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Introduction

People who have tested positive to the delta variant of concern of COVID-19 may be managed in the community.

The team responsible will vary according to local resourcing, geographic location and service models; but should be multidisciplinary in nature.

Purpose of this guideline

This document outlines guidance to assist staff to:  

  • triage patients who can safely be cared for in the community at the time of referral
  • predict those who may be at risk of requiring hospitalisation  
  • detect clinical deterioration
  • and escalate appropriately.

This guideline outlines the minimum standards for monitoring people with COVID-19 in the community. It does not address all elements of standard practice and is not a substitute for clinical judgement. In the absence of published evidence, these standards have been developed based on consensus through a consultation process with clinicians, communities of practice, NSW Health and pillar agencies.

This guideline outlines the community-based care for people with COVID-19, including the use of virtual care.

It should be read in conjunction with state and national documents addressing clinical care of people with COVID-19, virtual care and infection control:

Governance

Use of this guideline and other policy documents will be underpinned by local factors. These include location and demographics, as well as service factors such as leadership, governance, resources and policies/procedures.

Delta variant of concern

The Delta variant is defined by the World Health Organization as a variant of concern. It poses issues for disease control and management due to increased transmissibility (all household likely to be infected), severity and vaccine resistance.10

Compared with previous variants, Delta has been more common in younger people. Risk of a hospital admission is approximately doubled in those with the Delta VOC when compared to the Alpha strain, with risk of admission particularly increased in those with five or more relevant comorbidities.

Methodology

This guidance is based on current evidence, listed in references.

Expert advice was sought in the development of this guideline including Royal Prince Alfred Virtual, Sydney Local Health District (LHD), the Ministry of Health Hospital in the Home team; ambulatory care, maternity, mental health and emergency care specialists, and the Executive of the Virtual Care Community of Practice.

This guidance has been adapted from documents produced by Royal Prince Alfred Virtual Hospital.11

Outlines

This guideline is presented in four parts:

Principles

The following principles underpin this guideline:

  • The person and their carer are at the centre of all decisions.
  • Due tothe nature ofthis novel virus, elements of this document are based onthe best evidence available and clinician experience with the virus to date.
  • Clinical governance arrangements and monitoring and escalation pathways for people with COVID-19 should be locally agreed and documented between all service providers.
  • Local policy and procedures inrelation toclinical care, medication safety, clinical handover, clinical deterioration and advanced care directives underpin this document.
  • Effective partnerships between general practice and LHDs ensures safety, continuity of care, integration and quality health outcomes. General practitioners hold comprehensive health records and this shared information provides astrong foundation for continuity ofcare.
  • Virtual care teams, Hospital in the Home and community nursing may be separate services or delivered under a broader ambulatory care umbrella, sharing clinicians across different
    services. In this document, they are referred toas Community COVID-19 Services.
  • This is a living document that will be updated as more evidence about management ofpeople with COVID-19 inAustralia and elsewhere becomes available.

Part 1: Background

In-home management, risk factors and disease severity

Managing adults with COVID-19 in the home

NSW has adopted the use of virtual care to support management and monitoring of people with COVID-19 in the community. To determine appropriateness for care in the community, both severity of illness (symptoms) and risk factors (medical and social) should be considered.

The National COVID-19 Clinical Evidence Taskforce and other international bodies recommend that people with likely or confirmed mild COVID-19 be managed out of hospital and in the community, where possible.12 The Taskforce also recommends people with moderate COVID-19 are managed in hospital, when possible.12 People with severe COVID-19 should be managed in hospital or another facility that can provide the necessary level of care.

Clinical judgement should be used to determine where care can best be delivered. This includes consideration of care in the home for:

  • patients discharged early from hospital
  • those with moderate disease
  • pregnant women and their gestation.

When it is necessary to manage those with moderate COVID-19 in the community, medical and social risk factors must be considered to determine the appropriate level of care required.

A patient's wishes and goals of care (for example, an advance care directive) should be considered and appropriately documented prior to any decision to transfer the person to a hospital facility.

Management should include providing supportive care, taking steps to reduce the risk of transmission, and advising patients on when to contact a healthcare provider to seek further assessment.

The Australian guidelines developed by the National COVID-19 Clinical Evidence Taskforce note that most people infected with COVID-19 only experience mild disease symptoms and will recover without requiring special treatment.2 However, some people will experience moderate or severe disease.12

For people with COVID-19, monitor markers of clinical progression, including early signs of respiratory failure and sepsis, especially on days five to 10 after the onset of symptoms.12 The threshold for escalating care for older people (and those with existing medical conditions) in the community is much lower due to the risk of progression to severe disease.13

Emerging evidence suggests this is also the case for pregnant women, where adverse outcomes increase with gestation.

Importantly, COVID-19 and its variants have been found to have a variable disease trajectory and can impact younger people without underlying risk factors. Rapid deterioration of younger people without any identified risk factors has been observed. Frequent and thorough clinical monitoring is required to detect clinical deterioration (refer to Part 3, p.14 for more information).

The clinical care of children, people in residential aged care and palliative care is not detailed in this document. Further information and guidance for these patient groups can be found via the following links from NSW Health.

Delta variant

  • The Delta variant ofCOVID-19 isassociated with approximately double the risk of hospital admission compared with the Alpha strain.
  •  Risk ofhospital admission with the Delta variant increases inthose with five ormore relevant comorbidities.14
  •  Emerging evidence supports that hospitalisation is also more likely for those who are unvaccinated.15
  •  In Scotland and the United Kingdom, the Delta variant has been recorded mainly in younger people.14 This is consistent with the current Australian experience.

