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Illinois Clinical Service Lines

COVID-19 Guidelines

Updated as of: March 18, 2020

PLEASE Note-This is a continually changing environment and recommendations may

change over time, please watch for additional updates. Any reference herein to PPE,

non-urgent ambulatory appointments, and elective surgeries/procedures should be

verified by accessing the current system guidance documents at Coronavirus COVID-19

Information Center: https://www.advocatehealth.com/covid-19-info/

For any service line specific questions, please contact the accountable owners listed on the face sheet

before each service line section.

Table of Contents Behavioral Health…………………………………………………………………………………………2

Cancer………………………………………………………………………………………………………….5

Cardiology………………………………………………………………………………………………….18

Gastroenterology……………………………………………………………………………………….20

Neuroscience …………………………………………………………………………………………….31

Neurology………………………………………………………………………………………………….35

Orthopedic.……………………………………………………………………………………………….39

Women’s Health………………………………………………………………………………………..41

Additional specialty guidelines will be added as developed. In the meantime, please

reference the WI Aurora Health Care Medical Group COVID-19 Ambulatory Visits

Guidelines.

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Service Line:

Behavioral Health

COVID-19 Guidelines

Accountable Owners(s): Dr. David Kemp and Renee Donaldson

Created: March 18, 2020

Last Updated:

1.

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Behavioral Health Service Line IL COVID-19 Plan

Hospital Based Programs

• All IP units remain open. Bed capacity is recommended to remain at double occupancy, if possible, due to 3 State Operated Hospitals closed to civil admission for the next 2 weeks (minimum). Daily inpatient census/potential discharges as well as ED patient holdings will be gathered and reported to the SL by 8 a.m.

• Service Line Directors monitoring inpatient Scope of Services to focus on throughput from AAH Emergency Departments to inpatient unit admissions.

• Construction has been suspended at IMMC and CMC at this time. • Partial Hospital Program (PHP): Remains open and universal screening will be

implemented for both adults and children. Will monitor volume capacities due to social distancing needs.

• Intensive Outpatient Program (IOP): Remains open and universal screening will be implemented. Will monitor volume capacities due to social distancing needs.

• Trauma Recovery Center: Will have on-site, one team member to answer phones for triage and one clinician there to handle clinical emergencies. This will be on a rotation basis with no direct patient contact. All other team members will be working remotely.

• HUB: Monitoring daily volume throughout IL. Have remote working capabilities and will periodically implement to support social distancing needs and clinic space constraints.

• Electroconvulsive Therapy (ECT): For disease management and readmission prevention, will continue, if appropriate protocols and social distancing can be maintained.

• Some exceptions may need to be made and will be reviewed with BH Service Line.

Outpatient Visits

• Closing to new patient visits – except those that are being referred directly from in-patient or PHP that have documentation already in the medical record.

• Discontinuation of all group treatments – with regular safety check calls as appropriate. • New patients not being seen will be offered to be contacted as soon as we are able to

open new patient scheduling or will be given referral to external provider. • Clinics will remain open and staffed with one to two support staff through staff rotation

schedule beginning 3/18/2020. • Providers will be onsite as per their normal schedules. • Any requests to work remotely must be approved by leadership and should only be for a

designated period. • All visits will be via the telephone with established patients and scheduled as they would

be otherwise schedule if patient was coming to office. Scheduled appointment time, provider calling patient at that appointment time.

• Phone visit templates being developed for providers to do reach out visits.

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• Online Digital appointments are under review for capacity of technology.

Psychiatry Residents

• Will be in clinic and providing telephone care • Regular onsite supervision as normal • Residents that work from home for an approved reason will be capped at 3 hours of

patient care and a required scheduled supervision with an attending on the same day.

In the event that IL needs to start limiting follow up visits the following will

apply:

• Essential visit type: Any patient with active symptoms as described • Child: Self harm, aggressive behavior, psychosis, severe anxiety/panic attacks. • Substance abuse: need for detox, self-harm • Geriatric: Agitation • Adult: Psychotic, self-harm. • Long Acting Injectable Medication Appointments

• Non-Essential Visit Type: • Routine medication refills • Routine follow ups • Routine ongoing supportive therapy

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Service Line: Cancer

COVID-19 Guidelines

Accountable Owners(s): Dr. Jon

Richards, Dr. Jim Weiss, Amy Bock

and Karen Gordon

Created: March 18, 2020

Last Updated:

2.

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Cancer Service Line

Medical Oncology The following recommendations came from a meeting of AAH Medical Oncologists which

occurred 3/16/2020.

Considering the worsening of the Covid-19 pandemia, a team of AAH medical oncologists

developed the following recommendations to limit exposure to our patients. Limited data that

is available suggests that cancer patients are at a higher risk of infection and mortality from

COVID- 19. Among them, those on active chemotherapy are at the highest risk. This risk could

be modified by decreasing their exposure by way of social distancing. Even with this practice

we expect many Americans to be infected and many to die. By limiting exposure, we can

reduce and flatten the peak of infection. Hopefully these practices will result in caseloads that

do not overwhelm our ICU/ventilator/hospital bed capacity.

https://www.washingtonpost.com/graphics/2020/world/corona-simulator/

With the objectives of decreasing the number of individuals, both patients and practitioners at

risk, the Cancer Service Line has identified and created the following recommendations. As the

environment is changing rapidly, if you see anything that conflicts with specific

recommendations on the AAH COVID-19 website, please raise up your concern.

https://advocatehealth.sharepoint.com/sites/AO/Dept/infection-prevention/Pages/2019-nCoV-

Coronavirus-Toolkit-.aspx?csf=1&cid=1ece4b97-3a43-4a68-bda9-b6636350b7e9

RECOMMENDATIONS:

1. Single point of entry for patients and visitors. (Being addressed at the system level the

changes effective Monday 3/16/2020 at all clinics)

2. Educate all nurses, staff and patients on the signs and symptoms of COVID-19

3. Educate patients on the importance of social distancing at each clinic visit.

4. Educate patients to notify us if they have any respiratory symptom or fever, so they can be

evaluated/triaged by telemedicine if available or at least by phone.

5. Patients who arrive with symptoms should be masked, quarantined, and evaluated by staff

wearing appropriate PPE.

6. No sick providers to provide patient care by any capacity. With plans to develop testing

guidelines once tests are available. Caregivers with respiratory symptoms or fever should

stay at home.

7. Educate patient on the need to limit visitors to 1 visitor per patient. Patients should come to

visits alone if possible, with FaceTime or conference call attendance by significant others if

needed.

8. Schedule patients apart to minimize wait time in the lobby. Patients should be separated in

the waiting area and should only have 1 family member with them.

9. Place patient in the furthest chair from clinician in the exam room.

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10. Allow deferring of physical exams for patients undergoing chemo if there are no complaints

on the interview. Could add a phrase “physical exam deferred due to social distancing”

11. Patients may go to chemo directly without office visits if necessary, labs are within treatment

parameters and asymptomatic. Consider de-coupling office visits from chemo visits to

minimize exposure time.

12. Telemedicine may be an option for evaluation of certain patients both new consults as well

as follow ups after discussion with staff. (We are in the process of creating the workflow)

13. Minimize number of providers seeing patient as an example no more than 2 per patient (e.g.

APP+attending or trainee+Attending or APP)

14. Chest CT for infiltrates in patients considered suspect for Covid-19 (includes neutropenic

fever).

15. PATIENT DIRECTIONS: (Reminder Calls and/or Pre-Visit Phone Calls) Recommended

scripting:

a. If you have a fever or cough, call before coming to the office.

b. If you are not receiving therapy, reschedule your appointment.

c. Come by yourself to your visit. If you require assistance, only one attendant is

permitted.

CLINIC VISITS:

DEFER: Reschedule all non-essential visits by 4-6 weeks

1. Reschedule all FU appointments >6wks. (FU 3 mo, 6mo & 12mo) Any FU visit with a

timeframe of > 3 months should be automatically deferred unless patient reporting active

problems. Move by 4-6 weeks. If patient has results of scans, physician should consider

telephonic discussion. Discuss with physician and reschedule as appropriate.

