COVID-19 Meeting # 13 Medical Staff Updates and Discussion “Failing to prepare is preparing to fail” Benjamin Franklin July 22, 2020 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM Lee Health Continuing Medical Education Thank you for participating in the COVID Guidelines Update • To receive CME credits for todays event: 1. Go to www.eeds.com 2. Enter code: 32drys – Code is only good for 24 hours 3. Complete the evaluation on eeds • All attendees will be muted on entry • Questions to the speaker: Use the chat option in WebEx Guiding Premise “The one thing we know- We have no idea what the ideal management of these patients really is.” We will continue to learn, modify and adapt our guidelines as more information and literature becomes known. AGENDA Provider Well Being During COVID-19 COVID-19 Convalescent Plasma Update COVID-19 ED Disposition Algorithm Guide COVID-19 Infectious Disease Update Physician Well Being During COVID-19 Ashely Chatigny DO, FAPA 5 “Don’t suffer in silence: get help for emotional distress” Dr Mehta, Radiologist, Charlotte, NCCOVID-19 Pandemic Physician Protection Act Ensures mental health coverage for health care workers http://www.chestnet.org/-/media/chesnetorg/Publications/Documents/CHEST-Physician/Vol-15- 2020/072020.ashx?la=en&hash=1A0DCDCEE946E3BC67EA0168754308144274C394 6 Current Provider Resources Agency Phone Number Florida Crisis Line 833-848-1762 National Suicide Prevention 800-273-8255 National Help Line 800-662-4357 Samsha 877-726-4727 Healthcare Professionals Center for progress/excellence 844-395-4432 mobile crisis unit 7 8 CME Thursday, July 23, 2020 9 Contacts for You! Please contact these providers through Voalte! Ashely Chatigny DO, FAPA, LPG Psychiatric Services Paul Simeone, Ph.D., VP Medical Director, Behavioral & Mental Health 10 Convalescent Plasma for the Treatment and Prevention of COVID-19 Douglas Brust, MD, PhD and the Lee Health ThankResearch You Team Convalescent Plasma for the Treatment of COVID-19: The Lee Health Experience • As of 7/20/2020, we have enrolled and transfused 296 patients • There have been no serious adverse events thought to be associated with convalescent plasma use • VERY QUICK AND DIRTY: For all patients < 90 yo and with at least 28 days of follow-up, compared to COVID-19 patients who did not receive convalescent plasma over the same period, there appears to be a signal (for all comers) indicating a 27% improvement in mortality when using convalescent plasma (10.8% vs. 14.8%) “For internal Lee Health Use Only. Do Not Forward or Distribute” Convalescent Plasma for the Treatment of COVID-19: The Lee Health Experience Additional Criteria for Referral for Enrollment in Mayo Convalescent Plasma Protocol 1) Admitted patient who has been in ED within 24 hours. 2) Radiographic evidence of pneumonia. 3) Room air oxygen saturation < 94% requiring supplemental oxygen but not mechanical ventilation. Patients will be evaluated chronologically Monday-Friday, 9 AM - 5 PM until 10 patients have been enrolled that calendar day (if plasma available). Patients admitted on weekends and holidays cannot be offered enrollment. Convalescent Plasma for the Treatment of COVID-19: The Lee Health Experience • Because of our extensive experience, the Mayo has asked us to submit our data as part of a multi-center, case-controlled efficacy analysis they are conducting for publication • The goal of this analysis is to compare outcomes (e.g. improvement in clinical status, length of stay, mortality) between controls (i.e. patients who were admitted to Lee Health with COVID-19 who did not receive convalescent plasma) and convalescent plasma patients with the same disease severity Convalescent Plasma for the Prevention of COVID-19: • Can convalescent plasma serve as a post-exposure prophylaxis (i.e. prevent infection in people who have had a significant exposure but are asymptomatic)? • We are enrolling a clinical trial and truly appreciate your help referring potential subjects • We need to evaluate asymptomatic people with a recent, significant exposure (within 72 hours) to an ill COVID-19 patient, but who are SARS-CoV-2 NP swab negative • Participants will be randomized to receive either COVID-19 convalescent plasma or control plasma to determine if plasma can prevent the development of active COVID-19 Convalescent Plasma for the Prevention of COVID-19: Participants can be: 1) Health care workers (or anyone that works in a healthcare setting--e.g. transporters, housekeeping, etc.) who were not wearing PPE and had a significant exposure to a sick COVID-19 patient OR 2) Community members who are at high risk for serious COVID-19 who have been exposed while living with/caring for a sick patient at home. Participants