Covid-19 patient pathway 2020 – RHCG clinical policy

Patient has to have acute onset of any of the following symptoms:

• Fever >37.8
• Persistent cough (with or without sputum)
• hoarseness,
• nasal discharge or congestion,
• shortness of breath,
• sore throat,
• wheezing,
• Any history from the child or accompanying parent/carer of loss of taste or smell (anosmia)

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.

See flow chart below for guidance on testing

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 or if they are shielding (clinically extremely vulnerable).  Based on the answer to this question the patient will be directed to either the ED main waiting room (red pathway), CDU waiting room (green pathway) or OPC area 3 (green pathway).

Only one care giver is permitted to accompany patient.  Wherever possible this caregiver should be free of any respiratory/possible covid symptoms.

ED reception staff

ED reception staff will be located at the entrance of each of the 3 access points to the department:

• RHC ED main reception desk ( Red pathway)
• RHC CDU ( Green pathway)
• OPC area 3 (Green pathway)

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.  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 but should socially distance from other members of staff.

ED Triage Nurse

ED triage will occur in one of the 3 clinical areas where patients will be assessed:

• ED triage room (red pathway)
• CDU (Green pathway)
• OPD clinic area 3 (Green pathway).

ALL patients will be triaged by an ED nurse in PPE appropriate for contact and droplet precautions (see below under PPE requirements).

Patients triaged in the red pathway will be directed for clinical review in one of the three designated SATAs:

• CDU – if patient meets “SATA direct to CDU” criteria
• ED SATA cubicle in majors or minors
• Resus – see ‘Management of Resus patients’ guidance below

Patients over 5 and caregivers being directed to CDU should wear a face covering, and decontaminate their hands with alcohol based hand rub. those being directed to CDU 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 refer to appendix 1 for guidance on the use of clinic 3 in outpatients

Direct admissions to CDU

Proposed patients to be directed for assessment in CDU:

This is not an exhaustive list and is to be used as a guide to aid patient flow. At peak times of activity there may be a need to move other patients to CDU for first assessment.

It is vital that the workload is distributed across all clinical areas so there will be a need to alter things according to space and available staff at any time. This should be discussed and agreed by senior medical and nursing staff at the time.

 Clinically Extremely Vulnerable (CEV) patients with no red symptoms will be assessed in the green triage area in CDU and have their first assessment in a CDU cubicle as available. CEV patients with red symptoms will be identified by the greeter using the list overleaf, and the ED coordinator will be informed. These patients should be triaged in a CDU cubicle. A nurse will be identified to perform this triage by the ED coordinator at the earliest opportunity. The ED coordinator will request a set of obs from CDU nursing staff, If there will be an unavoidable delay to triage and they are in a position to do so.

Patients who require resuscitation should be taken directly to the resuscitation room to be seen by ED and or paediatric medical staff depending on the clinical presentation. If in doubt, this is the safest course of action.

Where the triage nurse in unsure of where a patient should go he/she should discuss this with the ED co-ordinator in the first instance. This can then be escalated to the ED and Medical consultants as required.

1. Patients discharged from CDU/inpatient medical ward in previous 72 hours returning with the same complaint.
2. Patients recalled by medical paediatric team (e.g. small babies with positive urine cultures)
3. Babies under 3 months old presenting with fever >38 degrees. Should include babies who have had a documented temperature at home/GP surgery of >38 degrees, even if the temperature is normal at triage.
4. Walking wounded diabetics.
5. Babies less than 3 months old with feeding difficulties/GORD as a presenting complaint, not as part of an acute illness
6. Patients being admitted from clinic when there is no inpatient bed available to go to and they are to be admitted under their specialty team.
7. Group of patients who require to be shielded as per RCPCH guidance (please see attached list)
8. There will be a separate plan for sub-specialty paediatric patients on how they access acute care. Meantime those going directly to CDU should include those sub-specialty patients who fall into category 7 above.

Clinically Extremely Vulnerable (CEV) patient definitions

If no assessment area available in CDU then patient should go to the first available assessment area within ED Majors or minors.

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 6 updated 22/07/20)

General PPE requirements

All staff are required to wear FRSM at all times within clinical areas.  They can be worn on a sessional basis within the clinical area. Face coverings may be worn elsewhere. Social distancing must be maintained whenever possible throughout the hospital irrespective of mask wearing. Staff are not required to wear face coverings (but may choose to) when on their breaks or in offices. 

In addition staff should wear a plastic apron and gloves when carrying out direct patient care with all patients even if not thought to be a possible case. 

