Interim Guidance - Clinical
Management of COVID-19 in
Hospitalised Adults
Introduction
Updated: 10 September 2021 – Next planned update 24 September 2021
• This guideline is for the clinical management of COVID-19 in hospitalised adults only
• The Clearance from Isolation section has been updated
This guideline is intended to be an accessible summary of key components of hospital management of
ADULTS with
confirmed or probable COVID-19. It has been adapted from international ‘living’ guidelines
for the New Zealand context by an advisory group of New Zealand clinicians, including representation from
Infectious Diseases, Respiratory Medicine, Intensive Care, General Medicine and Pharmacy.
New evidence informing the optimal management of patients with COVID-19 continues to accumulate
rapidly. This document wil be reviewed and updated periodically, or in response to significant changes in
evidence and/or recommendations by international guideline groups.
Further detailed guidance, including treatments that are either not recommended, or recommended only
within a clinical trial, can be accessed in links to international guidance at the end of this document. Local
specialist services with expertise in managing COVID-19 may consider emerging treatments outside of this
guideline.
Initial Management
MILD
MODERATE
SEVERE / CRITICAL
No symptoms
Stable adult patient presenting
Adult patients meeting any of the
OR URTI symptoms only
with shortness of breath and/or
following criteria:
OR cough, new myalgia or systemic symptoms or signs.
• Respiratory rate ≥30/min
DEFINITION
asthenia without new
Able to maintain oxygen
• Oxygen saturation <92% on
shortness of breath or
saturation ≥92% (or ≥90% for
4L/min oxygen via nasal prongs
reduction in oxygen
patients with chronic lung
• Clinically deteriorating
saturation
disease) with up to 4 L/min
oxygen via nasal prongs
• FBC, Creat, electrolytes, LFTs,
• FBC, Creat, electrolytes, LFTs,
CRP
CRP
• ECG only if specific indication
• ECG
• Chest x-ray
• Chest x-ray
• Pulse oximetry
• Arterial blood gas
• Arterial blood gas
• Other tests only as
• Investigations for CAP (e.g.
• Investigations for CAP (e.g.
BASELINE
clinically indicated
urinary antigens, sputum PCR
urinary antigens, sputum PCR
TESTING
• Low value testing is
panel) if radiography suggests
discouraged
panel) if radiography suggests
bacterial infection
& WORK-UP
bacterial infection
• Blood cultures if febrile or
• Blood cultures if febrile or
shocked
shocked
• d-dimer & ferritin
• Coag screen, d-dimer, ferritin,
BNP, Troponin
• ‘Probable’ COVID-19 (i.e. high suspicion with inconclusive testing): Collect serum sample in acute
phase, repeat ≥2 weeks later, for ‘COVID-19 serology’. Discuss confirmatory testing options with
local Microbiology/ID
• Assess ability to manage
in a quarantine (hotel)
setting and
• Assess & document individual risk factors for poor outcome
communicate any
• Early discussion of patient goals of care, including existing advanced
TREATMENT
difficulties to Public
care plans, with patient and their family/whānau
ESCALATION
Health (e.g. use of usual • Early, clear documentation of resuscitation decision and treatment
nocturnal CPAP for OSA)
escalation plan for all patients, specifically including appropriate
PLANNING
• Consider & document
modalities of respiratory support
risk factors for severe
COVID-19
•
NOTE – any new deterioration > 5 days post onset of il ness requires careful assessment,
observation & judgement. Severe COVID-19 frequently develops with a rapid deterioration
• Encourage discharge
• Liaise with Public Health
DISPOSITION
or Regional Isolation and • Admit to hospital
• Admit to hospital
DECISION
Quarantine (RIQ)
• Discuss with local COVID team
• ICU and/or Respiratory review
according to regional
processes
• Monitor for progressive respiratory failure and sepsis, especially after day 5 of illness
MONITORING
• Only repeat CXR in people with confirmed COVID-19 for specific clinical indications
&
• Perform a chest CT scan only if it would change management, in particular if concern for
MARKERS OF
pulmonary embolism
• Anticipate complications such as delirium, pulmonary embolism, other thromboembolism,
CLINICAL
arrhythmias, cardiac impairment, acute kidney injury, sepsis, shock and multi-organ dysfunction,
DETERIORATION
and address using existing standards of care. Also be aware of potential medication complications
• Repeat baseline investigations (see above) periodically in patients who are not clearly improving,
in order to detect & manage the above complications
• Discuss all cases with local COVID team at the earliest opportunity
NOTIFICATION
• If not already notified according to regional process, (e.g. by laboratory) contact local Public
Health Unit
• As the optimal management of COVID-19 is not yet known, the
standard of care is to be offered
CLINICAL TRIALS
enrolment in a clinical trial, if available
•
All patients should be screened for eligibility for a locally available COVID-19 clinical trial (e.g.
