Not a doctor? Click here for patient information on COVID-19, written by emergency physicians.
may 15, 2020: Guidelines on children with inflammatory syndrome
Virginia State Health Commissioner Dr. M. Norman Oliver distributed a letter to practitioners across the Commonwealth as well as to several medical associations and organizations regarding symptoms of COVID-19 in children.
VDH urges all healthcare providers in Virginia to immediately report any patient who meet the criteria below to the local health department by the most rapid means.
Multisystem Inflammatory Syndrome in Children Associated with COVID-19
On May 14, the Centers for Disease Control and Prevention (CDC) released a Health Alert Network (HAN) Advisory about multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. The first reports of this syndrome came from the United Kingdom in late April. U. S. cases were first reported in New York City in early May.
Prominent clinical features include persistent fever and a variety of symptoms, including hypotension, multiorgan (e.g., cardiac, gastrointestinal, renal, hematologic, dermatologic and neurologic) involvement and elevated markers of inflammation. Respiratory symptoms were not present in all patients. Some patients had clinical features consistent with Kawasaki disease. In New York, many of these patients have tested positive for SARS-CoV-2 by RT-PCR or serology. It is unknown whether this syndrome is limited to children.
To investigate this syndrome, public health officials developed a standardized case definition for suspected cases.
Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C)
An individual aged <21 years presenting with fever, laboratory evidence of inflammation**, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND
No alternative plausible diagnoses; AND
Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms
That’s all the letter says regarding the syndrome and the case definition, but the full letter has more general information on the COVID-19 update for Virginia.
*Fever >38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours
**Including, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin
APRIL 30, 2020 UPDATE
Our latest eNews offers full details of VACEP’s advocacy efforts over the last 7 weeks. Get it here.
Summary: As we near the end of Lockdown Week 7 across the Commonwealth and nation, our newsletter recaps the tireless work of our frontline members and supporting healthcare staff. In addition to their regular shifts, your VACEP Board and fellow members have spent many March and April hours advocating for emergency medicine during this crisis.
This has meant:
Video calls with Governor Ralph Northam and U.S. Senator for Virginia Tim Kaine, plus ongoing communications with their staff, to discuss our work and needs. We have advocated for more PPE, funding, and COVID-19 testing. We're getting results.
Communications with members of the Virginia General Assembly to advocate for emergency physician protections, and pushing our message that ERs are open and safe — especially for those with a medical emergency such as a stroke or heart attack.
Participating in ACEP’s Virtual Hill Day and meeting with (via phone) the offices of both U.S. Senators and nearly all U.S. Representatives for Virginia. Our members shared stories of their experiences, and we had productive conversations about liability protection, PPE and testing availability, current ED volumes, and coverage and financial protections for healthcare workers.
In addition, VACEP has representation on the Governor's new nursing home task force and testing advisory task force. Our staff and members take weekly calls with the Virginia Department of Health and Virginia Hospital & Healthcare Association, and are in daily check-ins with Medical Society of Virginia staff.
Also in the issue:
A VACEP-led win to protect healthcare workers from liability
ED Emeritus Bob Ramsey recognized by ACEP
Health worker discounts on hotels, pizza, transit, and donuts (the essentials)
ACEP/AAEM shoot down misinformation out of California
Financial resources for physicians
Poll showing majority of patients scared to visit ER
Our public "ERs are Open and Safe" message
APRIL 3, 2020 update
Federal Aid for Physician Groups
Federal coronavirus aid packages such as the Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security (CARES) Act offer financial support and tools for medical staffing groups and their healthcare employees. Learn more about two particular programs for physician groups: the Paycheck Protection Program and the CMS Advance Payments program.
Questions? Email Sarah Marshall, VACEP Executive Director, at sarah@vacep.org.
APRIL 1, 2020 UPDATE
Physician Staffing Groups Risking Emergency Medicine Safety Net During COVID-19 Pandemic
VACEP has released a statement condemning some physician staffing groups for cutting salaries and benefits to our frontline workers. These actions are unacceptable and unnecessary, and VACEP condemns any such actions, given that considerable relief is available through recent federal legislation. We call on these medical groups to explore federal coronavirus Acts. Read the full statement.
Weekly Action Items: March 31-April 1
We want to you to know that we’re working hard to make sure your voice is being heard. Take a look at our goals and what we plan to accomplish each week to advocate for you and all of the EPs in Virginia.
Scheduling call with Governor Northam to discuss concerns and solutions
Revising ACEP statement on PPE advocacy to share with patients and legislators
Researching federal aid opportunities for physicians
Creating an online forum for the state’s medical directors and EM leaders
Coordinating with other medical organizations and agencies on our concerns and pandemic response
March 17, 2020 Update
As COVID-19 continues across America, communities are minimizing its spread by self isolating and shutting down many stores, restaraunts, and community buildings. As the rest of the country slows down, it’s time for healthcare providers to ramp up prevention measures, screening processes, and equipment conservation for those that are in critical condition. Here’s what we know:
Two Emergency Physicians are in Critical Condition: In a statement from ACEP President William Jaquis, MD, FACEP, two ACEP members— one from Washington state and one from New Jersey are in critical condition as a result of COVID-19.