2. Consider delaying the supportive care appointments if appropriate for patients

(zometa/xgeva) Discuss with physician and reschedule as appropriate.

3. Extend therapy with depot medications (Lupron) to the longest acting option available (3,6

months). Discuss with physician and receive new order as appropriate.

4. PORT FLUSHES- OK to delay & reschedule 6 weeks.

CONTINUE: Patients that clearly need to be seen:

1. Newly diagnosis of cancer and/or urgent need for workup/eval

2. Recurrent patients with symptoms in need of urgent care

3. End of life discussion

4. Active chemotherapy cases - Any patient on maintenance treatment should continue therapy

unless there is a concern.

a. Patients with curative intent – continue therapy

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b. Patients with palliative intent – Discuss with physician and delay therapy 6 weeks receive new order as appropriate.

c. Any patient receiving Venofer – Defer - pregnant women may be an exception –

discuss with physician.

CHEMOTHERAPY:

There is data that patients on chemotherapy have a higher likelihood of serious

complications to COVID-19 infection. In addition, the frequent clinic visits increase risk of

COVID-19 exposure. Accepted recommendations to limit these risks are:

1. Consider the risk benefit ratio of chemo versus increased of exposure with possible

subsequent development of Covid-19 disease with enhanced risk to adverse

outcomes.

a. Examples adjuvant breast cancer, adjuvant lung cancer chemo, asymptomatic

patients in non-curative intent chemotherapy regimens, decrease in duration of

chemotherapy in colorectal cancer from 6-4 months. The question to ask is

adjuvant therapy appropriate could it be delayed?

b. Avoid starting chemotherapy in frail patients ECOG PS>1 and or >age 70 other

risk factors to consider include COPD, chronic respiratory conditions, DM

immunocompromised patient.

c. Consider delaying chemotherapy in asymptomatic metastatic patients. Unless

therapy to be done with curative intent.

d. Consider treatment breaks/holidays in patients in remission or doing well.

2. Drugs to use with caution include Cyclophosphamide and Taxanes due to

lymphopenia sec to these drugs, as well as drugs that induce profound mucositis (5fu

regorafenib).

Hematology CLINIC VISITS:

DEFER: Reschedule all non-essential visits >6 weeks

1. Routine follow up visits – excludes allogeneic transplant recipients less than Day

+180 or Autologous Recipients ≤ Day +100

2. Any new patient that does not have a diagnosis of hematologic malignancy - review

at pipeline Meeting for verification of delayed visit

CONTINUE: Patients that clearly need to be seen:

1. New diagnosis hematologic cancer/urgent auto or allo transplant consult

a. All allogeneic consults should be scheduled

b. Autologous transplant consults for DLBCL should be scheduled

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c. Discuss myeloma consults at Pipeline Meeting to determine urgency

2. Recurrent patients with symptoms needing urgent treatment

3. All allogeneic transplant recipients less than Day +180 or Autologous Recipients ≤

Day +100

CHEMOTHERAPY:

1. Any patient on maintenance treatment should continue therapy unless there is a concern

a. Patients with curative intent – continue therapy

b. Patients with palliative intent – delay therapy >6 weeks (Direction per MD)

2. Any patient receiving Venofer – DEFER

TRANSPLANT:

1. All Allogeneic transplants for a hematologic malignancy to proceed with transplant

2. Autologous transplants – DLBCL, other Hodgkin and non-Hodgkin lymphoma patient to

proceed with transplant

3. Myeloma/plasma cell disorder recipients for autologous transplant – DEFER >6 weeks

a. May need to collect stem cells if on therapy that will cause inability to achieve

needed cell dose.

INPATIENT CONSULTS:

After discussion with referring physician consider the possibility of providing recommendations

by phone or focus note. Providing guidance on differential diagnosis and workup prior to seeing

the patient may help decrease the number of face-face interactions.

Surgical Oncology Guidelines for Surgery on Patients with Proven or Suspected Cancer

The following recommendations came from an AAH meeting of the Cancer SL (breast &

hepatobiliary) surgeons which occurred 3/16/2020.

In response to the American College of Surgeons and the Surgeon General’s recommendations

to postpone elective surgery, the following guidelines have been developed to help patients with

proven or suspected cancer. This has been reviewed by senior leadership, and pertains to our

current situation, changes may be needed based on changes in our situation and resource

availability.

Most cancer operations are not elective. Delays may cause both physical and psychological

harm. All decisions about whether to delay surgery or procedures should be made by the

surgeon with judgement about the risk versus benefit of delaying surgery or proceeding as

scheduled.

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All multidisciplinary clinics where patients physically attend should be suspended until further

notice.

All tumor boards and cancer conferences should continue as virtual meetings.

The system is looking into virtual visits for patients who do not need to be physically seen and

examined. These guidelines will be modified and updated periodically as needed in response

to changes in resource availability.

SURGERY:

1. All cancer surgeries currently scheduled should proceed as planned provided the

resources are available to do so safely.

a. Surgeons should check that adequate resources are available prior to

starting any major resection (ICU bed, ventilator etc…)

2. If the surgery can be safely delayed, without harm to the patient, it should be

considered. (for at least 2-4 weeks)

3. Scheduling of surgical cases should consider the risks to the patient (Hospital

exposure), resource availability and the risks associated with delaying surgery.

a. Cancers patients may experience worse outcomes if infected due to the

compromise in their immune systems. CLINIC VISITS:

DEFER: Reschedule all non-essential visits >6 weeks

The following patients should have their office visits deferred for 2-4 weeks

a. Routine follow-ups

b. Non-urgent issues

CONTINUE: Patients that clearly need to be seen:

All office visits should be reviewed, with the following cases prioritized to be seen:

a. All new or suspected cancers

b. All fresh post-operative patients

c. All patients with ongoing or new problems

Breast Care & Surgery The following recommendations came from a meeting of the AAH breast surgeons which

occurred 3/16/2020.

In response to the American College of Surgeons and the Surgeon General’s recommendations

to postpone elective surgery, the following guidelines have been developed to help patients with

proven or suspected breast cancer. This has been reviewed by senior leadership, and pertains

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to our current situation, changes may be needed based on changes in our situation and resource

availability.

Most cancer operations are not elective. Delays may cause both physical and psychological

harm. All decisions about whether to delay surgery or procedures should be made by the

surgeon with judgement about the risk versus benefit of delaying surgery or proceeding as

scheduled.

1. Breast Screening

a. It was felt that we should hold off on breast screening for the next 2-4 weeks and

reassess as we see the availability of our resources and personnel

2. Benign lesions

a. Office visits and surgery for patients with benign lesions should be deferred 2-4

weeks

3. High risk screening visits in the absence of cancer or high-risk lesions should be deferred

2-4 weeks

4. Management of High-Risk Lesions

a. Patients with high-risk lesions who are scheduled (or need to be scheduled) for

surgery should be managed based on the best judgement of the surgeon

considering the following factors

i. Risk of delaying surgery

ii. Risk of having the patient come into the surgery center or hospital

iii. Available resources

iv. Age and health of the patient

v. Availability of alternative treatment strategies

5. Management of Cancers and DCIS

a. Patients with cancer or DCIS who are scheduled (or need to be scheduled) for

surgery should be managed based on the best judgement of the surgeon

considering the following factors

i. Risk of delaying surgery

ii. Risk of having the patient come into the surgery center or hospital

iii. Available resources

iv. Age and health of the patient

v. Availability of alternative treatment strategies (Neoadjuvant therapy)

b. Mastectomy patients

i. Reconstructions will be limited to tissue expander/implant for the next few

weeks (Per plastic surgery)

ii. Contralateral prophylactic and risk reducing mastectomies should be

delayed at least 2-4 weeks, at least until we have an idea of personnel and

resource availability

6. Routine follow-up visits should be postponed except for the following

a. New or potential cancers

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b. Fresh post-op patients

i. Virtual visits at the option of the surgeon

c. Any patients with new complaints or ongoing problems

Radiation Oncology The following recommendations came from an AAH meeting of the Radiation Oncologists which

occurred 3/16/2020.

