Note: This document adapts prior pandemic and Influenza-Like Illness (ILI) guidance to the current COVID-19 crisis. This document has been developed by the Provincial Critical Care Adult COVID-19 Working Group.This material is intended for general information only and is provided on an "as is", "where is" basis. Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or statutory, as to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. AHS staff who require legal advice regarding copyright should contact the Corporate & Commercial Division within AHS Legal & Privacy for further assistance. Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use.The links in this document are updated regularly and should be periodically reviewed.# Intention for use:
- To guide all providers of critical care in Alberta as to the basic care of adult critically ill patients with suspected, probable or confirmed COVID-19 infection to ensure such patients receive optimal, consistent and equitable care throughout the ICUs of Alberta. o Recognize that the application of the guidance in this document will need to be adapted to the characteristics of each individual unit, zone and department. o This guideline is not meant to be applied to patient groups outside of critical care units.  o "Humidity should be preferentially provided via in-line HME devices. Active/heated humidity systems should only be used when necessary (e.g., to manage difficult secretions or to provide inhaled epoprostenol) and only when such a system is part of a fixed integral part of a particular ventilator"

# AHS COVID-19 Website

# Table of Contents
- Replace prostacyclin with epoprostenol April 13, 2020
Robertson/Morrissey/Bagshaw/Zuege based on feedback from Provincial Working Group, feedback from the provincial critical care community and updated AHS Guidance documents. 

# Surveillance
Case Description for COVID-19 COVID-19 is an infectious syndrome caused by SARS-CoV-2, a novel coronavirus. COVID-19 is believed to be spread primarily via respiratory droplets (similar to influenza and other coronaviruses such as MERS and SARS) and/or contact (e.g., contaminated hands to mucous membranes). Numerous genetic variants of SARS-CoV-2 are now known to exist in addition to the original 'wild' type. Some variants may have differences in transmissibility and/or pathogenicity.

# Clinical Presentation
- Individuals infected with the virus that causes COVID-19 may have few or no symptoms and may range from mild to severe, life-threatening illness, with manifestations including fever greater than 38C (>90% of cases), new onset or exacerbation of chronic cough (80% of cases), shortness of breath (20% of cases), difficulty breathing, sore throat or runny nose. Canadian SPRINT-SARI Characteristic Data March 2021 - Severe disease from COVID-19 infection can cause viral pneumonia and respiratory failure, sepsis, septic shock and multi-organ failure or death.
- Susceptibility is assumed to be universal.
- The virus appears to cause more severe disease in older adults (greater than 60 years of age) and individuals with underlying comorbidities (e.g., cardiovascular, renal and liver disorders, diabetes and chronic respiratory diseases) or immune compromising conditions.
- There is evolving understanding of the immune response in COVID-19 disease, and the possibility of reinfection with SARS-CoV-2 has not been excluded. - All patients are to be assessed initially for symptoms and risk factors associated with respiratory communicable disease using Form 21615: Communicable Disease (Respiratory) Initial Screening Form (or equivalent electronic version).
- The initial assessment will then inform the use of AHS Acute Care COVID-19 Expanded Testing Algorithm.
- Ongoing assessment of admitted patients is to be completed using When an AGMP is in progress the following poster may be utilized: AGMP Poster There is no settle time required after AGMP is complete  5. Due to the high risk of aerosol generation, critically ill patients with suspected, probable or confirmed positive COVID-19 will be admitted to single patient rooms when available.
- Negative pressure (airborne isolation) rooms are not required and should be reserved for patients with disease processes requiring airborne isolation but may be utilized if available.
- If all single patient rooms are occupied, then attempt to cohort COVID-19 patients in one area with a minimum 2-meter separation between patients. IP&C guidance on cohorting of patients should be reviewed.
Of note, given the presence of SARS-CoV-2 variants, before considering cohorting patients with COVID-19 in the same room, the viral subtype must be identified (eg wild type or variant) for both patients being considered for cohorting. Viruses from all COVID-positive patients in Alberta are being subtyped with turn-around times currently being approximately 6 days. Viral subtyping results are not currently available within existing electronic medical records (though this is being actively explored).
- Strain typing of COVID-19 must be considered when cohorting.
- Patients with unknown COVID-19 strain are not to be cohorted.
- ii. If the patient is intubated, an ETA should be collected as soon as possible and sent for respiratory viral testing (irrespective of whether an NPS has been collected).
- If the patient is not intubated and has not had an NPS sent for respiratory viral testing, then an NPS should be collected as soon as possible.
- If there is a clinical possibility of other more unusual pathogens (e.g., as in an immunosuppressed patient), consideration should be given to performing bronchoalveolar lavage (BAL) recognizing that bronchoscopy is an aerosol generating medical procedure (AGMP).
- Bronchoscopy solely for the purposes of microbial sampling in an otherwise uncomplicated patient is not recommended. 8. If patient is intubated: a. Transport using an in-line filter, in-line suction catheter and heat moisture exchange filter (HMEF). b. Use of transport ventilators (with filtering systems) is preferred to minimize the need for manual bagging. If use of a transport ventilator is not possible, use a manual bagging unit (with PEEP valve). c. RRT will manage airway and oxygen requirements. d. Clean and disinfect transport ventilator after use and discard breathing circuit.
- If patient is not intubated: a. Transport with non-humidified (dry) oxygen supply -respiratory to identify the most appropriate oxygen delivery mask. b. Patients receiving oxygen by any type of nasal cannula should be given a procedure mask to wear if tolerated.
- Clean O2 cylinder(s) and transport stretcher with disinfectant wipes before returning to general circulation.

