covid-19 testing criteria, risk categorisation, de

COVID-19 Testing Criteria, Risk Categorisation, De-isolation and Bed Allocation Guideline

Version 1.8 Last updated: 15/10/2021

CONTENTS

Section 1. COVID-19 Testing Criteria

Testing criteria ......................................................................................................................................... 2

Section 2. Risk Categorisation and De-isolation

Release from isolation of a suspected case ............................................................................................ 3

Section 3. COVID-19 Patient Bed Allocation

OVERVIEW ............................................................................................................................................. 4

DECISION TOOLS

Patient Bed Allocation: Standard Cohorting Matrix – All Patients ............................................................ 5

Negative Pressure Room Priority Allocation …………………………………………………………………...6

Patient Cohorting: Definitions .................................................................................................................. 7

Patient Cohorting: COVID-19 Patient Decision Matrix ............................................................................. 8

WORKFLOW

Patient Bed Allocation: Decision and Escalation Workflow...................................................................... 9

… COVID-19 Testing Criteria, Risk Categorisation, De-isolation and Cohorting Guideline

COVID - 19 | Date: 15/10/2021, Version: 1.8, Author: James Molton, Approved by: Paul Eleftheriou

Western Health

Western Health

Section 1. COVID-19 Testing Criteria

Overview This QRG should be utilised to risk assess all patients require admission to Western Health that present via one of its Emergency Departments or are a request for direct admission or transfer in from another hospital. Elective surgical and medical admissions are managed via the elective bookings process.

There may be exceptions to this QRG (e.g. Stroke, STEMI, Neonates, Maternity) which will require assessment and decision on a case-by-case basis, noting that appropriate clinical care of the patient is priority. Unless specified, people without symptoms should not be tested.

People who meet the following clinical criteria should be tested and treated as suspected for COVID-19:

Clinical criteria for all patients

Fever OR chills in the absence of an alternative diagnosis that explains the clinical presentation.

(Consideration should be given for the potential of co-infection e.g. concurrent infection with SARS-CoV-2 and influenza)

OR

Acute respiratory infection (e.g. cough, sore throat, shortness of breath, runny nose or anosmia)

OR

Acute loss of sense of taste or smell (anosmia)

Other Potential COVID – 19 risk factors:

Older patients with new onset atypical COVID-19 symptoms and no alternative explanation such as, functional decline, delirium,

exacerbation of underlying chronic condition, falls, loss of appetite, malaise, nausea, diarrhoea and myalgia may be considered for

COVID-19 testing.

In addition, testing is recommended for people with new onset of other clinical symptoms consistent with COVID-19

(includes headache, myalgia, stuffy nose, nausea, vomiting, diarrhoea)

AND

people who are most at risk of severe illness

higher prevalence groups and settings

settings with a high risk of transmission.

Epidemiological criteria for all patients:

As per the current screening tool: o Medical History and Infectious Screening Tool o Outpatient and Home Visit Screening Tool o COVID-19 EMR Initial Screening Tool

Special circumstances requiring testing

• As part of outbreak management as directed by the DoH/WPHU/ Infection prevention (please refer to http://inside.wh.org.au/departmentsandservices/CorporateGovernance/Pages/COVID.aspx for a list of active outbreaks)

• As directed at times of enhanced surveillance (e.g. Pre-operative patients, RACF residents)

• Close contacts, persons exposed to Tier 1 or Tier 2 exposure sites, prior to the end of quarantine as directed by

the department (typically on day 13).

• Persons who have left hotel quarantine (day 17 and day 21)

Requirements following testing

• People tested for COVID-19 should be treated as suspected for COVID-19 until test results are confirmed unless the test is an administrative test.

• Appropriate isolation in the relevant Transmission Based Precautions based on current COVID risk level as per the PPE Guidelines and PPE Tiers Poster.

• People awaiting COVID-19 test results who return home should self-isolate until test results are available.

Patients who need to be quarantined regardless of indication for testing

Those who meet the high risk criteria defined on page 3 should be quarantined for 14 days from last exposure (unless otherwise

specified) when receiving care at Western Health.

