clinical guideline clinical guidelines for patients with … · 2021. 6. 21. · 6 covid - 19 |...

Be Safe -- Be Smart -- Be Kind COVID - 19

CLINICAL GUIDELINE Clinical Guidelines For Patients with

Suspected or Confirmed COVID-19

VERSION 10.1: LAST UPDATED 17/06/2021

This Guideline should be utilised for adult patients (16 years and older) with suspect or confirmed COVID-19 who are

admitted as an inpatient to Western Health.

For obstetric and neonatal guidelines, please see microsite for women and children: https://coronavirus.wh.org.au/clinical-

guidelines/womens-childrens/

Please note this is a rapidly evolving situation and aspects in this guideline may change on a regular basis. Ensure you are using the

current version of the guideline and check with ID if unclear.

Version 10.1 updates and additions:

Medical Therapy

o Updated indications and workflow for procuring remdesivir

o Addition of tocilizumab

Feedback and suggestions to [email protected]

https://coronavirus.wh.org.au/clinical-guidelines/womens-childrens/

https://coronavirus.wh.org.au/clinical-guidelines/womens-childrens/

2 COVID - 19 | Date: 17/06/21, Version: 10.1 Author: See governance box, Approved by: Paul Eleftheriou Western Health

Clinical Guidelines For Patients With Suspected or Confirmed COVID -19

Table of Contents

Ward Management of the Suspected or Proven COVID-19 Patient ..................................................................... 3

Assessment for hospital admission....................................................................................................... 3

Important- please read: EMR templates and data collection for research purposes .............................. 3

Patient Placement and Infection Control ............................................................................................... 4

Overview of patient care ....................................................................................................................... 5

Diagnostic work up ............................................................................................................................... 6

Investigation of proven or suspected cases .......................................................................................... 6

Adult resuscitation plan (ARP) .............................................................................................................. 7

General management ........................................................................................................................... 7

Adjunctive and antiviral drugs ............................................................................................................... 8

Escalation of Care .............................................................................................................................. 13

Hospital discharge .............................................................................................................................. 13

Victorian DHHS COVID-19 Notification Requirements ........................................................................ 13

COVID-19 Testing criteria, Risk Categorisation, De-isolation and Cohorting ...................................... 14

Death of the Suspected or Proven Covid-19 patient ........................................................................... 15

Death of a COVID-19 confirmed case ............................................................................................. 15

Death of a COVID-19 low and high risk suspected case ................................................................. 15

Safe use of respiratory therapy to minimise aerosolisation of COVID-19 ........................................................... 16

Management of Behaviours associated with Dementia and Delirium ................................................................. 17

Management of Behaviours of Concern in patients with acute and chronic Mental Health conditions ................ 18

Background: ....................................................................................................................................... 18

Management: ..................................................................................................................................... 18

Applies to: ....................................................................................................................................... 18

Does not apply to: ........................................................................................................................... 18

Consent and legislative requirements: ............................................................................................ 19

Missing patient and discharge against medical advice: ................................................................... 19

Monitoring ....................................................................................................................................... 20

Palliative Care in the Patient with COVID-19 ..................................................................................................... 21

Management of agitation and restlessness in adult patients with COVID-19 receiving end of life care

(EOLC) outside of ICU. ....................................................................................................................... 21



Management of respiratory distress in adult patients with COVID-19 receiving end of life care (EOLC)

outside of ICU .................................................................................................................................... 22

Management of respiratory tract secretions in adult patients with COVID-19 receiving end of life care

(EOLC) outside of ICU. ....................................................................................................................... 23

Patients with COVID-19 who are on immunosuppressive medication: ............................................................... 24

APPENDIX ........................................................................................................................................................ 27

Appendix 1: Clinical Frailty Scale ....................................................................................................... 28

Appendix 2: Communication in EOLC- sourced from the SICP 24032020 .......................................... 29

Appendix 3: Basic Life Support in ALL ADULT patients during the COVID-19 pandemic .................... 30

Appendix 4: Guidance with discussing goals of care and adult resuscitation plans ............................. 31

Ward Management of the Suspected or Proven COVID-19 Patient

Assessment for hospital admission

Community referrals attending for possible COVID-19 admission are directed to ED Triage

o Patients that look well and meet the DHHS case definition for suspected COVID-19 case are directed to the COVID-

19 Respiratory Assessment Clinic at SH.

Case definition located here: https://www.dhhs.vic.gov.au/health-services-and-general-practitioners-coronavirus-disease-covid-19

Many patients with COVID-19 will not need to be admitted to hospital. Consider admission if any of:

o haemodynamically unstable

o hypoxaemia (SaO2 on room air <92%)

o reduced platelet count <150 (associated with severity)

o acute exacerbation of comorbidities (e.g. heart failure, COPD)

o unsuitable home environment for home-based isolation

Some patients will be suitable for Hospital In the Home, see details in the HITH guideline that can be found under

clinical guidelines> ambulatory & HITH

Important- please read: EMR templates and data collection for research purposes

For COVID-19 Respiratory Assessment Clinic attendances use the EMR Template “COVID-19 Respiratory Clinic Form”

For admissions and daily ward round notes, please use the EMR template found via medical officer tab:

o IMPORTANT: this must be done via the medical officer tab view, so that data can be extracted for research

purposes. This is not possible if you access the template via the documents>add tab.

1. Admission note: See “COVID-19 EMR – Admission” for instructions. This can be found on the microsite under QRG “E”

https://www.dhhs.vic.gov.au/health-services-and-general-practitioners-coronavirus-disease-covid-19


https://coronavirus.wh.org.au/clinical-guidelines/ambulatory-care/

https://coronavirus.wh.org.au/quick-reference-guides/



2. Ward round note: See “COVID-19 EMR - Daily Ward Round” for instructions. This can be found on the microsite under QRG

“E”

Patient Placement and Infection Control

All patients – See QRG on microsite under “P”: PPE-WH COVID-19 PPE Guidelines

Aerosol-generating procedures

o Avoid aerosol-generating procedures and discuss for Senior Clinician approval if required.

o See “Safe use of Respiratory Therapy” and the PPE-WH COVID-19 PPE Guidelines for further details.


https://coronavirus.wh.org.au/ppe/

https://coronavirus.wh.org.au/ppe/



Overview of patient care



Diagnostic work up

Don’t forget differential diagnoses and assess as per usual practice.