# Staffing Considerations
The principle is to minimize the number of staff involved directly with the patient while providing quality patient care.
- The nurse in charge and the respiratory therapy supervisor are responsible to determine patient assignments and will coordinate care of all patients in the unit with the principle in mind that the total number of staff caring for a COVID-19 patient should be kept to a minimum. If possible, cohort staff so that RNs and RRTs caring for COVID-19 patients are not caring for non-COVID-19 patients. Geographical cohorting of COVID-19 patients may assist with staff assignments if appropriate to facilitate.
- All members of the healthcare team, inclusive of MRHP, NPs, RNs, RRTs, allied health, and support staff will continue to perform their usual duties. They must review and adhere to all appropriate isolation precautions prior to entering rooms.
- For students (medical or otherwise) working within an ICU, please check with current educational institution guidelines for any restrictions to practice or exposures.
- Individuals who are unable to competently adhere to the IP&C recommendations for COVID-19 (e.g., skin condition that precludes proper hand hygiene practices) should not provide care to patients who are under investigation for COVID-19, or those who have suspected, probable or confirmed COVID-19. Staff who are unable to be Fit Tested for N95 respirators should not care for COVID-19 patients that are intubated or those that require any AGMP.
- During a pandemic there may be a need to move towards team-based models of care delivery during surge. Although the structure of each team model (staff mix, staff to patient ratio) are site specific, there are common facilitating elements to team based model functionality.

# Resources for Team-Based Care Models during Pandemic

# Infection, Prevention and Control
Suspected, probable or confirmed positive COVID-19 cases in the ICU should be managed with contact and droplet precautions. Use N95 respirators for all aerosol generating medical procedures (Aerosol Generating Medical Procedure GuidanceTool) and for all suspected, probable or confirmed positive COVID-19 intubated patients.
Interim IPC Recommendations COVID-19
- All staff providing care must be successfully N95 fit tested and masks must be seal checked when applying.
- Continuous masking and eye protection must be adhered to in patient care areas. 

# PPE Guidance:
The following link contains all up to date information on PPE and should be reviewed periodically: Personal Protective Equipment (PPE).
Applying N95 respirators: All health care workers must have been fit tested within the last two years. Hold mask in your hand and pull both elastic ties, bottom first, over your hand for ease of putting mask on. Test to ensure that mask is secure and that there are no leaks. Discard immediately outside of room after use. Do not touch the outside of the mask while discarding as it is considered contaminated.
Proper wearing of an N95 respirator includes:
- Putting on the respirator before entering the patient's room.
- Molding the metal bar over the nose.
- Ensuring an airtight seal on the face, over top of the nose and under the chin. - Donning eye protection after N95 for AGMP.
- Leaving the room and changing the respirator when it becomes moist.
- Removing the respirator after leaving the patient's room by touching elastic only.
- Not wearing respirator around the neck.

# Personal Protective Equipment (PPE) Guidance to Help Make Continuous Masking Work for You
Eye protection (disposable face shields/goggles): Face shields or goggles are to be worn upon entering the patient room. Personal eyewear (glasses) is not sufficient. Face shields are single use. Discard face shields outside of the room after use. If googles are re-used they must be fully wiped down with disinfectant wipes prior to re-use.
Gloves: Always perform hand hygiene prior to putting on gloves and after removal. 

