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.
This document outlines guidance to assist staff to:
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:
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.
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.
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
This guideline is presented in four parts:
The following principles underpin this guideline:
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:
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.
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
People who are at high risk of severe illness:
People at moderate risk ofsevere illness include those with:
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:
Some specific communities and groups may be more at risk of exposure to COVID-19, or severe illness. These include:
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:
Risk factors for severe illness from COVID-19 in pregnant women include:
The National COVID-19 Clinical Evidence Taskforce defines COVID-19 disease severity in the following categories.12
No clinical features suggesting of moderate or severe disease or a complicated course of 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.
If the person meets any of the following criteria:
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.
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.
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.
If the patient is asymptomatic, count from positive swab day (day 0).
*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 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:
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
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:
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:
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.
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.
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.
People with COVID-19 and their carers should be provided with information and education about:
Information and education provided to patients should be noted in the person's medical record.
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.
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
People who speak a language other than English at home may experience lower health literacy. This could include:
Culturally and linguistically diverse communities may also be less likely to rate physical distancing as important.
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.
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:
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:
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.
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.
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
Frequency of clinician assessment and clinical observations
Frequency of medical review
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
* Video call is recommended, where possible.
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:
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.
For low or medium risk patients, wellbeing checks should include the following:
If mild symptoms worsen to moderate symptoms, the patient's care should be escalated to high risk.
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 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:
Ask the following questions (as relevant).
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.
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.25Patients should be provided with information onhow touse oximeters correctly. See the
onboarding and provision of devices section for further details.
For any of the following, call 000 to attend an emergency department (state COVID-19 status):
Source: adapted from RPA Virtual Hospital, Sydney Local Health District.30
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.
resources for consumers and carers for additional resources.
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.
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.
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 deteriorationshould be clearly defined by both teams.
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.
No – the clinician should have a plan with the person including:
The Delta variant may be associated with rapid deterioration. This may be detected by healthcare staff or by the patient, family or carers.
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
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.
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.
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.
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
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.
Hutchings O, Dearing C. vConsult to Detect COVID-19 Clinical Deterioration [Unpublished work]. 2020.
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.
Clinical experts managing the care of people with COVID-19 in the community including infectious disease, emergency care and hospital in the home specialists.