What is it like in your hospital right now?

Serhilda, ADN, RN · Mar 30, 2020

11 hours ago, bjz003 said:
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."

Incredibly helpful post, thank you. This is exactly what I've seen as well in our ER.

In our hospital, we just had our local police department donate p100 respirators to all ER nursing staff. Before that, we were required to use the same n95 respirator. Forever. We've had plenty of disposable gowns, surgical masks, gloves, hair covers, and shoe covers though.

Currently, we've just moved beyond the typical COVID rule out phase and are now seeing our positive patients come back with worsening symptoms. We've had some die, some intubated, and some admitted to our COVID unit. We're getting patients from our local nursing homes testing positive. Some we're getting unresponsive, unsure of whether or not they were positive. Our administrators are collaborating with nursing homes to urge patients and their families to discuss advanced directives. We've all become much more stressed.

Kastiara, ASN, RN · Mar 30, 2020

3 hours ago, DeaneB246 said:
Do y’all get to change masks, gloves, gowns as per rec standards or have to wear beyond what’s recommended?

Gloves and gowns are one time use only. N95s are used for up to 12 hours of continuous use then we get another one. Face shields are wiped down with Sani-Cloth in between uses.

Compared to some places, my hospital is doing a pretty good job at protecting their workers.

dria23, BSN, RN · Mar 30, 2020

I work in an ED in Georgia. For the first few hours of the shift, the census is low. Around 10 or 11AM, people begin to flood the ED some with serious complaints and others that should have stayed at home. All of the masks were removed from the floor and locked in our manager's office. The manager gives the charge nurse 1-2 boxes for the shift. You have to practically beg and give your first born to get a surgical mask. To get an N95, you have to sign your name in blood and give a limb. Even if you are in Triage, you cannot get a surgical mask, and if you are caught with one, you are asked to take it off immediately. This is crazy to me since 2 weeks ago, the hospital wanted all of us to wear masks. You can only get a surgical mask if you are immunocompromised or are treating a positive/rule out covid-19 patient. You are given 1 N95 mask and are asked to keep up with it and reuse it constantly until it falls apart. We are out of masks with face shields, so the ED director has supplied the ED with 5 reusable goggles that we all must share. This is not that helpful since we all end up with at least 2 covid-19 patients at a time. The last shift I worked, I had 4 rule out covid-19 patients, and one looked really bad. Between donning and doffing my PPE, I lost my N95 mask. I was given the 3rd degree by my charge before she would even give me a replacement. Going to work is causing me such great anxiety that I am having severe chest pains every time I go to work. Our hospital is getting full, and we already have 6 positive cases and 55 rule outs. Eventually, I believe the ED will become a holder unit since the testing results are taking so long to come back. This is just a never-ending nightmare.

SansNom · Mar 30, 2020

As of 7pm today, our hospital has made surgical masks mandatory for all employees at all times, unless over 6 feet away from other coworkers or patients.

We're still running short and rationing things, but at least we have that.

CJC · Mar 30, 2020

Same here in Phoenix, low census, I'm also PRN so we are being put on standby and canceled. I think this is the calm before the storm. I hope we will have the proper PPE and Policies in place in two weeks when we get sick patients coming in.

IDNP · Mar 30, 2020

3 hours ago, SansNom said:
As of 7pm today, our hospital has made surgical masks mandatory for all employees at all times, unless over 6 feet away from other coworkers or patients.
We're still running short and rationing things, but at least we have that.

I dont understand what a surgical mask is going to do when it has been said that this virus is airborne for 3 hours. Of course its better than nothing but absolutely irresponsible of hospitals, government. this 1st world country we call the US is a shame.

ClaraRedheart, BSN, RN · Mar 30, 2020

We had fewer patients on COVID isolation on Friday and Saturday than we did on Monday. I'm frankly sick of it. If our patient numbers are decreasing in the hospital, the community should be lifting some restrictions. I have friends and family who have lost jobs. I have co-workers who have been pushed and are losing their PTO. I am lucky that I'm precepting right now, so they can't push me. To COVID: Pee or get off the pot. I'm ready to get this over with. Maybe the warmer weather really is making a difference? I

Boog'sCRRN246, RN · Mar 30, 2020

10 hours ago, IDNP said:
I dont understand what a surgical mask is going to do when it has been said that this virus is airborne for 3 hours. Of course its better than nothing but absolutely irresponsible of hospitals, government. this 1st world country we call the US is a shame.

I don't understand this either. In the last two weeks, my hospital removed the mask requirement for those who had not gotten the flu shot and told everyone else if they were not involved in direct pt care and seen wearing a mask that they should "be prepared to answer why they were wearing it." As of this morning, they started handing out masks to anyone who enters the facility (currently only staff and very limited visitors) and they are NOT mandatory to put on. This was after creating a form letter on Friday letting people know where mask donations could be dropped off. To me, if we are to the point of having to accept mask donations, we have no business just handing them out all willy-nilly. They should be reserved for staff with direct pt contact.

JohnyPapr · Mar 30, 2020

We just admitted 3 MD’s who were Covid positive last night. An ER physician, A Pediatrician, and a G.I physician. One got it from a ski trip two weeks ago before the lockdown. Another from a family member. Another from just doing their job seeing patients. CDC was late in their warnings.

We are going to see a lot of healthcare workers coming in testing positive. Stay safe out there.

S84, ASN · Mar 30, 2020

Has anyone started receiving emails from their local board of nursing regarding a survey that is elective to see employment stance and availability in a call up of staff in a Pandemic response?

Indiana here

Guest862922, LPN, RN · Mar 30, 2020

Interesting and scary. What I’m missing that those cardiac, renal etc. conditions showed with people who where otherwise healthy or with people who already had diseases such as diabetes, cardiac conditions and so on.

That would be good to know

SansNom · Mar 30, 2020

17 hours ago, IDNP said:
I dont understand what a surgical mask is going to do when it has been said that this virus is airborne for 3 hours. Of course its better than nothing but absolutely irresponsible of hospitals, government. this 1st world country we call the US is a shame.

Current research is showing that it can be potentially rendered airborne for UP TO 3 hours after an aerosolizing treatment or procedure. It doesn't just have an allotted 3 hours of random air time it gets to use at will(haha, sorry, that thought just made me laugh). Most aerosol generating procedures and treatments are ICU specific that most med/surg nurses won't be exposed to (you can Google these pretty quickly).

Aside from the those specific situations, it is a droplet transmitted virus, and a surgical mask will suffice. I know many of you don't believe anything we're being told anymore, with some good reason, but I personally believe this particular bit of information and feel comfortable with a surgical mask unless I'm caring for a patient in the ICU receiving these treatments. I wash my hands frequently, of course, am very mindful of touching my face while at work, and then clean myself thoroughly when I get home.

In the situations we are caring for ICU patients receiving aersolizing treatments (in my hospital anyway) we are provided with N95s and much more protective gear. We have also converted quite a large number of rooms to be negative pressure so these droplets that have been rendered airborne are not just floating all over the hallway.