Archived Updates

25 May 2020

COVID Community Assessment Center - Given recent announcements about increased testing by Premier Doug Ford on the weekend, we have seen a large spike in patient volumes in both the CAC and ED. Although the preference is for booked appointments, walk in visits will remain available, which is consistent with direction from Ontario Health.

Testing Criteria -
- Symptomatic
- Asymptomatic but concerned about exposure to known or potential cases
- Asymptomatic and have risk from exposure in line of duty (essential workers, health care workers, etc.)

ID recommended caveats ID:
- If someone is tested, generally, they need to self-isolate until results are available.

Several questions have come of this recommendation, particularly for asymptomatic patients seeking testing, which are further clarified here by ID:
"The self-isolation post-testing for asymptomatic individuals is a discussion between the assessor and the patient. It’s about balancing an individual’s autonomy and public health.
1) If the patient is being tested due to a known exposure to a person with COVID or have been sent in by TPH as part of an outbreak investigation then they should self-isolate for 14 days from date of last exposure regardless of test result
2) If the person is an essential worker who does not meet the criteria above and is asymptomatic they can work and should follow public health messaging regarding social distancing and limiting exposures to others
3) If a person is not an essential worker and does not meet criteria 1 then they should self-isolate if feasible while awaiting test results. If self-isolation is not feasible then they should follow public health messaging regarding social distancing and limiting exposures to others."

Patients are counselled that the test is simply a ‘snapshot’ in time and a negative test today does not mean you won’t get COVID tomorrow or screen positive for COVID tomorrow.
If an individual is exposed, the best time to get the test is at least 7 days after exposure.

COVID community screening - In addition to MGH outreach to LTC and shelters, based on some "hot spot" maps shared, teams are being sent to local communities to offer universal swabbing to better survey at risk locations. This will mean that the 12-4 GP shift at the D-zone CAC may be more likely to be away.

COVID Assessment Center 2nd ED MD - June 1st till June 30th trial of 2nd ED physician coverage from 12-6pm. The intention is to staff up the CAC to manage increased volumes and allow for ongoing flexibility to bring ED cross covering shifts back to the ER to assist when needed.

12 May 2020

COVID19 Screening- Challenging to develop clear guidelines.
- Test symptomatic household contacts of MGH employees
- Test prior to initial chemo if requested by oncologist (even asymptomatic)
- No test for MGH employee prior to return to work; 14 days and 48-72hrs asymptomatic.
- No test for asymptomatic shelter patient – if outbreak concern, inform ID for shelter follow-up plan
- Test if sent by PH if has note, or seems likely that PH sent patient. Clinical judgement is key (e.g. if only telehealth suggestion)
- Consider testing if sent in by Occ. Health from private industry if seems part of structured plan.

ED COVID FU calls- REMINDER to please use this resource if appropriate. Now being EXPANDED to allow D-zone family physicians to trigger these follow up calls.

D-Zone shifts - This continues to be an important part of our ED planning. Please keep in mind that as our patient volumes increase in the ED, please monitor Power Chart and be open to returning to green/purple if the volumes are VERY low in D-zone and VERY HIGH in Green/Purple. It is critical to have a conversation with our family medicine colleagues working in this zone before leaving to ensure there is always physician coverage in D-zone.

D-Zone to Purple- To aid flow, if you are sending a patient from D-Zone to Purple; order any lab tests on a labelled orange order sheet, and order the x-ray on Powerchart.. Consider removing your name from Firstnet after patient leaves D-zone to minimize confusion as to MRP in Purple.

Wellness- Consider reviewing the excellent and comprehensive workbook for “first Aid” for frontline healthcare workers – easy to read, applicable and insightful.

Homeless PUI/COVID+ - increased bed availability for COVID+ patients, and some loosening of exclusion criteria. PUI patients with typical symptoms are admitted to medicine; atypical or asymptomatic can be discharged back to shelter.

Cardiology Consult- focus on referrals that are likely to lead to require cardiology intervention. Non-intervention cardiac diagnoses (ACS with conservative mgt, AFib, CHF with no BIPAP, pericarditis, etc.) should be referred to GIM on call. Full speciality by admitting diagnosis list here.

