COVID-19 Patient Flows...COVID-Med MRP: Paediatrics BCH 4 High-Level Summary of Medicine & Sub-Specialty Areas - EGH Area Non-COVID PUI or COVID+ PUI/COVID+ ED Consult and COVID-Med

1

COVID-19 Patient Flows

Table of Contents Page #

Guiding Principles for COVID Flow 2

ED Flow 3

High-Level Summary of Medicine & Sub-Specialty Flows (BCH) 4

High-Level Summary of Medicine & Sub-Specialty Flows (EGH) 5

COVID-Medicine Flow (BCH) 6

COVID-Medicine Flow (EGH) 7

Direct Admits from Clinic and Community 8

IPAC/Screening Flow – Patients Admitted to Hospital from ED/Clinic 9

IPAC/Screening Flow – Patient Develops Symptoms on Inpatient Unit 10

IPAC/Screening Flow Patients Admitted to Critical Care 11

IPAC/Screening Flow – Patients Admitted from Long-Term Care/Retirement Home 12

IPAC/Screening Flow – Patients Transferred to Long-Term Care/Retirement Home 13

Surgical Patients 14

Mental Health Patients - BCH 15

Mental Health Patients - EGH 16

Paediatric Mental Health Patients 17

Oncology Patients 18

Palliative Patients - BCH 19

Palliative Patients - EGH 20

CCU Patients 21

Pregnant Patient Requiring Admission 22

Post-Partum & NICU Flow for PUI/COVID+ Mother 23

Paediatric Patient 24

Inpatient Admission of Hemodialysis Patient 25

Inpatient Admission of Peritoneal Dialysis Patient 26

Care of Suspect/Confirmed COVID Deceased 27

Release of Deceased Patient Process 28

Peel Transfer Protocol 29

Protected Code Blue: EMS to ED Transfer 31

BCH ED Pandemic Plan 34

EGH ED Pandemic Plan 37

PMC UCC Pandemic Plan 40

GUIDING PRINCIPLES FOR COVID FLOW:

• Confirmed COVID+ cases are to be cohorted in semi or ward rooms.

• PUIs should always be placed in private rooms. Private rooms should be reserved for PUIs only.

• Asymptomatic contacts of PUIs can be cohorted in semi or ward rooms

• If an asymptomatic inpatient were to develop symptoms while on a non-COVID unit, follow the IPAC Flow Map.

COVID-Medicine Units

• If a PUI becomes COVID+, cohort patient in semi or ward rooms with other COVID+ patients.

• If the number of PUIs > the number of private rooms available on the COVID unit, then use semi or ward rooms as private rooms.

• If the number of PUIs > the number of private rooms available AND all semi and ward rooms have been turned into private rooms, then open the next COVID-Med Unit as per the phasing in the COVID Capacity Plan.

• If COVID+ units do not have private rooms /converted semis available, then transfer between the COVID units to optimize cohorting guidelines

Sub-Specialty Units

• If a PUI/COVID+ patient presents with a sub-specialty chief complaint that would compromise overall outcome if places on a COVID-Med unit, then the PUI/COVID+ patient is to be placed in a private room on the sub-specialty unit (refer to specific sub-specialty Flow Plans for details).

• If an asymptomatic inpatient becomes symptomatic (i.e. becomes a PUI) on a sub-specialty unit, call ID and move the patient to a private room on the same unit (unless the patient becomes symptomatic on BCH Onc/Pall, then isolate them on a COVID-Med unit).

• If a PUI becomes COVID+, cohort patient with other COVID+ patients on the most appropriate unit for their condition at that time (see sub-specialty flow plans for specific details).

• For sub-specialty patients on COVID-Med units, the typical referral patterns for MRPs are to stay the same (e.g. an Oncology patient on a COVID-Med floor would have an Oncologist MRP).

• For further information regarding admission or transfers to medicine from subspecialty areas, refer to the Admission guidelines on OslerNet.

Guiding Principles for COVID Flow

2

ED Flow

ER presentation

COVID Triage Screen or EMS Screen – err on side of screen positive

COVID + screenDo not submit swab until disposition known

NPS + Clinical assessmentDischarge home

Written discharge instructionsincluding follow up and self quarantine

guidelinesSubmit swab to Public Health

Meet admission criteria?*

• Requires 40% or greater• Unresolved lactate > 4 after

resuscitation• Requires vasopressors

Consult ICU

Critical care on offer?

Goals of care discussion**Requires ICU or HFNC?

Usual ER assessmentNEGATIVEPOSITIVE

NO

Refer to medicineNO

Goals of care discussion***Phone advice by ICU prn*

Admit prn COVID-MED bed or palliative care bed as appropriate †

Submit swab to Mount Sinai/ SickKids/Hamilton for expedited results

NO

*Admit if: O2 sat < 92% r/o, SBP <90 or lactate > 4, severe metabolic abnormality, unable to self isolate in communal living, unable to care for self or be cared for at home.

NO

Satisfactory response?

Good candidate for HFNC? Trial of therapy in ED (AIIR)

YES

YES

YES

YES

**Review “Prognostication” & “Offering Critical Care – General Principles”

Admit to ICU †Intubate as needed

Vasopressors as needed

Admit to Ward AIIR with HFNC if possible †

YES

YES

NO

NO

4

3

1

2

COVID-MEDNon-ventilated, non-HFNC, ward level

COVID-PALLNon-ventilated, non-HFNC, ward level for palliative care

COVID-HFNCAIIR, ward, with remote oxymetry

COVID-ICU1 2 3 4

3

† If a patient is on BiPAP, wait 4-6 hours from BiPAP initiation before transferring to unit.

https://covidcriticalcare.ca/prognostication/

https://covidcriticalcare.ca/offering-critical-care-general-principles/

High-Level Summary of Medicine & Sub-Specialty Areas - BCH

Area Non-COVID PUI or COVID+PUI/COVID+ ED Consult and COVID-Med MRP

Medicine

Phase 1: Ortho, Neuro, N4 Med, N6 Med

Phase 2: Neuro, N4 Med, N6 Med, Rehab A & B, DSU Med

Phase 3: Above + Onc/Pall

Phase 4: Above (minus N4 Med) + OPD, Cardiac Diagnostics, Auditorium/4th Dining

Phase 1: Respirology

Phase 2: Above + Orthopaedics

Phase 3: Above + ACE

Phase 4: Above + N4 Med

Surgery Patients

General Surgery & Short StayNo Surgery

COVID-Med UnitSurgery

General Surgery

ED Consult: Surgery

COVID-Med MRP: Surgeon

Mental Health

AdultPhase 1: Most appropriate MH bed (MH Geriatrics stays clean)

Phase 2: Transfer to appropriate bed at EGH

PaediatricPhase 1: PICU or CHAD

Phase 2+: CHAD

AdultPhase 1: MHESU (all PUI) andMHIU

Phase 2+: Above + Gen B

PaediatricPhase 1: MHESU

or PICU

Phase 2+: PICU

ED Consult: Psychiatry (24/7)

COVID-Med MRP: Hospitalist (due to medical

deterioration requiring transfer to COVID-Med unit)

OncologyPhase 1 - 3: Onc/Pall

Phase 4: Above + Onc OP ClinicCOVID-Med Unit

ED Consult: GIM

COVID-Med MRP: Oncologist

PalliativePhase 1 - 3: Onc/Pall

Phase 4: Above + Onc OP Clinic

Phase 1: Respirology (COVID-Med)

Phase 2+: Orthopaedics (COVID-Med)

ED Consult: GIM

COVID-Med MRP: Palliative Physician

Cardiology

Phase 1: Cardio (tele)

