5.3.1 Critical care units

5.3.2 Split pathways

5.3.3 Staff cohorting

5.3.4 Moving patients between pathways

5.3.5  Patient transfers

5.3.6 Single side room prioritisation

5.3.7 Patients returning from day or overnight pass

5.3.8 Local and National prevalence data

5.3.9 Discontinuing infection control precautions and discharging COVID-19 patients from hospital  

 

Defined pathways must be established to ensure segregation of patients determined by their risk of COVID-19.  Any other known or suspected infections and the need for any Aerosol Generating Procedures (AGPs) must be considered before patient placement within each of the pathways.

Examples of pathways are described here.  Your board may use different names for each of the pathways from those described and you should familiarise yourself with the pathways in your clinical area that align with those described here.

High-risk COVID-19 pathway

Known as the high-risk COVID-19 pathway in the UK IPC remobilisation guidance. It is more commonly known as the red pathway in many boards within Scotland.

1. Confirmed COVID-19 individuals.
2. Symptomatic or suspected COVID-19 individuals (as determined by hospital or community case definition or clinical assessment where there is a suspicion of COVID-19 taking into account atypical and non-specific presentations in older people with frailty those with pre-existing conditions and patients who are immunocompromised).
3. Those who are known to have had contact with a confirmed COVID-19 individual and are still within the 14 day self-isolation period and those who have been tested and results are still awaited.
4. See footnote 1.

Low-risk COVID-19 pathway

Known as the low-risk COVID-19 pathway in the UK IPC remobilisation guidance. Commonly known as the green or super green pathway in many boards within Scotland.

1. Patients who have been triaged and meet the following criteria – asymptomatic and no known contact with a COVID-19 case and meet isolation and testing criteria as per SIGN Guidance for for Reducing the risk of postoperative mortality due to COVID-19 in patients undergoing elective surgery.

   NB: Paediatric services refer to RCPCH guidance for pre-operative admission assessment and testing requirements only.  All other IPC guidance should be followed as per this addendum.

Medium-risk COVID-19 pathway

Known as the medium-risk COVID-19 pathway in the UK IPC remobilisation guidance. Commonly known as the amber pathway in many boards within Scotland.

1. All other patients who have been triaged and who do not meet the criteria for the pathways above and who do not have any symptoms of COVID-19.
2. Asymptomatic individuals who refuse testing or for whom testing cannot be undertaken for any reason.
3. See footnote 1
4. Recovered COVID-19 patients – see footnote 2.

5.3.1 Critical care units

Where facilities allow, boards may allocate separate critical care units to each of the defined pathways.  It is accepted however that critical care units in some NHS boards may have to house patients from each of the three pathways on the one unit. Pathways must be clearly signposted. 

Where all COVID-19 patients requiring Aerosol Generating Procedures (AGPs) on the high and medium risk pathways can be isolated in a single side room the whole unit does not need to be considered a 'High Risk' area and no longer requires unit-wide airborne precautions to be applied. 

However, consideration may need to be given to unit-wide application of airborne precautions where the number of cases of high and medium-risk pathway patients requiring AGPs increases and all such patients cannot be managed in a single side room.

Where AGPs on any medium and high risk patient is required on the main unit, this presents a risk to the surrounding patients and staff and unit-wide airborne precautions would be required.

Bed management needs to be considered preoperatively in the event that a critical care bed is required postoperatively to ensure there is a bed available on the correct pathway.

Further information can be found in Frequently Asked Questions (FAQs) for critical care units.

5.3.2 Split pathways

Where necessary, hospital care areas may designate self-contained areas on the same ward for the treatment and care of patients at high and medium risk or patients at medium and low risk of COVID-19 following a risk assessment undertaken in conjunction with the local IPCT and taking into account considerations such as the type of clinical area, the patient group, the ward environment (including single side room capacity) staffing levels and overall bed capacity and demand.  

Patients on the high and low risk pathways should not be on the same ward unless this is a critical care or regional specialist centre where clinical care cannot be provided anywhere else. This may require discussion with the IPCT. There should be clear physical segregation of pathways with signage in place to support this and staff should be cohorted to the different pathways within the same ward wherever possible. 

5.3.3 Staff cohorting

Efforts should be made as far as reasonably practicable to dedicate assigned teams of staff to care for patients in each of the different pathways.

There should be as much consistency in staff allocation as possible, reducing movement of staff and the crossover between pathways. 

Rotas should be planned in advance wherever possible, to take account of different pathways and staff allocation.

For staff groups who need to go between pathways, efforts should be made to see patients on the low risk pathways first, then the medium risk pathway, then the high risk pathway.  

FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a patient isolated with any other suspected or known infectious pathogens and when leaving high-risk (red) pathway areas

5.3.4 Moving patients between pathways

Any patient on the medium or low pathways who develop symptoms of COVID-19 should be isolated immediately and tested for COVID-19. 

Any patient who goes on to test positive for COVID-19 (whether symptomatic or asymptomatic) should be transferred to the high risk pathway. 

Patients may only move from the medium pathway to the low risk pathway where they have been isolated in a side room for the full 14 days and staff can document that there have been no recorded PPE breaches by staff or visitors who have entered the patient’s room during the 14 day period. 

A high level of suspicion should be applied so as not to expose patients on the low risk pathway to a patient who may potentially be incubating COVID-19.

Patients who have been on the high risk pathway having had confirmed COVID-19, may be moved to the Medium risk pathway after they meet the definition for a ‘recovered patient’ – see footnote 2. 

5.3.5 Patient transfers (please also refer to testing table for testing requirements on transfer)

Non-COVID-19 patient transfers between wards and departments in the same hospitals

• Patient movement between different bed bays and transfers between different wards should be minimised as far as possible.
• Where transfers are necessary, assess the suitability of the transfer from a COVID-19 perspective; good communication between clinical staff in both wards/departments is key. 
• Consider any cognitive impairment and ability to adhere with COVID-19 measures such as physical distancing, hand hygiene, cough etiquette, wearing of facemask. 
• Consider the type of ward to which the patient is being transferred and the vulnerability of the patient cohort. Patients must not transfer from a medium to a low risk pathway unless criteria in 5.3.4 is met.
• In all cases where the transfer occurs either prior to test being carried out, or prior to result becoming available (i.e. the patient’s status is unknown), the patient should be isolated on the receiving ward until the result is known.
• Patients should continue to be tested immediately if clinically indicated. A clinical or a public health professional may consider testing even if the definition of a possible case is not met.

Non-COVID-19 patient transfers to a new hospital (either within the same Board or new Board

• Patient movement between hospitals should be minimised as far as possible.
• Where transfers are necessary, assess the suitability of the transfer from a COVID-19 perspective; good communication between clinical staff in both hospitals is key. 
• Consider any cognitive impairment and ability to adhere with COVID-19 measures such as physical distancing, hand hygiene, cough etiquette, wearing of facemask. 
• Consider the type of ward to which the patient is being transferred and the vulnerability of the patient cohort.  Patients must not transfer from a medium to a low risk pathway unless criteria in 5.3.4 is met.
• Patients who are transferred to a new hospital should follow the medium pathway. 
• If patient is a planned transfer to a clinically vulnerable area, then pre-transfer testing must be built into the pre-transfer testing must be built into the transfer plan and a test undertaken pre-transfer wherever possible.
• In all cases where the transfer occurs either prior to test being carried out, or prior to result becoming available (i.e. the patient’s status is unknown), the patient should be isolated on the receiving ward until the result is known.

NB: A negative test does not mean that the patient is not incubating the virus. Staff should practice vigilance in monitoring for any symptom onset in the patient after transfer and reinforce the importance of COVID-19 measures. This includes physical distancing, hand hygiene, wearing of facemasks and respiratory etiquette.

Transferring suspected/confirmed COVID-19 patients between wards, departments or hospitals during infectious period

Wherever possible, patients who are confirmed or suspected to have COVID-19 should not be moved from the high risk pathway ward until they have completed 14 days of isolation and meet the definition for a recovered patient as described in footnote 1 and criteria contained within the stepdown guidance. There may however be instances where it is necessary to transfer a patient prior to completion of their 14 day isolation period such as;

• The patient no longer requires critical care and the critical care bed is required for another patient
• The patient requires escalation of care to a critical care unit
• The patient requires urgent treatment in a regional specialist unit and postponement would have a detrimental effect on the patient and the care cannot be provided on the ward they currently reside in
• The patient requires an urgent procedure or investigation to be undertaken and postponement would have a detrimental effect on the patient

The local IPCT should be notified of any patient transfer out of a high risk ward where the patient has not yet completed their 14 day isolation period.

Communication with the receiving department/NHS Board is vital to ensure appropriate IPC measures are continued during and after transfer.  The patient must continue to be managed as a high risk pathway patient. Communications must include;

• Patient symptom onset date
• Patient positive test date (if confirmed)
• Date when patient will have completed 14 days in isolation
• Current symptom status and any test results still awaited
• Any patient details which prevent or impact on the necessary transmission based precautions required for COVID-19 i.e. falls risk requiring door to remain open, patient does not adhere to isolation
• Confirm if local IPC team has been informed of transfer

Ensure transferring ambulance or portering staff are advised of the necessary precautions required for PPE and decontamination of transfer equipment.

