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Referring to Hospital Care
Most confirmed COVID-19 cases will be mild and uncomplicated and can safely be managed via telehealth.
Deteriorating respiratory function is the primary indicator for hospital admission. Do not rely exclusively on pulse oximetry, especially in those with darker skin.
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Triggers for moving patient to hospital or palliative care
Escalate care if the patient develops:
Respiratory compromise, indicated by any of the following: Talking with single words or short sentences Pausing between sentences to catch their breath Respiratory rate greater than 24 breaths per minute Profound exhaustion where pulse oximeter not available to exclude silent hypoxia Haemoptysis Change in oxygen saturation (SaO2): No baseline – SaO2 less than 92% Baseline greater than 94%
Baseline greater than 94%
Any of:
• SaO2 less than 92% • Drop of 3% or more from baseline • Drop of 3% from resting to after exercise • Exercise Note that the safety of formal exertional desaturation tests such as the 1 minute sit-to-stand test have not been evaluated for COVID-19 and should not be performed routinely. Asking the patient to walk around the room may suffice.
• Baseline 94% or less
Baseline 94% or less
Any of:
Features suggesting respiratory compromise are independent of SaO2 levels for seeking admission. SaO2 readings can be falsely high in darker skinned people.
Non-respiratory features: Rapid deterioration of any sign or symptom Falls in a frail person Fever greater than 40°C. New onset of confusion or drowsiness. Unexplained heart rate greater than 100 beats per minute Dehydration – reduced oral intake and minimal urinary output in 12 hours. Other factors indicating need for management in hospital. Chest pain or breathing with concerning features Cold, clammy, mottled, or pale skin
If escalation to hospital care is required call on call medical SMO via switchboard
WBOP 07 579 8044 and submit ereferral as per usual referral but mark as Covid Positive.
Inform the patient that they are to wear a mask when arriving at the hospital.
Transport to hospital
If ambulance transfer is required, then refer though the normal process. It is vital that the dispatch team is aware that the patient is covid positive
Alternate transport – if the patient is clinically stable and able to be transported by a household member then this can occur, only if it is clinically safe to do so
Funding
Information on funding and the claiming process has yet to be released. Please log all activity so you can claim for it when the funding model is issued.
Further Information
• Ministry of Health – Interim Guidance – Clinical Management of COVID-19 in
Hospitalised Adults • Dee Mangin, Hamilton Family Medicine, Canada: • Assessment, Monitoring and Management of COVID • COVID-19 Management of Mild to Moderate COVID in the Community: Learnings from Canada [video 55 minutes 58 seconds, hosted by Canterbury Primary Response Group (CPRG)] • COVID-19 Management of Mild to Moderate COVID in the Community: Learnings from Canada [slides] • General Practice Monitoring and Management of Mild to Moderate COVID19 Illness – Learnings from Canada [summary of unanswered/text Q&A from webinar] • Centre for Evidence-Based Medicine (CEBM) – Are There any Evidence-based
Ways of Assessing Dyspnoea by Telephone or Video? • NZ Telehealth Forum & Resource Centre – Providers
• World Health Organization – Home Care for Patients with COVID-19 Presenting with Mild Symptoms and Management of Their Contacts • BMJ – Remote Management of Covid-19 Using Home Pulse Oximetry and Virtual
Ward Support
Appendix 1: Guide to Models of Care
Level 1 / Low:
Asymptomatic or mild symptoms
Key Components
• Self-monitor symptoms • Telehealth health check monitoring every other day • Referral for other health and social supports
Providers
• General practice, telehealth services, Māori and Pasifika clinical providers, community pharmacy
Workforce (may include)
• Clinical workforce for monitoring and management: Nurses, nurse practitioners, GPs, telehealth services clinical team, clinical support through Māori and Pasifika providers, community pharmacists, physiotherapists, counsellors • Non-clinical workforce for support: HIPS & Health Coaches,
Māori and Pacific providers, translation services, community support workers, kaiāwhina, cultural support workers, service navigators
Decision-making framework
Triage and escalation pathway, testing and results for consults
Training / Guidance
COVID-19 Community HealthPathways, clinical webinars, 0800 COVID-19 Positive Line for cases, Clinician to Clinician helpline
