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Patients with severe or critical forms of novel coronavirus pneumonia may experience rapid development of the disease and often with many complications, which can be life-threatening. These Standards of Care are specially drafted to improve the quality of care for severely and critically ill patients, and to increase the success rate of treatment.
I. Set up of ICU areas for novel coronavirus pneumonia, and management of nursing personnel.
(1) Wards should be set up according to local conditions, with reasonable layouts, and strict division between contaminated areas, potentially contaminated areas, and clean areas. Set up buffer areas between contaminated areas, potentially contaminated areas, and clean areas. Post large striking signs in each area, to prevent mistaken entry. At the same time, set up channels for medical personnel and patients to ensure they don't intersect.
(2) Equipment and Facilities
- First Aid Materials and Medications: Allocate a definite amount of ambulances and first aid medications, oxygen cylinders with accessories, ECG monitors, ECG machines, defibrillators, syringe pumps, infusion pumps, intubation supplies, portable negative pressure pumps, non-invasive and invasive ventilators, hemofiltration machines, ECMOs and so on.
- Disinfectant Equipment: Air disinfection machines, bed unit disinfection machines, air purifiers, spray cans, etc.
- Gas and Negative Pressure Equipment: Prepare a wall oxygen system, a compressed air system, and a negative pressure system with sufficient pressure.
- Other Facilities: Refrigerator, treatment carts, wheelchairs, medical tables, etc.
(2) Allocation of nurses and shift scheduling principles
- Follow a 1:6 ratio of beds-to-nurses, and reasonably arrange shifts, with a recommended shift of 4 hours.
- Nurses should have a professional ICU background, stronger operational abilities, and a higher professional caliber.
- Be physically healthy and able to undertake a high degree of medical treatment work.
II. Clinical Characteristics of Serious and Critical Patients
- One week after the onset of symptoms, severely ill patients present with dyspnea and/or hypoxemia, shortness of breath, with a respiratory rate (RR) greater than 30 breaths per minute. Oxygen saturation measured by pulse oximetry is less than 93% at rest. Arterial oxygen tension (PaO2) / fraction of inspired oxygen (FiO2) < 300mmHg (1mmHg = 0.133kPa)
- Severely ill patients can rapidly develop acute respiratory distress syndrome, septic shock, hard-to-correct metabolic acidosis, coagulopathy, multiple organ failure and so on, and should be transferred to ICU as soon as possible.
- Severe and critical patients may have moderate to low fever or even no obvious fever during the course of the disease.
III. Monitoring and Care of Serious and Critical Patients
(1) Oxygen therapy
- As directed by clinicians, patients should be given nasal catheters or oxygen masks. Communicate well with patients who are conscious to obtain cooperation. Patients receiving oxygen through nasal catheters can wear surgical masks over the nasal catheters.
- Closely observe patients' vital signs and awareness, emphasizing monitoring blood-oxygen saturation.
(2) Care of patients on noninvasive mechanical ventilation
- Prior to noninvasive mechanical ventilation, explain its goals and methods to the patients.
- Correctly connect the oxygen mask of the non-invasive ventilator and guide patients to breathe through their nose.
- Observe whether air leaks are present; listen to patients' concerns; promptly adjust the tightness of the head strap/helmet to reduce air-leak from the mask.
- Promptly empty condensate water from the non-invasive ventilator pipeline.
- Prevention of complications
(1) Local skin abrasion: choose suitable masks, head straps or helmets; protect nearby skin.
(2) Bloating: reassure and educate patients; if conditions allow, help patients into a semi-recumbent position.
(3) Preventing aspiration: avoid non-invasive mechanical ventilation after a full meal; enteral nutrition should be paused in patients receiving nasogastric feeding; use gastrointestinal motility drugs as directed by physicians.
(3) Care of patients with invasive mechanical ventilation
- Set up the ventilator circuits properly. Inspect the ventilator operations; adjust the ventilation modes and settings in cooperation with the physicians.
- Connect the ventilator tube with the patient's artificial airway; properly stabilize and secure the ventilator tubes. Extension tubes can be added at the distal end of the ventilator tubes for patients who underwent a tracheotomy.
- Turn on the humidifier to ensure airway humidification. Adjust the humidification mode based on the properties of the patients' sputum.
- Keep the ventilation tube lower than the artificial airway, and the loop-end water trap at the lowest point to drain condensation. Empty the water traps promptly to prevent ventilator-associated pneumonia (VAP).
- Record ventilator settings timely and accurately. Closely monitor the changes in the vitals of the patients, especially RR and SpO2. Monitor whether patient-ventilator dyssynchrony and other problems are present, and promptly notify the physicians should abnormalities arise.
