This guidance details processes, pathways & equipment for all staff at RHC Glasgow who may be involved in the management of potential cases of COVID-19.
This guidance refers only to children who have been referred or attend RHC, separate guidance for community cases or other medical units in GGC is available here: https://www.nhsggc.org.uk/your-health/infection-prevention-and-control/covid-19/
All patients meeting the RHC criteria for possible COVID-19 infection must be assessed in a Specialist Assessment and Treatment Area (SATA).
IMPORTANT NOTE: Do not print and keep this document as information will be frequently updated in line with national infection control measures.
Date of release: 19.06.2020
Patient has to have acute onset of any of the following symptoms:
If the patient has none of these symptoms BUT the accompanying caregiver does (and no other alternative caregiver can be found to accompany the child) then the child must be assessed in a SATA.
Only 1 care giver should accompany the patient. Wherever possible this person should be free of any respiratory symptoms
ALL patients attending with ED who are not pre-alerted as a ‘standby’ will be met outside the main RHC ED entrance by a ‘Greeter’. The only exception to this will be where patients attending an outpatient clinic are felt to require assessment in ED/CDU. In this circumstance, the clinician seeing the child in outpatients should liaise with the ED Co-ordinator (phone 84585). The ED co-ordinator and referring clinician will agree whether the child requires triage/observations within the outpatient clinic, and where within the pathway the child should enter, dependent on symptoms and clinical condition. If there is no clinician available in the OPD, an ED nurse will attend OPD to assess the child.
Schiehallion patients asked to attend ED Pathway B following telephone triage should follow the above process for vulnerable patients, but have dedicated preferred rooms assigned in CDU (see Schiehallion Pathway below).
Role of the ED ‘Greeter’
The greeter will be in PPE appropriate for contact and droplet precautions (see below under PPE requirements). The caregiver accompanying the patient will be asked if they have any respiratory symptoms as per above RHCG case definition. Based on the answer to this question the patient will be directed to either Pathway A or B (SATA pathway).
Only one care giver is permitted to accompany patient. Wherever possible this caregiver should be free of any respiratory symptoms.
ED reception staff
ED reception staff will be located at the entrance of each of the 2 access points to the department:
The patient will be booked on to the TrakCare system as per standard processes.
ED reception staff will be advised to maintain a 2 metre distance from any patient meeting RHCG ED criteria for assessment in SATA. These staff will be advised to wear a fluid resistant surgical mask (Fluid-resistant (Type IIR) surgical face mask) and perform appropriate hand hygiene measures following each patient interaction – decontamination of their hands with alcohol based hand rub.
When behind the new screen at the front desk reception staff do not need any PPE.
ED Triage Nurse
ED triage will occur in one of the 3 clinical areas where patients will be assessed:
ALL patients directed to Pathway B will be triaged by an ED nurse in PPE appropriate for contact and droplet precautions (see below under PPE requirements).
Patients triaged in Pathway B will be directed for clinical review in one of the three designated SATAs:
Patients and caregivers being directed to CDU should be given a surgical face mask to wear, decontaminate their hands with alcohol based hand rub and should be transferred as per the ‘ Transfer of suspected COVID-19 patients within RHCG’ guidance below.
The negative pressure room in CDU (Rm 18) should be prioritised for patients who may require aerosol generating procedures (for definition see PPE requirements for AGP below).
Please professionally and politely challenge staff who are not following infection control guidance and expect to be challenged in return. A summary of all PPE requirements is available here (pdf version 5 updated 19/06/20)
General PPE requirements for ED Minors (Open cohort area RED pathway)
A fluid resistant surgical face mask (FRSM) should be worn by staff at all times (sessional use) while in the open cohort area of the RED pathway (ED minors). Gloves and apron must be changed between each patient. FRSM should be changed if they become damp or soiled. FRSM should stay fully on the face for the duration of sessional use i.e. DO NOT push up/down face, or hang round neck. Staff should use alcohol hand rub or wash their hands any time they touch/re-adjust the mask and after removal.
If there are shielded patients in the red pathway, a fresh FRSM should be used before entering the cubicle. This mask does not need to be changed on exit.
Parents should be offered a FRSM when entering the ward or when leaving the child’s room to exit the ward.
Following a risk assessment, due to the reduction in community transmission, FRSMs are no longer required to be worn at all times in ward 2C or CDU. In all areas other than ED resus, PICU and ED minors, use of a FRSM should be considered when in direct patient contact (within 2m) according to guidance for below.