Refer to PPE Guidelines for detailed PPE recommendations for suspected, confirmed or quarantine cases. Notify the department of confirmed cases as soon as practicable by calling 1300 651 160 24 hours per day. Continue to flag HCWs for internal monitoring

https://coronavirus.wh.org.au/wp-content/uploads/2021/08/AD-24-1-COVID-19-Medical-History-and-Infectious-Screening-Tool.pdf

https://coronavirus.wh.org.au/wp-content/uploads/2021/06/AD24.4-COVID-19-Outpatient-and-Home-Visit-Screening-Tool-15.06.2021.pdf

https://coronavirus.wh.org.au/wp-content/uploads/2020/05/COVID-19-EMR-Initial-Screening-Tool-V4.0-30.07.2020.pdf

http://inside.wh.org.au/departmentsandservices/CorporateGovernance/Pages/COVID.aspx


COVID - 19 | Date: 15/10/2021, Version: 1.8, Author: James Molton, Approved by: Paul Eleftheriou

Western Health

Western Health

Section 2. Risk Categorisation and De-isolation

* High risk epidemiology Within the last 28 days:

• Overseas travel

Within the last 14 days:

• Returned from a public health designated at-risk interstate area (e.g., Extreme risk, red, or orange zone) • Exposure to a Tier 1 exposure site • Contact with a confirmed case of COVID-19 • Secondary Close Contacts (quarantine until Primary Close Contact, PCC, has a negative COVID-19 test result

after complete separation from the patient. The PCC must remain separated from the patient.) • Patients who worked in settings at risk of higher COVID transmissions in the last 14 days (including COVID

streaming area, high risk work premises, quarantine facility, other port of entries) • Unknown epidemiological risk during COVID Active/Peak time (quarantine until epidemiology risk is clarified)

**Request a RAPID COVID PCR SWAB (or the appropriate Testing Priority as directed by Infectious Disease) if this patient: 1. Is in a shared room OR 2. Staff have been exposed without appropriate tier PPE # if the patient is unable to produce sputum, then the COVID-19 PCR on sputum does not need to be ordered but the team needs to clearly document this (separate to COVID-19 Risk Assessment and Order)


Western Health COVID - 19 | Date: 15/10/2021, Version: 1.8, Author: James Molton, Approved by: Paul Eleftheriou

Section 3. COVID-19 Patient Bed Allocation

Decision Tool and Documentation

The following section provides a guidance, communication and documentation of workflows for the bed allocation of patients at

Western Health during the COVID-19 pandemic.

OVERVIEW

Given the increased demand for single rooms during the COVID-19 pandemic, the following guidance from the Infectious Diseases

Team must be considered when implementing transmission based precautions, including allocating patient rooms.

Please note, when there are activated SCOVID/COVID wards at WH, all SCOVID/COVID patients are to be allocated to these

wards with the exception of those requiring ICU, telemetry monitoring, COVID Positive patients requiring telemetry will be allocated

to CCU and managed in a single room with a HEPA filter.

Transfer to a single room on a COVID ward whilst awaiting PCR result is allowed for patients with positive rapid antigen test and

high risk epidemiology and/ or typical clinical presentation. These patients should be admitted to a SCOVID ward if there are no

beds available on a COVID ward and transfer to an alternative streaming hospital is delayed. All other patients with suspected

COVID awaiting PCR results should be transferred to a single room on a SCOVID ward.

All COVID Positive patients clinically stable for a ward admission are to be allocated to designated COVID ward and managed

remotely by their speciality teams, e.g. patients who present with DKA/Acute Stroke.

All NON COVID patients who would normally require negative pressure, i.e. TB/measles/chickenpox/disseminated shingles are to

be discussed with ID in the first instance re suitability to be managed at home, if the patient still requires an inpatient admission

they are to be allocated to NON COVID ward in a single room with a HEPA filter. Intermediate Respiratory Care Unit (IRCU)

patients requiring NIV are allocated to CCU and Acute Stroke patients to 2A.

If there are any circumstances requiring clarification, please contact the Infectious Diseases consultant on-call.

Ward/Department Areas (in consultation with Infection Prevention and Infectious Diseases) must consider the following matrix when

making decisions regarding patient bed allocation. All efforts must be made to adhere to the guidance and matrix in this document.

If these recommendations are unable to be implemented at a ward/department level, escalation to the Access Manager or After Hours

Administrator must occur, as per the Decision and Escalation Workflow.



