COVID-19 Emergency Response Team ‘covERT’

ENDORSEMENT DATE: 29 April 2020 CHAPTER: COVID-19 AMENDMENT DATE/S:

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COVID-19 Emergency Response Team ‘covERT’

Policy Policy Statement

The best management for progressive hypoxic respiratory failure due to COVID-19 is early transfer to Intensive Care, intubation and ventilation. In patients with COVID-19, intubation places the patient and surrounding staff at risk. It is recommended that intubation be performed by the most experienced clinician available. The COVID-19 Emergency Response Team (covERT) fulfils this role. Related Clinical Documents

COVID-19 Policies Objectives

To outline the team membership of covERT

To describe the roles and responsibilities of team members Scope

This policy applies to staff working in The Department of Anaesthesia and Acute Pain Medicine, the Emergency Department (ED) and Intensive Care Unit (ICU) at St Vincent’s Hospital Melbourne (SVHM) and St Vincent’s Private Hospital Melbourne (SVPHM). Definitions

COVID-19 Patient For the purpose of this policy, a COVID-19 patient refers to both confirmed positive and suspected positive patients. covERT Response The critical care response to a COVID-19 patient requiring intubation. covERT Team A consultant anaesthetist and an anaesthesia nurse available to facilitate intubation in COVID-19 patients. Acronyms

covERT COVID-19 Emergency Response Team PACU Post-Anaesthesia Care Unit PPE Personal protective equipment NGT Naso-gastric tube

https://svhaorg.sharepoint.com/teams/StaffCOVID-19InformationSVHM/SitePages/Clinical-Policies.aspx



Index

1 Responsibilities ............................................................................................................................. 3

1.1 Roles of the covERT Team .................................................................................................. 3 1.2 Anaesthesia ........................................................................................................................... 3 1.3 Intensive Care Unit ................................................................................................................ 3 1.4 Emergency Department ........................................................................................................ 3 1.5 St Vincent’s Private Hospital Melbourne (SVPHM) ............................................................ 4

2 Pathways ....................................................................................................................................... 6 2.1 Emergency Department Patient ........................................................................................... 6 2.2 Ward Patient .......................................................................................................................... 6 2.3 Patient at St Vincent’s Private Hospital Melbourne ............................................................ 7 2.4 Unintubated Patient in SVHM ICU ....................................................................................... 7

3 General Principles......................................................................................................................... 7 3.1 Clinical Leadership ................................................................................................................ 7 3.2 PPE / Donning and Doffing .................................................................................................. 8 3.3 Intubation ............................................................................................................................... 8 3.4 Preparation of Intubating Spaces......................................................................................... 9 3.5 Staff for the covERT Response in each Location ............................................................... 9 3.6 Roles of Staff ....................................................................................................................... 10 Appendix A - covERT Response Process .................................................................................... 11 Appendix B - covERT Team PPE Donning / Doffing ................................................................... 12



Procedure

Responsibilities

1.1 Roles of the covERT Team

Airway management to facilitate mechanical ventilation in COVID-19 patients.

Transport of intubated COVID-19 patients from site of intubation, to intensive

care bed when necessary.

Insertion of invasive monitoring, venous-access and wide bore naso-gastric

tube (NGT) placement in discussion with ICU team, to facilitate assessment

with a single chest x-ray.

1.2 Anaesthesia

Provide an anaesthetist and anaesthesia nurse to staff the covERT team

o In hours (Monday to Friday 0800-1800) this will be provided by in house

staff

o Out of hours, this service will be provided by an on-call anaesthetist

o To respond to Code Blue PPE in the inpatient services building (Building

A), with equipment to facilitate intubation.

Provide clinical leadership in the period immediately surrounding airway

management.

Constantly review the staffing of the covERT team, in the context of patient load

and adjust staffing as appropriate.

1.3 Intensive Care Unit

Provide a consultant led service to triage all requests for intubation and

admission to ICU.

To be aware of COVID-19 patients who are at risk of deterioration and to

facilitate elective intubation of patients wherever possible.

To provide clinical assistance (doctor and nursing staff) with airway

management.

To provide a specified area for intubation of COVID-19 patients

o To provide pre-specified airway equipment

o To provide pre-specified medications to facilitate airway management and

potential consequences.

To provide clinical leadership in the airway management of COVID-19 patients,

except in the immediate period

1.4 Emergency Department

To identify COVID-19 patients in the Emergency Department for whom

intubation and ventilation is an appropriate form of treatment.

To communicate with on-call ICU consultant about the need for intubation.

To make and communicate a decision about the most appropriate location for

airway management to occur.

If intubation is to occur in the ICU (preferred), the ED team will communicate

with the ICU and the coVERT team, and transport the patient to the ICU.

