COVID-19 Provider Toolkit

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Introduction

The SAEM COVID-19 Provider Toolkit is intended for emergency medicine providers. Simple practice tips, facts, and summary guidelines are provided to help providers with communicating and caring for patients with suspected and / or confirmed COVID-19, along with easy to access references. Links to easy to downloadable fact sheets are also provided which can be given to patients to help them understand basic aspects of COVID-19 infection, treatment, self-care, and care for others in their homes.

COVID-19 is rapidly evolving. This toolkit was published on January 3, 2022. For the most updated information, see the NIH’s COVID-19 Treatment Guidelines.

Talking to Patients

Breaking Down Communication Barriers

Dispelling Misinformation

Tip #1: Minimize communication barriers associated with personal protective equipment

Minimize communication barriers associated with personal protective equipment, including opaque masks that cover face and muffled voice, particularly for those who are hearing impaired or at-risk for delirium; tele-communication - for example with pads device or smart phone, from outside the room, can be helpful so that patient can directly see the provider’s full face. For direct in-person encounters (when masks are required), ensure that empathy for the patient’s situation is conveyed using other verbal and non-verbal cues.

https://pubmed.ncbi.nlm.nih.gov/34807257/

https://pubmed.ncbi.nlm.nih.gov/34802856/

https://pubmed.ncbi.nlm.nih.gov/34735700/

Tip #2: Engage patient’s identified care partners

TIP #3: Understand the patient's health literacy and health numeracy and adapt communication

Understand the patient's health literacy and health numeracy, while adapting communication strategy and resources using techniques like “Teach Back” to ensure knowledge comprehension. Use infographics and be aware of basic shared decision making principles.

https://pubmed.ncbi.nlm.nih.gov/24673669/

https://pubmed.ncbi.nlm.nih.gov/26617669/

https://pubmed.ncbi.nlm.nih.gov/34600777/

https://pubmed.ncbi.nlm.nih.gov/26112797/

https://pubmed.ncbi.nlm.nih.gov/28559034/

Access and use the large number of one-page, patient-oriented handouts that can be resourced during an episode of emergency department (ED) care to overcome health literacy barriers.

https://jamanetwork.com/journals/jama/fullarticle/2783248

https://jamanetwork.com/journals/jama/fullarticle/2776307

https://jamanetwork.com/journals/jama/fullarticle/2771435

https://jamanetwork.com/journals/jama/fullarticle/2770415

https://jamanetwork.com/journals/jama/fullarticle/2768390

https://jamanetwork.com/journals/jama/fullarticle/2767351

https://jamanetwork.com/journals/jama/fullarticle/2767634

https://jamanetwork.com/journals/jama/fullarticle/2764955

https://jamanetwork.com/journals/jama/fullarticle/2764238

https://jamanetwork.com/journals/jama/fullarticle/2764560

https://jamanetwork.com/journals/jama/fullarticle/2762694

https://jamanetwork.com/journals/jama/fullarticle/2763533

TIP #4: Provide alternative communication stream options for follow-up

TIP #5: Recognize health care disparities

TIP #6: Avoid isolating cognitively frail patients from care partners

Avoid isolating cognitively frail patients from care partners when visitor restriction rules apply. When hospital policies cannot accommodate in-person care partners, ensure uniform access to alternative video communication options (every care partner has a smart-phone or pad device and every person living with dementia has assistance to use those devices in the room).

https://pubmed.ncbi.nlm.nih.gov/34659653/

https://pubmed.ncbi.nlm.nih.gov/33211114/

TIP #7: Understand empathetic communication from the most senior physician is valued

Discussing Vaccination

TIP #1: Display patient-friendly vaccine flyers

TIP #2: Provide basic vaccine information during the initial stages of non-critical ED evaluations

TIP #3: Use one-page, patient-oriented vaccine FAQ handouts to overcome health literacy barriers

TIP #4: Be prepared to answer patients' questions about vaccine safety or efficacy

My Patient Has COVID: Communicating Risk and Prognosis to Patients

Just the Facts: Basic Facts about COVID-19 Treatment Recommendations

Use of Dexamethasone

Daily dexamethasone is RECOMMENDED for patients with COVID-19 that have a new supplemental oxygen requirement.