Those meeting criteria for suspected COVID-19 case but not for admission will receive swabs via orderset labelled

“COVID-19 Novel Coronavirus Initial Testing” which includes:

o 1 single orange-top dry swab for nasopharyngeal and oropharyngeal samples combined (all cases).

o If able to produce sputum: 1 sputum specimen (yellow pot). Lower respiratory tract specimens have higher

sensitivity than upper respiratory tract.

If patient is for admission, use the EMR orderset labelled “Community Acquired Pneumonia (CAP) including

suspected COVID pneumonia” which includes above and viral NAD/PCR

o Please note, rapid viral PCR is no longer available- need to order standard viral NAD/PCR (multiplex, same swab as

covid, no need for 2nd swab)

An Infectious Alert will be automatically added to the patient’s record on EMR upon ordering COVID-19 testing.

Fever clinic tests, and those tested in ED before being sent home: Dorevitch will call the fever clinic to notify Doctor

of positive results

All other patients: it is the responsibility of the ordering doctor to chase the result and notify both patient and DHHS

Notify DHHS of positive cases only.

Please attempt to send both specimens (swab and sputum) to the lab at the same time to be processed together, to

conserve PCR testing resources (please advise the person collecting the specimens of this, as well as the person taking

the specimens to the lab).

If they are already intubated, order one tracheal aspirate for COVID-19 PCR.

Order one tube of serum for storage (no current clinical utility, may allow for future serological testing).

Please be aware that if multiple specimens are sent to the lab at the same time to be processed together, only one

combined PCR result will be received. Please keep this in mind when awaiting PCR results to de-isolate patients.

All positive COVID-19 PCR results are sent by Dorevitch to VIDRL for secondary testing. However, if the initial Dorevitch

result is positive, and the secondary test is VIDRL is negative, the test should still be considered as positive and the

patient managed as such.

Investigation of proven or suspected cases

Admission Investigations: type “covid” into EMR and choose orderset labelled “Community Acquired Pneumonia (CAP)

including suspected COVID pneumonia”:

This includes CRP, FBC, EUC, ferritin, LFTs, hsTn, CXR and 12-lead ECG. Consider pro-BNP if co-existent heart failure

suspected.

o If requiring oxygen consider VBG +/- ABG

Repeat CRP, FBC, EUC, and LFTs every 1-3 days, depending on severity.

Imaging:

o Repeat mobile CXR only if clinically indicated (e.g. if patient is deteriorating or has been recently intubated).

o No need for routine CT scanning

o See QRG under M- medical imaging https://coronavirus.wh.org.au/quick-reference-guides/




If critically unwell (hypotension, rapidly escalating oxygen requirements: monitor coagulation, hsTn, VBG (+/-ABG) and

ECG and perform bedside echocardiography (if in ICU or otherwise available).

Adult resuscitation plan (ARP)

The admitting team (or ED staff) must complete an ARP on admission in discussion with the patient or, if not possible,

their alternate medical decision maker. Factors to consider in the discussion:

Older patients, with multi-morbidity, clinical frailty, or cognitive impairment, have an especially high mortality rate

with COVID-19 disease. Consider and openly discuss pertinent issues including:

o Long intubation period (average of 11 days) is likely to be longer in the elderly who need to be particularly robust

to tolerate this

o Very high chance of a prolonged and complicated post-acute stay, with poor functional outcomes even if patients

do survive initial period of intubation

Patients to consider for a supportive care pathway

o Clinical Frailty Scale ≥5 (see Appendix for details)

o Known dementia

o See Appendix: Guidance with discussing goals of care and adult resuscitation plans

Communication Toolkit: SICP (Italian Palliative Care Society communication guideline)

General management

Oxygenation – Pneumonitis is common and can progress to ARDS. Aim oxygen saturation >= 92% and only give

supplemental oxygen if required. Use nasal prongs (0.5-4 l/min) and then Hudson mask 6l/min. If Hudson mask 6l/min

not maintaining oxygen saturation >=92% review ARP and if appropriate escalate supplemental oxygen therapy in line

with the safe use of respiratory therapy guideline. Higher flow oxygen therapy may generate aerosols and require

airborne infection control precautions.

Acute ventilatory failure – if baseline or subsequent VBG/ABG indicates acute ventilatory failure (ABG pH<7.35 AND

PaCO2 > 45) refer to the safe use of respiratory therapy guideline.

Fluids management – Excess fluids may worsen outcome. Use restrictive fluid strategies, 1-2 litres of IV fluid per day,

only if no oral intake, acute kidney injury or clinically dehydrated.

Blood pressure – Sepsis may be due to secondary bacterial infection and can progress to septic shock. If otherwise

unexplained hypotension (falling BP or SBP < 100 mmHg) administer up to three 250ml normal saline boluses. If patient

remains hypotensive review ARP, discuss with ICU as appropriate regarding need for inotrope support (may be

possible on ward with monitored bed), and consider indwelling urinary catheter (fluid balance) and lactate level.

Influenza – Order respiratory viral PCR (multiplex PCR) for all patients admitted with suspected COVID (as part of CAP

orderset). Pending influenza flu PCR result: Prescribe oseltamivir 75mg BD (or renally adjusted dose) if symptom onset

<48h ago and not critically ill, or <7 days ago if critically ill. Cease if influenza PCR negative.

DVT prophylaxis - COVID-19 is a hypercoagulable state. Commence chemical DVT prophylaxis in all inpatients unless

platelets <25 × 109/L or active major bleeding*. Standard recommended prophylactic dosing of enoxaparin preferred.