Phase 2: Above + 6 neuro (tele)

Phase 3 & 4: Above + 6 neuro (tele)

No Telemetry or CCU

COVID-Med

Telemetry or CCU

Cardiology or CCU(co-located beds

with hand monitorsstaffed by CCU)

ED Consult: Cardiology

COVID-Med MRP: Hospitalist

Women’s

Under 22 Weeks

Non-OB Issue:Non-COVID Medicine

OB Issue: Post-Partum

22 Weeks & OverNon-OB Issue: Non-

COVID MedicineOB Issue:

Antepartum or L&D

Under 22 WeeksNon-OB Issue:

COVID-MedOB Issue: Post-

Partum

22 Weeks & OverNon-OB Issue:Post-Partum

OB Issue:Antepartum or

L&D

ED Consult: OB (GIM/Intensivist as needed)

COVID-Med MRP:OB (under 22 weeks)

NICU NICU (except for POD 1 & 4)• PUIs in isolation room on NICU or

POD 1• COVID+ in POD 4

Paediatrics PaediatricsPaediatrics or COVID-Med if >14 years

old and Paeds is full

ED Consult: Paediatrics

COVID-Med MRP: Paediatrics

BCH

4

High-Level Summary of Medicine & Sub-Specialty Areas - EGH

Area Non-COVID PUI or COVID+PUI/COVID+ ED Consult and COVID-Med MRP

Medicine

Phase 1: 9th W Med, 9th E Med/Pall, 6th Surge, 8th Surgery, 7th Neuro/Cardio

Phase 2: Above minus 9th WMed

Phase 3: Above minus 9th E Med/Pall

Phase 4: Above + EGH ED

Phase 1: 10th Respirology

Phase 2: Above + 9W Med

Phase 3: Above + 9E Med/Pall

Phase 4: Above + 7W Neurology

Surgery Patients

8th SurgeryNo SurgeryCOVID-Med

Unit

Surgery8th Medicine

ED Consult: Surgery

COVID-Med MRP: Surgeon

Mental Health

5th Mental Health

• PUIs in private & observation rooms on 5th Mental Health

• COVID+ on COVID-Med unit (seclusions to go to BCH)

ED Consult: Psychiatry (24/7)

COVID-Med MRP: Psychiatrist if no medical

deterioration, Hospitalist if otherwise

PalliativePhase 1 & 2: 9th E Med/Pall

Phase 3 & 4: 8th Surgery

Phase 1 & 2: COVID-Med Unit

Phase 3 & 4: 9E Med/Pall

ED Consult: GIM

COVID-Med MRP: Palliative Physician

Cardiology 7th Cardiology

No Telemetry or CCU

COVID-Med

Telemetry or CCUCCU

ED Consult: Cardiology

COVID-Med MRP: Hospitalist

Women’s

Under 22 Weeks

Non-OB Issue:Non-COVID Medicine

OB Issue: MBU

22 Weeks & Over

Non-OB Issue:Non-COVID MedicineOB Issue:

Birthing Unit or MBU

Under 22 Weeks

Non-OB Issue:COVID-Med

OB Issue: MBU

22 Weeks & Over

Non-OB Issue:MBU

OB Issue:Birthing Unit or

MBU

ED Consult: OB (GIM/Intensivist as

needed)

COVID-Med MRP:Hospitalist (under 22

weeks)

NICUSatellite NICU (4th Level Paediatric Day Surgery)

Protected NICU (Fourth Level New NICU space)

Paediatrics PaediatricsPaediatrics or COVID-Med if >14

years old and Paeds is full

ED Consult: Paediatrician

COVID-Med MRP: Paediatrics

EGH

5

6

COVID-Medicine Flow

PUI Admission to COVID-Med Unit

Isolation bed on Respirologyavailable?

Private room(reserved for PUIs only)

Semi-private room

Ward room

PUI isolation bed priority on COVID units

Admit to Respirology

Isolation bed on next identified COVID-Med unit

Cohort with other COVID+ patients in ward/semi room on Respirology

Move to available bed on Non-COVID Med unit

POS SWAB

NEG SWAB

NO

YES

[Next COVID-Med unit to be

identified]

Isolation bed on Orthopaedics

available?

Admit to Orthopaedics

Cohort with other COVID+ patients in ward/semi room on Orthopaedics


POS SWAB

NEG SWAB

NO

YES

Isolation bed on ACE available?

Admit to ACE

Cohort with other COVID+ patients in ward/semi room

on ACE


POS SWAB

NEG SWAB

NO

YES

Isolation bed on N4 Medicine

available?

Admit to N4 Medicine

Cohort with other COVID+ patients in ward/semi room on N4 Medicine


POS SWAB

NEG SWABNO

YES

NO BED AVAILABLE

NO BED AVAILABLE

NO BED AVAILABLE

Confirmed COVID+ Admission to COVID-Med

Unit

PHASE 1

PHASE 2

PHASE 3

PHASE 4

BCH

7

COVID-Medicine Flow

PUI Admission to COVID-Med Unit

Isolation bed on 10th Respirology

available?

Private room(reserved for PUIs only)

Semi-private room

Ward room

PUI isolation bed priority on COVID units

Admit to 10th

Respirology

Isolation bed on next identified COVID-Med unit

Cohort with other COVID+ patients in ward/semi room

on 10th

Respirology


POS SWAB

NEG SWAB

NO

YES

Isolation bed on 9W Medicine

available?

Admit to 9W Medicine

Cohort with other COVID+ patients in ward/semi room on 9W Medicine


POS SWAB

NEG SWAB

NO

YES

Isolation bed on 9E Med/Pall

available?

Admit to 9E Med/Palll

Cohort with other COVID+ patients in ward/semi room on 9E Med/Pall


POS SWAB

NEG SWAB

NO

YES

[Next COVID-Med unit to be

identified]

[Next COVID-Med unit to be identified]

NO BED AVAILABLE

NO BED AVAILABLE

NO BED AVAILABLE

Confirmed COVID+ Admission to COVID-Med

Unit

PHASE 1

PHASE 2

PHASE 3

PHASE 4

EGH

Direct Admits from Clinic or Community

Patient in clinic/community

Patient meets criteria to be swabbed for COVID-19

Patient requires admission from the clinic/community?

Is bed available?

Inform clinic of bed assignment

Send to ER

Patient swabbed in the ClinicDo not submit swab until

disposition known

YESNO

Semi/ward room available

to use as private room?

Provide bed

8

NO

Private room available on COVID unit?

Provide bed

YES

NO YES

Contact Access & FlowSubmit swab to Mount Sinai/ SickKids/

Hamilton for expedited results

Contact Access & Flow to discuss bed placement

D/C home

Patient requires admission from the clinic/community?

Discharge homeWritten discharge

instructionsincluding follow up and self quarantine

guidelinesSubmit swab to Public

Health

Patient requires sub-specialty care?

Send to ER

NO

YES

NO

Semi/ward room available

to use as private room?

Provide bed

Private room available on sub-specialty unit?

Provide bed

NO YES

Send to ER

YES

NO

YES

YES

NO

NO

YES

IPAC Flow – Patients Admitted to Hospital from ED/Clinic

Patient meets the following criteria?

