Supporting Inpatient

ABOUT THIS SERIES

The Supporting Inpatient series provides information for physicians called to support COVID-19 wards. For upcoming events and registration, see the University of Calgary Office of CME&PD main website.

Help us provide COVID-19 education, training and resources for health care professionals by donating to CME&PD.


 

Webinars

COVID CORNER: Care of the Hospitalized Patient with COVID-19

Presentation and Q&A

Handouts

Q&A

Panelists also provided answers to additional questions that were not answered live: Panelist Responses

Time Question
1:10:03 Overall Alberta data thus far: What percent of admitted patients under and over 70 years old require intubation? What percentage of intubated patients under and over 70 years old do not survive?
1:12:45 Do we have current epidemiological data on local presentation and symptoms accoding to age?
1:15:45 Is anyone using point of care ultrasound to look at lung/pleural involvement?

Comment from Dr. Irene Ma: For those interested in POCUS - please see our Canadian website: https://sites.google.com/site/calgaryimus/covid-pocus. Lung POCUS findings are not specific but correlate quite well with CT, given COVID is peripherally-based. More sensitive than CXR, so benefit over CXR. Handhelds are easier to disinfect than the larger machines, but AHS is currently finalizing a provincial-based IP&C protocol for POCUS machines. In the mean time, a locally FMC based approved protocol is on our website.

1:17:38 The german experience seems to suggest not using NIV in Covid patients is increasing the mortality of the Covid patients especially considering that Ett / PPV requires more sedation and difficulties with ventilator induced lung injury as well as ventilation associated pneumonia { 25% in Wuhan patients)
1:22:45 Why is HOC risk as in QT elongation when this medication has been used over 50 years for malaria and other inflammatory issues why with COVID- 19 then ?
1:25:59 If patient are admitted and they are on the HQ RCT, are we too avoid Azithromycin?
1:26:15 Do we know how long viral shedding or positive swab goes on for in immunocompromised patients? I think the recommendation is for q7day Covid testing until negative.. if viral shedding for a long time, presumably these patients are committed to self isolating for a very long time?
1:29:03 Any information on arterial manifestations of hypercoagulable state or does this appear under vascular surgery?- lots of discussion on vascular surgery forums. Or does this not show up on Med service? Worthwhile to keep in mind.
1:30:05 Should d dimer be monitored serially in all patients? Even if initial ddimer not significantly elevated
1:32:04 What about early prone positioning/ prone ventilation?
1:35:07 I think you all are doing great work, rather than re-inventing the wheel, I think it would be great if your MEOC could perhaps connect with ECC/ZEOC (more operational) or simply with the different zones to give access to all physicians in Alberta to these great resources. awareness could also be spread through the AHS Daily Staff Update on the has website, and in the CEO’s daily email. Thanks!!
1:36:59 How does the Alberta ICU data compare to other countries? Mortality? I would find it hard to extrapolate data from China to the Alberta population.
1:38:30 For patients with bilateral pneumonia, should I have a high index of suspicion, even if 1 NP swab came back negative? Repeat another NP or throat swab is better?
1:40:30 Does an increased late febrile reaction response suggest impending cytokine storm? If they are recovering at home are there any symptoms which would give them a clue at the 7 to 9 day stage? China data suggest there are some lab data that change about 24h before rapid deterioration.
1:49:43 Has a guideline for discharge and removal of isolation been released for those COVID+ that have clinically recovered?
1:52:16 Have you noticed reinfection in your hospital discharged pt ( similarly seen in S Korea , China?
1:56:30 Have we been seeing heparin resistance in covid patients treated with unfractionated heparin? Especially in ICU patients? Are antithrombin levels significantly lower in these patients or is this all related to protein binding and inflammatory responses?
1:57:42 Given many nursing home patients are M or C-GOC patients and many/most deaths come in this population any trials going on that might ultimately guide us toward improved outcomes other than virus isolation/prevention strategies.

Calgary Medical Emergency Operations Command (MEOC) Physician Pandemic Response Plan:

Preparing Calgary’s acute care health system

ABOUT THIS WEBINAR

This webinar will outline the city-wide pandemic emergency plan for managing large hospitalization volumes of acutely ill COIVD-19 patients while protecting physician health and safety. Family physicians, especially those that have recent background or experience in working in acute settings are highly encouraged to attend and volunteer if interested.


WEBINAR RECORDING
Presentation

Handouts

 

