Clinical Practice Documents (March 26)
Providers, please click here to find Clinical Practice Documents.
COVID-19 UCHealth Update (March 24, 2020)
As health care workers, our communities are looking to us for leadership during this pandemic. It is imperative that we all are equipped with facts. We hope you find the below information helpful as you care for your patients and interact with your staff members.
- COVID-19 is a virus transmitted by droplets. Appropriate precautions include contact/droplet with eye protection.
- COVID-19 does have the potential to be transmitted by airborne particles when performing aerosol generating procedures or treatments. Appropriate precautions include airborne/contact with eye protection when performing aerosol generating procedures or treatments. All of UCHealth’s N95 respirators, half face piece respirators, and PAPRs are approved for use when performing aerosol generating procedures or treatments.
- UCHealth has a sufficient stock (inventory) of PPE as of today.
- Conservation efforts are helping us protect our supply against ever-growing needs. Conservation is important since we have no way to predict how long this pandemic will affect us.
- Health care workers (HCW) who perform direct patient care including operative and procedural areas will be provided one surgical/procedural mask per shift and as needed for clinical circumstances.
- Used PPE is being collected now as a potential safeguard for the future.
- Through connections with hospitals already seeing a surge in patients, UCHealth is learning best practices and planning for the possibility of a surge in patients here.
COVID-19 Testing Criteria (Updated March 21, 2020)
As there is now evidence of community transmission in Colorado, we are recommending only testing health care workers and hospitalized patients with symptoms of acute respiratory infection (e.g. fever, new cough, new shortness of breath). Patients who do not require admission should be encouraged to stay home and be given guidance on home isolation. Neither infectious diseases consultation service nor public health officials need to be notified if you are considering testing.
Health care workers
Health care workers who are concerned about exposure or symptoms should call the COVID-19 employee hotline at 720.787.3321 to be evaluated.
The decision to discontinue home isolation depends on several factors including improvement in symptoms (e.g. cough, shortness of breath) and resolution of fever without the use of an antipyretic medication. In general patients should be advised to practice home isolation as below:
- Non-hospitalized patients in whom you suspect COVID-19 due to symptoms, especially if risk factors such as contact with a known case, travel and predisposing medical conditions: At least 7 days after symptoms began AND no fever for 72 hours.
- Non-hospitalized healthcare workers: At least 7 days after symptoms began AND no fever for 72 hours.
Hospitalized patients: At least 7 days after hospital discharge, even if treated with antiviral medication UNLESS cleared from isolation during hospitalization. Patients with more severe illness may have prolonged viral shedding and isolation may be extended in discussion with public health.
New recommendations for non-essential travel (Updated March 16, 2020)
The U.S. Centers for Disease Control and Prevention has recommendations for non-essential travel. Go here: https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html
Travel to Eagle, Summit, Pitkin or Gunnison counties
On March 15, the Colorado Department of Public Health and Environment announced that visitors to Eagle, Summit, Pitkin, or Gunnison counties in the past week should minimize contact with other people due to evidence of community spread.
- Employees, providers and trainees who traveled to these areas in the last week will not be required to quarantine at home, but must wear a face mask while in any UCHealth facility.
- Practice hand hygiene at all times and practice social distancing when feasible.
- One face mask can be worn for an entire shift, unless becomes soiled and needs to be replaced.
When talking to patients:
- Reassure patients, always, that UCHealth care providers are vigilantly evaluating every patient that enters our facilities. If someone exhibits COVID-19 symptoms, we will provide appropriate care.
- If patients have questions about COVID-19, suggest they phone the CDPHE phone line, CO-Help at 303.389.1687 or 1.877.462.2911 or email COHELP@RMPDC.org, for answers in English and Spanish (Español), Mandarin (普通话) and more.
- Remind patients they can help slow the spread of the disease by:
- Washing their hands often with soap and water for at least 20 seconds.
- Staying home when they are sick, and keeping children at home when they are sick.
- Covering a cough or sneeze with a tissue.
- Cleaning and disinfecting frequently touched objects and surfaces using a regular household cleaning spray or wipe.
Lab Testing Information (Updated March 14, 2020)
The SARS-COV-2 NAAT orderset includes COVID-19 and a respiratory viral panel (RVP) if not done in the last 48 hours. Positive RVP results will no longer resulting in cancellation of COVID-19 testing.
1 swab for NP collection
1 tube of M6 or M4-RT viral transport media
Proper Specimen Collection
The quality of the specimen collection is critical, and the correct collection of the specimen is directly linked to the sensitivity of the test. Collect one NP swab for both the RVP and COVID-19 tests. Follow these steps.
- Perform hand hygiene before and after patient encounter.