will be compensated for their time. Convalescent Plasma for the Prevention of COVID-19: When you are seeing new COVID-19 patients, kindly let them know that family members living them, who are asymptomatic, can contact us to enroll in a trial to see if convalescent plasma can prevent them from becoming ill To make it easy, if you identify an exposed person, just call me on my cell (239-292-7291) and I can call that person to discuss trial Or have patient or family members contact me at 239-343-8579 or E-mail [email protected] ED DISPOSITION ALGORITHM GUIDELINE TIM DOUGHERTY, MD, DACMT, FAAEM CCH MEDICAL DIRECTOR/CHAIR DEPARTMENT OF EMERGENCY MEDICINE LEE HEALTH MEDICAL DIRECTOR, DISASTER PREPAREDNESS QUICK REMINDERS… PRONING ORDER SET PRONING WORKS! DEXAMETHASONE SUMMARY (CONSIDER REVIEWING DR. LAFFERTY’S REVIEW 6/17) • NIH Recommendations (6/25/20): • Covid 19 pts mechanically ventilated • Covd-19 pts who require supplemental O2 but who are not mechanically ventilated • NOT recommended for outpatient use or those who do NOT require supplement O2 • Dosage: Oral or IV 6 mg daily for 10 days • Pregnant/Breast feeding: Prednisolone po 40 mg/ Hydrocortisone 80 mg BID RECOVERY TRIAL • 2104 patients on dexamethasone, 4321 were not • Lowered Death Risk from 40 % to 28% on Ventilators • Lowered Death Risk from 25% to 20 % for those requiring supplemental 02 • Number needed to treat: 8 pts ventilated pts, 25 pts on O2 • NOT yet published in peer reviewed article (other factors may be at play) FDA: HYDROXYCHLOROQUINE, CHLOROQUINE • June 15, 2020 Update: Based on ongoing analysis and emerging scientific data, FDA has revoked the emergency use authorization (EUA) to use hydroxychloroquine and chloroquine to treat COVID-19 in certain hospitalized patients when a clinical trial is unavailable or participation is not feasible. We made this determination based on recent results from a large, randomized clinical trial in hospitalized patients that found these medicines showed no benefit for decreasing the likelihood of death or speeding recovery. This outcome was consistent with other new data, including those showing the suggested dosing for these medicines are unlikely to kill or inhibit the virus that causes COVID-19. As a result, we determined that the legal criteria for the EUA are no longer met. Please refer to the Revocation of the EUA Letter and FAQs on the Revocation of the EUA for Hydroxychloroquine Sulfate and Chloroquine Phosphate for more information. NEW ENGLAND JOURNAL OF MEDICINE • Mild or Moderate Covid 19 • https://www.nejm.org/doi/full/10.1056/NEJMcp2009249 • Severe Covid 19 • https://www.nejm.org/doi/full/10.1056/NEJMcp2009575 MILD SYMPTOMS • In China: 81% mild/moderate disease, 14% severe disease, 5 % critical disease • Mild illness usually can recover at home • Mild: Some do progress one week after onset of symptoms • New/worsening symptoms (dyspnea) – need further evaluation • Consider Home Pulse Ox to self monitor. RISK FACTORS • Established Risk • Unclear Risk • Age greater than 65 yrs old • Kidney Disease • Cardiovascular disease • Immunosuppression • Chronic lung disease • Cancer • HTN • Uncontrolled HIV • DM • Male (?) • Obesity NEW YORK EXPERIENCE • Fever often absent (31% Northwell Health, 25% Cornell) • At Cornell, • 31% of the patients required no supplement oxygen at presentation the ED, yet subsequently deteriorated leading to intubation. • Initial Chest X-ray clear 17%, unilateral infiltrate 16%, B/L 60% • At Columbia, • Median 3 days btw hospital admission and clinical deterioration. 80% patients intubated • Chest infiltrates present 98% X-rays (median presentation 6 days after symptoms started). ED DISPOSITION? Source: Socionomics Institute WHAT WE (DON’T) KNOW? • There is No literature directly address what clinical features indicate safety for discharge • Lack of current validated risk prediction tools for ED admission/discharge criteria • Admission decision driven largely by need for supplemental oxygen or factors that may put patients with mild disease at risk for sudden deterioration out of the hospital • No single laboratory test is reliable indicator who can be discharged or admission CAN WE BASE IT ON AN X-RAY? • Chest X-ray has low sensitivity 67- 69% for diagnosis of COVID • No single investigation, including CT scanning, showed sufficient sensitivity or specificity to be used to identify patients requiring admission • Clinically hypoxic patient with clear X-ray argue against COVID as the cause of hypoxia • Slightly ill patients with normal chest X-ray still could be COVID COVID-GRAM: A CLINICAL PREDICTION RULE TO PREDICT CRITICAL ILLNESS IN HOSPITALIZED COVID-19 PATIENTS • Liang W et al. Development and Validation of a Clinical