# General ICU Care
- Reduce all clinically unnecessary entries into the room.
See Appendix E for strategies to conserve personal protective equipment (PPE). 1. Point of Care Risk Assessment (PCRA) should be completed by all health care workers before initiating any resuscitation. 2. The AHS Scientific Advisory Committee has determined that the provision of chest compressions alone is not considered to be an aerosol generating medical procedure (AGMP) and only requires contact and droplet PPE.
- Assume patient is COVID-19 positive, unless otherwise identified/known.
- Consideration that the location of resuscitation may influence response and team processes (i.e. Critical Care Unit vs. Inpatient Unit or Emergency Department (ED)).
- Minimize number of participants in the resuscitation area during resuscitation. 6. Minimize equipment in the resuscitation area wherever possible. 7. If CPR is indicated, chest compressions alone can be initiated safely by a provider wearing contact/droplet PPE. 8. Contact and droplet precautions (including a fit-tested N95 respirator) shall be donned prior to initiating any AGMP (including manual ventilation and airway management) by all response team members, even if there is a perceived delay in resuscitation efforts. 9. Routine practices, such as defibrillation are otherwise unchanged from non-COVID-19 patients.
Communication:
- Current paging/notification processes should be followed.
- Clear identification of isolation requirements should be made to the response team on arrival. - Clear communication of current GOC status should be made to the responding resuscitation team members on arrival, where available/known. - Upon arrival to the code, team members should quickly clarify roles and which members will be working inside versus outside the room.
Arrival to Code Blue:
- Ensure that PPE is readily available for responding team members and that there is an available "safety/logistics officer' to monitor donning/doffing. Since the availability of suitable PPE in enough quantities at the site of the arrest may not be guaranteed, the use of PPE pre-made kits should be considered, to travel with the response team or to be stored with code carts (where possible). - Chest compressions alone are not an AGMP and an N95 respirator is not required to initiate hands-only CPR. Healthcare workers completing manual chest compressions are directed to continue to wear recommended PPE in alignment with our continuous masking directive, the point-of-care risk assessment, with the addition of contact and droplet precautions for patients with suspected, probable or confirmed positive COVID-19. Outside the room:
- RN/HCW "runner", to assist with supply of equipment stored on the unit and the activation of other HCWs, if required. - "Logistic/Safety Officer", who should be a senior HCW, to regulate access to the patient's room, monitor proper PPE donning and doffing, ensure that protocols and the opening and closing of doors is followed and communicate with the ICU prior to the initiation of patient transport.
Modifications to Advanced Cardiac Life Support (ACLS) in COVID-19 Patients:
- Intubate patients early and hold CPR during intubation to minimize aerosolization of particles and optimize intubation success. - The best pharmacotherapy for induction and intubation will be determined by the MRHP on a case-by-case basis but in general should include strategies that minimize chances of cough or aerosol generation via use of agents inducing deep sedation and often use of neuromuscular blockade when clinically appropriate (e.g. no signs predicting difficult intubation). - Manual bagging of non-intubated patients using a BVM should be avoided if possible. If necessary because of unsuccessful initial intubation, use two experienced practitioners to establish an intact seal and minimize the risk of aerosolization. - Avoid disconnections between the ETT and resuscitation bag. If required due to gas trapping, the plan to disconnect should be announced loudly in advance and the ETT should only be disconnected beyond the HEPA filter.
Post-Arrest: to minimize the need for manual bagging. - Transportation to a critical care unit should follow guidelines listed in Section D of this document. - For patients being transported to an ICU or an advanced care unit in a facility, consideration should be given to testing that can be safely completed on route to minimize the need for additional transports (e.g. CT scan).
Charting Considerations:
- Computer code narrator may be utilized with existing computers within the room or immediately outside the resuscitation room.
- No portable computer devices should be brought into the room.
- All efforts to maintain a clean paper chart should be taken.
- Papers are not a means of transmission. Handle all paper with clean hands, clean any shared items (like chart binders, pens or binders) with a low-level disinfectant wipe. o Transcribing for purposes of infection prevention will not be required.

