Inpatient Floors

Inpatient floors and step-down (non-vented)

Natural history of disease

Progression of symptomatic COVID-19 ranges from mild to critical. The largest cohort of patients in China with COVID demonstrated 

  • The majority, 81%, of patients displayed mild symptoms up to mild pneumonia
  • 14% of patients displayed severe symptoms (i.e. dyspnea, hypoxia)
  • 5% of patients displayed critical symptoms (i.e. respiratory failure, shock)
  • Overall case fatality rate is 2.3%, all of which were reported in severe or critical cases

A study of 5700 patients in New York Area calculated the average length of hospital stay 4.1 days.

Critical and Severe Illness

Among patients that developed severe and critical Infection, the median time from onset to 

  • Dyspnea ranged from an estimated median of 5 to 8 days
  • Acute respiratory distress syndrome (ARDS) ranged from 8 to 12 days
    • Typically manifested shortly after onset of dyspnea
    • 20 to 41 percent developed ARDS with COVID-19 confirmed pneumonia
  • Admission to ICU ranged from 10 to 12 days

Complications

  • Acute kidney Injury (AKI)
  • Liver dysfunction with elevated liver enzymes
  • Cardiac injury including arrhythmia, cardiomyopathy, pericarditis, and sudden cardiac death
  • Thromboembolic complications such as stroke and pulmonary embolism
  • Sepsis, shock, and multi-organ failure
  • Less common secondary bacterial pneumonia and encephalitis.

Mortality

Estimates on COVID-19 mortality range broadly and depend on a multitude of factors. As stated above, a large cohort study from China estimated the mortality to be 2.3%. 

An observational study that examined almost 9000 patients in 11 countries that died or were discharged calculated the case fatality rate to be 5.8%. The majority of these patients were from North America. 

List of References 

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet. 2020 Feb 15;395(10223):497-506.

Mehra MR, Desai SS, Kuy S, Henry TD, Patel AN. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19. New England Journal of Medicine. 2020 May 1.

Novel CP. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua liu xing bing xue za zhi= Zhonghua liuxingbingxue zazhi. 2020 Feb 17;41(2):145.

Poyiadji N, Shahin G, Noujaim D, Stone M, Patel S, Griffith B. COVID-19–associated acute hemorrhagic necrotizing encephalopathy: CT and MRI features. Radiology. 2020 Mar 31:201187.

Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, Barnaby DP, Becker LB, Chelico JD, Cohen SL, Cookingham J. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA.

Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y, Zhao Y. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. Jama. 2020 Mar 17;323(11):1061-9.

Wu C, Chen X, Cai Y, Zhou X, Xu S, Huang H, Zhang L, Zhou X, Du C, Zhang Y, Song J. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA internal medicine. 2020 Mar 13.

Yang X, Yu Y, Xu J, Shu H, Liu H, Wu Y, Zhang L, Yu Z, Fang M, Yu T, Wang Y. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet Respiratory Medicine. 2020 Feb 24.

Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 2020 Mar 11.

Last Updated 4 months ago
  • Vital Signs (frequency as deemed appropriate-q2h,q4h,q8h), Oxygen requirements, Input and Output at least daily
  • Physical Examination: Assess mental status, cardiac, pulmonary, skin examination (rashes, edema/swelling, signs of microthrombi) daily
  • Consider as needed psychological evaluation especially for patients with prolonged hospitalizations, post-ICU stay, post-extubation, and at-risk for delirium
  • Labwork: CBC, BMP, consider LFTs, troponin, pro-BNP, LDH, CRP, D-Dimer, Fibrinogen, Ferritin, PT, PTT as deemed appropriate
  • Reassessments as needed, see “The Deteriorating Patient”

 

Last Updated 4 months ago
  • Encourage fluid conservative management
  • Empiric antibiotics should be considered in septic patients with presumed bacterial infection or co-infection
  • Avoid systemic corticosteroids for treatment of COVID-19 unless underlying medical condition warrants use
    • Inhaled or oral corticosteroids for chronic medical conditions may be continued
  • Consider use of investigational therapeutics based on hospital procedures and protocols
  • See “Medication Precautions” for further discussion of use of other medications
    • ACEi/ARBs should be continued in patients unless otherwise indicated (hyperkalemia, acute kidney injury, hypotension)
    • Use of NSAIDs as an anti-pyretic, pain medication, or chronic medication may be used inpatient
    • Statin therapy should be continued in patients unless otherwise indicated

 

https://www.covid19treatmentguidelines.nih.gov/introduction/

https://covidprotocols.org/protocols/04-therapeutics-and-clinical-trials/#non-steroidal-anti-inflammatory-drugs-nsaids

Last Updated 5 months ago

For COVID-19, palliative care referral is based on individual need and is recommended for symptom control and end-of-life care. 