1) Patient has mild symptoms of upper respiratory tract infection or influenza-like illness AND ANY ONE OF:

• fever (temperature of 37.8 degrees or above)

• underlying immunocompromise (e.g. chemotherapy, HIV, dialysis)

• age under 3 months or age over 60

• community members from remote, isolated, rural or indigenous communities, or cross-boarder workers

• individuals who reside in long-term care or retirement homes or congregate living environments (e.g. group home)

• health care workers (including personal support workers), caregivers, care providers, or first responders

• clinical or radiological evidence of pneumonia

2) Patient is from Long-Term Care Facility (with or without symptoms)

Patient presents to the ED/Screening Centre

Admit to private room on COVID-Medunit or appropriatesub-specialty unit

with droplet/contact isolation

Consult IPAC AND ID and MRP to determine:

1. Remove from isolation as diagnosis accounts for symptoms

2. Keep on isolation and re-swab in 24-48 hrs using risk stratification (consult ID)

Admit to appropriate unit, no isolation

If patient develops symptoms on a unit, follow

the Inpatient IPAC Flow

NO YES

Patient is from a shelter, mental health institution, prison, hospice or other

congregate living settings (e.g. group home) AND has

any symptoms (including atypical symptoms)?

YES

(Low threshold testing)

Cohort with other COVID+

patients in ward/semi

room on unit and follow usual

process

POS SWAB

NONEG SWAB

COVID NPS swab

Admission required? Discharge home

COVID NPS swab

Admission required?NO NO

YES

IPAC Flow – Patient Develops Symptoms on Inpatient Unit

1st SWAB NEG

1st SWAB POS

IPAC Risk Assessment

Cohort on COVID-Med unit as per current flow

Patient develops ANY of the following symptoms on an inpatient unit

• Clinical radiologic evidence of pneumonia OR ARDS OR• Influenza-like illness OR• New respiratory symptoms (cough, URI, SOB) OR• Worsening of a pre-existing respiratory condition OR• Fever (temperature 37.8 or greater) without another cause OR• GI symptoms with fever (temperature 37.8 or greater) without an

alternate diagnosis.

NO YES

Patient is from a shelter, mental health institution, prison, hospice or other

congregate living settings (e.g. group home) or Long Term Care Facility AND has

any symptoms (including atypical symptoms)?

YES

(Low threshold testing)

Move to private room on droplet/contact on

unit

Swab for COVID-19

Cohort contacts if approved by IPAC

If contact develops symptoms, move to private

room on the current unit and swab for COVID-19

1. Risk Assessment (patient meets two or more criteria from list below)

• Fever• Requirement for oxygen• Cough• Abnormal chest x-ray• Diarrhea• Lymphopenia

Send 2nd COVID-19 NP swab 48 hours after first and maintain droplet/contact

precautions

2. No alternate diagnosis for admission or high suspicion by IPAC assessor

3. Risk assessment (patient meets one or less criteria from above list) andreasonable alternate diagnosis

Transfer to non-COVID unit; IPAC to re-assess

precaution requirements

COVID-19 is unlikely;

IPAC to reassess patient and precautions

2nd SWAB NEG

2nd SWAB POS

YES

YES

NO

NO

YES

IPAC Flow – Patients Admitted to Critical Care

PUI Admitted to COVID Pod/Unit(NPS swab pending)

Remain in COVID pod/unit, no

additional testing required

Send endotracheal aspirate (sputum) for COVID-19

Does the patient have ARDS NYD?

NEG SWAB POS SWAB

11

Remain in COVID pod/unit, no

additional testing required

ASPIRATE NEG ASPIRATE POS

Remain in COVID unit, treat as if positive until

symptom resolution

Transfer to non-COVID unit but remain in droplet/contact

isolation

IPAC should be consulted before

changing or discontinuing isolation

requirements

NO YES

Remember a single negative COVID-19 NPS does not exclude

COVID-19 if the pretest probability is high.

IPAC Flow – Patients Admitted from Long-Term Care/Retirement Home

Patient is referred for admission from LTC or retirement home

All patients receive COVID NPS swab at admission

12

*Criteria requiring COVID NPS Swab

• Clinical radiologic evidence or pneumonia OR ARDS OR• Influenza-like illness OR• New respiratory symptoms (cough, URY, SOB) OR• Worsening of a pre-existing respiratory condition OR• Fever (temperature 37.8 or greater) without another cause OR• GI symptoms with fever (temperature 37.8 or greater) without an

alternate diagnosis

Patients with any symptoms (even atypical symptoms) from shelters, mental health institutions, prisons, hospices or other congregate living settings *e.g. group home) will be tested with a low threshold

Isolate all patients using droplet/contact isolation for 14 days or the length of their admission, even if COVID NPS

is negative

If patients develop any symptoms* during their stay, perform NPS swab

Initial NPS upon hospital admission was negative AND last

swab was obtained more than 14 days ago?

Perform NPS prior to discharge. Discharge to

facility does not depend on the result of the exist NPS.

Discharge to facility

NO YES

IPAC Flow – Patients Transferred to Long-Term Care/Retirement Home

Patient to be transferred to LTC or Retirement Home

13

New LTC/retirement home admission?

Perform a surveillance NPS at time of discharge. This does not

require a change in isolation practice for the patient.

Initial NPS upon hospital admission was negative AND last

swab was obtained more than 14 days ago?

Perform NPS prior to discharge. Discharge to

facility does not depend on the result of the exist NPS.

NO YES

Discharge to facility

NO YES

Patient met swabbing criteria and was swabbed for COVID-19?

Surgical patient identified in the ER

Standard process is followed

NO YES

Contact Surgery for Consult

Is the case urgent?

NO YES

Does the patient meet admission criteria?

Does the patient require surgery?

Patient admitted to available

COVID-Med unitMRP: Surgeon

Patient is discharged home: written d/c

instructions including follow-up and self-

quarantine guidelines given

Patient transferred to inpatient Surgical

unit (General Surgery at BCH or 8th

Surgery at EGH) or discharged home to

waitMRP: Surgeon

Patient is transferred to the OR

NO YES

Procedure is completed

Patient recovers in the OR

Can the patient be discharged the same

day?

Patient admitted to unit (General Surgery at BCH or

8th Surgery at EGH)*Inpatient surgery to cohort

COVID+ patientsMRP: Surgeon

NO

YES

NO YES

14

Surgical Patients

BCH

EGH

Mental Health patient in the ED requires admission

No suspected COVID (Pt does not meet

swabbing criteria and therefore not a PUI)

PUI(Pt met swabbing criteria and was swabbed for COVID-19)

Confirmed COVID+ patient

Admit to available and appropriate MH bed

If no appropriate MH bed, transfer to

available bed at EGH

Phase 1

Phase 2

POS SWABNEG SWAB

Patient develops symptoms – febrile

illness with cough or diarrhea

Follow rest of IPAC COVID Flow for

patients developing symptoms on unit

Call ID if patient hospitalized for more than 48h and move to private room on unit.

Exceptions:• MH Geriatrics Unit to remain “clean”

• If MH Geriatrics PUI/COVID+, transfer to available bed on COVID-Med unit

• If MH Geriatrics PUI is negative, transfer from COVID-Med unit to MH Geriatrics

If patient deteriorates medically, call GIM

for transferMed MRP: HospitalistICU MRP: Intensivist

Transfer to private room on MHESU –ensure Security has

appropriate PPEMRP: Psychiatrist

NOTE: All COVID swabs are to be done in the ED prior to transfer to MH, including noncompliant

patients

15

Mental Health Patients - BCH

Psychiatrist to determine

appropriate MH bed

If no private room available on MHESU,

transfer to private room on MHIU

If MHESU and MHIU full, open new COVID-

MH area in Gen B

Patient to stay on MHESU or MHIU

(cohort with other COVID+ where

possible)

Phase 1

Phase 2

BCH

Contact Psychiatry for consult

Mental Health patient in the ED requires admission



PUI(Pt met swabbing criteria and was

swabbed for COVID-19)


Transfer to available bed on 5th Mental

Health

Transfer to private room on 5th Mental

Health (2 rooms)MRP: Psychiatrist

Seclusion required?