There is no need to test the patient again on transfer provided symptomatic cases have already had a test taken.

5.3.6 Single side room prioritisation

Any patient who has a co-infection with COVID-19 and any other known or suspected infectious pathogen must not be cohorted with other COVID-19 patients.

5.3.7 Patients returning from day or overnight pass

Patients who have been allowed to leave the healthcare facility for the day or for an overnight stay should be triaged in advance of their immediate return to the facility and again on arrival at the facility to determine which pathway they should be placed on.  Patients should not return to the low risk pathway and as a minimum should be placed on the medium risk pathway.

5.3.8 Local and National prevalence data

Boards must have an escalation action plan in place ready to deploy should prevalence increase triggering a potential cessation of elective services and an increase in high risk pathway cases. 

Local and national prevalence and incidence data as advised by country-specific public health organisations should be used to inform the pandemic plan which should include local systems for monitoring prevalence, triggers and a defined escalation process which takes account of bed capacity, COVID-19 cluster data and risks associated with disruption to elective services.  These considerations may be site-specific or board-wide.  

As case numbers of COVID-19 fluctuate, so too will the volume of patients on each of the pathways.  Where critical care units need to expand, this action plan should include allocated areas for additional ITU beds and sufficient staffing and equipment to support the expansion.

Footnote 1

When deciding patient placement for untriaged individuals where symptoms are unknown – for example, where the patient is unconscious – or individuals who have returned from a country on the quarantine list in the last 14 days, a full clinical and individual assessment of the patient should be carried out prior to placement in a side room on the red or amber pathway.  This assessment should take account of risk to the patient (immunosuppression, frailty) and clinical care needs (treatment required in specialist unit). 

Footnote 2

Recovered patients can generally be defined as those who have completed 14 days isolation whilst an inpatient starting from the date of symptom onset (or from positive test date if asymptomatic) and have had absence of fever for 48 hours (without use of antipyretics).  However, individual risk assessment is required to take account of those who are severely immunocompromised and those at extremely high risk of illness.  These patient groups are at increased risk of prolonged viral shedding.

5.3.9 Discontinuing infection control precautions and discharging COVID-19 patients from hospital  

It is important to note that patients deemed clinically fit for discharge can and should be discharged before resolution of symptoms and should continue to self isolate in the community for a total of 10 days.

Before control measures are stepped down for COVID-19, clinical teams must first consider any ongoing need for transmission based precautions (TBPs) necessary for any other alert organisms, e.g. MRSA carriage or C. difficile infection, or patients with ongoing diarrhoea.

Patient discharge advice leaflets are available 

Key notes below to be referred to in conjunction with tables 1-3;

• Number of isolation days required– All patients who have been in hospital must complete 14 days isolation if remaining in hospital or being discharged to a residential setting or care home.  This is because, in general, those with COVID-19 who are admitted to hospital will have more severe disease than those who remain in the community, especially if they require critical care. In addition, those admitted are more likely to have pre-existing conditions such as severe immunosuppression. In healthcare settings, including residential care facilities, there are considerable numbers of immunocompromised and vulnerable patients who will be at risk of nosocomial infection.

Other household members should complete their 10 day stay at home period (as described in Stay at Home guidance). If this did not start before the patient was admitted to hospital, then it should commence from the day the patient returns to the household, unless the patient has already completed their appropriate period of isolation within hospital.

• COVID-19 clinical requirements for stepdown – This can be done when the patient’s clinical status is appropriate for discharge and ongoing care needs can be met at home or in the facility to which they will be transferred.  Those with COVID-19 additionally require the following; Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics.  A cough or a loss of/ change in normal sense of smell or taste may persist in some individuals, and is not an indication of ongoing infection when other symptoms have resolved. If inpatient is being discharged home, they must be given clear advice directing them what to do if their symptoms worsen.

 

• Testing required for stepdown –some inpatients may require testing and this should be undertaken as per tables 1-3 below unless there are overriding clinical reasons where this is not appropriate.  Where testing is not possible (e.g. patient doesn’t consent or it would cause distress) and if discharged to care facility within the 14-day isolation period then there must first must be a risk assessment of the discharge location and the ability of the individual being discharged to adhere with the required isolation measures in the care facility for the remaining 14 day isolation period. 