Consider extending post-discharge until mobilising strongly. Consider aspirin if patient has any cardiac risk factors and

is not already taking it.

o * Symptomatic bleeding in a critical area or organ, such as intracranial, intraspinal, intraocular, retroperitoneal,

intra‐articular or pericardial, or intramuscular with compartment syndrome

o Monitor for signs and symptoms of VTE/PE



Avoid use of nebulisers (aerosol generating) - use metered dose inhalers with spacers where possible. If a nebuliser

must be utilised, see safe use of respiratory therapy for guidance.

Home-based NIV (CPAP/BiPAP) – Refer to safe use of respiratory therapy.

For all suspect or confirmed cases, in addition to the usual entry on daily ward rounds complete the EMR template

“COVID-19 Daily Ward Round”

Comorbidities:

o exacerbations of comorbidities due to COVID-19 may occur, including CAD (ACS), HF, COPD/asthma, diabetes,

acute on chronic kidney injury.

manage exacerbations as per existing treatment guidelines, or seek expert opinion from specialty team.

o T2DM - given potential risk withhold metformin and SGLT-2 inhibitors (e.g. empagliflozin, dapagliflozin) and

institute variable dose insulin if needed.

o Continue ACEi, ARB and beta-blockers unless reduction required for AKI or hypotension.

o Delirium and behavioural issues – see Behaviours of concern in patients with COVID and concurrent delirium or

dementia below.

Palliation – where treatment escalation is not in line with the agreed ARP, inappropriate, or futile it is important

symptoms are actively managed. Subcutaneous opioids and benzodiazepines should be used to manage respiratory

distress and, where necessary, cases discussed with or referred to the palliative care service. Where release from

isolation is possible (see below) options for home-based palliative care should be explored.

o Please see section “Palliation and symptom control in patients with COVID-19"

Restlessness and Agitation in EOLC

Respiratory symptoms in EOLC

Managing excess secretions in EOLC

Communication tool for discussion with family in the patient with COVID-19- See Appendix

Adjunctive and antiviral drugs

Antibiotics

Most patients meeting criteria for admission with COVID-19 will also meet criteria for initiation of antibiotics

Indication for antibiotics:

Hypoxaemic (oxygen saturation ≤92% on room air)

Pleural effusion (reportedly uncommon in COVID-19, assess alternative cause)

Purulent (yellow/green) sputum

Choice of antibiotics (see eTG for full details, including management in penicillin hypersensitivity)

<72h from admission: Treat as CAP

Moderate-severity:

Benzylpenicillin 1.2 g IV, 6-hourly PLUS

Doxycycline 100 mg PO, 12-hourly

High-severity:

Ceftriaxone 2 g IV, daily (if septic shock or ICU then 1g 12-hourly) PLUS

Azithromycin 500 mg PO/IV, daily

>72h from admission: Treat as HAP

Low- to moderate-severity:

Ceftriaxone 1 g IV, daily

https://tgldcdp.tg.org.au/etgcomplete



high-severity:

piperacillin + tazobactam 4.5 g IV, 6-hourly

Remdesivir – In the ACTT-1 trial remdesivir reduced time to recovery in hospitalised patients with COVID-19. A mortality

benefit was seen in those requiring supplemental oxygen, but not in those on NIV or mechanical ventilation.

o Remdesivir should be considered for immunocompetent confirmed COVID-19 cases (or close contacts with a

pending result) requiring supplemental oxygen within the first 7 days of illness.

o Remdesivir may be given at any point in the illness in immunocompromised individuals.

o Remdesivir should be continued with the appropriate dose and duration if it was started prior to requiring

ventilation.

o A limited supply of remdesivir has been donated by Gilead to the National Medical Stockpile (NMS) for patients

meeting the eligibility criteria.

Inclusion Criteria:

Informed consent provided by the patient, or patient’s legal representative.

Age ≥ 18 years, or aged ≥ 12 and < 18 years of age weighing ≥ 40 kg

Hospitalised with confirmed SARS-CoV2 or known contact of confirmed case with syndrome consistent

with coronavirus disease (COVID-19)

Oxygen saturation (SpO2) ≤ 92% on room air

Alanine aminotransferase (ALT) < 5 x upper limit of normal (ULN) by local laboratory measure and/or ALT

< 3 x ULN and bilirubin < 2 x ULN

Exclusion Criteria:

Evidence of multiorgan failure including but not limited to coagulopathy (significant

thrombocytopenia), hepatic failure (elevated bilirubin) or renal failure (low urine output or estimated

glomerular filtration rate (eGFR) < 30 mL/min), or significant cardiomyopathy (low cardiac output)

Renal failure (eGFR < 30 mL/min or dialysis or continuous venovenous haemofiltration)

Mechanical ventilation for longer than 48 hours at time of application

Receiving ECMO

Known hypersensitivity to the study drug, the metabolites, or formulation excipient

Special Considerations:

o The clinical benefit of remdesivir is uncertain in the following scenarios. Clinicians should give strong

consideration to whether remdesivir is likely to benefit the patient in the following scenarios:

Mechanical ventilation for less than 48 hours at time of application.

Presence of an intercurrent illness which is likely to lead to the patient’s death within one year

Advanced age with limitations on activities of daily living.

Need for more than a 5 day treatment course

o For applications where these considerations apply the Department may contact the prescribing clinician for

further information.

Dosing and administration:

o 200 mg IV as a single dose on day 1, followed by 100 mg IV once daily

o Duration is limited to 5 days for eligible patients

o The remdesivir use and administration fact sheet can be found here

https://www.nejm.org/doi/full/10.1056/NEJMoa2007764

http://inside.wh.org.au/departmentsandservices/Pharmacy/Documents/Remdesivir%20Quality%20Use%20of%20Medicines%20Factsheet.pdf



The Department of Health Application Process for Remdesivir:

1. The home team must obtain ID approval BEFORE submitting an application.

2. The home team must inform the ward pharmacist of the intention to submit an application.

3. The prescriber must complete all details on the Request to Access Remdesivir from the National Medical Stockpile

form. Endorse the correct hospital site on the form as either “Sunshine Hospital” or “Footscray Hospital”.