COVID-19 Palliative Care Referral Criteria:

  • Patient receiving treatment on pre-existing palliative care plan
  • Patient on ventilatory support
  • Uncertain prognosis or non-beneficial treatment options
  • Psychological factors: difficulty in controlling emotional symptoms, spiritual/existential distress
  • Patient or family may request for palliative care

Significant Palliative Care Referral Associations:

  • Breathlessness and agitation are the most prevalent symptoms for palliative care referral.
  • The most common comorbidities related to COVID-19 associated palliative care referral are hypertension, diabetes, and dementia.

Sources:

Center to Advance Palliative Care. Palliative care referral criteria: COVID-19 context [Internet]. Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai. 2020 [cited 31 May 2020]. Available from: file:///Users/alyssaanderson/Downloads/palliative-care-referral-criteria-covid-19-context.pdf

Lovell N, Maddocks M, Etkind SN. Characteristics, symptom management and outcomes of 101 patients with COVID-19 referred for hospital palliative care. Journal of Pain and Symptom Management. 2020 Apr [cited 2020 May 31]. Available from: doi:10.1016/j.jpainsymman.2020.04.015

Last Updated 3 months ago
  • Assess the patient including vital signs including temperature, mental status, pulmonary status (work of breathing, lung sounds, respiratory rate, pulse oximetry/oxygen requirement), cardiac status (heart sounds, assess for JVD, capillary refill, distal temperature), skin (signs of micro-thrombi), check temperature

Red Flags:

-Changes in vital signs including hyperthermia/hypothermia, tachycardia/bradycardia, changes in blood pressure (changes in pulse pressure as well), changes in respiratory rate (do not sit on tachypnea!), changes in pulse oximetry

-Agitation, decreasing mental status

-Increased work of breathing, new abnormal lung sounds, increasing oxygen requirements

-New JVD, delayed capillary refill, hot or cool distal extremities

-Mottling, petechiae, cyanosis, discoloration distally, edema

  • Assess recent intake/output (to assess for oliguria/anuria/developing renal failure)
  • Consider emergency labwork: POC glucose, CBC, BMP, lactate, LDH, LFTs, troponin, pro-BNP, arterial blood gas, D-Dimer, Fibrinogen, Ferritin, PT, PTT, new cultures
  • Consider stat EKG, portable radiography; bedside ultrasound; consider CT evaluation depending on signs and symptoms (Be cautious of having the patient leave the floor-ensure they are stable enough)
  • Are there simple interventions for the patient? (Increase oxygen supplementation, administer glucose, fluids, diuretics, antipyretics)
  • See Hypoxia management algorithm
  • Consider ICU team evaluation and triage
  • Establish plan for acute decompensation including protocols for ACLS, intubations (PPE, barriers, etc)
  • Consider contacting family of patient
Last Updated 5 months ago

Consider discharge if the following criteria is met:

  • Resolution of fever >48 hours without antipyretics
  • Improvement in illness signs and symptoms (cough, dyspnea, and oxygen requirement)

Consider disposition of patient:

  • Where will the patient be discharged? (Shelter, Home, Sub-acute rehabilitation, Skilled Nursing Facility, Long-Term Acute Care Facility); Do they require a PT/OT evaluation prior to discharge?
  • Will they be discharged home with oxygen?
  • Are there family members at home who are immunocompromised?
  • Does the patient have a primary care provider in this healthcare network?
  • Are there any psychological issues that need to be addressed prior to discharge?

Sources: COVID Protocols and CDC

Last Updated 5 months ago
  • Utilize electronic forms of communication for history, reevaluations, and family interaction when possible
    • Patient's cell phone (FaceTime or other video ideal)
    • Ipad/Tablet
    • Laptop with webcam and mic
    • Walkie Talk (handheld 2 way radio)
Last Updated 5 months ago
Missing content? Submit a content suggestion