COVID-19 Protocols – Draft

1. System Considerations
2. Intake Protocol
3. Floor Protocol
4. ICU Protocol
5. Respiratory Failure Protocol
6. Respiratory Therapy Protocol
7. Patient Transport Protocol
8. OR/Procedure Protocol
9. Viral Myocarditis/Cardiogenic Shock Protocol
10. ECMO Protocol
11. Code Blue Protocol
12. Isolation Protocol
13. Transfer from Satellite Facility Protocol
14. De-escalation protocol
15. Discharge Protocol
16. Clinical Pearls Unique to COVID
17. Order Sets
18. Checklists and Pocket Cards

1
 System Considerations
 Many centers are setting up a screening hotline to call in separate from their usual
clinic line to streamline efficiency
 Screening is being diverted from clinics and ER to a trailer, tent, or from cars to
allow for infection control and improved flow of non-COVID patients
 Consider appointing nurse navigator(s) to track COVID patients
o In charge of CDC PUI Case Report Form
o Daily call to patients on home quarantine to review symptoms and provide
ongoing education
 Consider establishing an internal command center
o 24/7 Internal line for urgent issues that arise (calls go through charge
nurses and house supervisors to screen urgency)
o Set up internal online platform for nonurgent submission of concerns by
staff (similar to CEOlink; Facebook Workplace has been used by other
programs)
o Coordinate daily updates to staff through huddles and email (when urgent)
o Coordinates with bed board to keep track of COVID patients with
isolation needs
o Coordinates with First Com for incoming patients from satellite hospitals
o Coordinates with Materials Management to make sure supplies are
distributed and used appropriately including reordering
o Coordinates with House Keeping to make sure rooms, equipment, and
procedure areas are appropriately cleaned in an urgent fashion
o Coordinates with Employee Health regarding exposure of health care
workers
o Communicates with Health Department, CDC, and TMF
o Coordinates with nurse navigator(s)
o Coordinates with marketing to update Facebook and website
o Coordinates with IT to update internal website information
o Coordinates with infection control team
o Notified of patient transfers within hospital (to other units, radiology,
procedures, etc) to assure proper isolation and PPE protocols used and to
notify security to clear route of other people

2
 Establish a policy for staff regarding compensation if required to quarantine from
exposure at work (workman’s compensation?) vs community exposure vs needing
to care for family (PTO?). Sharing with staff will help decrease anxiety over
caring for COVID patients.
 Establish a child care option in case schools are closed for an extended amount of
time so staff can come to work (work with teachers, other school staff, or
university students who are out of school to organize child care in small groups or
in home; consider “training” them on symptoms of COVID and proper
precautions)
 Consider making pregnant, immunocompromised, or elderly staff exempt from
being assigned to COVID cases
 Establish criteria for which staff must be evaluated by employee health (Fever,
URI symptoms, etc) so screening is not avoided out of fear of quarantine. Some
programs are performing temperature screening and logging of staff at the 2x per
shift.
 Generate critical supply list in addition to standard items of gowns, gloves,
shields, and N95 masks. For example: echo prove covers, ABG supplies,
endotracheal tubes, vent circuits, tracheostomy supplies, arterial lines, central
lines, FloTrac devices, viral filters for RT equipment, disposable stethoscopes
 Create COVID kits for frequent procedures to prevent the need to leave the room
for supplies and bringing an entire supply cart into the room (intubation, central
lines, phlebotomy, etc)
 Invest in disposable equipment such as laryngoscopes, EKG leads,
bronchoscopes, etc
 Re-educate staff on proper donning and doffing PPE as well as what cleaning they
are responsible for (wipe down computers with purple wipes q shift, keep all
disposed PPE in patient’s room, etc) (See CDC PPE Poster). Observational
studies show 90% of medical staff apply and remove PPE incorrectly. Training
video: https://youtu.be/bG6zISnenPg
 Consider increasing signage in high traffic areas (entry points, elevators, waiting
rooms) to educate visitors on isolation and hygiene procedures
 Consider limiting entry points for COVID patients
 Consider having patients wait in car until can be put in isolation room for
screening; call when ready instead of using waiting area
 Consider using Facebook and website to act as hub for public information. Post
protocol for screening (symptoms, contact concerns, number for telephone
screening, locations for screening). Consider Facebook live to allow public to ask
questions on a frequent basis to calm general panic. We want them to have a
reliable source of information and trust in our system. Also provide frequent
updates on news sources.

3
 Consider setting up video rounding for nurses to minimize contact. Cameras such
as Arlo can be purchased commercially and may be cheaper than other options.
Can also consider FaceTime from patient’s phone to a centralized nurse phone.
 WHO and CDC recommend all procedures that generate droplets (bronch,
intubation, etc) be performed in negative pressure isolation rooms. Please note
the Main OR as well as the Cath Lab and CVOR are not isolated. The
HVAC systems connect so in the past, we have been unable to treat TB
patients without shutting down all connected rooms. We need a protocol for
this situation that could include moving COVID cases to the end of the day or
moving nonCOVID cases to the Olympic Center.
 When considering the worst case scenario as in Italy, we need to develop a triage
system in case our system is overwhelmed and transfer is not an option. Italian
physicians are having to decide based on age and comorbidities who they have to
turn away for care. “Playing God” has resulted in psychological issues among the
medical staff. If we developed a protocol, it would take that psychological burden
away from the providers to some degree. Hopefully it would never need to be
used. It could include early interventions like canceling elective cases and training
physicians from different specialties in COVID specific responses for an all hands
on deck approach. Could also consider transfer of less critical patients (COVID or
not) to our outlying facilities and/or turning UT North into a COVID hospital as it
was set up for TB originally
 Develop visitation policy (limited number of people and time, track visitors and
symptoms, do not allow to go to other areas of the hospital like cafeteria,
PPE/isolation enforcement)
 Provide information manual to staff online and hard copies on each unit.
https://emcrit.org/ibcc/covid19/ is a great resource
 There are protocols available if the supply chain completely breaks down and we
need to reuse PPE equipment
 CDC recommends nurses screen non-COVID inpatients daily for symptoms; if
unexplained fever, respiratory symptoms, or CXR changes consistent with
COVID, add patient to usual intake screening and protocol
 Provide masks and sanitizer as needed to visitors rather than placing out to
prevent theft
 Hospitals across the country are having a difficult time with discharge planning
due to SNFs refusing COVID patients. In order to optimize inpatient beds, we
will need to discuss this with outlying facilities early in order to have efficient
discharge planning. If we can identify accepting facilities, we could perhaps
streamline with insurance companies to avoid the several day preauthorization
bottleneck per patient (similar to a preferred provider that the insurance company
authorizes now)

4
 Define plan for nurse staffing ratios on the floor (specific team of nurses for all
COVID patients to avoid exposing non COVID patients; decide if they get hazard
pay due to increased risk of exposure)
 Define plan for support staff interaction with patients in rooms (phlebotomy,
radiology, housekeeping, food service) to minimize interaction and cross
contamination to other patients/areas of the hospital
 For equipment that must be shared such as mobile computers, make use of clear
plastic drapes/bags that can be removed and discarded when leaving the room
 Set up support services for staff to address anxiety and burnout. Programs through
behavioral health program and psychiatric residency may help. Consider help line
 Consider participating in WHO registry to submit standardized data. Links are
available
 Consider setting up Pulsara style app for COVID inpatients
 Consider switching clinic visits (postop, initial consultation, follow-ups) to phone
call when possible
 Consider providing hospital issued scrubs for staff interacting with COVID
patients in order to reduce contamination of wearing soiled scrubs throughout the
hospital or in public. This would allow for proper laundering. If not possible to
provide scrubs, provide plastic bags and laundering instructions

5
 Initial Screening
1. Implement screening process and isolation (see established protocol) at entry
points (Provide Identify, Isolate, Inform pocket card from CDC for Staff)
a. Pt immediately has mask placed
b. Move patient to designated area or room
c. Minimize staff interaction
d. Staff wears gown, gloves, surgical mask, hat, shoe covers, and goggles or
face shield with interaction (See CDC PPE Poster)
2. Obtain baseline clinical information
a. CBC, CMP
b. CXR (bilateral infiltrates)
3. Deemed person under investigation
a. Notify health department/CDC (via command center)
b. Notify nurse navigator to open PUI checklist from CDC via command
center. https://www.cdc.gov/coronavirus/2019-ncov/downloads/pui-form.pdf
c. COVID testing per ID protocol
4. Triage clinical severity based on WHO categories – physician decision
a. Uncomplicated: URI symptoms with fever, cough, sore throat, congestion,
malaise, headache, or myalgias. Does not have SOB, dehydration, or signs
of sepsis
b. Mild pneumonia: clinical symptoms, lab and CXR findings of pneumonia
without evidence of severe pneumonia
c. Severe pneumonia: Temperature > 100.4 or respiratory symptoms with
respiratory rate > 30, severe respiratory distress, or O2 sat < 90% on RA
i. Peds: cough and SOB with cyanosis sat < 90, respiratory distress,
lethargy, inability to feed, seizures, or tachypnea
ii. Will evaluate for ARDS and Sepsis with severe clinical picture
d. Note that some centers are performing Chest CT on all patients since the
COVID pattern can appear before symptoms and before testing positive
e. Note that some elderly patients can present with mild disease or
asymptomatic hypoxia prior to decompensating; defer to physician if
further workup indicated in these patients but may be prudent to CT all
uncomplicated and mild patients above a certain age and/or admit to
observation
5. For patients deemed stable for home quarantine and monitoring (uncomplicated
and mild patients)
a. Daily phone follow up with nurse navigator for symptoms and adherence
to quarantine.
b. Provide Discharge Packet
i. CDC Home Care Guide (https://www.cdc.gov/coronavirus/2019-
ncov/hcp/guidance-prevent-spread.html)
ii. Home Care Guide from WHO (www.who.int/publications-
detail/home-care-for-patients-with-suspected-novel-coronavirus-

6
 (ncov)-infection-presenting-with-mild-symptoms-and-
management-of-contacts)
iii. Daily Log (Include temperature, RR, HR, O2 Sat if available,
Symptoms; list normal parameters and when to call physician or
nurse navigator)
iv. Follow up appointment and testing schedule
v. Appointment dates, times, and contact information
vi. Nurse navigator contact information
6. For clinically severe patients requiring inpatient admission (Severe pneumonia
with or without ARDS and sepsis
a. Place COVID Intake Order Set in ED to complete workup
b. Physical Exam
i. All staff use strict contact and droplet precautions (gown, gloves,
eye protection, surgical mask)
ii. Vital signs q 15 min
1. Notify physician if HR > 100, RR > 24, Sat < 90% on RA,
SBP < 100, Temp > 100.4
2. Continuous telemetry monitoring – viral myocarditis can
present with sudden arrhythmia
c. Lab workup (see Lab Dashboard worksheet for bedside nurse to manage)
i. CBC with diff
1. WBC tends to be in normal range
2. Flag Lymphopenia; poor prognostic sign
3. Flag Neutrophil/lymphocyte ratio > 3; poor prognostic sign
4. Thrombocytopenia common; Flag < 100 poor prognostic
sign
ii. CMP
1. Flag elevated transaminases
2. Flag elevated Cr
iii. Baseline PT/INR (DIC can develop over time)
iv. D-Dimer
1. Usually elevated
2. Flag > 1mg/L as associated with high mortality rate
v. Procalcitonin
1. Usually not elevated in COVID
2. Consider other diagnosis vs superinfection if elevated
vi. CRP
1. Elevation tracks with COVID severity and is related to
prognosis
2. If normal, consider other diagnosis for respiratory failure
such as heart failure
vii. Blood Cultures x 2
viii. Sputum Culture
ix. Flu and RSV
x. Troponin, BNP, and CKMB
1. Increasing incidence of COVID causing viral myocarditis

