>COVID-19 – SJRH and New Brunswick

This post is provided as an information resource specifically for HealthCare Professionals within the Saint John Region and New Brunswick Emergency Departments

This post will be updated continuously as required.

COVID-19 Clinical Management is posted HERE.

Internal Communication Daily Update Thread is posted HERE. Password has been emailed to all staff and is posted on Closed Group FaceBook SJRHEM Education page.


Public Health

WorkSafe New Brunswick

Infection Prevention and Control

SJRHEM Clinical Pathways

Academic Activity – News, Cancellations

National Organization COVID Resources

Staff Wellness

Dalhousie Medical Students – Volunteer Support


What is COVID-19

  • A novel betacoronavirus first reported in Wuhan, China on December 31st 2019
  • Symptoms for the novel coronavirus are similar to those for influenza or other respiratory illnesses.
  • New Brunswick Case Definition – see below– Note this continues to evolve
  • Current assumptions are that spread is via droplet and/or fomite to face
  • Infection Prevention and Control = Contact and Droplet precautions
  • Links to reliable COVID-19 Information: New Brunswick, Horizon, Canada, CDC, WHO
  • Other COVID -19 respected resources: EMCrit, RebelEM
  • COVID -19 Rounds – Dr. Duncan Webster (Infectious Disease Physician)

 


Active Screening for Emergency Physicians before Shift

At shift handover ask the following questions:

  • Do you have any Influenza Like Illness symptoms?
  • Have you reviewed the SJRHEM COVID webpage and Daily Updates?
  • Have you read the Donning-Doffing Posters?
  • Are you aware the Donning and Doffing requires a Buddy?


Personal Protective Equipment for COVID-19

PPE Evidence – Centre For Evidence Based Medicine Oxford – This paper reviews compares effectiveness of surgical mask to N95 effectiveness for coronavirus

 

PPE: What We Know, Conservation Strategies and Protected Code Blue – From EmergencyMedicineCases.com – a great summary on IP&C and how to use PPE.

Low Risk of Aerosolization 

  • Surgical mask
  • Gloves
  • Scrub hat,cap or bonnet
  • Visor or goggles
  • Gown

e.g pretriage screening walking patients

High or Unknown Risk of Aerosolization

  • N95 mask
  • Gloves
  • Scrub hat,cap or bonnet
  • Visor or goggles
  • Gown

Aerosol Generating Procedures = non-invasive positive pressure ventilation, high-flow nasal cannula, bag-mask ventilation, endotracheal intubation, cardiopulmonary resuscitation, bronchoscopy, open suction of respiratory tract, sputum induction, use of nebulizer therapy, high frequency oscillatory ventilation

 

 


Donning and Doffing PPE

  • When removing PPE, always start by first applying alcohol-based hand sanitizer to your gloves.
  • After fully removing PPE, sanitize hands and wrists with alcohol-based hand sanitizer again.

  • Note that we recommend also wearing a scrub hat,cap or bonnet to reduce risk of fomite transmission

 

Official Dalhousie Doffing and Donning Video

 

 


Horizon – Interim Infection Prevention and Control Guidelines for the Management of Suspect COVID-19

IPC Guidance for Suspect COVID 19 ( March 15 2020) V 2.0

GNB – Chief Medical Officer – COVID-19 – PPE for IPC from March 22 – Mar 23 2020

 


Self-Presenting Patient Flow Pathway – Saint John Regional Hospital Emergency Department

 

 

 

 

 


NB Health Screening Tool and Referral forms to Surge Clinic – 20 March 2020 

Screening Tool – http://sjrhem.ca/wp-content/uploads/2020/03/COVID-19-Screening-Tool-2020-03-19-MD.pdf

Referral Form – http://sjrhem.ca/wp-content/uploads/2020/03/Example-COVID-19-Referral-Form_EN-2-1.pdf

FAX Number = 506 462-2040

 


Self-Isolation Information Leaflet for Patients

Self-Isolate and Alternative Self-Isolate Leaflet

Self Management COVID

 


SJRH Emergency Department Patient & Staff IP&C Flow Map

 

Traffic Flow

(March 13, 2020)

COVID- 19:

  • Triaged at main ED vestibule
  • Travel the patient corridor until back entrance to RAZ à into the unit
  • For external procedures travel down the public corridor following all precautions

Clean patients needing x-ray or other external sever (ambulatory or via Porter)

  • Out internal RAZ doors (11.523) and travel down the main staff corridor
  • Returning via the staff corridor and can us AMB intercom for Safety service to provide re-entry

ED Staff / physicians

  • Travel the main staff corridor and loop back into the public corridor (11.161)
  • Will use the new card access doors to gain entrance to the “anti-room”

EMS

  • Any suspect case to park at the ED main entrance and use the established path to the Covid-19 Unit via the public corridor

Inpatient and Visitor traffic

  • All this traffic will be filtered through the main entrance
  • After hours that will be monitored by Safety services

 

Control points

  • Main staff corridor
  • RAZ- back entrance (main staff entrance to Covid-19 space)
  • RAZ – emergency exit into staff corridor (access needs to be restricted)
  • New access point @ link corridor (by ED conference room)
    • Need lists for who will be provide access
  • Public hall by RAZ waiting room entrance
    • Option 1- physical barrier with wall and door (bed accessible)
    • Option 2 – staff presence