# Respiratory Care
The basic principles are to always use personal protective equipment in addition to appropriate isolation precautions and minimize the use of aerosol-generating procedures.
For Non-Intubated Patients:
- Provide O2 as ordered with continuous SpO2 monitoring. 2. For patients receiving oxygen by any type of nasal cannula outside of single rooms should be given a procedure mask to wear, so to reduce others' exposure to cough/sneeze droplet spread, if tolerated. 3. Patients should be cared for with the head of bed elevated 30-45 degrees. 4. Minimize use of sedative and analgesic therapies (other than for palliative care). 5. No peak flow monitoring. 6. Nebulization should be avoided and be used only as an exception. Memorandum: Restricted use of Nebulized Treatment for Covid-19 7. Bronchodilator delivery via MDI via spacer is preferred if patients can effectively utilize. 8. If patient is on HHHF or NIV, aerosolization should be administered via in-line devices, rather than disconnection and delivery of MDI. 9. The evidence base for the efficacy and safety of awake prone positioning of nonintubated COVID-19 patients with hypoxemic respiratory failure is not well established and hence this practice is not recommended for routine or generalized application in this population of patients in the ICU. This does not preclude the selected use of this procedure based on best clinical judgement. Clinical trials of awake prone positioning are active and enrolling in various facilities in Alberta and consideration for trial participation is strongly encouraged. The following trials are currently underway in Alberta:
- COVI-PRONE CLINICAL TRIAL - CORONA
If this procedure is used, given uncertain efficacy and safety and the observation of significant failure rates with the need for more advanced management, there should be careful consideration of appropriate patient selection (fully awake and cooperative without hemodynamic instability or current signs of impending respiratory failure), initial tolerance and ongoing close monitoring needs. Patients should be closely monitored for evidence of clinical deterioration.
Heated Humidified High Flow Oxygen therapy devices (AIRVO, Optiflow or Vapotherm):
- Aerosolization of respiratory secretions may result from high flow heated humidity oxygen therapy devices and use of this therapy is considered a continuous AGMP. - The clinical efficacy in clinical trials of heated high flow oxygen therapy to support patients with significant acute hypoxemic respiratory failure is mixed with significant failure rates and the need for more advanced management.
- As such, the selective use of this procedure in the ICU for this population may be considered based on best clinical judgement. Patients should be closely monitored for evidence of clinical deterioration. - If used in patients with suspected or confirmed COVID-19 infection, treatment must be performed in a single patient room with the door closed and with staff using appropriate contact and droplet precautions, including use of N95 respirators.
Non-Invasive Ventilation (CPAP or BIPAP):
- Non-invasive positive pressure ventilation (NIV) may result in aerosolization of respiratory secretions and is considered a continuous AGMP. - The clinical efficacy of NIV in clinical trials of patients with significant acute hypoxemic respiratory failure is unproven with significant failure rates and the need for more advanced management. - As such, NIV is not recommended for routine use in suspected or confirmed COVID-19 patients with hypoxemic respiratory failure in the ICU. This does not preclude the selected use of this procedure based on best clinical judgement in patients presenting with patterns more suggestive of cardiogenic pulmonary edema or obstructive lung disease. - Patients with hemodynamic instability, multi-organ failure, or abnormal mental status are at high risk for failure and should not receive NIV. - Pro-active intubation under less emergent conditions is the preferred strategy and should be considered. - If NIV is used in patients with suspected, probable or confirmed COVID-19 infection, NIV treatment must be performed in a single patient room with the door closed and with staff using appropriate contact and droplet precautions, including use of N95 respirators. - During the COVID-19 pandemic, nocturnal CPAP will not be routinely used for hospitalized patients with OSA since it is an AGMP. Chronic CPAP or NIV should be continued only when deemed essential (i.e. life-sustaining). Consult pulmonary medicine as needed to help define the necessity of use during hospitalization. If therapy is deemed non-essential while the patient is admitted, then consider routinely reassessing to determine when it may safely be resumed.