Risk factors associated with severe disease

Some people are at greater risk ofexperiencing more serious illness from COVID-19. The Australian Government advises that the following people may be at higher risk.16

High risk of severe illness

People who are at high risk of severe illness:

  • are 65 years and older*
  •  have had anorgan transplant and are on immunosuppressive therapy
  •  have had abone marrow transplant inthe last 24 months
  •  are onimmune suppressive therapy for graft versus host disease
  •  have blood cancer,e.g. leukemia, lymphoma or myelodysplastic syndrome (diagnosed within the last five years)
  •  are having chemotherapy orradiotherapy
  •  are pregnant^.

Moderate risk of severe illness

People at moderate risk ofsevere illness include those with:

  • chronic renal failure
  •  heart disease (coronary heart disease orfailure)
  •  chronic lung disease (excludes mild ormoderate asthma)
  •  anon-haematological cancer (diagnosed inthe last 12 months)
  •  diabetes
  •  chronic liver disease
  •  severe obesity with abody mass index greater than 40kg/m2
  •  some neurological conditions, such asstroke or dementia
  •  some chronic inflammatory conditions and treatments 
  •  other primary or acquired immunodeficiency 
  •  poorly controlled hypertension.

Other risk factors

Having two or more conditions can increase aperson's risk, regardless of age.

Other factors can also increase the risk ofsevere illness for aperson who contracts COVID-19, including:

  • age (risk increases for people asthey get older; even for those under 70)
  •  being male
  •  lower socioeconomic status
  •  smoking.

Specific communities and groups

Some specific communities and groups may be more at risk of exposure to COVID-19, or severe illness. These include:

  • Aboriginal and Torres Strait Islander people
  •  people living in aged care facilities 
  •  people with disability
  •  people with severe mental health conditions.

Pregnancy and COVID-19

Current evidence indicates that pregnant women do not appear tobe at higher risk ofcontracting SARS- CoV-2; the virus that causes COVID-19. However, studies have shown that pregnant women are at increased risk ofdeveloping severe COVID-19 if they are infected, compared with non-pregnant women of a similar age.17

Compared tonon-pregnant women ofreproductive age, pregnant women with COVID-19 attending or admitted to the hospital for any reason are:

  • less likely tomanifest symptoms such asfever, dyspnoea and myalgia
  •  more likely tobe admitted tothe intensive care unit (ICU) or need invasive ventilation.
  • pregnant women with COVID-19 are more likely to deliver preterm and have an increased risk of being admitted to the ICU or maternal death. Their babies are more likely tobe admitted tothe neonatal unit.18

Risk factors for severe illness from COVID-19 in pregnant women include:

  • pre-existing comorbidities
  • non-Caucasian
  • chronic hypertension
  • pre-existing diabetes
  • advanced maternal age
  • high body mass index.

Definitions of disease severity

The National COVID-19 Clinical Evidence Taskforce defines COVID-19 disease severity in the following categories.12

Table 1: Definition of disease severity

Category Description
Mild illness

No clinical features suggesting of moderate or severe disease or a complicated course of illness.

Characteristics

  • No symptoms
  • Mild upper respiratory tract symptoms
  • Cough, new myalgia or asthenia without new shortness of breath or a reduction in oxygen saturation.
Moderate illness

Stable, presenting with respiratory and/or systemic symptoms or signs.

The person is able to maintain oxygen saturation above 92% (or above 90% for people with chronic lung disease) with up to 4L/min oxygen via nasal prongs.

Characteristics

  • Prostration, severe myalgia, fever >38°C or persistent cough
  • Clinical or radiological signs of lung involvement
  • No clinical or laboratory indicators of clinical severity or respiratory impairment
Severe illness

If the person meets any of the following criteria:

  • Respiratory rate ≥30 breaths/min
  • Oxygen saturation ≤92% at a rest state (note: in adults with darker skin, oximetry may underestimate hypoxemia)
  • Arterial partial pressure of oxygen (PaO2) or inspired oxygen fraction (FiO2) ≤300
Critical illness

If the person meets any of the following criteria:

  • Respiratory failure: occurrence of severe respiratory failure (PaO2 /FiO2 <200), respiratory
    distress or acute respiratory distress syndrome. This includes patients deteriorating despite advanced forms of respiratory support (non-invasive ventilation, high-flow nasal oxygen) OR patients requiring mechanical ventilation.

OR

  • Other signs of significant deterioration:
    • hypotension or shock
    • impairment of consciousness
    • other organ failure.

 

Part 2: Identification, initial assessment and appropriateness for management of COVID-19 in the home

Notification and identification of COVID-19 positive people in the community

COVID-19 is a notifiable disease. Positive cases are reported via the Notifiable Conditions Management System, based on the person's usual place of residence and provided on the NSW Health Patient Flow Portal. People who test positive are notified by a text message from the public health unit.

All patients who have tested positive in the last 28 days are visible in the Patient Flow Portal. New cases appear as unregistered. Community COVID-19 Services are responsible for onboarding all unregistered patients to be monitored for the duration of their illness. Patients should be contacted within 24 hours of appearing on the Patient Flow Portal and receive monitoring for 14 days, or as appropriate for the course of their illness.

The patient should be advised to self-isolate until they have recovered and have been cleared by NSW Health. This advice should be provided in their first interaction with a healthcare provider following their diagnosis (e.g. when the patient contacts their own general practitioner (GP) or when the Community COVID-19 Service makes initial contact).

The person should inform their close contacts that they have tested positive for COVID-19. This includes advising household members and other people they have been in contact with to selfisolate for 14 days. Any further cases in the household will re-start the requirement to isolate for 14 days. Close contacts must be tested on (or after) day 12 of isolation and will be required to provide evidence of the negative result to police if asked.

Shared care by a multidisciplinary team

The team that is responsible for the care of a person with COVID-19 will vary according to disease severity, local resourcing and service models. It must include access to rapid medical review.

Safe clinical care requires clear lines of responsibility and accountability. Managing the course of a person's illness with COVID-19 may also include specialist involvement from services such as pharmacy, mental health, psychology and other allied health services, infectious diseases, aged care, palliative care, intensive care, respiratory medicine and maternity.

