Screening and TriagingCopy Link!The screening and triaging process involves three parts: Show
Screening QuestionsCopy Link!Updated Date: December 20, 2020 Goal of screening: To quickly identify patients with possible COVID infections and prevent transmission of infection to other patients and healthcare workers. Where to screen: At the point of entry. Most healthcare facilities reduce the number of available entrances and set up screening stations with trained staff at every entrance. Whom to screen: All people entering a healthcare facility should be screened (patients, visitors, staff). Patients who are coming in for routine care should be screened prior to patient arrival if possible (typically via telephone 24 hours before the appointment) and again at the designated point of entry (whether or not the patient was already screened). Sample Screening Questions:
If the patient answers “No” to all of the above, continue routine check in. People who screen negative should be separated from those who screen positive. If the patient answers “Yes” to any of the above, give the patient additional PPE (a surgical mask) if screening in person and go to Acuity Triage below. Acuity TriageCopy Link!Updated Date: December 20, 2020 Literature Review (Virtual Care): Gallery View, Grid View Facility Acuity TriageCopy Link!Isolation: If the patient is positive during screening, they should be treated as a possible COVID-19 case, also called a “Person Under Investigation' (PUI) and be separated from patients who screen negative. Acuity triage: After screening positive, patients should next undergo an acuity assessment to determine how urgently they need to be seen by a medical provider. For urgent care or emergency visits, this should be done with a standardized triage system. One triage system designed for LMICs is the WHO/ICRC/MSF Interagency Triage tool (see below). Patients who are designated as higher acuity by a triage system should be seen first.. Triage should be conducted in a dedicated space with equipment to measure vital signs, and there should be clear pathways from triage to a resuscitation area for patients who are identified as critical. Tool: WHO/ICRC/MSF Interagency Triage Tool (Pages 11-15) Home and Virtual Acuity TriageCopy Link!When patients screen positive over the phone prior to a visit, a provider can assess symptoms over the phone or at a home visit to determine the urgency and best location of evaluation: at home via virtual visit (telephone or video), in person (outpatient), or in an emergency unit. Below is suggested guidance, but individualized provider assessments should always take precedent. If a provider feels that evaluation in an outpatient clinic or emergency unit is necessary,, they should ensure that the specific location recommended has appropriate IPC and PPE to safely care for PUIs as not all facilities are equipped for this purpose. Tool:
PIH Intake and Symptom Screening Tool
*If patient has home pulse oximeter, here are Instructions. Caution on the reliability of at home pulse oximeters: Trend may be more reliable than the value itself. Dyspnea does not always correlate with oxygen saturation (Shah et al). Likelihood Categories (Case Definitions)Copy Link!Updated Date: December 20, 2020 During or after the acuity assessment, a clinical staff member should verify the initial screening assessment and classify patients by their risk (likelihood) of having COVID. Patients who are acutely ill or unstable should not have care delayed for this step. Why Categorize?Copy Link!Not all patients who screen positive on questionnaires will have COVID and it is important to try to separate patients by how likely they are to have COVID in order to avoid exposing patients who do not have COVID. Patients who have tested negative or who are not suspected to have COVID-19 should never be co-housed with COVID positive or PUI patients. Keep risk categories as separate as possible. See Levels of Isolation. How to Categorize?Copy Link!Someone with clinical training should categorize patients by their likelihood of having disease using standard case definitions. This process can be combined with Clinical Evaluation and can be done in multiple locations (telephone, near facility points of entry, dedicated/ prepared clinics, or COVID-ready acute patient care settings). It is important to note that:
Tool: WHO Case Definitions Handout Adaptation of the WHO Guidelines for Case Definitions