Scope of the problem:

The consequences of an outbreak of COVID-19 in a Radiation Oncology department would be

catastrophic. There would likely be significant loss of life, both due to 1) direct effects from the

virus in patients who are immunocompromised or who have medical comorbidities 2) indirect

effects from treatment delays. These negative impacts are unique to cancer care in many ways

and require these patients to continue Radiation Therapy.

Consensus statement:

Radiation Oncologists and department administration should work together to adopt COVID-19

universal precautions put in place Radiation Oncology-specific guidelines/recommendations to

protect the health of our patients by 1) reducing the risk of transmission of COVID-19 by utilizing

universal precautions for patients with COVID-19 into and within the department and 2)

minimizing the negative impact of infected staff and patients.

Policy statement: Adopt COVID-19 Toolkit, with the following caveat: Radiation

Oncology patients considered at risk, should be gowned, masked, and placed in

isolation for evaluation by Radiation Oncologist for continuation of Radiation Therapy.

Radiation Oncologists will consider risk and benefit of continuing radiation therapy

relative to risks of COVID-19.

Option 1: Continue radiation therapy and send for COVID-19 testing

Option 2: Delay radiation therapy and refer for COVID-19 testing

Treatment Algorithm Single Vault Facility

1. Decrease staff to limit staff exposure*

2. Treat all asymptomatic patients in the morning

3. Defer suspected COVID patients to afternoon treatment appointments

a. Patients are masked, gowned, and gloved prior to entry into facility

b. Staff must wear appropriate PPE (gown, glove, mask)

c. Room patient in private area while awaiting treatment

4. Terminally clean vault at the end of patient treatment for the day

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*Keep back-up staff remote/offsite in case of exposure

Treatment Algorithm Multiple Vault Facility

1. Decrease staff to service single vault, if feasible, with skeleton staff*

2. Treat all asymptomatic patients in the morning

3. Defer suspected COVID patients to afternoon treatment appointments

a. Patients masked, gown, glove, prior to entry into facility

b. Staff wear appropriate PPE gown, glove, mask

c. Room patient in private area

4. Terminally clean vault at the end of patient treatment for the day

*Keep back-up staff remote/offsite in case of exposure

**If volumes don’t allow for single vault treatment, staff should still remain offsite for

backup

Additional Detailed Guidelines:

I. Following COVID-19 Toolkit:

1) Follow enhanced hygiene practices – frequent hand washing, no handshakes or

otherwise unnecessary bodily contact, patients and staff should use hand sanitizer

before entering vault.

2) Treat all patients and staff as potential carriers

3) Minimize the number of people coming into clinic (One to No Visitors)

4) Follow enhanced sanitation practices

a Wipe down all patient areas (chairs, tables, etc) and staff areas at end of day

b Wipe down treatment table after each patient

• Encourage patients in waiting areas to maintain > 6 feet from each other

• Encourage patients to wait in automobiles or have family members wait in

automobile.

5) Cancel all non-critical meetings and move all remaining meetings to virtual

meetings as possible.

II. Other Recommendations:

• Reduction in onsite Physician, Physicist, Therapist, Dosimetry staff

• Rotate staff – if volumes are decreased, it may be possible to set up rotations where

staff work in a week on/week off capacity. Keeping some staff out of clinic increases the

number of uninfected staff, which would allow infected staff to quarantine and uninfected

staff to rotate in.

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• Daily Huddle--daily huddle will continue to take place. This will be done via Skype/call

in procedure. Lead therapist will send out outlook invite with conference bridge number.

Work from home therapists will be expected to be on call. (Remote access will be

requested for remote therapists to support for weekly chart checks, insurance

verification's, preparing new patient charts, etc.)

• Follow Up Procedure- MD and RN to discuss timing of follow up for existing patients.

Each week physicians and NPs will review their follow up schedule for the next 1-2 weeks.

o Physician/NP to review schedule and decide which patients must be seen and

which patient appointments can be delayed (per clinically appropriate decision

making)

Decision to be made for in-person/telephone/reschedule

Any patient appointment delays MUST be documented in EPIC through a

telephone encounter.

o Scripting needed

Prior to telephone follow-up front desk/nursing need to verify

insurance/registration information. Nursing to update information in

electronic medical record

Patient needs to consent verbally to allow telephone follow-up

Physician must document initially that this was a phone conversation in lieu

of in person visit

• Consults-telephone consults only to be performed in rare instances

o Similar scripting as above with need for verification of insurance and registration

information as well as intake forms by nursing/front desk

o Patient needs to consent verbally to allow telephone consult

o Physician must document initially that this was a phone conversation in lieu of in

person visit

• Simulations-consider delaying patient's simulation/new starts as medically appropriate

per physician

• Treatments-

o Consider expanding treatment appointment times for more thorough cleaning of

treatment table and accessories between patients

III. Minimize the negative impact of infected patients

Treatment of cancer patients is time sensitive. This problem is particularly acute in Radiation

Oncology, where treatment breaks can negate the beneficial impact of radiation. Ultimately,

the decision whether or not to treat patients testing positive with COVID-19 rests with the

treating MD. One potential algorithm:

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• Palliative patients

o Pain or other non-life-threatening symptom → treat with single fraction or

terminate treatment in progress if delivered BED > 8 Gy/1 fx

o Cord compression, brain mets, or other immediately life-threatening symptom →

shorten course of treatment as feasible

• Definitive patients o Low risk (no severe cough or pneumonia/ICU) → complete course

of treatment or defer at MD discretion, accelerating as feasible

o High risk (severe cough or pneumonia/ICU) → defer remainder of treatment and

make up after symptoms resolve and out of quarantine

Reference: Guidelines for accelerating treatment and dealing with large breaks in treatment can

be found in Table 3 of Gay H et al. Lessons Learned From Hurricane Maria in Puerto Rico:

Practical Measures to Mitigate the Impact of a Catastrophic Natural Disaster on Radiation

Oncology Patients. PRO 2019;9(5):305-321.

(https://www.sciencedirect.com/science/article/pii/S1879850019300797)

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Cancer Service Line APPENDIX: COVID19 Workup and General information Even in the setting of a normal chest radiograph it can still be COVID-19. If abnormal and not

typical of community acquired bacterial infection or tuberculosis, consider viral infection including

COVID-19. Use clinical judgment and do PCR when appropriate

#CoVID19 presents with lymphopenia and eosinopenia rather than lymphocytosis

https://www.ncbi.nlm.nih.gov/m/pubmed/32077115/

CONCLUSION: Detailed clinical investigation of 140 hospitalized COVID-19 cases suggests

eosinopenia together with lymphopenia may be a potential indicator for diagnosis. Allergic

diseases, asthma, and COPD are not risk factors for SARS-CoV-2 infection. Older age, high

number of comorbidities, and more prominent laboratory abnormalities were associated with

severe patients.

Raised CRP with a lymphopenia also seem to be key blood

markers

https://twitter.com/PCH_SF/status/1237423822917099520?s=20

COVID19 Treatment???

