COVID-19

Page Outline

Go To PUI pathway for Suspected COVID-19
Go To MIS-C Pathway
Go To AHA PUI/COVID Resuscitations and Arrest Update

Treatment-Specific Updates

New COVID Asthma order-set for suspected COVID-19 patients:

  • Order-set has specific orders for MDIs as opposed to news to limit aerosols.
  • Located with in the ED Asthma Order-set
    • Selection box labeled FOR SUSPECTED/POSITIVE COVID-19 PTS
    • Select weight (either > 30 kg | < 30 kg)
    • It will auto-populate with MDI vs Circulaire
    • Use judiciously, as there have been MDI shortages

Enemas

  • Currently avoiding enemas during COVID pandemic
  • If hard stool found on rectal examination, prescribe home enema or MiraLAX.
  • If there is a true concern for impaction with failed home clean-out requiring inpatient disimpaction, discuss with inpatient GI fellow or attending.
  • In extremely rare cases where an enema is ordered in the ED, inform charge nurse because restroom that is used will have to be cleaned immediately afterward.

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General Principles

  • For PUIs, try to limit exposure (both providers, nurses, and ancillary staff) as much as possible.
    • For well appearing patients with stable vital signs, best practice is to minimize work up, give strict return precautions, and resources for community COVID-19 testing if deemed necessary.
  • Only 1 parent/caregiver back to a room with PUI patient. No exceptions.
  • Avoid aerosolizing modalities such as HFNC or NIPV (i.e., CPAP, BiPAP) if able.
    • You may have to have a lower threshold for intubation.
    • If you anticipate NIPV, consult PICU earlier and transport to PICU before initiating.

Follow NIH Treatment Guidelines for Pediatrics

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ED COVID Testing Guidelines

Outpatient Guidelines (Discharged home):

Live as of December 10, 2020

Patients that are being tested in the ED should have been sent or elected to go to the ED for ED-related illness evaluation and not sent/presented specifically for testing even if they have symptoms. We are not a “testing site” as this will cause undo surge that may delay care to patients that are sick and need urgent/emergent evaluation and management.

Appropriate for testing:

  • Symptomatic or high risk patients with symptoms consistent with COVID-19 without another explanation for symptoms. Symptoms can appear between 2-14 after exposure.
    (Per CDC Definition)
    • Fever or chills
    • Cough
    • Shortness of breath of difficulty breathing
    • Fatigue
    • Muscle of body aches
    • Headache
    • New loss of taste or smell
    • Sore throat
    • Congestion or runny nose
    • Nausea or vomiting
    • Diarrhea

Not appropriate for testing:

  • Asymptomatic patients being discharged home

Ordering COVID test:

  • Enter “COVID-PCR” and in comments enter “NASAL swab“
  • Results in 48-72 hours

Specifics and Testing Follow-up:

  • Specimens will be collected using NASAL swab (as opposed to nasopharyngeal swab)
  • RTs, RNs, and CAs will be able to obtain specimens
  • Specimens will be batched as they will have to walked to Lab. Patients can be discharged home
  • If COVID positive, Infection Control is to fill out ADPH form (not needed for negatives)
  • For test results:
    • Available in Patient Portal in 72 hours (DO NOT CALL ED for results)
    • ED follow up nurses will call patient/family with POSITIVE results ONLY
    • Negative results available on portal
  • HERE for Patient handouts and will be available on “Disposition Handout Instructions”
  • HERE for School notes and Instructions

Inpatient Testing (Admissions):

  • We are are doing universal testing for all admissions
    • Admitting team will be ordering COVID tests
    • You may be asked to order test between 4AM and 12PM
    • If ordering in the ED, order both VRPL (PCR) and COVID-19 qPCR test
    • Test can be done with only 1 swab in viral media
    • Notify charge nurse if testing the patient in the ED
  • COVID-19 tests are run twice a day during the week (0630 and 1200), once on weekends (0800)
    • 1st run: specimens delivered to COA Main Lab by 0630 – results by 1200
    • 2nd run: specimens arriving from 0630 to 1200 – results by 1700
      • Specimens received after 1200 will be tested the following day, as above.
    • Weekend specimens received by 0800 – results by 1430.
      • Specimens received after 0800 will be tested the following day.
  • ADPH form should be filled out by admitting team (for follow up results)
  • PUI vs COVID+ Bed placement and bed requests:
    • On bed request document, remember to state whether patient is PUI
    • For PUI vs screening definition, see COVID algorithm
    • PUIs and COVID+ can go to 7Dearth (only acute care) or PICU (SCU & PICU status)
    • SCU ONLY taking known COVID+ patients (not PUI or COVID pending)
    • Outside COVID results and PUI vs non-PUI:
      • Non-PUI if outside test was PCR and done within 24 hours
      • Still PUI if test was not PCR, done > 24 hours, or if type of test is unknown
      • FDA COVID-19 Testing Basics

Admission to COA inpatient psych:

  • All COA Inpt psych admissions must have COVID19 testing and NEGATIVE results BEFORE admission to inpatient psych units.
    • Patient must WAIT in the ER until negative test results.

Admissions to UAB, Grandview, and Hillcrest inpatient psych units:

  • All admissions require COVID-19 testing in ED AND NEGATIVE results before transfer. 