Q&A

Questions Answered Live

Time Question
00:30 In the Calgary Health Zone we have had a few cases of patients who presented with ILI suggestive of COVID19 and were appropriated swabbed and isolated. When the Resp pannel and COVID19 swab came back negative the isolation was d/C. Subsequently due to ongoing symptoms the patients had repeat swabs and these were positive. Unfortunately in that interval a significant number of HCW had inadvertent Unprotected exposure. This raises the question of what is the false negative rate of swabs in symptomatic patients? What protocols for retesting and ongoing isolation should we use for patients with ongoing symptoms and negative swabs?
05:10 Further to the asymptomatic/symptomatic with false negative testing patients question above, how are we ensuring safety of all HCW in the setting of asymptomatic/paucisymptomatic/ symptomatic but not upfront about symptoms patients?
07:30 Can the leadership outline how they plan to deal with information overload, specifically with regards to new protocols and processes from multiple levels within AHS that come out on an hour to hour basis. To put another way how can we limit the barrage of information and distill it into a couple pages that someone can read the day before their shift on a covid team, it would save some mental load if we could ignore these 100s emails and know someone is distilling the info in the background for when we need it?
10:30 There had been a plan to redeploy physicians in different waves, how does this relate to the current call to sign up for pods? Are the “volunteers” the first wave regardless of their years post GIM etc?
16:15 How do you sign up for the critical safety training simulations? And what is being recommended now for HCWs in the hopsital- ie mask and face shield for the entire shift?
21:50 Can you please discuss the plan to engage MDs from other departments?
24:25 Can you please discuss the plan to engage MDs from also from Edmonton (where their numbers are much lower)?
25:47 Many academic internal medicine sub-specialists manage large numbers of outpatients. Those hospital based outpatient clinics have been closed except for very limited “in the flesh” access for urgent patients. We can’t run a practice on the phone before very long before we have a crisis situation. Is the department of medicine or UCMG considering lease of clinic space outside of the “hot zones” in hospital so that we can manage our huge outpatient population?
27:10 Is there any interest to create non covid sites to reduce risk of transmission of covid to non covid patient groups. Or will all sites be covid?
29:00 Is the leadership looking into a similar 8-hour work model for residents? Juniors are still doing 26 hour call and seniors are still doing 12 hour shifts. Neither juniors or seniors get a 4 on - 3 off model.
31:25 Can you comment on CPR protocols for a COVID patient? I recall reading no chest compressions until airway secured in a closed circuit. Is this so? What is the emergency response plan code blue/anestheisa airway?
34:15 The biggest impact we can have is keeping acute care beds open ….that means supportive discharge and keeping non-covids out of hospital , and as lots of docs want to contibute in the ambuatory care setting we need to keep this sector going. PPE is a big concern for community docs. Can the panel comment on the supply of same?
37:00 Has anyone at ZEOC advocated yet for testing EVERY patient and EVERY healthcare worker to help ensure patients are put in the correct zone? Tests will never be perfect, especially from upper respiratory tract specimens. At some point will we treat every patient as potentially infected? Will MDs who have had COVID and recovered play any special roles in this process given that they may be then be immune?
38:40 Could you present the data of PPE supply? And the models that you are using to base your response?
40:25 Will all pods need to be deployed or are some theoretical (eg deployed if required), so if we are signing up is this is dependant on volumes? For example should we be cancelling other duties/clinics now for scheduled pod shifts or wait a bit to see if the pods actually need to be deployed.
41:20 Do we have information on recovery time in those patients who end up on a ventilator and in the ICU? What is the known rate of survival in those patients and what is the median time to come off a ventilator? It would be helpful to know this information as palliation becomes important.
42:40 Could we have a summary of the atypical presentations described so far?

 

Additional Answered Questions

Question Answer
Please let us know if Cardiologists have been enlisted in this plan as they should be central figures in the plan if all of the DOM members are expected to contribute (even though they are technically separate) Yes, cardiology has been engaged. The ones who have expertise in CCU settings will be helping in the ICU. Plan is to engage them from the DOM as well
Would shadowing a GIM team be possible prior to POD deployment? Or would this just increase risk of exposure etc. Please reach out to site leads for GIM or resp. I think this would be fine but should check to make sure
How are we incorporating physicians who want to help but have chronic respiratory or other chronic conditions? There is lots of work to do - both COVID related and unrelated. Division heads are working to develop lists of essential services and align physician roles with these services
Can you clarify what are the essential specialties that are not going to be part of this innitiative? I’m not aware that there are any divisions not participating as a whole. Should discuss with your division head for clarity
How will the process from ER determine what type of patient is admitted to the hospitalist service vs. Covid inpt team. I am assuming that some of these patients will be admitted to the hospitalist based on Gabe's earlier presentation. And...is there a way to mitigate disputes associated with this? There are pathways that have been developed to streamline this. Both IM and hospitalist services agree that we should minimize disputes/number of pages to expedite flow through ED and prevent multiple don/doff and PPE errors. Basically we let the ED and EL docs make these decisions with everyone accepting the disposition decisions and transfering across services if necessary
Morbid question. Is the department providing life insurance for physician participants in the event of their death? Physicians are independent contractors. If you have a GFT appointment with the U of C, you should have some life insurance and disability. Otherwise, physicians are responsible for their own benefits, disability insurance, life insurance.

 


ENLISTMENT & FEEDBACK LINKS

If you are interested in providing care to patients in acute care settings during this time of pandemic, please fill out the form here: https://www.calgarymdcovidresponse.ca/

If you would like to give comments or feedback regarding the response plan, you can do so via the Calgary MEOC - COVID-19 Response Improvement Database.

 

PPE TRAINING

To register for the online modules, please fill out the registration form here: https://ecme.ucalgary.ca/ppe-certification-course-registration/

Please note: The face-to-face simulation training is currently by invitation only. For more information visit: https://cumming.ucalgary.ca/cme/courses/PPE

 

QUESTIONS?

If you have questions regarding the Calgary MEOC Physician Pandemic Response Plan, please email meoc [at] ucalgary [dot] ca

Other Resources
Calgary Emergency Medicine Department COVID-19 Airway Management

First, do no harm. How do you keep yourselves, your patients, and your families safe when using Personal Protective Equipment (PPE) while caring for patients in isolation? The Personal Protective Equipment Certification Course aims to prepare healthcare providers to care for patients who require droplet and contact isolation on medical admission units in the Calgary Zone, assuring adherence to existing infection prevention and control (IPC) protocols and avoid exposure to suspected pathogens.

Credits: 1.0 Mainpro+ / 1.0 MOC Section 3

Delivery Options:

  1. Stand-alone online modules
  2. Online modules, face-to-face practice session, face-to-face simulation-based training session**

Register Now (Online Modules)!

** The in-person practice and the simulation-based training session is currently only available in Calgary, based on priority needs, and is offered as invitation only.