Convalescent sera

https://www.jci.org/articles/view/138003

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Tocilizumab

http://chinaxiv.org/abs/202003.00026

hubs.ly/H0nzmn40 Steroids

Anti-virals

ICI patients (see below)

Other Cancer and COVID19 Resources

#COVID19nCancer

is the hashtag for the intersection of these 2 diagnoses

ASCO Coronavirus Resources

https://www.asco.org/asco-coronavirus-information

COVID-19 coronavirus and cancer – HemeOnc.org - https://hemonc.org/wiki/COVID-

19_coronavirus_and_cancer#Guidance_for_transplant

Managing Immune Checkpoint Inhibitor (#ICI) patients when #COVID19 is suspected or

prevalent. http://ow.ly/h8fn30qpPUg

#COVID19nCancer #ImmunoOnc #irAE

Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China [Feb 14, 2020] Liang et

al. http://ow.ly/lqVW30qmr41#2019nCoV #COVID19 #IDonc #mmsm

Coronavirus (COVID-19) & Multiple Myeloma

[2020] @HJChoMDPhD1 @theMMRF http://ow.ly/a9A730qp0Zx #mmsm #2019nCoV

#coronavirus #COVID19

Young & Unafraid of the Coronavirus Pandemic? Good For You. Now Stop Killing People [Mar 11,

2020] A Doctor in Western Europe

@Newsweek

http://ow.ly/wqdC30qpzNP #2019nCoV #COVID19 Fatality is the wrong yardstick. Catching the

virus can mess up your life in many, many more ways...

POLL via @chanyooncheah #mmsm #bmtsm #2019nCoV #coronavirus #COVID19

myeloma tweeps: with #COVID19 here (or imminent) what are you advising your patients due

autologous stem cell transplant? This is not curative intent treatment...

https://twitter.com/chanyooncheah/status/1237750223637606400?s=20

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Service Line:

Cardiology

COVID-19 Guidelines

Accountable Owners(s): Vincent

Bufalino, MD; Julie Kozlowski,

MSN, ARPN, CNS; Laura Grafrath

and Virginia Friesen

Created: March 18, 2020

Last Updated:

3.

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Cardiovascular and Thoracic Service Line

Access current system guidance documents at COVID-19 Information Center website: https://advocatehealth.sharepoint.com/sites/AO/Dept/infection-prevention/Pages/2019-nCoV-Coronavirus-Toolkit-.aspx?csf=1&cid=1ece4b97-3a43-4a68-bda9-b6636350b7e9 Key documents:

• Guidance on Elective Surgeries and Procedures

• Guidance on Non-urgent Ambulatory Visits

• Guidance of Telephonic Visits

• Guidelines Essential Anticoagulation (AC) Monitoring

Ambulatory Setting

Type of Encounter determined based on

trigger risk assessment

Telephone visit p/risk assessment

(Med Rec/refill, Symptom Assessment, pt. self-

reported weight, B/P)

Reschedule p/telephone visit

based on provider

recommendation

Proceed with encounter as

scheduled (COVID screen)

Routine follow up visit for stable chronic conditions

X X

New Patients TBD – may not be able to do phone visit

X X X

Consults X X

Hospital Discharge (including device wound checks)

X X

HF Clinic visit X X

Symptoms-based X

Anti-Coag/INR Clinic (see COVID-19 Information Center website)

X

Urgent Cath, Periph, Device, Ablation, X

Elective Cath, Periph, Device, Ablation, X

Routine device remotes in-clinic X

Device Programming (risk assess) X

Pre-Operative CV Eval X

RN Visits X

Routine Vein Proc X

Echo, Nuclear, Stress (risk assess) X X

Holters (risk assess) X

Event Monitors X (by APS or Biotel) MAIL

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Service Line:

Gastroenterology

COVID-19 Guidelines

Accountable Owners(s): Blake Meyer

and Dr. Rick Bone

Created: March 18, 2020

Last Updated:

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COVID-19: Recommendations to Protect GI Physicians and Staff By Jennifer Frankel, MD, Noura Sharabash, MD, Nadia Bozanich, MD, Cynthia Lau, MD and Constance Pietrzak, MD Updated March 16,

2020

Primary goals during the outbreak from Dr. Vincent Bufalino, MD - Chief Advocate Medical

Group Officer:

1. Prevent the spread of COVID-19

2. Keep our healthcare providers healthy

3. Take care of our sick patients

Background on Endoscopy during the COVID-19 outbreak

- High quality, safe care is our priority. Infection prevention measures and guidelines in the endoscopy department are needed to provide a high quality and safe environment for both patients and

staff. These measures need to be implemented immediately and maintained to avoid unrecognized

spread of disease.1

- Novel Coronavirus Transmission Sources. SARS-CoV-2 virus causes the COVID-19 illness. It

is a novel virus and has similarities to SARS-CoV-1 and MERS-CoV which previously caused smaller

outbreaks with significant mortality. SARS-CoV-2 transmission occurs via respiratory droplets, feces,

contact with infected surfaces, and person-to-person spread. The World Health Organization (WHO) is

considering airborne precautions for all medical staff after a study shows that aerosolized SARS-CoV-2

can survive in the air for at least 3 hours. The virus is most stable on plastic and stainless steel. Viable

virus could be detected up to 34-72 hours post application.

- SARS-CoV-2 can be transmitted by asymptomatic individuals. The mean incubation period is

5 days with a range of 0-14 days. Symptoms include fever, fatigue, dry cough, anorexia, myalgia,

dyspnea, headache, sore throat, rhinorrhea, and GI symptoms (diarrhea, nausea). The virus can be shed

for prolonged periods even after recovery (up to 37 days in some reports).

- COVID-19 patients can have significant GI symptoms. Up to 50% of patients have GI

symptoms. Some patients present with GI symptoms before they develop the other symptoms. This is

thought to be a major driver of spread to healthcare workers (HCW) in Wuhan who took care of patients

presenting with diarrhea that was not recognized initially to be from COVID-19. We need to be

cognizant of this and keep our clinical suspicion high so patients can be tested and

isolated.

- Asymptomatic patients or patients without typical symptoms should be treated as

potential positives during the outbreak until proven otherwise.

1 Repici, A et al. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know.

Gastrointestinal endoscopy March 2020. Epub ahead of print.

https://els-jbs-prod-cdn.literatumonline.com/pb/assets/raw/Health%20Advance/journals/ymge/Coronavirus

Outbreak-1584123417883.pdf

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- Endoscopy is High Risk for Exposure and Transmission. Airborne precautions are universally

recommended for aerosol generating procedures, including endoscopy, which are considered high-risk

for transmission of SARS-CoV-2.

- High Healthcare Worker Infection Rate. HCWs are contracting the illness at high rates with significant morbidity and mortality. For example, 20% of HCW have been infected in Italy and some have

died.1 In a study from China, 29% of infected patients were HCW and 41% of the patients in this study

were infected in the hospital.1 Inadequate personal protective equipment (PPE), improper use of

PPE, and poor hand hygiene are potential factors that can lead to transmission to the bedside HCW.

Health care workers often have more severe disease than non-health care workers. despite their

younger age on average and the mechanisms of this are not yet known. One thought is that they may be

infected with a higher dose of the virus.

Recommendations for Endoscopy Procedures

● Stop all elective procedures to minimize exposure to health-care personnel, exposure to

patients. This will also minimize PPE use during the outbreak and save PPE for urgent cases.

● Severely restrict GI procedures to only life-threatening GI bleeding, obstruction of esophagus

by food bolus or foreign body, and ascending cholangitis.2

● All patients who need urgent/emergent endoscopic procedures should be screened

keeping in mind that “asymptomatic” patients or patients with “atypical” symptoms should be treated as

potential positives during the outbreak until proven otherwise.

● Procedures in all patients requiring urgent/emergent endoscopy should be considered

high-risk procedures. EGD, ERCP and EUS procedures involve suctioning and aerosolization of oral

and respiratory secretions. Colonoscopy should also be considered high risk given exposure to feces

which is also suctioned along with suctioning of oral secretions during the colonoscopy.

● All personnel should have appropriate Personal Protective Equipment (PPE) during any

endoscopy procedures. This includes N95 masks, goggles, face masks, gowns, gloves, shoe covers,

hair protection for everyone involved with the procedure, full body suit if possible with head coverage

under gown

● Endoscopic procedures should be performed with airborne precautions including N95

respirators

● Confirmed positive COVID-19 patients or patients under investigation requiring

endoscopy should have procedures performed in a negative-pressure room

● All equipment needs to be immediately available (e.g. staff should not be leaving the room to get

additional equipment or supplies)

● Staff need to keep a reasonable distance (6 feet desirable) from every patient during all steps before the

beginning of the procedure (e.g. informed consent, vital signs, patient instructions, etc.).