- In the event of a ventilator malfunction, disconnect the patient's trach tube from the ventilator immediately and connect a readied manual resuscitator to an oxygen source. Perform resuscitation and notify the physicians to switch to a backup ventilator.
- Single-used ventilator circuits are recommended. Routine replacement is not advised. Replace immediately if contaminated.
(4) Care of artificial airways
- Properly fixing
(1) Securing an endotracheal tube: attach the AB side of a "工" shaped tape (Length: approx 15cm, width: approx 2cm) on the face of the patient; use the CD side of the tape (length 8-10cm, width 1cm) to secure the dental pad to the trach tube. Put one "工” shaped tape each at the top and bottom of the trach tube.
1) A and B should be pasted naturally when being attached to the face, and should not be stretched.
2) When affixing CD to the dental pad, at least one side should be wrapped around the trach tube separately in order to prevent the loosening of the trach tube caused by excess saliva.
3) The dental pad should be placed above the tongue to prevent tongue injury caused by the jamming of the tongue into the dental pad. A children's dental pad should be selected for child patients.
4) If the patient is irritable or lacks teeth to stabilize the dental pad, straps may be used for additional stability. Pay attention that the skin underneath the bands needs to be protected by gauze or foam dressings.
(2) Securing a trach tube: tie the stabilizing strap into a knot to prevent loosening, at a distance of 1-2 finger widths from the patient's neck. Dressings should be applied behind and on each side of the neck to protect the skin. Check the tightness of the fixing strap each shift.
(3) Keep patients' faces clean and dry to ensure the stickiness of the fixative tape. Loosened tape should be replaced promptly to prevent accidental extubation.
(4) For patients who are irritable or unconscious, sedatives and analgesics may be used. Access and prevent the onset of delirium. Protective restraints can be used to prevent accidental extubation.
- Monitor air-bag pressure: monitor and record air-bag pressure every 4 hours. The normal range is 25-30cm of water (adult).
- Prevention of ventilator-associated pneumonia.
(1) Strictly implement hand sanitation.
(2) Promptly clear patients' oral and nasal secretions, and strengthen oral care.
(3) If there is exudation from the tracheotomy wound, promptly change the dressing.
(4) It is recommended to insert a gastric tube for bedridden patients to reduce gastric retention. The head of the bed is to be raised more than 30 degrees to prevent aspiration caused by gastroesophageal reflux.
4. Suctioning of artificial airways.
(1) Keep airways clear, promptly assessing and suctioning as needed.
(2) Prepare materials prior to suctioning, give the patient pure oxygen for 2 minutes, and adjust the pressure of the aspirator to 150-200 mlg.
(3) Strictly implement hand sanitation, strictly using sterile techniques during suctioning.
(4) Connect the airtight suctioning unit. Use one hand to stabilize the connection between the trach tube and ventilator to prevent circuit breakage. Turn off suction and open the valve of the suctioning unit. Introduce the tip of the suctioning catheter to the distal end of the trach tube. Turn on suction and withdraw the catheter while rotating it with the thumb and index finger. The procedure should not exceed 15 seconds.
(5) Give patients another 2 minutes of pure oxygen after suctioning, close the valve of the sputum aspirator and flush the negative pressure suction pipeline.
(6) Suction oral and nasal secretions as required.
(7) Close attention should be paid to patients' vital signs during suctioning.
(8) Properly dispose of the materials used and make detailed records of volume and characteristics of sputum.
(5) Care for ventilation treatment in the prone position
- Prepare supplies and assess the patient: explain the procedure to the conscious patient; assess stomach fullness; pause gastrointestinal pump feeding ahead of time; clear secretions from mouth, nose and the respiratory tract; disconnect inessential IV circuits; stabilize the drainage tubes; protect the skin in compressed regions.
- Remove hospital gowns from the patient. Move the electrode pads to the shoulders and sides of the abdomen. Secure the pulse oximeter to ensure that the heart rate and oxygen saturation are continuously monitored during the turning process and to ensure patient safety.
- Turning the patient: coordinating between at least 5 medical workers (1 in charge of the patient's head and protecting the trach tube and assisting the turn; 2 at each side of the patient), first turn the patient into a side-lying position, then into a prone position. Make sure the chest, hips, and knees of the patient are supported by polymer pads or soft pillows to prevent compression. The patient's head should tilt to one side. A U-shaped pillow should be placed underneath the patient's head to prevent crushing the trach tube and for patient comfort.
- Prevention of brachial plexus injury: when ventilating in the prone position, position the patient's arms parallel to the body or slightly outwards; place the upper arms next to the head or beside the body; maintain a functional position to avoid strain or compression, which induces ischemia and subsequent brachial plexus injury.
- Reconnect IV circuits and secure drainage tubes.
