5.8 Placement and management of a service user with respiratory symptoms

5.8.1 Staff cohorting

5.8.2 Transfer of service users with respiratory symptoms/confirmed respiratory pathogen

5.8.3 Day/overnight pass

The COVID-19 patient pathways/categories will now be replaced with a respiratory pathway.  This is determined as a route to which patients symptomatic of respiratory infection should be directed.

The pathway should be further split into appropriate cohorts determined by presenting symptoms and when available, test results to determine the causative pathogen. Rapid Diagnostic Testing (including POCT) or LFD testing may be undertaken in addition to a laboratory based PCR test to support rapid patient placement assessment on the respiratory pathway.

Entrances to facilities must clearly display the requirement for individuals entering the facility to don a face covering and alcohol based hand rub (ABHR) should be provided for use prior to entry for those who are able to do so.

Waiting areas should be segregated with an area set aside for use by service users who present with respiratory symptoms.  Markers to identify segregation should be clear and service users must be advised not to circulate around waiting areas and remain seated until called . 

Cleaning within waiting areas segregated for respiratory patients should be undertaken as laid out in environmental cleaning section.   

Removing toys and books may help prevent children circulating in these areas and instead parents may be advised to bring a toy or book belonging to the child to help keep them occupied during the wait time.  Children should be supported by parents/carers with hand and respiratory hygiene

 

Primary Care and Community Health and Social Care settings 

Patient/Individual Service user placement

Health and care facilities should identify in advance areas/routes/consultation rooms for individuals who require to follow the respiratory pathway and have been assessed as requiring a face to face consultation. It is recognised that some small practices will not have space to facilitate separate waiting areas for individuals on the respiratory pathway.  In this case, a local risk assessment should be undertaken to determine how best to manage these individuals and whether it is suitable for them to attend for face to face consultations.

Where possible, consultation/treatment rooms should be identified for placement of individuals who require placement on the respiratory pathway.  Some health and care facilities may be very small with limited consultation rooms and the ability to dedicate a room to respiratory individuals may not be possible.  If this is the case, consider allocating respiratory cases to the end of a session.  Ensure cleaning of touch surfaces within the consultation room is undertaken thoroughly immediately after the patient/individual leaves the room.  Particular attention should be paid to anything touched by the individual and anything within short range of individuals who are coughing/sneezing.

Individual Service user placement in residential facilities

All admissions from the community to a residential health and care setting should be assessed first by the health and care setting team using the respiratory screening questions outlined above for care homes, prisons and social community and residential care settings.  This applies to all types of residential heath and care setting admissions (including for respite).

For those residents who are displaying respiratory symptoms, the admission should be delayed if possible until they have completed their COVID-19 self-isolation period, OR if COVID-19 negative, until symptoms are resolving provided the admission is non urgent.

If the admission cannot be delayed, a local risk assessment should be conducted with the support of the local HPT  to ensure all necessary mitigations can be accommodated for the individual as well as other residents, some of whom may be more vulnerable to COVID-19, in as safe a manner as possible

See PHS Social Care and Residential Care COVID-19 guidance for further information on admissions to these settings including for respite.

Isolation of a resident within their own room, if required, would ideally include provision of meals to their room, en suite facilities if available and measures to prevent the sharing of communal items and spaces.  In some settings where there are limited vulnerabilities amongst the residential group, full isolation may not be required and the suspected/confirmed COVID-19 case may follow general population advice for self isolation.

Only essential staff wearing appropriate PPE should enter the rooms of residents with respiratory symptoms.  All necessary care should be carried out within the resident’s room.

 

Dental settings - Patient/Service user placement

Where possible, waiting areas should be segregated with an area set aside for use by patients who require placement on the respiratory pathway.  Markers to identify segregation should be clear and patients must be advised not to circulate around waiting areas and remain seated until called.  Cleaning within areas segregated for the respiratory pathway should be undertaken as per guidance laid out in environmental cleaning section.It is recognised that some small practices will not have space to facilitate separate waiting areas for patients on the respiratory pathway.  In this case, a local risk assessment should be undertaken to determine how best to manage these patients  e.g. wait in car until called or schedule for end of a session,  or whether it is suitable for them to attend for face to face consultations.Dental services should identify in advance areas/routes/consultation rooms for patients who require to be placed on the respiratory pathway and who have been assessed as requiring treatment. Ideally, these patients  should be seen at the end of the day/session to reduce any post Aerosol Generating Procedure (AGP) fallow time (if an AGP is performed) impacting on the remaining patient consultation list.Where space allows, a dedicated consultation/treatment rooms should be identified for placement of patients on the respiratory pathway.  Some dental practices may be very small with limited consultation rooms and the ability to dedicate a room to respiratory patients may not be possible.

