My Chimichurri sauce:

Fresh: Italian Parsley Cilantro Marjoram Thyme Oregano Tarragon Shallots Garlic Salt Pepper Serrano Pepper Pine nuts (roasted) Olive oil Red Wine Vinegar Lemon Zest Cumin

My good friend jthingelstad just dropped off some delicious breakfast treats on my front deck. Can’t wait for our Saturday AM Facetime Virtual Coffee time, this time with sweets!

We are piloting pulling our medical scribes out of the ED and placing them in safe nearby spaces (with social distancing). Phones, phone based applications, and tablets will be utilized. This will reduce their exposure and save PPE.

Increasingly, if you come to the ED, expect some part of the interview to occur via phone and/or tablet. This reduces healthcare worker exposure and saves PPE. Very low risk patient may entirely be seen via telemedicine, especially as limited testing continues.

Our group has developed small intubation kits, medication packs, and mapped out smaller teams (in smaller rooms) for intubation. This keeps more staff safe. Video laryngoscopy is preferred to add more distance to the aerosol source (Glidescope, CMAC, etc.)

We are working on Traffic Control Bundling for ED prep. Cohorts: Green (low risk), yellow (intermediate risk), and Red (high risk) COVID patients. Green is currently Gray (unknown risk given lack of testing). This keeps patients and staff more safe, and limits PPE.

Tips from the frontline #3: 10. One patient at a time. Know the moral lens. 11. Patients can do well on HFNC and NIPPV once COVID is everywhere (especially DNI patients). 12. As the pandemic advances over time, most ED symptoms presentations are COVID 3/3

Tips from the front line #2: 6. Operate ED command center continuously, 24/7 availability. 7. Don’t let changing uncertainty create confusion. 8. Socialize the concept of dynamic clinical guideline (they are always changing). 9. Palliative care is a critical resource. 2/3

Tips from the COVID front line in NYC, courtesy of Dr. McGreevy (via webinar): 1. Over prepare, 2. Think system and region wide response, 3. Think in phases, as this is the manner in which the pandemic unfolds, 4. Create capacity before it seems necessary. ½

Good ideas for COVID19 ED Operations: 9. Prepare intubation kids and meds, use video laryngoscopy, drill in small negative airflow rooms with small teams. 10. Practice with PAPR/CAPR hood for intubation, if not familiar. 11. Use viral filters on BVM, Vent, etc. 3/3

Good ideas for COVID19 ED Operations: 6. Decant low acuity patients away from the ED (tents, etc.). 7. Use telehealth (ipads, phones) to reduce staff exposure and save PPE. 8. Avoid High Flow Nasal Cannula and Non-Invasive PPV in favor of early intubation. 2/3

Good ideas for COVID19 ED Operations: 1. Daily emails. 2. Frequent Zoom meetings. 3. Over-communicate. 4. Maintain a central repository of updated protocols (web-based). 5. Traffic control bundling and cohort “cold”/“hot” zone patients. 1/3

It’s difficult to watch press briefings noting the wide availability of COVID testing when it’s still limited (in MN) to sick inpatients and symptomatic healthcare workers. Most patients in the ED are turned away with no testing and simply told to stay at home.

COVID-19 outcomes in the Seattle Cohort. Note the # of days on mechanical ventilation. The mortality rate was also quite high. Source: NEJM.

CXR and CT findings in COVID-19 (NEJM source). Bilateral ground glass infiltrates. This leads to low oxygen levels (hypoxia) and frequently requires ventilatory support (mechanical ventilator).

Many thanks to Medtronic for helping our hospital teams with critical flow work to prepare for this pandemic.

Benefits of Traffic Control Bundling and Risk Zone Strategy: 1. COVID19 patients are housed in the defined contamination zone rather than scatter throughout the hospital. 2. Clear Zone delineation increases the efficient use of PPE. 3. HCWs have increased trust in the workspace

The goal of Traffic Control Bundling is: 1. Reduce/Eliminate Health Care Worker infection, 2. Reduce/Eliminate nosocomial spread to patients.

Traffic Control Bundling: 4. Clear signage reminding you that you are in one zone, transitioning to another, and the guidance you must take. 5. Gloves on hand disinfection at checkpoints between zones of risk. 6. Installing alcohol dispensers for gloves at all checkpoints

We are instituting Traffic Control Bundling in many EDs (as implemented in Taiwan). 1. Triaging and dispatching patients before they enter the hospital. 2. Clear delineation of zones of risk between contaminated and clean zones. 3. Confining confirmed patients to “hot” zones

COVID-19 Minnesota: 18,822 tests. 576 positive cases. 10 deaths. 92 hospitalizations. 56 currently in the hospital. 24 of the 56 are in the ICU.