If no private room available, transfer to observation room on 5th Mental Health (3

rooms)MRP: Psychiatrist

POS SWABNEG SWAB






Transfer to available COVID-

Med unit with assistance from

MH nursingMRP: Psychiatrist

Transfer to BCH Mental Health

Intensive

NO YES

16

Mental Health Patients - EGH

NOTE: All COVID swabs are to be done in the ED prior to transfer to MH, including noncompliant

patients

EGH




Paediatric Mental Health Patient in the ED requires admission





Admit to available and appropriate CHAD or

PICU bed

Transfer all non-COVID related PICU

patients to CHAD

Phase 1

Phase 2

POS SWABNEG SWAB








Transfer to private room on MHESU –ensure Security has

appropriate PPEMRP: Psychiatrist

17

Paediatric Mental Health Patients

Psychiatrist to determine

appropriate MH bed

Occupy all PICU beds

Patient to stay on MHESU or PICU

(cohort with other COVID+ where

possible)

Phase 1

Phase 2

BCH


BCH Oncology patient in the ED requires admission





Transfer to available semi/ward bed on

COVID-Med unit, cohort with other COVID+

patientsMRP: Oncologist

Transfer to Onc/Pall unit

POS SWABNEG SWAB

Patient develops symptoms –febrile illness with cough or

diarrhea

Follow rest of IPAC COVID Flow for patients

developing symptoms on unit

Call ID if patient hospitalized for more than 48h and move

to private room on unit

18

Transfer to available private/isolation room

on COVID-Med UnitMRP: Oncologist

Oncology Patients

NOTE: Oncology patients at EGH would follow the Medicine flow

Contact GIM for consult as usual

BCH

19

Palliative Patients - BCH

Palliative patient in the ED requires admission

No suspected COVID(Pt does not meet




Transfer to Onc/Pall unit

Transfer to available semi/ward bed on Respirology (COVID-Med)

unit, cohort with other COVID+ patients

MRP: Palliative Physician

Transfer to available private room on Respirology (COVID-Med) unit


Transfer to available private room on Othropaedics (COVID-Med)

unitMRP: Palliative Physician

Transfer to available semi/ward bed on Orthopaedics (COVID-Med) unit, cohort with other

COVD+ patientsMRP: Palliative Physician

NEG SWAB

POS SWAB

Phase 1

Phase 1

Phase 2+ Phase 2+

Medicine PUI/COVID+ patient becomes

palliative/EOL

MRP to initiate order set with palliative consult as required

Can be transferred to COVID palliative unit if appropriate (ie. complex, not

imminent)


EGH Palliative patient in the ED requires Palliative admission

No suspected COVID

(Pt does not meet swabbing criteria and therefore not

a PUI)



Palliative Patients - EGH

Transfer to 9E Med/Pall unit

Transfer to available semi/ward bed on COVID-Med unit, cohort

with other COVID+ patientsMRP: Palliative Physician

Transfer to available private room on COVID-Med unit


Transfer to available private room on 9E Med/Pall (COVID-Med) unit


Transfer to available semi/ward bed on 9E Med/Pall (COVID-Med)

unit, cohort with other COVD+ patients


NEG SWAB

POS SWAB

Phase 1 & 2Phase 1 & 2

Phase 3+ Phase 3+

Transfer to 8th

Surgery unitMRP: Palliative

Physician

Phase 3+

Medicine PUI/COVID+ patient becomes

palliative/EOL

MRP to initiate order set with palliative consult as required

Can be transferred to COVID palliative unit if appropriate (ie. complex, not

imminent)



CCU Patient

CCU patient needs BIPAP

Needs pressors/higher CCU level

CPU admitMRP: CCU

NO YES

NO

YES

NO

CCU Patients

21

Contact Cardiologist for consult

Contact Cardiologist for consult

Critically ill (pressors, BIPAP, FiO2 – 50 or

greater)?

Admit to ICUMRP: ICU

Cx: Cardiology

YES

Admit to Cardiology with

TelemetryMRP: CCU

NO

Cardio approval for ward

YES

YES

NO

BCH

EGH

If telemetry is no longer required,

transfer to COVID-Med unit

MRP: Hospitalist

Pregnant PUI (patient met swabbing criteria and was swabbed for COVID-19) or confirmed COVID+ patient

presenting to the ED

Pregnant Patient Requiring Admission (Under 22 Weeks)

A pregnant PU/COVID+ patient alone is NOT a reason for admission

22

BCH

EGH

If admission required to PP/MBU

BCH RMs 110, 113, 115;

EGH RMs 80, 81

OBS and ICU to discern most appropriate

disposition, MRP (OB), and shared model of carebased on deteriorating

condition and critical care capacity

Admit to COVID-Med Unit*

MRP: Hospitalist

PUI Medical

complaint

ED to Consult GIM

If Admitted for Obstetrical

presentation + medically complexOBS Consult GIM

Under 22 weeks OBS

Presenting condition

If MEWS criteria warrants,OBS consult ICU

Under 22 weeks NON-OBSPresenting condition

To ED for assessment;Consult OBS as needed*

To ED for assessment and ED consult OBS;

Manage per OBS care pathway

Isolation/private rooms L&D/BU:BCH-12,14,16,18; EGH-12,10,14,16,18

Isolation/Private rooms PP/MBU:BCH rooms 110, 113, 115; EGH rooms 80,81

Admit to COVID-Critical

Care Unit*

PUI critically ill

GIM to Consult ICU

Pregnant PUI (patient met swabbing criteria and was swabbed for COVID-19) or confirmed COVID+ patient

presenting to the ED

Pregnant Patient Requiring Admission (22 Weeks or Over)

A pregnant PUI/COVID+ patient alone is NOT a reason for admission

23

BCH

EGH

If admission required for

labour, admit to isolation /private room

L&D/BU

OBS assessment in L&D/BU and triage in isolation room

(OTAS & MEWS)

If delivered and clinically

stable, to isolation /

private room PP/MBU

22 weeks or overNON-OBSPresenting condition

22 weeks or overOBS

Presenting condition

If Admitted for Obstetrical

presentation + medically complexOBS Consult GIM

If MEWS criteria warrants,OBS consult ICU

OBS and ICU to discern most appropriate

disposition, MRP (OB), and shared model of carebased on deteriorating

condition and critical care capacity and

Gestational age(i.e. tertiary care)

If antepartumadmission required, admit to

isolation / private room

PP/MBU

Isolation/private rooms L&D/BU:BCH-12,14,16,18; EGH-12,10,14,16,18

Isolation/Private rooms PP/MBU:BCH rooms 110, 113, 115; EGH rooms 80,81

Consult GIMConsult OB

Consult CCRT/ICU

Admit to PP/MBUMRP: OB

• GIM Med consult to follow daily until discharge

• CCRT to follow 72 hours minimum – may be extended

• CCRT MD daily + as needed• CCRT RN qshift + as needed

Patient requires more than 3L NP to maintain O2 sat of 95% or increased

work of breathing?