‘REMAP-CAP’ and ‘ASCOT-ADAPT’)
Supportive Management
MODALITY
PATIENT SUB-GROUPS
RECOMMENDATION
• Switch nebulisers to metered dose
inhalers via spacer if possible
All patients
• Monitor closely for worsening hypoxia if
elevated work of breathing or respiratory
rate
• Administer dry oxygen (1-4 L/min) via
standard nasal prongs
• Aim for SpO2 92–96% (88–92% for those
RESPIRATORY
SpO2 <92% at rest
at risk of hypercapnic respiratory failure)
•
SUPPORT
Use Hudson mask (5-10 L/min) or Venturi
device if higher flow rates required
• Consider use of self-proning
• Consider CPAP or High Flow Nasal
Unable to maintain SpO2 ≥92% on conventional
Oxygen (HFNO)
oxygen at 6 L/min via Hudson mask (required Fi02
•
Choice depends on availability, staff
>36%)
expertise, patient tolerance
• Consider use of self-proning
•
Hypercapnic patients with underlying COPD or OHS
Consider BiLevel Non-Invasive Ventilation
(NIV)
FLUID
• Assess for hypovolaemia and correct as required. Anticipate and monitor ongoing fluid losses
MANAGEMENT
• Avoid excessive resuscitation or ‘maintenance’ fluids
•
All patients enrolled in ASCOT-ADAPT or
REMAP-CAP (anticoagulation domains)
•
As per trial protocol
Hospitalised adults with:
• mild COVID-19 and any additional VTE risk
factors
Enoxaparin 40mg SC once daily (standard
• OR severe and critical COVID-19
prophylaxis)
• Adjust dose for impaired renal function
AND no contra-indication to anticoagulation e.g.
risk for major bleeding
VTE PROPHYLAXIS
Therapeutic dose anticoagulation
may be
considered over standard prophylaxis for
up to 14 days, or until clinical recovery
(discharge or resolved hypoxia) if there are
NO additional risk factors for bleeding
Moderate COVID-19
• Enoxaparin 1mg/kg SC twice daily
(max 150mg BD)
• Adjust dose for impaired renal
function
All other patients should receive
standard prophylaxis as detailed above
Regular, open and early discussions between ward-based clinicians and local ICU team is strongly
encouraged. In addition to local referral guidelines, ICU review should be prompted by the
following:
• Significant oxygen requirement (e.g. requiring FiO2 of 0.4 to maintain SpO2 >92%, or needing
INTENSIVE CARE
HFNO or CPAP)
• Increased work of breathing with impending respiratory failure
• Haemodynamically unstable and / or hypotension not responsive to fluid bolus
• Rapidly worsening tachypnoea or hypoxaemia
Detailed clinical guidelines for ICU care of COVID-19 is beyond the scope of this guideline
Mild or moderate COVID-19 without specific
evidence of concurrent bacterial infection (rare in
Do not use antibiotics
the first 7 days of illness)
• Evaluate for secondary infection,
ANTIBIOTIC
Severe/critical COVID-19 especially with any
including hospital-acquired infection
THERAPY
deterioration occurring >7 days post onset and/or
• Discuss with local Infectious Diseases /
>3 days after hospital admission
Microbiology team if concern for
(not routinely
secondary infection
indicated)
Any severity of COVID-19 AND specific evidence of
concurrent bacterial pneumonia (e.g. positive
culture/antigen, purulent sputum, focal/unilateral
Antibiotics as per local guidelines for
consolidation, unilateral pleural effusion,
community acquired pneumonia
neutrophilia)
Encourage for all patients:
• Clearly communicate typical symptoms and anticipated clinical course with patient,
family/whānau or carers
• Reinforce importance of complying with all Public Health messages, including self-isolation and
testing
• When possible, explain risks, benefits and likely outcomes of treatments with patients,
family/whānau or carers
COMMUNICATION • Use an interpreting service to assist communication if required
& HOLISTIC CARE
• Facilitate regular clinical updates, and video calls between patient family/whānau or carers
• Routinely refer to local cultural and/or spiritual support services