● All patients should wear a surgical mask and gloves the entire time they are in endoscopy/OR. The

surgical mask is replaced with the Procedural Oxygen Mask (POM mask) for EGDs but can remain in place

23

during colonoscopy if considered safe by anesthesia. They should be replaced as promptly as possible if

they have been removed

● The patient should be brought directly to the endoscopy procedure room/OR without waiting in the

holding area. The patient should be brought out of the room as soon as they are stable after the

procedure without waiting in the holding area.

● No family or visitors to endoscopy/OR or any holding areas/waiting rooms

● For outpatients, Family/escorts should not come into the facility but can drop pt off/pick them up,

conversations about findings can be done by phone

● For outpatients, individual rooms, placement of beds >6-10 feet apart in open areas if they must be used

(?curtains in the rooms, concern this could be a point of exposure)

● Terminal cleaning process for each room to minimize risk of spread. There should be a detailed process

for the terminal clean so contaminated surfaces are not missed.

● Consider phone follow-up at 7 and 14 days to ask about a new diagnosis or development of symptoms of

COVID-19.

2Advice from the Canadian Association of Gastroenterology for Endoscopy Facilities as of March 16,

2020. https://www.cag-acg.org/images/publications/CAG-Statement-COVID-&-Endoscopy.pd f

● Staff should be trained in safe donning and doffing of PPE and signage posted. A

designated area for donning and doffing as well as instruction for management of waste

must be created

● https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf

Recommendations for GI Inpatient Consults

● Minimize unnecessary contact with all patients during COVID-19 outbreak

○ Physicians will use their clinical and professional judgement to minimize unnecessary contact

with patients. Consultation requests will be reviewed and the consultation will be completed by obtaining

information without face to face contact if appropriate (e.g. chart review, radiology review, phone

interviews with patients or nurses, etc.). ● PPE for consults

○ Mask, goggles/face shield, gown, bonnet, shoe covers, scrubs (of note, this is standard

of care now for even routine appointments in Taiwan)

○ Masks for all HCW in the facility at all times is also part of CDC mitigation

recommendations in Seattle

○ Masks reduce viral load by droplet spread, decrease spread by asymptomatic carriers

Next Steps and Current Needs:

● Develop Standard Operating Procedures for COVID-19 prevention and control

● Need an accounting of all PPE in stock for all staff

24

● Need an accounting of the number of POM (Procedural Oxygen Masks) available for EGDs

● Immediate training for all staff including anesthesia on donning/doffing without contamination

● Protocol for urgent outpatients who need endoscopy

● Protocol for urgent inpatients who need endoscopy

● Training on protocols for all staff

● Protocol for terminal cleaning after cases and for scope processing

ADDITIONAL RESOURCES AND BACKGROUND INFORMATION

Endoscopy recommendations from Italy

https://els-jbs-prod-cdn.literatumonline.com/pb/assets/raw/Health%20Advance/journals/ymge/Coronavirus

Outbreak-1584123417883.pdf

● An excellent overview of endoscopy management in the setting of the COVID-19 outbreak in Italy was

recently e-published in GIE (Gastrointestinal Endoscopy) “Coronavirus (COVID-19) Outbreak: What the

Department of Endoscopy Should Know” 2

● “Endoscopy departments face significant risk for diffusion of respiratory diseases that can be spread via

an airborne route, including aspiration of oral and fecal material via endoscopes.”

● “Even though health care personnel working in endoscopy units are not directly involved in the

diagnostic and therapeutic evaluation of COVID-19 positive patients, endoscopy should still be regarded

as a risky procedure. This risk of exposure and subsequent infection of endoscopy personnel is, in fact,

substantial in cases of patients with respiratory disease that can be spread via an airborne route. A

recent study from Johnston et al confirmed the significant and unrecognized exposure of the

endoscopist’s face to potentially infectious biologic samples during endoscopy. Endoscopy procedures

demand short physical distance from patients to the personnel and according to studies performed

during the global SARS outbreak of 2003 droplets from infected patients could reach persons located 6

feet or more from the source.”

● “Finally, we do believe that the risk of exposure of endoscopy personnel is not limited to upper

endoscopy procedures considering the recent detection of SARS-CoV in biopsy specimens and stools,

suggesting a possible fecal-oral transmission. This could be even more relevant given that the virus

transmission can occur during the incubation period in asymptomatic patients.”

Canadian Association of Gastroenterology recommendations March 16, 2020 https://www.cag-

acg.org/images/publications/CAG-Statement-COVID-&-Endoscopy.pdf

2 Repici, A et al. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know.

Gastrointestinal endoscopy March 2020. Epub ahead of print.

https://els-jbs-prod-cdn.literatumonline.com/pb/assets/raw/Health%20Advance/journals/ymge/Coronavirus

Outbreak-1584123417883.pdf

25

● “Aerosol-generating medical procedures (AGMP)s carry a high risk of COVID-19 transmission. Upper GI

procedures are considered high risk procedures. Therefore, airborne, contact and droplet precautions

with appropriate selection and use of PPE including filtering face-piece (e.g. N95, FFP2/3), gloves, gown,

facial protection (e.g. goggles and/or face shield) and hairnet are required. Given that community

transmission from apparently asymptomatic patients with COVID-19 has already been documented in

China and Italy, and now in Canada, and the fact that the prevalence of the disease is likely to be

underestimated due to limited testing and restricted criteria for testing in Canada, we suggest regarding

all upper GI procedures as high-risk procedures regardless of whether patients are considered low or

high risk for COVID19. This suggestion deviates from Repici et al.”

● “When any endoscopic procedures are being performed on patients considered to be at high-risk for

COVID-19 infection, airborne, contact and droplet precautions with appropriate selection and use of PPE

including filtering face-piece (e.g. N95, FFP2/3), gloves, gown, facial protection (e.g.

goggles and/or face shield) and hairnet should be used.”

American Society for Gastrointestinal Endoscopy (ASGE) recommendations

https://www.asge.org/docs/default-source/default-document-library/press-release_impact-of-covid-19-

onendoscopy.pdf

● “Endoscopy is a place where patients and physicians have very close distance and physicians are exposed

to splashes, mucus or saliva during procedures especially upper gastrointestinal (GI) endoscopy.

Moreover oral-fecal transmission has been postulated as a potential route for COVID-19 transmission.

Endoscopy is also a place with significant concentration of people (staff, patients, caregivers, relatives,

etc.). This is why establishing detailed and strict rules is of paramount importance to protect both

personnel and patients.

● “Even though health care personnel working in endoscopy units are not directly involved in the

diagnostic and therapeutic evaluation of COVID-19 positive patients, endoscopy should still be regarded

as a risky procedure. This risk of exposure and subsequent infection of endoscopy personnel is, in fact,

substantial in cases of patients with respiratory disease that can be spread via an airborne route.

● “The risk of exposure of endoscopy personnel is also not limited to upper endoscopy procedures,

considering the recent detection of SARS-CoV in biopsy specimens and stools, suggesting a possible

fecal-oral transmission. This could be even more relevant given that the virus transmission can occur

during the incubation period in asymptomatic patients. Establishing infection prevention measures and

guidelines within an endoscopy department is essential for creating a high-quality and extremely safe

environment to protect both patients and personnel. In this new era of the COVID-19 outbreak, it is

26

imperative that these measures be implemented and maintained to avoid further spread of the disease.” 3

Joint Statement from the four GI Societies regarding COVID-19 posted March 15, 2020

https://gi.org/2020/03/15/joint-gi-society-message-on-covid-19/

● Strongly consider rescheduling elective non-urgent endoscopic procedures. Some non-urgent

procedures are higher priority and may need to be performed (examples include cancer evaluations,

prosthetic removals, evaluation of significant symptoms). Classification of procedures into non-

urgent/postpone and non-urgent/perform may be useful. Of note, the Surgeon General on 3/14/20

advised hospitals to postpone all elective surgeries and elective procedures/surgeries were stopped by

order of Mayor DeBlasio on March 15, 2020 in New York

● For urgent outpatient endoscopy/consults: Prescreen all patients for high risk exposure or symptoms or

close contact with someone with these symptoms:

- Fever

- Respiratory illness including cough, sore throat, URI symptoms

- Travel to a high risk area (although now that there is community spread, this isn’t as helpful)

● Avoid bringing patients or their escorts into the medical facility who are over age 65 or who have

comorbid conditions. Family/escorts should not come into the facility but can drop the patient off and

pick them up. Conversations about findings can be done by phone.

