What is it like in your hospital right now?

[FloatFNP-C]

I'm PRN and have been on call because of low census. I know we have COVID and r/o COVID patients; I'm actually "assigned" to the COVID floor, but because of my status + elective surgeries canceled + people avoiding the hospital, our census is low.

I wonder what it will look like a week or 2 from now.

In the Denver Metro area for reference!

[DeaneB246]

A make shift mask/face protection that can help as a general barrier - easy, quick

Need 3-4 items:

-a shoe cover (woven poly, looks like ‘paper’, not waterproof/vinyl).
Open it with your hands, fit it over your face (horizontally) to just get a ‘feel’ for it

- scissors, pointy sharp.
Make a TINY snipped hole OUTSIDE the sewn seam on each side, about an inch or less from the opening

- a thin elastic band
Slip it through holes, tie knots on each end.

-tape, option-
an added small piece of scotch tape over each hole before you snip, or after and include the knot, helps it stay stronger if lowering mask/taking it on and off.

The elastic in the shoe cover conforms to your face covering your mouth, nose, and chin, though obviously not a tight seal. It’s pretty comfortable, and disposable.

One box of 50 pair makes 100 masks.

We used ready made elastic used in crafts for mask/hat making (Amazon pk of 50).
It has metal tips on the ends, as a ‘real’ mask/hat would. Makes it easy to feed through the tiny hole and also to tie in knots.
Any thin elastic should work.
20 inch length worked well.

Best of luck to all, be well!

[Kastiara, ASN, RN]

I'm in GA. My unit has a couple r/o Covid patients and several confirmed Covid. The patient's that are confirmed aren't doing very well. All of them are on ventilators and pressure support and we'll more than likely be proning them soon. We've had a couple nurses and doctors end up testing positive.

All employees are screened for fever or SOB when coming on shift. Our PPE has been locked up and is being rationed out. We use N95 masks, face shield, and gowns for all r/o or confirmed patients. We also have to change into a set of hospital issued scrubs if we are taking care of these patients.

Our census has been pretty low. Before this my unit was full. They were begging nurses to come work OT last week; this week, they're calling people off. The ED has been seeing fewer patients as well. It's eerie.

[bjz003]

Nurse south Jersey 12 yrs. Our hospital closed all visitors over a week ago. Now we all have to enter through the parking garage where you are issued a mask and a bag. The mask goes on immediately and stays on throughout the day for all hospital staff. You exit the same, put your mask in a bag at exit trash. Of course ED and ICU changes masks and gets not as needed on units. I'm Behavioral health unit. They are now asking through survey monkey your skills from previous jobs in health care and your comfort level. Getting ready for a higher influx of infected patients. I transferred from a step down unit a few years ago so with a little refreshing I'm comfortable getting pulled back to the med floors. Stay safe everyone ❤

[HiddenAngels]

Things are changing rapidly. Initially yes they were telling us to not wear mask unless caring for patients on precautions. They even started saying no mask or gowns for MRSA VRE CRE etc. Now upon entry to the building, all staff have to wear mask the entire time, from entry to exit and we are changing our clothes as well... AGAIN, stay SAFE everyone!!

[verene, MSN]

Things are changing rapidly - I work inpatient psych - we shut down admissions temporarily - converted several units over to quarantine status for confirmed/suspected cases, went from 2 negative pressure beds to ~100 negative pressure beds in under a week. PPE is very limited for those not on quarantine unit(s). So far no confirmed cases, several suspected and 2 or 3 confirmed negative. We're running on skeleton crews with many people teleworking to try to reduce #s of people in the building so we can maintain 6+ feet distance more easily. Due to the slow down on admissions and reduction in non-essential meetings - my workload is lower than usual which feels a little weird. We're screened going into work for all employees (not that different from usual as we a a secured facility - just added covid related questions and temperature check into the process). As others have commented it feels a bit like the calm before a storm.

I'm just grateful to live in a state that is taking the risk seriously and that my hospital is having the time to initiate protocols and come up with game plans BEFORE things hit hard. It's probably still a matter if when not if we get our first case - but I think we are about as prepared as we can be at this point. I am worried about our medical hospitals in the area - they are starting to be hit hard.

[SansNom]

Another interesting aspect of this situation is that hospitals are now changing standards for other contact precautions. Just a couple of weeks ago, you stood getting reprimanded or punished for not wearing a gown to fix an IV pump in an MRSA contact room, and now we're saying no gowns necessary for MRSA and VRE unless there are open wounds, and even then only for baths and wound care.