“I am deeply saddened by this news, but not surprised. As emergency physicians, we know the risks of our calling. We stand united with our colleagues and our thoughts and prayers for a full and speedy recovery are with each of them and their families.”
AMA’S Physician Guide to COVID-19: Learn how to prepare your practice or health system for COVID-19 with a quick-start physician guide to COVID-19, curated from comprehensive CDC, JAMA and WHO resources, that will help prepare your practice, address patient concerns and answer your most pressing questions.
Prioritizing PPE: Concerning the shortage of personal protective equipment (PPE), physicians are experiencing across the country, here's a summary of what you need to know, including advocacy asks and how your state can request more PPE.
Communicating With Triage Patients: Read this sample conversation with triage patients to understand how to communicate and handle patients who are triaged and specially placed based on their COVID-19 symptoms.
EPIC Screening template: Use this template from EPIC to screen for URI with COVID-19 symptoms.
Liability Protections During COVID-19 Pandemic: Outlining what we believe to be appropriate liability protections for physicians during the outbreak.
Medicare waiver for Telehealth Facts: Under a new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. A range of providers will be able to offer telehealth to their patients. Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
Pharma recommendations/no ibuprofen: As you know, scientists and senior doctors have backed claims by France’s health minister that people showing symptoms of COVID-19 should use paracetamol (acetaminophen) rather than ibuprofen, a drug they said might exacerbate the condition. More info at the link.
MARCH 13, 2020 UPDATE
First: today, we issued simple public health guidance for Virginians, instructing them on what to do (and when to go to the emergency department) if they feel sick, have been exposed to COVID-19, or are having a medical emergency. As frontline medical professionals, is our duty to provide clarity to the many people who are concerned — and confused.
Share this graphic far and wide. You can find it on our Facebook page.
We encourage members to share the attached graphic on social media to help people “Know When To Go.” You will see it on our Facebook page, too. Helps us get the word out.
Second: COVID-19 testing is limited, and therefore, so is confirmed data about this pandemic.
VACEP members continue to advocate to policymakers for more testing to understand the true denominator of this virus. As you know, we can only test with approval from the Virginia Department of Health, based on CDC criteria, and the hospital’s infection control team. Some emergency physicians can request testing through private labs, usually with a 72-hour turnaround. There is no consensus on which threshold to test for COVID-19.
If you are not doing so already, please communicate with urgent care clinics, PCPs, military clinics, and other referral sources to advise them emergency departments do not have any “special testing” capabilities. The "walking well" do not need to be visiting the ED and putting others, or themselves, at risk.
In addition, we must continue to push our leaders to establish separate areas at hospitals for COVID-19 testing, confirmed patients, or those under investigation.
Better testing and clearer procedures help us:
Keep staff safe. Hospitals and EDs are already short-staffed, and there are no replacements when our team members get sick.
Protect the most vulnerable patients. We cannot allow potential COVID-19 patients into waiting rooms to infect others.
For more resources, such as ACEP’s Clinical Alert on COVID-19, keep scrolling below.
Thank you to all our members and their staff and other healthcare provider friends who are on the front lines of combating this global pandemic. This is what we signed up for, and I know you’ll make us proud.
Beyond your shifts, here are five ways you can advocate and help end the COVID-19 pandemic.
March 10, 2020 UPDATE
Resources for Emergency Physicians and other Medical Professionals
We have compiled regularly updated resources for our members and healthcare professions on the outbreak of the coronavirus disease 2019 (COVID-19). Specific to emergency physicians, this includes a Clinical Alert from ACEP. In addition, you can find the latest from the Virginia Department of Health and the CDC guidelines for providers.
March 6, 2020 Update
Today, VACEP released the following statement on the outbreak of COVID-19:
Virginia policymakers must establish alternative COVID-19 testing sites for faster, more cost-effective testing outside of emergency departments.
While COVID-19 is a concern, the Commonwealth must implement changes to free up hospital capacity for those who need it most, and allow those who test positive to self-quarantine. Emergency department resources are limited, and policy changes can prevent overcrowding and save lives.
Among VACEP's other recommendations:
- Designate alternative sites of care for patients with respiratory symptoms to prevent contamination of other patients and reduce the amount of personal protective equipment (PPE) that health care workers use.
- To prevent hospital and emergency department crowding, provide resources and accommodations for those without adequate means or space to self-quarantine effectively at home.
- Provide public education on when and where to seek testing (including alternative testing sites as mentioned), when and where to seek care, self-quarantining procedures, home care if infected (including supplies to have on hand).
- Ensure production of medications and supplies relevant to treatment of COVID-19 is prioritized and that they are distributed directly to needed sites of care. Increase transparency of the supply chain for these products to better identify and proactively address potential shortages.