# AHS Scientific Rapid Response Report: Oxygen Therapy Recommendations
Tracheostomy care and management in the non-ventilated patient:
Patients spontaneously breathing via a tracheostomy and remaining on contact and droplet precautions for COVID-19 should:
- Continue to be managed in single patient rooms with use of appropriate PPE.
- Provide humidity as indicated and per current practice.
- Closed suction systems are recommended for these patients.
If single patient rooms are unavailable, patients cohorting may be considered. See guidance. IP&C Cohorting Recommendations for COVID-19 in Acute Care Intubation Guidelines:
Moderate to severe hypoxemic respiratory failure/ARDS usually requires support with endotracheal intubation and mechanical ventilation. NIV and high-flow oxygen therapies frequently fail to adequately support such patients making intubation necessary. Close monitoring is crucial in order to detect failure of non-invasive support means so that intubation can be performed in a timely and controlled manner using all optimal infection prevention strategies.
- Endotracheal intubation should, ideally, be performed by the most experienced MRHP available.
- Minimize number of people involved. Close the room door. Nursing and RRT support ideally should be provided by the same individuals assigned to patient.
- In units with adjustable room airflow rates, increase the rate of airflow (or put the room in "bronchoscopy mode") prior to intubation.
- Don full PPE including N95 respirator, face shield, gown and gloves. Proper application of PPE should be verified by an independent observer prior to entry into the patient room.
- Consider the additional use of goggles given the potential for expectorated secretions to flow around front-covering face shields and contact ocular mucus membranes with coughing and during head turns of the intubator. If goggles are re-used, they must be fully wiped down with disinfectant wipes prior to re-use.
- Patients with hypoxemic respiratory failure usually have poor oxygenation reserves. Pre-oxygenate as much as possible using non-invasive oxygen.
Reserve use of bag-valve-mask ventilation via facemask to situations where noninvasive oxygen delivery is failing (to reduce aerosolization risks).
- The best pharmacotherapy for induction and intubation will be determined by the MRHP on a case-by-case basis but in general should include strategies that minimize chances of cough or aerosol generation via use of agents inducing deep sedation and often use of neuromuscular blockade when clinically appropriate (e.g. no signs predicting difficult intubation).
- Consider use of visual technological devices (e.g., video laryngoscope) for the initial attempt at intubation (to reduce the risk of aerosol contact by reducing the need to look directly down the airway); however, MRHP should use the technique most familiar to them that will ensure the greatest probability of successful intubation.
AHS Scientific Advisory Rapid Evidence Report: Video Laryngoscopy 9. Place in-line suction catheter on in all patients. Use either HMEF or heated humidity systems (if they are fixed integral system of a particular ventilator).
- In patients not already diagnosed with COVID-19, if sputum samples have not already been collected, collect ETA while all infection control precautions are already in place for intubation.
- If difficult airway cart or other stand-by equipment is brought to the area, do not bring entire cart/equipment into the room -bring in only the necessary equipment as it is needed.
See additional intubation guidance and tools in Appendix C.
For Intubated Patients: 2. In patients with refractory hypoxemia (e.g., Pa02/Fi02 ratio < 150 after attempting all the above strategies), consider the following additional strategies: a. Non-conventional modes of ventilation, such as Airway Pressure Release Ventilation (APRV). b. Inhaled epoprostenol: i. Provided per local policy. Dosing 10 -50 ng/kg/min. An active humidification system is required to use this therapy. ii. Use only in intubated patients. iii. Patients who do not demonstrate a physiological response (increase in PaO2 of 20% from baseline) after 30 minutes should be discontinued from inhaled epoprostenol therapy. iv. A daily assessment should be performed in an attempt to discontinue inhaled epoprostenol therapy.
- If advanced ICU respiratory care (defined as the use of all of the above measures possible to apply) has failed to improve oxygenation or can only be accomplished by applying mechanical ventilation that is not lung protective, consider consulting the ECLS Team (Edmonton for Northern Alberta, Calgary for Southern Alberta).
To initiate a referral: a. For Calgary, Central and South Zones, page the on-call CVICU Intensivist at the Foothills Medical Centre (403) 944-1110. b. For Edmonton (sites other than UAH) and North Zones, page the on-call Intensivist for the UAH General Systems ICU. c. For the UAH site, page the on-call Mazankowski CVICU Intensivist.
An early consultative process is recommended as ideally potential ECLS candidates should be first transferred to the ECLS referral center and then, if deemed suitable candidates, cannulated.
Consider referral to ECLS team when the following criteria are met:
- PaO2:FIO2 ratio  3 hours with inability to maintain lung protective ventilation (LPV) as defined in section 1 above. - PaO2:FiO2  6 hours even with maintenance of lung protective ventilation. - An arterial blood pH of  6 hours. - Endotracheal intubation and high-pressure mechanical ventilation for less than 7 days. - Near maximization of conventional therapies.
- No severe life-limiting chronic illnesses. Expected life expectancy of at least 2 years of independent functioning, should the patient survive.
ECLS Recommendations for COVID-19 4. If a patient is not deemed a suitable candidate for ECLS support and continued care is pursued, consider:
- Permissive hypoxemia -accept Sp02 85-90%, Pa02 50-60.
- Target Hemoglobin >85 g/L (maximize oxygen carrying capacity).
- Target temperature <37.5 C (reduce oxygen demand). Extubation Guidelines:
Extubation of patients is an AGMP. Careful consideration should be given to the safety of HCWs during the extubation procedure and to reduced reintubation rates.
- Ensure readiness for extubation - Extubate from spontaneous or pressure support with low PEEP.
- FiO2  0.50.
- Patient should be ready for extubation onto low-flow oxygen.
- Per usual practice, ensure cuff leak.
- Apply PPE per AGMP.
- Two staff members are recommended during extubation to monitor safety given the time to apply PPE should any assistance be required.
- Strategies should be employed to minimize coughing - Oral suctioning may be performed with care taken not to precipitate coughing. - Medication to minimize coughing may be employed such as use of intravenous opioids, lidocaine or dexmedetomidine.
- Post ventilation handling of ventilator: Follow site specific protocols for cleaning and disposal.

