This information is for staff attending to adults presenting to NSW emergency departments during the COVID-19 pandemic.
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.
If you are unable to zone within your department, where possible identify vulnerable patients who would benefit from being streamed into a dedicated reverse isolation zone to provide protection from COVID-19.
PCR/RAT testing should be prioritised for this cohort of patients to protect them from cross infection and early identification for use of COVID therapies.
When considering whether there is a high epidemiological risk use this document in combination with your clinical assessment to determine whether this is suspected COVID-19:
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
These are only a guide for complexity of disease and should not replace clinical judgement.
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.
Check recent eMR entries for any community care team notes for COVID related care.
Further information on the current testing regime for COVID - see Clinical Excellence Commission Recommendations for COVID Surveillance Testing in NSW Healthcare Facilities
Undertake all investigations for moderate and severe and:
Severe disease has been correlated with:
Discharge home with education on self-management
Consider referral for disease modifying treatments according to hospital or local health district supply and policy
Consider if the patient has an advanced care directive and whether referral to palliative care is appropriate.
Respiratory support
For further information see, Clinical Practice Guide for respiratory support in adults with COVID-19
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)
Unable to maintain SpO2 >92% on HFO2 or CPAP, then escalate to bilevel pressure support or intubation in consultation with ICU.
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
If not responsive, then commence vasopressors
250mL boluses up to 3 times if SBP <100mmHg
Commence dexamethasone 6mg IV/PO daily for 10 days if requiring supplemental oxygen to maintain SpO2 >/=92%
Disease modifying treatments
Further information available at NSW TAG
Consider other pharmacological therapies in consultation with ID, respiratory or ICU specialists
For example: Remdesevir Baricitinib (for consideration in those with raised CRP)
For example:
For example: Tocilizumab (indication is for those requiring immediate intubation and for moderate to severe pregnant patients).
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
Admit patient and notify ICU
For rural facilities transfer to a facility with HDU/ICU onsite, unless an Advanced Care Directive is in place
Provide education on self management and signs of deterioration and escalation Refer patient to Information about COVID-19 resources on the NSW Health website
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.
COVID-19 Emergency Department COP Clinical Reference Group and ECI.
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.
Emergency Department COP and ECI.
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 on this document can be provided to aci-ecis@health.nsw.gov.au