4. Monday to Friday 8:15am – 5pm:

a. Contact the Clinical Trials Pharmacist

i. Sunshine: 8345 0818

ii. Footscray: 8345 6344

b. Email the form to both:

i. [email protected] from a Web browser/Outlook (NOT a printer/fax machine).

ii. CC the email: Sunshine Clinical Trials Pharmacist: [email protected]

Footscray Clinical Trials Pharmacist: [email protected]

c. If the patient fulfils the eligibility criteria the applicant will receive an immediate notification.

d. The Pharmacy Department will organise supply of remdesivir.

5. Weekend, Public Holidays or Out of Hours:

a. Contact the On Call Pharmacist through the After-Hours Administrator and notify them of the completed

application form. Request the On Call Pharmacist’s email.

b. Email the form to both:

[email protected] from a Web browser/Outlook (NOT a printer/fax machine).

CC the email: Sunshine Clinical Trials Pharmacist: [email protected]

Footscray Clinical Trials Pharmacist: [email protected]

Western Health On Call Pharmacist

c. If the patient fulfils the eligibility criteria the applicant will receive an immediate notification.

d. Contact the after-hours administrator to obtain the first dose of remdesivir (2 x 100mg vials) from the

Sunshine or Footscray after-hours cupboard.

e. Further doses of remdesivir will be dispensed by the Pharmacy Department the following day during

business hours.

6. If treatment is no longer required/deemed appropriate:

a. Notify the ward pharmacist to return unused stock to the Pharmacy Department

http://inside.wh.org.au/departmentsandservices/Pharmacy/Forms/Request%20to%20Access%20Remdesivir%20from%20National%20Medical%20Stockpile_28-08-2020.pdf

mailto:[email protected]

mailto:[email protected]



Steroids - In the Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial, dexamethasone showed a mortality

benefit in ventilated patients and those requiring oxygen. There was no benefit among those patients who did not require

respiratory support. Benefit was only seen in those commenced on steroids beyond day 7.

o Steroids should be considered for confirmed or suspected COVID-19 cases requiring oxygen/ventilation beyond

day 7 of illness

o Dosing

Dexamethasone 6 mg PO/IV once daily for 10 days

If dexamethasone is required during pregnancy, antenatal corticosteroids should not be administered.

Discuss with an MFM Consultant prior to administration to consider alternative steroid administration.

Potential alternative steroid regimens in pregnancy or breastfeeding women include oral prednisolone

40 mg daily or intravenous hydrocortisone 80 mg twice daily.

Tocilizumab

o The off-label use of tocilizumab in patients hospitalised with COVID-19 who require supplemental oxygen

probably reduces the risk of death. Consider using tocilizumab for the treatment of COVID-19 pneumonia in

adults with oxygen saturation ≤ 92% on room air, particularly where there is evidence of systemic inflammation

(CRP ≥ 75 mg/L).

o In addition, the RECOVERY and REMAP-CAP trials have demonstrated a significant benefit when using

corticosteroids in conjunction with tocilizumab. However, the optimal sequencing of tocilizumab and

corticosteroid use is unclear.

o As tocilizumab inhibits the production of CRP, a reduction in CRP should not be used as a marker of clinical

improvement.

Inclusion criteria:

Age ≥ 18 years old

COVID-19 Confirmed by PCR on NP swab or sputum

Evidence of systemic inflammation: CRP ≥ 75 mg/L

Oxygen saturation (SpO2) ≤ 92% on room air

Exclusion criteria:

Known hypersensitivity to tocilizumab

Evidence of active tuberculosis

Clear evidence of active bacterial, fungal viral or other infection (besides COVID-19)

AST > 5 x upper limit of normal

Neutrophils <0.5x109/L

Platelets <50x109/L

Prescription and Supply:

o For patients who meet the inclusion criteria, tocilizumab must be prescribed on the MAR (or ICCA for ICU

patients) by a consultant (or registrar on the consultant’s advice).

o The prescriber must inform the ward pharmacist about the treatment order.

o Tocilizumab will be prepared and supplied by the Pharmacy Department during business hours (Monday to

Friday 8:15am – 5pm; Weekends 8:30am - 12:30pm).

https://www.nejm.org/doi/full/10.1056/NEJMoa2021436?query=recirc_curatedRelated_article



o For requests made out of hours, tocilizumab will be prepared and supplied by the Pharmacy Department on the

next business day.

o The prepared infusion is stable at room temperature (25◦ Celsius) for 24 hours.

o Do not shake the prepared infusion.

o Refer to the Monoclonal Antibodies section of OP-GC6 Hazardous Medications – Cytotoxics Procedure for

handling requirements.

Dosing and administration

o Tocilizumab should be administered as a single intravenous infusion over 60 minutes (see AIDH), with the

potential for a second dose to be administered 24 hours later if the patient's condition has not improved.

o Tocilizumab may be considered in pregnant and breastfeeding women.

o The suggested dose is dependent on actual body weight (including pregnant or breastfeeding women):

>90 kg: 800 mg

66–90 kg: 600 mg

41–65 kg: 400 mg

≤ 40 kg: 8 mg/kg

Monitoring

o The patient must be observed for possible hypersensitivity reactions during and for at least 30 minutes after

the infusion. Resuscitation facilities must be readily available. Refer to OP-GC6 Adrenaline (Epinephrine) Use

in Adults and Paediatrics.

o Transient headache and skin reactions may occur with intravenous infusion.

