19 Treatment Guide Version 1.36 04/05/2020. https://www.massgeneral.org/assets/MGH/pdf/news/coronavirus/mass-general-COVID-19-treatment-guidance.pdf. Published 2020. Accessed April 8, 2020.</ref>
*Department of Defense Practice Managment - <ref>https://www.health.mil/Reference-Center/Technical-Documents/2020/03/24/DoD-COVID-19-Practice-Management-Guide</ref>
* Bedside checklist: [[:File:Harbor COVID checklist v3-21-20.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]]

==Example Hospital Protocols on WikEM==
*[[Harbor:Infectious_Disease_Threats#Coronavirus_.28COVID-19.29|Harbor-UCLA Medical Center]]
*[[OVMC:ED#COVID-19|Olive View-UCLA Medical Center]]
*[[WLAVA:COVID19_ED_Operational_Updates|West LA VA]]

==See Also==
{{Special:Prefixindex/COVID-19 |hideredirects=1}}

==References==

[[Category:COVID-19]]