Secondary care settings

Inpatient placement

At the point of admission to the facility it is unlikely to be known what pathogen is the cause of respiratory symptoms.  Respiratory pathways should be developed in hospitals in a bid to separate patients with  respiratory viral symptoms/confirmed respiratory pathogens from all other patients as far as possible.  Respiratory pathways may be dedicated wards, dedicated bed bays within wards or individual single rooms within wards. Patients with respiratory viruses should be placed in a single side room.  Where single side rooms facilities are lacking, patients with the same confirmed pathogen should be cohorted together. Laboratory based PCR test or optionally Rapid Diagnostic Testing (including POCT) or LFD testing may be used to help support patient placement risk assessments on the respiratory pathway.Where test results are not yet available to determine the viral pathogen causing the respiratory symptoms it may be necessary to cohort suspected respiratory infections together in the same multi bed bay.  NB: This carries the risk of transmitting multiple respiratory viruses to multiple patients and should be avoided wherever possible and only used as a last resort during times of extreme bed pressures.The following principles should be followed when considering cohorting of respiratory cases still awaiting test results;

Patients who should not be placed in multi bed bay cohorts;

Patients on the respiratory pathway who require AGPs should be prioritised for a single side room.  Critical care areas and wards where AGPs are undertaken more routinely should also prioritise single side rooms for those on the respiratory pathway undergoing AGPs.  However, where single side room capacity is lacking and patients with respiratory symptoms on the unit increases, unit-wide application of airborne precautions should be considered where all the patients in the same bed bay are test positive for the same respiratory pathogen.  Where patients are positive for different respiratory pathogens there is a risk of transmission of multiple pathogens to multiple patients.

Paediatric inpatient placement

The principles applied within this guidance aim to mitigate the risk of transmission of all respiratory viruses including RSV.  Many paediatric settings will have well established RSV pathways.  Wherever possible, both COVID-19 and RSV point of care testing should be undertaken as a minimum on admission to help allocate patient placement and ensure that cohorts of RSV are segregated from cohorts of COVID-19.  See also cohorting principles for secondary care inpatients above. Regardless of the infectious pathogen detected, whilst the patient is symptomatic, they should be managed in line with the TBPs within this guidance.  If single room capacity is limited/ being exceeded, prioritise clinically vulnerable children to a single room (See RCPCH guidance on clinically extremely vulnerable children). Children with bronchiolitis requiring a continuous AGP should be prioritised to a single room over those not requiring a continuous AGP if possible.When children require an inpatient stay, local policy should be followed regarding resident carers. Education and written information for resident carers should be made available regarding respiratory virus, local policies, and include use of communal facilities, face coverings (unless exempt), hand hygiene and PPE.

Elective care pre-admission planning

Whilst the COVID-19 pandemic continues, it is important that any risk associated with acquiring COVID-19 pre/intra/post operatively for patients being admitted for elective surgical procedures be reduced as far as possible. Some studies have shown that patients diagnosed with COVID-19 around the time of a surgical procedure have a higher than predicted mortality however, it is not possible to determine precise risk for each individual patient.  In advance of patients attending for elective surgery they should be advised of ways in which they may be able to reduce their post-operative risk. Appendix 19 of the NIPCM provides details of Elective Surgery IPC principles which have been developed in conjunction with the Scottish COVID-19 Clinical cell and aim to reduce COVID-19 transmission risk during the ongoing COVID-19 pandemic. 

 Care Home Settings 

Admissions and resident placement

Full guidance for admission to a care home during the COVID-19 pandemic can be found in PHS COVID-19: Information and Guidance for Care Home Settings (Adults and Older People)

Any resident who answers yes to any of the respiratory screening questions for care home settings should be placed in their own individual room until a full assessment can take place to determine the cause. 

Where single rooms are limited cohorting may be considered.  Cohorting in care homes should be undertaken with care. Residents who are high risk and previously considered to be on the shielding list must not be placed in cohorts and should be prioritised for single occupancy rooms.

Where all single room facilities are occupied and cohorting is unavoidable, then cohorting could be considered in conjunction with the local Health Protection Team (HPT).

5.8.1 Staff cohorting

Efforts should be made as far as reasonably practicable to dedicate assigned teams of staff to care for service users on the respiratory pathways where TBPs are applied.

There should be as much consistency in staff allocation as possible, reducing movement of staff and the crossover between the respiratory pathway and all other service users. 

Rotas should be planned in advance wherever possible, to take account of the respiratory pathway and staff allocation.

For staff groups who need to go between pathways, efforts should be made to see service users on the non-respiratory pathway first.  

Type IIR FRSMs should be changed if wet, damaged, soiled or uncomfortable and must be changed after having provided care for a service user with any other suspected or known infectious pathogens and when leaving respiratory pathway areas.

5.8.2 Transfer of service users with respiratory symptoms/confirmed respiratory pathogen

Wherever possible, service users with respiratory symptoms or a confirmed respiratory pathogen should remain on the respiratory pathway until they meet criteria for discontinuation of precautions. There may however be instances where it is necessary to transfer a service user whilst TBPs are ongoing including;

Communication with the receiving department/NHS Board/Care provider is vital to ensure appropriate IPC measures are continued during and after transfer.  The service user must continue to be managed on the respiratory pathway. Communications must include;

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 service user again on transfer provided symptomatic cases have already had a test taken where the health and care setting has the ability to do so.

5.8.3 Day/Overnight Pass

Service users who have been allowed to leave the healthcare facility for the day or for an overnight stay should be assessed using the respiratory screening questions in advance of their immediate return to the facility and again on arrival at the facility to determine any known or potential exposure whilst out of the healthcare facility on pass and subsequently which pathway they should be placed on.