Do not use any antivirals (except remdesivir), or immunomodulators (except corticosteroids or tocilizumab), outside the

context of a randomised controlled trial. They may lack efficacy and may even be harmful and/or in short supply.

http://inside.wh.org.au/policies-procedures-forms/_layouts/WordViewer.aspx?id=/policies-procedures-forms/WHDocuments/Hazardous%20Medications%20-%20Cytotoxics.doc&DefaultItemOpen=1

https://aidh.hcn.com.au/browse/t/tocilizumab

http://inside.wh.org.au/policies-procedures-forms/_layouts/WordViewer.aspx?id=/policies-procedures-forms/WHDocuments/Adrenaline%20(Epinephrine)%20Use%20in%20Adults%20and%20Paediatrics.doc&DefaultItemOpen=1

http://inside.wh.org.au/policies-procedures-forms/_layouts/WordViewer.aspx?id=/policies-procedures-forms/WHDocuments/Adrenaline%20(Epinephrine)%20Use%20in%20Adults%20and%20Paediatrics.doc&DefaultItemOpen=1



Escalation of Care

In the event of cardiac or respiratory arrest, the first priority is for health care workers to don PPE.

o Then commence compression only CPR for Basic Life Support- until the code response team arrives and can take

over airway support.

o See Appendix 4: updated BLS guideline.

Do not refer to ICU if the patient has an advanced care directive or ARP precluding ICU care.

Discuss urgently with ICU if patient:

o Requiring >40% FiO2 to maintain O2 saturations 90-92% (or acceptable O2 saturation in those with lower baselines)

– refer to safe use of respiratory therapy .

o Rapidly worsening tachypnoea or hypoxaemia.

o Haemodynamic instability despite appropriate limited fluid replacement.

o In surge situation limited inotrope support may be able to be given on the ward. Discuss with ICU.

Hospital discharge

Once patients have been afebrile for 24hr they can be discharged according to good clinical judgement.

If a confirmed case of COVID-19 or quarantine case is to be discharged prior to de-isolation criteria being met, please

inform DHHS and request that the patient maintain home isolation until informed otherwise by DHHS.

o DHHS will conduct a risk assessment to determine whether there is any risk to the household, and follow up home

isolation and clearance in the community.

o Consideration should be given for the requirement to be PCR negative on at least two consecutive respiratory

specimens collected at least 24 hours apart and at least 7 days after symptom onset, prior to patients going into

an at-risk setting. This can be discussed with the department on a case-by-case basis if required.

o For all suspect or confirmed cases complete the EMR form: “COVID-19 Discharge form (For WHO Reporting)”, in

addition to the standard discharge summary.

If a low risk suspected COVID-19 patient is to be discharged prior to the de-isolation criteria being met, they should

maintain home isolation until their COVID-19 results are available. It is not necessary to inform DHHS unless the result

is positive.

Those who meet criteria for de-isolation and are clinically improving, can return home without isolation, and advised

to phone GP if they begin to deteriorate.

Victorian DHHS COVID-19 Notification Requirements

The treating doctor/medical team of a confirmed COVID-19 case is required to notify DHHS as soon as possible on 1300

651 160 or at https://forms.business.gov.au/smartforms/servlet/SmartForm.html?formCode=novelcoronavirus regarding

the following events:

Initial diagnosis

If the patient is admitted to ICU

When the patient is discharged from hospital

Death of the patient

https://forms.business.gov.au/smartforms/servlet/SmartForm.html?formCode=novelcoronavirus



The treating doctor/medical team of a suspected COVID-19 case is required to notify DHHS as soon as possible on 1300

651 160 regarding the following events:

Death of the patient

o NOTE: please ensure before doing so that the patient is still a true suspected case. If test results have returned

that allow for the patient to be cleared of suspected COVID-19, then no notification is required

COVID-19 Testing criteria, Risk Categorisation, De-isolation and Cohorting

Please refer to the “COVID-19 Testing criteria, Risk Categorisation, De-isolation and Cohorting Guideline” available at https://coronavirus.wh.org.au/clinical-guidelines/covid-19-patient-management/.

Please follow the steps outlined here https://coronavirus.wh.org.au/covid-19-de-isolation-process/ to commence the process of de-isolating suspected or confirmed cases of COVID-19 or quarantine patients.

https://coronavirus.wh.org.au/clinical-guidelines/covid-19-patient-management/

https://coronavirus.wh.org.au/covid-19-de-isolation-process/



Death of the Suspected or Proven Covid-19 patient

Complete verification of death with PPE precautions according to the WH PPE guideline and DHHS guidelines for Health

services and general practitioners: Handling the body of a deceased person with suspected or confirmed COVID.

Please note, although death of someone with confirmed COVID-19 is not reportable to the coroner, standard reporting

rules still apply for coroners cases. Click here for more information.

Death of a COVID-19 confirmed case

Notify DHHS of the death urgently on 1300 651 160

The death does not need to be referred to the coroner unless required for other reasons

Death of a COVID-19 low and high risk suspected case

The following must happen before the death certificate is completed (as it will inform the cause of death) and before

the body is moved from the ward to the morgue

o Check EMR or call the pathology lab to see if pending PCR results are available

If results are back and the patient can be cleared of COVID-19 as per de-isolation procedure, document this in EMR

and remove the associated infectious alerts. Verbally inform the patient’s nurse and the nurse in charge.

o This has important implications for management of the body and funeral arrangements

If results are positive or still pending

o Notify DHHS of the death urgently on 1300 651 160

o The death does not need to be referred to the coroner unless required for other reasons



https://www.coronerscourt.vic.gov.au/report-death-or-fire/healthcare-professionals



Safe use of respiratory therapy to minimise aerosolisation of COVID-19

Please refer to the latest version of “Safe use of respiratory therapy” available at





Management of Behaviours associated with Dementia and Delirium

Background:

Patients with COVID-19 who have dementia or delirium may have associated behaviours (such as wandering and

agitation) that make provision of care challenging, and increase the risk of cross-infection to others.

Due to the increased risk to others in the COVID-19 pandemic, usual non-pharmacological management may be insufficient

to maintain isolation, and thus earlier consideration for anti-psychotics and sedatives may be required. These should be

charted as prn’s for patients deemed at high risk for behaviours of concern.

Patients should specifically be checked for hypoxia, dyspnoea and fever as potential behavioural triggers. Other non-

pharmacological management can be reviewed in the Western Health Delirium Guidelines.

COVID-19: Pharmacological management of behaviours of concern associated with delirium and dementia

Note: In line with the Medical Treatment, Decisions and Planning Act 2016, anti-psychotics are considered a significant

treatment and require consent from the medical treatment decision maker. However, treatment can be instituted in the

case of emergency, if the patient is a risk to self or others (such as risking spread of COVID).

