NSW Quick reference guide
On this page
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When a patient arrives at emergency
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Initial assessment
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Investigations
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Management
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Disposition and transfer
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Document information
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?
- Respiratory symptoms including cough, runny nose, sore throat
- Fever
- Change in taste or smell
- Fatigue.
| - Gastrointestinal (GIT) symptoms, including vomiting and diarrhoea
- Headache
- Abdominal pain
- Chest pain
- Mild haemoptysis.
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This table of symptoms is based on recent experience of Delta in Sydney and South Western Sydney Local Health Districts.
Initial assessment
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% |
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| Respiratory rate | 10-25 | 8-10 and 25-30 | <8 and >30 |
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| Heart rate | 50-120 | 40-50 or 120-140 | <40 or >140 |
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| GCS | 15 | 15 | ≤14 |
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Some people are deteriorating rapidly and significantly within 6-12 hours. |
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Severe GI symptoms – diarrhoea, vomiting, abdominal pain > 4x/day |
Hypotension including symptomatic postural hypotension |
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Syncope |
Transient
hypoxia – mild hypoxia is escalating to major hypoxia quickly with the Delta strain |
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Chest pain |
Silent hypoxia – without tachypnoea
OR subjective symptoms of shortness of breath –
more prevalent in older populations |
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Persistent tachycardia |
Confusion |
- 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
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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
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, LHD, Ca, Mg, PO4
- Blood culture if febrile equal to or more than 38.5 degrees
- ECG
- Chest x-ray
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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
Consider if the patient has an advanced care directive and whether referral to palliative care is appropriate.
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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 |
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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 |
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Position | Consider awake prone position to increase saturations for those desaturating | Consider prone position to increase oxygen saturations for those desaturating |
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Venous Thromboembolism (VTE) prophylaxis | Start VTE prophylaxis as soon as possible, unless contraindicated | Start 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: - Baricitinib
OR - Tocilizumab (only indicated in most severe cases and for pregnancy)
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Additional therapies | Treat suspected bacterial pneumonia | Treat suspected bacterial pneumonia |
Disposition and transfer
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 LHD | For 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 | | |
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