Coronavirus update

To All Faculty and Staff:

As reported by multiple media sources today and confirmed by the CDC, a person currently hospitalized at Providence Regional Medical Center Everett was diagnosed yesterday with a respiratory tract infection due to the 2019 Novel Coronavirus. This is the new virus that is responsible for the outbreak in Wuhan, China. As of  January 21st , there are approximately 400 cases and 6 deaths worldwide.  Reports also indicate an outbreak in at least 1 healthcare facility leading to more than 12 additional cases.

Key points about the 2019 novel coronavirus outbreak:

  • The exact mechanism of transmission is unclear, but likely similar to or the same as other respiratory coronaviruses (coughing, sneezing, and hands contaminated by touching surfaces).
  • Although initial cases were linked to animal exposures, it is now clear that human-to-human transmission is ongoing.
  • Infection with this coronavirus can lead to pneumonia. As is the case for many viral infections, care is mainly supportive.
  • Cases have been reported in China, Japan, Thailand, The Republic of Korea and the United States, but all were likely infected while in China. It is very likely that additional cases will be diagnosed and reported in the coming days.
  • Both exit health screening (in Wuhan, China) and arrival screening (Los Angeles International, San Francisco International and JFK in New York) were initiated at the end of last week. The CDC expanded the number of airports to ~14 over the weekend.
  • There are no direct flights from Wuhan to Seattle-Tacoma International Airport.
  • The patient in Everett had no symptoms on the day of arrival. When he developed symptoms, he contacted his healthcare provider and was admitted for care and testing quickly. A contact investigation is on-going.

Actions at UWMC:

Emergency Department and Clinics

  1. All patients presenting with a respiratory illness (coughing, sneezing, runny nose) will be given a surgical mask to wear and will be moved to a private space as soon as possible.
  2. All patients presenting with a respiratory illness will under go travel screening specifically for travel to China in the last 2 weeks.
  3. If there are clinical features (fever, respiratory illness) and epidemiological risk (travel to China), the patient will be placed in AIRBORNE RESPIRATOR/CONTACT PRECAUTIONS immediately (N95 mask and eye protection or PAPR unit plus gown and gloves).
  4. The ED or clinic team will immediately contact UWMC IPC and Public Health Seattle & King County for next steps, including testing for the virus.
  5. Standard respiratory viral testing can be performed per protocol but a positive result for another virus (e.g. influenza) does not automatically preclude infection with the novel coronavirus. A negative coronavirus does not rule out novel coronavirus. All admissions and discharges of patients meeting clinical and epidemiological criteria must be discussed with public health and UWMC IPC.
  6. If a patient contacts a clinic or the ED with concern for infection prior to arrival, contact UWMC IPC to assist with coordination of entry and precautions. 

Screening for 2019 Novel Coronavirus:

FRONT DESK and PHONE TRIAGE STAFF for Acute Appointments:

Questions: 

1) “Do you have fever or symptoms of lower respiratory illness (e.g., cough, difficulty breathing)?” 

2) “Have you been to Wuhan City, China or had contact with anyone from Wuhan City in the last 14 days?”

If “NO”:  Proceed with check-in as usual

If “YES” to 1: instruct the patient to put on a mask on the way into clinic. 

If “YES” to both:

If by PHONE advise the patient to remain in the car until clinic staff comes to escort them

    • Contact provider
    • Have the patient don a surgical mask
    • Clinic staff don, gown, gloves, and mask with face shield and escort patient 
    • Use backdoor or unoccupied elevator if available
    • Preferentially schedule appointment at the end of the day

If at FRONT DESK and suspect a possible Coronavirus

    • Mask the patient immediately
    • Discuss immediately with provider and room the patient ASAP
    • Staff don gown, gloves, and mask with face shield

Rooming:

Isolate the patient and any person accompanying the patient if not already done so. Put Infection Control sign on door of exam room where patient is isolated. If a negative pressure room is not available, use HEPA tower if available. Door to remain closed. Staff and provider should wear mask with face shield until patient is cleared by the provider.