Emergency physicians and medical providers: For the latest information, visit ACEP’s Clinical Alert page.
A note to emergency physicians
Hospitals and EDs should review their pandemic plan. ACEP has activated its Epidemic Expert Panel, who are monitoring the situation. They are preparing a checklist for ACEP members.
Given that there is no specific treatment for COVID-19 and no commercially available testing in the emergency department, it important to keep patients with mild symptoms away from the ED in order to avoid spreading a contagious pathogen to our most vulnerable patients — those with compromised immune systems and the elderly who are in the hospital already.
Treatment is symptomatic. There is no antiviral known to be effective.
Of the cases with pneumonia in China, most have been older men with comorbidities.
Pneumonia appears around day 7.
ARDS appears in about 17-29%. Secondary infection appears in about 10%.
About 25-30% require ICU with some receiving mechanical ventilation and a few have been treated with ECMO.
Some patients have had acute cardiac or kidney injury during the course of the disease.
The commercial panel that screens for coronavirus and other respiratory viruses such as RSV do not detect coronavirus. It is unclear how long patients may shed the virus and may be infectious. That should be known as the disease is further studied.
Media reports about a "cure" or "treatment" are not correct. There was one patient that received a combination of anti-virals and did recover, however that is not evidence in favor of any treatment. Treatment remains supportive.
A note to patients
Virginia emergency departments have initiated infection-control procedures to stop the spread of disease and ensure the well-being of patients and staff. If you ever feel ill, you must decide how serious it is and how soon you require medical care. You can call your primary care provider or visit an urgent-care clinic. Emergency departments are always an option for anything, anytime if you are concerned. We stand ready to assist.
At every emergency department, patients who are experiencing upper-respiratory tract infections will be questioned about their travels in recent weeks, particularly to mainland China. Those who have traveled to China or other parts of the globe will be given masks and placed in a private setting.
“Disruption to everyday life may be severe.”
For more on healthcare setting procedures during an infection, see the Centers for Disease Control website.
The Facts on COVID-19:
Cases of COVID-19 are being reported in a growing number of countries internationally, including the United States, where the first case of COVID-19 was confirmed on January 21, 2020 in a traveler who had recently returned from Wuhan.
No cases have been confirmed in Virginia at this time.
TIMELINE:
February 11: the virus was officially named severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), and the World Health Organization (WHO) named the disease coronavirus disease 2019 (COVID-19).
January 30: the WHO declared the outbreak a “public health emergency of international concern.”
January 31: Health and Human Services Secretary, Alex M. Azar II, declared a public health emergency. On February 7, Virginia State Health Commissioner, Dr. M. Norman Oliver, declared COVID-19 a Communicable Disease of Public Health Threat for Virginia.
February 24: the WHO reported over 79,000 confirmed COVID-19 cases globally.
The following is a note from M. Norman Oliver, MD, MA, Virginia’s Health Commissioner:
The vast majority of cases to date are in China. Although most cases outside of China are travel-related, community spread of the virus is now being detected in a growing number of countries, including Hong Kong, Iran, Italy, Japan, Singapore, South Korea, Taiwan and Thailand. At this time, person-to-person spread in the United States appears to be limited, but Centers for Disease Control and Prevention (CDC) recommends planning at all levels for the eventuality of community spread in the United States.
As of February 25, CDC issued a Level 3, Avoid Nonessential Travel notice for China and South Korea. A Level 2, Practice Enhanced Precautions notice has been issued for Japan, Iran and Italy and a watch Level 1 has been issued for Hong Kong.
The CDC also recommends that all travelers reconsider cruise ship voyages to or within Asia. This is a rapidly evolving situation, so please refer to the CDC website for the most up-to-date travel information, and obtain a detailed travel history for patients with fever or acute respiratory illness. The CDC recently published clinical guidance for management of patients with COVID-19 and guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with COVID-19.
Additionally, CDC has developed a real-time Reverse Transcription-Polymerase Chain Reaction (rRT-PCR) test that can diagnose COVID-19 in respiratory specimens. On February 4, the U.S. Food and Drug Administration (FDA) issued an Emergency Use Authorization to enable use of this test at any CDC-qualified laboratory across the country, including the Virginia Division of Consolidated Laboratory Services (DCLS). The DCLS will validate that assay and then implement COVID-19 rRT-PCR testing in-house.
The success of any response to a public health threat like the one posed by COVID-19 depends on how quickly and effectively we can mobilize our public health workforce and Medical Reserve Corps volunteers.
If you are willing to volunteer to support the COVID-19 response, if needed, please register to become a Virginia Medical Reserve Corps volunteer at www.vamrc.org/vvhs or email vamrc@vdh.virginia.gov.
Clinicians are advised to visit the VDH Novel Coronavirus webpage for the most up-to-date guidance and current surveillance statistics in Virginia. Additionally, please visit the CDC Coronavirus Disease 2019 (COVID-19) webpage for more information on this evolving situation. These webpages are updated as new information becomes available.