• Consider early involvement of Palliative Care and/ or Liaison Psychiatry services to assist with
symptom management, particularly anxiety, dyspnoea and delirium/agitation
• Ensure appropriate housing, financial and social support is in place prior to discharge (including
a working phone). If concerns, refer to social work
• If welfare or cultural support issues identified, liaise with Public Health or Regional Isolation
Quarantine (RIQ) according to regional processes as part of discharge planning
Consider change usual vented CPAP mask to a
• Nocturnal CPAP for Obstructive Sleep
non-vented mask + expiratory port + filter
Apnoea
(decision depends on equipment availability and
staff expertise)
• ACE-inhibitors / ARBs
THERAPIES FOR
• Oral contraceptive pill (with or without
EXISTING
•
oestrogen)
Usual care (i.e. may be continued in COVID-19
unless otherwise contra-indicated)
INDICATIONS
• Antenatal steroids for high risk of preterm
birth
•
• Corticosteroids for asthma/COPD (inhaled or
Usual care
•
oral, with or without bronchodilators)
Do not use a nebuliser unless definite clinical
need
• Oral menopausal hormone therapy / HRT
• Consider stopping until after recovery
•
Elective surgery should generally be deferred until at least eight weeks following recovery from
SURGERY
COVID-19
•
Non-deferrable surgery should be discussed with local ID and infection control services
PREGNANCY &
• Out of scope for this guideline; detailed guidance is included in the
Australian COVID-19
PERINATAL CARE
guidelines
• Input from Obstetrics, in discussion with ID and/or other relevant specialties, is essential
COVID-19 Therapeutics
MODALITY
PATIENT SUB-GROUPS
RECOMMENDATION
Adults who do not require oxygen
Do not use systemic steroids to treat COVID-19
Adults without oxygen, but another
evidence-based indication for systemic
Steroids as per usual practise
steroids (e.g. asthma/COPD
STEROIDS
exacerbations)
Dexamethasone 6mg daily IV/PO for up to 10 days OR
Adults with sustained oxygen
until hospital discharge
requirement
Consider a minimum dexamethasone duration of 5
days, if discharged within this time
All patients enrolled in ASCOT-
As per trial protocol & randomisation (in addition
ADAPT trial (anti-viral domain)
to remdesivir, if indicated below)
• Do not use remdesivir
Adults with mild COVID-19
• Do not use any other anti-viral outside of a clinical
trial
Adults within the first 7 days of illness,
Commence remdesivir:
ANTI-VIRAL
with moderate COVID-19
• 200mg IV on day 1, then 100mg IV q24h for up to
•
Note – must have ALT <5 x ULN and/or
further 4 days (maximum 5 days total)
THERAPY
ALT <3 x ULN and bilirubin <2 x ULN
• PHARMAC access form to be completed
•
Adults with severe / critical COVID-19
Do not start remdesivir
•
who require ventilation (invasive or non-
Complete course (5 days) if started earlier in illness
•
invasive)
Do not use any other anti-viral outside of a clinical
trial
Adults with significant
immunocompromise
Discuss with local infectious diseases team
In patients receiving systemic steroids in combination with immune modulation, we
recommend screening for, and consider empiric treatment of latent infection, e.g. Hepatitis
B or strongyloidiasis (in patients who have lived in an endemic region)
There are no trials of immune modulation therapies currently recruiting in New Zealand Adults with moderate COVID-19:
• AND receiving both oxygen + systemic
steroids
• AND elevated CRP or other evidence of
severe systemic inflammation
Give tocilizumab:
• AND there is not another active, severe • 8mg/kg (actual body weight) rounded to nearest
IMMUNE
concurrent infection
200mg (max dose 800mg), as a single dose
MODULATION
• Complete PHARMAC funding application on next
THERAPY
Adults with severe / critical COVID-19:
working day
• Within 48h of starting HFNO, NIV,
•
Notes:– risk of secondary infection is increased; CRP
mechanical ventilation or organ