7
 2. Troponin commonly elevated in COVID due to myocardial
injury that does not represent NSTEMI
3. Elevated Troponin or CKMB is a poor prognostic sign
xi. ABG
1. ARDS develops in 17-29% of hospitalized patients
2. Calculate the PaO2/FiO2 ratio to determine ARDS
presence and severity
3. WHO Classification
a. Mild = 200-300
b. Moderate = 100-200
c. Severe < 100
d. If ABG not available, SpO2/FiO2 < 315 suggestive
of ARDS
xii. Lactate
1. Flag if > 2
2. Sepsis in < 5% of COVID patients
d. Imaging and Tests
i. EKG
ii. Chest CT
1. Bilateral ground glass opacities focused on periphery
2. Should not demonstrate pleural effusions, nodules, cavitary
lesions, or severe lymphadenopathy
3. Can show findings consistent with COVID before COVID
tests positive and before symptoms arise
iii. Echo
1. Baseline EF and effusion check to determine cardiac
involvement (myocarditis vs CHF causing cardiogenic
pulmonary edema rather than ARDS)
e. Initial Management
i. Respiratory Management
1. Initiate oxygen therapy at 5L NC for a goal O2 sat ≥ 94%
during resuscitation
2. Titrate NC to maintain sat ≥ 90% (If pregnant, ≥ 92%)
thereafter
3. If unable to maintain O2 sat ≥ 90% on 6L NC
a. Inform physician
b. Notify command center to prepare ICU admission
c. Increase FiO2 by Increasing NC, using simple mask
or reservoir bag
d. High flow NC and BiPap are associated with
increased aerosolization and containment risk; also
have a high rate of failure
e. If fails oxygenation via mask, move to early
intubation (See Respiratory Failure Protocol)
ii. Start Empiric Antibiotics in case of bacterial pneumonia or
superinfection

8
 iii. Employ conservative fluid management strategy
1. Patients rarely dehydrated or in septic shock; rule out
metabolic and cardiac etiology
2. Mortality related to ARDS and myocarditis – exacerbated
with fluid overload
3. WHO recommends FACTT Algorithm from ARDSnet
4. If shock present
a. Provide gentle fluid challenge with 250mL
crystalloid bolus and reassess
b. Patient should have central line and arterial line
placed in ED so pressor support can be initiated and
volume status measured
f. Disposition
i. Notify command center to coordinate hospital admission and
consults
ii. Admit to observation if patient has uncomplicated or mild disease
but has significant comorbidities including age
iii. Admit to hospitalist for floor admission if patient is stable on nasal
cannula without respiratory distress
iv. Admit to intensivist for ICU admission if requiring respiratory
support more than nasal cannula, has hemodynamic instability, is
in respiratory distress, has major comorbidities, or shows signs of
cardiac involvement
v. See Patient Transport Protocol

9
 Floor Protocol
1. See COVID Floor Admission Order Set
2. Admit to hospitalist
3. Unit of admission designated as follows:
4. Charge nurse to notify command center of arrival
5. Command center verifies COVID team consulted (ID, pulmonary, infection
control, nurse navigator, case management) and notifies hospitalist of arrival
6. Provider from hospitalist team to assess patient at bedside within 30 minutes of
arrival
7. Patients require continuous telemetry (acute or remote)
8. Isolation (See CDC PPE Poster)
a. Admit to negative pressure room if available
b. Patient requires surgical mask when interacting with other people (out of
room for tests and procedures and in room with visitors or staff)
c. Staff require strict contact and droplet precautions
d. Patient must remain in room with door closed
e. Post visitor policy on door
f. Provide visitors with PPE and educate on procedures
g. Create lab draw kits for scheduled labs so phlebotomy does not have to
bring all equipment into room
h. Consider hourly bedside rounding via phone or video rather than in person
to control exposure and preserve PPE
i. Use clear cassette drape/probe covers for portable imaging to minimize
equipment contamination
j. Minimize number of staff interacting with patients; bedside nurse and
physicians should perform the bulk of the duties rather than CNAs, food
service team, etc
k. Bundle patient care duties to minimize number of interactions with patient
by nurse (medications, vitals, I/Os, lab draws, meal service, etc)
9. Determine Code Status and identify DPOA/Next of Kin
10. Vital signs q4h and prn by nurse to minimize exposure; keep equipment in room
11. Continuous pulse oximetry with documentation q1h
12. Document symptom review (Symptom Review Checklist) q4h and prn when vital
signs taken
13. Strict I/Os q4h
14. Clinical Decompensation
a. Tends to occur 7-10 days after onset of symptoms
b. Notify charge nurse, rapid response, and physician STAT if any of the
following criteria present
i. Increasing respiratory rate > 24bpm while at rest
ii. Need to increase NC by more than 2L from baseline
iii. Need > 6L NC or need to add additional support such as facemask
to maintain O2 sat ≥ 90%

10
 iv. New onset arrhythmia (frequent PVCs, a-fib, a-flutter,
nonsustained VT, VT, bradycardia, heart block)
v. HR > 100 bpm or < 60 bpm
vi. SBP < 100 mmHg
vii. Increased work of breathing, feelings of dyspnea, or other signs of
respiratory distress
c. Order STAT ABG, EKG, CXR
d. Charge nurse to notify house supervisior, pulmonary or CRNA and
command center of possible ICU transfer with intubation to allow time to
prepare room and staff
e. Decompensation should not be managed on the floor as COVID patients
tend to rapidly decompensate. Normal interventions such as HFNC,
BiPap, and aggressive diuresis have not been shown to be helpful in
COVID patients, so assessment for ICU transfer with early intubation is
preferred. Per Respiratory Failure Protocol, intubation is best performed in
a negative pressure room with airborne precautions
f. Physician to make final decision regarding transfer
g. Hospital security responsible for clearing route of other visitors, including
in elevators
15. Diet based on other comorbidities; enteral fluid restriction decisions per physician
16. Saline lock IV; employ conservative fluid management to prevent exacerbation of
respiratory failure
17. Medication
a. COVID Medication
i. Ascorbic acid 1.5g IV q6h
ii. Thiamine 200mg IV q12h
iii. Anti-viral medication to be determined case by case per ID
iv. ACE-I and ARB do not yet have clear evidence but might be used
at discretion of ID or pulmonary
v. Avoid steroids unless needed for superimposed COPD
exacerbation – steroids have not been proven to help and can be
harmful to the immune response
b. Stop empiric antibiotics if blood and sputum cultures remain negative after
48 hours
c. Protonix 40 po qd for GI prophylaxis
d. Lovenox and SCD VTE prophylaxis per protocol
e. Electrolyte protocol if normal Cr; check with physician if Cr elevated
f. Reserve Lasix for clinically hypervolemic state or superimposed CHF
(peripheral edema, pleural effusions, JVD); COVID induces inflammatory
change in the lung which does not respond to diuresis. Inappropriate use
of diuretics in this setting can lead to intravascular depletion, hypotension,
and renal failure
18. Labs
a. Nurse to review baseline labs and fill in Lab Dashboard Worksheet
i. To be placed in bedside chart and updated/reviewed by bedside
nurse.

11
 ii. Call physician when critical values arise and note during physician
rounds
iii. Go over flagged labs in handoff reports
iv. Verify lab orders have been placed and labs drawn
b. Lab schedule
i. Daily CBC with Diff
ii. Daily CMP
iii. Daily INR
iv. Daily Troponin and CKMB
v. Check Blood and Sputum Cx results at 48 hours
vi. COVID testing
1. q2-4 days recommended
2. Will not be cleared to stop isolation unless afebrile and free
of symptoms; consider skipping interval COVID testing
until above criteria met in order to preserve test kits
3. See De-escalation Protocol
vii. CRP q3d
viii. ABG q3d and prn
ix. Lactate q3d and prn
c. Tests
i. CXR qd
ii. Limited echo for function
1. Every 3 days scheduled
2. PRN for hypotension, arrhythmias, or increased TP
3. Perform day of discharge as cardiomyopathy tends to
present suddenly after lung improvement in COVID cases
iii. EKG prn rhythm disturbances, increase in TP, or chest pain (nurse
should perform
19. Respiratory Therapy
a. Bronchodilators should be given as MDI as nebulizers increase droplets
and contamination
b. IS and Flutter Valve
c. Goal is to maintain O2 sat > 90%
d. Perform awake prone ventilation tid as patient tolerates
i. Tape NC to nose
ii. Allow patient to lay prone in bed as tolerated
iii. Has shown clinical improvement in COVID patients regardless of
ARDS
e. See Respiratory Therapy Protocol for further detail on procedures
20. See Patient Transport Protocol for any transport within hospital
21. Perform daily anxiety and depression screening for patients in isolation (Daily
Behavioral Health Screening Form); if behavioral health consult needed, perform
via phone or video
22. See Discharge Protocol for details on criteria, education, follow up and resources
to leave inpatient treatment

12
 ICU Protocol
1. See ICU Admission Order Set
2. Admit to intensivist
3. Unit of admission designated as follows:
4. Charge nurse to notify command center of arrival
5. Command center verifies COVID team consulted and notifies intensivist patient
has arrived (ID, infection control, nurse navigator, case management)
6. Provider from ICU team to assess patient at bedside within 30 minutes of arrival
7. Isolation (See CDC PPE Poster)
a. Admit to negative pressure room if available; if not enough negative
pressure rooms available for all admitted COVID patients, preference
given to non-intubated patients since their respiration is in an open system
and they may require intubation
b. Patient requires surgical mask when out of room for tests/procedures
c. Staff require strict contact and droplet precautions
d. Patient must remain in room with door closed
e. Post visitor policy on door
f. Provide visitors with PPE and educate on procedures
g. Use clear cassette drape/probe covers for portable imaging to minimize
equipment contamination
h. Nurses to perform lab draws from lines to minimize contact among staff
i. Minimize number of staff interacting with patients; bedside nurse and
physicians should perform the bulk of the duties rather than CNAs, food
service team, etc
j. Bundle patient care duties to minimize number of interactions with patient
by nurse (medications, vitals, I/Os, lab draws, meal service, etc)
8. Define code status and identify DPOA/Next of kin
9. Central line and arterial line to be placed upon admission to ICU
a. Allows for close monitoring of hemodynamics to guide fluid status
b. Allows for nurse lab draws to minimize exposure to other staff and
equipment
c. Follow routine CLABSI protocol
d. Intraosseous Catheter is an alternative option for access until line can be
placed
10. Vital signs q15 min until stable, then q1h and prn
11. Continuous monitoring of EKG, SaO2, CVP and arterial tracings
12. Will defer to ICU team regarding need for FloTrac monitoring on case by case
basis
13. Strict I/Os q1h
14. Foley Catheter to gravity
15. Daily weights
16. Notify physician for the following criteria:
a. HR > 100 bpm or < 60 bpm
b. RR > 24 if not on the ventilator

13
 c. Signs of worsening respiratory distress
d. Temperature > 101 degrees
e. UOP < 0.5cc/kg/hr
f. Frequent PVCs or the development of arrhythmia
g. O2 sat < 90% or increase in oxygen requirement to maintain O2 sat > 90%
17. Activity
a. Should be the maximum level tolerated given the patient’s clinical
condition
b. For sedated patients on the ventilator, turn q2h if tolerated. If not tolerated,
place patient in air bed to minimize risk of decubitus ulcers
c. Follow routine protocols to prevent decubitus ulcers and contractures in
patients requiring prolonged immobility
d. Activity with PT/OT should be limited to prevent exposure
18. Diet
a. For patients not on the ventilator, diet as tolerated
b. For patients on the ventilator, place NG/NJ tube on admission to ICU and
initiate tube feeds within 12-24 hours
19. IV Fluids and Pressor Support
a. Follow WHO and ARDSnet recommended FACTT Algorithm
b. Pharmacy to concentrate all IV medications
c. Enteral fluids to be determined on case by case basis by intensivist
d. Note Cardene can cause pulmonary shunting and hypoxia; should be
avoided in these patients
e. If patient develops cardiogenic component, refer to Cardiogenic Shock
Protocol
20. Medication
a. COVID Medication
i. Ascorbic acid 1.5g IV q6h
ii. Thiamine 200mg IV q12h
iii. Anti-viral medication to be determined case by case per ID
iv. ACE-I and ARB do not yet have clear evidence but might be used
at discretion of ID or pulmonary
v. Avoid steroids unless needed for superimposed COPD
exacerbation – steroids have not been proven to help and can be
harmful to the immune response
b. Stop empiric antibiotics if blood and sputum cultures remain negative after
48 hours
c. Protonix 40 po qd for GI prophylaxis
d. Lovenox and SCD VTE prophylaxis per protocol
e. Electrolyte protocol if normal Cr; check with physician if Cr elevated
21. Labs
a. Nurse to review baseline labs and fill in Lab Dashboard Worksheet - ICU
i. To be placed in bedside chart and updated/reviewed by bedside
nurse.
ii. Call physician when critical values arise and note during physician
rounds

