Key Points

  • We are collecting and curating information to help clinical professionals stay up to date during this crisis
  • We now have guidance for both hospitalized patients and outpatients
  • Please be aware of the dates the documents were created. We are working to keep this page updated, but they may not be the latest versions

DISCLAIMER: This document and any policies described were prepared (in March-April, 2020) by and for Partners HealthCare medical professionals (a.k.a. clinicians, care givers) and employees and is being made available publicly for informational purposes only, in the context of a public health emergency related to COVID-19 (a.k.a. the coronavirus) and in connection with the state of emergency declared by the Governor of the Commonwealth of Massachusetts and the President of the United States. It is based on pertinent published medical literature, national and state guidances, and/or expert consensus, which continues to evolve relative to COVID-19. It is neither an attempt to substitute for the practice of medicine nor as a substitute for the provision of any medical professional services. Furthermore, the content is not meant to be complete, exhaustive or a substitute for medical professional advice, diagnosis or treatment. The information herein should be adapted to each specific patient based on the treating medical professional’s independent professional judgment and consideration of the patient’s needs, the resources available at the location from where the medical professional services are being provided (e.g., healthcare institution, ambulatory clinic, physician’s office, etc.), and any other unique circumstances. This information should not be used to replace, substitute for or overrule a qualified medical professional’s judgment. You assume full responsibility for using this information and understand and agree that Partners HealthCare is not responsible or liable for any errors or omissions or for any claim, loss or damage resulting from the use of this information.

This website may contain third party materials and/or links to third party materials and third party websites for your information and convenience. Partners is not responsible for the availability, accuracy or content of any of those third party materials or websites nor does it endorse them. Prior to accessing this information or these third party websites you may be asked to agree to additional terms and conditions provided by such third parties which govern access to and use of those websites or materials.

Inpatient Care Recommendations

Treatment Recommendations from Infectious Diseases

Treatment recommendations from Infectious Diseases on the evaluation, medications, transplant care and suggested lab work ups of patients both under investigation and confirmed infected with COVID-19. If viewing these documents electronically, the guides contain hyperlinks to the supplementary documents. Direct links to these supplementary documents are provided in case you would like to print them.

Complete Treatment Guidance (PDF) (4/5/2020)

Supplementary Documents


Pulmonary/Critical Care

On the care of patients in the ICU with known or suspected COVID-19 infection.

Critical Care Guidance (PDF) (4/5/2020)

Supplementary Documents

Related Resources

Critical Care Triage (PDF) (3/20/2020)

ECMO Protocol During COVID-19 Pandemic (PDF) (3/20/2020)

COVID-19 ECMO Cannulation Strategies (PDF) (3/20/2020)

Prone Positioning Protocol for Intubated Patients (PDF) (4/8/2020)

Prone Positioning Protocol for Non-intubated Patients (PDF) (4/2/2020)


Serious Illness Conversation

Basic Guide for Serious Illness Discussion (PDF) (4/1/2020)

Talking about CPR with Very Sick Patients (PDF) (4/1/2020)

EOL Symptom Management (PDF) (4/2/2020)

Opioid Decision Tree for Treatment of Dyspnea (PDF) (4/2/2020)


Surge Resources: Inpatient Medicine Guidance

Primer on regularly encountered situations in the inpatient setting. For PCPs, subspecialists, and other non-hospitalists volunteering to work on the inpatient floors. Assembled by the Core Educator Faculty.

Common Inpatient Topics (PDF) (March 2020)

Teaching on Resident Services (PDF) (3/24/2020)

IV Access and Blood Draw Algorithm, Including PICC Screening (PDF) (3/25/2020)


Infection Control Guidance

Guidance for Patients with Suspected Viral Respiratory Illness Including Suspect or Confirmed COVID-19 in Emergency Department, Inpatient, Ambulatory and Peri-procedural Locations (4/3/2020)

Guidance for Patients with Confirmed COVID-19: Criteria for Resolution of COVID-19 Infection Status and Discontinuation of Isolation (PDF) (3/24/2020)

Guidance On Extended Use and Reuse of N95 Respirators, Surgical Masks, Procedural Masks and Eye Protection (PDF) (3/23/2020)

List of Aerosol Generating Procedures (PDF) (4/4/2020)

Guidance on Fit Check and Fit Testing of N95 Respirators (PDF) (3/25/2020)

Guidance on Respiratory Protection During Aerosol Generating Procedure (PDF) (3/25/2020)

Guidance on Transport and Movement of Patients with Viral Respiratory Illness Within the Hospital (PDF) (3/27/2020)

Partners HealthCare Return to Work Criteria for Health Care Workers (PDF) (3/28/2020)

Guidance on Non-Hospital Issued N95 Respirators, Surgical Masks and Procedural Masks (PDF) (3/23/2020)

Work Attire and COVID-19 (PDF) (3/24/2020)

Guidance on Infection Statuses and Resolution (PDF) (4/3/2020)