Standard Cohorting Matrix – All Patients

Negative Pressure Ventilation Isolation Room (may add McMonty hood* +/- portable HEPA filter)

Priority 1 COVID-19 Confirmed undergoing AGPs/ AGBs

Priority 2 COVID-19 Suspected (High Risk) undergoing AGPs / AGBs

Priority 3 COVID-19 Quarantine undergoing AGPs/ AGBs

Priority 4 COVID-19 Confirmed – symptom onset < 2 weeks ago

Priority 5 COVID-19 Suspected (High Risk)

Priority 6 COVID-19 Quarantine

Priority 7 Tuberculosis (TB) Suspected / Confirmed1 – aim to discharge once treatment started if possible

Priority 8 COVID-19 Suspected (Low Risk) undergoing AGPs / AGBs (active/ peak phase)

Priority 9 Measles1

Priority 10 Chickenpox / Disseminated Shingles1

Single Rooms with McMonty Hood2 and/or portable HEPA filters

Priority 11 COVID-19 Suspected (High Risk) (if no negative pressure rooms available)

Priority 12 COVID-19 Suspected (Low Risk) undergoing AGPs (COVID alert/ ready phases)

Priority 13 COVID-19 Suspected (Low Risk) (COVID alert/ ready phases)

Priority 14 COVID-19 Confirmed – symptom onset > 2 weeks ago

Priority 15 COVID-19 Suspected (High Risk) – symptom onset > 2 weeks ago

Single Rooms Without Negative Pressure

Priority 16 Diarrhoea

Priority 17 Candida auris confirmed or suspected due to overnight stay in overseas hospital

Priority 18 CPO - confirmed or suspected due to overnight stay in overseas hospital

Cohorting Patients With The Same Organism

Patients can be cohorted if they have been identified as colonised or infected with the single same organism

Influenza and other non COVID-19 respiratory viruses (utilise rapid flu testing)

NOTE: side curtain must be drawn between patients to act as a physical barrier

Multi-drug resistant organisms (excluding CPS and Candida auris) AND

Patient has risk factors e.g. MRSA and exudating wound

COVID Positive may share rooms when all cohorted individuals are within individual McMonty Hoods

SCOVID Step-Down Quarantine (Between 5 - 14 days from last exposure to high risk epidemiology)

Patients Suitable For Standard Shared Rooms

Multi-drug resistant organisms AND

Patient does not have risk factors

CPO – contact due to overnight stay in a Transmission Risk Area, including WH dialysis patients or contact with a known

CPO patient. If patient has diarrhoea, please isolate as above^

AGP/B = Aerosol generating procedure/behaviour • CPO = Carbapenemase Producing Organism

1 Non COVID patients cannot be allocated to negative pressure rooms in a COVID ward. In event that no negative pressure rooms are available for

non COVID patients, call ID for risk assessment; 2 Use of the McMonty Hood must first be discussed with line management, at a minimum the

respective Divisional Director. In addition, the McMonty Hood can be used in areas which have adequate training and capacity.



Negative Pressure Rooms Priority Allocation

Note: “COVID” in this table refers to any suspected, quarantine or confirmed COVID-19 patient. Refer to cohorting matix on previous page to determine risk prioritisation within these groups, and liaise with IP and ID if necessary to ensure that the patients at greatest transmission risk are isolated accordingly If patient movement necessary, notify the treating unit of the effected patients (either consultant on the bed card or HOU). If at all possible avoid moving patients who are planned for imminent discharge. 1 If no negative pressure rooms are available in ICU, then manage in a normal ICU cubicle space with a McMonty Hood. Given the highly transmissible nature of the delta variant the time when the hood is up should be minimised. Liaise with ID to ensure the patient with the greatest clinical and epidemiological risk is managed in the single ICU isolation room. 2 If no negative pressure rooms are available, then review the patients according to the prioritisation matrix and utilise a single room with a Hepafilter +/- McMonty Hood 3 For TB or VZV, in event that no negative pressure rooms are available, call ID for risk assessment. Unless heavily smear positive TB, these can be managed in a single room with an air purifier, as long as universal N95 mask use is in place. Measles must always be managed in negative pressure. In the unlikely event that we have a patient with high suspicion for measles please contact ID for risk assessment, they may require transfer out.

Location Priority Allocation

Footscray

1. ED Clinically appropriate ED COVID

2. ICU Clinically appropriate ICU COVID1

3. 2D Room 15 COVID2




Sunshine


2. ED Paeds Clinically appropriate Paeds ED COVID

3. ED SSU Clinically appropriate ED COVID

4. 1E treatment room TB3, measles, VZV

5. 3F Room 25 COVID2








13. 2G Room 15 COVID2

14. 2G Room 16 COVID2

15. ICU Room 10 Clinically appropriate ICU COVID1

Joan Kirner

1. 6.01 COVID2, TB3, measles, VZV









Williamstown




COVID-19 Cohorting Matrix: Patients

DEFINITIONS

Presumed non-COVID No high risk epidemiology OR Completed any required quarantine period

No COVID symptoms OR Symptomatic with negative PCR tests

Susceptible

Presumed non-Infectious

SCOVID quarantine

(close contact alert in EMR)

No COVID symptoms

Within 14 days of last exposure to high risk epidemiology (defined on page 3)

