Treatment cONCEPTS.
The room designation will use the same principles outlined in the Facility Layout section.
As patient numbers increase you will use more of your rooms.
Do not backwards convert rooms from COVID to Non-COVID if possible, but do it if you need to.
Again, if a patient does not need treatment: keep them out of the building if you can.
Infrastructure
Initially Avoid using the Crash Rooms for sick COVID patients, since the room must be left for 4 hours if not negative pressure before it can be cleaned.
Set up an Alternate Acute room for treating sick COVID patients. DO THIS NOW
See the example facility, which is using Rooms 10 & 9 shown in the diagram above.
Set up an Airway Rapid Bag outside this room. (See contents of the Airway Rapid Bag section)
Avoid taking charts into rooms. They will be contaminated and impossible to clean.
You may need to revisit your Crash Room allocation as volume ramps up
The Unwell COVID Patient
(This information is constantly being revised.)
In general, COVID patients develop hypoxia with atypical Acute Respiratory Distress Syndrome (ARDS). Lungs are more compliant than usual ARDS, with atelectasis and fluid filled alveoli. They literally die drowning in their own secretions.
There is also the phenomenon of silent hypoxia. Clinically, patients appear well with no increase in work of breathing or dyspnea, and then sudden decompensation.
There is also the description of the Happyish Hypoxemic. Low sats, but mentating and otherwise ok apart from tachypnea.
From:
Emergency Medicine Cases. April, 2020. https://emergencymedicinecases.com/em-quick-hits-covid-19-oxygenation-trauma-addictions-cardiovascular-complications/. Accessed [date].
Gattinoni L. et al. COVID-19 pneumonia: different respiratory treatment for different phenotypes? (2020) Intensive Care Medicine; DOI: 10.1007/s00134-020-06033-2
At the moment 3 main presentaions (phenotypes:)
Cold/flu-like symptoms Vital signs near normal
“Happy hypoxic” – Tachynpeic, low sat ( <90% despite 5-6L NP and 15L NRB) otherwise appearing comfortable. So Called Type L pattern
Respiratory failure – severe hypoxia and tachypnea who are decompensating - altered LOC or increased work of breathing; consider early intubation and preoxygenation with CPAP or gentle controlled BVM 2 person (6-10 breaths/min) so called (Type H pattern, fully fits the severe ARDS criteria: hypoxemia, bilateral infiltrates, decreased the respiratory system compliance, increased lung weight and potential for recruitment.)
There is a risk that some of your usual oxygenation therapies will aerosolize secretions and spread the infection. This is bad.
A very unwell patient is also considered an aerosol risk.
Therefore: Avoid Aerosol Generating Procedures.
Before seeing a patient - you must wear appropriate PPE. If there is an aerosol risk, use an N95 mask and eye protection.
You must know how to don and doff PPE properly. This is an entire subject on its own.
Click here for WHO Don & Doff Guidance
Intubation
The initial approach advised from Italy was to give 6L O2 and then if sats in the 80’s to Intubate quickly to avoid a crash airway situation. This may possibly be harming more than helping. Anecdotally it appears some do worse when on Mechanical Ventilation. Unclear if this is selection bias.
Not all hypoxemic patients crash. So called Happy hypoxemics Sat in the mid 80’s. If talking and interactive - they may be ok, cycling between worse and better. Use O2 and encourage repositioning and proning.
I’ve decided to ignore much of the conventional ‘wisdom’ out there. Is Covid mostly droplet or not? Don’t know, don’t care. Let’s treat it as super easy to catch and take all precautions necessary. In 2 years when we have enough data to be smart about it - let’s talk.
So to attack it from an engineer’s standpoint - divide the task into:
Protection Inside the Room
Source Control ie Decrease amount from patient Mask on patient
Between the Source and Recipient (e.g. Barrier eg Plexi Box)
Recipient (Health Care Worker) protection = PPE
Protection Outside the Room
Using a Negative Pressure Room to protect those outside.
Temporary Neg Pressure setup or Hepa Filter? Finding out more. Stay tuned.
PPE of staff outside if no negative pressure available.
Testing: Strategies and How
This will not be covered in detail at the moment. Please refer to guidelines for doing 1 swab in oropharynx, then both narines and into pink viral medium.
In general in places that have succeeded in controlling the spread have used aggressive testing to identify and isolate cases, e.g. South Korea.