Guidance on Screening Before Home Visits and Home Visit PPE (PDF) (4/5/2020)

Videos


Outpatient Care Recommendations

Respiratory Illness Clinic (RIC) Management

Patient Flow Through RIC (PDF) (3/25/2020)

A bulleted summary of clinical workflow from patient scheduling to discharge through an RIC. Involved staffing include the following: PSC, MA, RN, APP, and MD

Triaging RIC Patients (PDF) (3/25/2020)

A bulleted summary describing the procedure for patients transferring from an RIC to the ED or the Ambulance Bay (COVID-19 testing)

Algorithm for Chest X-ray (PDF) (3/28/2020)

A bulleted summary describing the procedure for patients transferring from an RIC to the ED or the Ambulance Bay (COVID-19 testing)


Primary Care Guidance

Guidance for responding to, categorizing and documenting patient encounters over the phone.

Triage for COVID Testing and RIC Referral (PDF) (3/26/2020)

Surge Clinic/RIC Testing Sites COVID-19 Testing Kit (PDF) (3/31/2020)


Serious Illness Conversation

Common Questions from Patients (PDF) (March 2020)

Outreach Communication Guide (PDF) (March 2020)


Mass General Psychiatry Guidance

Mass General Psychiatry Guide to Mental Health Resources


Cancer Center Guidance

Cancer Center Ambulatory Viral Triage (PDF) (3/23/2020)

For pathways to accelerate viral work up and minimize patient movement for oncology patients reporting viral symptoms within the practices.


Fast Literature Updates

Mass General FLARE is a collaborative effort within the Pulmonary and Critical Care Division and the Department of Medicine. Its mission is to appraise the rapidly evolving literature on SARS-CoV-2 with a focus on critical care issues.

Core members include Laura Brenner, MD; Tiara Calhoun, MD; Raghu Chivukula, MD, PhD; David Dudzinski, MD; Jason Maley, MD; Camille Petri, MD; and Vlad Vinarsky, MD. The group is led by Corey Hardin, MD, PhD. Please send questions, comments or concerns about FLARE to charles.hardin@mgh.harvard.edu.

Latest Letters

Testing for SARS-CoV-2 (April 6, 2020)

  1. Two major types of assays are used to detect respiratory viral infections: Reverse-Transcriptase Polymerase Chain Reaction (RT-PCR) and Direct Fluorescent Antibody (DFA); RT-PCR continues to be the method of choice for detecting SARS-CoV-2 due to its wider availability and high sensitivity
  2. True positive predictive value and negative predictive value for SARS-CoV-2 RT-PCR remain unknown this early in the COVID-19 pandemic. Without a clear gold standard test, clinical sensitivity and specificity are difficult to determine
  3. Sampling, anatomic location, and disease stage and severity likely play critical roles in determining the sensitivity and specificity of PCR testing testing
  4. Serological tests for COVID-19 promise to supplement PCR based strategies testing

COVID-19 Risk Factor Round-Up (April 5, 2020)

  1. To date, over a dozen studies have attempted to identify risk factors associated with severe COVID-19 or related death
  2. A minority of patients with COVID-19 require ICU-level care. Early reports from China indicated that risk factors for severe disease included advanced age, cardiac disease and diabetes
  3. More recent reports are largely consistent with early reports and emphasize that risk factors for severe COVID-19 are qualitatively similar to risk factors for mortality in general critical illness

Investigational Therapies for ARDS (Part II) (April 4, 2020)

  1. The therapy for ARDS, including ARDS associated with COVID-19, is centered on lung-protective ventilation, conservative fluid management and treatment of the underlying process
  2. ARDS is thought to result from a complex interaction between the inciting insult and the host response
  3. Numerous studies are currently evaluating novel therapies targeting the pathologic cascade of ARDS and the host response to SARS-CoV-2
  4. It is important to consider future studies in the historical context of failed investigational therapies for ARDS

Investigational Therapies for ARDS (Part I) (April 3, 2020)

  1. The therapy for ARDS, including ARDS associated with COVID-19, is essentially supportive
  2. To date, the only specific therapies that have been found to help in cases of ARDS are those that target the underlying process that led to ARDS, such as antibiotics for bacterial infection
  3. There are many suggestions for novel therapies targeting the pathologic cascade of ARDS and the host response to SARS-CoV-2. Many of these are being evaluated in trials. Some have been suggested for clinical use
  4. Proposed therapies must be evaluated in light of the long history of failed investigational therapies for ARDS

Managing PEEP and Recruitment (April 2, 2020)