YES

NO

Admit to COVID-Critical Care unitOB to follow and

see daily + as needed

Post-Partum & NICU Flow for PUI/COVID+ Mother

24

Admit to COVID-Med

UnitMRP: OB

If medically complex re

COVID symptoms, OBS consult

GIM

Well Mother

Unwell Mother per MEWS

criteria

Post-Partum PUI (patient met swabbing criteria and was swabbed for COVID-19) or confirmed COVID+ patient

Asymptomatic and Well Baby

Unwell or Symptomatic Baby

Admit to isolated or private PP/MBU BCH rooms 110, 113, 115;

EGH rooms 80,81)

Neonate to go to Protected

NICU and baby swabbed

POS SWAB for Mother

NEG SWAB for Mother

Baby swabbed

Move neonate to PP/MBU

with mother if mother well

Discharge home with

father if mother unwell

NEG SWAB

POS SWAB

Neonate remains in Protected NICU on

isolation precautions,

discharge when well enough

BCH

EGH

If MEWS criteria

warrants, OBS

consult ICU

Admit to COVID-

Critical Care Unit

If IPAC clears precautions and

neonate still requires NICU care, move to NICU satellite (non-

COVID NICU)

In either situation of NEG or POS mother or baby: If

both are well, they can go home together

EGH COVID versus NON-COVID dispositionProtected NICU – Fourth Level New NICU space for Suspected or Positive COVID NICU admissionsSatellite NICU – Fourth Level Paediatric Day Surgery Space for NON-COVID NICU admissionsBCH COVID versus NON-COVID dispositionIsolation room and then POD 4 for Suspected or Positive COVID NICU admissions

Paediatric Patient

25

Paediatric Patient presents to ED



PUI(Pt met swabbing criteria and was

swabbed for COVID-19)


Admit to semi/ward room on Paediatrics

unit

Admit to isolation/private room

on Paediatrics unit

Cohort with other Paediatric COVID+

patients on Paediatrics unit

POS SWABNEG SWAB






BCH

EGH

• If capacity high for COVID + paediatric patients, patients over 14 could be considered for adult COVID unit

• For critically ill deteriorating paediatric patient, call CritiCall for transfer to tertiary paediatric ICU

If no bed available on Paediatrics, patients over the age of 14 to

be considered for adult COVID-Med unit

MRP: Paediatrician

Contact Paeds for consult


In-center hemodialysis patient requires admission

Patient requires ICU support and

management?

Admit to non-COVID-CC unit

NO YES

NO YES

Inpatient Admission of Hemodialysis Patient

Renal Program estimates that 12% of chronic dialysis patients will become positive COVID-19.

This translates to approximately 50 inpatients. Of these patients testing positive for COVID-19, 5% is estimated

to require ICU admission.

Send patient to ED for further assessment and

admission – Nephrologist to contact ED physician prior to

transfer

Admit to available non-COVID-Med unit

MRP: Hospitalist

Nephrologist to determine if patient

is stable

If patient requires 1:1 RN dialysis

treatment, then off-unit RN will be

scheduled

Transport to Hemodialysis unit

for treatment

UNSTABLE STABLE

Patient will require

hemodialysis and may require CRRT

or SLEDD


management?

Admit to COVID-CC unit

NO YES

Admit to available COVID-Med unitMRP: Hospitalist

Nephrologist to determine if patient

is stable

If patient requires 1:1 RN dialysis

treatment, then off-unit RN will be

scheduled

Transport to Hemodialysis unit

in designated COVID Pod and

isolated (droplet/contact)

for treatment

UNSTABLE STABLE

Patient will require

hemodialysis and may require CRRT

or SLEDD

26

BCH


Patient on PD requires admission


management?

Admit to non-COVID-CC unit

NO YES

NO YES

Inpatient Admission of Peritoneal Dialysis (PD) Patient

The volume of inpatient PD patients ranges from 0-12 patients. At BCH, select

nurses on the ACE unit have been trained to manage inpatient and emergency PD patient

needs after hours.

Admit to available bed on ACE


management?

Follow Direct Admit flow

and admit to COVID-CC unit

NO YES

Follow Direct Admit flow and admit to

available COVID-Medunit

MRP: Hospitalist

Phase 1 & 2

If in Phase 3 and ACE is a COVID-Med unit,

admit to N4 Medicine* PD nurses to be on

N4 Medicine

Phase 3

27

BCH

28

Care of Deceased: Suspect or Confirmed COVID Patient

Patient Deceased

Deceased patient

Put body in a zippered body pouch or double wrap in existing body shroud ensuring PPID, and all identification

tags match

Identify the zippered body pouch or double wrapped body shroud with

yellow sticker labelled“Infectious Risk – Handle with Care”

Prior to leaving patient space, wipe down the exterior of the body pouch

or shroud with a cavi wipe

Porter to transport body to morgue wearing droplet/contact PPE

When signing into the morgue, note that the body is an infectious risk

Follow the rest of the sign-in process

Is this a Coroner’s case?

After the patient has died, clamp endotracheal tube or place HME viral filter on end of endotracheal tube (this may already be present

from resuscitation)

An RRT can help locate an appropriate clamp or HME viral filter

if not readily available

Prepare the body as per usual practice, but delay removal of ETT

Using the same precautions, just prior to closing the body pouch, deflate cuff on ETT and carefully remove. This is not an AGMP in

deceased patient.

Discard the endotracheal tube (or other airway) in a plastic bag in a

yellow biohazard bin

Close the pouch over the patient’s face

Do not remove any tubes or lines (including

endotracheal tube (ETT)). Phone Coroner’s

office for guidance

Patients pronounced in EMS bay should be transferred onto an ED

stretcher and moved into a room in the “COVID zone” before proceeding

with the steps below.

Is the patient intubated?YES YES

NONO

This process applies to:• COVID positive patients• Patients under investigation for COVID• Patients who die following endotracheal intubation prior to

reliable historical screening (i.e. COVID status unknown)

Personal Protective Equipment• Droplet-contact precautions are always required• If death occurred within 1 hour of AGMP, droplet-contact plus

fit tested N95 mask are required.

Release of Deceased Patient Process

Funeral Home (FH) Calls LocatingLocating transfers call to Patient Flow Centre ext. 57041

FH advises coming to pick up body

Patient Flow Centre updated that FH on way to pick up body

Sodexo Supervisor notified a porter to come to Patient Flow Centre

Security is notified to come to Patient Flow Centre

Sodexo Porter/EVS/Security meet in the Patient Flow Centre and gather appropriate PPE (if deceased patient is suspect or

confirmed COVID positive)

A&F and/or EDRT Lead/Security/Sodexo (EVS at EGH) go to morgue and meet FH on loading dock with paper death certificate

Confirm deceased patient being picked up with FH

Body pouch/shroud wiped down with cavi wipe, morgue table cleaned 2x with cavi wipe

Deceased patient handed off to FH in release area (loading dock)

“Release information” updated on morgue tracking document by Security

Take FH stretcher into body holding area, confirm patient identification utilizing tag affixed to outside of the body

pouch/shroud (do not open body shroud/body bag), and transfer patient onto FH stretcher

COVID+/PUI

Non-COVID/Non-PUI

Gather appropriate PPE from Patient

Flow Centre

Porter/EVS and Security don

appropriate PPE

COVID+/PUI

Non-COVID/Non-PUI

30

Peel Transfer Protocol – Flow Map

* Admission Criteria:• O2 sat below 92 on room air at rest• SBP < 90 or lactate > 4• Severe metabolic abnormality i.e. ARF, elevated trop

** Critical Care Consultation Criteria:• Requires 40% or greater O2 to keep stats above 92• Persistent lactate > 4• Vasopressor Support required

Patient presents to UCC with O2 sat <92 on RA at triage

Triage Nurse alerts Resource Nurse

Patient is taken straight to a room to

be assessed

Resource Nurse calls EMS and pages A&F stat through Locating with COVID-19 patient transfer from UCC

UCC MD calls GIM on call at

receiving facility

UCC MD calls ICU on call at

receiving facility

ICU accepts transfer

Bed available on ward?