response is inhibited, and consequent reduction in
support
CRP does not necessarily correlate with response to
• AND receiving systemic steroids
treatment
• AND elevated CRP or other evidence of
severe systemic inflammation
• AND there is not another active, severe
secondary infection
COVID-19 not meeting the criteria
above
Do not use immune modulation therapy
Discharge Planning and Follow-up
Patients with Suspected, Probable or Confirmed COVID-19 who are being considered for discharge need to
have specific decisions made about the fol owing aspects of post-discharge care:
• Follow-up investigations are not universally required after COVID-19
FURTHER
• A repeat chest x-ray in 6-12 weeks to confirm resolution of pulmonary opacities should be
INVESTIGATIONS
arranged for individuals with significant radiographic abnormalities and / or risk factors for
lung cancer
• Ensure follow up serology is arranged for ‘probable’ cases
• Suspected cases being discharged before results are available should be notified to the Medical
DISCHARGE
Officer of Health, who may request discharge to a quarantine facility
DESTINATION
• All probable/confirmed cases who remain in isolation will be discharged to a quarantine facility.
Exemptions may be approved by Public Health in exceptional circumstances
1. While each case is different, the following guidance is designed to assist individual decision
making. This advice applies to patients in ICU, hospitalised, and those in hospital (due to
COVID-19) for part of their illness.
a) In general, a case should be released if it has been at least 14 days since onset of
symptoms and the individual has been symptom free for at least 72 hours.
b) In most cases a patient can be considered to no longer be infectious 20 days after
CLEARANCE FROM
symptom onset (even if symptoms persist) if they have developed an antibody response.
ISOLATION
c) Consider serology to determine antibody response especially if patient is
immunocompromised or has had a prolonged admission to Intensive Care.
d) Note that PCR testing is not a useful modality for determining release from isolation as
shedding of non-infectious viral RNA may persist for many days or months.
e) When the determination for release is not clear, then the decision should be made in
consultation with the medical officer of health, infection prevention and control, and
infectious disease specialists.
Telephone fol ow-up within 6 weeks of discharge with
All patients
Primary Care Provider: to assess trajectory of recovery,
identify persistent symptoms and facilitate referral to
specialty services as required
Patients with significant respiratory
Specialist clinic follow-up, investigations and support
failure (and/or persistent
following discharge (as advised by local specialty
FOLLOW-UP
dyspnoea), or other persistent
services)
organ dysfunction
Consider providing a non-vented mask + expiratory port
+ filter, depending on equipment availability and staff
Patients discharged with nocturnal
expertise. Can transition to vented mask on return to
CPAP (usual OR new device)
own home. Sleep service remote fol ow-up within 48
hours of hospital discharge is recommended.
Links to other guidelines
•
Australian COVID-19 living guidelines: https://covid19evidence.net.au/
•
NICE (UK) living guideline: https://www.nice.org.uk/guidance/ng191
•
National Institute of Health (USA): https://www.covid19treatmentguidelines.nih.gov/
•
WHO COVID-19 living guideline: https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-
2021-1
•
Ontario COVID-19 Science Advisory Group guideline (Canada) : https://covid19-
sciencetable.ca/sciencebrief/clinical-practice-guideline-summary-recommended-drugs-and-biologics-
in-adult-patients-with-covid-19-2/
•
Australian guidance for Pregnancy and perinatal care: https://covid19evidence.net.au/
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