# Medical Care
Goals of care discussions should occur early in admission consistent with our regular practice. Streamlined Goals of Care Designation decision-making for COVID-19
Other standard practices of medical care will apply such as nutrition in the ICU and ventilator acquired pneumonia prevention protocols.
Currently there are no robust evidence-based effective direct antiviral therapies for the treatment of the novel coronavirus, SARS-CoV-2, and supportive care remains the mainstay of therapy for infected individuals. For patients presenting with an ILI where SARS-CoV-2 is one possible etiology, it is important to recognize the possibility of additional common viral and bacterial pathogens to underlie the patient's presentation, even in the presence of exposure to COVID-19 infected individuals or relevant travel exposures.
Current Guidance for the Management of Adult Hospitalized Patients with COVID-19

# Microbial Testing
Even in patients with proven COVID-19 infection, particularly in patients with severe disease, bacterial and/or other viral co-pathogens may be present.
All patients evolving severe illness should be tested for the full spectrum of respiratory viruses (including SARS-CoV-2) and bacterial pathogens.
This should include:
i In all patients, an NPS and/or ETA for respiratory viruses (including SARS-CoV-2) (see admission testing Section C above).
ii In intubated patients, an ETA sample for bacterial culture.
iii For non-intubated patients NPS will be used for diagnosis of SARS-CoV-2, and in those able to produce sputum, expectorated sputum can be sent for bacterial culture. Sputum induction is not recommended in non-intubated patients (to reduce exposure risks).
iv Blood cultures x 2 drawn from separate lines/sites.
v Sampling of pleural fluid as appropriate if present is significant quantities.
Bronchoscopy solely for the purposes of microbial sampling in otherwise uncomplicated patients is not recommended (unproven benefit; high risk procedure). If there is a clinical possibility of other more unusual pathogens (e.g., as in an immunosuppressed patient), consideration could be given to performing bronchoalveolar lavage (BAL) recognizing that bronchoscopy is an AGMP. If necessary, bronchoscopy should be performed only in intubated patients and avoided in non-intubated patients with COVID-19 in order to minimize the risk of aerosolization.

# Empiric Antimicrobial Therapy
Antibiotics will generally have a limited role in managing patients with proven COVID-19 though they are indicated for Initial empiric management of patients with severe pneumonia while COVID-19 is being confirmed and bacterial superinfection is being excluded.
Patients evolving severe illness should be empirically treated with intravenous antibacterials along with consideration for oseltamivir (seasonally depending on circulation of influenza) pending results of initial microbial testing. Appropriate antibacterials should take into consideration patient presentation (isolated respiratory vs more generalized illness), allergies, prior or high risk for colonization with ARO (e.g., MRSA), local microbial resistance patterns and comorbid disease that might influence antibiotic use (e.g., conduction delay). As per current guidelines for community-acquired pneumonia management, initial empiric antibacterial coverage should include an agent to cover atypical microbes (e.g., macrolide, respiratory quinolone or tetracycline) and typical bacterial species. Initial empiric therapy should be de-escalated or discontinued as microbiology results return as appropriate.
COVID-19 Specific Antiviral Therapy 

# Systemic Corticosteroids
The RECOVERY (and other) trials have provided new rigorous evidence to support use of treatment with dexamethasone 6 mg delivered intravenously or enterally once daily for up to 10 days to reduce 28-day mortality in patients with COVID-19 who are receiving respiratory support. This recommendation is limited to patients who are receiving respiratory support (i.e., supplemental oxygen and/or invasive mechanical ventilation) with the greatest mortality benefit seen in those requiring invasive mechanical ventilation. 

