Al, We added ambulatory Pulse oximetry to our triage. When the Nurse or Tech walks the patient back to the room; we use a portable Pulse ox to see if they Desat. It's been a great way to pick up the marginal Covids who might decompensate over next few hours to days. Pete Favini
The Roth Score has been pulled from MD calc and is no longer recommended due to false reassurance. https://www.cebm.net/covid-19/roth-score-not-recommended-to-assess-breathlessness-over-the-phone/
We have been placing IV pumps right next to the door so RNs can fiddle with them without using a gown. In Washington, they're actually placing them outside the room (our infection control people veto'd this), and using the statlock from a foley catheter to manage the tubing as is snakes out the room.
We have started separating the control surface from the rest of the ventilator and placing it outside the patient room. We worked with the UMass electrical engineering department to source longer cables that connect the touch screen to the rest of the vent. This only works for one of our vents. For the others we have a small video screen with a VGA cable connected to the vent, so while you can't adjust anything, you can actually see the waveforms, etc. The cable is small enough it fits under the door when closed.
While I was on the ICU, I would round with a pair of binoculars so I could actually see things like the IV pumps (if it wasn't left next to the door) or the vent (before we got the extensions and displays), or the monitor.
We also developed a 3d printable adapter for a full face snorkel mask that fits one of our standard viral filters. This is used by intubators and can be decontaminated an used multiple times.
Pharmacy has been great about making suggestions to tweak medication timing, bundling doses together to reduce the number of time RNs are in and out of the room. We're purposely erroring on the side of ordering drips over pushes also to reduce patient interactions.
Our system has also taken people who aren't busy right now (like surgical techs) are trained them as PPE coaches by infection control. They observing donning and doffing, point out contamination, and are the always up to date source on "how many times do I re-use my mask today".
Our department created a google doc that compiles all the latest information on testing criteria, whats on shortage, care pathways, etc that's specifically relevant to us. The top of the document highlights what been changed most recently so you can quickly review it at the start of your shift. Someone highlights those recent changes during the start of shift huddle, which everyone actually does and takes seriously now.
I'm concerned that some of the anti-fogging ideas could affect mask effectiveness. I would recommend a fit test study with mole skin or band-aids before implementing. I know some of our noses are in bad shape, so at the bare minimum make sure the mask passes a user seal check with your chosen solution. As far as the antibiotic ointment, this has the potential to reduce the mask fiber's static charges which are part of effective filtration. I really appreciated this piece. Thanks for the time put into it.
Brian: You make good points, however, if the goggles are fogging the mask is already not sealed. For many of us it is a no win situation, a truly tight fitting N-95 mask is very very difficult to work in for 8-12 hours. But if you let it leak a little, which will occur with fogging you run the risk of an ineffective mask. Stay safe.
“Gloves as the new skin“- many of us wear the same gloves all shift maybe change them a couple times, essentially washing with them on as if they are your own skin. These new “hands” have less nooks and crannies and you don’t have to worry about your ring, easy to wash, easy to purell. A couple funny looks when you’re washing your “hands“ but it caught on pretty quick.
Robert: Makes sense to me. Have seen that at a number of sites now. Our infection control has blessed the process so some of our clinicians are using it.
Hi Al , I hoped you could comment on a question I have about PPE. I am a PA at a rural ED in Georgia. So far we have had very few COVID-19 patients but we are seeing 5-6 per week. Listening to the docs like you working in New York and New Jersey who have been hit so hard, it sounds like wearing an N95 mask at all times in the ED is advised. At my ED, most folks seem to be wearing only surgical masks unless it is very obvious that the virus is likely. I am a little older (68) and I really appreciated your discussion on older provider. In a case like mine would you advise wearing a simple surgical mask unless in high risk exposure OR wearing an N95 at all times since asymptomatic presentation is not uncommon.
We do wear N-95 masks at all times,along with googles. They are very uncomfortable to say the least. However, if you look at the statistics from NY and NJ, only a few healthcare providers have contracted COVID-19, disease, so the PPE recommendations seem to work.
That said, there is nothing to say that simple surgical masks would not work as well.
Peter F. - April 24, 2020 10:38 AM
Al,
We added ambulatory Pulse oximetry to our triage.
When the Nurse or Tech walks the patient back to the room; we use a portable Pulse ox to see if they Desat.
It's been a great way to pick up the marginal Covids who might decompensate over next few hours to days.
Pete Favini
Alfred S. - April 24, 2020 2:27 PM
Pete: Good to hear from you.
We do the same only we do prior to discharge.
Take care my friend.
Al
Danish K. - April 24, 2020 11:28 AM
The Roth Score has been pulled from MD calc and is no longer recommended due to false reassurance.
https://www.cebm.net/covid-19/roth-score-not-recommended-to-assess-breathlessness-over-the-phone/
Alfred S. - April 24, 2020 2:27 PM
Danish:
Thanks, was not aware of that.