*These case definitions are based on the World Health Organization classification system Algorithm for Case Definitions Clinical EvaluationCopy Link!Updated Date: December 20, 2020 HistoryCopy Link!When assessing a patient with possible COVID-19, ask the following:
ExamCopy Link!In addition to standard physical exam, pay particular attention to:
Differential DiagnosisCopy Link!Keep a broad differential diagnosis, both in patients suspected of having COVID-19 and in patients with confirmed COVID-19, given the many diseases that can mimic features of COVID-19 and the risk of secondary infections or sequelae. Mimics: Other diseases that can cause symptoms mimicking COVID-19 include tuberculosis, malaria, bacterial pneumonia, congestive heart failure, chronic obstructive pulmonary disease, urinary tract infections, and gastrointestinal illnesses. Any of these diseases can also coexist with COVID-19. Patients should be evaluated for alternative or coexisting diagnoses based on the local burden of disease, patient risk factors, and clinical presentation. Over the course of their treatment, if a patient’s condition or symptoms change, providers should consider whether the cause is due to COVID-19 or if another process is contributing. Coinfection: Patients with confirmed COVID-19 commonly have concurrent secondary infections. Most studies on co-infection and secondary infection are done in high-income or upper-middle income countries; it is unknown if and how co-infection patterns vary in low-income countries
Complications: Patients with confirmed COVID-19 can also present with or develop a number of complications:
Disease Severity and DispositionCopy Link!Updated Date: December 20, 2020 The decision about severity of illness and where to admit varies considerably depending on the availability of beds, the location, and the patient’s resources to monitor and care at home. This is a general set of suggestions based on BWH, PIH, and WHO criteria, and should be adapted to local needs. In some settings, patients with severe or critical COVID may need to be transferred to facilities with higher-levels of care. Tool: WHO Classification of Disease
Severity (page 13)
Vitals and MonitoringCopy Link!Updated Date: December 20, 2020 Pulse Oximetry: Please note that pulse oximeters are less reliable in patients with darker skin tones, and accuracy is improved by trending over time or using both resting and exertional measures. See Home Pulse Oximetry for more details. We base these recommendations on the assumption of staff and equipment availability. These frequencies may need to be adjusted based on resource availability in different settings.
Lab MonitoringCopy Link!Laboratory FrequenciesCopy Link!Updated Date: August 19, 2021 The table below provides a summary of the laboratory monitoring at a well-resourced academic tertiary institution. Monitoring labs such as IL-6 levels will not be possible in most institutions, and excellent care can still be provided without these specialized labs.
*Note: Consider discontinuation on day 8 if patient status and lab values are stable or improving If the patient is acutely worsening
When lab availability is limited, this is an alternate lab schedule:
Common Laboratory FindingsCopy Link!Updated Date: May, 2020 Laboratory abnormalities are more frequent and significant in patients presenting with severe disease. Many of these are associated with more severe disease or death. (Arentz; Chen; Du et al; Guan et al; Young et al; Zhang et al; Zhou et al). Some common abnormalities in COVID patients include:
Interpretation:
ImagingCopy Link!Updated Date: December 20, 2020 Chest X-rayCopy Link!Chest x-ray can help identify alternate causes of shortness of breath. Some chest x-ray findings can suggest a diagnosis of COVID-19. Normal chest x-rays do not rule out COVID: Chest X-rays may be normal in up to ~30% of COVID patients requiring hospitalization, particularly in early disease (Wong). Sensitivity 59% in one study, as compared to 86% for CT scan (Guan). Low-risk patients with mild symptoms and confirmed PCR testing do not routinely need chest imaging. Most patients with Findings of COVID-19 Pneumonia can safely be managed at home unless clinically unstable, at high-risk of decompensation, or with pneumonia involving >50% of lung parenchyma. Where possible, portable chest X-rays are usually sufficient and require less personnel. Consider chest x-ray in these circumstances:
Tool: BWH Guide on Radiology in COVID and Guidance for Radiologists CT ScanCopy Link!CT scan plays no role as a screening test for patients for COVID-19, for either diagnosis or exclusion (Simpson). CT can be used if there is a concern for other pathology. Consider CT in these circumstances:
Tool: BWH Guide on Radiology in COVID andGuidance for Radiologists Tool: Radiopedia on COVID UltrasoundCopy Link!Serial ultrasound is showing promise as a low-cost method to assess disease progression. Although ultrasound findings in COVID-19 have been shown to correlate with CT scan results, the false negative rate of ultrasound is not currently known (Zani et al). A standardized approach using 12 designated zones has been proposed and is strongly recommended to allow for serial comparison (Kruisselbrink et al; Convissar et al). Tool: POCUS 101 Complete Guide to Lung Ultrasound Patients with Comorbid DiseasesCopy Link!Updated Date: December 20, 2020 Patients with chronic conditions have specific risks and needs related to COVID-19 diagnosis, treatment, and social support (e.g. to allow safe isolation/quarantine if needed.) Patients with diabetes, hypertension, heart disease, and obesity have been shown to have higher rates of hospitalization and severe illness due to COVID-19. (See Prognostic Indicators) Relevant comorbidities are covered in greater detail in different chapters, and include the following:
Management of existing medications is an important consideration in these patients. These medications are discussed in Treatments for Comorbid Diseases and may include the following.
Interfacility TransferCopy Link!Updated Date: January 11, 2021 Reasons to transferCopy Link!There are many potential reasons to transfer a COVID19 patient to another facility including:
When deciding whether or not to transfer, consider:
Stabilization Prior to TransferCopy Link!A full discussion on stabilization for transfer is beyond the scope of this site. For the transfer of COVID19 pneumonia patients the top concern is generally the amount of oxygen required by the patient safe for transport and whether to intubate prior to transfer. This is especially true as patients considered for transfer often have a rapidly worsening trajectory and are at high risk for deterioration. Whether to Intubate Prior to TransferCopy Link!Intubation should not be done if it is not indicated (see Candidacy for Intubation). Intubation carries risks, especially in certain patients (e.g. patients with right heart failure or a difficult airway). The decision about whether to intubate prior to transfer should balance risks and benefits and take into consideration the following questions:
Calculating Transport Oxygen NeedsCopy Link!Non-intubated patients on oxygen delivery devices with high oxygen flows (e.g. high flow nasal cannula, non-rebreather facemask, CPAP/BIPAP/NIPPV) may rapidly exhaust or exceed the available oxygen supply during transport. This can be life threatening.
Additional air transport needs: During air transport barometric pressure drops, while FiO2 stays constant. The result is less partial pressure of oxygen delivered to the alveoli and the volume expansion of any trapped gas. This can precipitate the deterioration of a patient in two ways:
Other Factors that May Affect Transfer DecisionsCopy Link!
Tool: Tools for Interfacility Transfer and Documentation (OCC) Tool: Interfacility Transfer Checklist Tool: IPC Guidelines for Interfacility Transport Without Ambulance Systems (PIH) Tool: Algorithm for COVID-19 Triage and Referral by WHO Tool: Medical Transport Accreditation Standards, 11th Edition by Commision on Accreditation of Medical Transport Systems Which findings should the nurse anticipate when assessing a client developing right sided heart failure?The main sign of right-sided heart failure is fluid buildup. This buildup leads to swelling (edema) in your: Feet, ankles and legs.
Which of the following should the nurse include as a risk factor for the development of hypertension?Risks for the development of primary hypertension include family history, advancing age, obesity, high sodium diet, alcohol consumption and physical inactivity.
Which information should the cardiac nurse include in discharge instructions for a client diagnosed with congestive heart failure?Discharge Instructions for Heart Failure. Activity. Ask your healthcare provider about an exercise program. ... . Diet. Follow a heart healthy diet. ... . Tobacco. If you smoke, it's very important to quit. ... . Medicine. Take your medicines exactly as prescribed. ... . Weight monitoring. Weigh yourself every day. ... . Follow-up care. ... . Symptoms.. |