FIGURE 1: MANAGEMENT OF BEHAVIOURS OF CONCERN IN PATIENTS WITH SUSPECTED

OR PROVEN COVID-19 WHO ARE AT RISK TO SELVES OR OTHERS



Management of Behaviours of Concern in patients with acute and chronic Mental Health conditions

(including missing patient and discharge against medical advice).

Background:

Patients with COVID-19 may display acute behavioural disturbance which may lead to wandering, agitation and request

for discharge against medical advice. This is particularly a risk in patients with impaired decision-making capacity. Such

behaviours may make provision of care challenging, place the patient at risk of harm, and pose a risk of cross-infection to

staff, other inpatients and the community more generally.

All attempts should be made to manage such behaviours through negotiation, a low stimulus environment and other non-

pharmacologic means and, where necessary, in consultation with the local Consultation

Liaison (CL) Psychiatry service and CL psychiatric nursing staff. Early use of pharmacologic management

may nonetheless be required in patients in which non-pharmacologic management is ineffective. For patients viewed at

high risk (pre-existing demonstrated impulsivity; harm to others; prior missing/discharge against medical advice; acute

psychiatric issues) medications suggested for the management of Mild Agitation and Escalating Behaviour (Table:

Pharmacologic Management of Behaviours of Concern below) should be charted as prn’s to allow early management of

behaviours of concern before escalation.

Patients should specifically be assessed for hypoxia as a potential behavioural trigger and this addressed.

Management:

Applies to:

This guideline is applicable to ward-based inpatients aged 16 – 65 years with suspect/confirmed COVID19 and co-existent:

1. Acute behavioural disturbance and inability to follow medical direction and care;

2. Acute stress reaction on a background of chronic mental illness or personality vulnerability/disorder; or

3. Impaired decision-making capacity including but not restricted to those with intellectual impairment, Acute Brain

Injury (ABI), or neurodevelopmental disorders

who demonstrate an inability to safely maintain required isolation with a risk to themselves, staff or other patients.

Does not apply to:

1. Patients over 65 years of age or where dementia or delirium is suspected where the guide for Management of

Behaviours associated with Dementia and Delirium should be followed.

2. Acute substance withdrawal – refer to Addiction Medicine and Alcohol Withdrawal (Guideline code: OG-GC6, Current

version: May 2017) and Nicotine Replacement Therapy (Guideline code: OG-GC6, Current version: June 2019)

3. Inpatients in the emergency department – for inpatients currently situated in the emergency department refer to

Pharmacological Management of Acute Behavioural Disturbance in the Emergency Department (Guideline code:

DG-GC6) and utilise in consultation with Emergency Medicine consultants/senior registrars



Consent and legislative requirements:

Treatment for behaviours of concern may be instituted without consent in the case of an emergency where the patient

is a risk to themselves or others (such as risking spread of COVID). This must be clearly documented in the EMR. Ongoing

treatment for management of behaviours of concern requires reference to the Medical Treatment, Decisions and

Planning Act 2016 and Medical Duty of Care.

Wherever possible consent for treatment should be obtained from the patient, or where this is not possible, their

alternate medical decision maker in line with the Medical Treatment, Decisions and Planning Act 2016.

Where an acute mental illness is reasonably suspected to be contributing to behaviours of concern, or the person needs

immediate treatment to prevent deterioration, in their mental and physical health, or serious harm to the person or

another person, and IF there is no less restrictive means then the person meets the criterion for the requirements of

the Mental Health Act 2014, and an Assessment Order should be completed. This requires a medical practitioner or

mental health practitioner to complete the relevant MHA 2014 form. Mental illness is characterized by a significant

disturbance of thought mood, perception, or memory. If a MHA 2014 assessment order form is completed, the authorized

psychiatrist (refer to your local CL Psychiatry service) needs to be notified as soon as possible.

Missing patient and discharge against medical advice:

Suspected or confirmed COVID19 who are missing or wish to discharge against medical advice pose a potential risk to

themselves and the community. This guidance applies to all inpatients aged 16 years or older.

Ascertain the status of current COVID19 testing results to determine if the patient meets current criteria for

community-based isolation clearance. If in doubt contact the Infection Prevention or ID service.

Make an assessment of capacity of person.

Meets criteria for community-based clearance for COVID19

Discharge against medical advice and has capacity - discharge and document.

Discharge against medical advice and lacks capacity – consider emergency treatment as above. If possible contact

alternate medical decision maker for consent of treatment and consider need for Assessment Order

Missing – ward staff search area and if not found notify NIC (who will then notify security, operations

manager/Divisional Director (out of hours After Hours Administrator (AHA)) and family/power of attorney/guardian)

and where necessary patient welfare check

Does not meet criteria for community-based clearance for COVID19

Discharge against medical advice and has capacity - determine likelihood of adhering to self-isolation and community

follow-up.

o Self-isolation and community follow-up likely – discuss with infection prevention or ID to confirm arrangements.

o Self-isolation and community follow-up unlikely – escalate to CMO (in hours) or AHA and Executive on call (out of

hours)

Discharge against medical advice and lacks capacity – remains in hospital (see Management above)

Missing – as above AND escalate to CMO (in hours) or AHA/Executive on call (out of hours)



Pharmacologic Management of Behaviours of Concern Assessment:

Level of Agitation

Mild Agitation Escalating Behaviour Behavioural Crises Behavioural Emergency

Behaviours displayed

Anxious and agitated

Controlling their behaviour

Escalation of aggressive behaviour, reduced capacity to control emotions and behaviour

Aggressive behavior is an overt, imminent safety threat

Persisting aggressive behaviour despite sedation

Treatments

Aim of intervention

Maintain safe environment

Prevent a crises situation Restore a safe environment Maintain staff and patient safety at all times

Immediate consideration

Low stimulus environment

Low stimulus environment Code grey and MET call Code grey and MET call

Medication Lorazepam 1- 2mg PO (preferred) (maximum 8mg/24 hours) OR Diazepam 10–20 mg PO (greater risk of respiratory depression) Repeat in 2 hours if necessary