05 May 2020

Updates: pandemic planning has stabilized somewhat; we will try to reduce information overload by more focused and shorter friday weekly ED update meeting as well as reduced COVID 19 email updates to 3/week. The focus will try to be on major changes in the dept.

Screening: Continue to review screening criteria; available on wall of assessment centre and website here. Please don’t screen asymptomatic patients unless sent by PH or our ID team; even shelter patients should not be screened if asymptomatic.

Mental Health: Effective this week CAH patients will be sent to the general pediatric floor (G7) if they require admission. Dr. Lemke remains on call 24/7 after hours for patients who cannot be seen by the CAH (10-22) , discharged or held in the department till the following day.

ED COVID19 telephone calls: Continue to identify patients (especially if not swabbed) whom you think a clinical check-in in 2 days would be helpful (e.g. risk of deterioration, or high risk). Please confirm the contact phone number and write it on the callback form. The Recall shift is responsible for the callbacks.

ID: Isolation requirements for patients with protracted illness is a challenge; if symptoms are active URTI (rhinitis, cough, fever) consider full 14 day isolation. If Passive (body ache, fatigue or post viral symptoms) isolation beyond 2 weeks of initial symptoms may not be necessary. A negative swab done correctly has ~3% false negative rate.

AGMP: AIRVO is likely low risk AGMP, but still not supported outside of ICU and in RR1 only as bridge to ICU (see latest AIRVO flowmap). Still No BIPAP access, but discussions ongoing for post-pandemic planning. Discuss exceptional cases with ID & ICU. High flow oxygen (<15L/min) is not an AGMP even without filter. Chest compressions are NOT AGMP (PH April 6th); CPR (entire event) is. Hospital policy is still to treat chest compressions as AGMP – practice expected to be variable and challenging until sorted out. Clinical discretion is advised.

Screening Imaging: Routine CT (pre-op, etc. ) to aid in the diagnosis of COVID19 is not recommended

Physician wellness: a donation of $1700 has been made to the Distress Center of Greater Toronto on behalf of the MGH Emergency Department Physician Group in light of the recent passing of our colleague in New York Dr. Lorna Breen.

Billing practices: Many complex issues surrounding billing, shift roles/position are ongoing given large departmental and coding changes during pandemic. For now continue to practice as per previous, and please continue to code for each patient seen. New: please capture diagnosis and visit coding for COVID assessment patients

29 April 2020

ED social Event: Tomorrow night and every Thursday in May at 9pm, join us for a Zoom social meeting. Make your own Zoom cocktail!

ICU Consult: Although we are benefiting from increased ICU access and support, standard ICU consulting for non-AGMP issues apply. ICU on-call from 0800-1800; Medicine on-call 1800-0800.

Mental Health: Policies and procedures continue to be very dynamic; consider contacting Crisis/CAH crisis during day for clarification; CAH MD on call or the mental health Clinical Operations Manager after hours. Once again, we CANNOT send CAH (child and adolescent) patients to the holding or inpatient units. Follow the guidelines in the Mental Health section.

Uninsured Patients: Treat these patients like insured OHIP patients; Bill OHIP codes and submit yellow/patient list sheet to Leith through usual billing practices. No need to fill out hospital spreadsheet.

ED COVID telephone follow-up: – ED telephone follow-up pathway is now running. First call-backs occurred today and went smoothly! Please review the process carefully. Identify appropriate patients pull referral form from PINK folder and place patient sticker and complete top section on referral forms. Forms can then be placed in the GREY folders awaiting collection. Call backs will occur using the 9:30 physician and potentially morning shifts depending on volumes. We are implementing this pathway to ensure adequate follow up for those patients who do not qualify for testing and who have other risk factors who would benefit from follow up for early identification of deterioration. A follow up call at 2 days post discharge using a paper referral will be completed. The process will likely change somewhat as issues are identified. More details are available here.

Reporting of Non-Compliant COVID Patients: We have been advised by the Associate Medical Officer of Health that Public Health should be notified via public health hotline 416-338-7600 (8am-8pm) or 311 after hours for any PUIs or COVID+ patients that are believed to potentially be non-compliant with self-isolation direction to support any contact tracing and enforcement where possible.
Similar to our processes for PH notification currently in place, please have the clerk call PH hotline or 311 to connect you with PH if appropriate. We will need some time to digest the contents of this communication as a group.