Patient transferred to ED

UCC MD alerts ED MD to patient transfer

(GIM already aware)

Only if absolutely necessary, critical

procedures such as intubation carried out

after discussion with ICU on call prior to transfer

Patient transferred directly to ward†;

transfer orders written by UCC MD

ICU patients transferred straight to

the ICU†; transfer orders written by UCC

MD

Admitting at BCH/EGH creates patient chart

GIM consultation on ward on arrival

GIM accepts transfer

GIM Consult*

NO

Transfer orders written by UCC MD

YES



GIM consult in the ED on arrival

ICU Consult**† If a patient is

undifferentiated at the time of transfer,

GIM/ICU can request patients be sent to the

ED regardless of an inpatient bed being

available

A&F responds to page with appropriate site for transfer

31

Peel Transfer Protocol

Guiding Principles:

1. Align with existing Osler A and F procedures and COVID admission guidelines on covidcriticalcare.ca

2. Minimize steps /HCW exposure between UCC and ward/ICU at BCH/EGH whenever possible

3. Maintain Flow of new patients arriving at UCC

4. Intubation prior to transfer for critically hypoxemic patients only that do not respond to other measures

Part A: Medicine and ICU Patients

Admission Criteria:O2 sat below 92 on room air at restSBP < 90 or lactate > 4Severe metabolic abnormality ie. ARF, elevated trop

Critical Care Consultation Criteria:Requires 40% or greater 02 to keep sats above 92Persistent lactate > 4Vasopressor Support required

Part B: Transfer Plan

1. If O2 sat <92 on RA at triage, triage nurse alerts the resource nurse who calls EMS and pages A&F stat through Locating with COVID-19 patient transfer from UCC

2. Patient is taken straight to a room to be assessed

3. Early transfer facilitated

4. UCC resource nurse and A&F determine appropriate receiving facility (BCH or EGH)

5. UCC MD calls GIM on call or ICU on call at receiving facility depending on patient condition (either based on criteria on initial presentation or if patient decompensates while in UCC requiring step up to ICU)

6. GIM/ICU accepts transfer

7. If there is a delay in EMS transfer then private patient transfer can be utilized (will be on standby)

8. Patient is transferred to ED if no bed is available on the ward

9. UCC MD alerts ED MD to patient transfer, GIM already aware

10. Transfer orders written by UCC MD

11. Only if absolutely necessary, critical procedures such as intubation carried out after discussion with ICU on call prior to transfer

12. Delay intubating whenever possible (i.e. awake proning <6L)

13. Patient transferred directly to the ward or to ED if no bed available

14. Admitting at BCH/EGH makes a chart

15. GIM consultation happens on ward on arrival if bed available, otherwise consult takes place in ED

16. ICU patients go straight to ICU

32

Protected Code Blue: EMS to ED Transfer

33

Protected Code Blue: EMS to ED Transfer

Guiding Principles1.

Ensure staff safety2. Clear and consistent communication with EMS3. For patients for whom CPR is indicated minimize CPR interruption

Protected Code Blue: EMS to ED transfer

1. Patch from EMS received at least 5 minutes before arrival.

2. Patch must include 3 criteria for cessation of CPR https://covidcriticalcare.ca/cardiac-arrest/

3. Plan to stop CPR if unwitnessed by EMS + no ROSC prehosp + no shockable rhythm with EMS.

4. Pulse/rhythm check in EMS bay while patient still on EMS monitors, defibrillate if necessary, continue CPR

5. If plan is to continue CPR: ED team meets EMS in ambulance bay with hospital stretcher - 3 person resusteam (1 MD and 2 RN) in airborne precautions as per protected code blue policy.

6. 1 RT in resus room preparing room in airborne precautions. Runner nurse can help prep room in droplet precautions but must leave room before patient arrives.

7. On arrival patients transferred from EMS stretcher on to hospital stretcher in EMS bay.

8. Security to clear the main hallway.

9. If LMA/ETT by EMS, then connect to BVM with viral filter and do not bag. If patient does not have advanced airway then cover mouth Tavish NRB or surgical mask + NRB on top.

10. Decision to continue or hold CPR through transport of patient from EMS bay to Resus room is made by lead MD. Security to keep hallway clear

11. Continue with protected code blue in resus bay

Risks:

• EMS services need to be repeatedly reminded to patch in advance given ED team time to prepare. Consider large stop signs in both EMS bays for CTAS 1 patients. EMS not to proceed into department without meeting ED team in bay.

• EMS can’t be involved in transport from EMS bay to Resus as they are in dirty PPE and would risk contaminating the ED team.

• Potential overuse of airborne PPE will be mitigated by pronouncing futile CPR cases in EMS bay. However, if the team is not in airborne precautions ready to accept care of these cases there is small risk that patient is in fact salvageable (ie rosc on route after patch) and the team not ready

https://covidcriticalcare.ca/cardiac-arrest/

34

EMS Stretcher/Wheelchair Flow to Room

BCH ED Surge Plan

35

PHASE 1 PHASE 2 PHASE 3 PHASE 4

CO

VID

-19

UN

IT(P

REV

IOU

S M

AU

)

• CTAS 4 ± 3 patients who are COVID-19 PUIs or atypical presentations• O2 sats <94% - ill appearing but not requiring ventilatory support • Attempt to reserve negative pressure RM 48/49 for higher acuity/“more ill” patients• 2 RNs staff unit with floating RN/RPN for breaks – NEVER SINGLE COVERAGE

• SAZ/MAU Pod Leader (RN) present at junction of SAZ/MAU to triage patients to areas

• If overflow - chairs to be set in hallway and vestibule between SAZ/MAU and backhall as waiting area - triage nurse ± MD to attend to area to treat/vital and triage

• RN to triage in junction between SAZ/MAU ± MD

SAZ

• CTAS 5 ± 4 patients who are COVID-19 PUI or atypical presentations and expected discharge• O2 sat >94% - well-appearing/ambulatory patients• SAZ/MAU Pod Leader (RN) present to triage patients to areas• 2 RNs or RN/RPN staff with floating RPN/RN for breaks – NEVER SINGLE COVERAGE

• If overflow – chairs to be set in hallway and vestibule between SAZ/MAU and backhall as waiting area – RN ± MD to be present for treatment/vitals

• RN to triage in junction between SAZ/MAU ± MD

AC

UTE

• RN – 5-7; RN 8-10; RN 11-13; RES RNs 2:1 ratio R1-4 and 14-17 + Safety Officer RN• All acute RNs resuscitation trained

• Continue to see routine NON-COVID(CTAS 2) ER patients

• CTAS 1-2 COVID-19 patients -Rooms 5-13 (see schematic)

• RN resus trained for R4-1/14-17 – acute RNs for 5-13

• Resusc. rooms utilized R4 ➡ R3 ➡ R2 ➡ R1 ➡ 14 ➡ 15 ➡ 16 ➡ 17 (14-17 HEPA filters)• CTAS 2 patients fill acute in order 5 ➡ 6 ➡ 7 ➡ 8 ➡9 ➡ 10 ➡ 11 ➡ 12 ➡ 13 (NON-COVID

patients moved to SUBACUTE or floors)• See schematic for “trigger points” for emptying rooms• CAZ relocated into RAZ/ATC areas

SUB

AC

UTE

• All NON-COVID patients only• RN staffing same – RN 18-20; RN 21-24; RN 25-28; 2