For severely immunocompromised individuals or those at extremely high risk of severe illness (as determined by an individual assessment by the clinician), one negative test is acceptable for stepdown. If repeat testing is carried out and patients remains positive after 14 days, further testing should be considered after a further 7 days if the patient remains in hospital, or at intervals of 2 weeks in the community, e.g. if attending hospital for another pressing indication. Further testing should be determined by the senior clinician in conjunction with the local laboratory. For example, if the patient is being transferred to an inpatient environment containing severely immunosuppressed patients (e.g. Bone Marrow Transplant unit) 2 negative tests 24 hours apart may be considered.

Table 1 - Stepdown requirements for hospital inpatients and positive staff remaining in hospital

Inpatient cohorts	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
Inpatients - General	14 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics	Not routinely required
Inpatients - Severely Immunocompromised and individuals at high risk of severe illness	14 days from symptom onset (or first positive test i symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics.	Consider testing for clearance. – 1 negative test would be  acceptable to stepdown.
Staff working in healthcare	10 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery.  Absence of fever (>37.8oC) for 48 hours without use of antipyretics.	Not routinely required. Resume routine testing after 90 days from first positive isolate unless symptoms develop before then in which case test should be repeated.

Table 2 - Stepdown requirements for inpatients being discharged from hospital

Discharge cohort	Number of isolation days required	Does isolation need to be completed in hospital?	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
Patient discharging to a care facility including nursing homes and residential homes	14 days from symptom onset (or first positive test if symptom onset undetermined)	No – patient may be discharged to care home but only after 2 negative tests achieved and must be placed in a single room facility on discharge until 14 day isolation complete.  Provide care as per NIPCM COVID-19 Care Home addendum	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics	2 negative tests required commencing on day 8 & taken 24 hrs apart
Patient discharging to their own home - General	14 days from symptom onset (or first positive test i symptom onset undetermined)	May complete at home and follow Stay at home guidance .  Must be given clear advice for what to do if their symptoms worsen	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics.	Not routinely required
Patient discharging to their own home – someone in household is severely immunocompromised or at risk of severe illness	14 days from symptom onset (or first positive test if symptom onset undetermined)	Wherever possible, patient should be discharged to a different household from anyone immunocompromised or at severe risk of infection.  If not possible – see ‘testing required’	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics.	Testing for clearance is encouraged.

Table 3 - Stepdown requirements for outpatients

Discharge cohort	Number of isolation days required	COVID-19 Clinical requirement for stepdown	Testing required for stepdown
Outpatient	14 days from symptom onset (or first positive test if symptom onset undetermined)	Clinical improvement with at least some respiratory recovery. Absence of fever for 48 hours without use of antipyretics	Virological clearance is encouraged for those severely immunocompromised, at high risk of severe disease and those discharged from critical care. If  required to help inform actions at next OP appointment

Transferring between pathways on stepdown

Regardless of stepdown location remaining in hospital, care facility, home (receiving care at home or attending OPDs) all patients must remain on the high risk pathway until stepdown criteria is met at which point they may be transferred to the medium risk pathway.

Transporting COVID-19 patients home safely when still within the self-isolation period

On discharge, patients should be transferred home by the safest method possible to prevent onward transmission of COVID-19.  Transport home can be arranged via a variety of routes, e.g. if the patient has their own car at the hospital, and is well enough, they may drive home. If they are taking shared transport, the need for further isolation of discharged patients with COVID-19  who have not completed  their self isolation period and who do not have virological evidence of clearance should be communicated with transport staff (e.g. ambulance crews or relatives). Those transporting them should not themselves be at greater risk of severe infection.

The following guidelines apply to all methods of transport:

• the patient should be given clear instructions on what to do when they leave the ward to minimise risk of exposure to staff, patients and visitors on their way to their transport
• the patient should wear surgical face masks for the duration of the journey, and advised that this should be left on for the entire time if tolerated (not pulled up and down)
• the patient should sit in the back of the vehicle with as much distance from the driver as possible (e.g. the back row of a multiple passenger vehicle), and where possible use vehicles that allow for optimal implementation of physical distancing measures such as those that have a partition between the driver and the passenger, or larger vehicles that allow for a greater distance between the driver and the passenger
• vehicle windows should be (at least partially) open to facilitate a continuous flow of air
• vehicles should be cleaned appropriately at the end of the journey using a household detergent active against viruses and bacteria
• ensure the patient has a supply of tissues and a waste bag for disposal for the duration of the journey. The waste bag should then be taken into their house and held for a period of 72 hours before disposal with general household waste