● Body temperature check immediately upon arrival, screen again for high risk exposure or symptoms and

immediately isolate if they screen positive.

Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1

https://www.medrxiv.org/content/10.1101/2020.03.09.20033217v2

● SARS-CoV-2 remained viable in aerosols throughout the duration of our experiment (3 hours) ● SARS-

CoV-2 was most stable on plastic and stainless steel.

● Viable virus could be detected up to 34-72 hours post application

COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission

https://www.gastrojournal.org/article/S0016-5085(20)30281-X/pdf

● EGDs are aerosol generating procedures, cough which can occur during EGD or during suctioning during

a colonoscopy can also generate aerosols

● Asymptomatic spread can occur during the prodromal phase, viral shedding greatest at time of

symptoms but the mean incubation period is 5 days (0-14)

3 ASGE Press Release “ASGE Releases Recommendations for Endoscopy Units in the Era of COVID-19” March

13, 2020

27

● HCoV-19 can present with GI symptoms including nausea, vomiting and diarrhea (5-50% of patients, may

be the only symptoms without fever, cough or other respiratory symptoms or may precede the onset of

other symptoms for several days)

● HCoV-19 viral nucleic acids have been found in saliva and stool (live virus has been isolated)

● Mild to moderate liver injury has been reported in up to 60% of patients

● “A growing number of clinical evidence reminds us that the digestive system other than the respiratory

system may serve as an alternative route of infection when people are in contact with infected suffers,

asymptomatic carriers or individuals with mild enteric symptoms at an early stage must have been

neglected or underestimated in previous investigations”

● “Altogether, many efforts should be made to be alert on the initial digestive symptoms of COVID

19 for early detection, early diagnosis,early isolation and early intervention”

Endoscopy specific PPE guidelines

● Our colleagues in Italy, China and Canada as well as other countries are using higher level PPE than what

the CDC/WHO recommends.

● PPE Management early in the outbreak in Italy was not effective to control spread of the infection to

HCW and guidelines for PPE were changed. 20% of HCW were infected in Italy and some have died. 4

● Staff need training in donning and doffing with emphasis on safely doffing, using a buddy JAMA video

https://youtu.be/TKS1pahoPR U 3/14/2020 (around minute 18-19)

https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf

● N95 mask for all HCW in the room (GI, anesthesia, nurse, tech) as well as those involved in scope

processing

● Goggles, face shield

● Bonnet

● Shoe Covers

● Scrubs (change after case?, where do you put the dirty scrubs?)

● Hazmat suit? Cover up/bunny suit

● Water resistant gown, back closure done by a buddy

● Double Gloves which must cover the wrists

● Importance of training in donning and doffing, buddy to watch

● Hand hygiene

● Despite ASGE suggestions to perform endoscopic procedures in a negative-pressure room, in most

endoscopy facilities around the world, this is not available. Therefore, it would be advisable to patients

with respiratory symptoms. When this is not feasible, we recommend performing endoscopy on patients

who are high-risk or positive for SARS-CoV-2 in negative-pressure rooms located outside of the

endoscopy department as long as this space is properly equipped to perform any endoscopic procedures

safely and properly

4 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30627-9/fulltext

28

Endoscopy Room management during a COVID-19 outbreak

● Excellent video on how to manage the endoscopy room during an outbreak of covid-19 virus from the

Thai Association of GI Endoscopy by a Chinese gastroenterologist from Wuhan presenting CSGE

recommendations https://youtu.be/tVOWgTswkWY ● Summary of the video:

○ GI symptoms may be the only symptoms a patient has

○ Endoscopic staff are at high risk of infection

○ No routine endoscopy, emergent cases only (bleeding, foreign body, cholangitis) ○

How to minimize risk:

■ Patient Screening:

● Screening form asking about contact history (they have a standard form),

respiratory symptoms

● Temperature check

● Before the procedure all patients had blood test and CT scan, then if

COVID-19 infection was not suspected an endoscopy room was used. If COVID-

19 infection was suspected, the procedure was done in a negative pressure

room.

■ Staff protection:

● Before the procedure: All staff had symptoms and contact history checked, if

positive need to be isolated and tested

● Cover body surface as much as possible -- they are shown wearing gear with

their head covered

● Good practice with disinfection after the procedure

● Patients monitored for infection for 14 days after (not clear if patients are tested

or just followed up on)

● Notification and quarantine of staff if diagnosis is made after the procedure

■ Disinfection - Negative pressure zone is the best

● All surfaces in the room disinfected post procedure

● UV and ozone treatment used as well

● Keep all material in good order - photo shown with equipment in plastic

containers with lids

● Keep all waste separate, bag sealed

● For mobile cases, cart/equipment covered with disposable cover, everything

disinfected after

Limit Spread by Limiting non urgent/emergent cases

29

● Recommendations for Endoscopy during the COVID-19 Pandemic/What are

other people doing

○ American College of Surgery recommendation to stop all elective cases including

endoscopy

○ The surgeon general has advised that hospital cancel elective surgery 3/13/19, reasons

include decreasing nosocomial spread of the virus, use of PPE leading to shortages later, free up

hospital beds/ventilators

○ Mayor DeBlasio has cancelled all elective surgery in NYC via an executive order 3/15/20

○ Governor Baker in Massachusetts announced hospitals will postpone elective surgeries

3/15/20

○ Perioperative considerations-Anesthesia Patient Safety Foundation:

https://www.apsf.org/news-updates/perioperative-considerations-for-the-2019-novel-coro

navirus-covid-19/

○ A colleague at Mt Sinai in New York presented the following:

30

31

Service Line:

Neuroscience

COVID-19 Guidelines

Accountable Owners(s): Mike Busky

and Dr. Dean Karahalios

Created: March 18, 2020

Last Updated:

32

COVID-19 NEUROSCIENCE GUIDELINES

NEUROSURGICAL GUIDELINES

Considering the anticipated worsening of the Covid-19 pandemic, the Neuroscience Executive Council

of the Brain and Spine Institute has developed the following recommendations pertaining to

neurosurgical patients and staff. The goal of these recommendations is to address two major goals: 1)

Limit exposure in order to protect the greater population (especially at-risk groups such as the

immunocompromised and the elderly) and to flatten the peak of infection. 2) Maximize the availability of

anticipated high demand resources (ICU beds, ventilators, PPE, etc.).

With these objectives in mind, the Neuroscience Service Line has identified and created the following

recommendations related to neurosurgery:

Ambulatory

1. Screen clinics and postpone all non-essential visits.

2. Essential visits may include but are not limited to:

a. New patients necessitating an in-person exam based on triage protocol.

b. Post-operative patients requiring wound checks.

c. Patients with concerning symptoms that may represent conditions that if not evaluated

expeditiously may lead to severe or permanent harm (I.e. “red flag” symptoms

commonly used in current triage practices).

3. Non-essential visits may include but are not limited to:

a. Routine follow up of spine patients who do not have new or progressive symptoms.

Imaging may be obtained and results communicated to the patient by phone.

b. Routine surveillance of cranial patients (trauma, tumor, or vascular) who do not have

any new or progressive symptoms. Imaging may be obtained and results communicated

to the patient by phone.

c. New spine clinic patients who have chronic and stable conditions or minor symptoms.