A collaborative approach will ensure the delivery of safe, efficient and integrated healthcare.

Determining level of risk and appropriateness for care in the community

For people diagnosed with COVID-19, patient care is tailored to individual risk. During the initial phone call with new patients, follow the flow chart (figure 1 on p.09) using the patient's information.

Once the level of risk is determined, see associated box for care package appropriate to the patient's current level of risk.

NOTE: DAYS ARE CALCULATED BASED ON THE DAYS THAT SYMPTOMS COMMENCED (DAY 0).

If the patient is asymptomatic, count from positive swab day (day 0).

Figure 1: New COVID-19 risk stratification patient flowchart

 

*The risk of hospitalisation is a validated algorithm that presents a meaningful prediction of a patient’s clinical deterioration. It is based on demographic and socioeconomic factors, as well as hospitalisation and medical history. The risk of hospitalisation algorithm has been built into the Patient Flow Portal and is automatically calculated daily. The risk of hospitalisation score should be used in conjunction with clinical judgement.

 ** Video call is recommended, wherever possible.

Initial clinical assessment

Initial assessment is required to determine the person's disease severity, risk factors and suitability for care in the home environment. This assessment may occur in the emergency department, face-to-face in the person's home or via virtual care.

If virtual care is being used, the assessment should be conducted via videoconference (where possible)to allow for visual assessment of the person and their home environment.

The assessment should include:

    • suitability for home-based care (as described below)
    • medical history
    • current medications
    • allergies
    • smoking history
    • onset of symptoms
    • pregnancy gestation (if applicable).

Initial assessment must include thorough education on the signs and symptoms of deterioration and processes for escalation when any changes are observed.

Details for the person's regular GP and other key care providers (e.g. maternity, mental health, drug and alcohol) should also be captured. If the person consents, these providers should be informed of the person's COVID-19 diagnosis and their management plan.

During the initial clinical assessment, the person should also be screened for appropriateness of sotrovimab in line with the Model of care for the use of sotrovimab in adults in NSW.4

Assessment of appropriateness for home-based virtual care and remote monitoring

A healthcare professional should assess whether the home setting is appropriate for care. This should take into account the COVID-positive patient, children and the extended family unit or others living in the place of residence.

The decision to monitor a patient in the community setting should be made on a case-by-case basis.

Where it is deemed that the patient or the family unit cannot be managed in the home because the environment is unsuitable and/or there are welfare concerns, patients should be transferred to special hotel accommodation when available.

Considerations for care to be delivered appropriately in the home include whether the person:

  • consents to receiving care and isolating at home, as required
  • is stable enough to receive care at home
  • has risk factors that cannot be managed in the home
  • has other medical conditions that cannot be managed in the home
  • has appropriate caregivers at home
  • has caregivers with the capacity to recognise signs of deterioration (as explained to them) and escalate care.
  • is living with other people at higher risk
  • has access to food and other necessities
  • lives within one hour of a hospital with an ICU (refer to additional considerations for rural patients on p.13)
  • has access to appropriate, recommended personal protective equipment (at a minimum, gloves and face masks).

The person and other household members must also be able to adhere to precautions recommended as part of home care or isolation (e.g. respiratory hygiene and cough etiquette, hand hygiene, etc).19

In the following circumstances, alternative accommodation should be considered (such as a special health accommodation or care in hospital), as clinically appropriate:

    • Family units where both parents are COVID-19 positive with young dependents.
    • Domestic and family violence has been disclosed or identified by a health clinician.
    • The person lives alone or is socially isolated without local supports who can assist with frequent monitoring, in addition to the health service.

Considerations for virtual care

Reliable mechanisms for communication must be available, including devices such as a telephone, tablet, or computer, as well as internet connectivity and data.

The person and their carer need to have adequate health literacy, digital literacy, communication and language skills. Virtual care requires the person or their carer to be able to describe or report symptoms and use remote monitoring devices where they are available.

A person's capacity to participate may be impacted by physical or intellectual disability, or low level of English language proficiency. For example, a video consultation may be inappropriate for people with vision or hearing impairments without additional modified equipment and platforms, or for people from culturally and linguistically diverse backgrounds who have low levels of English proficiency and where regular interpreter services are difficult to secure.

Caring for people using home-based virtual care and remote monitoring

Virtual care, including remote monitoring devices and platforms, can be used to monitor a person's symptoms and identify changes in symptoms or health status for escalation of care. There are a range of different technologies and devices that may be considered. Clinicians must determine the most appropriate modality and/or device to support the clinical needs of the person.

Due to the variable disease trajectory, frequent and thorough wellbeing and clinical monitoring is required to detect any clinical deterioration

Devices are automated and have limitations compared with direct manual measurements performed by a skilled health professional. If there are concerns over technological or measurement inaccuracy, arrange for an in-person assessment.

Where possible, video call is preferred, as it provides additional visual cues and therapeutic presence. 

Onboarding and provision of monitoring devices

All COVID-positive patients being cared for inthe home should have apulse oximeter (along with any other devices used inthe local model ofcare) delivered totheir home assoon aspossible. As aminimum, a family unit should be provided with one oximetry device. It isrecommended that athermometer isalso provided, where possible.
Education and support regarding the use ofapulse oximeter (and anyother devices) must be provided to the person and/or their carers.
Resources developed by RPA Virtual Hospital can be found on the ACI website.11 These include guidance on how to use a pulse oximeter to check oxygen and heart rate; ranges for measurements; and actions to take if a measurement is out of range.

Resources for consumers and carers

People with COVID-19 and their carers should be provided with information and education about:

  • care in the home and consent to treatment by the designated health service
  • home isolation
  • how to use remote monitoring devices, troubleshooting and howtorecord and report results (if not automatically uploaded)
  • what symptoms tomonitor and when and who to call for help.

