Adult Admission and Care Pathway during COVID-19
Purpose and scope
This pathway aims to guide staff working primarily in the Respiratory Red Zone (ED, Medicine
COVID-19 team, Paediatrics +/- ICU) at Whangarei Hospital regarding the identification,
assessment, management and disposition of patients presenting to our facility who may have
COVID-19 infection as a presenting issue or comorbidity.
This pathway wil necessarily be flexible and needs to be adapted in response to the demands we
face in terms of patient numbers and acuity, community prevalence of COVID-19, staff availability
and competencies, departmental layouts, and the availability of beds and other resources. It should
not be a static document, but rather refined as together we work out what works.
Method
Is the patient
COVID-19-PCR positive or
at high risk for COVID-19?
• Close contact of
known case
• Attendance at
location of interest
• Classical COVID-19
symptoms/signs/investigations
• Resident in
area with uncontrolled community spread
Does the patient require hospitalisation?
• Severe
dyspnoea at rest, or
sustained SaO2 <92% on room air despite self-proning (see
below)
• Signs of other
end-organ compromise (including renal impairment, acute cognitive
changes, falls)
• Social issues, lack of home support or access to help
• Inability to access satisfactory follow-up
under Official Information Act
Released
Northland District Health Board
Document Owner: Physician General Medicine
Version: 2.0
Authorisers: Incident Management Team Planning
Last Updated: Sep 2021
Identifier: CD04050
Next Review: Sep 2023
If printed, this protocol is valid only for the day of printing or for the duration of a specific patient’s admission:
19 October 2021
Adult Admission and Care Pathway during COVID-19 | Page 1 of 6
What is the severity of disease?
Severity
Symptoms
Admission and Medication
Notes and Cares
Mild
No evidence of lower □ No medical indication for
□ Give (
self-)proning
airway disease; may
admission
instructions
have troubling benign
symptoms, e.g., sore
□
Paracetamol PO PRN
□ Self-monitoring with
throat, anosmia, fever,
pulse oxymetry and
□ Consider
inhaled budesonide
cough
virtual support if
(800 mcg BD for 14 days)*
possible
Moderate
Evidence of lower
□ Consider medical admission
□ Goal-directed
fluids.
Act
respiratory tract
Aim for neutral (or
- Red ward
infection and dyspnoea □
Enoxaparin 40 mg SC OD
negative) fluid balance.
or other compromise.
□
Paracetamol PO PRN
No oxygen
□ Give (
self-)proning
requirement.
□ Consider
inhaled budesonide instructions or careful
(800 mcg BD for 14 days)*
proning cares
□ Continuous
Moderately
Evidence of lower
□ Medical admission
monitoring if non-
severe
respiratory infection
□
Enoxaparin 40 mg SC OD
rebreathing mask or
and
new oxygen
- Red ward
HFNC used
requirement: SaO2
Information
□
Paracetamol PO PRN
<92% or RR >22/min
□ Consider
□
Dexamethasone (see below)
social/spiritual/cultura
□ No
antibiotics unless bacterial
l input
infection likely (see below)
□ Consider
remdesivir (see
Official
below)
Severe
Evidence of
severe
□ ICU/ILC admission
respiratory
- ICU (or ILC)
compromise requiring □
Enoxaparin 40 mg SC BD
under
invasive ventilation or
□
Paracetamol PRN
high-flow nasal
cannulae, or
severe
□
Dexamethasone (see below)
inflammatory
response
□ No
requiring
antibiotics unless bacterial
infection likely (see below)
invasive monitoring
□ Consider
tocilizumab (see
below)
Released
*If >65 or >50 years with co morbidities
Northland District Health Board
Document Owner: Physician General Medicine
Version: 2.0
Authorisers: Incident Management Team Planning
Last Updated: Sep 2021
Identifier: CD04050
Next Review: Sep 2023
If printed, this protocol is valid only for the day of printing or for the duration of a specific patient’s admission: 19 October 2021
Adult Admission and Care Pathway during COVID-19 | Page 2 of 6
Investigations on admission
Blood tests:
□ standard: FBC, U&E, LFT, CRP
□ in (moderately) severe disease add:
• Markers for disease severity: ferritin, coagulation studies incl. D-dimer, LDH
o Note: Do not use D-dimer to rule in/out PE
• Gas exchange: ABG
• Procalcitonin and TnT
□ Two sets of blood cultures if febrile OR sepsis OR CRP >100 mg/dL
Act
□ bHCG in women of childbearing age
□ Portable CXR
□ ECG (document QTc on admission)
□ Nasopharyngeal COVID-19 PCR-swab if not done prior
Monday-Wednesday-Friday investigations (until stable)
□ FBC, U&E, LFT, CRP
Information
□ ABG, procalcitonin and other markers as clinical y indicated
Nasopharyngeal swabs
□ Retain in isolation i
f clinical suspicion remains high despite a negative first COVID-19
PCR, and repeat swab the fol owing day. If stil negative, discuss with microbiology/infectious
diseases SMO.