Staff should wear eye protection for all red pathway patient contacts and consider eye protection based on a risk assessment of patient and procedure to be undertaken for green pathway patients. Eye protection should be worn when examining the throat,taking throat swabs and if there is a splash risk from other bodily fluids in green pathway patients

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. Hand hygiene is essential after donning mask and apron BEFORE donning gloves and approaching a patient and after removing apron and gloves +/- mask following contact. Do not touch face or mask once gloves are donned. If unavoidable, remove gloves and practice hand hygiene before donning new gloves.

General PPE requirements for Shielded Patients

For resuscitation or aerosol generating procedures (AGP) follow the PPE guideline for AGP below.

A new surgical face mask, apron and gloves should also be worn for any “shielded” patients. Close attention should be paid to hand hygiene before gloves are put on and after they are removed. 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.

Precautions for parents and other visitors

All visitors are now required to wear a face covering anywhere within the hospital including outpatients departments. Children over 5 years who are visiting the hospital e.g. outpatients should also wear a face covering if able. 

Resident parents are not required to wear a face covering when they are in the room with their child however other visitors will be required to do so. Resident parents should still wear a face covering and practice social distancing elsewhere in the hospital. Parents of possible/confirmed COVID cases should be encouraged to stay in the child’s room. If leaving the room to leave the hospital then a fluid resistant face mask should be worn.

Both parents are able to be with their child at the same time. Please refer to local risk assessments on maintaining social distancing within your area.

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:

• Fluid resistant surgical mask (sessional use)
• Disposable apron (single use)
• Gloves (single use)
• Eye/face protection (single or sessional use) – should be worn for all direct patient care

PPE requirements for high risk 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:

• Intubation, extubation and related procedures
• Tracheotomy/tracheostomy procedures
• Manual ventilation
• Open suctioning of the respiratory tract (oral/pharyngeal suctioning is not an AGP)
• Bronchoscopy
• Non-invasive ventilation (NIV) e.g. Bi-level Positive Airway Pressure (BiPAP) and Continuous Positive Airway Pressure ventilation (CPAP)
• High-speed cutting in surgery and post-mortem procedures if this involves the respiratory tract or paranasal sinuses
• High-frequency oscillating ventilation (HFOV)
• High-flow Nasal Oxygen (HFNO)
• Induction of sputum (physiotherapy induced cough)
• Dental procedures using high speed devices such as ultrasonic scalers and high speed drills

• Induction of sputum using nebulised saline (physiotherapy induced cough)

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.

The following is the specific PPE for AGPs:

• Filtering face piece (class 3) (FFP3) respirator (single or sessional use)
• Eye protection (single or sessional use)
• A disposable long sleeved gown (single or sessional use)
• Gloves (single use)
• Plastic apron (Depending on role in resus, see below)

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.

COVID 19 Neonatal Pathway GGC

Significantly unwell 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.

All resus spaces are operational and fully stocked 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.

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. In addition name and role stickers should be clearly visible.

All staff involved in direct patient care should wear a yellow apron over their gown. Staff not in direct patient contact (runner / buddy /scribe /) should wear a green apron over  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 then this apron should be removed and a yellow apron donned. All staff involved in making up drugs should wear a purple apron over PPE appropriate for AGPs  Staff involved in a major haemorrhage response should wear a red apron over PPE appropriate for AGPs.

RHC ED Resus: Apron – colour code

	Patient contact
	No patient contact e.g. runner, scribe
	Drug preparation
	Major haemorrhage e.g blood bank liason, administration of blood products

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 AGP being undertaken in any space within resus.
• For a minimum of 20 minutes (preferably 1 hour) after any AGP in any space within resus.

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. The doffing area for removal of FFP3 respiratory masks is in the resus corridor outside resus space 1.  FFP3 mask should be removed and disposed into clinical waste here.  Hand sanitiser is available and ED staff will direct staff unfamiliar with the area to the nearest hand washing facilities.

Cardiac Arrest

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 (other spaces 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. PPE grab bags are in each space. (Nursing and medical resus 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) Equipment 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)

• Airway Doctor

• Primary Survey/ Procedure Doctor (roles can be separated once adequate staff)

• Monitoring nurse

• Drug nurse

• Scribe

• Runner

• 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 (green 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) Equipment and PPE grab bags should be restocked when the resus space is cleaned and form part of the daily resus checks.

Trauma Calls

Trauma calls should activated as per usual protocols.

If there is a history of:

• Traumatic cardiac arrest
• Major haemorrhage or prehospital code red
• Significant trauma that will likely require early intubation (e.g. reduced GCS/significant head injury)

The following team members should be in PPE for the arrival of the patient.

• Trauma Team Leader
• Airway Doctor (should be the most senior anaesthetist present)
• Airway Assistant
• Monitoring Nurse
• Primary Survey Doctor

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 each resus space.  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 1. A separate “difficult airway trolley” can be found in space 1 and is clearly labelled.

