2019 Novel Coronavirus (COVID-19) Clinical Pathway — Emergency

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Provider Resources

Related Pathway

Current Screening for 2019 Novel Coronavirus Disease (COVID-19)

ED Process for Arrival of COVID-19 Positive Patient

Patient Arrival at Security Desk at Emergency Entrance to ED Waiting
- Encounter created and exposure screen completed
- PAC Assessment, Sort ESI Level, Place Pt ID Band
- ED Visitation Guidance, Mask All Patients, Family Members

Triage PPE
Hand Hygiene
- Mask + Eye Protection

No Respiratory Symptoms

Cough, SOB with or without Fever

All Acuities
Main ED Waiting B,C

ESI 1, 2, 3
Waiting A

ESI 4,5
Waiting A or D

Escort Patients to Next Available Room

AGP Existing/Likely
- Negative Pressure Rooms as available;
- Single room, door closed if not available

BH Patients
- BH-1, ECBH 7-10, as available

Mask + Eye Protection for All Patients (Gowns per symptoms)
Modified Expanded Precautions for Respiratory Symptoms, Exposure , Known COVID
Expanded Precautions for Aerosol-Generating Procedures

ED Room Precaution Recommendations

Precaution Video

SARS-CoV-2 Testing Recommendations

Use ED EPIC Order Set: Symptomatic vs Screening COVID Test

Patient Care Considerations
Symptoms History
Fever (Temp > 100.4°F) or
Sore throat or
Cough, respiratory distress, tachypnea, or hypoxia

Exposure History
No close contact with person with COVID-19 pending or positive test within the last
14 days
Neither patient nor family on self-isolation for presumed disease or from current
High-Risk regions within the last 14 days

Collection of COVID-19 Testing
ED EPIC Order:
- Screening COVID Test
- Symptomatic Pt COVID Test

CHOP Radiology COVID-19
ED Order Guidance CHOP Radiology

ED Asthma Pathway Changes in the setting of COVID-19
For patients requiring Asthma Treatment, MDI is preferred

Therapeutic Considerations for Patients with Severe COVID-19
Introduction/Overview
Supportive Care
- NSAIDS, Steroids, Anticoagulation
- VTE Prevention Pathway, Inpatient
Recommended labs
Antivirals Medications
Convalescent Plasma
Clinical Trials for COVID-19 Patients ≥18 yrs

Resuscitation
Resuscitation Planning
Resuscitation Guidance
Resuscitation Schematic
Communication
ECMO Guidance
Transport of suspected/ confirmed cases of COVID-19
Care of the Deceased Patient with Suspected COVID-19

Management of Previously Positive Patients

PATIENTS LIKELY TO REQUIRE HOSPITAL ADMISSION
Test all patients as soon as possible at initiation of patient evaluation
TESTING CONSIDERATIONS FOR PATIENTS STABLE FOR CARE AT HOME
Symptoms	Patient Factors	Testing	Comments
Asymptomatic	Regardless of high-risk medical conditions or presence of high-risk household contacts	No	If there was an exposure, follow self-isolation procedure for 14 days after exposure with symptom monitoring High-Risk Regions
Asymptomatic	Exceptions: Patient scheduled for aerosol-generating procedure within next 24-72 hrs Peri-Operative Guidance	Yes	Examples: shelters, residential facilities
Symptomatic	Healthy pts with no high-risk or healthcare/ first responder household members	No	Treat patient as presumed positive in home isolation
Symptomatic	With the any of the following: Unavoidable contact with high-risk household members Unavoidable contact w/essential worker household member who has current in-person work requirements Patients with high-risk medical conditions and/or will require critical health services within 14 days after symptom onset Patients with high risk medical conditions and will require critical health services within 14 days after symptom onset Reside in congregate living facilities	Yes	High-risk medical conditions: Immunocompromise Significant underlying chronic disease High-risk household members: Immunocompromise, immunosuppression Underlying chronic disease of any age Age > 60 years Critical services: Dialysis, chemotherapy, non-elective surgery, etc. Treat patient as presumed positive in home isolation, until SARS-CoV-2 results available
Clearance of home isolation applies to confirmed/suspected and symptomatic/asymptomatic patients and caregivers, but NOT exposed patients and caregivers Clearance of Transmission-Based Precautions for Patients and Caregivers with Confirmed SARS-CoV-2 Asymptomatic/SARS-CoV-2 Positive Home isolation for a minimum of 10 days from the time of diagnosis Symptomatic/SARS-CoV-2 Positive or Suspected Home isolation for at least 10 days since symptoms first appeared AND No fever for 3 days without taking fever medications AND Other symptoms (cough, trouble breathing) are much better Exposed Patients Home isolation for 14 days after exposure with symptom monitoring CDC: Discontinuation of Home Isolation for Persons with COVID-19 (Interim Guidance)

Disposition

Discharge

Admission

Use COVID-19 Discharge Smart Set if patient tested
Follow self-isolation procedure for 14 days
Process for revisit
APP Follow-up
COVID Discharge Instructions

Peri-Operative Guidance
Patients should have pre-procedure screening the
day prior
If unable, testing 72 hrs prior is acceptable if:
- All household members/patient self-monitor for symptoms and
- Have no social contact outside of their household
- Report symptoms immediately
CHOP Provider can enter EPIC order:
- “Consult to drive Through”
- Testing can be scheduled at Roberts or
  Bucks SCC

Admission Locations, Positive/Pending Testing based on Symptoms, Exposure, AGP vs Admission Screening Testing
- COVID-19-positive/pending patients who need PICU level of care:
  - Admit to Pediatric Special Treatment Unit (PSTU)
  - Highly resourced, ill pts may be admitted with pending test results
- COVID-19-positive/pending patients who need admission:
  - Special Isolation Unit (SIU/9S)
  - Patients with pending results will be admitted based on ED capacity
- EDECU eligible: Stable COVID pending patients
- COVID-19-negative patients: Follow routine procedures
- Considerations for BH Patients
- OR
- COVID-19-negative patients: Follow routine procedures
- Transport of suspected/confirmed cases of COVID-19

COIVD 19 Patient Placement

Posted: January 2020
Revised:
February 26, 2020;
March 2, 9, 13, 17, 18, 20, 23, 26, 27, 30, 31, 2020;
April 1, 2, 3, 6, 8, 11, 15, 17, 18, 22, 23, 24, 2020;
May 1, 4, 5, 15, 2020;
June 8, 17, 24, 2020;
July 7, 2020;
Authors: K. Cohn, MD; L. Handy, MD; J. Sammons, MD; V. Kampalath MD; J. Lavelle MD; K. Chiotos, MD;
S. Myers, MD; M. K. Abbadessa, MSN, RN; S. Coffin, MD

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.