Official
Imaging
□
Portable CXR on admission
- Repeated imaging is not indicated unless significant deterioration.
under
- Further imaging (CXR or CTPA) may be helpful if clinical suspicion of bacterial
superinfection or pulmonary embolism.
Released
Northland District Health Board
Document Owner: Physician General Medicine
Version: 2.0
Authorisers: Incident Management Team Planning
Last Updated: Sep 2021
Identifier: CD04050
Next Review: Sep 2023
If printed, this protocol is valid only for the day of printing or for the duration of a specific patient’s admission: 19 October 2021
Adult Admission and Care Pathway during COVID-19 | Page 3 of 6
Antibiotics
-
Do not routinely prescribe antibiotics as secondary bacterial infection is rare (around 5%
on admission, around 20% on day 7 of admission).
- If
high clinical suspicion for bacterial superinfection AND serum procalcitonin >0.25 ng/ml
OR CRP >50 mg/dL, OR new-onset sepsis (defined as
qSOFA score 2 or higher):
□ consider
ceftriaxone 2g IV OD
for maximum 5 days, adding
azithromycin 500mg
PO/NG OD if in ICU, maximum 3 days.
□ only consider replacing ceftriaxone with
piperacillin-tazobactam 4.5g IV q8h if high
suspicion of hospital-acquired pneumonia AND hospital admission for at least 72h.
Act
-
Note: fever is not an indication to start or switch antibiotics.
□ RR 22 or above
□ Altered mental
□ SBP <100mmHg
qSOFA score: _____
status
Oxygen
□ Aim to
establish SaO2 at 92%, and maintain at
>90% or higher, unless known CO2
retainer (aim 86%)
- Use
nasal cannulae in the first instance (1-3l/min), graduating to
Hudson mask (max 4-
Information
8L/min) or
non-rebreather masks (6-15L/min) if required.
- If unable to maintain SaO2 >92% or discomfort with dry oxygen; consider
High Flow Nasal
Oxygen (HFNO “Airvo”) or
CPAP with supplemental oxygen. Discuss with Respiratory or
ICU SMO at this point.
-
Non-Invasive Ventilation (NIV) remains appropriate in hypercapnic patients e.g., those
Official
relating to COPD exacerbation, heart failure, and OSA/OHS.
Fluids
□ IV bolus as required. Aim for neutral (or negative) fluid balance.
under
Released
Northland District Health Board
Document
Owner: Physician General Medicine
Version: 2.0
Authorisers: Incident Management Team Planning
Last Updated: Sep 2021
Identifier: CD04050
Next Review: Sep 2023
If printed, this protocol is valid only for the day of printing or for the duration of a specific patient’s admission: 19 October 2021
Adult Admission and Care Pathway during COVID-19 | Page 4 of 6
Antipyretics □ Paracetamol PRN, preferably PO
□ Consider NSAIDs if stil distressed with fever and no contraindications
Anticoagulation
□ Commence
enoxaparin 40mg SC OD (if eGFR > 15ml/min) for all patients admitted to
hospital in the absence of contraindications. Give BD prophylaxis in ICU/ILC patients.
- In women >20 weeks pregnant, consider prophylactic
heparin after discussing with
obstetrician.