4. Consider virtual visits over the phone or telemedicine platform for new patients requiring visits.

5. For those patients who call, drop in, or who are instructed to present for an in-person visit,

adhere to the universal screening pathway and outpatient clinical pathway (for those patients

who screen positive).

6. Patients with imaging studies already completed may either drop off CDs or upload imaging via

LifeImage to be nominated to PACS to facilitate virtual and in-person visits.

7. Schedule patients 20 min apart to minimize wait time in the lobby. Patients should be separated

in all waiting areas and roomed as soon as possible.

8. Patients who arrive with symptoms should be masked, quarantined, and evaluated by staff

wearing appropriate PPE.

9. Place patient in the furthest chair from clinician in the exam room.

33

10. Allow deferral of non-acute or non-emergent exams for patients if there are no relevant

complaints on the interview. Could add a phrase “physical exam deferred due to social

distancing”.

11. Educate patients on the importance of strict hygiene and social distancing.

12. Patients should come to visits alone if possible, or if necessary, with only one additional

supporting individual.

13. If possible, limit referrals for advanced imaging to ambulatory sites.

14. Educate all nurses, staff and patients on the signs and symptoms of COVID-19.

15. If possible, segregate staff into teams between which contact can be limited.

16. If possible, maximize the distance of providers within teams (i.e. physician and APC may interact

remotely to accomplish virtual patient visits).

17. Providers who are ill should stay home and contact their primary care physician for guidance.

Inpatient

1. Postpone all elective surgical procedures (applies to both hospital and ambulatory surgical

center settings). These are broadly defined as cases that may be reasonably delayed without

significant risk of severe or permanent harm. These may include but are not limited to:

a. Spine cases in patients with chronic stable conditions and/or minor symptoms/deficits

(i.e. minor radiculopathy).

b. Peripheral nerve decompression.

c. Cranial cases in patients with benign and/or stable neoplastic or vascular conditions.

d. Cases that might otherwise result in the need for prolonged ICU stay especially with the

potential for prolonged ventilator support.

e. Chiari decompression.

f. Shunting for normal pressure hydrocephalus.

g. Functional cases (i.e. deep brain stimulator, vagal nerve stimulator).

h. Routine follow-up diagnostic neurovascular testing.

2. Continue to operate on patients with emergent or urgent conditions. These may include but are

not limited to:

a. Trauma (i.e. subdural or epidural hematomas, intracerebral hemorrhages, open

depressed skull fractures).

b. Spontaneous intracerebral hemorrhage.

c. Large benign tumors creating symptomatic mass effect that cannot be managed

medically, and/or obstructive hydrocephalus.

d. Malignant metastatic lesions and primary brain tumors.

e. Intracranial infection (abscess, empyema).

f. Shunting for obstructive hydrocephalus.

g. Unstable spine fractures.

h. Spinal infections (discitis/osteomyelitis).

34

i. Spinal tumors causing symptomatic mass effect and/or neurologic deficits.

j. Degenerative spinal conditions causing acute or subacute progressive myelopathy.

k. Emergent neuroendovascular diagnostic testing and interventions.

3. Avoid admissions for non-surgical care (i.e. medical treatment for sciatica).

4. Facilitate the discharge of current inpatients to home, SNF, or rehab as is deemed most

appropriate.

5. If possible, segregate staff into rotating teams between which contact can be limited.

6. Consider requesting remote consults if appropriate from other services (i.e. Neurology).

Administrative

1. To help guarantee availability, limit unnecessary travel of frontline providers (surgeons and APCs) to

prevent exposure/infection, and to avoid quarantine.

2. If possible, allow staff to work remotely.

3. Cancel all unnecessary in-person meetings.

4. Limit communications to those pertaining to immediate patient care, COVID-19 related issues, and

business critical topics.

5. Provide remote access to case conferences.

6. Continue quality initiatives such as mortality and morbidity conferences.

7. Continue clinical trials in progress. Hold on starting new trials.

8. Cancel or terminate student rotations.

9. Team huddle on a frequent basis to facilitate critical communications.

10. The guidelines outlined in this document will be reviewed and possibly modified by the Neuroscience

Executive Council of the Brain and Spine Institute on a frequent basis.

AMERICAN COLLEGE OF SURGEONS: SURGICAL CARE & COVID-19

35

Service Line: Neurology

COVID-19 Guidelines

Accountable Owners(s): Mike Busky

and Dr. Nina Paleologos

Created: March 18, 2020

Last Updated:

36

COVID -19 NEUROLOGY GUIDELINES

With these objectives in mind, the Neuroscience Service Line has identified and created the following

recommendations related to neurology:

Ambulatory

1. Screen clinics and postpone all non-essential visits.

2. Essential visits may include but are not limited to:

a. New patients with concerning symptoms that may represent conditions that if not

evaluated expeditiously may lead to severe or permanent harm.

b. Follow up patients with concerning symptoms and/or conditions or concerns that if not

evaluated may lead to severe or permanent harm.

c. Patients with conditions that require infusions or treatments which, if deferred or

postponed may lead to severe or permanent harm.

d. EMGs, EEGs, other procedures for patients with concerning symptoms that may

represent conditions that if not evaluated expeditiously may lead to severe or permanent

harm (for example progressing neuropathy, acute/progressing myopathy, subclinical

seizures, possible seizure disorder in which EEG results would likely change management,

procedures for severe medication intractable trigeminal neuralgia).

3. Non-essential visits may include but are not limited to:

a. Routine follow up of patients who do not have new, progressive or worrisome symptoms.

Imaging, if needed, may be obtained and results communicated to the patient by phone.

b. Routine surveillance of patients (for example: stable migraine, non-acute neuropathy,

stable seizure disorder, stable low grade or “benign” neoplasms) who do not have

significant new or progressive symptoms. Imaging, if needed, may be obtained and

results communicated to the patient by phone.

c. New patients who have chronic and relatively stable conditions or minor symptoms.

d. EMGs, EEGs, other procedures in patients whose symptoms are relatively stable and/or

minor (carpal tunnel, many radiculopathies, mild non acutely progressing neuropathy,

possible seizures in which the EEG is not likely to change management).

4. Consider virtual visits over the phone or telemedicine platform for new or follow up patients

requiring visits.

5. Some guidance regarding patients with Multiple Sclerosis and Neuromuscular Diseases with links

to useful websites is below.

6. For those patients who call, drop in, or who are instructed to present for an in-person visit,

adhere to the universal screening pathway and outpatient clinical pathway (for those patients

who screen positive).

7. Patients with outside imaging studies already completed may either drop off CDs or upload

imaging via LifeImage to be uploaded to PACS to facilitate virtual and inpatient visits.

8. Schedule patients 20 min apart to minimize wait time in the lobby. Patients should be separated

in all waiting areas and roomed as soon as possible.

37

9. Patients who arrive with symptoms should be masked, quarantined, and evaluated by staff

wearing appropriate PPE.

10. Place patient in the furthest chair from clinician in the exam room.

11. Allow deferral of non-acute or non-emergent exams for patients if there are no complaints on

the interview. Could add a phrase “physical exam deferred due to social distancing”.

12. Educate patients on the importance of strict hygiene and social distancing.

13. Patients should come to visits alone if possible, or if necessary due to cognitive or neurological

impairment with only one supporting individual. If warranted others may be included via phone

on speaker.

14. If possible, limit referrals for advanced imaging to ambulatory sites.

15. Educate all nurses, staff and patients on the signs and symptoms of COVID-19.

16. If possible, segregate staff into teams between which contact can be limited.

17. If possible, maximize the distance of providers within teams. (i.e. physician and APC or RN or

CMA may interact remotely to accomplish virtual patient visits or care).

18. Providers who are ill should stay home and contact their primary care physician for guidance.

Inpatient Consults

1. If possible segregate staff into rotating teams between which contact can be limited.

2. Limit the number of people having contact with patients, for example 1 APC or resident and 1

attending.