General PPE requirements for GREEN Pathway and Shielded Patients
For resuscitation or aerosol generating procedures (AGP) follow the PPE guideline for AGP below.
For all other direct patient contact, the minimum PPE within the Green Pathway (no respiratory symptoms or fever) is now gloves and an apron for ALL patients. Examination of the throat and throat swabs should be avoided in green pathway patients where possible. Where these are absolutely necessary, they should be undertaken using droplet precaution PPE (gloves, apron, FSRM, visor) as used for red pathway patients. Use of FRSM and eye protection should also be considered if there is a splash risk from other body fluids.
A surgical face mask should also be worn for any “shielded” patients. Shielded patients include; solid organ transplant recipients; most children with cancer; BMT/stem cell transplant in last 6 months; severe respiratory conditions including all cystic fibrosis and severe asthma; and children with immune deficiency or immunosuppressing therapies.
Ward 4B(QEUH) has specific BMT protective PPE and isolation guidelines which should be followed.
If patients on the Green Pathway develop new fever or respiratory symptoms, follow PPE and requirements for possible/confirmed COVID-19 patients until a clinical risk assessment can be made.
Possible/Confirmed COVID-19 patients – General Care
For resuscitation or aerosol generating procedures follow the PPE guidelines for AGP below. For all other close contact (within 2 metres) with possible/confirmed COVID-19 patients the following PPE should be worn:
PPE requirements for aerosol generating procedures (AGPs):
AGP PPE should be worn when carrying out an AGP on ANY paediatric patient even if not thought to be a possible or confirmed case.
Aerosol Generating procedures include:
NB Nebulised medication in general is not an AGP (for example salbutamol or other nebulisers for wheeze). Use of nebulisers to promote induction of sputum by physiotherapy is an AGP.
Certain other procedures or equipment may generate an aerosol from material other than patient secretions but are not considered to represent a significant infectious risk. Procedures in this category include administration of pressurised humidified oxygen and entonox.
The following is the specific PPE for AGPs:
PPE for AGP
PPE requirements in high-risk acute areas
High risk acute areas where AGP are frequently undertaken include ED resuscitation area and PICU bed bays and cubicles. In these clinical areas, AGP PPE must be worn at all times. Use of gowns, masks and visors can be sessional (see above). Gloves and aprons must be changed and hand hygiene undertaken between each patient.
Parents visiting in PICU should wear a gown and FRSM when in the patient’s cubicle or bed bay and if possible be 2m away from a child during AGPs.
PPE requirements in neonatal units/maternity wards
There are specific risk-based PPE requirements in neonatal units and in maternity wards. Please see separate neonatal/maternity guidelines for details.
Significantly unwell possible COVID-19 patients do NOT go directly to CDU and are managed in the Resuscitation room.
Attempts should be made to rationalise the number of medical and nursing staff in direct contact with patients being managed as possible COVID-19.
For most standby calls this would represent 2 doctors and 1 nurse. See Trauma call section below for specific staffing preparations.
Resus spaces 1,3 and 4 are operational for use for any patients regardless of possible or confirmed COVID -19 status. Resus space 1 should be used preferentially to receive stand by patients including those in cardiac arrest.
Resus space 2 is the designated resus kit storage area where all required airway, IV and other specialist equipment is clearly labelled and readily available for use. Emergency grab bags with age appropriate basic airway and IV equipment are available in the first cupboard in spaces 1 and 4 and are clearly labelled.
PPE requirements for resus:
All staff MUST wear PPE appropriate for AGPs (FFP3/eye protection – visor /gloves/theatre gown) for the initial reception and assessment of all patients in resus .
All staff in resus but not in direct patient contact (runner / buddy /scribe / drug nurses) will wear a purple apron over the above PPE appropriate for AGPs. This is to denote that they have not had direct patient contact (within 2 meters). If they require to assist with direct patient care ten this apron should be removed.
The PPE donning station is the resus corridor
All necessary PPE is located here.
Open first responder PPE is available for two people as you enter resus space 1 and 4 to allow rapid donning if a patient arrives with little or no pre alert.
When the patient is placed in a Resus space the curtain should be drawn and doors opposite the relevant space closed with signage on the outer aspect stating: DO NOT ENTER. All further entry and exit should be from doors at the opposite end of Resus where possible.
Curtains dividing the resus spaces should be drawn at ALL times
Store room door adjacent to Resus space 4 should be locked at all times
Full AGP PPE is mandatory for all staff in resus in the following circumstances:
Any accompanying parents or carers with a child in any space in resus should be provided with a FRSM and surgical gown when either of the above points apply.
