post-mortem care of covid-19 patients - chi st. gabriel's ......may 05, 2020 · post-mortem...
TRANSCRIPT
Post-mortem care of COVID-19 patients
COVID-19 ECHO5/21/2020
Sandy Stover, MD; Quinn Strobl, MD;Stacy Holzbauer, Leslie Kollman, MDH Epidemiology
Sally Almond, MDH Office of Vital Records
What we want to cover
● Why is talking about death important right now?● How can we best serve our communities in tracking Covid deaths in rural
Minnesota? ● How do we fill out the death certificates and cremation approvals
appropriately? ● A new category: Probable COVID-19● What are best practices for handling patients postmortem who are suspected
to have had Covid-19 infection?● Where can providers go to get help on post-death issues?
Postmortem issues in the news:
Serving our communities: Public Health Issues
Tracking cases
Tracking contacts
Understanding disease numbers
Predicting trends
Special issues in rural areas
https://www.health.state.mn.us/diseases/coronavirus/situation.htmlDownloaded 5/18/2020
Clinical care of the patient - after deathPhysician
● Determining cause of death of hospitalized patient● Determining cause of death of patient who dies at home ● Death Certificate completion● Communicating with family about COVID concerns
Medical Examiner/Coroner physicians
● Evaluating patients who die without clear cause / manner○ Do they require an autopsy to clarify cause of death?○ Communicating cause of death to providers; determining who will complete Death Certificate○ If they have underlying health issues, is COVID also a concern?○ Communicating with Primary Care provider and family about COVID concerns
We doctors are not very good at filling out death certificates
58% of death certificates were found to have an unacceptable error: unacceptable cause (30%), non-specific error (15%), incorrectly completed forms (6%), irrelevant information error (4%), incorrect order (3.5%).The Accuracy of Death Certificate Completion in a Suburban Community (2010).
Death certificate agreement between on-site completion of death certificate and investigator-adjudicated death certificates in the UPLIFT trial was complete only 50% of the time (no agreement 31.3%).Lorcan McGarvey, Cause specific mortality adjudication in the UPLIFT COPD Trial: findings and recommendations, Respiratory Medicine, April 2012; col 106(4). 515-521.
Pre-education errors ranged from 32%(FM) - 75%, varying by specialty. Post education showed sustained reduction of error to 24% at 2 months. Kimberly Wood, Death Certification in Northern Alberta: Error Occurrence Rate and Educational Intervention, American Journal Forensic Medical Pathology, March 2020; vol 41(1) 11-17.
Common mistakes with death certificates -and how to do this better:
Dr. A. Quinn Strobl
Chief Medical Examiner, Midwest Medical Examiner’s Office, Certified Forensic Pathologist
Case #1: What is the
cause of death?
Case #1:
Cause of death -● Respiratory failure?● Pneumonia?● Heart Failure?
And what is carcinogenic shock?
Death Certificates: Know you have an “audience”
Who reads death certificates?
● Family● Insurance companies● Attorney/legal system
Will they understand the diagnosis?
Is the information clear and helpful?
● Did my loved one die of heart disease? Cancer?● What impact to family: heritable diseases? Infectious diseases - COVID?
Pearl #1: be relevant, use contributing diagnoses
Pearl #2: Don’t use a mechanismor non-specific cause
Common “causes” on a death certificate
● Cardiac arrest● Cardiorespiratory arrest● Anoxic brain injury
What do these all mean?
● The patient died - but this has no information for the family or for gathering vital statistic data
Some specific causes of death:
Myocardial infarction
Atherosclerotic heart disease
Cerebrovascular infarction
Complications of dementia
● Inanition and dehydration● Aspiration pneumonia
But what if the cause of death is still unclear?
Pearl #3: What if they died of “old age”…..
Diagnosing COVID-19
Diagnostic criteria for Covid
Chest x-ray
CT findings
Clinical scenario
Lab testing in the clinical setting
● PCR● Serology
Lab testing postmortem
https://radiopaedia.org/cases/covid-19-pneumonia-12
What if Covid has not been diagnosed but you are clinically suspicious?