If intubation needs to occur in the ED



o If emergent intubation is required and the covERT team has not arrived, the

most experienced airway physician will undertake intubation in Level 4 PPE

o If the covERT team (preferred) is going to intubate

Provide clinical assistance (doctor and nursing staff) with airway

management

Provide a specified area for intubation of COVID-19 patients

Provide pre-specified airway equipment

Provide pre-specified medications to facilitate airway management

and potential consequences

Provide clinical leadership in airway management of COVID-19 patients

except in the immediate period around

1.5 St Vincent’s Private Hospital Melbourne (SVPHM)

Early and constant assessment of all COVID-19 patients to identify those at risk

of hypoxic respiratory failure.

Early transport of COVID-19 patients at risk of hypoxic respiratory failure to St

Vincents Hospital Melbourne.

SVPHM ICU consultant consults with SVHM ICU consultant.

SVPHM ICU consultant contacts the covERT team on 9231 4471, if emergency

intubation of a COVID-19 patient is required to facilitate safe transport to the

public ICU

Provide clinical assistance (doctor and nursing staff) with airway

management

Provide a specified area for intubation of COVID-19 patients

Provide pre-specified airway equipment

Provide pre-specified medications to facilitate airway management

and potential consequences

Provide clinical leadership in the management of COVID-19 patients except

in the immediate period around airway management

Ensure all covERT responders are capable of donning and doffing PPE as

described in departmental guidelines.

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Figure 1. A graphic overview of the covERT response

Medications



Pathways

2.1 Emergency Department Patient

COVID-19 patients who are likely to benefit from intubation and ventilation

should be discussed at a consultant level in the ED, considering functional

state, frailty, major co-morbidities and age, as per the Patient Triage flowchart.

The ICU consultant on call should be contacted via the switchboard and a

decision about treatment options made, considering the patient factors and

hospital resources available.

If the decision to progress with intubation and airway management is made, the

ED physician should make a recommendation about whether the patient can be

transported to ICU or whether the intubation should occur in the ED.

The ED physician should contact the covERT team by phoning 4471, during the

day this will reach the Anaesthetist in charge, afterhours it will reach the after

hours anaesthesia registrar

o If the patient requires immediate intubation, this should be performed by the

most experienced airway physician available, following the guidelines for

intubation of COVID-19 patients listed later in this document and wearing

Level 4 PPE

o If the patient is too unstable to be transferred to the ICU but can wait for the

arrival of the covERT team

The covERT team will arrive in Level 4 PPE, having donned PPE in the

PACU

The Emergency Department should prepare the space around the

patient, pre-specified medications and airway equipment

The covERT response will require the covERT team, a senior ED

physician to act as second physician, an ED nurse to act as a runner,

an ED nurse to act as an outside runner and someone to control the

scene

Intubation and insertion of a large bore NGT should be performed

simultaneously wherever possible

Following successful intubation of the patient and stabilisation of their

condition, the covERT team will transport the patient to the ICU. If the

ED team is available to participate in this transport they will. It is

expected that they will frequently have other clinical duties.

o If the patient can be transported to the ICU before intubation, the transport

will be performed by the ED team. The covERT team will meet the patient

in the ICU and will work in tandem with ICU staff.

2.2 Ward Patient

In an ideal situation, COVID-19 patients on the ward will be carefully monitored

and those who might require intubation will be identified early allowing

intubation to occur in an elective fashion.

Should an acute deterioration occur on the ward necessitating emergency

intubation a ‘Code Blue/PPE’ should be called via the switchboard

o Basic life support as per Basic Life Support in the COVID-19 Patient

o The covERT team will attend a ‘Code Blue/PPE’ after donning PPE in

PACU

o The decision to intubate the patient and transfer the patient to ICU will be

made by the ICU consultant wherever practical

https://svhaorg.sharepoint.com/teams/StaffCOVID-19InformationSVHM/Shared%20Documents/Clinical%20Policies%20and%20Procedures/COVID-19%20Patient%20triage%20flowchart.pdf?web=1



https://svhaorg.sharepoint.com/teams/StaffCOVID-19InformationSVHM/Shared%20Documents/Clinical%20Policies%20and%20Procedures/COVID-19%20Basic%20Life%20Support.pdf?web=1



o Once the patient is intubated they will be transported to the ICU by the

covERT team and further invasive monitoring and lines placed as

necessary.

2.3 Patient at St Vincent’s Private Hospital Melbourne

The SVPHM ICU consultant can call the covERT team (9231 4471) to assist in

the emergency intubation of COVID-19 patients.

The covERT team will meet in the PACU, don their PPE and travel to SVPHM

via the tunnels. They will be met by a security officer at the lift and a nurse on

exiting the lift on the second floor of SVPHM, where the operating theatre is

located.