COVID-19 resources for consumers and carers

  • NSW Health Fact sheet for confirmed COVID-19 cases – provides key information for people who have COVID-19, including what to do, how COVID-19 is managed, symptoms, support for access to food and mental health support (available in more than 25 languages). 
  • Australian Department of Health. COVID-19 frequently asked questions – answers to common questions for patients, their families and carers about spread, testing, isolating, etc. 
  • NSW Health Hygiene at home – information on cleaning and handwashing to prevent the spread of COVID-19. 
  • Healthdirect Caring for people with COVID-19 – information for people caring for someone with COVID-19, including preventing the spread of illness to others in the household.

Information and education provided to patients should be noted in the person's medical record.

Social factors and considerations

Health literacy

Health literacy describes how well people can access, understand and apply information about health and healthcare, and make decisions about their health. People with lower health literacy skills may have trouble understanding their condition, treatment options and care choices. They are more likely to have an adverse health outcome than someone who has higher health literacy. Teach-back is a best practice communication method for addressing health literacy and can be used with people to reduce misunderstandings. The method confirms the person understands what they have been told using their own words. The health professional gives information and then asks the person to respond and confirm their understanding before adding any new information.

Violence, abuse and neglect risks and vulnerabilities

COVID-19 may exacerbate risks related to people experiencing, or at risk of, violence, abuse and neglect. Emerging evidence suggesting that during COVID-19 lockdowns and self-isolation, there is an increased incidence of family violence and increased neglect of children and vulnerable people.20, 21 This is consistent with evidence that shows the risks and impacts of violence, abuse and neglect increase during and after natural and other disasters as usual routines and supports are disrupted.22

The mental health implications of living through natural and other disasters can be cumulative and can intensify existing experiences of trauma. The complex coping responses to violence, abuse and childhood neglect, such as alcohol and other drug use, or the impacts on existing mental health issues, may increase during times of natural and other disasters, requiring enhanced healthcare.

There are additional risks relating to provision of virtual care services to people who are experiencing, or at risk of violence, abuse and neglect. The use of screening questions regarding violence, abuse and neglect via virtual care is not recommended because privacy cannot always be established.

Where violence, abuse or neglect is disclosed, or clinicians identify concerns and suspicions, they should respond in accordance with NSW Health and relevant district guidance.

For more information, please refer to the NSW Health Violence, abuse and neglect and COVID-19 advice.22

Culturally and linguistically diverse communities

People who speak a language other than English at home may experience lower health literacy. This could include: 

  • a reduced understanding of COVID-19 symptoms 
  • a reduced ability to identify and adhere to household behaviours that prevent infection 
  • difficulty understanding government messaging about COVID-19. Culturally and linguistically diverse communities may also be less likely to rate physical distancing as important.

Culturally and linguistically diverse communities may also be less likely to rate physical distancing as important.

Verbal information and health resources should be translated, as required.

The ACI Virtual care in practice guide provides advice on undertaking virtual consultations, including the use of interpreters.23 The guide also briefly explains the functions of CALD Assist, which can provide timely and effective interactions with culturally and linguistically diverse patients when an interpreter is not available.

Large households

Care teams should seek tounderstand household structures that may include multiple generations or families within one home. For managing infectious diseases and household transmission in larger inter- generational households, consider the following:

  • Isolation within a household immediately following onset of symptoms isassociated with asignificantly reduced risk of transmission of COVID-19.
  • Expect that the whole family unit islikely tobe infected, including children.
  • Ensure behavioural reminders for reducing transmission within large households are prominent.

People living in rural areas

For people living in rural and remote areas, additional factors should be considered when determining the best place for a person toreceive care. These factors include:

  • logistics and distance toreceiving definitive care, including access to an intensive care or high dependency unit
  • underlying risk ofdeterioration
  • patient and/or family wishes
  • severity ofillness.

For people with moderate illness who have ahigh or very high baseline risk, consideration ofproactive transfer closer toahospital that can support definitive care isrequired. This may include transfer tospecial hotel accommodation, other supported accommodation oradmission to a COVID-designated health facility located less than one hour away.

Community teams should have knowledge of access to local transport and retrieval options, particularly for people living greater than one hour from a facility with an intensive care or high dependency unit.

For people with severe illness, transfer toafacility with intensive care orhigh dependency capability should be expedited, inconjunction with retrieval services.

It isimportant torespect the wishes ofpatients and their families. Shared decision-making should occur in the event ofanytransfer. This includes discussion with the patient and/or their family. Should aperson choose toremain onCountry orbe managed close tohome, it isimportant toexplain the risks and benefits ofthe treatment and/or transfer options.

Part 3: Assessment, recommended management and deterioration pathway

Assessment

Regular measurement and documentation of physiological observations is essential to allow early identification of clinical deterioration; optimised supportive care; and safe, rapid admission to a hospital facility, if required. The frequency of observations should be consistent with the clinical situation.

Virtual home monitoring is delivered via telephone and videoconference, along with the use of remote monitoring devices. The modality of care will depend on the service and the availability of hardware, monitoring devices and connectivity.

Frequency of assessment

Table 2 identifies minimum monitoring requirements. However, a person's individual characteristics and circumstances should be considered when developing a schedule that meets their preferences, needs and ability to self-manage, while ensuring that any deterioration is escalated in a timely manner.

The clinical team should establish and document a schedule of monitoring with the person, their carer and the extended clinical team. The schedule should ensure the person receives monitoring either by devices, clinical checks, or carer observation to detect any deterioration as early as possible. Frequency of monitoring should not overwhelm

Table 2: Minimum frequency of clinical assessment and monitoringthe person.