  1. ARDS is a disease of surfactant dysfunction and alveolar collapse that results in regions of V/Q mismatch and shunt. The application of PEEP can open, or "recruit," poorly ventilated alveoli. Opening alveoli decreases shunt, improves oxygenation and can simultaneously improve pulmonary mechanics since the higher regional volume may be associated with higher compliance
  2. Overdistension of lung units, however, results in decreased compliance and barotrauma. PEEP must be titrated to balance the benefit from recruitment of affected lung units against the risk of over distending unaffected units
  3. Many people are saying that patients with COVID-19 oxygenate well on low to moderate levels of PEEP but do not improve with more aggressive maneuvers. Patients are thus simultaneously easy to recruit (i.e. fully open at low PEEP), but do not respond to (aggressive) recruitment
  4. Care must therefore be taken to choose the PEEP that captures the benefit of recruiting the easily recruitable lung units without the pitfall of over distending the large amount of normal lung. No method of PEEP optimization is known to be superior to any other. Tabulated PEEP-FiO2 tables are likely a reasonable first approach while a select group of patients may benefit from more individualized PEEP titration

Myocarditis and COVID-19 (April 1, 2020)

  1. Prior reports from outbreaks of SARS and MERS suggest that coronaviruses may have tropism for cardiac tissue
  2. SARS-CoV-2 has been reported to cause a variety of cardiac manifestations in the current pandemic. Some have posited that myocarditis, an inflammatory disease with a variety of etiologies, may be a culprit
  3. Reports of COVID-19-related myocarditis are extremely limited, and do not abide by the clearly defined criteria for diagnosis of myocarditis
  4. Though patients with COVID-19 may suffer from cardiac compromise, the underlying mechanism is currently not understood. Providers should seek clear evidence of a diagnosis and exercise caution prior to initiating empiric therapy for myocarditis

Coagulation and ARDS in COVID-19 (March 31, 2020)

  1. Damage to the alveolar endothelium in ARDS activates the coagulation cascade, causing accumulation of platelet-fibrin thrombi in the alveolus. This can promote further lung injury
  2. Case series of patients with severe COVID-19 have suggested that coagulation abnormalities in the serum are associated with ARDS and higher mortality
  3. Anticoagulants and thrombolytics have been studied in both pre-clinical models and patients with ARDS, but studies have been plagued by heterogeneity in methods and study design
  4. Though ARDS and COVID-19 are associated with hypercoagulability, the currently available evidence does not suggest that therapeutic anticoagulation or fibrinolytics will improve patient outcomes

iNO in COVID-19 (March 30, 2020)

  1. Inhaled pulmonary vasodilators (iNO, epoprostenol) are periodically used to improve oxygenation in ARDS
  2. Despite frequent use, inhaled pulmonary vasodilators have never been shown to improve outcomes
  3. There may be a role for these interventions when there is an emergent need to improve oxygenation
  4. There are postulated, but unproven, direct antiviral effects of iNO
  5. iNO may be preferable to other pulmonary vasodilators due to both direct antiviral effects and mode of delivery

Prone Position in the Non-intubated Patient (March 29, 2020)

  1. What is the effect of prone position in a non-intubated patient?
  2. Should it be considered in patients with severe COVID-19?

Of ACEs, ARBs and COVID-19 (March 28, 2020)

  1. The basic biology of the ACE2 pathway, explore the existing data regarding ACE2 and lung injury
  2. Existing data regarding ACE2 and lung injury
  3. Implications for patients receiving these medications in the setting of COVID-19

Use of convalescent plasma (March 27, 2020)

  1. The rationale and evidence for utilizing convalescent plasma in COVID-19
  2. Current trials and biotech developments

CT scans & early tracheostomy (March 26, 2020)

  1. What is the utility of chest CT in patients with suspected or confirmed COVID-19?
  2. What is the role for early tracheostomy in patients with respiratory failure from COVID-19?

The spectrum of disordered inflammation in critical illness (March 25, 2020)

  1. Elevated inflammatory biomarkers are common in critical illness, including severe COVID-19
  2. Hypothesis: a dysregulated immune response, or “cytokine storm”, contributes to the progression of critical illness and/or SARS-CoV-2 infection
  3. The pathophysiology of cytokine storm and the evidence for immune modulation in the treatment of critical illnesses

FAQs, GI Disease, Washington and Italy (March 24, 2020)

  1. FAQs about the Mass General Critical Care Guidance
  2. COVID-19 presenting as GI disease
  3. Analysis and comparison of newly published clinical data from Washington State and Italy

PEEP, ARDS and COVID-19 associated respiratory failure (March 23, 2020)

  1. Discussion of ARDS, PEEP strategy and ARDS subphenotypes in COVID-19 by Dr. Corey Hardin

  2. Summary of major PEEP strategy trials

    • ALVEOLI – High PEEP vs. Low PEEP

    • EXPRESS – High PEEP vs. Moderate PEEP

    • LOVS – Open lung approach vs. Low Vt

 Additional therapeutics for SARS-CoV-2 (March 22, 2020)

  1. Chloroquine and its potential role in COVID-19

  2. Data re-analysis and review of recent HCQ +/- Azithromycin trial

  3. COVID-relative points about ARDS management

    • Use of methylprednisolone in ARDS via the LaSRS Trial

    • ARDS phenotyping and differential response to treatments