The intubating space should be prepared with specified airway equipment,

medications and staff in appropriate PPE.

The covERT team will work in conjunction with the SVPHM ICU consultant and

SVPHM nursing staff to safely intubate the patient and place a large bore NGT.

The covERT team will take responsibility for the transport of the patient to

SVHM ICU, utilising the portable ventilator provided by the SVPHM ICU. The

patient will be transported on a SVPHM bed and transferred to a SVHM bed on

arrival in our ICU.

Once in our ICU the covERT team will place any other invasive monitoring and

lines that are required.

2.4 Unintubated Patient in SVHM ICU

When a decision is made to intubate a patient already in the ICU, the ICU

consultant should call the covERT team on 4471.

The covERT team will meet in PACU and don PPE.

The covERT team will attend the ICU.

The ICU will prepare the intubating area including specified staff, airway

equipment and medications.

The covERT response will involve at least, the covERT team, ICU consultant,

an ICU nurse in the room, an external nurse and someone to perform scene

control.

Following successful intubation and wide bore NGT placement the covERT

team will place appropriate invasive monitoring and lines.

General Principles

Clinical Leadership

When the covERT team arrives, clinical leadership will be held by an ED

physician, ICU physician or anaesthetist, depending on the patient’s location.

Once the covERT team has assessed the patient and formulated a plan, they

should formally assume clinical leadership and receive a response from the

existing clinical leader.

The covERT team retain clinical leadership until the airway is declared secure

unless they are involved with transport of the intubated patient or have further

procedures to perform.

The transfer of clinical leadership should be openly discussed and clearly

communicated.

See Appendix A.



PPE / Donning and Doffing

Intubation is considered an aerosol-generating procedure (AGP). During the

covERT response AGP may create a viral plume that could put staff at risk. All

staff in close proximity (2 m radius) to the patient during intubation should be

wearing level 4 PPE.

Meticulous attention to detail is required whilst donning or doffing PPE. During

donning and doffing the specified procedure should be followed exactly and an

observer used.

See Appendix B for the covERT donning and doffing guide.

Intubation

Ensure the patient is optimally positioned.

The airway physician and assistant will remove the patient’s O2 mask and

replace immediately with a mask attached to the circuit, obtaining the best

possible seal. A two handed technique is recommended to optimise the seal,

utilising end tidal CO2 (EtCO2) and observing a square wave form acts as

confirmation of a good mask seal.

Perform best possible pre-oxygenation.

Turn off bag valve mask (BVM) O2 prior to removing BVM to minimise aerosol

generation.

Induce with a rapid sequence induction avoiding positive pressure ventilation

wherever possible. Rapid muscle relaxation is preferred to minimise the chance

of cough and infectious aerosol

o Either suxamethonium (succinylcholine) or high dose rocuronium could be

utilised. Suxamethonium may produce marginally quicker intubating

conditions, however, it must be quickly followed by a longer acting agent to

ensure muscle relaxation is maintained and the chance of aerosol generation

is minimised.

Videolaryngoscopy utilising a system where the screen is separate from the

laryngoscope blade is preferable, this will usually be with a Glidescope. At

SVPHM there is a C-MAC® system.

The cuff of the endotracheal tube should be inflated before positive pressure

ventilation proceeds.

If in the operating room, the intubating physician should only touch the

adjustable pressure limiting (APL) valve and bag component of the anaesthesia

circuit, all other ventilator manipulations should be made by the observer under

instruction.

A large bore NGT should be placed and secured in all patients by the covERT

team at the time of intubation. The glidescope and McGill forceps may be a

useful adjunct to ensure the procedure is performed efficiently.

Once the airway is secure this should be declared. At this point clinical

leadership can be returned to the ‘home team’ if that is appropriate.

Once the airway is safely secured all disposable airway equipment should be

disposed of in the appropriate bin within the patient’s room.

Reusable equipment (e.g. glidescope stylet) should be placed in a sealed bag.

The bag should be wiped down within the room and then placed into a second

bag held by the outside runner.




Preparation of Intubating Spaces

In order to facilitate the covERT response the following airway equipment and medications should be available on arrival of the covERT team, see Tables 1 and 2.