Admittedly, I've always thought some of the contact isolation policies were overboard, but now they're basically admitting it. Furthermore, does this mean from here on out MRSA of the nares and the like will no longer require isolation? Or are we just accepting that during this covid crisis we're going to also be setting other microbial organisms loose into the population?

[Xevious]

Much the same here...

There is now a tent outside triaging patients before entry. All staff is having their temps checked on entry. They've erected new walls around the ICU and adjacent intermediate floor in preparation of making them all negative pressure. Those areas are now COVID and r/o COVID only. Census is low, but they're anticipating a surge soon. PPE is low and being locked up and rationed. All staff members are wearing surgical masks at all times though.

Strange times.

[Justin Katen]

I am working on the biggest designated covid unit which used to be a 7 bed ICU on one side with a 9 room step down unit directly across. They have turned it into one big 16 bed ICU for covid patients now. The past week we have had an influx of covid rule/out patients and many positives as well. The scary part is that many of these rule out patients expire before their test results come back, which means they are not counted in the statistics that you see in the news. My first patient I took care that expired about a week ago has had his test pending for 12 days and still has not resulted yet. This is unacceptable considering some countries have tests that result in 15-20 minutes! On top of that, the hospital is keeping what PPE they have left locked in closets and managed like most of the hospitals are doing now. We are allowed one gown per shift to be used for all patients and one n95 mask for the week! They make us put the mask and goggles in a brown lunch bag after each use in the rooms and hang our gown up outside the rooms. I was told to use my gown inside a positive patients room and then use that same gown to go into a rule outs room and hang it up right outside the door. We have one negative pressure room, yet there are patients on highflow and bipap all over the unit just aerosolizing this virus right through the ventilation system into the nursing station for everyone to breath. The icing on the cake is that they are still tripling our nurses with these very unstable patients on numerous drips and without any help at all while providing care. You have to turn, boost, and clean these patients all by yourself no matter how heavy they may be. The only time anybody else comes into the room beside the nurse is when you have to intubate, prone, or code the patient, which is happening with all of these critically ill covid patients btw. Add the fact that we have no lab tech, pharmacy tech, ekg tech, or anyone else for that matter to help, so we have to do it all. Yes I signed up to take care of my patients and that I will do. But this is absolutely not what I signed up for. Hopefully this shed some light for some people that don’t work on the frontlines.

[bjz003]

I was happy to come across this from a friend. It was very informative.

Repost from another group. Interesting read.

"I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.

Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.

Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.

China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.

Diagnostic
CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.

Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.

Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.

A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.

An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.

Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.

Disposition
I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.

Treatment
Supportive

worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.

We are also using Azithromycin, but are intermittently running out of IV.

Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.

I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all."

[SICUMurse123]

I reckon with everybody having a "low census", it's a good time to be in Critical Care. I pulled 115hrs last pay period and will likely do the same this pay period. They are begging us to work and paying us well to do so. We are on Critical Care divert as all of our units are full w/ COVID patients and we get called to the floors multiple times a day to look at patients that usually end up needing Critical Care services... Unless ED patients are absolutely dying, we are transferring them out. We have finally got some other hospitals to accept our patients.

Most insane thing I've ever seen in my life. Luckily, we got multiple truckloads of supplies recently. We are doing our best to conserve our supplies and are re-using PPE, but we do have it readily available.

[DeaneB246]

On 3/28/2020 at 7:30 AM, Kastiara said:

I'm in GA. My unit has a couple r/o Covid patients and several confirmed Covid. The patient's that are confirmed aren't doing very well. All of them are on ventilators and pressure support and we'll more than likely be proning them soon. We've had a couple nurses and doctors end up testing positive.

All employees are screened for fever or SOB when coming on shift. Our PPE has been locked up and is being rationed out. We use N95 masks, face shield, and gowns for all r/o or confirmed patients. We also have to change into a set of hospital issued scrubs if we are taking care of these patients.

Our census has been pretty low. Before this my unit was full. They were begging nurses to come work OT last week; this week, they're calling people off. The ED has been seeing fewer patients as well. It's eerie.

Do y’all get to change masks, gloves, gowns as per rec standards or have to wear beyond what’s recommended?

[haveyourbowelsmoved]

I want to buy my own FFP2 or N95 mask as I feel safer with them, but very hard to find online? are you guys wearing the same mask ?how are u cleaning them?