ICU Management of COVID19

Published 14 March 2020.

Please check Alfred ICU Intranet to ensure most up to date version as this document is being updated
regularly.

The following is specific information for management of a patient with proven or suspected Novel Coronavirus
(COVID19) in the ICU while maintaining staff safety. It should be used in conjunction with the wider hospital
guidelines. Current evidence suggests that if severe, COVID19 will present with severe respiratory failure
(ARDS) and potentially shock. There are also reports of associated cardiac and renal failure.

TOP TIPS FOR COVID19

1. Unintubated patients should preferentially be in negative pressure room. If this is not possible a
single closed room.
2. All intubated patients should be in at least a cubicle with a closed door and cohorted within an area
of the unit (general pod)
3. Set up the cubicle and equipment as per the guide at the end of this document
4. Make sure you are trained in PPE and fit checked for N95
5. There must always be a PPE monitor to check both PPE and Equipment
6. Use the intubation guide for COVID19 (Attached)
7. Be safe when you transfer COVID19 patients
8. Ensure the swabs are sent early for COVID19

Look after yourself and your colleagues, please speak up if you see something unsafe!

Contents:

1. Personal Protective Equipment

Use of Powered Air Purifying Respirators
2. Patients Location
3. Staffing and Equipment
4. Transfer of Patients
5. Laboratory Testing
6. Clinical Management of Patients
Intubation
Respiratory Failure

Appendix:

1. Intubation guide
2. Room set up
3. Equipment set up

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 Personal Protective Equipment

Precautions for staff caring for patients with proven or suspected COVID19 should include contact, droplet and
aerosol precautions as per the Alfred Infection Control Guidelines. Staff safety is an ABSOLUTE priority – let’s
look after each other and speak up if there is something not safe.

All staff who care for a patient must be accredited in use of PPE, including a fit check of the N95 mask. PPE is to
be applied as per the Alfred hospital guidelines. In combination with an N95 mask, it should be ensured that
face shields or goggles that are suitable for prolonged use are used. Hospital scrubs can be worn if that is the
preference for staff.

Staff EXCLUDED from caring for patients include staff who are:

 Pregnant or potentially pregnant,

 Immunocompromised

 Chronic Respiratory disease

 Those that cannot adequately fit an N95 mask.

 If you have a concern about your health that would prevent you working with these patients please
speak to your supervisor/manager/consultant immediately.

If a patient or multiple patients are admitted to ICU then an additional nursing team member will be
allocated as PPE monitor. This person will supervise the APPLICATION and REMOVAL of all PPE for all
staff entering the patient’s cubicle.

Use of Powered Air Purifying Respirators (PAPR)

The use of Powered Air Purifying Respirators (PAPR) may be considered for:

 Staff performing Aerosol generating procedures (AGP). AGP include intubation, bag/mask ventilation
and bronchoscopy potentially lead to an increased risk for staff.
 If a staff member is required to remain in a patient’s room continuously for a prolonged period, for
example the resuscitation of an unstable, non-ventilated patient.

To prepare, check and apply PAPR takes approximately 15 minutes. It is also vital that:

 The staff member wearing the PPE has been trained in the use of the equipment

 That another staff member is available to assist with application and removal of the equipment. This
staff member MUST have received specific training in how to apply and remove PAPR from clinical
staff.

Patients Allocation:

The ICU should only be used for the care of COVID19 patients that are critically ill. Patients will preferably be
cared for in negative ventilation rooms. If no negative ventilation rooms are available, patients will be cared for

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in single rooms with doors closed. If possible non-intubated patients, particularly if requiring intubation should
be cared for in negative ventilation rooms in preference to patients receiving mechanical ventilation.

Rooms 33,34,35,36 are positive pressure and should NOT be used.

Please use the patient allocated guide available on the intranet.

Staffing and Equipment

Waste removal and cleaning of equipment to be done as per the infection control team. Disposable equipment
should be used if possible.

Staff entering the patient’s cubicle should be minimized to those required for clinical care.

Refer to Appendix 1) for cubicle and trolley set up

Transfer of patients to ICU.

Please refer to the Transport of COVID-19 patients available on the intranet.