14
 iii. Go over flagged labs in handoff reports
iv. Verify lab orders have been placed and labs drawn
b. Lab schedule
i. Daily CBC with Diff
ii. Daily CMP
iii. Daily INR
iv. Daily Troponin and CK-MB
v. Check Blood and Sputum Cx at 48 hours
vi. COVID testing
1. q4 days recommended
2. Will not be cleared to stop isolation unless afebrile and free
of symptoms; consider skipping interval COVID testing
until above criteria met in order to preserve test kits
3. See De-escalation Protocol
vii. CRP q3d
viii. ABG q6h and prn including after change in vent settings
ix. Lactate q3d and prn
c. Tests
i. CXR qd and prn
ii. Limited echo for function – Sudden onset of severe heart failure
due to myocarditis has been shown to contribute to 33% of COVID
mortalities
1. Daily scheduled
2. PRN for hypotension, arrhythmias
iii. EKG prn rhythm disturbances, increase in TP, or chest pain (nurse
to perform)
iv. Benefit of surveillance CT chest has not been demonstrated
22. Respiratory management (Respiratory Management Schema)
a. Respiratory Therapy in nonintubated patients
i. Bronchodilators should be given as MDI as nebulizers increase
droplets and contamination
ii. IS and Flutter Valve
iii. Goal is to maintain O2 sat > 90%
iv. Perform awake prone ventilation tid as patient tolerates
1. Tape NC to nose
2. Allow patient to lay prone in bed as tolerated
3. Has shown clinical improvement in COVID patients
regardless of ARDS
v. See Respiratory Therapy Protocol for further detail on procedures
b. Normal interventions such as HFNC, BiPap, and aggressive diuresis have
not been shown to be helpful in COVID patients, so early intubation is
preferred.
c. See Respiratory Failure Protocol for criteria for mechanical ventilation
and details on intubation
d. Ventilator Management

15
 i. 17-29% of COVID patients develop ARDS, which is an
inflammatory rather than fluid overload process
ii. COVID patients tend to retain their lung compliance and instead
have small airway closure with atelectasis
1. Avoid disrupting the ventilator circuit as this would lead to
loss of recruited alveoli
2. Favor a high PEEP/low FiO2 strategy (see table on
ARDSnet protocol)
3. COVID patients generally do not require high driving
pressures
4. Recruitment maneuvers have not been shown effective in
this population
5. In-line endotracheal suctioning q4h and prn
6. AVRP ventilator mode is beneficial in some and can be
attempted for 12-24 hour trial to determine case by case
benefit
iii. Sedation per ICU team; employ routine sedation scales
iv. Paralysis is not recommended in COVID patients unless patients
develop dyssynchrony or refractory hypoxemia/hypercapnea that
cannot be otherwise resolved
v. COVID patients have been found to have a significant amount of
recurrent hypoxemia if weaned from the ventilator too fast; centers
dealing with COVID patients recommend a minimum of 4-7 days
of ventilation under deep sedation before trying to wean
vi. The timeline of sudden malignant cardiac arrhythmias, cardiogenic
shock, and cardiac arrest due to viral myocarditis has anecdotally
corresponded with the improvement of lung function leading to
ventilator weaning
vii. A 10-14 day ventilator course should be anticipated in COVID
patients with ARDS; the risk of exposure to staff will need to be
balanced with the benefit of tracheostomy
viii. WHO recommends following ARDSnet protocol
1. Inclusion Criteria
a. PaO2/FiO2 ≤ 300
b. Bilateral infiltrates consistent with noncardiogenic
pulmonary edema
c. No clinical evidence of left atrial HTN
2. Ventilator Set Up and Adjustment
a. Calculate Predicted Body Weight
i. Males = 50 + 2.3 [height(in) – 60]
ii. Females = 45.5 + 2.3 [height(in) – 60]
b. Select ventilator mode per ICU physician
c. Set ventilator settings to achieve initial tidal volume
8mL/kg PBW
d. Reduce tidal volume by 1mL/kg q2h until reach 4-
6mL/kg PBW

16
 e. Set initial rate to approximate baseline minute
ventilation (not to exceed 35 bpm)
f. Adjust tidal volume and RR to achieve pH and
plateau pressure goals
3. Oxygenation Goal
a. PaO2 55 -80 mmHg OR
b. SpO2 88-95%
c. Can use incremental FiO2/PEEP combinations on
ARDSnet pocket card chart
4. Plateau Pressure Goal ≤ 30 cm H2O
a. Check Pplat (0.5 second inspiratory pause) at least
q4h and after each change in PEEP or tidal volume
b. If Pplat > 30 cmH2O, decrease tidal volume by
1mL/kg steps (minimum 4mL/kg)
c. If Pplat < 25 cmH2O and tidal volume < 6mL/kg,
increase tidal volume by 1mL/kg until Pplat > 25
cmH2O or tidal volume = 6 mL/kg
d. If Pplat < 30 cmH2O and breath stacking or dys-
synchrony occurs, may increase tidal volume in
1mL/kg increments to 7 or 8 mL/kg as long as Pplat
remains ≤ to 30 cmH2O
5. pH Goal 7.30 -7.45
a. If pH 7.15 – 7.30, increase RR until pH > 7.30 or
PaCO2 < 25 (maximum set RR = 35)
b. If pH < 7.15, increase RR to 35
i. If remains < 7.15, increase tidal volume in
1mL/kg steps until pH > 7.15 (Pplat target
of 30 may be exceeded)
ii. Give Sodium Bicarb
c. Some COVID patients have tolerated respiratory
acidosis down to pH 7.15 as long as hemodynamics
are stable; decision deferred to ICU physician
6. If unable to meet goals, move to more advanced respiratory
failure options (prone ventilation and/or ECMO
assessment; see Respiratory Failure and ECMO Protocols)
ix. Ventilator Weaning
1. Conduct a Spontaneous Breathing Trial daily when:
a. FiO2 ≤ 0.40 and PEEP ≤ 8 OR FiO2 ≤ 0.50 and
PEEP ≤ 5
b. PEEP and FiO2 are less than values of the previous
day
c. Patient has acceptable spontaneous breathing efforts
(may decrease vent rate by 50% for 5 minutes to
detect effort)
d. SBP ≥ 90 mmHg without vasopressor support
e. No neuromuscular blocking agents

17
 2. Spontaneous Breathing Trial
a. Trial of up to 120 minutes of spontaneous breathing
with FiO2 ≤ 0.50 and PEEP 5
b. Place on CPAP ≤ 5 cmH2O with PS 5
c. Assess for tolerance as below
i. SpO2 ≥ 90 and/or PaO2 ≥ 60 mmHg
ii. Spontaneous tidal volume ≥ 4 mL/kg PBW
iii. RR ≤ 35bpm
iv. No respiratory distress (≥ 2 of the following)
1. HR > 120% baseline
2. Marked accessory muscle use
3. Abdominal paradox
4. Diaphoresis
5. Marked Dyspnea
d. If tolerates for at least 30 minutes, can consider
extubation
e. If does not tolerate, resume pre-weaning settings
23. See Patient Transport Protocol for any transport within hospital
23. Perform daily anxiety and depression screening for awake patients in isolation
(Daily Behavioral Health Screening Form); if behavioral health consult needed,
perform via phone or video
24. See De-escalation Protocol for details on criteria to transfer to floor

18
 Respiratory Failure Protocol
1. COVID patients tend to rapidly decompensate on days 7-10 of their illness (See
Respiratory Management Schema)
2. Patients maintaining goal oxygenation on low flow nasal cannula (1-6 L) should
remain on floor
3. Patients requiring high flow nasal cannula (6-15 L) or facemask should be under
close observation for escalation to ICU setting; may be moved to ICU in this
phase depending on capacity and risk profile
4. Decompensation should not be managed on the floor. Normal interventions such
as HFNC, BiPap, and aggressive diuresis have not been shown to be helpful in
COVID patients, so rapid assessment for ICU transfer with early intubation is
preferred. NIV risks include delayed intubation, large tidal volume administration,
injurious pulmonary pressures, and exposure to medical staff
5. If patient develops decompensation, standing order will allow for STAT ABG and
CXR
6. Patients should be carefully monitored for need to rapidly escalate care. The
patient should likely be transferred to the ICU when requiring increasing O2
requirements (addition of ≥ 3L NC to baseline requirement or > 6L NC) even if
they do not yet meet intubation criteria
7. If a patient is bridged with HFNC or BiPap, airborne precautions with N-95
masks are required; patient may be given 1 hour trial before moving to intubation
or de-escalating care
8. Intubation Protocol
a. Criteria for Intubation
i. Increased work of breathing and signs of respiratory distress
ii. RR ≥ 25 bpm
iii. O2 sat < 90% with face mask with reservoir bag flow at 10-15
L/min
iv. ABG
1. pH < 7.30
2. PaO2 < 50
3. PaCO2 > 50
4. SaO2 < 88%
b. Intubation Procedural Considerations (See COVID-19 Intubation
Checklist and APSF Card)
i. Use airborne precautions (N-95, gloves, gown, and eye protection
with optional hat/hood and shoe covers)
ii. Isolation room
iii. Minimize staff in room
iv. Most experienced staff available should perform intubation to
minimize attempts
v. Should perform with GlideScope when available to protect staff
from exposure during visualization

19
 vi. Calculate optimal ETT depth to avoid exposure risk with
auscultation and repositioning
vii. BVM should be equipped with a PEEP valve and viral filter
viii. Rapid Sequence Intubation
ix. ET tube cuff needs to be inflated prior to ventilating with bag or
ventilator
x. Check ETCO2
xi. Initial ventilator settings: Vt 8mL/kg (use predicted body weight)
with plateau pressure < 30 cm H2O, FiO2 1.0
9. Prone Ventilation
a. COVID patients with refractory hypoxemia despite mechanical ventilation
have shown improvement with prone ventilation
b. Can attempt 12-24 hour trial of AVRP mode prior to proning
c. WHO recommends patients who have severe ARDS undergo prone
ventilation 12-16 hours per day if
i. PaO2:FiO2 ratio < 150
ii. Have been on mechanical ventilation > 36 hours
iii. MAP > 65
iv. Not requiring inhaled vasodilators
d. Prone training available at
www.nejm.org/doi/full/10.1056/NEJMoa1214103
e. Pregnant patients should be placed in the left lateral recumbent position
f. Patients who are unable to prone or who are unable to reach goals through
prone ventilation should be evaluated for ECMO