These numbers matter:
● Keeping public health records accurate
● Tracking contacts● Insurance issues● Family knowledge
Lab testing postmortem
Who: which patients should have testing done?
What:
● Which swab?
When: best timing for collection?
Where:
● Nasopharyngeal?● Posterior pharyngeal?● Other?
Partners in collecting swabs
● Hospice nurses● Field epidemiologists● Funeral Home Directors
Does your community have a plan for post death testing?
https://www.mprnews.org/story/2008/10/31/u-of-m-marks-100-years-of-mortuary-science-training
Reporting COVID 19 Deaths
Death certificates listing COVID-19 are reviewed and placed in one of the following categories:
● Confirmed COVID-19 Death
○ Laboratory confirmed positive SARS-CoV-2 PCR test
● Probable COVID-19 Death
○ COVID -19 listed on the death certificate but no confirmatory test
Medical Examiner Case Reviews
Medical Examiners have a role reviewing many death certificates
● Death record referrals – ‘trigger words’ – when injury or toxicity is listed as COD
● Cremation approvals - making sure a swab was obtained and sent to MDH, if COVID is on certificate; assisting MDH to obtain a swab before cremation
Case #2: What did the patient die of?
Case #3: What is the cause of death?
48 year old man with end stage renal disease, on dialysis.
Tested positive on routine screen at dialysis unit: no symptoms of COVID.
Patient finalizes a long-term decision to stop dialysis; two weeks later he dies.
● Girlfriend calls ambulance as he was more lethargic, low blood sugar● Patient was alert, deemed competent; declined transfer.● Patient died at home.
Working with patients and families
Types of management: pre-morbid discussion on cremation or burials (or other) as part of Advance Directives
Post-death: exposure management
● PPE● Cleaning facilities● Quarantine recommendations
Stress management for families
● How can we honor a family member at the time of passing?● Grief issues / PTSD
Taking care of your patient after they die -working with your team
Medical team
● EMS: First Responders, EMT’s, Paramedics● Nursing
Post-death Team
● Law Enforcement● Body-transporters● Funeral Directors
Everyone should have best-practices in place for handling bodies
Taking care of the body
● Safety measures for providers and staff
● Transportation● Storage
https://www.health.state.mn.us/diseases/coronavirus/guidefuneral.pdf
Office of Vital Records
Office of Vital RecordsGood help desk!
● OVR help desk: 651-201-5970● Help desk email: [email protected]● For system support: [email protected]
Death Certificates can be held or changed later as more information comes in.
Working together as a team to keep the data accurate: primary care, Medical Examiner, Department of Health and the Office of Vital Records
Helpful tools from the CDC
There is a webinar on certifying deaths due to COVID-19 that offers free CE just for watching. https://emergency.cdc.gov/coca/calls/2020/callinfo_041620.asp
This is a link to the CDC training and instructional manuals for DC certification. There is also a link for the Mobile App for death certification. https://www.cdc.gov/nchs/nvss/training-and-instructional-materials.htm
A quick (3”) video reviewing death certificates and COVID: https://www.youtube.com/watch?v=oL3VMwieAms&feature=emb_title
Written Guidelines for COVID-19 death certification -https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf
https://www.cdc.gov/nchs/nvss/writing_cod_statements.htm
Where else can you go for help?
Call your County’s Coroner or Medical Examiner
Call or email the Minnesota Department of Health - regional epidemiologists available
Minnesota Department of health information:
● Mortuary recommendations: https://www.health.state.mn.us/diseases/coronavirus/guidefuneral.pdf
CDC clarification:
● Cause of death reporting: https://www.cdc.gov/nchs/nvss/writing_cod_statements.htm
Contact information
Sandy Stover, MD, University of Minnesota Medical School Duluth Campus, [email protected]
Quinn Strobl, MD, Midwest Medical Examiner’s Office, [email protected]
Leslie Kollman, Epidemiologist, Minnesota Department of Health, [email protected]
Stacy Holzbauer, Epidemiologist, Minnesota Department of Health, [email protected]