If Concern for Possible Novel Coronavirus:

Notify King County Public Health (206-296-4774) or Snohomish County (425-339-5278), and UWMC Northwest Infection Control (206-668-1705) or UWMC Montlake Infection Control (206-598-6122). Notify the Medical Director and Manager for the clinic. Do not use the exam room for at least 2 hours after patient is discharged. Call for terminal cleaning after 2 hours

Inclement Weather Plan

Hi team,

There is snow in the forecast beginning on Monday 1/13 and expected to last several days. Please review the information below:

  1. UWMC staff and providers are all considered “essential staff”. This means we continue to report in, even when Campus is closed. The Medical Center does not close, and as an extension of the Medical Center, we also remain open during our normal business hours from 8am-5pm. We could also be redeployed to other units in need and/or the main hospital.
  2. Staff will be texting their direct supervisor on the day-of an inclement weather event by 6am, to report if they can make it in to work or not.
  3. Attending Providers/ARNPs will text Jake by 6am to coordinate if they can make it to clinic or not.
  4. Resident Providers will follow the same protocol as it currently stands today, which is call the sick line by 6am at 598-2640 and email clinicchange@uw.edu for any absence from clinic, including inclement weather.
  5. Jake, Candace, Kate, Ruth, and Kahlia will then communicate as a leadership team early and often to confirm who we are expecting each session during the inclement weather event, and make any alternate business plans, as needed.
  6. Providers, please do not contact your patients directly/cancel your own clinics. Last year, we had providers available who could have seen the patients of their colleagues that were unable to make it into clinic. Please let the clinic staff handle all communication to patients regarding cancellations and reschedules.
  7. Create a plan now to get to work under inclement weather scenarios—if you typically drive to work, do you know the nearest bus line and schedule? Does anyone from clinic/Roosevelt II live near you that you may carpool with? Who has a 4WD/AWD vehicle, grew up in the tundra, and can confidently drive in the snow? Early preparation will ensure we have a successful plan to care for our patients, should an inclement weather event occur this season.
  8. Your safety is of paramount importance. While we are all essential staff of the medical center, please do not put yourself at unnecessary risk!

Clinic Updates

BHIP Update:

Dr. Mark Newman is now transitioning out of GIMC at least for the January-April time frame. While we continue to make progress on establishing a solid long-term plan for supporting a BHIP psychiatrist at GIMC, we will be without a dedicated BHIP psychiatrist for at least the next few months.

The interim plan is for Dr. Lindsey Enoch to support the role of BHIP Psychiatrist for case and chart review. BHIP patients with not be scheduled with Dr. Enoch; if there are medication management needs, patients will be directed to their GIMC PCP for those needs. If a patient needs to be seen by a psychiatrist, they will be referred to UWMC Outpatient Psychiatry Clinic (OPC) at Roosevelt I building. Kendra’s BHIP service should continue uninterrupted; new BHIP consults should be therapy-only patients referred to BHIP. At this time, please refer diagnostic and medication management patients to OPC.

During this time frame, please note the following:

  • BHIP social work consults (for Kendra Koeplin) can continue unchanged

  • Please do not route any psychiatry consults to BHIP

  • For particular psychiatry diagnostic and/or therapeutic questions that arise in the course of Kendra Koeplin’s BHIP social work care, Dr. Lindsey Enoch has graciously agreed to collaborate with Kendra on case review, though Dr. Enoch does not have the bandwidth to see BHIP patients. Any psychiatry questions or recommendations that emerge from this case review will be routed back to the PCP/referring provider for action.

  • For psychiatry consult needs, our best available resources include the UWMC-Roosevelt outpatient psychiatry clinic and the new Provider-to-Provider Psychiatry consult line (see below)

UW Psychiatry Consultation Line

The UW Psychiatry Consultation Line (PCL) helps eligible providers in Washington state who want advice regarding patients with mental health and/or substance abuse disorders. The program is fast, free, and connects community providers to psychiatrists at the University of Washington.