Pandemic Recovery Plan: - Discussions are now starting across the medical services to look towards what the future state of practice looks like for the various divisions. It is clear that we are all interconnected and to ensure we collaboratively plan and anticipate the effects of our practices on each other this process needs to begin for the ED as well. We will discuss as a group and start examining what we anticipate the future state of practice is for our group.

23 April 2020

ED follow-up of low risk COVID19 patients: Next week we are going to start a new process to call discharged ED patients who did NOT qualify for testing, whom we think would benefit from a call (e.g. high risk,etc) to catch early deterioration. This is to help complement the Hospital’s inpatient process for same. It will initially start as a simple paper process; put the sticker of appropriate patient on paper; leave in new folder next to recall folder. Rest of process to be explained over weekend. Eventually we hope to transition to a fully electronic process
Mock Protected Code blues: Will continue weekly, but will now also incorporate elements of critical care resource triage decision making (e.g. do we intubate this person or not).
Protected Code Blue in rest of hospital: When attending a PCB in areas of the hospital that are our responsibility (e.g. first floor, DI, dialysis) priority is to “scoop and run” to RR1 to ensure proper PPE. Not really possible to do CPR at scene and maintain AGMP policy. Consider AED/defibrillator on scene in case cause is shockable rhythm prior to transport. Challenging situation with no clear algorithm yet.
OPD referrals: for planning purposes, please indicate if referred patient is a Probable/COVID+ case.
Medical Residents: Volunteer Residents will be re-introduced in mid May. Donning & Doffing proficiency will be required, but limited involvement in AGMPs will be the expectation.
Non-Clinical COVID efforts: Continue to collect the hours you spent on administrative, leadership, education, and training in relation to hospital planning for COVID pandemic between March 2nd and April 10th. These will be submitted once details are clear as there are potential funds available from the ministry.
COVID Testing: Ongoing Hospital and Provincial testing are expanding. We are now testing people in essential services, and consider testing sickest member of a HCW family; This will be adopted by our COVID clinic as well.
ER office moving: We have mostly moved to 2 rooms down the J1 Corridor past the ER conference room. Rooms have typical code button lock (review e-mail for code); one room with shoes and bags; second room an office which will have a computer soon. Billing box and computer are still in the old office. Water cooler is planned, but no other food/drinks due to sanitary and infectious concerns. There is even a washroom next to the offices!

17 April 2020

LTC transfers: Clarification: No Change to Current ED process for Transfer of patients back to LTC; They can be discharged from ED to LTC if appropriate.
D-Zone: ED Resource MD’s continue to staff D-Zone. Although occasionally appropriate to come back to ER for need, it is very important to continue our ED physician presence in the D-wing to maintain Capacity, as well as possibility of single coverage if family physician leaves to care for LTC in community.
Mental health referral continues to be dynamic and thus confusing. All patients should have the Medical clearance form filled once appropriate. During regular Crisis hours, they are seen as per usual. After hours, can be sent upstairs (either B4 if URTI/COVID concerns , or H6 if none) without contacting psychiatry on Call. There is no holding area for CAH.
Homeless referrals continue to be a challenge with daily changing criteria, and now limited resources. ONLY low risk COVID+ve patients can be referred. PUI patients should be referred to Medicine for admission.
Strongly consider holding Suicidal alcoholic patients overnight in ER , since they may develop withdrawal and medical need, but more importantly may no longer be suicidal in am and may be appropriate for ED physician discharge.
To ensure timely assessment of Purple zone patients, a visual cue in the Green zone pickup rack will be used. If volume or acuity is high in Purple zone, visual cue will be moved up as per usual triaging practice.
No Gown changes between patients if multiple droplet patients seen at same time. Always remove dirty gown before returning to desk/charting/ leaving area.
In limited Cases ED physician may remove droplet precautions from Purple zone patients after careful assessment, and patient may be moved to other ED areas (to minimize risk to patient)
If eye room is used with droplet precautions, please inform green zone team lead re: appropriate cleaning of room and used equipment
ICU will Allow AIRVO in ICU Negative pressure rooms. We can provide AIRVO in RR1 only; Consider as temporizing measure before intubation and expedited call to ICU (on a 24) to consider transfer upstairs for continued AIRVO to empty RR1 for next patient. Avoiding intubation with AIRVO in select patients may actually improve outcomes.
Further Billing issues explored; Continue to track patients seen in D-Zone and with recalls, but submit to Leith/Angela and do not bill privately. New OMA codes would only take effect in the circumstances of a declared Surge Triage Protocol. Do collect administrative and learning hours as those (TBD) will likely be reimbursed as they do not need the Surge Triage Protocol.