Negative tests so far

Potentially infectious

SCOVID Step-Down Quarantine

No COVID symptoms

Between 5 - 14 days from last exposure to high risk epidemiology (defined on page 3)

Negative tests so far


Not in quarantine for the following reasons: (i) COVID positive household exposure, (ii). Tier 1

exposure site with known transmission

Suspected COVID-19

(Low Risk)

COVID symptoms

No high risk epidemiology


Suspected COVID-19

(High Risk)

COVID symptoms

High risk epidemiology (defined on page 3)


COVID positive COVID symptoms or no COVID symptoms, with positive PCR

Infectious

Has not yet met criteria for clearance (process on page 3 and on microsite)

COVID recovered De-isolated/cleared from laboratory confirmed COVID-19 within 60 days of onset of symptoms

of COVID-19 or from first positive PCR if illness asymptomatic

Non-infectious immune (for 60 days)

Can discharge to outbreak ward

Can discharge to Residential Aged Care Facility (RACF)



COHORTING MATRIX

Presumed

non-COVID SCOVID

quarantine

SCOVID Step-Down

Quarantine

Suspected COVID

(Low Risk)

Suspected COVID

(High Risk)

COVID positive

COVID recovered

Presumed non-COVID

Can share room

Do not share room

Do not share room

Do not share room

Do not share room

Do not share room

Can share room

SCOVID quarantine

Do not share room

Do not share room

Do not share room

Do not share room

Do not share room

Do not share room

Can share room

SCOVID Step-Down Quarantine

Do not share room

Do not share room

Can share room1

Do not share room

Do not share room

Do not share room

Can share room

Suspected

COVID

(Low Risk)

Do not share room

Do not share room

Do not share

room

Do not share room

Do not share room

Do not share room

Can share room

Suspect

COVID

(High Risk)

Do not share room

Do not share room

Do not share

room Do not share

room Do not share

room Do not share

room Can share

room

COVID positive Do not share room

Do not share room

Do not share room

Do not share room

Do not share room

Can share

room2 Can share

room

COVID recovered Can share room

Can share room

Can share room

Can share room

Can share room

Can share room

Can share room

1Patients that are in quarantine for any other reason other than household exposure or Tier 1 exposure site with known transmission must be placed in a single room for 5 days, be re-tested, and if negative after 5 days be assessed for suitability to be managed as a Step-Down Quarantine on a non-SCOVID ward. If ABP/AGBs – care for in single room with air purifier +/- McMonty Hood. Others (Non ABP/ABGs) – care for two SCOVID Step-Down Quarantine Patients in a two-bed room, cohorted with air purifier

2May share rooms only if all cohorted patients are within individual McMonty Hoods



Patient Cohorting: Decision, Escalation and Documentation

IP = Infection Prevention • AHA = After-Hours Administrator (also referred to as the ‘After-hours co-ordinator’)

EMR = Electronic Medical Record • ID = Infectious diseases

Patient Cohorting During Covid-19 Pandemic

Workflow/ Decision/ Documentation Tool

Patient identified by ward/ department requires transmission

based precautions (Airborne, Droplet, or Contact).

OR

Ward/ department notified by Infection Prevention (IP)

patient requires transmission based precautions.

Infection Prevention enter EMR “Alert”.

AFTER HOURS

(IP on call til 2030)

IN HOURS

(0730 – 1600)

Refer to COVID-19

Cohorting Matrix

Refer to Standard

Cohorting Matrix

Ward/ department to implement precautions as soon

as infectious condition is suspected.

Transmission based precautions implemented

Transmission based precautions UNABLE to be implemented

(i.e. isolation or single room not available in current ward)

IN HOURS

(0730 – 1600)

AFTER HOURS

(IP on call til 2030)

Ward to notify IP of

commencement of

precautions via telephone

8345 6113

Ward to notify IP

of commencement of

precautions via email

InfectionPrevention-WH

@mh.org.au

Unit Manager/ In Charge discuss with Operations Manager

or AHA and document outcome in EMR

IP to document precautions

in EMR under “alerts”

(if not previously entered)

Ward/ department to

document precautions in

EMR under “alerts”

Operations Manager

and Access Manager

to consider options to

accommodate patient on

another ward in consultation

with Infection Prevention

AHA to consider options

to accommodate patient

If transfer not possible,

Access Manager to liaise

with ID on-call regarding

alternative solutions

If transfer not possible,

AHA to liaise with ID

on-call regarding

alternative solutions

Unit Manager/ In Charge documents outcome in EMR

covid-19 testing criteria, risk categorisation, de

Documents