Where possible, all equipment that is likely to be required for the patient should be prepared in advance of their arrival. This includes IV, airway and additional equipment from trolleys and cupboards. In the situation of a “RED” patient undergoing an AGP in resus any exposed equipment must be either cleaned or quarantined. The following plan has been agreed with infection control:

Following an AGP for RED patients:

1. Quarantine IV trolley until 72hrs or negative swab
2. Quarantine Airway trolley until 72hrs or negative swab (only if drawers opened during/after an AGP - otherwise it is a closed box and contents are clean)
3. If cupboard doors are opened during/after an AGP contents to be cleaned or discarded - we are aiming to minimise this by forward planning.

(Quarantined trolleys should be moved to the resus store. Printed cards detailing quarantine times are kept in the Blue resus trolley check folder in majors)

There is yellow and black taping on the floor to mark out each resus space.

Covid-19 Intubation Checklist

Public Health England. Removal of (doffing) personal protective equipment (PPE). (pdf)

For ED SATA cubicle (previous RHC ED minors area):

Patient area is within the taped marking.

Enter cubicle from sink 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 possibly 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 prior to leaving the cubicle. 

Keep fluid resistant surgical mask (FRSM) in situ as you are departing the cubicle into a clinical area.

Video: Doffing PPE for droplet / contact spread in RHC SATA (previously known as ED Minors)

For Resus:

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 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 the resus corridor outside resus space 1.  FFP3 mask should be removed and disposed into clinical waste here.  Hand sanitiser is available and ED staff will direct staff unfamiliar with the area to the nearest hand washing facilities.

Public Health England. Removal of (doffing) personal protective equipment (PPE). (pdf)

Video: Doffing of PPE for AGP precautions in RHC Resuscitation area

Any patient requiring admission to hospital for greater than 6 hours should be tested. If the patient is admitted to a ward upstairs this test will be done in ED, if they are going to CDU aim to do the test in ED.  Any interhospital transfer patients that are going direct to a ward will have their test done on the ward.

If the sample is done in ED this will be marked on a sticker placed at the top right-hand side of the ED card front cover and on the SBAR handover sheet.

All inpatients should be tested again at day 5. All patients undergoing continuing AGPs should be tested twice weekly.

Any patient who is going home but will return the following day for a surgical procedure should have a testin ED prior to discharge.

Ensure PPE includes eye protection when taking a sample, regardless of red or green pathway status.

See SOP below in section 8 for classification of priority

Labs

COVID-19 & Blood samples:

1. Print forms before taking samples and ensure info on form states that samples are ‘possible COVID-19’
2. Pre label bottles/containers
3. Position silver procedure trolley outside cubicle with sample forms and bags on lower shelf
4. Take samples in cubicle
5. ‘Clean’ buddy (outside cubicle) will hold sample bag open to drop samples in
6. Buddy will add request form ensuring request form details match those on the samples
7. Buddy will send samples – bloods sent via pod system.
8. See below for virology swab process

For COVID-19 virus swab -

Taking the sample: 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.

Trakcare ordering:

• Asymptomatic SARS-CoV-2 screening (COVID19 only screening) 
  • Please continue to select the SARS-CoV-2 (COVID19) option in Trakcare  

• Patient exhibiting respiratory symptoms 
  • select from Trakcare, both the SARS-CoV-2 (COVID19) and Respiratory Virus PCR (influenza A/B/RSV) options.  Do not select this option for asymptomatic covid19 screens. 

•  The extended respiratory screen is still available for the below patients: 
  • Please do NOT request this if you only require influenza or RSV testing in the patient. 
  • Hi Flo 
  • Long term ventilated/NIV/tracheostomy patients/chronic lung disease 
  • Immunocompromised 
  • Specific patients with major diagnostic uncertainty where the test will influence management 

If other patients require the extended screen or it is missed then email the lab to ask for the extended screen to be added but please provide clinical details.  The email is now west.ssvc2@nhs.scot

Please note that this would now need to be requested within 48 hours of the sample arriving at the lab or a re-swab for the extended screen will be required. 

Provide the family with the COVID testing information leaflet (pdf)

POC blood gas analyser testing:

The buddy system should be utilised as per for taking lab samples. 