20
 Respiratory Therapy Protocol
1. Respiratory Therapists are at high risk of droplet exposure since interventions
induce aerosolization of particles and coughing
2. Respiratory Therapists should wear contact and droplet PPE for interactions
involving titration of O2, ventilator changes, and ABG sampling (if nurse unable
to draw for RT via a-line) (See CDC PPE Poster)
3. Respiratory Therapists should add N-95 mask, face shield, hat/hood, and shoe
covers if performing intervention such as NT suctioning, nebulizers, EZ Pap,
bagging patient, etc.
4. Bronchodilators should be administered via MDI rather than nebulizer when
possible
5. Nebulizer
a. Only use if there is not another option for delivery
b. Only use if low risk for COVID and has a history of asthma or COPD
c. Perform in a negative pressure room
d. Use NIPPV mask, multi-adapter with 15mm ID x 22mm OD, and viral
filter
6. High Flow Nasal Cannula and BiPap should be avoided as much as possible in
COVID patients as this increases the risk of exposure through aerosolization of
particles and has not shown benefit due to rapid decompensation
7. Venturi Mask is contraindicated
8. Due to risk of rapid decompensation, notify physician if patient requiring
increased O2 requirement (See Respiratory Management Schema)
a. Increase of ≥ 3L NC or addition of mask on nonintubated patient
b. Requirement of more than 6L NC
c. Increase in ventilator settings
d. Demonstrating respiratory distress
9. COVID patients will take priority when an urgent call is made; RT expected to be
at bedside within 10 minutes of call
10. ABG machine will need to be placed on each designated COVID unit including
Main OR and CVOR/Cath Lab
11. BiPap
a. If BiPap is used, a 2-tube closed circuit needs to be used
b. 2 viral filters need to be placed
c. Can be used in a negative pressure room
12. BVM
a. Turn BVM flow up to flush rate, higher flows do not translate to the
patient end of the BVM
b. Place the viral filter between BVM stem and mask
c. Addition of NC underneath will allow CPAP with PEEP valve if needed
d. Requires 2 hand seal
13. Intubation
a. Viral filter placed at the wye of vent or stem of BVM

21
 b. EtCO2 monitor placed behind the biral filter to allow monitoring of mask
seal
c. ET tube cuff must be fully inflated and viral filter placed on ETT prior to
bagging or hooking up the vent
14. Transport
a. ETT must be clamped and gas flow turned off prior to disconnecting vent
circuit
b. Ideally, patient transported on designated transport ventilator
15. Mechanical Ventilation
a. See ARDSnet Ventilator Protocol for initial ventilator settings,
adjustments, and goals
b. ET suction should be via an in-line catheter
c. RT should coordinate with pulmonary regarding oxygenation goals and
ventilator management; it is potentially within the scope of RT to make
ventilator changes and conduct SBT according to the COVID protocol but
will need to have close communication with pulmonary given the COVID
patients’ risk of decompensation with loss of recruitment
d. Notify Attending if PEEP increased to 20 cm H2O
e. Clamp ET tube for any disconnection
16. Remember contamination can occur when taking off PPE – be especially careful
and wash hands immediately
17. See Patient Transport Protocol for any transport within hospital

22
 Patient Transport Protocol
1. Notify Command Center of transport so security can escort to clear route
including elevators
2. Nonintubated Patient
a. Patient to wear surgical mask with NC under
b. Transporting staff to wear full contact and droplet PPE
3. Intubated Patients
a. Designated transport ventilator should be used
b. COVID ARDS patients at high risk for derecruitment and decompensation
when ventilator disconnected. Patient may not tolerate transport with
BVM
c. If unable to use a transport ventilator, BVM must have PEEP valve and
viral filter
d. When switching ventilators, ET tube must be clamped and gas flow turned
off; Airborne PPE must be used when ventilator circuit disconnected
e. If patient transported with BVM, staff must use airborne precautions

23
 OR/Procedure Protocol
1. NonCOVID Patients Undergoing Surgery/Procedures
a. Consider decreasing elective surgery and procedures to preserve resources
b. Extra time should be allotted in the surgical schedule to allow for
screening and infection prevention measures
c. All patients should be screened prior to arrival and upon arrival for
symptoms using a standard questionnaire
d. Anesthesia staff should wear contact and droplet PPE for all patients (non
COVID) during intubation and extubation since COVID patients can be
contagious prior to symptoms; consider for all staff
2. COVID Patients Undergoing Emergent Surgery/Procedures
a. Emergent procedures for patients with known or suspected COVID will
undergo a risk/benefit assessment prior to proceeding with the case. The
review will be conducted with the care team, medical director (or
designee) and infection prevention team at a minimum
b. Consider appointing COVID coordinator who can oversee COVID cases
to help staff remain vigilant to new protocols and workflow as this will
present a high stress situation with unfamiliar routines
c. Consider running simulations with staff prior to COVID case
d. OR Setup (See APSF Card and Canadian OR Flowsheet)
i. One operating room should be designated for COVID patients
1. Ideally remote from other ORs
2. Airflow within the OR is crucial to minimize risk of
infection
a. Need negative pressure room
b. If not available, will need to shut down ORs with
shared HVAC and turn off positive pressure in
room to prevent contaminating hallway
3. Ideally will have ante room to allow for application of PPE
and passing of labs/supplies with runner
4. Lock all doors to OR during case except designated point
of entry
5. Place signs on doors to alert other staff of PPE precautions
and COVID case
6. Designate one area for donning and doffing of PPE; place
poster on wall to detail sequence of proper protocol
7. Cover monitors, computers, ultrasound, etc with plastic
cassette drapes that staff can work through to make
decontamination easier
ii. One anesthesia setup should be designated for all COVID patients
1. Remains in COVID OR
2. Heat and Moisture Exchanger filter on expiratory limb of
circuit

24
 3. Anesthesia medication cart and airway cart should remain
in room
4. Anesthesia staff should pull medication and equipment and
keep in tray so carts do not need to be manipulated as much
5. Use disposable equipment as much as possible (Dial-a-flow
rather than pumps, Disposable intubation equipment)
e. Patient Transport
i. COVID patients should not be brought to Preop Holding or be
taken to PACU. All recovery should occur in OR or ICU setting
ii. See Patient Transport Protocol for any transport within hospital
f. Anesthesia
i. Anesthesia staff to wear airborne precaution PPE (N-95 mask or
respirator, face shield, hat/hood, gown, gloves, and shoe covers)
during induction and during extubation
ii. If an airway case is being performed or a case where the ET tube
will be repositioned/manipulated (Double lumen tube), anesthesia
must wear full precautions for the duration of the case
iii. Any staff within 6 feet of patient must also wear full airborne PPE
iv. Regional anesthesia preferred if possible; patient to wear NC under
surgical mask if sedated
v. Avoid noninvasive ventilation, high flow nasal cannula, Venturi
masks, and LMA as all increase airborne particles
vi. Use in-line suction for ET Tube
vii. Follow Respiratory Therapy Protocol for ventilator circuit
disconnections and BVM
viii. Place surgical mask on patient after extubation
ix. Provide liberal anti-emetics to prevent retching and increased risk
of exposure
g. Intraoperative Practices
i. Keep a log of which staff are involved with each COVID case to
allow infection control tracking
ii. Runner needs to be placed outside the OR so the circulating nurse
does not have to leave the room
iii. Labs/specimens coming out of the room and equipment going into
the room should be exchanged in the ante room with runner
wearing contact and droplet PPE
iv. Staff should remain in room for entire case to minimize number of
people at risk of exposure
v. Communication from control desk and other staff should take
place over phone rather than coming in the room
vi. Only essential staff allowed in case (no students, residents,
observers,etc)
h. Conclusion of Surgery
i. Call command center to alert ICU of pending transport and bring
security escort to OR

25
 ii. All contaminated equipment should be sealed in a double
biohazard bag for contamination and labeled as a COVID case so
staff can wear appropriate PPE
iii. All unused items are considered contaminated
iv. Anesthesia vent circuits and soda lime must be discarded
v. PPE should be discarded in ante room
vi. Allow at least 1 hour before next scheduled case
vii. Decontamination of all surfaces, screens, keyboards, cables,
monitors, and anesthesia machines must occur
viii. All staff must shower and change scrubs prior to resuming duties
ix. Contaminated scrubs should be gathered and bagged
x. Hydrogen peroxide vaporizer or UV-C radiation decontamination
of OR performed as final cleaning
xi. If surgery was performed in OR that was not isolated with negative
pressure, all associated rooms will need to be decontaminated
3. Special Considerations for Interventional Areas
a. Should comply with precautions on nonCOVID patients as stated in
section 1
b. Portable procedures in COVID patient’s room preferred if possible
c. If procedure must be performed in lab
i. Physicians usually do not have access to anesthesia for these cases
1. Physician will be responsible to make sure patient
maintains face mask throughout procedure OR
2. Physician may request CRNA assistance to manage airway
depending on complexity of case and patient
3. If patient is intubated, transport protocol applies
4. Recovery must be completed in procedure room or ICU
ii. Note HVAC and airflow issues detailed previously may cause
contamination to other areas that will also need to be shut down
and decontaminated
iii. Should be in a dedicated area (dedicated CT or cath lab) after other
cases for the day have been completed and patients have left
PACU
iv. Remove unnecessary equipment from room
v. Cover remaining equipment with plastic cassette drapes
4. Special Considerations for cardiothoracic surgery and OB
a. Consider moving CPB machine and TEE to designated COVID OR if
planning on performing emergent cases outside of CVOR
b. COVID C-sections should be performed in dedicated COVID OR to
decrease risk of exposing pregnant patients and neonates
c. Consider using Hybrid OR on 4th floor as the COVID OR as it has CPB
capability and is in close proximity to L&D

26
Viral Myocarditis/Cardiogenic Shock
Protocol
1. Viral myocarditis is responsible for 7% of COVID deaths and contributes to death
in 33% of mortalities
a. Sudden decrease in single or biventricular function to 10% EF resulting in
acute cardiogenic shock
b. Acute onset of malignant arrhythmias (V-Tach, V-fib)
c. Pericardial effusion with tamponade
2. Patients may also have underlying coronary disease and increased myocardial
demand can induce an acute MI
3. Decompensation has been reported after pulmonary status appears to have
improved
4. Patients can develop an elevated troponin from the virus without having coronary
disease or fulminant myocarditis; elevated TP are a poor prognostic sign
5. Surveillance
a. Due to the high mortality rate and risk of sudden circulatory collapse,
proactive testing will be performed
b. All patients will undergo baseline EKG, Echo, Troponin and BNP
c. Patients admitted to the floor will have continuous telemetry monitoring,
daily TP, BNP q3d, and limited echo q3d for function and effusion
d. Patients admitted to the ICU with have continuous EKG monitoring, daily
TP, BNP q3d, and a daily limited echo for function and effusion
e. If any patient develops frequent PVCs, arrhythmia, hypotension, or signs
of circulatory collapse, STAT Echo will be performed
6. Cardiac Decompensation
a. Urgent
i. Patient develops a-fib, a-flutter, has frequent PVCs, develops EF <
50% or decreases more than 10% from baseline if baseline was
abnormal
ii. STAT EKG
iii. Urgent cardiology consultation
1. Will determine which heart failure medications and anti-
arrhythmic medications should be administered
2. Will determine if patient needs to be transferred to ICU or
dedicated cardiac unit
b. Emergent
i. Patient develops nonsustained VT, VT, bradycardia, or heart block,
severely decreased function from baseline on echo or any EF ≤
25%, chest pain, severe orthopnea, hypotension, or signs of poor
perfusion, end organ damage, or circulatory collapse
ii. Immediately notify physician and charge nurse
iii. STAT Echo and EKG

27
 iv. STAT cardiology consult
v. Charge nurse to notify house supervisior and command center for
STAT CVICU transfer if on floor
vi. Bring crash cart to patient’s room
vii. Follow ACLS Protocol and see Medical Emergency Protocol
c. ICU Management
i. Follow COVID ICU Admission order set with admission to
CVICU
ii. Patient will likely require intubation to decrease myocardial
demand and improve oxygen delivery
iii. Place central line and arterial line at minimum; Swan placement
with continuous SvO2 monitoring would be beneficial
iv. Labs and tests
1. STAT ABG with electrolytes
2. STAT Echo (if not completed on floor)
3. STAT EKG (if not completed on floor)
4. STAT CXR
5. STAT CBC, CMP, PT/INR, Type and Cross
v. Arrhythmia Management
1. Correct electrolytes
2. Start amiodarone bolus and drip per protocol. If patient
hypotensive with SBP < 90, forego bolus and just use the
drip
vi. Hemodynamic Management (See Cardiac Hemodynamic
Flowsheet)
1. Goal Cardiac Index > 2.2; SBP > 100, MAP > 60, SvO2 >
60
2. Inotropic Support
a. Dobutamine
i. Allows for positive inotropic effect with
peripheral vasodilation to counteract
“clamping down”
ii. Start infusion at 5mcg/kg/min and titrate
according to protocol
iii. Can induce tachycardia and arrhythmias
b. Milrinone
i. Provides positive inotropic effect with
pulmonary and peripheral vasodilation
ii. Beneficial with right heart failure,
pulmonary arterial hypertension, and if
patient does not tolerate other inotropes due
to arrhythmia
iii. Start at 0.375mcg/kg/min and titrate per
protocol
c. Epinephrine