Airway Equipment

Inside Outside (brought by covERT team)

Videolaryngoscope

Airway Tray o Ambu bag / HME o Medium mask o Tracheostomy tape o 10 mL syringe o 7.5 ETT o MAC 4 VL blade o Satin slip stylet o Large bore NGT o McGill forcep o Lubricant o Plastic sheet o Nasofix / NGT spigot

ETT 6,7,8

3 sizes of guedel airway

iGel 3,4,5

Glidescope stylet

D blades, Mac 3 / 4 blades

Flexitip bougie

Frova bougie

Range of face masks

Oropharyngeal / nasopharyngeal airways

CICO kit

Table 1. Airway equipment required at the start of covERT intubation

Medications

Prepared

(CoVERT Intubation Kit A)

Immediately available

(CoVERT Intubation Kit B)

Fentanyl 200 microg in 4 mL (5mL syringe) Propofol 200 mg in 20mL (20mL syringe) Rocuronium 2 x 50 mg in 5mL (red 5mL syringe) Metaraminol 10 mg in 20mL (20mL syringe)

Midazolam 5 mg in 5mL Ketamine 200 mg in 2mL Vercuronium 10mg Water for Injection 10mLSuxamethonium 100 mg Atropine 2 x 600microg in 1mL Adrenaline 1 mg in 10mL

Infusion of morphine and midazolam and syringe pump Infusion of noradrenaline and syringe pump

Table 2. Pharmaceuticals required at the start of covERT intubation

Staff for the covERT Response in each Location

covERT team - Anaesthetist and Anaesthesia Nurse

Second Physician o ICU - ICU consultant o ED - Emergency physician o Ward - most senior physician available o SVPHM - SVPHM ICU consultant

In room assistant o ICU - patient’s ICU nurse o ED - ED nurse o Ward - ICU nurse from Code team o SVPHM - Anaesthesia nurse / ICU nurse supplied by SVPHM

Assistant outside room o ICU - ICU nurse o ED - ED nurse o Ward - ICU / ward nurse o SVPHM - Anaesthesia nurse / ICU nurse supplied by SVPHM



Scene control o Member of nursing or medical staff

Roles of Staff

Second Physician o Wears Level 4 PPE, ensures other members of the home team are

appropriately attired o Has clinical leadership of the patient in the time leading up to intubation o Gives clinical handover to covERT team o Cedes clinical leadership during intubation and takes on a role focusing on

situational awareness o Administers medications during intubation including induction medications

and medications to maintain haemodynamic stability o Takes back clinical leadership if appropriate once the airway is declared

secure o Meticulously doffs PPE, observed doffing by others

In Room Assistant o Wears Level 4 PPE o Ensures the intubating space, specified airway equipment and medications

are prepared and available o Assists covERT team when unfamiliar with ED / ward / ICU / SVPHM

environment o Obtains equipment from outside the intubating area by communication with

outside assistant o Meticulously doffs PPE, observed doffing by others

Outside assistant o Wears Level 3 PPE o Provides extra equipment or additional medications to the team in the

intubating area on request

Scene Control o Wears appropriate PPE o Minimises staff in the vicinity of the covERT response o Co-ordinates the response outside of the intubating area

Anaesthetist o Dons Level 4 PPE in the PACU, observes anaesthetic nurse donning o Travels to the site of intubation with anaesthesia nurse o Takes clinical handover from second physician o Assesses patients airway o Discusses airway plan with covERT response team in the intubating area o Pre-oxygenates patient o Intubates patient o Declares airway secure o Discusses with secondary physician whether it is appropriate to cede clinical

leadership o Meticulously doffs PPE, observed doffing by others

Anaesthesia Nurse o Dons Level 4 PPE in the PACU, observes anaesthetist donning o Travels to the site of intubation with the anaesthetist o Readies airway equipment o Assists in process of intubation o Assists in ensuring contaminated waste is correctly disposed of and reusable

equipment is correctly bagged to be sterilised o Meticulously doffs PPE, observed doffing by others








Appendix A - covERT Response Process



Appendix B - covERT Team PPE Donning / Doffing

CovERTresponse-Donningv3.1

StVincent’sDepartmentofAnaesthesiaandAcutePainMedicine



CovERTresponse–DoffingGuidev3.1



Authorship Details

Name: Position:

Primary Policy Author(s):

covERT response simulation group Representatives from critical care specialties

Stuart Dilley Emergency Physician

Alexander Handrinos Emergency Physician

Jonathan Karro Emergency Physician

Bernadette Hickey Intensive Care Physician

Yvette O’Brien Intensive Care Physician

Steven Musca Intensive Care Physician

Tim Haydon Intensive Care Physician

Ben Slater Anaesthetist

Tuong Phan Anaesthetist

Abarna Devapalasundaram Anaesthetist

Elizabeth Coyle Anaesthetist

Others Consulted, including Committees:

Joanne Cocks Co-ordinator infection control

John Santamaria Director, ICU

Andrew Walby Director, ED

David Scott Director, Anaesthesia

Medication Safety Committee

Head of Department Responsible for policy:

Antony Tobin Chief Medical Officer