Rapid (Cepheid) COVID-19 Testing:

  • Requirements for rapid testing:
    • Behavioral health patients being admitted that have a bed available
    • Behavioral health patients accepted as a transfer to another facility
      • Weekdays: between noon and 0300 (after 0300, wait for AM lab test)
      • Weekends: after 0830
    • Post-heart transplant outpatients undergoing heart biopsy
  • Ordering provider to call lab at (205) 638-9577 to order test
    • Provide patient’s MRN, COVID exposures, signs, and symptoms
    • Lab will place a verbal order and RT will collect

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COVID-Specific Operations

Staff Masking Policy:

  • As 4/9/2020 all staff on PICU, 7Dearth, and ED are REQUIRED to wear masks.
  • Staff welcome to use cloth masks or masks handed out at Employee Screening Stations.
  • Homemade/donated masks can be worn around unit or in patient rooms not on isolation.
  • Staff must wear regular surgical masks while at bedside for all patients on isolation.
  • Please store regular surgical masks in brown paper bags for reuse.
  • Please do not give masks out to any other patient parents/guardians that are not on isolation

Psych consults:

  • Call the PIRC (8-7472), Voalte, or page PIRC Therapists to request a consult.
  • Admissions in setting of known POSITIVE COVID-19:
    • If 1:1 observation is required, admit to PICU
    • 7Dearth rooms cannot provide observation without sitter being in the room
    • If no 1:1 observation required, admit to 7Dearth
    • Psych will provide daily evaluations and therapy

RNICU admissions:

  • Still taking infants needing ICU care (febrile, ALTE, BRUE).
  • RNICU will perform COVID-19 testing upon the patient’s arrival to their unit.

Reporting PUI or COVID+ deaths to Medical Examiner:

  • MD in charge of patient care to report to Medical Examiner’s office: 205-930-3603
  • Select option #1 if M-F 8:00AM – 3:00PM.
  • Select option #3 after hours and on weekends.

Peds Pathway:

  • PUI and febrile PP patients will be placed on Sports.
  • Non-PUI or febrile patients will continue to be placed in PP.
  • PP physicians will see PP patients on Sports.

School Excuses:

  • School excuses for febrile children.
  • If tested for COVID and discharge, see school note info ABOVE
  • Follow up nurses are able to approve excuses for up to 10 days following the onset of fever for patients who result positive after discharge – per CDC recommendations.

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N95 Mask Disinfection

  1. Obtain mask from Central Distribution (x9028) with a brown paper bag.
  2. Continue to use the mask for one week or until soiled.
  3. Label the outside of the mask with first initial, last name, date put in service and unit or resident designation.
  4. After one week of use place in the brown paper bag and print information on mask on the outside of brown paper bag
  5. There are two options for getting the mask reprocessed (disinfected). 
    • Consolidate with the masks of the unit that you primarily work on.
    • Take the mask to Sterile Processing Department (SPD) on the 4th floor of Benjamin Russell.
    • If dropping of in Sterile Processing Department, there is a call button at the double doors and someone will let you in if your badge does not give you access.
    • Place the mask on the cart on the right side of the hallway and sign the log book.
    • The mask should be reprocessed within 24 hours and can be picked up from where you dropped the mask off.
    • If the mask is in a white paper bag, then it has been reprocessed and labelled appropriately.
    • Each mask can only be reprocessed three times and should be returned to SPD the week after the third reprocessing.
  6. Documents that go with this update include the N95 Mask Policy, an example photo of mask labeling, and the log sheet in SPD. 
Instructions on Reuse of N95 (Dr. Davis email)Download

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Outpatient/Community Testing Resources

ADPH site for testing sites based on county of residence
JCDH Pediatric COVID-19 Drive thru testing

General COVID-19 Handouts for Patients:

UAB COVID-19 Handouts
UAB COVID-19 Handouts (Spanish)
UAB Community Resources

For Employees:

CDC COVID-19 Updates
White House Coronavirus Guidelines
Johns Hopkins COVID-19 Tracker
Institute for Health Metrics and Evaluation (IHME) Alabama
Institute for Health Metrics and Evaluation (IHME) United States
UAB Department of Pediatrics Resources
COVID-19 Wellness Resources
COVID-19-related articles (updated 5/18/2020)
Department of Pediatrics PPE Guidelines.
ADPH Guidelines for Alternative SARS-CoV-2 testing.
ADPH COVID-19 website.
List of Counterfeit Respirators / Misrepresentation of NIOSH-Approval
CDC Recommendation Regarding the Use of Cloth Face Coverings, Especially in Areas of Significant Community-Based Transmission (4/4/2020)

Disclaimer: These clinical pathways are intended to be a guide specifically for residents, fellows, CRNPs, and physicians (“practitioners”) at Children’s of Alabama (“COA”). These clinical pathways may be adapted for each patient depending on clinical scenarios based on the practitioner’s judgment, consideration of unique circumstances, needs of the patient and their respective family, and availability of resources of where the patient is located. These clinical pathways are not to be construed as medical advice or treatment. COA does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one of more of them apply to a particular patient or medical condition. COA is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.