Why PCL? Increased access to mental health care can lead to earlier diagnosis, improved adherence to evidence-based treatment, and better patient outcomes. The provider-to-provider PCL leverages mental health experts at the UW to provide mental health consultation when and where providers need it.

How does PCL work? Providers call 877-WA-PSYCH (877-927-7924) and after a short intake with a UW health navigator, are connected to a UW psychiatrist. At the conclusion of the conversation, the UW psychiatrist will send a brief written documentation of the recommendations to the caller via email.

Who is eligible to call? Prescribing health care providers in Washington State from:

  • primary care clinics

  • community hospitals

county and municipal correctional facilities

What PCL psychiatrists CANNOT do:

  • speak directly to patients

  • review written records

  • manage psychiatric emergencies or satisfy Single Bed Certification requirements

When are PCL psychiatrists available?

The consultation line (877-927-7924) is open 8 AM – 5 PM, Monday through Friday (closed on federal and UW holidays). If calling outside of business hours, providers can leave a message which will be returned within one working day.

Post-ED Follow-Up Pilot:

Starting January 14, 2020, GIMC will be participating in a UWMC pilot designed to improve the post-ER visit options for relatively high acuity patients, specifically targeting patients who could avoid admission if they had appropriate close clinic follow up. As part of this initiative, we will hold 2 slots everyday across the clinic for post-ED visits. These will be long slots, mostly on the schedules of residents who are on ambulatory care blocks, though sometimes on attending schedules, never more than 1 per provider per day. If the slot is unfilled at midnight the night before, it will be released for general scheduling.

NOTE: In addition to established GIMC patients, in this initiative, GIMC has been asked provide this close follow up option for appropriate patients without a PCP. These patients may go on to establish care at GIMC, or UWMC social work may assist them in establishing primary care at a location that suits them well, with GIMC providing a bridging after care function.

Influenza Vaccines

The flu shot is here (well the standard quadrivalent is here, the high dose trivalent is still coming), and ALL of your patients should get it! Why?

The flu is bad! Though most healthy people get through the flu without problems, the CDC estimates that influenza is responsible for 140K-710K hospitalizations and 12K-56K deaths each year. Elderly patients, very young children, pregnant women and patients with underlying health problems are at greatest risk.

The flu vaccine gives pretty good coverage! While it is impossible to know vaccine effectiveness until the flu season is over, vaccine effectiveness in recent years has ranged around 40-60% — though its not perfect, this protection significantly decreases the incidence of flu cases and complications.

…and has relatively few side effects! Pain at the injection site is noted in about 65% of people, but it usually does not interfere with activity. Though some patients will tell you that the vaccine has given them the flu, flu-like symptoms are similar after receiving the vaccine and placebo; perhaps some of them were actually exposed to a URI after getting the vaccine. Allergic reactions to vaccine components are rare and Guillain-Barre after the flu vaccine is very rare.

“But I am allergic to eggs.” You can still get the flu vaccine! Per the CDC, “persons with a history of egg allergy of any severity may receive any licensed, recommended and age appropriate flu vaccine.” Some of the vaccines do contain egg proteins (including the one we have in clinic), but the risk of an allergic reaction is minimal and the benefits of the vaccine are thought to outweigh this risk. However, in patients who have a history of angioedema, respiratory distress, lightheadedness or recurrent emesis from egg exposure should receive the vaccine in the presence of health care professional (i.e. in clinic rather than a pharmacy); those who have just had hives do not need special precautions. Only the RIV4 (Flublok Quadrivalent) vaccine is considered egg-free; th ccIIV4 (Flucelvax Quadrivalent) vaccine has minimal egg exposure.

“I’m afraid of needles.” Although the intranasal vaccine has not been available for the past two seasons, it is this year. The intranasal vaccine is a live attenuated virus so it is contraindicated for: immunocompromised patients, close contacts of immunocompromised persons, pregnant women, patients who have receive influenza antiviral meds within the past 48 hours, and parents or caregivers whose child has asthma or wheezing within the past 12 months. Also note that there are additional precautions for patients with egg-allergy who receive the intranasal vaccine.