Guess makes sense that CHF is not the same as SARS-CoV-2 pneumonia.
Al
Alfred S. - April 24, 2020 2:25 PM
Pete: Good to hear from you.
We do the same only we do prior to discharge.
Take care my friend.
Al
Mat G. - April 24, 2020 3:35 PM
We have been placing IV pumps right next to the door so RNs can fiddle with them without using a gown. In Washington, they're actually placing them outside the room (our infection control people veto'd this), and using the statlock from a foley catheter to manage the tubing as is snakes out the room.
We have started separating the control surface from the rest of the ventilator and placing it outside the patient room. We worked with the UMass electrical engineering department to source longer cables that connect the touch screen to the rest of the vent. This only works for one of our vents. For the others we have a small video screen with a VGA cable connected to the vent, so while you can't adjust anything, you can actually see the waveforms, etc. The cable is small enough it fits under the door when closed.
While I was on the ICU, I would round with a pair of binoculars so I could actually see things like the IV pumps (if it wasn't left next to the door) or the vent (before we got the extensions and displays), or the monitor.
We also developed a 3d printable adapter for a full face snorkel mask that fits one of our standard viral filters. This is used by intubators and can be decontaminated an used multiple times.
Pharmacy has been great about making suggestions to tweak medication timing, bundling doses together to reduce the number of time RNs are in and out of the room. We're purposely erroring on the side of ordering drips over pushes also to reduce patient interactions.
Our system has also taken people who aren't busy right now (like surgical techs) are trained them as PPE coaches by infection control. They observing donning and doffing, point out contamination, and are the always up to date source on "how many times do I re-use my mask today".
Our department created a google doc that compiles all the latest information on testing criteria, whats on shortage, care pathways, etc that's specifically relevant to us. The top of the document highlights what been changed most recently so you can quickly review it at the start of your shift. Someone highlights those recent changes during the start of shift huddle, which everyone actually does and takes seriously now.
Mat G. - April 24, 2020 3:41 PM
Some others I forgot. Our palliative care team was been fantastic, and is consulted on every COVID admission to help with goals of care conversations.
It took a pandemic, but we finally got Butterfly ultrasounds because they're easier to clean.
On the wellness side, we do weekly trivia nights via zoom. A local personal trainer is donating his time hosting zoom workouts for us every night.
Alfred S. - April 24, 2020 5:44 PM
Figured this would only be the tip of the iceberg for COVID Hacks. All good suggestions Mat,
Thanks
Brian T. - April 25, 2020 7:12 AM
I'm concerned that some of the anti-fogging ideas could affect mask effectiveness. I would recommend a fit test study with mole skin or band-aids before implementing. I know some of our noses are in bad shape, so at the bare minimum make sure the mask passes a user seal check with your chosen solution. As far as the antibiotic ointment, this has the potential to reduce the mask fiber's static charges which are part of effective filtration. I really appreciated this piece. Thanks for the time put into it.
Alfred S. - April 25, 2020 7:41 AM
Brian: You make good points, however, if the goggles are fogging the mask is already not sealed. For many of us it is a no win situation, a truly tight fitting N-95 mask is very very difficult to work in for 8-12 hours. But if you let it leak a little, which will occur with fogging you run the risk of an ineffective mask. Stay safe.
Robert M. - April 25, 2020 9:00 AM
“Gloves as the new skin“- many of us wear the same gloves all shift maybe change them a couple times, essentially washing with them on as if they are your own skin. These new “hands” have less nooks and crannies and you don’t have to worry about your ring, easy to wash, easy to purell. A couple funny looks when you’re washing your “hands“ but it caught on pretty quick.
Alfred S. - April 26, 2020 9:21 AM
Robert: Makes sense to me. Have seen that at a number of sites now. Our infection control has blessed the process so some of our clinicians are using it.
Al
mike V. - May 25, 2020 2:05 PM
Hi Al ,
I hoped you could comment on a question I have about PPE. I am a PA at a rural ED in Georgia. So far we have had very few
COVID-19 patients but we are seeing 5-6 per week. Listening to the docs like you working in New York and New Jersey who have been hit so hard, it sounds like wearing an N95 mask at all times in the ED is advised. At my ED, most folks seem to be wearing only surgical masks unless it is very obvious that the virus is likely. I am a little older (68) and I really appreciated your discussion on older provider. In a case like mine would you advise wearing a simple surgical mask unless in high risk exposure OR wearing an N95 at all times since asymptomatic presentation is not uncommon.
Alfred S. - May 25, 2020 5:09 PM
Mike
We do wear N-95 masks at all times,along with googles. They are very uncomfortable to say the least. However, if you look at the statistics from NY and NJ, only a few healthcare providers have contracted COVID-19, disease, so the PPE recommendations seem to work.
That said, there is nothing to say that simple surgical masks would not work as well.
If you can tolerate it, I would wear the N95.
Al
mike V. - May 26, 2020 5:22 AM
Thank you so much.