Olanzapine 5-10 mg PO (wafer preferred – rapid onset) (maximum 30mg/24 hours) OR 5-10 mg IM if refusing PO (maximum of 20mg/24 hours AND/OR (if not already given) Lorazepam 1-2mg PO (preferred) (maximum 8mg/24 hours) OR Diazepam 10-20 mg PO (greater risk of respiratory depression) Repeat in 2 hours if necessary

Olanzapine 10 mg IM (can repeat after 2 hours) (maximum of 20mg/24 hours) + if not controlled after 30 minutes Haloperidol 5-10mg IM (maximum 20mg/24 hours) WITH Promethazine 25-50mg IM (beware respiratory depression) (maximum 100mg/24 hours) + if not controlled after further 30 minutes Midazolam* 2.5-5mg IM (beware respiratory depression) (maximum 10mg/24 hours) + if not controlled after further 60 minutes Olanzapine 10 mg IM (maximum of 20mg/24 hours) and consider escalation to Behavioural Emergency

See management of Behavioural Crisis No further doses of olanzapine should be given Further doses of IM haloperidol or midazolam* may be possible (noting maximum daily doses and 30-60 minute dosing interval) May require referral to HDU/ICU for parenteral midazolam, ketamine or propofol.

Mechanical restraint#

No No Consider if behaviour is not controlled/escalating

Consider if behaviour not controlled

* IMPORTANT IM olanzapine and midazolam dosing MUST be separated by at least 60 minutes to minimise risk of respiratory depression

# refer Mechanical Restraint, Assessment and Application (Patients) (Procedure code: OP-SE1.3.1, Current version: July 2018)

Monitoring: The use of pharmacotherapy in patients with respiratory symptoms and disease is associated with the risk of respiratory depression. Appropriate

monitoring following administration in ward-based patients is important.

Frequency 15 minute visual observation and hourly vital signs including oxygen saturation

As for mild agitation One on one (mental health special) nursing Maintaining physical distancing Hourly oxygen saturation and other vital signs where possible Behaviour of Concern (BOC) charting

As for Behavioural Crisis



Palliative Care in the Patient with COVID-19

Palliative care is available as a consult service both at Sunshine and Footscray. Due to the risk of transferring patients,

inpatient palliative care will not be available for patients with suspected or proven COVID-19.

Community based palliative care poses high risk to family, and community based staff. This will not be offered to patients.

However, if family feel strongly despite education and counselling around the risks of taking their loved one home, then

contact the palliative care team to explore this option.

Management of agitation and restlessness in adult patients with COVID-19 receiving end of life care (EOLC) outside of

ICU.

These medications will be used in conjunction with opioids for the management of respiratory distress

Exclude pain as a contributor to distress e.g. urinary retention

Terminal restlessness is a distinct entity and should be managed with Non pharmacological and pharmacological

measures

Non-pharmacological

Repositioning may assist comfort

Eliminate nonessential interventions e.g. observations

Turn off artificial lighting

Pharmacological

1st line

Midazolam 2.5mg sub cut every 15mins PRN

If patient requires > 3 prn doses in 24hours:

o Start syringe driver with midazolam 10mg SC over 24 hours

o Give stat dose of midazolam at same time as starting syringe driver

o Titrate up dose of driver as needed. Maximum dose midazolam is 60mg/24hrs.

If no syringe driver is available:

o Midazolam 2mg sub cut strictly every 4 hours and every 15mins PRN

OR Clonazepam 0.5mg sub cut BD and 0.5mg every 15 mins PRN

o DO NOT put clonazepam in a syringe driver

2nd line

Once total dose of midazolam reaches 30mg in 24 hours, consider adding the following:

Haloperidol 0.5mg sub cut every 15mins PRN or 1.5 - 5mg SC over 24 hours

(DO NOT give >5mg in a 24-hour period)

OR

Duration 4 hours 4 hours 4 hours 4 hours



Levomepromazine 6.25 - 12.5mg sub cut every 15mins PRN or 25mg – 50mg SC over 24 hours via syringe driver

(Maximum dose of levomepromazine is 200mg/24 hours)

3rd line

Phenobarbitone – must be discussed with a Palliative Care Consultant

Management of respiratory distress in adult patients with COVID-19 receiving end of life care (EOLC) outside of ICU

Patients fear suffocating to death.

No patient should die in respiratory distress as symptoms can be managed with appropriate drug treatment

MILD/MODERATE RESPIRATORY DISTRESS IN END OF LIFE CARE

All patients should have the following medications charted:

1. Morphine 2.5mg subcut every 15mins PRN

2. Midazolam 2.5mg subcut every 15mins PRN

N.b. DO NOT use morphine if eGFR < 30 → Hydromorphone 0.5mg SC every 15mins PRN

If a patient requires > 3 prn doses in 24 hours:

o Start syringe driver: morphine 15mg (or HM 3mg) and midazolam 10mg SC over 24 hours

o Give stat dose of morphine and midazolam at same time as starting syringe driver

If no syringe driver is available:

o Morphine 2.5mg (or Hydromorphone 0.5mg) subcut strictly every 4 hours

o Midazolam 2mg subcut strictly every 4 hours (0600, 1000, 1400, 1800, 2200, 0200)

o PRN doses to continue and are in addition to 4hourly doses

SIGNIFICANT RESPIRATORY DISTRESS (RR> 30) IN END OF LIFE CARE

Morphine 5mg (or HM 1mg) Subcut and Midazolam 5mg subcut

o Give both drugs every 15mins until symptomatic improvement

Then start syringe driver, dose will depend on dose needed to settle.

o Suggested starting doses:

Morphine 30mg (or HM 5mg) and midazolam 15mg Subcut over 24hours

Morphine 5mg (or HM 1mg) subcut every 15mins PRN

Midazolam 2.5mg subcut every 15mins PRN

If NO syringe driver:

o Morphine 5mg (or HM 1mg) every 4 hours strictly and every 15mins PRN

o Midazolam 2.5mg every 4 hours strictly and every 15mins PRN

Refer to Palliative Care

NOTE

There is no ceiling on the maximum dose of opioid

Maximum total daily dose of midazolam is 60mg. See separate guideline on restlessness.