- For patients who can not tolerate ventilation in the prone position, sedatives and analgesics should be given as directed by the physician. When necessary, muscle relaxants and protective restraints may be used. Score level of sedation.
- Closely monitor disease progression and vitals. Continuously monitor intra-arterial blood pressure, ECG, and blood oxygen saturation. Collect arterial blood samples as required by the physicians for blood gas analysis.
- Keep repiratory paths clear, tapping on backs to eliminate phlegm, and observing the character, volume, and color of patients' phlegm.
- Turn the patient every 2 hours. Observe the conditions of the skin and blood flow in the compressed areas to prevent pressure injury.
(6) Care for patients on sedatives and analgesics
- Pain assessment includes the position, characteristics, provocation/palliation, and severity of pain. Ask patients who can self-report to rate their pain on a numeric scale. Patients who are unable to communicate should be evaluated using a behavioral pain scale.
- After the administration of sedatives, closely monitor the effectiveness of sedation, circulation, and breathing. Promptly adjust the sedative dosage accordingly, and as directed by the physicians to prevent insufficient sedation or oversedation. Periodically assess patient pain and record the results.
- Assess and record RASS scores on time. Closely monitor the level of sedation in the patients and promptly notify the physicians to adjust the type and dosage of sedatives should changes occur.
- For patients who are deeply sedated (RASS score < -3), daily sedation interruption should be implemented. The nurses should assess and record the sedation levels and increase monitoring and assessment.
- Patients with a RASS score greater than 2 should be assessed with CAM-ICU (the confusion assessment method for the ICU) for delirium, in order to facilitate the early detection and treatment of delirium.
(7) Extracorporeal Membrane Oxygenation
ECMO (Extracorporeal membrane Oxygenation) refers to the cardiopulmonary support where the blood is drawn outside of the body through a venous cannula, passed through a membrane oxygenator (artificial lung) for oxygenation and the removal of carbon dioxide, and finally pumped back into the body through an artery or a vein. During ECMO therapy, the systemic oxygen supply and hemodynamics remain relatively stable, which allows the patient's heart and lung to rest, and buys time for the recovery of heart and lung function.
- Patients on ECMO should be given sufficient sedatives and analgesics. The circuits should be properly secured to prevent extubation.
- Ensure the ECMO circuit is unobstructed. Pay attention to the speed and flow rate of the centrifugal pump. The flow rate should be constant. Monitor whether the membrane oxygenator has leaks, whether the venous cannula shakes. Abnormalities should be reported to the physicians promptly.
- Ensure uninterrupted oxygen supply to the membrane oxygenator.
- Observe whether active bleeding, oozing blood, swelling and so on near the ECMO cannulation site. Promptly change the dressing to maintain a sterile local environment. Should abnormalities arise, notify the physicians promptly for treatment.
- Closely monitor the following indices: venous oxygen saturation (SvO2), mean arterial pressure (MAP), PaO2, PaCO2, arterial blood gas analysis, activated coagulation time (ACT), hematocrit (Hct) and so on. If a Swan-Ganz catheter was inserted, monitor cardiac output and pulmonary arterial pressure. Monitor the patient's perfusion indices, record urine volume, and prevent complications.
- Monitor patients' body temperature, and keep them warm.
- Hemorrhage prevention and care: monitor platelet count, APTT and other coagulation indices. When necessary, infuse required blood products as directed by physicians.
- As directed by the physicians, administer anti-coagulation treatments. Be gentle while performing various nursing tasks to prevent injury that leads to hemorrhage.
- Hemolysis prevention and care: monitor free hemoglobin concentration in plasma and the volume and color of the patient's urine. Promptly notify the physicians should abnormalities arise.
- Nutrition support: ensure that the patients have sufficient nutrition intake.
(8) General Care
- Have close cooperation between doctors and nurses, with nurses fully understanding and taking responsibility for the patients' conditions, and clarifying the key points of care.
- Critical patients are to be continuously monitored by ECG 24 hours a day, with patients' HR, RR, Bp, and Spo measured hourly, and body temperature measured and recorded every 4 hours.
- Reasonably and correctly use venous access, controlling infusion speed as directed by a doctor and using an infusion pump when necessary.
- Critical patients should be given a urinary catheter, to be maintained long-term and kept open, with the 24/hr input and output calculated every day.
- Keep all types of pipelines unobstructed and properly fixed.
- For patients without special posture requirements, the head of the bed should be raised 30 degrees.
- Do a good job of morning and evening patient care to keep their bed clear.
- Change the position regularly to avoid pressure sores.
- Promptly and accurately make special care records.
- Promptly evaluate the psychological state of conscious patients, and do a good job of psychological care.