IT
Integration with shared care record between NCTS, public health, primary care (PMS), telehealth and secondary care providers
Equipment
Patient access to cell phone with data or landline (video capability if available), testing kits, PPE
Escalation
Via telehealth or 111 if symptoms deteriorate
Level 2 / Medium:
Moderate symptoms / At risk of complications
Key Components
• Self-monitor symptoms • Telehealth health check monitoring every other day • Referral for other health and social supports
Providers
• Whānau at the center of a general practice virtual multidisciplinary team providing shared care approach for daily virtual/telehealth monitoring and supportive management of
COVID, co-morbidities and chronic care. • Virtual team ‘hub model’ for the coordination of health services to be regionally determined across primary, community and secondary care
Workforce (may include)
• Clinical workforce for monitoring and managing care: GPs and
Urgent Care doctors, nurse practitioners, nurses, clinical support through Māori and Pasifika providers, community pharmacists, secondary care clinicians and nursing, telehealth services clinical team, paramedics, physiotherapists, counsellors • Non-clinical workforce for support: HIPS & Health Coaches,
Māori and Pacific providers, and Pasifika providers, translation services, community support kaiāwhina, cultural support workers, service navigators
Decision-making framework
Triage and escalation pathway, testing and results for contacts
Training / Guidance
COVID-19 Community HealthPathways, clinical webinars, 0800 COVID-19 Positive Line for cases, Clinician to Clinician helpline
IT
Integration with shared care record between NCTS, public health, primary care (PMS), telehealth and secondary care providers
Equipment
Pulse Oximeters, thermometers, cell phone with data or landline (video capability if available), testing kits, PPE, 02 (in exceptional circumstances
Escalation
Via telehealth or 111 if symptoms deteriorate
Appendix 2: Release letter
Toi Te Ora Public Health
PO Box 2120
TAURANGA 3140
Date
To Whom It May Concern
RE: [Name] Reference: Case Clearance
[name] has been identified by Public Health as having had a notifiable infectious disease as listed in the Health Act 1956.
They were placed in isolation to prevent spreading the illness to others.
[name] has completed the required period of isolation and is now released by Public Health from isolation. They are now able to return to their usual activities.
Should you have any questions please feel free to call your GP or local health provider or Toi Te Ora Public Health on 0800 221 555 between 0800 - 1630hrs.
Yours faithfully,
[Name]
On behalf of the Medical Officer of Health
Toi Te Ora Public Health
Appendix 3: Checklist for release from primary care
1. NHI number:
2. Date:
3. Case has completed required isolation period: Y/N
4. Case has been symptom free for 72 hrs: Y/N
5. For cases who were asymptomatic at time of diagnosis, did the case develop any symptoms later? Y/N
If Yes, date of onset of symptoms:
What where the symptoms? List all:
6. Was the case hospitalised? Y/N
If yes, date of hospitalisation:
Name of hospital:
Date of discharge:
Please email to Covid Primary Response Team: cprt@healthbop.org.nz
Appendix 4: Ministry of Health Care Framework for Pregnant Women and people isolating in the community for COVID-19 – depending on gestation and clinical risk stratification
Gestation LMC COVID-19 Designated Clinical Lead (may be GP, Nurse Practitioner or other provider) DHB Obstetric and Maternity Units
<28 weeks Low risk of complications from COVID-19
<28 weeks Mod/High risk of complications from COVID-19
• Referral for consultation to Obstetrics • Clinical responsibility for Maternity care remains with LMC / Midwife • Continue to provide routine care by phone or video where appropriate, keeping in -person physical assessment <15 minutes if possible, whereit cannot be reasonably or safely postponed • In-person acute care continues • Any concerns about worsening COVID 19 condition should be escalated tothe COVID 19 clinical lead and the obstetric team - See Health Pathway COVID- 19 pregnancy pathway • Manage COVID-19 care depending on woman’s clinical situation • Escalate as clinically required- See Health Pathway COVID-19pregnancy pathway • Communicate any changes in management with LMC / Midwife. • Consultation with Obstetric Team is indicated, a case review will take place and a plan of on-going and follow up care will be made and communicated as part of the three-way consultation with the woman and the LMC, an in-person visit may not be required.