Care protocol

Frequency of clinician assessment and clinical observations

Frequency of medical review

Low or medium care protocol
  • Initial consult – day 1
  • Wellbeing check – daily
  • Discharge check – day 14+

Medical review should take place when there is clinical concern, symptoms change or there is any deterioration to ensure appropriate clinical escalation and assessment of ongoing suitability for home-based care

​ ​
High care protocol
  • Initial consult – day 1
  • Video call – twice daily*
  • Discharge check – day 14+
Very high care protocol
  • Initial consult – day 1
  • Video call – twice daily*
  • Discharge check – day 14+


* Video call is recommended, where possible.

Pregnant women

For pregnant women, risk of adverse outcomes from COVID-19 increases with gestation. In addition to the above clinical assessment and monitoring, pregnant women should receive care from their maternity care provider/s, based on the following gestation:

  • Less than 14 weeks gestation: general supportive care and should be linked with their local maternity service.
  • 14 to 28 weeks gestation: maternity support, including initial contact and weekly follow up (as a minimum) by their maternity care provider.
  • From 28 weeks gestation: maternity initial triage assessment, and maternity support and assessment every third day (as a minimum).

If there are any concerns identified by Community COVID-19 teams relating to pregnancy, the person's maternity care provider should be contacted for advice.

Wellbeing check

For low or medium risk patients, wellbeing checks should include the following:

  • Reiteration of public health advice.
  • Management of pre-existing conditions.
  • Social support needs, for example the need for medical or food supplies, connection to income support services.
  • Questions about the persons wellbeing, such as:
  • The presentation of any symptoms such as fever, cough, breathlessness and gastrointestinal symptoms.

If mild symptoms worsen to moderate symptoms, the patient's care should be escalated to high risk.

Assessment method

For high and very high-risk patients, twice daily assessment should occur focusing on signs and symptoms and any changes which indicate the onset of deterioration. If presentation worsens, this is most likely to occur on days five to 10 after onset of symptoms.

Monitoring symptoms

Monitoring of symptoms can occur via virtual care (phone or videocall) or via a smartphone app for COVID-19 symptom tracking.

Specific questions should be asked regarding:

  • the presence of any of the symptoms listed below
  • any changes in current symptoms
  • the development of new symptoms.

Respiratory symptoms, such as breathing and shortness of breath

Ask the following questions (as relevant).

  • How is your breathing?
  • Is it worse today than yesterday?
  • What does your breathlessness prevent you from doing?
  • How independent are you with activities of daily living?

The Guide to undertaking virtual respiratory assessment for adults has more detailed information.24

Interpret any reported breathlessness in the context of the wider history and physical signs.

In most adult patients, if dyspnea develops, it tends to occur between four and eight days after symptom onset, although it can also occur after 10 days. While mild dyspnea is common, worsening dyspnea, worsening and severe dyspnea and severe chest pain or tightness suggest the development of progression of pulmonary involvement.

Adult patients with dyspnea should be followed closely; particularly during the first few days following the onset of dyspnea, to monitor for worsening respiratory status.

Pulse oximetry

A pulse oximeter should be provided toall patients to help assess overall clinical status.

Research has shown patients most at risk ofbecoming very unwell from COVID-19 are best identified by oxygen levels. Using apulse oximeter means rapid deterioration and silent hypoxia are more likely tobe identified rapidly, and people can be escalated as quickly aspossible. Silent hypoxia (when people have lowoxygen levels inthe absence of significant shortness ofbreath) has been noted insome COVID-19 patients.25
Patients should be provided with information onhow touse oximeters correctly. See the onboarding and provision of devices section for further details.

Recommendations for healthcare teams

  • Become familiar with the equipment before use.
  • Ensure patients know the difference between oxygen saturations and heart rate onthe oximeter.
  • Ensure patients know torespond tochanges from baseline, rather than asingle reading inisolation.
  • Use clinical judgement when interpreting readings provided bypatients.
  • Tailorsupport based onthe patient’s and carers’ individual needs and circumstances.

Signs and symptoms for assessment

  • Fever or chills
  • Cough
  • Sputum
  • Runny nose Tiredness orsevere fatigue
  • Headache
  • Muscle aches and pain
  • Coughing upblood
  • Loss ofsense oftaste or smell
  • Diarrhoea
  • Nausea orvomiting
  • Loss ofappetite.

For any of the following, call 000 to attend an emergency department (state COVID-19 status):

  • Symptoms orsigns of pneumonia
  • Shortness of breath or difficulty breathing
  • Blue lips or face
  • Pain orpressure inthe chest
  • Cold, clammy orpale and mottled skin
  • New confusion orfainting
  • Becoming difficult to rouse
  • Little orno urine output
  • Coughing up blood.

Virtual A-G Systematic Assessment

  • The A-G method provides a systematic and structured assessment approach and can be uses inaddition tothe above assessment ofsymptoms. The following version is modified for virtual monitoring ofcommunity-based people with
    COVID-19.
  •  The frequency ofthe A-G assessment depends on the person’s clinical presentation, disease severity and risk rating. 
  • Assessment questions should be modified depending on the type ofremote monitoring devices available and in use. For example, if bluetooth remote monitoring provides automatic results of temperature, do not askthe person toprovide this information again.
  •  The virtual A-G requires clinical judgement from the clinician.