12 April 2020

Happy Easter & Passover! Certainly a time of reflection for the whole planet this year; I hope you all are able to reach out to help and be helped by others.

Consider the wellness Zoom meeting this Wednesday April 15th at 10:00 with Dr. Khorasani who will talk about resiliency and resources.
Some significant changes in the approach to COVID testing; a return to more testing of non-admitted high risk community individuals. More details to follow once we have a succinct document to share.
Reminder that if you see patients with exhalation valve N95 masks in the dept. to instruct them to switch to loop masks to prevent them contaminating the environment.
Upcoming risk stratification tool to allow us to make good clinical discharge decisions for COVID patients seen in the ER.
Please review the Paper Shift templates in ER to see where you are covering in the ER for your shift.
Visors are to be worn at all times, so minimize its donning and doffing – the front is considered contaminated.
Please give us some feedback on the website; we want to make it as excellent and targeted a resource as possible to the ER physicians.

10 April 2020

we are currently NOT at any level of surge or triage, and so continue to provide medical care as per the usual (protected) protocols
continue to call ICHA for homeless PUI patients, recognizing that a new facility with expanded capacity has opened up in Etobicoke. ICHA pager not answered overnight, therefore patients should be admitted.
we continue to staff D wing assessment centre even as acuity and volume in Purple Zone increases. If on Resource shift, continue to work in Assessment centre although welcome to check back in ER if help required
psychiatry referral in ED occurs as per normal between 0830-2330. Outside those hours, complete clearance form and holding orders, and do try to d/c any patients that do not need to urgently be seen by psychiatry. Child and Adolescent Health crisis is available 1000-2200 and psychiatry on-call available after these hours. These patients should not go to holding area.
MGH Covid Dashboard: https://icare.tehn.ca/coronavirus-resources/documents/covid-19-dashboard
CT is now available 24/7

06 April 2020

We are going live with an updated website! Main purpose is to greatly expand the number of documents, links and general information we can provide to you in a structured and intuitive manner. Some areas are still under construction, and small and medium changes are likely to occur now that we can get feedback in the live environment. We will keep the original site up for a few days while you accommodate to the new look. Please Contact me, David Rosenstein with any issues.
Please do not order swabs on admitted patients without COVID symptoms; this even includes patients coming from a facility with an outbreak. IPAC will follow-up.
New since a few days ago: B4 child and adolescent inpatient unit is now closed. Reasonable to assume the temporary holding area is also closed; In the Interim, CAH is now available M-F 10am-10pm.
Harmony hall can accommodate COVID patients.
We will upload the new Palliative Care order set for COVID patients as soon as it is available. It will be under the physician forms section.
Enjoy the new site!

April 02

We now have several multilingual COVID patient handouts, they can be accessed and printed from here or in the patient resources section of the website. Great job Adam.
Mock Pediatric code blue finishing up with a session tomorrow and 1 last session Monday.
Ongoing COVID preparation with CMAC Laryngoscope ordered, Innovative 3D printed Face shields to be trialed tomorrow.
Ongoing modification of standard practices including consideration of Ventolin MDI sharing if Ventolin shortages continue, changes in standard workup for first time seizure, and further development of MTC Virtual assessments.
We are again reminded to familiarize ourselves with the new MH medical clearance form for adults and adolescent to minimize issues with safe transfer out of the ER dept. Consider outpatient crisis follow-up if at all possible.