• Referral to Obstetrics for clinical transfer of care for duration of illness • Three-way discussion to negotiate LMC involvement in care including responsibility for in- person acute care • Clinical responsibility for care is returned to the LMC whenthe woman/person has recovered from Covid-19 • Routine visiting schedule is provided (if LMC remains involved in care) by phone or video where appropriate, keeping in -person physical assessment <15 minutes if possible, where it cannot be reasonably or safely postponed • Any concerns about worsening COVID 19 condition should be escalated tothe COVID 19 clinical lead and the obstetric team - See Health Pathway COVID-19 pregnancy pathway • Manage COVID-19 care depending on woman’s clinical situation • Escalate as clinically required • Increased monitoring as clinically indicated – See Health Pathway COVID19 pregnancy pathway • Communicate any significant changes in management with LMC /Midwife and the local maternity unit obstetric service. • Transfer of care to Obstetric Team is indicated, a case review will take place and a plan of on-going and follow up care will be made and communicated as part of the three-way consultation with the woman and the LMC, an in-person visit may not be required.
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>28 weeks
• Referral to Obstetrics for clinical transfer of care for duration of illness • Three-way discussion to negotiate LMC involvement in care • Clinical responsibility for care is returned to the LMC when the woman/person has recovered from Covid-19 • Routine visiting schedule is provided (if LMC remains involved in care) • Any concerns about worsening COVID 19 condition should be escalated to the COVID 19 clinical lead and the obstetric team - See Health Pathway COVID-19 pregnancy pathway Intrapartum • Referral to Obstetrics for clinical transfer of care • Three-way discussion to negotiate LMC involvement in care • Escalate as clinically required- See Health Pathway COVID-19 pregnancy pathway • Manage COVID-19 care depending on woman’s clinical situation • Escalate as clinically required • Increased monitoring as clinically required – See Health Pathway COVID19 pregnancy pathway • Communicate any changes in management with LMC / Midwife and thelocal maternity unit obstetric service.
Postpartum • Clinical responsibility transferred to LMC on discharge from hospital • Referral to Paediatrics if new infection in the postnatal period • Routine visiting schedule is provided • Any concerns about worsening COVID 19 condition should be escalated tothe COVID 19 Clinical lead and the assigned clinical lead for COVID care (GP) and paediatric teams - See Health Pathway COVID-19 pregnancy pathway • Manage COVID-19 care depending on situation • Escalate as clinically required- See Health Pathway COVID-19pregnancy pathway • Communicate any changes in management with LMC /Midwife. • Clinical responsibility for Maternity care to be transferred to ObstetricTeam for duration of illness • Three-way discussion to: o negotiate LMC involvement in care o plan follow up care for post infection depending on thewoman’s clinical situation.
• Clinical responsibility for Maternity care to be clinically transferredto Obstetric Team until discharge from hospital. • Three-way discussion to plan: o follow up care for post infection depending on the woman’sclinical situation. • Consultation with Obstetric and Neonatal Teams • Three-way discussion to plan: o follow up care for post infection depending on the woman’sclinical situation.
Further information
1. This diagram is to be read alongside the Health Pathway for providing clinical care to COVID-19 confirmed pregnant women and people, to determine the pregnant woman or person’s riskstratification. 2. Three-way discussions: the groups involved in these conversations are expected to include the pregnant woman or person, the
Midwife/LMC and Obstetricians as per the Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines). 3. Robust processes will be needed that enables information sharing between Midwives, COVID Clinical leads, DHB Obstetric and Maternity Units and the COVID-19hub. 4. DHBs COVID Care Coordination Hubs will need to establish processes that enables coordination and triaging of women’s/people’s care requirements. 5. If a clinical transfer of care to Obstetric Teams takes place, it is expected that the care will be returned to the LMC once clinically appropriate to doso. 6. LMCs will be paid for the care they provide. From 28 February 2022, if they are not involved in providing care, they will not be able to claim for that module ofthe Notice.
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