Thread by @BrighamSK

Well, @TheCurbsiders, it’s been over a week since I’ve posted here… but it seems like it’s been mere days. #COVID19 has not necessarily overwhelmed our hospital system, but has absorbed our lives.

Resources will be included in this "Tweetorial"

covid19toolbox.com

Our colleages at @SCCM has put out some excellent resources for treating #COVID19 patients. I've asked all our staff to review the modules at:

sccm.org/Disaster/COVID…

Furthermore, @SCCM released some guidelines that can be helpful; however, as this information is ridiculously fast moving, these guidelines may be approaching obsolescence as time goes on.

sccm.org/getattachment/…

The most appropriate “case definition” is still beingrefined, but includes gastrointestinal symptoms (>50%), fevers (>70%),lymphopenia (>60%), and multiple other signs/symptoms.

Cardiac manifestations are commonly present, especially inpatients that do not survive. This includes myocardial injury, myocarditis, heart failure, arrhythmias...

Poorly predictive factors include lymphopenia severity, ALT(>40), D-Dimer (>1), LDH (>245), Ferritin (>300), qSOFA (>0),and presence of cardiac involvement (myocarditis, infarction, heart failure) which CAN be a late manifestation AFTER recovery from respiratory failure.

Some of the most interesting presenting symptoms actuallyinclude anosmia, hyposmia, or dysgeusia which can oftentimes beoverlooked. AAO-HNS actually recommendpatient self-quarantine if they endorse these symptoms.

I’m uncertain of thiswisdom, especially as these symptoms can present with allergic rhinitis aswell. It is worth considering, however.

Additionally, GI Symptoms are actually fairly common in #COVID19 with diarrhea (~34%) and anorexia (~79%) being the most common.

journals.lww.com/ajg/Documents/…

Imaging criteria might miss some patients andcannot be used in isolation; neither should a negative RT-PCR exclude thediagnosis, especially in cases of primary pulmonary disease. In the case below, a gentleman was initially diagnosed with a "Lobar PNA," but check the CT.

However, not all patients with #COVID19 have abnormal imaging.

If a patient presents w/Viral URI syndrome without a source, COVID-19 must be considered, especially if the patient has unexplained lymphopenia and radiographic findings suggestiveof disease. A negative NP RT-PCR shouldnot be considered an effective rule-out in these cases.

The next series of tweets focus on what we have done with our own hospital system.

Outpatient clinics have transitioned to #Telehealth almost exclusively, possibly for the better. @CMSGov has relaxed multiple rules to include interstate licensure, 3-midnight rule, DME requirements, etc. It will be hard to reinstate these rules after this is over, for sure.

Here is the initial @CMSGov release for your reference:

cms.gov/files/document…

Additional @CMSGov #COVID19 toolkits available here as well:

cms.gov/outreach-educa…

Additionally, #HIPAA rules have changed for #COVID19 patients to cover telecommunications technologies not routinely used for patient care.

hhs.gov/hipaa/for-prof…

Inpatient services have instituted multiple workflow changes and, now, we have three wards dedicated to #COVID19 PUIs and confirmed cases with one ICU ward; all of this is surely to change.

Right now, only staff physicians provide direct face-to-face care while residents help with workflow, documentation, calling patients ahead of time, rounding telephonically. This reduces overall exposure risk.

We are establishing multiple international networks and, to that end, I've already sat in on teleconferences with Italy, China, and have constant contact with South Korea and Japan even now. This is unheard of... and very welcomed indeed.

Currently, I'm working with some fantastic programmers to develop a web portal to autopopulate a Microsoft SQL database to identify trends, diagnostic factors, etc. Ultimately, we should be able to hone a case definition that might avoid RT-PCR or imaging.

FDA approves convalescent plasma (not sure where to put this... so here you go):

fda.gov/vaccines-blood…

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