Patients already on existing opioids will have different requirements – contact Palliative Care



Management of respiratory tract secretions in adult patients with COVID-19 receiving end of life care (EOLC) outside of

ICU.

Retained secretions can be very noisy and distressing for family.

Explain to family that the patient is too weak to clear their own secretions but the patient is not distressed and will

not choke.

Anticholinergics do not clear existing secretions but may stop further production

Anticholinergics can be helpful for upper airway secretions but do not work for secretions due to lower respiratory

tract infection/pneumonia

Nursing Care

The best way to manage secretions is with side to side nursing with the patient in the recovery position

Slight head down tilt may aid in drainage

Do NOT suction

Anticholinergic drugs

Preferred drug

Glycopyrrolate 200mcg subcut every 15mins PRN

Glycopyrrolate 600-1200mcg subcut over 24 hours via syringe driver

Maximum dose is 1200mcg in 24 hours.

This drug is preferred as it does not cross the blood brain barrier and so does not have any CNS effects.

Alternatives

Hyoscine hydrobromide 400mcg subcut every 30 mins PRN

o Syringe driver 1.2 to 2.4mg subcut over 24 hours

Hyoscine butylbromide (Buscopan) 20mg subcut every 30 mins PRN

o Syringe driver 60-120mg Subcut over 24 hours

Atropine 600mcg subcut every 30 mins PRN



Patients with COVID-19 who are on immunosuppressive medication:

Examples include:

Biologic therapy e.g. Abatacept(Orencia), Adalimumab (Humira), Etanercept (Enbrel), infliximab (Remicade), interferons,

rituximab (Rituxan).

Non biologic therapy e.g. methotrexate, long-term steroid, azathioprine, cyclosporine, mycophenolate mofetil

Evidence for this patient population is evolving quickly. We currently recommend to contact the appropriate department

for specific advice on medication management.



Version details

Status: (WIP, Draft, Final) Final- Version 1.0 270320

Author & Department

Adele Mollo (Divisional Director, Maternity)

James Molton (Infectious Disease, COVID-19 response team)

Maria Coperchini (Palliative Care Physician)

Melissa Yang (Respiratory Medicine)

Sandra Crikis (Nephrologist)

Claire Long (Geriatric Medicine)

Adrian Tramontana (Infectious Disease)

Contributors:

Alex Stewart (Infectious Disease)

Anne Marie Southcott (Respiratory Medicine)

Anne Marie Southcott (Respiratory)

Craig French (Intensive Care Medicine)

Craig Nelson (Nephrologist)

Cristina Mateevici (Infectious Disease)

Graeme Maguire (General Medicine)

Harin Karinajeewa (General Medicine)

James Bartlett (Respiratory Medicine)

Marion Kainer (Infectious Disease)

Maureen Canning (Infection Control)

Rick Horton (Anaesthetics)

Sarah Boyd (Infectious Disease)

Lauren Nacey (Geriatric Medicine)

Mizhgan Fatima (Geriatric Medicine)

Authorized by HOU & CSD n/a

Date: n/a

Authorized by CMO Paul Eleftheriou

Date 16/04/2020



APPENDIX

Appendix 1: Clinical Frailty Scale

Appendix 2: Communication in EOLC

Appendix 3: Updates to BLS at WH

Appendix 4: Guidance with discussing goals of care and adult resuscitation plans



Appendix 1: Clinical Frailty Scale

Very Fit: 1

People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the

fittest for their age.

Well: 2

People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active

occasionally, e.g. seasonally. Well older adults share most attributes of the very fit, except for regular, vigorous exercise.

Like them some may complain of memory symptoms, but without objective deficits.

Managing Well: 3

People whose medical problems are well controlled, but are not regularly active beyond routine walking. Those with

treated medical problems who exercise are classed in categories 1 or 2.

Vulnerable: 4

While not dependent on others for daily help, often symptoms limit activities. A common complaint is being "slowed up",

and/or being tired during the day. Many rate their health as no better than "fair". Memory problems, if present, can begin

to impact on function (e.g. having to look up familiar recipes, misplacing documents) but usually do not meet dementia

criteria. Families often note some withdrawal - e.g. needing encouragement to go to social activities.

Mildly Frail: 5

These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy

housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal

preparation and housework. Often, these people have several illnesses, and take several medications. This category

includes people with mild dementia. Their common symptoms include forgetting the details of a recent event, even

though they remember the event itself, asking the same question, or telling the same story several times a day and social

withdrawal.

Moderately Frail: 6

People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need

help with bathing and might need minimal assistance (cuing, standby) with dressing. If a memory problem causes the

dependency often recent memory will be very impaired even though they seemingly can remember their past life events

well.

Severely Frail: 7

Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not

at high risk of dying (within - 6 months).

Very Severely Frail: 8

Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.

Terminally Ill: 9

Approaching the end of life. This category applies to people with a life expectancy of <6 months, who are not otherwise

evidently frail.



Appendix 2: Communication in EOLC- sourced from the SICP 24032020



Appendix 3: Basic Life Support in ALL ADULT patients during the COVID-19 pandemic

LOOK for absence of signs of life, absence of normal breathing

Check COVID status and don PPE as required

Minimise responders to essential staff only

NO airway adjunctsApply O2 @ 10L/min via

Hudson maskDO NOT listen or feel for breathing by placing face close

to patient’s mouthAVOID bag mask ventilation

COMPRESSION ONLY CPR until code response team

arrives

Early rhythm check in AED modeSTOP O2 flow at wall

(do not remove mask)Re-start O2 flow when compressions

start

100-120 compressions/minute

BLS modifications for ALL ADULT patients during the

COVID-19 pandemic

v1.2 9/4/2020



Appendix 4: Guidance with discussing goals of care and adult resuscitation plans