PPE can be down-graded (see under PPE Requirements) following a risk assessment of the RHCG ED SATA criteria by the treating clinician only when points 1 & 2 above do not apply.
Doffing of PPE should be as per guidance below (Donning and Doffing PPE process). All PPE except for FFP3 masks can be removed in resus, masks should be taken off in the room across the corridor from the resus entrance at space 4. Mask disposal and hand washing facilities are available here.
Cardiac arrest patients should be met from the ambulance by an ED nurse and doctor in full PPE. CPR should continue until the patient is out of the ambulance and then respiratory support paused while the patient is transferred along the resus corridor until they are in a resus space. Chest compressions should be continued. Paramedics should accompany the patient and ED staff to allow a handover to the resus team leader in the receiving space.
Unheralded patients requiring immediate resuscitation
The following SOP should be followed for unheralded presentations to resus-
1) Child is taken to space 1 resus from triage/ waiting room (spaces 3 or 4 should be utilised only if space 1 is in use)
2) Emergency buzzer is pulled
3) First responder PPE is donned in resus by the most senior doctor and 1 nurse who begin initial assessment/ resuscitation. (Nursing and medical first responders should be allocated daily at the start of each shift change.)
4) All other responders quickly don full PPE in resus corridor before entering resus at which time, if needed, the first responders should then be relieved to allow them to don adequate PPE.
5) 2222 call is put out and ED consultant called in if not resident by the ED co-ordinator if appropriate.
6) Grab bags accessed for correct age/weight of child and placed at the bedside on a silver tray by the resus runner if not already done.
7) Greeter role established in resus corridor to ensure 2222 responders don appropriate PPE and access resus correctly for the duration of the resuscitation.
8) Role allocation undertaken as soon as is practical and should include a minimum of:
Team Leader (may also need to assume a ‘hands on’ role until adequate staffing arrives)
Primary Survey/ Procedure Doctor (roles can be separated once adequate staff)
Additional roles can be established at the discretion of the team leader once additional help arrives.
9) At the end of the resuscitation staff should doff PPE in resus as per departmental guidance. Assistance can be provided by the clean resus runner (purple apron).
10) Documentation should be completed out with the resus room.
11) Consider a ‘hot’ debrief for the team ensuring social distancing is maintained.
12) Grab bags and first responder PPE should be restocked when the resus space is cleaned and form part of the daily resus checks.
Trauma calls should activated as per usual protocols.
If there is a history of:
The following team members should be in PPE for the arrival of the patient.
Otherwise trauma calls should be met by 2 ED doctors and 1 ED nurse in full AGP PPE. The rest of the trauma team should still attend the ED and will be directed to a nearby holding area to await further instruction.
Equipment set up for standby calls:
All T-piece circuits should be set up with appropriate filter (see pic below)
The fully stocked IV and airway trolleys are in resus space two. One airway trolley has been assigned as the COVID airway trolley and contains the specific additional equipment requested by the anaesthetic team; this is clearly labelled in resus space 2.
To avoid contamination of these trolleys they should remain in resus space 2 with specific equipment placed on the silver trolleys until required. When needed the trolleys can then be wheeled in by the ‘buddy’.
Prior to patient arrival Airway ‘Kit dump template’ should be used on a silver trolley with age / size appropriate airway equipment set out.
IV access equipment appropriate for age and size of patient should be set up on a silver trolley until required.
If any further equipment is required from either the airway or IV trolleys then the “buddy system” will be used where staff in direct contact with patient will remain within the isolation area and equipment will be passed to them from staff out with the isolation area whilst maintaining appropriate infection control measures for the clinical situation.
There is yellow and black taping on the floor to mark out each resus space.
For ED SATA cubicle (previous RHC ED minors area):
Enter cubicle from sink side (clean side) of room in PPE which has been donned prior to entering cubicle.
Complete history from more than 2 metres from patient.
Cross room to complete relevant examination.
On completing examination leave all ?contaminated equipment on desk.
Retract curtain sufficiently to facilitate exit from cubicle
Apply alcohol based hand rub to gloves.
Take Alcohol/Clorox wipes from clean side of room work surface
Clean the ?contaminated equipment (ie stethoscope) with wipe and place on clean work surface. The stethoscope should remain in the cubicle.
Clean re-usable goggles (if used) with wipe and place up onto forehead.
Complete doffing of apron and gloves as per PHE instructions above.
Keep fluid resistant surgical mask (FRSM) in situ as you are departing the cubicle into an area identified as a cohorted possible COVID area.