□ Consider
omeprazole 40mg PO/IV OD for critically unwell patients or those with high risk of
Act
GI bleed, careful y balancing with the increased risk of a bacterial respiratory superinfection.
Steroids
□ Commence
dexamethasone 6mg IV/PO OD for ten days in al admitted patients if al of the
following apply:
□
oxygen requirement
□ disease duration
five days or longer
□ Assess response after two to five days, reconsidering concurrent pathology if no
improvement.
Information
□ Steroids can be discontinued on discharge.
- In
pregnant patients, reassess after four days and discuss with an obstetrician whether a
switch to
prednisone thereafter is appropriate.
- For
patients taking long-term steroids who do not require dexamethasone, consider
stress-dose prednisone (double the normal dose) for two days, then return to normal dose if
Official
clinically improving.
□ Do not use oral steroids to treat mild COVID-19. Consider inhaled budesonide in patients
over 50 or with comorbidities.
under
Remdesivir
- The benefits and risks of this drug are not yet fully clarified by empirical evidence. It is not
yet registered in New Zealand, requiring section 29 approval and postage from Auckland.
□ In consultation with the admitting consultant, consider
remdesivir (200mg IV, then 100mg IV
for four days) for adults with moderate-severe disease who satisfy
all of the fol owing criteria:
□ new SaO2 <92% on air
□ do
not require ventilation
Released
□
either ALT <3x ULN with bilirubin <2x ULN
and/or ALT <5x ULN
□ do
not have multiorgan failure - eGFR <30, cardiomyopathy, coagulopathy,
significant impairment to ADLs, or significant life-limiting intercurrent il ness
No
rthland D
istrict
Health Board
Document Owner: Phy
sician G
eneral Medicine
Ver
sion: 2
.0
Authorisers: Incident Management Team Planning
Last U
pdated: Sep 2021
Identifier: CD04050
Next Review: Sep 2023
If printed, this protocol is valid only for the day of printing or for the duration of a specific patient’s admission: 19 October 2021
Adult Admission and Care Pathway during COVID-19 | Page 5 of 6
Tocilizumab
□ Consider
single dose 8 mg/kg (max. 800 mg) IV in deteriorating ward or ICU patients, in
discussion with respiratory/microbiology/infectious diseases SMO. Do not start if neutropenic,
thrombocytopenic, hepatitis, or at high risk of TB. Funding for this indication currently requires
a rapid NPPA (ward pharmacist can help with this).
Regular Medications □
Continue ACE inhibitors or ARBs except in case of AKI.
□
Continue statins, metformin, and aspirin if normally taking these.
□
Discuss immunosuppressants and immunomodulators with prescribing doctor at the earliest
opportunity.
Act
Inhaled Medications
□ Al inhaled medications should be given
via MDI and nebulizer use kept to a minimum to
reduce aerosolisation risks.
□ Continue patients’ normal inhaled medications as possible.
Self-proning
□ Advise patients on
self-proning, a non-pharmacological therapy to delay to time to
respiratory deterioration. See https://onlinelibrary.wiley.com/doi/10.1111/acem.14067 for
instructions.
Information
Ceiling of care □ Discuss and
clearly document ceiling of care with patient and their whānau
at admission,
including candidacy for CPR, ICU, and intubation, while careful y considering resource
allocation, likelihood of satisfactory clinical outcome, and cultural appropriateness.
□ Seek
palliative advice early in case of uncontrolled symptoms in a deteriorating patient.
Official
Skin cares □ Regular
pressure point checks and consider pressure mattresses.
Social/psychological cares □ Enable
virtual communication with family and friends.
under
□ Attend to needs for
in-person social interaction as much as possible within distancing
constraints.
□ Facilitate liaison with
spiritual/cultural leaders if appropriate.
□ Al Māori patients must be offered virtual consultation with
cultural support worker.
Released
Northland District Health Board
Document Owner: Physician General Medicine
Version: 2.0
Authorisers: Incident Management Team Planning
Last Updated: Sep 2021
Identifier: CD04050
Next Review: Sep 2023
If printed, this protocol is valid only for the day of printing or for the duration of a specific patient’s admission: 19 October 2021
Adult Admission and Care Pathway during COVID-19 | Page 6 of 6
Document Outline