Table 3: A-G method for virtual monitoring of community-based people with  COVID-19

Airway
  • Airway patency.
  • Appearance: sitting, lying in bed, state of dress.
  • People in respiratory distress may voluntarily sit up or lean over by resting arms on their legs to enhance lung expansion.26
Breathing
  • Look for the general signs of respiratory distress (such as sweating), the effort needed to breathe, abdominal breathing and central cyanosis.27
  • Count the person's respiratory rate. The normal respiratory rate in adults is between 12 and 20 breaths per minute.28 The respiratory rate should be measured by counting the number of breaths a person takes over one minute by observing the rise and fall of the

    chest. A high respiratory rate is a marker of illness or an early warning sign that the person may be deteriorating.
  • Assess the depth of each breath the person takes; the rhythm of breathing and whether chest movement is equal on both sides; ease and comfort when talking; breathlessness; ability to finish sentences; flaring of nostrils or pursing of lips.
  • Measure the person's peripheral oxygen saturation using pulse oximetry, including oxygen saturation upon exertion.
  • Escalate care immediately if oxygen saturation is below 92% (or below 90% for people with chronic lung disease).
  • There is no evidence that attempts to measure a person's respiratory rate over the phone will give an accurate reading, and experts do not use such tests. However, it is possible to measure respiratory rate via a good video connection. Video may allow a more detailed assessment and prevent the need for an in-person visit.29
Circulation
  • Skin tone – flushing, pallor, cyanosis.
  • Visual assessment via video link is preferred.
Disability (neurological)
  • Speech not slurred.
  • Orientated to time, place and person. Ask: What is the time and day today?
  • Early signs of hypoxia are anxiety, confusion and restlessness.26
Exposure
  • Person's temperature.
  • Night sweats, feeling feverish or chills.
Fluids
  • Fluid intake and urine output.
  • Ask: Are you urinating as frequently as usual, less frequently as usual, or much less frequently than usual?
Glucose
  • Normal food intake?
  • If diabetic, record of blood sugar level.

 Source: adapted from RPA Virtual Hospital, Sydney Local Health District.30

Mental health screening

The coronavirus outbreak and self-isolation can be stressful and impact on the individual’s mental health and wellbeing. People who are self-isolating may struggle with the unpredictable nature of the illness and long isolation periods. They may experience arange of emotions, such as stress, worry,anxiety,boredom or low mood. People who have no tpreviously experienced a mental health problem may also be at risk.
For people with pre-existing mental health conditions, a pandemic can further heighten anxious thoughts or compulsive behaviours. Previously managed symptoms may escalate, requiring additional care.

Disrupted support systems and social isolation can leave people vulnerable to acute stress reactions.
Healthcare staff should consider how to link people with services relevant totheir presentation. It is important to ensure that people receiving care from a mental health professional are engaged with their care provider.

Mental health resources for consumers and carers

Refer to resources for consumers and carers for additional resources.

Screening tools

Regular mental health review is recommended where risks are identified in daily wellbeing checks. Suicidal behaviours may be symptoms ofunderlying mental health problems or disorders. Asuicide risk assessment cannot be undertaken in isolation from an overall mental health assessment.

Ask the following questions to inform handover tothe Mental Health Line. 

  1. Have you ever thought about harming or killing yourself?
  2. Do you have aplan for what you might do? (Check if the person has access tothe intended means.) 
  3. Have you taken anyactions outlined inthe plan?
  4. Do you have access to a firearm? (Any such disclosure requires mandatory notification topolice.)

Harm to others screening

  1. Some suicidal people may also have thoughts of harming others, e.g. their children or partner. Ask the following questions.
    Are you having thoughts ofharming others? 
  2.  Who are you thinking ofharming? 
  3. Is the person living with you?

If there isanimmediate risk, ring 000. Activate NSW Ambulance and/or NSW Police Force to take the person tohospital for acomprehensive mental health assessment.
If you have concerns about the person’s safety, or evidence ofanacute mental illness orother disorder, immediately warm transfer them to the 1800 011 511 Mental Health Line and handover using ISBAR guidelines. The Mental Health Line isalso available for advice around the person, their assessment ormeans oftransporting aperson to hospital. For some people, it may be safe for their carers to bring them to the hospital or community mental health service.

People with severe mental health conditions

Identify whether the person iscurrently receiving care orknown toamental health professional. If so, a combined team approach between the COVID-19 team and the mental health team isrecommended.
Escalation pathways for mental health deterioration
should be clearly defined by both teams.

Table 4: Mental wellbeing screening

1. How are you coping with your isolation? 
2. Are you feeling anxious or worried?No – no further questioning required. Yes – go to Q3
3. How are you managing your anxiety and worries? 
4. Do you think you need any extra support to manage?

No – no further questioning required.

Yes – depending on level of distress, consider referring them to the Coronavirus Mental Wellbeing Support Service on 1800 512 348.

If level of distress is significant, go to Q5.

5. Do you have a history of mental health problems?Yes – go to Q6.
6. Are you experiencing any symptoms of your mental health problems?Yes – go to Q7.
7. Are you currently seeing a mental health professional? 
8. Are you having any thoughts of harming yourself?

No – the clinician should have a plan with the person including:

  • strategies for them to manage their distress and safety until next contact with the health professional
  • details of their carer or other third party who can provide support or consultation, if required
  • contact details of emergency services and a mental health professional.

    Yes – go to Q10.
9. Have things been so bad lately that you have thought you would rather not be here?Yes – indicates warm transfer to the 1800 011 511 Mental Health Line.

Source: adapted from RPA Virtual Hospital, Sydney Local Health District30 

COVID-19-positive patient clinical escalation pathway

The Delta variant may be associated with rapid deterioration. This may be detected by healthcare staff or by the patient, family or carers.

Figure 2: Escalation pathway

Uncontactable patients

Daily contact must continue through the isolation period. All services must have an escalation process if a patient cannot be contacted.

Patients and carers must be informed of their responsibilities and obligation to be at home throughout their isolation period, and to be contactable at agreed times for daily assessments. They must understand what will happen if they cannot be contacted at these times.

If all attempts to contact the person or their carer have failed (for example, if the person does not answer a text message stating 'if you do not respond within 30 minutes the police will be called'), emergency services must be contacted.

If a person is absconding or a breach of isolation is disclosed during contact with the person, this must be escalated to the local public health unit or police.

