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NSW quick reference guide

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This information is for staff attending to adults presenting to NSW emergency departments during the COVID-19 pandemic.

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.

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:

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

COVID-19 symptoms

  • 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

Initial assessment

ObservationsMild
ModerateSevereCritical

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% Any/all of the severe assessment observations and:

  • hypoxia despite oxygen therapy
  • hypotension or shock
  • impairment of consciousness
  • other organ failure
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

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

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

Investigations

MildModerateSevereCritical
COVID-19 testing as per current guidelines
Investigations to be determined as clinically necessary with known risk factors for severe disease
  • FBC, EUC
  • 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 (if chest pain present or clinically indicated)

Undertake all investigations for moderate and severe and:

  • COAGs
  • D-dimer
  • Ferritin

Severe disease has been correlated with:

  • Lymphopenia(<1.1×10⁹cells/L)
  • Thrombocytopenia (<50 x109 cells/L)
  • D-dimer >1.0mg/L
  • New acute kidney injury
  • Raised ALT/AST
  • Raised inflammatory markers (CRP, WCC)
  • Raised troponin
  • Lactate (VBG) >3.0mmol/L

Management

Mild

No known risk factors for disease progression

Discharge home with education on self-management

Risk factors present

Consider referral for disease modifying treatments according to hospital or local health district supply and policy

Resources for clinical guidance

Consider if the patient has an advanced care directive and whether referral to palliative care is appropriate.


ModerateSevereCritical

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.

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

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%

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

Commence dexamethasone 6mg IV/PO daily for 10 days if requiring supplemental oxygen to maintain SpO2 >/=92%
PositionEncourage prone position for minimum >3hrs at a time (aim for at least 8hrs within a day)Prone position for minimum >3hrs at a time (aim for at least 8hrs/24hrs in prone position)Prone position for minimum >3hrs at a time (aim for at least 8hrs/24hrs in prone position
Venous Thromboembolism (VTE) prophylaxisStart VTE prophylaxis as soon as possible, unless contraindicatedStart VTE prophylaxis as soon as possible, unless contraindicatedStart VTE prophylaxis as soon as possible, unless contraindicated

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)

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)

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

For example: Tocilizumab (indication is for those requiring immediate intubation and for moderate to severe pregnant patients).

Additional therapiesTreat suspected bacterial pneumoniaTreat suspected bacterial pneumoniaTreat suspected bacterial pneumonia

Disposition and transfer

Mild Moderate SevereCritical

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

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 LHDFor rural patients consider the critical care network for patient transfer in conjunction with local surge plans within the LHD

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.

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: Wednesday 2 February 2022
Contact page owner: Health Protection NSW