NSW Quick reference guide

 

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This information is for staff attending to adults presenting to NSW emergency departments with suspected or confirmed COVID-19 infection.

When a patient arrives at emergency

Wear PPE according to local facility and current NSW COVID-19 guidance.

Patients meeting case definition criteria should be streamed into a dedicated 'high-risk' zone, ensuring immediate isolation from other waiting patients.

When considering whether there is a high epidemiological risk use this document in combination with your clinical assessment of the following to determine whether this is suspected COVID-19.

  • The rate of COVID-19 infection in your area
  • Is the patient, or any household members known close or casual COVID-19 contacts?
  • Is the patient, or any household members essential workers, working in high-risk areas?

Well recognised COVID-19 symptoms

  • Respiratory symptoms including cough, runny nose, sore throat
  • Fever
  • Change in taste or smell
  • Fatigue.

Emerging Delta strain COVID-19 symptoms

  • Gastrointestinal (GIT) symptoms, including vomiting and diarrhoea
  • Headache
  • Abdominal pain
  • Chest pain
  • Mild haemoptysis.

This table of symptoms is based on recent experience of Delta in Sydney and South Western Sydney Local Health Districts.

Initial assessment

ObservationsMildModerateSevere

Oxygen saturations

(room air)

Undertake an ambulatory SpO2 for exertional hypoxia

>95%

If any exertional hypoxia noted discuss with your inpatient admission team

92–95% including

exertional desaturations

<92%
Respiratory rate10-258-10 and 25-30<8 and >30
Heart rate50-12040-50 or 120-140<40 or >140
GCS1515≤14

 

Red flags - A person presenting with these signs and symptoms should be flagged as a higher risk for further deterioration

Some people are deteriorating rapidly and significantly within 6-12 hours.

  • Severe GI symptoms – diarrhoea, vomiting, abdominal pain > 4x/day
  • Hypotension including symptomatic postural hypotension
  • Syncope
  • Transient hypoxia – mild hypoxia is escalating to major hypoxia quickly with the Delta strain
  • Chest pain
  • Silent hypoxia – without tachypnoea or subjective symptoms of shortness of breath – more prevalent in older populations
  • Persistent tachycardia
  • Confusion

Risk factors for increased severity of disease in COVID-19

These are only a guide for complexity of disease and should not replace clinical judgement.

  • Age, over 65
  • Chronic respiratory disease
  • Chronic kidney disease
  • Hypertension
  • Chronic cardiovascular disease
  • Diabetes
  • Immunosuppression
  • Unvaccinated people
  • Obesity, BMI greater than 40
  • Cancer
  • Dementia
  • Social factors
  • Significant mental health conditions
  • Pregnancy
  • Vulnerable populations
  • Aboriginal background

Check if your patient has had a recent previous positive COVID-19 diagnosis and belongs to a community care team or is allocated to a virtual service.

Investigations

For mild, moderate and severe:

  • COVID-19 nucleic acid detection swab +/- other viral panels as indicated (use local protocol)
  • Investigations to be determined as clinically necessary
    • FBC, EUC, COAGs, D-dimer, Ferritin
    • Troponin (if chest pain present)
    • VBG (including lactate and glucose)
    • LFT, CRP, LDH, Ca, Mg, PO4
    • Blood culture if febrile equal to or more than 38.5 degrees
    • ECG
    • Chest x-ray

Severe disease has been correlated with:

  • Lymphopenia(<1.1×10⁹cells/L)
  • Thrombocytopenia (<50 x109 cells/L)
  • D-dimer >1.0mg/L
    Newacutekidney injury
  • RaisedALT/AST
  • Raisedinflammatory markers (CRP, WCC)
  • Raisedtroponin
  • Lactate (VBG) >3.0mmol/L

Management

Mild 

  • Consider administration of Sotrovimab according to hospital or local health district supply and policy. For clinical guidance see Model of care for the use of sotrovimab in adults in NSW  
  • Consider if the patient has an advanced care directive and whether referral to palliative care is appropriate.

ModerateSevere
Respiratory support

Aim for >/= 92% - 95%

Commence oxygen via nasal prongs and titrate to SaO2 92% - 95%

If unable to maintain SaO2>/=92% on 6L/min or if RR remains >30/min, then escalate support to HFO2, or NIV

Consult respiratory or ICU

Consider intubation as clinically necessary

Use appropriate PPE as per guide for aerosol generating procedures (AGPs)

Consider your fluid therapy

For those with GI symptoms

- do not withhold fluid therapy

250mL boluses up to 3 times if SBP 100mmHg

If not responsive commence on severe pathway as clinically indicated

No maintenance fluids unless specific indication

250mL boluses up to 3 times if SBP 100mmHg

If not responsive, then commence vasopressors

No maintenance fluids unless specific indication

Steroid use

Commence dexamethasone 6mg IV/PO daily for 10 days if requiring supplemental oxygen to maintain SpO2 >/=92%

For those already on steroids, increase current dose accordingly

Commence dexamethasone 6mg IV/PO daily for 10 days if requiring supplemental oxygen to maintain SpO2 >/=92%

For those already on steroids, increase current dose accordingly

PositionConsider awake prone position to increase saturations for those desaturatingConsider prone position to increase oxygen saturations for those desaturating
Venous Thromboembolism (VTE) prophylaxisStart VTE prophylaxis as soon as possible, unless contraindicatedStart VTE prophylaxis as soon as possible, unless contraindicated

Supportive anti-infectious therapy

Further information available at NSW TAG

Consider other pharmacological therapies in consultation with ID, respiratory or ICU specialists

For example: Remdesevir

Consider other pharmacological therapies in consultation with ID, respiratory or ICU specialists

For example:

  1. Baricitinib or
  2. Tocilizumab (only indicated in most severe cases and for pregnancy)
Additional therapiesTreat suspected bacterial pneumoniaTreat suspected bacterial pneumonia

Disposition and transfer

Mild Moderate Severe

Discharge – if no oxygen required or if weaned off oxygen and SpO2 is at, or above, 95% on room air

If exertional oxygen saturation drop is equal to, or more than 3% discuss with inpatient admissions team

Admit patient

For rural regions, consider presence of red flags or risk of severe disease when determining if a patient requires transfer to a facility with ICU

Admit patient and discuss with ICU

For rural facilities consider transfer to a facility with HDU/ICU onsite, unless an Advanced Care Directive is in place

Transfer of care to local COVID community care team for ongoing care

Educate patient about signs of deterioration and escalation

For rural patients consider the critical care network for patient transfer in conjunction with local surge plans within the LHDFor rural patients consider the critical care network for patient transfer in conjunction with local surge plans within the LHD
If accommodation is required, follow local process

NSW Health guidance document

Caring for adults with COVID-19 in the community

Intrahospital transfer processes. See current guidance - Intrahospital transfer of COVID-19 positive and suspected COVID-19 positive patients from the emergency department.Intrahospital transfer processes. See current guidance - Intrahospital transfer of COVID-19 positive and suspected COVID-19 positive patients from the emergency department.

Document information

Developed by

COVID-19 Emergency Department COP Clinical Reference Group and ECI.

Consultation

Endorsed by

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

Reviewed by

Emergency Department COP and ECI.

For use by

This document is a quick reference guide for ED clinicians treating adults presenting to ED with symptoms consistent with suspected or confirmed COVID-19. This advice should be considered in conjunction with local guidelines.

Feedback

Feedback on this document can be provided to aci-ecis@health.nsw.gov.au



Current as at: Tuesday 28 September 2021
Contact page owner: Health Protection NSW