28
 i. Provides strong inotropic and
vasoconstriction effects
ii. May induce tachycardia
iii. Start at 4mcg/min or 0.04mcg/kg/min and
titrate per protocol
3. Vasopressor Support
a. Aim for SVR < 1000
b. Levophed
i. Strong vasoconstrictor with some inotropic
action
ii. Cardiogenic shock patients are usually
clamped down with a high SVR state;
further increase in SVR with pressors can
accelerate heart failure
iii. Should not focus only on blood pressure for
this reason
c. Vasopressin
i. Strong vasoconstrictor
ii. Unlikely to benefit and may cause harm if
patient is in acute cardiogenic shock
d. Phenylephrine
i. Vasoconstrictor
ii. Unlikely to benefit and may cause harm if
patient is clamped down in acute
cardiogenic shock
e. Dopamine
i. Not optimal in cardiac patients as it induces
tachycardia, increases myocardial ischemia
and has variable effects on SVR
ii. Can be used as an emergent bridge given
ability to infuse via peripheral IV
f. May need to introduce vasodilator such as Cardene
or Nipride if patient clamped down; can cause
pulmonary shunting in some cases
4. Correct Metabolic Derangements
a. Replace Bicarb with bolus if < 20
b. Replace calcium IV if ionized calcium on ABG <
1.20
5. Mechanical Support
a. Impella placement indicated if patient is requiring
escalation of 2 drips to meet goals
b. If Impella fails or if has biventricular failure,
consider moving to ECMO protocol

29
 ECMO Protocol
1. Transport ECMO support currently provided by Baylor University Medical
Center in Dallas under Dr. Dan Meyer
2. Consult Dr. Cooley to assist with transfer process and cannulation
3. ECMO Inclusion Criteria
a. Age 18-75 years
b. Bridge to durable LVAD, heart, or lung transplant if doesn’t recover
c. Witnessed cardiac/respiratory arrest with adequate CPR in progress < 30
minutes
d. Cardiogenic shock with patient on 2 or more vasoactive drips, urine output
< 30mL/h, SvO2 < 60%, lactate ≥ 2mmol/L
e. Respiratory failure with RR ≥ 30, inspiratory pressure ≥ 30, FiO2 ≥ 0.8,
PEEP ≥ 10 mmHg
4. ECMO Exclusion Criteria
a. DNR or cancer with predicted survival < 1 year
b. Age ≥ 75 years
c. Evidence of severe neurological injury
d. Unwitnessed cardiac arrest or CPR for > 60 minutes
e. Latate > 16 mmol/L
f. AST or ALT > 2000
g. INR > 4.5
h. Advanced microcirculatory failure with severe mottling or established
purpura
5. ECMO Transfer process
a. Notify Command Center of potential transfer
b. Notify case management to assist with transfer
i. Print patient facesheet to fax to transfer center
ii. Obtain hard copy of chart including stat discharge note and copies
of imaging on CD for transport
c. Physician to fill out ECMO clinical checklist from Baylor
d. Designate intensivist, cardiologist, or cardiac surgeon to perform doc to
doc for acceptance
e. Call ECMO referral center at 214-820-6444
i. Emphasize on each interaction with transfer center that flight team
will need to land at UTH helipad, NOT Tyler Pounds Airport
ii. Advise ECMO team of COVID status
iii. If Dr Cooley available to cannulate, notify transfer center surgeon
is not needed
f. After transfer accepted
i. Stat Lactate, ALT, AST, and INR
ii. Stat Type and Cross with 2 units of PRBC for transport
iii. Assemble items on ECMO Readiness Checklist and organize at
bedside
iv. Place right femoral arterial and venous lines

30
g. ECMO Cannulation
i. Only essential staff in room
ii. All staff will need airborne isolation PPE with N-95 masks, face
shields, hat, gown, gloves
iii. Obtain ABG as ECMO team landing
iv. Defer to ECMO team for cannulation instruction
h. Transport
i. Call Command Center to notify patient is ready for transfer
ii. Security to escort patient and ECMO team to Helipad to clear route
iii. ECMO team to maintain PPE throughout transport process
iv. Staff to maintain PPE while cleaning room
v. Double bag all contaminated equipment being sent for processing
and label with COVID status
vi. All staff to change scrubs and gather soiled scrubs in bag labeled
COVID

31
Code 44/Medical Emergency Protocol
1. In critically ill COVID patients (especially elderly with comorbidities), there is a
low chance of survival if require CPR
2. The risk of extensive exposure to medical team performing code is very high
3. Other centers have policies on place that allow the medical staff to inform
families CPR would not be appropriate in a given situation even if the family
would like to push forward. Examples of compassionate phrasing are “it does
appear your family member is dying and due to the COVID infection, this is not a
situation where we do CPR.” This decision is deferred to the care team.
4. Ideally, these discussions would take place prior to the code and may require the
assistance of palliative care
5. If a patient is made comfort measures, palliative care will need to coordinate with
infection control to determine a visitation policy
6. If patient expires, charge nurse should notify the control center to coordinate with
the medical examiner, health department, CDC, and infection control prior to
releasing the body. When the patient is moved to the morgue, staff needs to wear
contact and droplet PPE and have security escort to clear the route
7. Conduct of Code
a. If patient does not have adequate IV access, place IO
b. Only essential staff should be allowed in room
c. Recorder should log all personnel in room and role and verify PPE
d. Strict adherence to PPE including N-95 masks is of utmost importance
even if this delays code
e. Runner should be assigned to stand in hall to obtain items needed by staff
in room
f. Designated staff or security should stand outside door to send people not
involved in code away
g. Students and other support staff should not be involved with code
h. Airway management should adhere to Respiratory Therapy Protocol

32
 Isolation Protocol
1. Admit to negative pressure room if available; if not enough negative pressure
rooms available for all admitted COVID patients, preference given to non-
intubated patients since their respiration is in an open system and they may
require intubation
2. Patient requires surgical mask when out of room for tests/procedures
3. Patient must weak surgical mask when guests or staff in room
4. Staff require strict contact and droplet precautions
a. Place sign on door
b. Place isolation cart outside room
c. Post CDC PPE Poster above cart in hall
d. Place biohazard disposal within room
e. Post CDC PPE Poster above disposal in room
5. Patient must remain in room with door closed
6. Post visitor policy on door
7. Provide visitors with PPE and educate on procedures
8. Use clear cassette drape/probe covers for portable imaging and equipment (mobile
work stations) to minimize equipment contamination
9. Nurses to perform lab draws when possible to minimize contact among staff. If
unable to do so, create lab draw kits for scheduled labs so phlebotomy does not
have to bring all equipment into room
10. Minimize number of staff interacting with patients; bedside nurse and physicians
should perform the bulk of the duties rather than CNAs, food service team, etc
11. Consider hourly bedside rounding via phone or video rather than in person to
control exposure and preserve PPE
12. Bundle patient care duties to minimize number of interactions with patient by
nurse (medications, vitals, I/Os, lab draws, meal service, etc)
13. Any procedure that involves airway manipulation (nebulizers, BVM, temporary
high flow nasal cannula, temporary BiPap, intubation, bronchoscopy, invasive
procedures, etc) requires airborne precautions with N-95 mask, hat/hood, face
shield +/- goggles, gown, gloves, and shoe covers
14. After contact with the patient, scrubs should be changed before leaving the
hospital. If a procedure was performed requiring airborne isolation, scrubs should
be changed immediately with shower recommended.
15. All patient transport should follow Transport Protocol

33
Transfer from Satellite Facility Criteria
1. Transfer from satellite facilities should be vetted through control center and
appointed medical director
2. Patients who are COVID negative should only be transferred if primary facility is
unable to provide adequate care and the patient has an urgent condition (high
level ICU care, urgent/emergent procedures or surgery)
3. COVID patients will only be accepted under the following conditions
a. Patient in critical condition with ARDS (requiring > 6L NC to maintain
O2 sat ≥ 90%), cardiogenic shock, septic shock, or multisystem organ
failure and require ICU AND
b. Care cannot be provided at outlying facility AND
c. Patient not highly likely to die of disease soon AND
d. Patient willing to accept intubation with prolonged mechanical ventilation
4. When COVID patient arrives, command center to be notified by EMS or house
supervisor
5. Patient Transport Protocol will apply. Patient and transfer team should be met at
door by hospital staff to ensure proper protocol
6. Accepting physician must see patient at bedside within 30 minutes

34
 De-escalation Protocol
1. Criteria to remove precautions
a. Free of fever and not taking antipyretics
b. Signs and symptoms resolved for 72 hours
c. Negative COVID swab x 2 > 24h apart
d. If patient meets criteria, notify command center and they will notify all
pertinent parties
e. Infection control and ID must be informed as they are the only ones
authorized to remove precautions
2. Timing of Testing
a. CDC and WHO recommend COVID testing q 2-4 days
b. Given need to ration test kits, other centers are developing different
protocols based on clinical picture
c. Nonintubated patients
i. Testing is performed on hospital day 7 or after patient free of
symptoms for 72 hours (whichever is longer)
ii. If both tests negative, patient can come off isolation
iii. If one test is positive, process restarted in another 72 hours
d. Intubated patients
i. Testing performed on hospital day 10
ii. If both tests are negative, patient can come off isolation
iii. If one test is positive, process restarted in another 72 hours

35
 Discharge Protocol
1. Per CDC recommendations, patients may be discharged when they are clinically
stable
2. Patients are not required to have negative COVID tests for discharge as they can
continue with home isolation
3. Patients will receive a COVID discharge packet upon discharge
a. Must be reviewed with nurse or nurse navigator
b. Patient must sign form stating they were educated on the packet and all
questions were answered
c. Contents
i. CDC Home Care Guide (https://www.cdc.gov/coronavirus/2019-
ncov/hcp/guidance-prevent-spread.html)
ii. Home Care Guide from WHO (www.who.int/publications-
detail/home-care-for-patients-with-suspected-novel-coronavirus-
(ncov)-infection-presenting-with-mild-symptoms-and-
management-of-contacts)
iii. Daily Log (Include temperature, RR, HR, O2 Sat if available,
Symptoms; list normal parameters and when to call physician or
nurse navigator)
iv. Follow up appointment and testing schedule
v. Appointment dates, times, and contact information
vi. Nurse navigator contact information
4. Case management should be involved upon admission to assist with discharge
planning given the extension coordination that will be required
a. Many systems are having difficulty with the discharge process as SNFs
and HHC are not accepting COVID patients
b. Case management will have list of facilities accepting COVID patients
c. Home Health Care
i. Home Health Care should be reserved for patients with underlying
comorbidities and residual issues from hospitalization that require
skilled assistance. Due to the risk of exposure, home health care
visits for education or “check ins” are not appropriate. These issues
can be managed over the phone by HHC or by the nurse navigator.
ii. Currently UT Home Health does not have PPE to support
accepting COVID patients. Once the supply line is restored, the
will accept
iii. Encompass Home Health does have PPE available and is ready to
accept COVID patients. They have protocols in place
5. When patient ready for discharge, charge nurse to call command center to
coordinate transport to vehicle per transport protocol. Command center also
responsible for notifying the nurse navigator, health department, and CDC.