RN MHAZ

• Systemic occupation of COVID-19 patients in the order (18 ➡ 19 ➡ 20 ➡ 21 ➡ 22 ➡ 23 ➡ 24 ➡ 25 ➡ 26 ➡ 27 ➡ 28 ➡ 29 ➡Partition 30➡31➡32) ± hallway patients

• SUBACUTE patients to be relocated to RAZ – remains NON-COVID only in RAZ

• MHAZ relocated to waiting room of RAZ and/or MHESU• RN 18-20; RN 21-23; RN 24-27; RN 28-30; RN 31-32 and RN Safety

Officer

• Also relocated non-COVIDs from ACUTE

• RN added if exceed room capacity for Non-COVID patients

RA

Z/A

TC/U

CC

• Status quo for typical RAZ/ATC/UCC NON-COVID patients• NON-COVID patients only• UCC - 2 RPN• ATC - 6RNs – 1 RPN

ATC• COVID-19patients filled in order

(37➡38➡39➡40➡41➡42➡43➡44➡45) then (33 ➡34 ➡35 ➡36)

• 2 RNs –33-36; 3RNs 37-45; RPN –floating + Safety Officer

RAZ/UCC• COVID-19 patients fill in order

(59➡60➡61➡62➡63➡64➡65➡66➡67 – partition waiting room to three beds – 68A – 68B)

• Ability to flex RNs/RPNs between zones ±MAU/SAZ

ATC• CAZ patients relocated to ATC

RAZ• 4 RNs

RAZ• All NON-COVID CTAS 2-3

not requiring ventilatorysupport

• MHAZ in waiting room• RN MHAZ; RN 59-62A; RN

63-65; RN 66-68 – floating RN

FRACTURE CLINIC OR OP CLINIC (L3)• ATC/RAZ/UCC/MHAZ/CAZ

patients relocated to Fracture Clinic

• Entire ER NON-COVID patients and non-ventilator support patients relocated here

BCH ED Surge Plan

36

SCREENING – REMAINS SAME THROUGH ALL LEVELS• Screening to identify PUI• Expanded to include URTI/SOB/GI symptoms/febrile• Patients escorted to MAU/SAZ directly if screen positive• All non-COVID-19 patients to other areas of ER as usual• Vitals at screening O2 sat/HR/temp or immediate arrival to MAU/SAZ• 1 RPN at Screening – 2 RNs Greet – 2 RNs Desk – 1 RN – Offload• Can flex 1 RN Desk to offload if needed

**** CTAS 1-2 requiring ventilating support and/or immediate resuscitation will triage to acute/resuscitation region - all resuscitation are Protected Code Blue ****(order R4 ➡ R3 ➡ R2 ➡ R1 ➡ 14 ➡ 15 ➡ 16 ➡ 17 – HEPA filter to 14-17)

EMS protocol to be followed - see EMS Offload document

DAILY - EFFORTS TO MITIGATE ED VISITS; DECANT ED, ENSURE ADEQUATE PPE AND OTHERSUPPLIES AND ENSURE PROTOCOLS ARE FOLLOWED

• External Care Options For Well ILI Patients - CTAS 4-5 - Peel Assessment Centre• External Care Options For Well Non ILI Patients - CTAS 4-5 - Walk in Clinics; Family Doctor, Urgent

Care Centres• Daily Review of PPE Supplies in Covid-19 Positive Areas - Safety Officer Assignment• Daily Review of ADU’s with Pharmacy• Daily Huddle With IPAC To Review PPE Concerns• Daily or BID Huddles With Staff From ED - Review General Principles of Pandemic Plan and

Pandemic Flow• Consultants Urged and Pressured For TImely Consultation and Disposition• Resource RN To Work With Multidisciplinary Team For Potential Discharges (GEM RN; Social

Work; Physio/OT; CCAC; LHIN)• Access and Flow Constant Pressures To Move Patients to Floor• Sodexo Pressured To Porter Patients and Clean Rooms

BCH ED Surge Plan

37

EGH ED Surge Plan

38


TRIG

GER

S

Current State 4 ISO bed capacity in Acute exceeded bypotential/confirmed COVID-19 patients

4 ISO bed capacity in Acute AND the Pandemic Zone capacity in Acute (Rooms 1914-1928) being exceeded bypotential/ confirmed COVID-19 patients

Defined as the conversion of ALL of Acute into a HOT Zone (4 ISO beds, Pandemic Zone (Rooms 1914-1928), Hallway A and B) to treat potential/confirmed COVID-19patients.

MA

U

COVID ASSESSMENT AREA – Rooms 1774-1788ILI patients or any febrile patients with O2 sat > 94%

OFF-SITE COVID ASSESSMENT AREAThe EGH COVID Assessment area will be closed and be moved off site (Location TBD).

ILI’s or febrile patients with O2 sat > 94% are redirected to the new offsite EGH COVID Assessment area

MAU – Rooms 1774-1788Sick Non ILI/non-febrile patients (CTAS 2) requiring admission

PHASE 4: Non ILI or non-febrile admitted patients in MAU that require resuscitation that are not a Code Blue/Pink are treated in the 2 FT Procedure Rooms (RMs 1727 and 1732)

AC

UTE

ISO (NEGATIVE PRESSURE) ROOMS -1834, 1832, 1830 (R1), 1857 (R2)ILI patients, any febrile patients, or any potential COVID-19 patients with O2 sat < 94%, or ill requiring admission, go to one of the 4 ISO negative pressure rooms with Anteroom in Acute -Rooms 1834 ➡ 1832 ➡1830 (R1)➡ 1857 (R2) in order of ascending acuity

PANDEMIC ZONE –Rooms 1914-1928ILI patients, any febrile patients, or any potential or confirmed COVID-19 patients with O2 sat < 94%, or ill requiring admission, go to the 8 bed Pandemic Zone in Acute (Rooms 1914-1928)

HALLWAY A – Rooms 1830-1930Potential/confirmed COVID-19 patients with O2 sat < 94%, or ill requiring admission -recruiting an additional 6 beds (Rooms 1930-1940) for potential/confirmed COVID-19 patients.

HALLWAY A – Rooms 1830-1930

HALLWAY B – Rooms 1849-1912

HALLWAY B – Rooms 1849-1912Sick Non ILI/non-febrile patients (CTAS 2) requiringadmission

REST OF ACUTESick Non ILI/non-febrile patients (CTAS 2)

RESUSCITATION ROOMS – 1830 (R1), 1857 (R2), 1856 (R3) and 1858 (R4)

• Any Code Blue/Pink arriving from outside or from within Acute is a Protected Code Blue and is carried out in the available 4 Resus rooms in Acute - Rooms 1830 (R1) ➡1857 (R2)➡1856 (R3) ➡ 1858 (R4) in that order

• Non ILI or non-febrile patients requiring resuscitation that are not a Code Blue/Pink are treated in the 4 available Resusrooms in Acute - Rooms 1830 (R1) ➡1857 (R2)➡1856 (R3)➡ 1858 (R4) in that order

OFF

LOA

CC

AZ

MH Sick Non ILI/non-febrile patients (CTAS 2)

• OFFLOAD increased by 8 beds• Sick Non ILI/non-febrile patients

(CTAS 2)OFFLOAD remains at 8 beds

ATC

P

AZ

FT Well Non ILI/non-febrile patients (CTAS 2-5)

EGH ED Surge Plan

39

EGH ED Surge Plan

40


• RN Nurse assignments remain the same on the Roster. Pandemic Surge MD Pool created that could add up to 82.6% additional flex capacity, if needed.