1. The capillary blood gas tube or blood gas syringe should be placed on a tray by the staff member within the isolation area which is being held by the buddy in PPE appropriate for droplet/contact (including eye protection) who is out with the isolation area.
2. The buddy then processes the blood gas sample in the blood gas analyser nominated for COVID-19 risk patients within the specific department they are working (for RHC ED this is the analyser in Resus).
3. Once analysis has been completed the blood gas syringe or capillary tube must be disposed of into a sharps bin.
4. The surface and screen of the blood gas analyser, the handle of the barcode scanner and the immediate worktop area must be decontaminated after each use. 70% alcohol wipes are the preferred agent for cleaning the screen, and should be used for this purpose.
5. After using the blood gas analyser staff should doff their PPE, dispose of this as clinical waste and decontaminate their hands

Risk Assessment Form for Operation of GEM 5000 Blood Gas analyser for suspected (COVID-19) samples (Word doc)

See Covid-19 Swab Transit SOP for transport of samples.

In ED non-urgent samples should be batched in the box in the ED lab (where the pod system is) and request for collection by porters on 82097 each day at 10am every day.

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. 

Room prioritisation

PPVL cubicles throughout the 2^nd and 3^rd 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:

• Airborne infections e.g. Varicella, TB (especially sputum positive/MDR)
• Confirmed COVID-19 patients likely to require aerosol generating procedure e.g. tracheostomy patients, high dependency patients at risk of deterioration
• Suspected COVID-19 patients likely to require aerosol generating procedure
• Immunocompromised confirmed COVID-19 patients
• Other confirmed COVID-19 patients.

The decision to move any patient out of 2C6 to accommodate a higher priority patient should be consultant led.

ED triage or ED to CDU:

Patient treatment can be commenced in ED minors while awaiting transfer to CDU

Patients over 5 and caregivers being directed to CDU should wear a face covering, 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 over 5 and caregivers being transferred should wear a face covering, 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).

Staff can leave resus (including after an AGP)  without changing PPE to transfer to PICU or other areas of the hospital. The transfer will require designated ‘clean’ staff member(s), wearing freshly donned PPE (AGP level if required) to assist with opening doors, carrying notes and operating the lift. After handing the patient over at the bedside, transfer staff must dispose of PPE at their destination as per guidance and perform hand hygiene.

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 potential covid symptoms. 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:

• clinical improvement with at least some respiratory recovery
• absence of fever (>37.8) for 48 hours
• no underlying severe immunosuppression

A test at 14 days after symptoms should be considered in the following circumstances:

• Immunocompromised patients
• Before transfer to protected areas eg 3B, 3C, 4B, 6A
• Before accommodation in 4 bed areas.
• Patients in PICU
• Patients being discharged to a household where an extremely vulnerable person is being shielded

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.

Transfer and testing of Green Pathway patients between wards and use of 4 bed bay

 ‘Green’ pathway patients can be moved between wards and where possible should be placed in cubicles. Standard droplet protection PPE should be employed in their ongoing care. 

4 bed bays should be used in the following situations:

1. on ward 3B/3A/3C Ortho – for elective surgery green pathway patients who have tested negative for COVID within the previous day when cubicle capacity is exceeded. 
2. in the event of all cubicles in the hospital being occupied 4 bed bays can be used for green pathway patients (no fever, no respiratory symptoms and no recent contact with COVID) even if they do not have a recent COVID swab result (within 72 hrs). The 4 bed bay on 3C should be used last where possible.
3. in a small number of situations where a specific cohort of patients require specialist nursing care then a risk assessment can be carried out with infection control to determine whether that group of patients can be managed on the 4 Bed Bay of the specialist ward rather than being dispersed across cubicles in the hospital

’Green’ pathway patients moved to 4 bed bays should not be deemed ‘extremely clinically vulnerable’ (i.e. shielding) and should preferentially be more containable within their designated bedspace area e.g. under 1 or adolescent. Only 1 parent/carer should attend with the infant/adolescent and are required to stay within the footprint of the individual bedspace and should wear a FRSM outwith this area. When patients require to use shared toilet/shower facilities then they must wear FRSM and alert nursing staff to ensure facilities are decontaminated between each patient use. No patients requiring AGPs should be placed in these areas unless part of a previously agreed cohorting policy

Symptomatic parents

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.

Emergency patients presenting via ED with ‘green pathway’ symptoms are admitted to CDU/3rd floor or 1E (awaiting outcome of covid test).
Admit to PPVL cubicle if neutropenic/immunocompromised.

Clinical staff phoning families should use the following information:

Standard message for communicating test results – medical (pdf)

Non clinical staff can phone patients using this information:

Standard message for communicating test results – non-clinical (pdf)

Information regarding isolation exemption is below

Policy framework on return to work for Health and Social Care staff following close contact with a postive Covid-19 Case (includes checklist as an appendix). August 2021.

The checklist needs to be completed and verified by the Head of Human Resources for the area and emailed to james.farrelly@ggc.scot.nhs.uk 

SOP - Clinic 3 opening, Emergency Department RHCG (v4 October 2020)