36
 Clinical Pearls Unique to COVID
1. Statistics
a. 20-30% of hospitalized patients require ICU management
b. 17-29% of hospitalized patients develop ARDS
c. 3-12% of ICU patients need ECMO
d. Viral myocarditis is responsible for 7% of COVID mortalities and
contributes to 33% of COVID mortalities
e. Only 5% of COVID patients develop sepsis
i. DO NOT place immediately in sepsis protocol as fluid
resuscitation will be detrimental to survival through exacerbation
of respiratory failure.
ii. Consider metabolic and cardiogenic sources if patient in shock
iii. Start pressors early rather than fluid in sepsis bundle
2. Safety
a. Review the proper procedure for PPE (See CDC PPE Poster)
b. Mind the Gap – areas with gaps in coverage often cause contamination
i. Between gloves and cuff of gown
ii. Between mask and collar of gown
c. Contamination often occurs when removing PPE
i. Keep exposed PPE in patient’s room
ii. Wash hands immediately after removal
iii. If performing a procedure or have gross contamination, shower and
change scrubs
d. PPE recommendations
i. When in routine contact with COVID patient, staff should wear
isolation gown, gloves, and surgical mask for droplet and contact
precaution
ii. If performing a procedure or you anticipate aerosolization of
particles (respiratory therapy, intubation, lines, etc), switch to
airborne precautions – addition of N-95 mask, face shield,
hat/hood, shoe covers
iii. Patient should put surgical mask on any time they will be around
other people, including in their room. If they are alone in the room,
they can remove their mask
iv. Patient’s door must remain closed
v. Do not bring extra staff into the room (students, outpatient nurses,
CNAs, etc)
vi. Mobile computers, blood pressure monitors, phlebotomy
equipment, etc should not be moved from room to room.
e. Use of stethoscopes is considered a high risk of contamination. Avoid if
possible.
3. Clinical Course (See Global Picture of Severe Cases Chart)
a. Patients tend to remain relatively stable early in the course of the disease
but can rapidly decompensate around 7-10 days

37
b. Screen non COVID inpatients for symptoms daily
i. Any unexplained fever with cough or SOB and bilateral diffuse
infiltrates on CXR should be placed in isolation and formal
COVID screening
ii. Elderly patients have been reported to develop asymptomatic
hypoxia prior to developing symptoms
c. ARDS results from inflammatory changes to the lung through a cytokine
storm
i. As opposed to non COVID forms of ARDS, lung typically retain
their compliance; small airway collapse and atelectasis of adjacent
lung result in respiratory failure
ii. Fluid overload can be deadly in ARDS so patients are run dry
iii. Inflammatory changes cannot be diuresed so Lasix can also be
detrimental if used in euvolemic or hypovolemic patients
iv. Chest CT
1. Bilateral ground glass opacities focused on periphery
2. Should not demonstrate pleural effusions, nodules, cavitary
lesions, or severe lymphadenopathy
3. Can demonstrate typical COVID pattern before patients
become symptomatic
d. Viral myocarditis and circulatory collapse can occur rapidly
i. Presents with arrhythmias, hypotension, cardiogenic shock with
end organ damage, or cardiac arrest
ii. Myocarditis can also cause pericardial effusion with tamponade
iii. Myocarditis may present as pulmonary symptoms are improving
iv. If pleural effusions identified, consider cardiac etiology
e. Patients also at particular risk for hepatic failure, renal failure, and DIC
f. Risk of co-infection with RSV or Influenza < 2%; can develop
superimposed bacterial pneumonia
g. Factors associated with poor prognosis
i. Comorbidities
1. Age
2. HTN
3. CAD
4. DM
5. Cerebrovascular disease
6. Underlying lung disease
7. Cancer/Immunosuppression
ii. Labs
1. Lymphopenia
2. Neutrophil : Lymphocyte ratio > 3
3. Platelets < 100K
4. D-Dimer > 1 mg/L
5. CRP > 60 (tracks with disease and correlates with severity
6. Elevated TP
7. Elevated BNP

38
 iii. Benefit of surveillance CT chest has not been demonstrated
4. Management
a. Nebulizers should be avoided due to high contamination risk with
aerosolization – switch bronchodilators to MDI if possible
b. High flow nasal cannula and BiPap increase exposure risk and have not
been shown to be beneficial in decompensating COVID patients – move to
early intubation
c. Steroids should be avoided outside of pre-existing COPD or asthma with
obvious superimposed exacerbation

39
 Order Sets
COVID INTAKE ORDER SET

 Isolation Precautions
o Follow COVID isolation protocol
o Admit to negative pressure room if available
o Patient requires surgical mask when interacting with other people (out
of room for tests and procedures and in room with visitors or staff)
o Strict contact and droplet precautions
 Place sign on door
 Place isolation cart outside room
 Post CDC PPE Poster above cart in hall
 Place biohazard disposal within room
 Post CDC PPE Poster above disposal in room
o Patient must remain in room with door closed
o Post visitor policy on door
o Provide visitors with PPE and educate on procedures
 Notify COVID Command Center of Person Under Investigation
 COVID Command Center to notify nurse navigator, health department, and
CDC per protocol

INITIAL LABS
 COVID testing per protocol
 CBC with manual differential
 CMP
 XR Chest Re: SOB

INITIAL DISPOSITION
 Home Isolation
o Provide COVID education packet including CDC and WHO Home
Guides, Symptom Log, Discharge instructions including follow up
plan, and nurse navigator contact information
 Hospital Treatment
o Continue Below

VITAL SIGNS
 Vital signs q 15 min
 Notify physician if HR > 100
 Notify physician if RR > 24
 Notify physician if O2 Sat < 90% or unable to maintain on ≤ 6L NC
 Notify physician if SBP < 100
 Notify physician if Temp > 100.4

40
 Continuous EKG monitoring
LABS
 CBC with manual differential if not already performed
 CMP if not already performed
 PT/INR
 Troponin
 CK-MB
 BNP
 Procalcitonin
 CRP
 ESR
 ABG with co-oximetry
 Lactate
 Influenza A and B
 RSV
 Blood Cultures x 2
 Sputum Culture

DIAGNOSTICS
 CT Chest w/o contrast RE: SOB, COVID
 Echocardiogram Re: COVID, myocarditis
 EKG Re: COVID, myocarditis

RESPIRATORY
 Oxygen
o Initiate O2 5L via Nasal Cannula for goal O2 sat during resuscitation
of 94%
o Titrate O2 via Nasal Cannula for O2 sat ≥ 90% once stable
o If unable to maintain O2 sat ≥ 90% on 6L NC
 Inform physician
 Notify command center to prepare ICU admission
 Provide O2 Therapy via Simple Mask or Non Rebreather
 Place COVID Intubation Kit outside patient’s room
 Place Airborne Isolation Cart outside patient’s room
o DO NOT USE HIGH FLOW NASAL CANNULA
o DO NOT USE BIPAP
o DO NOT USE VENTURI MASK
 Bronchodilator Protocol
o Bronchodilator MDI protocol only
o Do not administer bronchodilators via nebulizer
o Albuterol
o Atrovent
o Xopenex
 Follow COVID Respiratory Failure Protocol

41
IV ACCESS
 Place 18g peripheral IV x 2
 Saline Lock IV

IV Fluids
 Normal Saline 250mL bolus

ANTIBIOTICS
 Vancomycin IV pharmacy to dose
 Zosyn IV pharmacy to dose

DISPOSITION
 Notify command center to coordinate hospital admission and consults
 Admit to observation if patient has uncomplicated or mild disease but has
significant comorbidities including age
 Admit to hospitalist for floor admission if patient is stable on nasal cannula
without respiratory distress
 Admit to intensivist for ICU admission if requiring respiratory support more
than nasal cannula, has hemodynamic instability, is in respiratory distress, has
major comorbidities, or shows signs of cardiac involvement
 Institute Patient Transport Protocol

42
COVID FLOOR ADMISSION ORDER SET

CPOE COVID HOSPITALIST ADMISSION

ADMIT
 Patient Status: Admit to COVID Med/Surg Unit with Continuous Telemetery
Monitoring (location per COVID Command Center and Bed Board)
 Admitting and Attending Physician: Hospitalist
 Anticipate Discharge to
o Home COVID Isolation with HHC
o SNF with COVID Isolation
 Isolation Precautions
o Follow COVID isolation protocol
o Admit to negative pressure room if available
o Patient requires surgical mask when interacting with other people (out
of room for tests and procedures and in room with visitors or staff)
o Strict contact and droplet precautions
 Place sign on door
 Place isolation cart outside room
 Post CDC PPE Poster above cart in hall
 Place biohazard disposal within room
 Post CDC PPE Poster above disposal in room
o Patient must remain in room with door closed
o Post visitor policy on door
o Provide visitors with PPE and educate on procedures

CONDITION
 Patient Condition Stable
 Patient Condition Fair
 Patient Condition Serious
 Patient Condition Critical
 Patient Condition Poor

CODE STATUS
 Code Status: Full Code
 Code Status: Do Not Resuscitate
 Obtain Advanced Directives and place on chart
 Identify and document durable power of attorney or next of kin

VITAL SIGNS
 Vital signs q 4 hours and prn clinical change
 Continuous telemetry monitoring
 Calculate NEWS Score q12h

DVT PROPHYLAXIS (Required)

43
 Apply Sequential Compression Device
 DVT Prophylaxis Medications
o Enoxaparin (LOVENOX) 40mg SUBQ Q 24h
o Enoxaparin (LOVENOX) 30mg SUBQ Q 24h (est CrCl < 30mL/min)
o Heparin 5000 units/mL SUBQ Q 8h
o Heparin 5000 units/mL SUBQ Q 12h
o Fondaparinux (ARIXTRA) 2.5 mg SUBQ Q 24h (only if CrCl >
30mL/min)

NURSING INTERVENTIONS
 Communication
o Charge nurse to notify COVID command center of patient’s arrival to
unit
o Command center to verify COVID team consulted (ID, pulmonary,
infection control, COVID nurse navigator, and case management)
o Command Center to notify hospitalist of patient’s arrival to unit
o Bedside nurse to document symptom review q4h and prn using
COVID Symptom Review Checklist
o Bedside nurse to utilize Lab Dashboard Worksheet
 Record baseline labs if not already completed
 Review baseline labs; call physician to notify of flagged values
verbally and on rounds
 Review labs during shift report and note flags
 Verify new labs have been ordered and draw according to set
schedule
 Record new labs daily according to schedule; call physician to
notify of flagged values and note on rounds
o If not ordered by admitting physician, review home medications to
restart and notify physician for clarification/orders
o Perform daily Behavioral Health Screening per phq9 form

 Protocols
o COVID Transport Protocol
o COVID Respiratory Failure Protocol
o COVID Medical Emergency Protocol
o Hypoglycemia Protocol
o Adult Subcutaneous Insulin Protocol
o Non-ICU Electrolyte Protocol Nursing Communication
o Oral Care Protocol
 Provide oral care supplies
 Instruct patient to perform
 Nursing not to perform oral care unless under airborne
precautions

 Precautions

44
 o Precautions: Aspiration
o Precautions: Seizure
o Precautions: Fall

 Oxygen Orders
o Titrate O2 via Nasal Cannula for O2 sat ≥ 90%
o O2 Therapy – Simple Mask
o O2 Therapy – Non Rebreather
o DO NOT USE HIGH FLOW NASAL CANNULA
o DO NOT USE BIPAP
o DO NOT USE VENTURI MASK
o
 Pulse Oximetry
o Pulse oximetry continuous – record q1h

Intake/Output
 Assess patient weight daily
 Strict Intake and Output q4h

Tubes and Drains

 Urinary Catheter
o Apply External Catheter
o Insert Indwelling Urinary Catheter
o Care/Reason: Urinary Catheter Site Twice a Day
o Urinary catheter removal protocol
 IVs
o Patient to maintain PIV
o Dress and change PIV per line protocol
o Consult IV team for Midline
o Consult IV team for PICC

NOTIFY Physician, Charge nurse and rapid response team IF

 Increasing respiratory rate > 24bpm while at rest
 Need to increase NC by more than 2L from baseline
 Need > 6L NC or need to add additional support such as facemask to maintain
O2 sat ≥ 90%
 New onset arrhythmia (frequent PVCs, a-fib, a-flutter, nonsustained VT, VT,
bradycardia, heart block)
 HR > 100 bpm or < 60 bpm
 SBP < 100 mmHg
 Increased work of breathing, feelings of dyspnea, or other signs of respiratory
distress