# Immune Modulating Therapies
Severe COVID disease is often associated with ARDS and cytokine release. There is an evolving evidence base exploring the use of IL-6 receptor antagonists for the treatment of patients with severe COVID-19 disease.
AHS has approved tocilizumab for the treatment of severe COVID-19 pneumonia, restricted as follows:
- Patient was admitted to hospital due to COVID-19 seven or fewer days ago OR patient developed symptoms due to hospital-acquired COVID-19, while in hospital for other reasons, seven or fewer days ago AND 2. The patient is experiencing significant respiratory failure, due to COVID-19 pneumonia, which requires: a. Invasive or non-invasive ventilation (e.g. Continuous Positive Airway Pressure or Bilevel Positive Airway Pressure) OR b. Supplemental oxygen to achieve a minimal SpO2 of 90%, in the form of one of the following: i. Heated high flow oxygen with FiO2 > 0.5 (e.g. Optiflow, Airvo) ii. Oxygen delivered via nasal prong at a rate > 6 L/minute iii. Mask delivered oxygen with FiO2 > 0.5 (e.g. non-rebreather or Venturi mask) AND 3. No more than 24 hours has elapsed since initiation of ventilation as defined above or since the patient met the oxygen thresholds stated above AND 4. The patient has not received another dose of tocilizumab for the same indication at any point during their current hospitalization. 

# Appendix D

# Timing
- Prone positioning of a patient should always occur in a planned fashion o Patients benefit most from prone positioning when used for 14-16 consecutive hours per day o The initial decision to prone should be made early, in consideration of clinical indicators and staff availability o Efforts should be made to plan subsequent prone and supine (unproning) positioning to occur during daytime hours (or when staffing is maximal) - Unplanned prone positioning may be done when a patient acutely deteriorates. This may be more common in the first 24 hours of patient admission to the intensive care unit.

# Requirements
- Team size will be determined by each site and guided by the size of the patient and members of the prone positioning team - The attending physician or assigned delegate must be present for the initial prone positioning procedure. - The attending physician or assigned delegate must always be aware of any subsequent prone/supine positioning maneuvers, and available for support as needed. Follow local processes. - At a minimum prone positioning of a patient can be accomplished by 5 team members o One respiratory therapist -primary responsibility is management of the airway o One registered ICU nurse -primary responsibilities are the lines, catheters, tubes and drips o Three additional healthcare workers  Can be ICU or non-ICU staff including RRT/RN/HCA/allied health workers/physicians.

# Equipment
- 2 -Flat sheets - 1 -Proning head cushion and one pillow case to cover cushion/plastic bag - 1 -Absorbent pad - 3 -pillows - Skin protection dressing (duoderm, mefix, etc.)
- Proning checklist

# Care of the Proned Patient
- Refer to existing local policy and procedure for detailed information - Patients may be in prone position for up to 20 hours per day (of which at least 14-16 hours should be continuous, as directed by attending physicians' orders) - Continue with regular clinical, physiologic and laboratory assessments:
- Follow oxygenation and hemodynamic status closely to monitor for deterioration -as patients can experience transient deterioration in gas-exchange shortly after proning prior to improvement o Chest and heart sounds can be assessed by slipping stethoscope under patient's chest (if using a special care bed this will be easier if air pressure is decreased in the area to be assessed) - Minimize sedation and paralytics as patient condition allows, as ordered by the attending physician - Head turns and arm repositioning are done q2h to prevent skin break down, contractures, and nerve compression
- Use a support under the patients face (e.g., gel horseshoe, foam cushion, or folded pillow) to ensure the downward eye is free from pressure. Apply eye lubrication q2h to prevent eye damage. - Keep the bed in reverse Trendelenburg whenever possible to prevent venous congestion of the head and neck. - Avoid over extension of the neck with positioning. Facilitate PT/PROM exercises as tolerated.