• MD assignments in the ED remain the same as on the Roster; 2nd Back Up On-Call will be added to Roster - current MAU MD (MAU closed) will become 2nd Back-Up On-Call (with some revisions). Both Back-up On -Call (7am-7pm) and 2nd Back-up On-Call (7pm-7am) will be available to help with volume/acuity/patient transfer/MD attrition to illness. Pandemic Surge MD Pool will be available and can add up to 82.6% additional flex capacity, if needed.

• RN assignments in Hallway A changes to 1:3 for Rooms 1930-1934 and 1936-1940.

• RN assignments in Hallway B changes to 1:3 for Rooms 1902-1906 and 1908-1912

• RN assignment for Offload changes with additional RN deployed to Offload

• MD assignments in the ED remain the same as on the Roster; 2nd Back Up On-Call will be added to Roster - current MAU MD (MAU closed) will become 2nd Back-Up On-Call (with some revisions). Both Back-up On -Call (7am-7pm) and 2nd Back-up On-Call (7pm-7am) will be available to help with volume/acuity/patient transfer/MD attrition to illness. Pandemic Surge MD Pool will be available and can add up to 82.6% additional flex capacity, if needed.

• RN assignments in Hallway A changes to 1:3 for Rooms 1930-1934 and 1936-1940.

• RN assignments in Hallway B changes to 1:3 for Rooms 1902-1906 and 1908-1912

• RN assignment for Offload changes with additional RN deployed to Offload

STAFFING PLAN

PMC UCC Surge Plan

41

PHASE 1 PHASE 2 PHASE 3

TriggersCurrent State ISO capacity of 1 neg pressure

room and FT rooms 1,2,3 with HEPA filters exceeded

Capacity of isolation rooms and pandemic rooms (rooms 1,2,3, and ENT/eye room) and main waiting room area exceeded

ASSESSMENT CENTRE

• ILI patients or any febrile patients with an O2 sat > 92% (and no other chief complaint requiring workup) from pre-screen go to the Assessment Centre and D/C home

YELLOW ZONE• ILI patients or any febrile patients with O2 sat < 92% go to the negative pressure isolation room in yellow zone (room

1.A.119)• AGMPs to be carried our in negative pressure isolation room is High Acuity Room 1 is occupied

FAST TRACKHALLWAY

• If negative pressure isolation room occupied, then fast track hallway rooms 1,2 and 3 utilized next• FT hallway rooms 1,2,3 equipped with HEPA Filters for overflow rooms where patients remain in rooms until

disposition

• Fast Track Hallway beyond room 3 converted to cold zone with area behind the fracture room serving as cold/Non-COVID waiting area as well as Gyne and Procedure rooms

HIGH ACUITY• Critically ill ILI patients treated in High Acuity Room 1• AGMPs to be carried out in High Acuity Room 1 (equipped with HEPA filter) or the negative pressure isolation room if

High Acuity 1 is occupied

TRIAGE • Status quo • Divide triage into ILI/febrile patients and non ILI patient zones post pre-screening

ENT/EYE• Remain as cold

zone• Hot/COVID zone• ENT/eye room to be moved to gyne room

MAIN WAITING AREA

• Remain as cold zone

• Main waiting area serves as hot/COVID zone, add chairs as needed to accommodate

YELLOWZONE • Status quo • Yellow Zone in its entirety converted to hot/COVID zone

PROCEDURE ROOMS


• Remain as cold zone• Casting room to be moved to procedure room

REASSESSMENT WAITING AREA


GYNE ROOMS• Remain as cold

zone• Remain as cold zone• ENT/eye room to be moved to gyne room

FRACTUREROOMS

• Remain as cold zone • Remain as cold zone• Area behind the fracture room serving as cold/NON-

COVID waiting area

MOVEMENTOF PATIENTS

At all steps:• Stable Assessment Centre patients requiring a work up in the UCC are to wait in the AC if no room is available for

them immediately and will be triaged in their room• Unstable AC patients are to be brought directly to the high acuity room

• ILI/febrile patients can be walked directly from pre-screening to the above rooms to be triaged in their rooms

• Non ILI patients go back out to the main hallway to register at the DI desk #1 area and then enter the UCC through the door next to DI desk #1 that leads to the fracture room

• Main hallway to be blocked off past the DI registration area

• Drive through pre-screening initiated• Drive-through pre-screening will be conducted from the

front driveway entrance with patients divided into:• ILI febrile patients (if O2 sat > 92% (and no other

chief complaint requiring workup)- Assessment Centre and D/C home) and (if O2 sat < 92% then patients are to go to main triage area as in Step 2 to register)

• Non-ILI patients register at the DI desk #1 area and then enter the UCC through the door next to DI desk #1 that leads to the fracture room as in Step 2

PMC UCC Surge Plan

42

PHASE 1 PHASE 2 PHASE 3

Current State 4 ISO bed capacity in Acute exceeded bypotential/confirmed COVID-19 patients

4 ISO bed capacity in Acute AND the Pandemic Zone capacity in Acute (Rooms 1914-1928) being exceeded by potential/ confirmed COVID-19 patients

STAFFING

• MD/Nursing assignments remain the same as on the current schedule that is running until April 1/20 (4 MD shifts per day with an on call MD to be initiated officially as of April 2/20)

• MD assignments to include 4 shifts per day that can be scheduled as two MDs on at the same time to avoid any overlap into hot/COVID and cold/non-COVID zones

• There will be one on call physician as well as a second physician whose shift will be reinstated if the volumes surge

• Nursing assignments to be increased to account for separate triage zone (capacity to increase by 3 staff at present time)

• MD assignments of 4 shifts per day with two MDs on at the same time to avoid any overlap into hot/COVID and cold/non-COVID zones

• There will be one on call physician as well as a second physician whose shift will bereinstated if the volumes surge

• Nursing assignments to be increased to account for separate triage zone (capacity to increase by 3 staff at present time) and hot/COVID and cold/Non-COVID zones

PPE & EQUIPMENT

• COVID Assessment PPE required (surgical mask, yellow gown, gloves, eye protection)• Portable CXR• AGMP PPE required for AGMPs (impervious gown, N-95 mask, bouffant cap, goggles, face shield, gloves)• Any Code Blue/Pink is now a protected Code Blue and is run with AGMP PPE

ED STAFFING CONTINGENCY PLAN

43

SHIFT FORMERLY

ON CALL 0800 – 1600 O/C 0800 – 2000

O/C ATC 1600 – 2400 ATC 1400 – 2100

ON CALL 2400 – 0000 O/C 2000 – 0800

O/C ASA 1600 – 2400 ASA 1400 – 2000

ADDITIONAL O/C POTENTIAL MAU DOCTOR

ASA 0400 – 1000 ASA 0400 – 1100

ASA 0700 – 1300 ASA 0700 – 1400

ATC 0800 – 1600 ATC 0800 – 1500

ASA 1000 – 1600

ATC 1100 – 1800 ATC 1100 – 1900

ASA 1300 – 1900 ASA 1200 – 1800

ASA 1600 – 2200

ATC 1600 – 2300 ATC 1700 – 2400

ASA 1900 – 0100 ASA 1800 – 2400

ASA 2000 – 0200

ATC 2000 – 0200

ATC 2200 – 0400

ASA 0000 – 0700

Documents

COVID-19 Patient Flows...COVID-Med MRP: Paediatrics BCH 4 High-Level Summary of Medicine & Sub-Specialty Areas - EGH Area Non-COVID PUI or COVID+ PUI/COVID+ ED Consult and COVID-Med