Refer to section 9.3 of the Adult and Paediatric Hospital in the Home Guideline for further information.6

Managing people who refuse daily wellbeing and health checks

Patients refusing care should initially be assessed in relation to capacity (ruling out hypoxia) and counselled regarding the risks of rapid clinical deterioration.

Patients should be encouraged to contact the service if they experience new or changes in symptoms and advised that the COVID-19 service will conduct a welfare check in a couple of days.

The patient lack of compliance and counselling advice to patient should be clearly documented.

If a person is absconding or a breach of isolation is disclosed during contact with the person, this must be escalated to the local public health unit or police.

 

Part 4: Transfer of care and reporting  

Transfer of care from acute care

Formal arrangements for transfer of clinical care back to the GP should be made by the COVID-19 medical team. A formal transfer of care should be given to the general practitioner, including a written summary of the person's episode of care and follow-up advice.

Release from isolation criteria

The Communicable Diseases Network Australia National Guidelines for Public Health Units outline Australia's national minimum standard for de-isolation.3

NSW community COVID-19 teams are responsible for releasing patients from isolation based on the following criteria.

  • If not significantly immunocompromised and has remained asymptomatic – release from isolation 14 days after the positive test. 
  •  If not significantly immunocompromised and symptomatic – release from isolation 14 days after the onset of symptoms, if no fever for at least 72 hours and acute respiratory symptoms have been substantially improved for 72 hours. 
  •  If not significantly immunocompromised and symptomatic but fever not resolved and/or acute respiratory symptoms not substantially resolved for three days, release from isolation: 
      •  20 days after onset of symptoms OR 
      •  at least 14 days after onset and no fever for 72 hours and substantial improvement in respiratory symptoms and two consecutive nose and throat swabs taken at least 24 hours apart after day 10 from symptom onset are negative. 
  • If significantly immunocompromised, any of the above criteria plus two swabs taken at least 24 hours apart at least 10 days after symptoms are negative. While under the self-isolation public health order, the person's release must be approved by a medical practitioner. This may occur through criteria-led discharge with authorisation from the designated medical office.

Documentation

It is a clinical requirement that all clinical activity, including virtual care consultations, is documented in the person’s health record.

Any incidents related to the care of COVID-19 patients in the community should be reported through the ims+ system.

Reporting

People with COVID-19 who are managed in the community by NSW Health will either be admitted or non-admitted, depending on their disease severity and risk rating. For accurate weighting and funding, the level of care delivered to people with COVID-19 should be reflected in reporting.

People receiving hospital level care as hospital substitution (i.e. if the clinical service was not offered in the home the person would be in hospital), should be reported in the admitted patient data collection as a bed type 25 patient. Some districts have established specific COVID-19 virtual wards.

People with a mild disease rating who receive less intense clinical monitoring should be reported in the non-admitted patient data collection.

Post discharge, specific classification of diseases (ICD-10) codes will identify people as positive, suspected or negative COVID-19 status.