45
RESPIRATORY FAILURE PROTOCOL ORDERS
 STAT ABG with Co-oximetry and Electrolytes
 STAT portable CXR Re: SOB
 STAT EKG with CVC to read
 Charge nurse to notify COVID command center of status change
 Command center to notify house supervisor and pulmonary physician or
CRNA of possible ICU transfer with intubation to allow time to prepare
transfer
 Place COVID Intubation Kit outside patient’s room
 Place airborne precaution cart outside patient’s room

RESPIRATORY THERAPY
 COVID Respiratory Therapy Protocol
 Bronchodilator MDI protocol
 Do not administer bronchodilators via nebulizer
 RT to educate Incentive Spirometery
 Patient to perform IS q2h and prn
 Do not use EZ Pap
 Goal O2 sat > 90%
 Perform awake prone ventilation tid as patient tolerates
o Tape NC to nose
o Allow patient to lay prone in bed as tolerated

MEDICATIONS
 Ascorbic Acid 1.5g IV q6h
 Thiamine 200mg IV q 12h
 Acetaminophen (TYLENOL) 650mg oral q4h prn Temp > 101.0
 Protonix 40mg oral daily
 Ondansetron (Zofran) 4mg IV q4h prn nausea/vomiting
 Benzonatate (TESSALON PERLES) 100mg mg oral q6h prn

LABS
 CBC with manual differential daily routine am x 7 days
 CMP daily routine am x 7 days
 PT/INR daily routine am x 7 days
 Troponin daily routine am x 7 days
 CK-MB daily routine am x 7 days
 CRP q3 days routine am x 5 times
 ABG with co-oximetry q3 days routine am x 5 times
 Lactate q3 days routine am x 5 times

DIET
 Oral Diets

46
 NPO
 Fluid Restriction
o Fluid Restriction every 24 hours of (specify amount)
o Fluid Restriction of 1000mL every 24 hours
o Fluid Restriction of 1500mL every 24 hours
o Fluid Restriction of 2000mL every 24 hours

ACTIVITY
 Up as Tolerated
 Bedrest Bathroom Privileges
 Bedrest Bedside Commode
 Bedrest Strict
 Bath: May shower
 Bath: May shower with assistance
 Out of Bed: Assistance
 Stand at Bedside with Assistance
 Up to chair tid with meals
 Do not ambulate in halls

IV FLUIDS
 Saline lock IV

DIAGNOSTICS
 XR Chest 1 view daily AM routine Re: COVID, SOB
 Echo, Limited q3d Re: COVID, Function and effusion check
 EKG prn rhythm change, elevated troponin, or chest pain

47
COVID ICU ADMISSION ORDER SET

CPOE COVID ICU ADMISSION

ADMIT
 Patient Status: Admit to COVID ICU (location per COVID Command Center
and Bed Board)
 Admitting and Attending Physician: Intensivist
 Anticipate Discharge to
o Home COVID Isolation with HHC
o SNF with COVID Isolation
 Isolation Precautions
o Follow COVID isolation protocol
o Admit to negative pressure room if available
o Patient requires surgical mask when interacting with other people (out
of room for tests and procedures and in room with visitors or staff)
o Strict contact and droplet precautions
 Place sign on door
 Place isolation cart outside room
 Post CDC PPE Poster above cart in hall
 Place biohazard disposal within room
 Post CDC PPE Poster above disposal in room
o Patient must remain in room with door closed
o Post visitor policy on door
o Provide visitors with PPE and educate on procedures

CONDITION
 Patient Condition Serious
 Patient Condition Critical
 Patient Condition Poor

CODE STATUS
 Code Status: Full Code
 Code Status: Do Not Resuscitate
 Obtain Advanced Directives and place on chart
 Identify and document durable power of attorney or next of kin

VITAL SIGNS
 Vital signs q15min until stable and then q1h and prn clinical change
 Continuous monitoring of EKG, SaO2, CVP and arterial tracings
 Continuous FloTrac monitoring

DVT PROPHYLAXIS (Required)

 Apply Sequential Compression Device
 DVT Prophylaxis Medications

48
 o Enoxaparin (LOVENOX) 40mg SUBQ Q 24h
o Enoxaparin (LOVENOX) 30mg SUBQ Q 24h (est CrCl < 30mL/min)
o Heparin 5000 units/mL SUBQ Q 8h
o Heparin 5000 units/mL SUBQ Q 12h
o Fondaparinux (ARIXTRA) 2.5 mg SUBQ Q 24h (only if CrCl >
30mL/min)

NURSING INTERVENTIONS
 Communication
o Charge nurse to notify COVID command center of patient’s arrival to
unit
o Command center to verify COVID team consulted (ID, infection
control, COVID nurse navigator, and case management)
o Command Center to notify intensivist of patient’s arrival to unit
o Bedside nurse to utilize Lab Dashboard Worksheet
 Record baseline labs if not already completed
 Review baseline labs; call physician to notify of flagged values
verbally and on rounds
 Review labs during shift report and note flags
 Verify new labs have been ordered and draw according to set
schedule
 Record new labs daily according to schedule; call physician to
notify of flagged values and note on rounds
o If not ordered by admitting physician, review home medications to
restart and notify physician for clarification/orders
o Perform daily Behavioral Health Screening per phq9 form in
nonintubated patients
 Protocols
o COVID Transport Protocol
o COVID Respiratory Failure Protocol
o COVID Medical Emergency Protocol
o Hypoglycemia Protocol
o Adult Subcutaneous Insulin Protocol
o ICU Electrolyte Protocol Nursing Communication
o Oral Care Protocol
 Provide oral care supplies
 Instruct patient to perform
 Nursing not to perform oral care unless under airborne
precautions
 Precautions
o Precautions: Aspiration
o Precautions: Seizure
o Precautions: Fall

 Oxygen Orders

49
 o Titrate oxygen for O2 sat ≥ 90%
o O2 Therapy – Nasal Cannula
o O2 Therapy – Simple Mask
o O2 Therapy – Non Rebreather
o DO NOT USE HIGH FLOW NASAL CANNULA unless ordered by
physician
o DO NOT USE BIPAP unless ordered by physician
o DO NOT USE VENTURI MASK

Intake/Output
 Assess patient weight daily
 Strict Intake and Output q1h

Tubes and Drains

 Urinary Catheter
o Apply External Catheter
o Insert Indwelling Urinary Catheter
o Care/Reason: Urinary Catheter Site Twice a Day
o Urinary catheter removal protocol
 IVs
o Obtain consent for central line and arterial line placement
o Obtain consent for intraosseous catheter placement
o Place COVID central line kit at bedside
o Place COVID arterial line kit at bedside
o Place SonoSite outside room
o Place packaged clear cassette drape with SonoSite for draping
o Patient to maintain PIV
o Dress and change PIV per line protocol
o Consult IV team for Midline
o Consult IV team for PICC
o CLABSI Protocol
 Place NG Tube
 Place NJ Tube

NOTIFY Physician if
 Increasing respiratory rate > 24bpm in nonintubated patient
 Need to increase NC by more than 2L from baseline
 Unable to maintain O2 sat > 90% on 7-15L NC, simple face mask, or
nonrebreather
 Patient has signs of worsening respiratory distress despite 7-15L NC, simple
face mask, or nonrebreather
 New onset arrhythmia (frequent PVCs, a-fib, a-flutter, nonsustained VT, VT,
bradycardia, heart block)
 HR > 100 bpm or < 60 bpm

50
 SBP < 100 mmHg
 Temperature > 101 degress F
 UOP < 0.5mL/kg/hr x 2 hours
 O2 sat < 90% on ventilator

RESPIRATORY FAILURE PROTOCOL ORDERS

 STAT ABG with Co-oximetry and Electrolytes
 STAT portable CXR Re: SOB
 STAT EKG with CVC to read
 Charge nurse to notify COVID command center of status change
 Command center to notify house supervisor and pulmonary physician or
CRNA of possible ICU transfer with intubation to allow time to prepare
transfer
 Place COVID Intubation Kit outside patient’s room
 Place airborne precaution cart outside patient’s room

RESPIRATORY THERAPY
 COVID Respiratory Therapy Protocol
 Bronchodilator MDI protocol
o Albuterol
o Atrovent
o Xopenex
 Do not administer bronchodilators via nebulizer
 RT to educate Incentive Spirometery
 Nonintubated patient to perform IS q2h and prn
 Do not use EZ Pap
 In nonintubated patients, perform awake prone ventilation tid as patient
tolerates
o Tape NC to nose
o Allow patient to lay prone in bed as tolerated

MECHANICAL VENTILATION
 Ventilator settings to follow COVID ARDSnet Protocol
 ABG with co-oximetry q6h
 ABG with co-oximetery prn respiratory decompensation
 ABG with co-oximetery prn 30 minutes after ventilator setting change
 In-line endotracheal suctioning q4h and prn secretions
 Prone ventilation 12h qd

MEDICATIONS
 Ascorbic Acid 1.5g IV q6h
 Thiamine 200mg IV q 12h
 Nozin nasal antiseptic (NOZIN) 1 apply NASL BID while in ICU

51
 Protonix 40mg oral daily

PRN MEDICATIONS
 Acetaminophen (TYLENOL) 1000mg oral q6h prn Temp > 101.0
 Acetaminophen (TYLENOL) 1000mg rectal q6h prn Temp > 101.0
 Acetaminophen liquid UD (TYLENOL) 1000mg PT q6h prn Temp > 101.0
 Non-Narcotic Analgesic
o Tramadol (ULTRAM) 50mg oral q6h prn moderate pain
 Narcotic Analgesic
o Hydrocodone 5-325mg (NORCO) 1 Tab po q6h prn pain
o Hydrocodone 10-325mg (NORCO) 1 Tab po q6h prn pain
o Morphine 4mg IV q4h prn pain
o Hydromorphone PF (Dilaudid) 2mg IV q4h prn pain
 Mag hydrox-Al hydrox-simeth (MAALOX) 15mL oral q4h prn
 Ondansetron (Zofran) 4mg IV q4h prn nausea/vomiting
 Promethazine (PHENERGAN) 12.5mg IM q6h prn nausea/vomiting
 Promethazine (PHENERGAN) 25mg IM q6h prn nausea/vomiting
 Benzonatate (TESSALON PERLES) 100mg mg oral q6h prn
 Constipation
o Colace
o Sennakot
o Milk of Magnesia
o Miralax

SEDATION
 Diprivan
 Fentanyl
 Versed
 Precedex
 RAAS Score and sedation protocol

IV MEDICATION
 Levophed
 Vasopressin
 Phenylephrine
 Dobutamine
 Milrinone
 Epinephrine
 Amiodarone bolus and drip protocol

LABS
 CBC with manual differential daily routine am x 7 days
 CMP daily routine am x 7 days
 PT/INR daily routine am x 7 days

52
 Troponin daily routine am x 7 days
 CK-MB daily routine am x 7 days
 CRP q3 days routine am x 5 times
 Lactate q3 days routine am x 5 times

DIET
 Oral Diets
 NPO
 Fluid Restriction
o Fluid Restriction every 24 hours of (specify amount)
o Fluid Restriction of 1000mL every 24 hours
o Fluid Restriction of 1500mL every 24 hours
o Fluid Restriction of 2000mL every 24 hours
 Enteral Tube Feeds

ACTIVITY
 Up as Tolerated
 Bedrest Bathroom Privileges
 Bedrest Bedside Commode
 Bedrest Strict
 Bath: May shower
 Bath: May shower with assistance
 Out of Bed: Assistance
 Stand at Bedside with Assistance
 Up to chair tid with meals
 Do not ambulate in halls
 Turn q2h
 Progressive Mobility Protocol
 Consult wound care for air bed and pressure boots
 Place Mepalex dressing to sacral region