Patients are to be transferred to the ICU physical bed, if possible with ICU equipment already attached, prior to
commencing transfer to ICU - either from ED or the ward. Early and precise notification of the time of transfer
must be made to the IU PAN / medical coordinator to ensure appropriate preparations prior to transfer to ICU.

For patient transfer to ICU:

 Minimise staff involved in transfer

 Clear patients planned route of other staff/visitors prior to transfer

 If possible, the patient should wear a surgical mask

Laboratory Testing and Specimens.

 Please refer to the HAVE2019 Novel Coronavirus (COVID-19): Guidance for clinical staff regarding
current testing and procedure to cease isolation precautions.
 All patients must have two swabs taken (24 hours apart) and results with infectious diseases consultant
on call prior to clearance from COVID19 precautions. In very low risk patients one swab may be enough
for clearance after discussion between the ICU and ID consultant.
 Samples are sent off site and must be walked down to the pathology reception immediately – DO NOT
USE THE CHUTE. Please contact the pathology service to confirm the collection times for each day as
these are changing as demand increases and also vary from weekdays to weekends.

Clinical Management

Intubation of Patients with Coronavirus

Refer to intubation guide in appendix.

The time taken to apply PPE in an emergency situation is considerable and with PAPR is at least 15 minutes.
This needs to be considered when determining the timing of intubation or other escalation of respiratory
supports such as NIV. It needs to be ensured:

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  Intubation is performed by the practitioner most likely to achieve first pass success without
physiological compromise.

 Number of staff in the room to perform intubation can be determined by the ICU consultant, balancing
safety and minimising staff exposure. The minimum intubation team recommended is 3, ideally with an
additional staff member wearing PPE on standby outside the room.

 The airway trolley will be kept outside the room so necessary equipment should be taken into the
room for intubation, for Plan A to D. These can then be discarded or kept in the room for use on the
same patient later. Video laryngoscopy is preferred.

Management of Respiratory Failure in COVID19

Decisions around the appropriate mode of respiratory support for patients with COVID19 are complex and
should be made only by the ICU consultant(s). There are risks and benefits for the patient and staff with any
form of respiratory support including oxygen mask, high flow nasal prongs (HFNP), NIV and intubation with
mechanical ventilation.
Current international guidelines recommend that well fitted HFNP is appropriate to use if staff caring for the
patient wear PPE appropriate for aerosol precautions and the patent is in a negative ventilation room. NIV is
not recommended in hypoxic respiratory failure so for patients with COVID-19 is unlikely to offer significant
therapeutic benefit.

It is likely that the risk of aerosol transmission is reduced once the patient is intubated with a closed circuit.
Due to the challenges of intubation it is preferable to commence mechanical ventilation in a deteriorating,
unstable patient rather than continue with a high-level respiratory support such as NIV and HFNP.
Proning a patient with COVID19 is potentially beneficial and we have developed a process for this in patients
with COVID-19.

WHO provides guidance on management of severe illness: https://www.who.int/publications-detail/clinical-

management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected

Visitors

ICU reception staff to ask visitors the Alfred Health Patient questionnaire for outpatient clinicians to determine
their risk of having COVID. Visitors will only receive an orange visitor sticker once they have been asked the
screening questions. Link found via the intranet COVID19 resource page under Patient Posters.

For confirmed patients discuss with nurse manage on call:

 Allow 1 visitor per day, for one visit only
 Have the visitor call ahead to notify unit that they intend to visit.
 Place surgical mask on visitor on arrival at ICU reception
 Ensure visitor dons PPE (equivalent to staff PPE)
 Supervise safe doffing of PPE and refit surgical mask

For visitors of potential patients under the new case definition, the DHHS guidance is that there is no special
requirements (unless they themselves meet criteria for suspected COVID or unwell).

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 Appendices

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Cubicle Set Up

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Equipment Set Up

Trolley Set Up

Stock of COVID-19 PPE

The items you will need for COVID19
are on the trolley in room 36. Please
ensure this stock is strictly used for
COVID19 purpose. Please notify the
resp team in hours or ICU Equipment
nurse out of hours if items have been
depleted.

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Stock of PAPR batteries and charges
Purple box holds the PAPR batteries
and charges. Found out in resp room
clean side under bronch equipment

Stock of PAPR consumables

PAPR boxes and their consumables
items to be able to restock boxes are
located out in the equipment store
area near transport monitors, defib,
drug box area.

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