References

  1. NSW Agency for Clinical Innovation. Virtual care [Internet]. Sydney: ACI; 2021 [cited 2021 Sept 23]. Available from: https://aci.health.nsw.gov.au/statewide- programs/virtual-care
  2. NSW Ministry of Health. Community of Practice: Virtual Care [Internet]. Sydney: NSW Ministry of Health; 2021 [updated 2020 July 16; cited 2021 Sept 23]. Available from:   https://www.health.nsw.gov.au/Infectious/covid-19/communities-of-practice/Pages/virtual-care.aspx
  3. Australian Government Department of Health. Coronavirus Disease 2019 (COVID-19): CDNA National Guidelines for Public Health Units. Version 4.8 [Internet]. Australian Government Department of Health; 2021 [updated 2021 September 07; cited 2021 Sept 23]. Available from: https://www1.health.gov.au/internet/ main/publishing.nsf/Content/cdna-song-novel- coronavirus.htm
  4. NSW Agency for Clinical Innovation. Model of care for the use of strovimab in adults in NSW. Version 4. Sydney: ACI; 2021. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0008/673253/ACI-Model-of-Care-for-the-use-of-sotrovimab-in-NSW.pdf 
  5. NSW Ministry of Health Caring for children with COVID-19 in the community [Internet]. NSW Ministry of Health; 2021 [updated 2021 Sept 03; cited 2021 Sept 23]. Available from: https://www.health.nsw.gov.au/ Infectious/covid-19/communities-of-practice/Pages/ Caring-children-COVID19-community.aspx.
  6. NSW Ministry of Health. Adult and Paediatric Hospital in the Home Guideline. GL2018_020. Sydney: NSW Ministry of Health; 2018. Available from: https://www1. health.nsw.gov.au/pds/Pages/doc.aspx?dn=GL2018_020 
  7. Clinical Excellence Commission Deteriorating Patient Program [Internet]. Sydney: Clinical Excellence Commission;  [cited 2021 Sept 23]. Available from: https://www.cec.health.nsw.gov.au/keep-patients-safe/ deteriorating-patient-program
  8. Clinical Excellence Commission. Infection Prevention and Control information [Internet]. Sydney: Clinical Excellence Commission; [cited 2021 Sept 23]. Available from: https://www.cec.health.nsw.gov.au/keep- patients-safe/COVID-19.
  9. NSW Ministry of Health. Guidance for community-based and outpatient health services [Internet]. Sydney: NSW Ministry of Health; 2021 [updated 2021 April 21; cited 2021 Sept 23]. Available from: https://www.health.nsw.gov.au/Infectious/covid-19/Pages/outpatient.aspx
  10. Williams H, Hutchinson D, Stone H. Watching Brief: The evolution and impact of COVID-19 variants B.1.1.7, B.1.351, P.1 and B.1.617. Global Biosecurity.3(1).
  11. RPA Virtual Hospital. [Stakeholder pack]. Sydney: ACI; 2021. Available from: https://aci.health.nsw.gov.au/       data/assets/pdf_file/0007/665125/RPA-Virtual- Hospital-Stakeholder-Pack-COVID-19-Remote-Monitoring.pdf
  12. National COVID-19 Clinical Evidence Taskforce. Australian guidelines for the clinical care of people with COVID-19, v42.0 [Internet]. National COVID-19 Clinical Evidence Taskforce; 2021 [updated 2021 Aug 26; cited 2021 Aug 26]. Available from: https://covid19evidence.net.au/
  13. Sheikh A, McMenamin J, Taylor B, et al. SARS-CoV-2 Delta VOC in Scotland: demographics, risk of hospital admission, and vaccine effectiveness. Lancet. 2021 Jun 26;397(10293):2461-2. DOI: 10.1016/s0140-6736(21)01358-1
  14. Havers FP, Pham H, Taylor CA, et al. COVID-19- associated hospitalizations among vaccinated and unvaccinated adults ≥18 years – COVID-NET, 13 states, January 1 – July 24, 2021. medRxiv.2021:2021.08.27.21262356.  DOI:10.1101/2021.08.27.21262356
  15. Australian Government Department of Health. Advice for people at risk of coronavirus (COVID-19) [Internet]. Canberra: Australian Government Department of Health;  [updated 2021 Jul 7; cited 2021 August 30]. Available from: https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/advice-for-people-at-risk-of-coronavirus-covid-19
  16. World Health Organization. Coronavirus disease (COVID-19): Pregnancy and childbirth [Internet]. World Health Organization; 2020 [updated 2021 August 30; cited 2021 August 30]. Available from: https://www. who.int/news-room/q-a-detail/coronavirus-disease- covid-19-pregnancy-and-childbirth
  17. Allotey J, Stallings E, Bonet M, et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ. 2020 Sep 1;370:m3320. DOI: 10.1136/bmj.m3320 
  18. Centers for Disease Control and Prevention. Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19) [Internet]. Centers for Disease Control and Prevention; 2020 [updated 2020 Oct 16; cited 2021 August 30]. Available from: https://www.cdc.gov/ coronavirus/2019-ncov/hcp/guidance-home-care.html
  19. Usher K, Bhullar N, Durkin J, et al. Family violence and COVID-19: Increased vulnerability and reduced options for support. Int J Ment Health Nurs. 2020;29(4):549-52. DOI:  10.1111/inm.12735
  20. S S Teo S, Griffiths G. Child protection in the time of COVID-19. J Paediatr Child Health. 2020;56(6):838-40. DOI: 10.1111/jpc.14916
  21. NSW Ministry of Health. Violence, abuse and neglect and COVID-19 [Internet]. 2021 [updated 2021 April 21; cited 2021 August 30]. Available from:  https://www.health.nsw.gov.au/infectious/covid-19/pages/violence- abuse-neglect.aspx.
  22. NSW Agency for Clinical Innovation. Virtual care in practice. Sydney: ACI; 2021. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_ file/0004/651208/virtual-care-in-practice.pdf
  23. NSW Agency for Clinical Innovation. Guide to undertaking virtual respiratory assessment for adults: Basic and extended. Sydney: ACI; 2020. Available from: https://www.health.nsw.gov.au/Infectious/covid-19/ communities-of-practice/Documents/guide-virtual- resp-assessment.pdf
  24. NHS. FAQs – COVID Oximetry @home and COVID virtual wards [Internet]. United Kingdom: NHS; [cited 2021 August 30]. Available from: https://www.england.nhs.uk/nhs-at-home/faqs-for-for-covid-virtual-wards- and-covid-oximetry-home/.
  25. Doyle GR, McCutcheon JA. Clinical procedures for safer patient care [Electronic book]: BCcampus; 2015 ]. Available  from: https://opentextbc.ca/clinicalskills/
  26. Nabwami L. How To Assess a Deteriorating / Critically Ill Patient (ABCDE Assessment) [Internet]. Melbourne ( VIC): Ausmed; 2020 [updated 2020 March 19; cited 2021 August 30]. Available from: https://www.ausmed.com.au/cpd/articles/abcde-assessment
  27. Prytherch DR, Smith GB, Schmidt PE, et al. ViEWS-- Towards a national early warning score for detecting adult inpatient deterioration. Resuscitation. 2010 Aug;81(8):932-7.  DOI:  10.1016/j.resuscitation.2010.04.014
  28. Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ. 2020 Mar 25;368:m1182.  DOI: 10.1136/bmj.m1182
  29. Hutchings O, Dearing C. vConsult to Detect COVID-19 Clinical Deterioration [Unpublished work]. 2020.

Document Information

Developed by

Consultation

  • Expert advice wassought from Hospital inthe Home, Ambulatory Care, Mental Health, Ministry ofHealth Prevention and Response toViolence Abuse and Neglect (PARVAN)Unit and Aged Care Unit (Health and Social Policy Branch), emergency care specialists and the Executive ofthe Virtual Care Community of Practice.
  • Consultation wassought from the Clinical Excellence Commission, Primary Care, Community Health, Emergency Care, Virtual Care, and Respiratory Communities ofPractice.
  • This document has been informed byexisting clinical NSW COVID-19 services and inparticular SydneyLocal Health District RPAVirtual Hospital. The Guideline isinformed bytheir COVID-19 Remote Monitoring Clinical Protocol and Model ofCare written collaboratively by SLHD’s RPAVirtual, Respiratory, Infectious Diseases, Emergency Care, Paediatric, Public Health and Mental Health disciplines and shared with the Virtual Care COP.

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.

Reviewed by

Clinical experts managing the care of people with COVID-19 in the community including infectious disease, emergency care and hospital in the home specialists.

For use by

  • Virtual care services
  • COVID response teams
  • Community nursing
  • Hospital in the Home
  • Integrated care teams
  • Primary care
Current as at: Wednesday 13 October 2021
Contact page owner: Health Protection NSW