Video: Doffing PPE for droplet / contact spread in RHC SATA (previously known as ED Minors)
PPE appropriate for AGPs (FFP3/ eye protection – visor /gloves /theatre gown) should be donned prior to entering Resus space (Resus corridor donning station).
Prior to exit from isolation resus space the curtain should be retracted sufficiently to allow safe exit.
Apply alcohol based hand rub to gloves.
Complete standard doffing procedure for AGP as indicated in PHE doffing instructions within the Resus cubicle where patient being cared for with the exception of the FFP3 respiratory mask. This mask should remain in situ until HCW has exited resus room. The doffing area for removal of FFP3 respiratory masks is in room 14 off the resus corridor (identified as ‘Doffing of FFP3 Mask area’). FFP3 mask should be removed and disposed into clinical waste here. Hand washing should be completed her after mask removal.
Video: Doffing of PPE for AGP precautions in RHC Resuscitation area
Any patient meeting the case definition for RHCG ED requiring patients to have primary assessment in a SATA AND requiring admission to hospital (this is not the same as a patient being transferred to CDU for further observation). There should be no routine testing of admitted children who do not have COVID-19 symptoms.
URGENT sample request should be made for the following cases where COVID-19 is suspected:
COVID-19 & Blood samples:
For COVID-19 virus swab - take a combined throat/nasal swab using droplet PPE including eye protection. A combined swab is simply the use of a single swab into the throat first followed by the nose and then introduced into viral transport medium (pre-labelled with TrakCare request label for patient), agitated, removed and discarded. The transport medium is then closed and dropped into a clear sample bag.
For ventilated or tracheostomy patients a BAL or tracheal aspirate should be obtained if AGP precautions are already in place.
COVID testing is specified on TrakCare – request ‘Covid-19 (SARS-CoV-2)’
The order item can be found by entering Covid, SARS, 2019, Novel or Corona in the Item box and selecting the spyglass search icon.
POC blood gas analyser testing:
The buddy system should be utilised as per for taking lab samples.
During working hours (Monday – Fri 09:00-22:00), samples can be sent via the routine hospital transport. The sample is placed in the clear sample bags then into the Teal Category B UN3373 virology bags (bags in each SATA area in ED /CDU – to replace stock contact virology labs).
Non-urgent samples should be batched and request for collection by porters on 82097 each day at 10am (Mon-Fri).
Urgent sample transport, out with routine hospital transport (ie. taxi), should still be packed in the Category B UN3373 boxes.
During working hours (Monday – Fri 09:00-22:00) email email@example.com with subject reading ‘URGENT COVID-19 test request RHC’.
The following information should be included in email:
Out of hours (including weekends) – then contact duty Virologist directly to discuss.
Before any transfer of patients from one clinical area to another there must be contact with the receiving area to ensure the patient destination area is ready for the patient arrival.
PPVL cubicles throughout the 2nd and 3rd floor may be allocated to Green pathway Schiehallion and other vulnerable patients (see pathway below).
The negative pressure cubicle on ward 2C (room 6) will be prioritised for the following:
The decision to move any patient out of 2C6 to accommodate a higher priority patient should be consultant led.
ED triage or ED SATA (minors) to CDU:
Patient treatment can be commenced in ED minors while awaiting transfer to CDU
Patients and caregivers being directed to CDU should be given a surgical face mask to wear, decontaminate their hands with alcohol based hand rub and not touch any surfaces during their transit between the two clinical areas.
A staff member wearing a FRSM will escort the group between the two areas.
Transfer from ED / CDU to 2C / PICU:
Patients and caregivers being transferred should be given a surgical face mask to wear, decontaminate their hands with alcohol based hand rub - (where appropriate), and not touch any surfaces during their transit between the two clinical areas.
Patients should ALL be transferred on a bed. A member of staff should be in PPE specific to the risk posed by the patient (see above definitions) and be the only person in direct patient contact (in certain circumstances this may require more than 1 member of staff).
Another member of staff will remain 2 metres from direct patient contact and be responsible to transporting any non-contaminated equipment / notes. This member of staff will not have direct patient contact therefore only requires to wear a face mask as they will be transferring the patient into a COVID cohort area.
A porter will be requested to ensure all doors and elevators are clear for use without delays in transit between clinical areas.
The patient lifts (next to CDU) will be used to transfer these patients.
Transfer from ED / CDU to theatres or CT:
The same process for ‘Transfer from ED / CDU to 2C / PICU’ should be followed with the exception that the Core G lift (Helipad lift) should be used.