- Don appropriate PPE.
- If the patient has nasal congestion or a moderate-large amount of rhinorrhea, ask them to clear their nose into a tissue.
- Tilt their head back slightly (70 degrees)
- Ask them to close their eyes, if possible.
- Insert the swab into the nostril parallel to the palate until resistance is met by contact with the nasopharynx.
- Leave swab in place for 2-3 seconds then rotate completely around for 10-15 seconds. Note: Although not painful, patients generally feel very uncomfortable with this procedure. Be prepared for them to pull their head and/or body away. This procedure may also generate a cough so prepare to move to the side if possible, especially after completing the process.
- Remove swab and repeat the same process in the other nostril with the same swab.
- After the second swab is completed, immediately
- place into the sterile vial containing the universal transport media.
- Ensure that cap is closed tightly and label is on tube.
- Place the tube into a biohazard bag.
Please walk specimens to Clinical Laboratory, do not use the tube system
Contact local Clinical Laboratory
Please note: This information is current as of 3/14/2020 and is subject to change with new information.
If you suspect a patient has COVID-19, identify, isolate, inform (Updated March 11, 2020)
- Immediately place a surgical mask on the patient and place the patient in a private room with the door closed. Locations that have an available airborne infection isolation room should use this room.
- Health care personnel entering the room should use standard contact precautions (gowns and gloves), airborne precautions (an N-95 respirator mask) and use eye protection (e.g., goggles or a face shield; glasses are not sufficient).
- Patients who have general questions can call the Colorado Department of Public Health and Environment at CO-Help at 303.389.1687 or 1.877.462.2911 or email COHELP@RMPDC.org. Answers are available in English and Spanish (Español), Mandarin (普通话) and more. Resources for health care providers can also be found on the CDPHE website.
- The U.S. Centers for Disease Control and Prevention website
- Most patients with mild symptoms, or no symptoms should be sent home. The decision to quarantine a patient is based on their risk factors for having been exposed to COVID 19. This will change as the prevalence of the disease increases in the state and/or county. The CDC does provide guidance for how long to remain in quarantine at home (14 days at the moment). Any patient with respiratory distress, unstable vital signs or signs of significant illness that would require hospitalization regardless of cause should be considered for transfer to a health care facility.
- If you believe your patient needs to be transferred to a health care facility, call your local health department or the Colorado Department of Public Health and Environment.
- One of the safest ways to have a patient evaluated is through UCHealth’s Virtual Urgent Care team. They now has capabilities and protocols to screen patients for COVID-19 symptoms and exposure, and if needed, refer patients for testing. Patients can quickly set up virtual urgent care visits through My Health Connection app or through the Virtual Urgent Care website.
- You may also call DocLine, 1.844.285.4555 or 720.848.2828 to consult or discuss whether a patient needs to be hospitalized. If the patient needs hospitalization, the transferring doctor would ask DocLine to facilitate an ambulance – which may involve initiating and alerting EMS to a possible COVID 19 exposure.
What is the clinical presentation of COVID-19?
- Incubation = 14d (mean of 5d).
- Presentation = fever (99%), cough (59%), myalgias (35%), sob (31%, median of 5 days).
- Illness can wax and wane
- 81-to-83% cases have mild symptoms
- 14% severe, 5% critical (data from China)
- Complications can include:
Pneumonia – >cytokine storm – > ARDS
- Common to have lymphopenia
- Elevated aminotransferase levels
- Normal serum procalcitonin seen in cases of pneumonia (though once in ICU more likely to elevate)
- CXR/CT chest = bilateral patchy shadow or ground-glass opacities
- Admission criteria is based on clinical condition, not diagnosis
- Care is supportive (research on antivirals ongoing)
- Avoid glucocorticoids (unless otherwise indicated)
- No evidence transmission to fetus in pregnancy – but droplet precautions postpartum apply and neonate a PUI
According to World Health Organization:
- Mild cases about 2 weeks
- Severe cases about 3-6 weeks
- Still unclear how long patients can shed the virus.
What screening questions should I ask of patients?
- Have you traveled out of the country in the last 14 days? If so, where?
- In the last 14 days, have you had close contact with someone else who had a recent travel history to a country with known transmission and became ill?
UCHealth’s Epic team has expanded a travel screening Best Practices Advisory (BPA) to follow the CDC’s guidelines for COVID-19. This BPA now prompts staff and providers to ask patients travel screening questions every seven days rather than every 21 days. The specific list of countries included in the travel screen has not changed. This means patients may be asked travel screening questions more often, and staff caring for current inpatients may get additional alerts. Please redocument the travel screening for any admitted patients who have not recently traveled.
For more information
Learn more about this virus by going to the CDC website.