IV FLUIDS
 Saline Lock Peripheral IVs when not in use
 Pharmacy to concentrate all IV medications

DIAGNOSTICS
 XR Chest 1 view daily AM routine Re: COVID, SOB
 Echo, Limited daily Re: COVID, Function and effusion check
 EKG prn rhythm change, elevated troponin, or chest pain

53
 Checklists and Pocket Cards
1. Identify, Isolate, and Inform Pocket Card
https://emcrit.org/ibcc/covid19/#checklists_&_algorithms

54
55
2. CDC PPE Poster
https://www.cdc.gov/HAI/pdfs/ppe/ppeposter148.pdf

56
3a. Lab Dashboard Worksheet - Floor

Lab Flag Baseline D1 D2 D3 D4 D5 D6 D7

WBC > 12

Lymphocyte

Platelets <100

AST

ALT

Cr > 1.5

INR > 1.5

D-Dimer > 1.0

Procalcitonin

CRP > 60

ESR

BCx +

57
 SCx +

Flu +

RSV +

COVID +

TP

CKMB

pH < 7.3

PaO2 < 75

PaCO2 > 50

Base Deficit < -2

Bicarb ≤ 20

Lactate >4

EF < 50

58
3b. Lab Dashboard Worksheet – ICU

Lab Flag Baseline D1 D2 D3 D4 D5 D6 D7

WBC > 12

Lymphocyte

Platelets <100

AST

ALT

Cr > 1.5

INR > 1.5

D-Dimer > 1.0

Procalcitonin

CRP > 60

ESR

BCx +

59
 SCx +

Flu +

RSV +

COVID +

TP

CKMB

pH < 7.3

PaO2 < 75

PaCO2 > 50

Base Deficit < -2

Bicarb ≤ 20

Lactate >4

EF < 50

60
 4. Symptom Review Checklist

Symptom 1a 1p 2a 2p 3a 3p 4a 4p 5a 5p 6a 6p 7a 7p

Fever

Cough

SOB

Sputum

Myalgias

Malaise

Headache

Nausea/Vomiting

Diarrhea

Symptom 8a 8p 9a 9p 10a 10p 11a 11p 12a 12p 13a 13p 14a 14p

Fever

Cough

SOB

Sputum

Myalgias

Malaise

Headache

Nausea/Vomiting

Diarrhea

61
5. Daily Behavior Health Screening Form (phq9)
https://newroadstreatment.org/five-warning-signs-of-mental-illness/

62
Overview for scoring the PHQ-9 is as follows: 

Step 1:  Questions 1 and 2 – Need one or both of the first two questions endorsed as a
“2” or a “3” (2 = “More than half the days” or 3 = “Nearly every day”). 

Step 2: Questions 1 through 9 – Need a total of five or more boxes endorsed within the
shaded area of the form to arrive at the total symptom count (Questions 1-8 must be
endorsed as a “2” or a “3,” and Question 9 must be endorsed as “1” a “2” or a “3”).

Use of the PQH-9 for treatment selection and monitoring as follows: 

Step 1:  A depression diagnosis that warrants treatment or a treatment change, needs at
least one of the first two questions endorsed as positive (“more than half the days” or
“nearly every day”) in the past two weeks.  Also, the tenth question, about difficulty at
work or home or getting along with others should be answered at least “somewhat
difficult.” 

Step 2:  Add the total points for each of the columns 2-4 separately (Column 1 = several
days; Column 2 = More than half the days, Column 3 = Nearly every day.  Add the totals
for each of the three columns together.  This is the Total Score that equals the Severity
Score. 

Step 3:  Review the Severity Score using the following TABLE for PHQ-9 Scoring:

++ If symptoms present > one month or severe functional impairment, consider active treatment.*
If symptoms present > two years, then probable chronic depression which warrants
antidepressants and psychotherapy (ask yourself, “in the past two years have I felt depressed or
sad most days, even if I felt okay sometimes?”)

63
6. ARDSnet FACTT Algorithm: ICU Fluid Management Protocol
http://www.ardsnet.org/files/factt_algorithm_v2.pdf

-
Footnotes, Version VI (Clarified)

A. Dobutamine

1. Start at 5 mcg/kg/min and increase by 5 mcg/kg/min increments at 15 minute

intervals until ineffective circulation reversed (CI greater than or equal to 2.5 for
PAC or fewer than 3 physical findings of ineffective circulation for CVP) or
maximum dose of 20 mcg/kg/min reached.

2. Begin weaning 4 hours after ineffective circulation is reversed. Wean by

greater than or equal to 25% of the stabilizing dose at intervals of less than or
equal to 4 hours to maintain effective circulation

3. If a patient is on dobutamine as a result of an earlier cell assignment,

dobutamine should be ignored for the purpose of subsequent cell assignment, but
should continue to be weaned per protocol.

B. Furosemide - If the protocol instructs the use of furosemide, and furosemide is

unavailable, then bumetanide should be substituted for furosemide, with a dose
equivalency ratio of 40:1 (40mg of furosemide = 1 mg of bumetanide). As the protocol
allows with furosemide, bumetanide can be delivered either via bolus or continuous

64
infusion at the discretion of the physicians caring for the patient. If and when furosemide
becomes available again, furosemide should be utilized to carry out protocol instructions.

1. Withhold if:
a. vasopressor or a fluid bolus given last 12 hours OR

b. renal failure present (dialysis dependence)* OR

c. oliguria with creatinine >3, OR

d. oliguria with creatinine 0-3 and urinary studies indicative of acute renal
failure.

2. For cells 3, 7, and 8: Begin continuous infusion of 3 mg/hour OR 20 mg bolus

OR last known protocol specified effective dose. Reassess in 1 hour. Double dose
hourly until urine output is greater than or equal to 0.5 ml/kg/hour OR maximum
infusion of 24 mg/hour or maximum bolus of 160 mg is reached. Discontinue
furosemide if no response to maximum dose after 1 hour.

3. For cells 11, 15, 16, 18: Begin continuous infusion of 3 mg/hour OR 20 mg
bolus OR last known protocol specified effective dose. Reassess in 4 hours; if still
in a cell for which furosemide is indicated then:

a. If intravascular pressure has declined by one or more pressure ranges

(rows) repeat the same dose as before, and then reassess in 4 hours.

b. If intravascular pressure range has not declined by one or more pressure

ranges (rows), and if average urine output over the preceding four hours is
less than or equal to 3ml/kg/hr, double the preceding dose and reassess in
4 hours. If average urine output over the preceding four hours is greater
than 3ml/kg/hr, then give the same dose as before and reassess within four
hours. Maximum daily infusion dose = 24 mg/hour x 12 hours (3 four
hour cycles); maximum bolus dose = 160 mg q 4 hours x 3 doses.

4. If either the maximum daily infusion (24mg/hr x 12 hrs) or maximum bolus

dose sequence (160 mg x 3) is given, then do not give additional furosemide
doses for 12 hours following the end of the 12 hour infusion or for 12 hours after
the third 160 mg bolus. .

If at least one cell has passed that does NOT call for Lasix to be given, or at least
12 hours has passed from a sequence of maximum furosemide dosing, you can
either start back at 20 mg, give the last known effective dose, or give any dose in
between (as determined by the ICU team).

C. Fluid Bolus

65
 1. Administer 15 ml/kg PBW normal saline, Plasmalyte, or Ringer's lactate
(rounded to the NEAREST 250 cc) or 1 unit of RBCs or 25 grams albumin
(choice at discretion of physician) over less than or equal to 1 hour then reassess
patient . For cells 5,6,9,10, reassess within one hour. For cells 13,14,19, reassess
within four hours. Administer up to 3 boluses over 24 hours if indicated by
protocol. This 24 hour period begins with the first protocol-mandated non-shock
bolus OR the first protocol-mandated bolus following shock reversal.

2. Additional fluid boluses are allowed at the discretion of the physician.

E. KVO IV:

1. Also minimize as much as possible all other fluid volume (e.g., for delivery of
antibiotics etc.), except as required for nutrition support.

F. Guidelines for Management of Shock

 Shock is defined as a MAP < 60 mmHg or a MAP > 60 while receiving

vasopressors.
 Assessments during shock should be recorded at least every 4 hours and at the
time of each new entry or exit from a shock cell (cells 1 and 2).
 Physicians have the choice of either fluid bolus and/or vasopressor therapy (in
any order) as follows:

1. Fluid Bolus (Shock): Use 15 ml/kg PBW normal saline, Plasmalyte, or Ringers
(rounded to the NEAREST 250 cc) or 1 unit of RBCs or 25 grams albumin
(physicians discretion) over less than or equal to 1 hour then reassess patient.

2. Vasopressor Therapy: Choice of any single agent or any combination of the

following:

a. Dopamine 5 mcg/kg/min, increase to a maximum of 25 mcg/kg/min.

b. Norepinephrine at 1 mcg/min, increase to a maximum of 100 mcg/min.

c. Epinephrine at 1 mcg/min, increase to a maximum of 20 mcg/min.

d. Phenylephrine at 10 mcg/min, increase to a maximum of 500 mcg/min.

e. Intravenous Vasopressin 0.005-0.04 international units/minute

3. Vasopressor Weaning (includes any dose of dopamine):

a. When MAP > 60 mmHg on a stable dose of vasopressor, begin

reduction of the vasopressor by greater than or equal to 25% of the

66
stabilizing dose at intervals of less than or equal to 4 hours to maintain
MAP greater than or equal to 60 mmHg.

b. Dopamine is considered "discontinued" for vasopressor use and cell

assignment when it is weaned to less than or equal to 5 mcg/kg/min, but
should continue to be weaned per protocol (footnote F.3.a. above).

67
7. Respiratory Management Schema
https://emcrit.org/ibcc/covid19/#checklists_&_algorithms

68
8. ARDSnet Ventilator Protocol http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

69
9. COVID-19 Intubation Checklist
https://emcrit.org/ibcc/covid19/#checklists_&_algorithms

70
10. APSF Card
https://www.apsf.org/wp-content/uploads/news-updates/2020/apsf-coronavirus-airway-management-
infographic.pdf

71
11. Canadian OR Flowsheet
https://media.springernature.com/full/springer-static/image/art%3A10.1007%2Fs12630-020-01617-
4/MediaObjects/12630_2020_1617_Fig1_HTML.png

CD = Controlled Drugs
NM = Nurse manager
PAPR = Powered air purifying respirator
PC = Personal computer

72
12. Cardiac Hemodynamic Flowsheet

73
13. ECMO Pocket Card (Can obtain hard copies)

74
14. ECMO Clinical Form

75
15. ECMO Readiness Checklist

EQUIPMENT

_____ Sonosite with sterile probe cover and gel

_____ Extra bedside table (if possible, obtain large table from CVOR)

_____ IV Pole

STERILE SUPPLIES

_____ Large Chloraprep skin prep x 4

_____ Sterile OR towels x 8

_____ Sterile OR laparotomy drape

_____ Sterile 4x4 gauze x 3 packs

_____ Sterile gloves size 6.5 x2, 7 x 2, 7.5 x 2

_____ Sterile gown x 4

_____ Sterile disposable needle driver x 2

_____ Sterile plastic bowl and bulb syringe

_____ Sterile NS 1L bottle x 1

_____ Silk suture, size 2 with cutting needle x 2

_____ Sterile 11 blade disposable scalpel

_____ Sterile Mayo scissors

_____ Sterile multi pack of O-Ethibond pop off sutures

NON-STERILE SUPPLIES

_____ Surgical bouffant caps x 8

_____ Surgical masks with face shields x 8

76
_____ N-95 masks x 8

MEDICATIONS
_____ Normal Saline x 2 liters

_____ Heparin 5000 units / mL vial x 2

_____ Albumin 5% 250 mL IV bottle x 3

_____ Extra bag of each drip patient is currently on (vasoactive drip, sedation)

_____ 2 units type and crossed PRBC

77
16. Global Picture of Severe Cases Chart
https://emcrit.org/wp-content/uploads/2020/03/COVID-19-3-6.pdf

78