Before transfer from either ED/CDU to wards, staff must re-confirm whether the patient OR accompanying parent/adult has respiratory symptoms or fever. Patients should then be transferred and procedures followed as per the above Red and Green in-patient pathways.
Theatre guidelines should be followed for patients who require theatre-based procedures.
Radiology guidelines should be followed for patients who require imaging.
Repeat testing and consideration of de-escalation of COVID-19 negative patients
Once the COVID-19 test result is known, the decision to de-escalate PPE or isolation precautions should be consultant led and should be clearly communicated to nursing staff. Decisions to de-escalate should be informed by the initial clinical likelihood of COVID-19 including contact history or of an alternative diagnosis and consideration of patient co-morbidities.
If there is a high clinical suspicion of COVID-19 , a second COVID-19 test may be indicated. A lower respiratory tract sample (eg BAL or tracheal aspirate) should be sent if possible. If clinical suspicion remains high, diagnosis can be assumed if there are typical radiographic appearances. Complex cases can be discussed with the Paediatric ID consultant on call.
De-escalation of confirmed COVID-19 positive patients
Infection prevention and control measures for hospitalised COVID-19 patients can be stopped 14 days after onset of symptoms (or first positive test if onset time unclear) if there is:
A test at 14 days after symptoms should be considered in the following circumstances:
De-escalation of isolation/PPE precautions in previously positive patients should be a consultant led decision. It is important to establish that there is no other reason for continued isolation, such as symptomatic or exposed parent/carer, or other condition requiring source isolation such as diarrhoea before all precautions are discontinued. Decisions to de-escalate should be communicated clearly to nursing staff. Complex cases can be discussed with the Paediatric ID consultant on call.
Covid-19 positive dialysis/oncology patients who have been discharged, but who need to attend as day cases for treatment should be re-tested on their first re-attendance after 14 or more days have passed since the onset of symptoms , then on subsequent visits (no more frequently than every 3-4 days) until a negative swab is obtained.
COVID-19 testing of Green Pathway patients
COVID 19 testing should be considered in any child who deteriorates or develops new respiratory symptoms, fever or loss of smell during their admission, irrespective of their initial reason for admission. Inpatients who develop new symptoms should be managed in a cubicle and COVID-19 PPE used until their test result is known. Transfer of patients to the Red Pathway area should be a consultant led decision, based on individual patient risk assessment. This assessment should include consideration of the likelihood of COVID-19 as the cause of symptoms, and the patient’s care needs. For example, the risk of transfer of post-operative or tracheostomy patients should be carefully considered. Complex cases can be discussed with the paediatric ID consultant on call.
Ideally, symptomatic parents should remain at home and an asymptomatic parent should attend. If this is not possible, parents with respiratory symptoms should be asked to wear a surgical face mask when entering or leaving the hospital. Staff should wear a FRSM when entering the child’s room.
Parents with COVID-19 symptoms should not be tested by RHC staff unless there are exceptional circumstances, discussed with ID team or infection control. Parents who are unwell enough to require clinical assessment should follow the standard COVID-19 referral pathways unless considered sufficiently unwell to require urgent review.
Asymptomatic children of symptomatic parents should not be routinely tested for COVID-19 unless they develop symptoms.
Schiehallion patients presenting with respiratory symptoms/fever should be admitted where possible to the rooms allocated in the above pathway. The decision to transfer COVID-negative patients to 6A should be consultant led, following a similar risk assessment to that described for other patients above.
Clinical staff phoning families should use the following information:
Non clinical staff can phone patients using this information:
ED Majors Consultant
Pamela Joannidis (Nurse Consultant and Lead)
Angela Johnson (Senior IPCN)
Sharon Carlton (Adminstrator)
Infectious Diseases Consultant on call:
Resus space 1
Resus space 4
Virology lab (West of Scotland Specialist Virology centre)
SORT ambulance for patient transfer
Last reviewed: 19 June 2020
Next review: 19 June 2021
Author(s): Dr Conor Doherty (Consultant in paediatric infectious diseases and immunology, RHCG), Dr Rosie Hague (Consultant in paediatric infectious diseases and immunology, RHCG), Dr Louisa Pollock (Consultant in paediatric infectious diseases, RHCG), Dr Ciara Carrick (Consultant in paediatric emergency medicine, RHCG), Dr Steven Foster (Consultant in paediatric emergency medicine, RHCG) & Gillian Bowskill (Lead Nurse Infection Prevention & Control South Paediatrics Royal Hospital for Children).