Which one do I give – the standard dose quadrivalent or the high dose trivalent?

 For individuals ≥ 65 years of age, UpToDate suggests the high-dose trivalent IIV (Fluzone High-Dose) where available rather than a standard-dose quadrivalent inactivated vaccine, particularly in those taking a statin. It should be noted that the ACIP has not stated a preference for this vaccine over other influenza vaccines in older adults, although several studies have shown that the high-dose vaccine is more effective than the standard-dose trivalent vaccine in older adults (including a mortality benefit). Mild to moderate local reactions are more common with the high-dose vaccine than with standard-dose trivalent vaccine, but the incidence of serious adverse events is similar.

What about my transplant patients?

There is a preference for the HIGH-DOSE trivalent rather than the standard dose quadrivalent influenza vaccine for all pre-transplant patients >65 years old and all post-transplant patients (regardless of age). For pre-transplant patients <65 years old, and others for whom the high-dose trivalent vaccine is not feasible, standard dose quadrivalent inactivated vaccine is recommended. Pre transplant patients and potential living donors should be vaccinated as soon as possible. For post-transplant patients we recommend:

  • Defer vaccination until 1 month after either transplant or ATG administration
  • Routine vaccination with the injectable high-dose trivalent inactivated vaccine,  regardless of age 
  • Do NOT use the live attenuated nasal vaccine (“Flumist”)
  • For all close contacts transplant candidates or post-transplant patients, any of the
  • available flu vaccines (other than the live “FluMist” vaccine) should be given.

Also, please find here a recent study that may inform decision-making around optimal timing of flu vaccination given potential for waning immunity.

GIMC Measles Protocol

There are multiple ways patients with concern for measles may be scheduled at GIMC. If the measles concern is identified over the phone or otherwise in advance of the appointment, clinic staff will advise the patient and provider on the appropriate protocol to follow. If the concern for measles is identified at the point of arrival in clinic or during the visit, provider and staff should reference the protocol below.

 

  • Patients who screen positive for a high-risk of infection transmission on our general infection control protocol at the Front Desk will be roomed on an expedited basis and will follow our current rooming standard work for infection control

 

  • The rooming MA will ask patient the patient “Do you have RASH + Cough, Fever, Runny Nose, or Red Eyes?”
    1. If yes, patient will be preferentially roomed in the negative pressure rooms (Rooms 6, 7, or 8) and the MA will immediately have a face-to-face with the visit provider to determine what immediate assessment is needed.
    2. If no, the usual rooming standard work for infection control will be followed

 

  • If the provider identifies a concern for measles in the course of the visit, the provider should immediately pause the visit, step out of the exam room, and check-in with an MA to initiate appropriate general and measles infection control precautions (see below).

 

  • For measles infection control precautions, staff and provider should wear N95 or PAPR and gown when in the exam room with patient unless/until patient is cleared by the visit provider. Only non-pregnant staff with documented immunity should interact with patient.

 

  • An Airborne Contact Precautions sign will be placed on exam room door where patient is isolated.

 

  • Provider should notify King County Public Health (206-296-4774) or Snohomish County (425-339-5278) for public reporting purposes and for guidance on proceeding with testing.

 

  • Provider should notify UWMC Infection Control (206-598-6190) for institutional tracking purposes and for safe patient and infection control management.

 

  • MA should notify the Medical Director and/or Clinic Manager either in-person or by paging the Medical Director. Staff and provider can direct any immediate questions about how to proceed with the protocol to the Medical Director or Clinic Manager. If Medical Director or Clinic Manager are unavailable, questions can be directed to AWR/On-call.

 

  • Following the conclusion of the visit, all spaces used by the patients (waiting room seat, exam room, restroom if used) will be decontaminated per standard protocol, including any exam rooms or restrooms used being closed down for 2 hours following the time of the patient’s departure. The MA involved will contact Environmental Services to coordinate the cleaning with them.