01 April

We wish to Thank Adil for having developed and managed the ER Pandemic website through its critical initial phase. We are freeing up his time to allow him to move on to other areas of preparation for the challenging days ahead.
As we progress in our planning, the original Covid 19 Working Group will be sunset with active subcommittees continuing on with any further planning for the Dept. Thank you to an amazing team, all of whom are still heavily engaged in Covid preparation activities.
Please take note of David Ng’s succinct and easy to follow new infographic on “Protected Airway Management Guideline for Hypoxia/Resp Failure” that can be found by clicking the new blue button on the right of this page.
Our upcoming Zoom meeting on Friday will first start with a Business Manager update, so plan your timing accordingly.
New increased 24/7 DI availability for both CT & US starting Monday! Ensure COVID isolation protocols are followed & communicated with DI.
ID reminds us that once vented and moved out of RR1, the COVID patient’s precautions can be downgraded to droplet.
We will be getting additional supplies by RT for our protected intubations.
For now, we continue to treat all STEMI’s as per usual CODE STEMI protocol, but they are considered PUI’s so will need to take that into account (precautions, transfer time). MGH backup TNK protocol almost complete if it comes to that eventually.
CCSO snapshot shows that almost 30% of all current critical care patients are with confirmed or presumed COVID patients.

31 March

resident program in the ER will be suspended for the next 3-4 weeks
all code blues as of April 1 at MGH to be treated as protected code blue (PCB)
resuscitation: PCB to take place in RR1 and rapidly cleared once pt stabilized/intubated; if second PCB occurs simultaneously, this takes place in RR2 and pt in RR3 moved out
temporary call rooms now available on A4. Details on how to access here.
all staff advised to wear mask when they can expect to be within 6 feet of other people (i.e. even when not seeing patients)
plan being finalized for CAH consultation 24/7 (either CAH crisis worker or psychiatrist depending on time) with ability to transfer to B4 or H6 if medically cleared (which must be documented on a specific form, available in ER). Additional details here.
clinical criteria for Yellow Zone (Intermediate Acute Care) nearly finalized and are available here. Kindly review and provide feedback to Adil.

30 March

MGH Clinical Assessment Guide for COVID19 now quick-linked from home page. It is a superb document (thanks David Ng) but should not replace individual clinical judgment.
a corrected AGMP protocol has now been posted that excludes nebulized bronchodilators. Please see here.

29 March

please note important clarification to AGMP protocol under Clinical Guidelines. Specifically, nebulized bronchodilators are not to be used in the emergency department despite the lack of clarity in the graphic
a table of ED leadership and committees has now been posted to facilitate collaboration with other leaders within the hospital

28 March

new documents added to Department Flow and Clinical Guidelines sections including an MGH ED Guide to Clinical Assessment
additional links added to Clinical Library with helpful information on intubation and COVID19 from other institutions

27 March

burden of COVID19 rapidly escalating within community
COVID19 nursing home outbreaks continue within our catchment area
droplet precautions to be used throughout all patient areas of department. Do not wear gowns at nursing stations or in common areas. Goggles now being issued upon entry. Please make sure to return them.
MTC now live for virtual visit option for appropriate patients. Surgery clinics referrals faxed through central booking or fracture clinic. Urgent referrals require approval from on-call.

Protected Code Blue

additional PCB and simulations to continue through this weekend and next week. See email from Ruchi dated Mar 27 @ 1500 for dates and times. Please attend.

26 March 2020

burden of COVID19 rapidly escalating within community
COVID19 nursing home outbreaks continue within our catchment area
virtual MTC to begin Friday, 26 March. Check with ward clerk if your pt meets criteria
please exercise caution when ordering DI for probable COVID19 pts; make note in indication box when ordering on Powerchart and request portable where possible
droplet precautions to be used throughout all patient areas of department. Do not wear gowns at nursing stations or in common areas. Goggles now being issued upon entry. Please make sure to return them.

25 March 2020

resuscitation room being transitioned to an entire negative pressure room
some drugs may soon have limited hospital inventory so conservation measures are being preemptively put into place, e.g. ventolin
note that there are now COVID19 nursing home outbreaks within our catchment area
droplet precautions to be used throughout all patient areas of department. Do not wear gowns at nursing stations or in common areas. Goggles now being issued upon entry.

Protected Code Blue

mock codes continue with increased complexity and variation. Please attend.

Department Reorganization

new mental health pathway - stable, medically-cleared psychiatric patients can now be transferred to the new H6 Mental Health Assessment Centre. Guidelines and criteria regarding this important change here. Process map depicted here (second from top).
D wing respiratory assessment centre steadily increasing patient volume and relieving pressure from Purple Zone. Any concerns contact Jessica Sampson.

