Orlando ED: Recent Episodes
Blake, Max, Patti
CRITICAL CARE, MEDICINE, & ED PHYSICIAN LEADERSHIP COVID CONFERENCE 7-15-20
- ICU physician consultation process
- 6 hour + ED ICU holds should consider ICU consult
- ICU Consult - put in consult to the critical care or call them and ask for a consult
- PCU borderline patients - narrowed fio2 >50%, >RR rate, comorbid conditions - employing consultation with pulmonary or ID, ICU downgrades watch very carefully
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Increase severity of patients going to PCU - 10% ICU conversion rate observed
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should we start the Covid power plan?
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- Probably start to help identify care needs in the ED
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should we have full ICU admit orders
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- Probably to start identifying care needs of patient
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should we initiate the ICU vent power plan
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- Very labor intensive plan
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should we initiate the sedation and vasoactive agents ICU power plan
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- Basic sedation order sets
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Does the ED power plans differ much from the ICU power plans for Vents, vasoactive, etc?
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- Similar order sets, will review with critical care physicians
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Should prone in the ED possible or should be avoided
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- Very labor intensive process, difficult to perform in the ICU
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Will nurses follow the orders and tasks
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- Nursing / physician leadership task force to work and help implement ICU admit hold orders
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Fluid Resuscitation
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- treat the symptom, give normal resuscitative fluid bolus as clinically indicated. Treat shock with resuscitation
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10.Medications / Novel Therapies
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- Anticoagulation - prophylaxis initially
- Ketamine and paralysis- for dysonchrony / refractory hypoxemia
- Antibiotics - CAP / HCAP based on classification (nursing home, etc.)
- Plasma - not for ED ICU holds, long wait list.
- Steroids - best benefit from literature is later presentation, doesnt have to be in the ED
- Remdesivir - shortage of this medication, dosage can wait until ICU admission
- Hyrdoxychlorquine - questionable utility, not recommended
- Tocilizumab - cytokine storm presentation patients that are ventilated may benefit. Will be prescribed by critical care or ID
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Capacity
Hospital very full
Expanding ICU units to alternative locations (NICU, PCU)
ICU Capacity very tight - each transfer being reviewed based on needs
ICU ECMO at south full - no additional capacity
Ventilators - some strategic changes in vent types based on location, RT and ICU updated. Plenty of vent
We discussed updates to our clinical care processes in Central Florida.
Testing- We continue to utilize the PCR test as the gold standard and are working to introduce the antigen test for specific applications
Capacity - very limited / very full. Idea to create another COVID ICU. ICU transfers to other campuses already occurring.
ED ICU Holds - Consult the local ICU physician for prolonged ICU holds. They will help with evaluation and long term care orders
We met with the clinical leaders of ED, critical care, and hospital medicine to discuss updates in patient care in our central Florida Hospitals.
The ICU and ED leadership set up a series of meetings to discuss best clinical practice recommendations. This is the recording of the meeting on 4-15-20
At the end of November we will begin a new way to admit and transfer patients. Dr Sanjay Pattani is lead this innovative initiative and we sat down to speak with him.
Blake and Max discuss the MIPS 2018-2019 measurements. Make sure to sign your attesation online.
Test of using podcast for our weekly campus update. Let us know how you like it. well make it more fun and improved audio in future episodes.