 

COVID-19 Testing – Public Health Advise and Viral Swabs 

Summary of Current Guidance :

  • Need to balance the need for detection of as many imported cases of COVID-19 as possible is critical to mitigate the spread of this virus in the community setting with the the fact that Laboratory capacity and supplies are limited provincially and nationally.
  • We need to be careful to choose wisely to maintain the integrity of our diagnostic system
  • Consider:
    • Travel history outside NB in last 14 days
    • At Least one of: Fever/Chills, Cough, Difficulty Breathing
    • Note 80% of COVID-19 cases are mild so clinical severity is not a marker of likelihood of infection
    • More severe clinical presentations (pneumonia, unusual presentation should be considered for testing regardless of travel history
  • Collect (or arrange for collection of) ONE nasopharyngeal swab for COVID-19, indicating symptom onset date, travel history including date of return, and clinical severity (if indicated)
  • 5 Hospitals across NB, only SJRH in R2
  • 5 per day of those being discharged
  • 5 per day of those being admitted
  • Use pre labeled ‘sentinel swab’
  • Fever or Cough but NO travel or contact hx

 

How to Collect NP Swab

 


COVID-19 Triage

Full process here:  COVID Full triage to mild moderate severe critical V5

 


PoCUS

Indications for PoCUS are limited in COVID-19 patients. The usual lung, cardiac and procedural guidance indications may be appropriate in assisting with resuscitation and managing complications. Specific findings in COVID include:

  • Focal B-lines and fused B-lines
  • Discontinuous, rough appearance to the pleural line, with subpleural consolidation
  • Foci of disease located predominantly in the posterior lung fields, particularly in the lower lung fields
  • Images can be viewed here

Neither PoCUS, CXR or CT are sufficiently sensitive to provide a diagnosis of COVID. The use of PoCUS should be limited to assisting with resuscitation and managing complications.

Infection Prevention and Control measures are divided into two areas

Assuming that we are in the containment phase (i.e we are successfully identifying cases of COVID at Triage) – This may change.

General Emergency Department

  • These patients have been screened as low risk for COVID-19, i.e they are presenting with an unrelated pathology.
  • Before and after using the ultrasound machine on each patient the following established protocol applies
    • Using the viru/bactericidal hydrogen peroxide wipes, thoroughly clean the:
      • Transducers and cables
      • Keyboard and cart handles
  • Only use the ultrasound machine for clinically indicated examinations (No scanning rounds or non-clinical teaching scans)
  • In the presence of blood or other bodily fluid contaminants use a transducer sheath

 

High Consequence Infection Decision Unit

  • These patients have been screened as moderate to high risk for COVID-19, i.e they are presenting with an Influenza Like Illness (ILI) and meet the case definition criteria.
  • A dedicated ultrasound machine has been located in the HCIDU
  • Before and after using the ultrasound machine on each patient the following established protocol applies
    • Using the viru/bactericidal hydrogen peroxide wipes, thoroughly clean the:
      • Transducers and cables
      • Keyboard and cart handles
  • A transducer sheath must be used on every patient.
  • During the examination, try not to directly touch the machine controls. Use a transparent polythene drape / or alternative barrier over the keyboard controls
  • After use, move the machine back to its storage area away from the patient beds.
  • Try to avoid using the machine on another patient for at least 30 minutes.

 


Case Definition – New Brunswick

based on the Canada Public Health  –  NB Interim national case definition  – March 24

Person under investigation (PUI)

A person with fever and/or cough who meets the exposure criteria and for whom a laboratory test for COVID-19 has been or is expected to be requested.

Probable

A person:

  • with fever (over 38 degrees Celsius) and/or new onset of (or exacerbation of chronic) cough
    AND
  • who meets the COVID-19 exposure criteria
    AND
  • in whom laboratory diagnosis of COVID-19 is inconclusive,negative (if specimen quality or timing is suspect), or
    positive but not confirmed by the National Microbiology Laboratory (NML)

Confirmed

A person with laboratory confirmation of infection with SARS-CoV-2 as a result of nucleic acid amplification testing (NAAT).

 

SJRHEM ADVICE – 19 March 2020

Consider any patient who presents with an Influenza Like Illness – irrespective of above case definition as being suspicious for COVID-19 and take appropriate PPE precautions.


Exposure Criteria

In the 14 days before onset of illness, a person who:

  • Traveled to an affected area i.e. anyone who travelled outside New Brunswick. OR
  • Had close contact with a person with acute respiratory illness who has been to an affected area (anyone who travelled outside NB within 14 days prior to their illness onset) OR
  • Had laboratory exposure to biological material (e.g. primary clinical specimens, virus culture isolates) known to contain COVID-19.

Close contact = A close contact is defined as a person who provided care for the patient, including healthcare workers, family members or other caregivers, or who had other similar close physical contact or who lived with or otherwise had close prolonged contact with a probable or confirmed case while the case was ill.


Affected Areas

Public Health Canada Affected Area List

UPDATEAll travel outside New Brunswick


 

 

 

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