COVID-19 patients who require mechanical ventilation benefit the most from daily dexamethasone treatment (8.7% absolute risk reduction, number needed to treat to prevent one death is 12). Hospitalized patients with a new supplemental oxygen requirement who receive dexamethasone also experience a mortality benefit (2.9% absolute risk reduction in the RECOVERY trial, number needed to treat to prevent one death is 35).
Strongly consider 6 mg of dexamethasone daily for all patients who require supplemental oxygen - including those being discharged on home oxygen therapy.
Do NOT start dexamethasone on patients who do not require supplemental oxygen. There is no benefit in these patients and there was a non-significant signal of potential increased mortality for these patients in the RECOVERY trial.
Consider the potential risks of steroid treatment in treated patients so that these risks can be mitigated.

*For patient’s born or recently living in certain regions of Africa, Asia or Latin American where Strongyloides stercoralis is endemic, consider getting an infectious disease consultation prior to starting treatment with immunosuppressive agents.

Key References:

WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group et al, Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19: A Meta-analysis, 2020, JAMA, 324(13):1330-41, doi: 10.1001/jama.2020.17023

The RECOVERY Collaborative Group et al, Dexamethasone in hospitalized patients with COVID-19, 2021, N Engl J Med, 384:693-704, doi: 10.1056/NEJMoa2021436

Evolving and Emerging Therapeutics: Where to Go to Keep Up

The standard of care for COVID-19 therapeutics can rapidly evolve with the emergence of new viral variants that are resistant to current treatments and with the availability of newly developed treatments. The most up-to-date COVID-19 treatment guidelines vetted by the US public health community (the NIH, FDA, and CDC) are available at:

https://www.covid19treatmentguidelines.nih.gov/

Use this website to find the most up-to-date information about treatments that will work for your patients including monoclonal antibody infusions, oral antivirals, and antiviral infusions.

Use of Monoclonal Antibodies

Monoclonal antibody therapy is a highly effective treatment for COVID-19 patients when available.

Sequence variation in circulating viruses can impact the effectiveness of each of the individual monoclonal antibody treatments.

These medications may be INEFFECTIVE if a variant of concern contains mutations that allow the virus to escape the specific monoclonal antibody or antibodies in each different medication. Therefore, the choice of monoclonal antibody medication is typically made at a regional or local level for the treatment that best covers locally circulating variants. Know your healthcare system and consult with local health authorities in your area to know what treatments will work in your community.

When an effective option is available, monoclonal antibody therapy is administered to patients with HIGH RISK for disease progression that DO NOT currently require hospitalization IF the medication can be administered within 10 days of the onset of symptoms.

The highest level of evidence exists to treat patients with 7 or fewer days of symptoms - so we recommend starting these medications in appropriate patients as early as possible after the onset of symptoms.
Advanced age (>55) is the strongest risk factor for disease progression. Chronic medical conditions such as diabetes, heart disease and obesity - among others - are also risk factors for COVID-19 disease progression. Immunosuppression is another key risk factor for COVID-19 disease progression.
A limited meta-analysis of the small number of studies performed with these medications show that they reduce the risk of hospitalization by about 70%.
1. Risk of hospitalization in placebo group 6%, risk in the treatment group 1.8%; absolute risk reduction 4.2%, number needed to treat to prevent one hospitalization is 24.
The process providers must use to access monoclonal antibody treatment for their patients is variable. It is important to know how to get your patients these and other acute treatments in the specific environment you are working in. The US Department of Health and Human Services has a website to help you/your patients locate local treatment centers. Therapeutics Distribution | HHS Protect Public Data Hub

Key Reference:

COVID-19 Education Task Force

Richard Eric Rothman, MD, PhD

Chair, COVID-19 Education Task Force

Johns Hopkins University School of Medicine

Philip A. Mudd, MD, PHD