24 March 2020

new drugs in ER: sugammadex and TNK
allotment of two masks per shift (request more if both become soiled)
droplet precautions to be used throughout all areas of department. Change gown and mask when soiled only; change gloves after each patient
ear loop masks with face shield now switched to goggles - pick up and return to ER conference room, clean with hydrogen peroxide before and after use

Protected Code Blue

new protocol in effecti including addition of out-of-hospital PCB (EMS call) - review protocols here
highlights: 1) pre-code or code situation - n95+droplet precautions now approved; 2) PCBs will be almost all codes in ER; 3) RR1 for PCBs, intubate and get out fast; 4) NP, FM okay for O2 delivery but no airvo or bipap, use non-humidified air only
see excellent email from Ruchi dated Mar 22 for all details

D Wing Expansion

ED now expanded into D wing, staffed by existing FM docs, 1000 and 1530 resource shifts, plus an additional ER shift 23-31 March
e-charting only in this area - instructions here (bottom of page)
patients not meeting stability criteria will be referred to Purple Zone
full details of expansion - see here and Kyle's email dated 22 March

22 March 2020

Droplet precautions to be used throughout all areas of department effective now. Change gown and mask when soiled only; change gloves after each patient
ear loop masks with face shield now switched to goggles - pick up and return to ER conference room, clean with hydrogen peroxide before and after use

Protected Code Blue

protocol has been updated effective today including addition of out-of-hospital PCB (EMS call) - review protocols here
highlights: 1) pre-code or code situation - n95+droplet precautions now approved; 2) PCBs will be almost all codes in ER; 3) RR1 for PCBs, intubate and get out fast; 4) NP, FM okay for O2 delivery but no airvo or bipap, use non-humidified air only
see excellent email from Ruchi dated Mar 22 for all details

D Wing Expansion

ED expands into D wing on Monday 23 March to relieve pressure from Purple Zone
will be staffed by existing FM docs, 1000 and 1530 resource shifts, plus an additional ER shift 23-31 March
e-charting only in this area - instructions here (bottom of page)
patients not meeting stability criteria will be referred to Purple Zone
full details of expansion - see here and Kyle's email dated 22 March

21 March 2020

please familiarize yourself with AGMP guideline here
only essential visitors for pediatric, labouring, surgical, or end-of-life patients allowed in hospital

PPE

Droplet precautions to be used throughout all areas of department effective now. Change gown and mask when soiled only; change gloves after each patient
ear loop masks with face shield now switched to goggles - pick up and return to ER conference room, clean with hydrogen peroxide before and after use

Purple Zone

staffed by 1000 and 1530 resource shifts. J1 conference room is overflow waiting area
minimize contamination: assess by phone if pt well; if entering, avoid taking pen/paper

20 March 2020

please familiarize yourself with AGMP guideline here.

PPE

Droplet precautions to be used throughout all areas of department effective March 21. Change gown and mask when soiled only; change gloves after each patient
ear loop masks with face shield now switched to goggles - pick up and return to ER conference room, clean with hydrogen peroxide before and after use

Purple Zone

staffed by 1000 and 1530 resource shifts. J1 conference room is overflow waiting area
minimize contamination: assess by phone if pt well; if entering, avoid taking pen/paper

COVID19

notify IPAC for any patient with high suspicion of COVID-19 and concern re: deterioration that requires admission to hospital
testing in ER is reserved for acutely ill patients presenting with respiratory symptoms/febrile or being admitted. Screening criteria here (near bottom of page).
only essential visitors for pediatric, labouring, surgical, or end-of-life patients allowed in hospital effective March 21 @ 0600

Hypercare

use Locating tab for up to date on-call schedules and COVID19 Resources

19 March 2020

Weekly Teleconference

Friday, 20 March @ 1000. See email for Zoom instructions.

Yellow Zone Transformation

minor trauma patients have now been moved to GZ53
newly liberated space in YZ dedicated to "clean" high acuity patients

Purple Zone

additional waiting space opened up in J1 conference room

Assessment Centre

expanding within D wing to allow >16 rooms, likely beginning Monday, 23 March

PPE

we are switching to goggles - please clean with hydrogen peroxide wipe (from green top bottle) and leave in Physician Office when done using them

COVID19 Results

Patients can now access their results online. Instructions in Clinical Tools --> Patient Resources