DoD COVID-19 PRACTICE MANAGEMENT GUIDE Clinical Management of COVID-19 This Practice Management Guide does not supersede DoD Policy. It is based upon the best information available at the time of publication. It is designed to provide information and assist decision making. It is not intended to define a standard of care and should not be construed as one. Neither should it be interpreted as prescribing an exclusive course of management. It was developed by experts in this field. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of this guideline is responsible for evaluating the appropriateness of applying it in the setting of any particular clinical situation. The Practice Management Guide is not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within this guide does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. Leads: Lt Col Renée I. Matos and COL Kevin K. Chung 5-14-2020 DoD COVID-19 Practice Management Guide v3.0 Summary of Changes New Sections: Outpatient Management (replaced Treatment of Mild Infections) Removed Oxygen Therapy and Monitoring and combined it with the ARDS Section Rehabilitation Section Telemedicine Section put back in Public Health Section Ethics Section is back, but shorter Updated throughout with new literature, studies, and society guidelines across disciplines Major Updates and Changes by Section: Planning & Preparation: paragraph on “returning to the new normal” Infection Prevention & Control: updated with new CDC guidance. Emory visuals on PPE removed from the Appendices and included as a link. New Appendices for this section. Collection of Specimens: updated with IDSA recommendations from late April advising against use of serologic testing for patient screening due to high false positive rate. Two negative tests are no longer recommended by the CDC to document clearance of infection in hospitalized patients. Co-infections Section: mentions risk of Aspergillus ARDS Section: more liberal criteria for intubation; no longer recommending early intubation, but using criteria of progressive hypoxia, worsening chest infiltrates, hypercarbia, decreased mental status, or worsening dyspnea. Added section on Extubation, including an Extubation protocol in the Appendices. Discussed hypothesis of two types of COVID-19 ARDS: Light “L” type and heavy “H” type with the potential for different management strategies for PEEP based on physiologic differences. This is not an evidence-based discussion, but merely a hypothesis mentioned for completeness. Prevention of Complications: Hematology section is completely rewritten Code Blue: updated to reflect newly released AHA guidelines with ACLS/PALS algorithms included in the Appendices. Focus is on protecting healthcare personnel (HCP). Imaging: Includes Fleischner Society recommendations for chest imaging (CXR, CT). Also discusses increased risk of thromboembolic complications and related imaging to address this. Adjunctive Therapies: Updated with new data, literature and includes a summary statement at the top of the section regarding the need for RCT results and that there is no data to support use outside of a clinical trial. Remdesivir preliminary results from SIMPLE and ACTT trials included, although these are not published or peer-reviewed at this time. The FDA cautions use of hydroxychloroquine and chloroquine outside of a clinical trial due to the risk of heart problems associated with these medications. Convalescent plasma is moving through approval for DoD FHP IND, although there is not yet data from controlled trials to suggest benefit. Special Populations: Several updates to the Pregnancy section, including new guidance on ultrasound cleaning in the Appendix and the section is now organized by stage of labor with a new table on common OB medications. The neonatal and pediatric sections were updated to reflect new AAP guidance. The Pediatric section has several changes, including movement of all pediatric-related topics to this section. It also discusses new reports of children presenting with a multisystem inflammatory syndrome similar to Kawasaki disease, toxic shock syndrome, and myocarditis. Peds ID dosing recommendations were also included for some of the adjunctive therapies. Surgical Implications: Significant updates to reflect new publications from multiple societies. Operational: Significant updates, including new TRANSCOM guidance for transport. Behavioral Health: Changed from Mental Health with several updates throughout the section. En Route Critical Care: Completely updated. Facilities: Now includes discussion on HEPA filters and UV (bullets 6-9 are new). DoD COVID-19 PRACTICE MANAGEMENT GUIDE Clinical Management of COVID-19 To consolidate resources and optimize the management for patients requiring clinical care during the global COVID-19 pandemic. First Publication Date: 23 March 2020 Publication Date: XX May 2020 Supersedes PMG Dated 13 April 2020 TABLE OF CONTENTS Background ....................................................................................................................................................................................................... 4 Clinical Presentation ......................................................................................................................................................................................... 4 Planning and Preparation ................................................................................................................................................................................. 6 Screening and Triage (Early Recognition of Patients with COVID-19) ............................................................................................................. 11 Immediate Implementation of Infection Prevention & Control (IPC) Measures and Personal Protective Equipment (PPE).......................... 13 Collection of Specimens for Laboratory Diagnosis ......................................................................................................................................... 14 Management of COVID-19 Based on Illness Category .................................................................................................................................... 15 Outpatient Management COVID-19: Symptomatic Treatment & Monitoring .............................................................................................. 15 Management of Severe COVID-19: Treatment of Co-Infections ..................................................................................................................... 16 Management of Critical COVID-19: Oxygen and Acute Respiratory Distress Syndrome (ARDS)..................................................................... 17 Management of Critical Illness and COVID-19: Prevention of Complications ................................................................................................. 21 Management of Critical Illness and COVID-19: Septic Shock and Cardiac Arrest ........................................................................................... 26 Imaging of COVID-19: Radiology Department Guidance and Imaging Findings .............................................................................................. 29 Adjunctive therapies for COVID-19: Treatment Protocols .............................................................................................................................. 32 Caring for Special Populations with COVID-19: Pregnancy and Lactation, Infants, Children and the Elderly ................................................. 35 Palliative Medicine During the COVID-19 Pandemic ...................................................................................................................................... 47 Implications of COVID-19 on Surgical Care ..................................................................................................................................................... 50 Operational Considerations for COVID-19: Planning and Preparation ........................................................................................................... 54 Behavioral Health and Wellness in COVID-19 Clinical Management .............................................................................................................. 56 Rehabilitation Considerations for Persons with COVID-19 ............................................................................................................................. 58 Telemedicine Support During the COVID-19 Pandemic .................................................................................................................................. 59 Emergency Medical Services (EMS) and Ground Transport of Persons with COVID-19 ................................................................................. 63 En Route Critical Care Considerations of Persons with COVID-19 .................................................................................................................. 67 Public Health Considerations and Response ..................................................................................................................................................