3. After discussion with referring physician consider the possibility of providing recommendations

by phone or in a focused note. Providing guidance on differential diagnosis and workup prior to

seeing a patient may help decrease the number of face – face interactions.

4. Avoid admissions for non-urgent care that may be handled over the phone or in the outpt

setting (i.e. medical treatment for sciatica, one or a few brief focal seizures).

5. Facilitate the discharge of current inpatients to home, SNF, or rehab as is deemed most

appropriate.

Administrative

1. To help guarantee availability, limit unnecessary travel of frontline providers (MDs, APCs, RNs,

PSRs, CMAs to satellite sites) to prevent exposure/infection, and to avoid quarantine.

2. If possible, allow staff to work remotely.

3. Cancel all unnecessary in-person meetings.

4. Limit communications to those pertaining to immediate patient care, COVID-19 related issues,

and business critical topics.

5. Provide remote access to case conferences.

6. Continue quality initiatives such as mortality and morbidity conferences.

7. Continue clinical trials in progress. Hold on starting new trials.

8. Cancel or terminate student rotations.

9. Team huddle on a frequent basis to facilitate critical communications.

38

Multiple Sclerosis Guidelines

MS patients should remain on their immunotherapies and follow the CDC recommendations for

limiting their risk of acquiring infection with regard to avoiding public gatherings and travel.

CDC COVID-19 HIGH RISK PATIENTS

If the patient is concerned about being at increased risk because of their medications, acknowledge

that some medications may increase the risk of illness, but that the risk of MS relapse may be more

significant, and that they should take more vigorous steps to prevent contact while remaining on their

medication.

COVID-19 & MS DISEASE MODIFYING TREATMENT

COVID-19 & MS MEDICATION MANAGEMENT

Neuromuscular Guidelines

All patients, families and providers should continue to follow the recommendations set forth by the

CDC.

The Conquer MG association put out excellent information on 3/12/20.

GBS|CIDP Foundation regarding COVID-19

Other Helpful Links

CDC

NIH

WHO

39

Service Line:

Orthopedic

COVID-19 Guidelines

Accountable Owners(s): Elaine

Kempers and Dr. Gregory Caronis

Created: March 18, 2020

Last Updated:

40

Orthopedic Service Line – Orthopedics, Podiatry It has been requested that to mitigate the potential risks of disease spread, a restriction in ambulatory patient scheduled visits, to be initiated immediately and maintained for at least the next two weeks onward, should prioritize only patients requiring urgent or acute care of their conditions. Please limit patients for ambulatory evaluation that meet the following criteria:

• Acute post-operative or fracture evaluation affecting health outcomes up to six weeks (Individual clinician discretion for patients with delayed or deteriorating outcome)

• Patients with identified acute injury, presumptive or suspected infection, mass lesion, or acute deterioration in neurologic status, joint stability, or other acute deterioration of previously stable condition

• Requested services designated as Stat, Urgent, or ASAP by the referring physician. With the guiding principles is leaving an element of discretion between the referring physicians and orthopedists is important to maintain appropriate care.

• At this time, it is requested that patients treated for chronic stable conditions, routine follow-up, requesting temporizing care such as injection, be deferred or completed telephonically at this time.

41

Service Line: Women’s

Health

COVID-19 Guidelines

Accountable Owners(s): Dr. Thomas

Iannucci and Beth Boland

Created: March 18, 2020

Last Updated:

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Women’s Health Service Line

The following guidelines have been established by the Women’s Health Service Line, in accordance with guidelines from the CDC; ACOG; SMFM; ACS and our internal physician experts. Our goal is to keep our patients and team members healthy. We want to support social distancing, as such, we encourage postponing non- essential visits. As always clinician discretion will be key in the delivery of safe, quality care for our patients and should be take into consideration with all recommendations. Below is a guide to assist in determining those visits that should be considered for deferral. These visits will be deferred through March 31 (*and preparing to extend beyond, if needed)

Ob/Gyn

1. Continue prenatal care and visits per usual as this is what is recommended by ACOG,

including ultrasounds for pregnant patients.

2. Continue to schedule labor inductions and c-sections as would otherwise be appropriate

and keep those that are already scheduled.

3. Well women visits should be delayed.

4. Post op and post-partum patients without complaints should be evaluated for possible

rescheduling at a later date. Consider a telephone/tele-med visit with an appropriate

team member/clinician to evaluate for PP/Post Op issues and for depression that may

require an office visit.

5. Visits with established patients for medication refills, UTI symptoms, yeast infections

and other necessary but not acute issues should be managed by a telephone visit with

either clinical staff or a physician. This should change to an in-person visit if symptoms

worsen.

6. If patient with an urgent but not emergent OB/Gyn need, we should continue to provide

access to care in the office to avoid patients presenting unnecessarily to the Emergency

Dept.

7. Delay visits for fertility evaluation and treatment

8. If a procedure is to be done in the office in regard to high concern for malignancy,

evaluation should not extensively delayed if at all. (see Gyn Oncology guidelines)

9. For LARCs, if the patient has no other contraception method options, they may continue

with appropriate visits for insertion of the LARC.

10. Telephone visits with physician/APN may be billed and patients should be alerted to that

when they are scheduled/initiated. Verbal consent is needed and appropriate.

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MFM 1. MFM patients will continue to be seen as scheduled, aligning with the SMFM recommendations to provide “patients with high risk conditions necessary prenatal care and antenatal surveillance when indicated”.

2. Pre-conception consultations will be rescheduled to a later date 3. Genetic counseling visits should be transitioned to phone/telehealth consultations.

Fertility

1. Defer all new visits and follow up consultations

2. Delay all procedures at our fertility center and hospital moving forward until guidance is received from the CDC and others

a. No vaginal ultrasounds with the exception of pregnancy ultrasounds for the confirmation of intrauterine pregnancy versus ectopic pregnancy

b. No intrauterine inseminations

c. No office hysteroscopy

d. No hysterosalpinograms in the hospital.

e. No hysterosonograms in the office

f. Cancelling all frozen embryo transfer cycles i. canceling all egg retrievals with the exception of the patients currently in cycle

ii. Those patients would be advised about the option of freezing eggs and deferring embryo creation

Gyn Oncology

1. New Patients:

a. All cancers and clinical scenarios that are trying to rule out cancer will be scheduled ASAP

b. All precancerous conditions including CIN, VIN, VAIN will be deferred

c. All surgically complicated benign patients (these usually come with a biopsy that is negative) will be seen after March 31st or a later date if needed.

2. Existing patients: these apply to patients without any concerns.

a. All uterine cancers greater than 2 years out from treatment/diagnosis will be moved to an appointment after March 31*

b. All pre cancer surveillance visits will be rescheduled to an appointment after March 31st

c. All vulvar cancers greater than 2 years out from treatment/diagnosis will be rescheduled until after March 31 *

d. Annual visits for cancer diagnosed 5 years or greater from now will be rescheduled to be seen after three months.

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e. All benign surveillance patients will be rescheduled to be seen in 3 months.

3. All ovary cancer patients will keep their appointments as scheduled.

Urogynecology 1. New Patients

a. Patients with Prolapse and OAB symptoms will be seen

b. Recurrent UTI patients will be seen

c. All other Patients including those with SUI only, pelvic pain, IC will be evaluated by phone for possible deferral based on severity of symptoms

2. Existing Patients: apply to patients without any concerns

a. Postop patients will be seen if surgery with the last 3 months

b. Preop appts will be postponed if surgery is to be postponed

c. Annual med check or annual postop will be deferred until after March 31*

d. Pessary checks if seen within the last 6 months will be deferred to until after March 31*

e. Med check/pelvic floor therapy follow-up will be deferred until March 31*

3. Procedures such as botox, coaptite and cystoscopy will be done at the provider’s discretion

4. Nurse visits for bladder instillations and PTNS will be evaluated on a case by case basis

Please note, this is a continually changing environment as such recommendations may change over time, so

please watch for additional updates