# FAQs
- CRRT -Can be run while in prone position. The patient should have an easily visible line (jugular). - CPR -CPR can be performed while in the prone position while awaiting team to flip.
- Paralysis -Neuromuscular blockade is strongly suggested prior to a trial of prone positioning. Femoral lines -Caution needs to be exercised if patients have venous or arterial femoral lines as these are not visualized while patients are in prone position.
staff members to enter patient room.
- Staff already in isolation should be utilized to complete ECG and blood draws vs a lab tech entering.
- Adjust alarm parameters to reduce non-relevant alarms.
- Utilize bed functions such as turn assist, rotation, percussion and vibration.
- Utilize the function of overhead lifts and repositioning slings to reduce the number of staff for repositioning. Single person techniques should be reviewed and utilized in possible.
- During prone positioning, only team members directly involved in the turn need to be in the room.
- Minimize patient washes and linen changes if appropriate.
- RN & RRT to remove garbage when full to reduce frequency of housekeeping entering the room. Garbage must be properly disposed of. o Minimize the frequency of blood draws and review at rounds each day o Bundle order times of required bloodwork o Before redrawing determine if required order can be added to previously drawn bloodwork.
- Do not order routine CXR or ECG -order only as needed when clinically indicated.
- Minimize off unit procedures or interventions. Review the need for off -unit care with the care team. Deliver care at the bedside as much as possible.
- Nursing in collaboration with pharmacy to adjust medication administration times so that regularly scheduled medications can be administered in a cluster vs staggered administration. Suggest alignment with feeding tube water flushes.
- Physician assessments should be kept to one per 24 hours unless clinical indication requires further assessment. This includes Residents, Fellows and Attending Physicians.

# Care of the Adult Critically Ill COVID-19 Patient - 42
- To reduce the frequency of entry into isolation room consider utilizing MRI tubing as an extension to regular IV tubing and have IV pumps located outside of the patient room.

# Caution and Guidelines
- ACLS and critical medication bolus cannot be infused via extension tubing.
- Patients who are highly dependent on the infusion to achieve set RASS and hemodynamic goals should have infusions in the room.
- Lines must be marked with color tabs to make them visible.
- Lines should be located in areas that are not going to result in injury to staff or dislodgment of line.
- Extension tubing can only be connected to central line.
- Line cannot be touching the floor.
- MRI tubing must be labeled with all medications infusing through it.
- Ensure that lines are positioned to reduce risk of occlusion.
- Use triple lumens or manifolds to connect medications before attaching to MRI tubing.
- MRI tubing must be primed with all medications prior to connection
The use of tocilizumab as above is restricted to a SINGLE DOSE per patient, based on the following weight-based dosing: 40 or less kg: 8 mg/kg 40 kg to 65 or less kg: 400 mg 65 kg to 90 or less kg: 600 mg Greater than 90 kg: 800 mg

# Venous Thromboembolism (VTE) Prevention
Patients admitted to critical care with COVID-19 are at significant risk of thrombotic complications such as VTE. Standard prevention therapy is recommended for all COVID-19 positive patients with a preference for low molecular weight heparin (LMWH) administered at standard doses. Pneumatic Compression Stockings (PCS) should be used when pharmacological interventions are contraindicated.
There is no high-quality evidence to suggest vitamin D at supplemental or higher doses is effective in the prevention or treatment of COVID-19.

# Scientific Advisory Group -Rapid Evidence Brief -Vitamin D Clinical Trials
Consideration should be given to enrollment in any locally active clinical trials (epidemiologic or treatment related) if available. Contact the local research coordinator or MRHP as appropriate. - PPE conservation strategies are to be initiated immediately.

# Handling of Patient Care Items and Equipment
- PPE usage should be restricted to direct patient care use only.
- PPE should not be used for simulation, orientation and education purpose unless it is expired.
Considerations to maximize time spent in isolation room 1. Reduce doffing of PPE and leaving room to collect supplies.
- Keep stock in rooms that is not excessive.
- RN and RRT to discuss patient care supply requirements during shift handover.
- Staff to determine required supplies before going into room for care and procedures.
- Use call bell for supply runners rather than leaving isolation.
- Utilize supply runners as 'clean staff' to assist isolation staff to fetch required supplies. This could be staff that has been redeployed to critical care including students.

# Group documentation together.
- Utilize existing computers in room for charting.
- Charting does not need to be completed in real time.
- Utilize whiteboards or glass doors for interim documentation with a dry erase marker for later translation into the health record.
- If staffing allows, utilize a staff to transcribe outside the room while care provider remains in the room. - RRT & RN to share tasks and responsibilities and determine if it is necessary for 2