CORPORATE OFFICE
Level 1
32 Oxford Terrace
Telephone: 0064 3 364 4134
Christchurch Central
[email address];
CHRISTCHURCH 8011
5 October 2021
Paul Jones
Email: [FYI request #16754 email];
Dear Paul Jones
RE Official Information Act request CDHB 10713
I refer to your email dated 14 September 2021 requesting the following information under the Official
Information Act from Canterbury DHB. Specifically:
1. The Triaged Protocol used for Covid-19 cases in Hospitals under your district used for
assessing patient case severity.
2.
For each level of severity, provide the treatment protocol given including medicines and
dosage prescribed.
3.
What Antivirals, Immune-Modulators, Anti-inflammatory, Anti-coagulant, and Convalescent
plasma's are used along with their Indications.
Canterbury DHB follows the guidance published on the Ministry of Health website (refer to link below)
and we also refer to the Middlemore Hospital guidance (please find attached as
Appendix 1).
https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-information-
health-professionals/covid-19-advice-all-health-professionals
I trust this satisfies your interest in this matter.
Please note that this response, or an edited version of this response, may be published on the
Canterbury DHB website after your receipt of this response.
Yours sincerely
Tracey Maisey
Executive Director
Planning, Funding & Decision Support
Introduction
Initial clinical assessment for potential COVID-19 in al patients should be guided by the
Clinical Assessment Tool. Further
guidelines on infection control precautions, bed management etc. are also found at the same link.
This guideline has been adapted from the
Australian National COVID-19 Clinical Evidence Taskforce, jointly revised by
Respiratory and Infectious Diseases, for use at Counties Manukau Health. It refers to ongoing clinical management
FOR
RELEASED
ADULTS ONLY in the fol owing patient groups:
Confirmed COVID-19
Probable COVID-19
(SARS-CoV-2 test positive during current il ness)
(tested negative, but ID decision to treat as COVID)
i.e. does not apply to ‘Suspected’, ‘Surveil ance’, ‘Acute respiratory infections’ or ‘Exposed’ groups.
Initial Management
MILD
MODERATE
SEVERE / CRITICAL
UNDER
No symptoms
Stable adult patient presenting with
OR URTI symptoms only
shortness of breath and/or systemic
Adult patients meeting any of the
OR cough, new myalgia or
symptoms or signs.
fol owing criteria:
DEFINITION
asthenia without new
Able to maintain oxygen saturation
• Respiratory rate ≥30/min
shortness of breath or
≥92% (or ≥90% for patients with
• Oxygen saturation <92% on 4L/min
reduction in oxygen
chronic lung disease) with up to 4
oxygen via nasal prongs
saturation
L/min oxygen via nasal prongs.
• Clinical y deteriorating
THE •
• FBC, Creat, electrolytes, LFTs, CRP
FBC, Creat, electrolytes, LFTs, CRP
•
• ECG
ECG only if specific indication
•
• Chest x-ray
Chest x-ray
OFFICIAL
• ABG
BASELINE TESTING
• Only as clinical y indicated.
• ABG
• Investigations for CAP (urinary
& WORK-UP
• Low value testing is
• Investigations for CAP (urinary
discouraged.
antigens, sputum PCR panel) if CXR
antigens, sputum PCR panel) if CXR
shows focal consolidation.
shows focal consolidation.
•
• Blood cultures if febrile or shocked
Blood cultures if febrile or shocked
•
• Coag screen, d-dimer, LDH, ferritin,
d-dimer & ferritin
BNP, Troponin
• Assess ability to manage in
• Early decision & documentation of ceiling of therapy (including respiratory
TREATMENT
a quarantine (hotel) setting.
support modalities).
INFORMATION
ESCALATION
• Consider & document risk
• Consider & document risk factors for poor COVID outcome.
factors for severe COVID.
•
PLANNING
Complete blue resuscitation decision form for al patients.
• NOTE – any new deterioration >7 days post onset of il ness requires careful assessment, observation &
judgement. Severe COVID-19 frequently develops with a rapid deterioration.
• Admit to Ward 7 under Gen Med.
DISPOSITION
• Encourage discharge
•
•
Admit to ICU or Ward 7.
Admit under Respiratory if
DECISION
(discuss with JetPark via ID).
• Discuss with ICU and/or Respiratory
•
requiring oxygen >2L/min and/or
Liaise with Public Health.
comorbid respiratory disease.
regarding destination.
PROBABLE ONLY
Col ect serum sample in acute phase, repeat ≥2 weeks later, for ‘COVID serology’
• Monitor for progressive respiratory failure and sepsis, especial y on days 5 to 10 after onset of symptoms.
MONITORING
• Only repeat CXR in people with suspected or confirmed COVID-19 if clinical y indicated (e.g. in cases of clinical
deterioration or recent intubation).
ACT
&
• Do not routinely perform CT scanning - only if clinical y indicated.
MARKERS OF
• Anticipate complications such as pulmonary embolism, other thromboembolism, arrhythmias, cardiac
CLINICAL
impairment, acute kidney injury, sepsis, shock and multi-organ dysfunction, and address using existing
DETERIORATION
standards of care. Also be aware of potential complications from trial drugs, if applicable.
• Repeat baseline investigations (see above) periodical y in patients who are not clearly improving, in order to
detect & manage the above complications.
NOTIFICATION
• Discuss al cases with ID at the earliest opportunity
• If not already notified, send e-ref to Auckland Regional Public Health AND notify by telephone (09 623 4600)
• Al patients should be screened for eligibility for one of two clinical trials currently recruiting at CMH
CLINICAL TRIALS
• ‘REMAP-CAP’ is recruiting patients admitted to ICU, and ‘ASCOT-ADAPT’ is recruiting hospitalised patients
outside of ICU. Discuss with ID in the first instance.
Document ID:
CMH Revision No:
2.0
Service:
Infection Services / Respiratory
Last Review Date:
25/06/2021
Document Owner:
COVID-19 Response Manager
Next review date:
25/08/2021
Approved by:
Infection Services / Respiratory
Date first issued:
05/09/2020
This information is correct at date of issue. Always check on Counties Manukau DHB Control ed Documents site that this is the most recent version.
Treatment
NOTE:- the standard-of-care for patients with COVID-19 is to be offered enrolment in one of our clinical trials.
This table indicates which treatment modalities are affected if the patient is enrolled in a trial:
MODALITY
PATIENT SUB-GROUPS
RECOMMENDATION
Adults who do not require oxygen
Do not use steroids to treat COVID-19
RELEASED Adults requiring oxygen and/or ventilatory Dexamethasone 6mg daily IV/PO for up to 10 days or until
STEROIDS
support to maintain oxygen saturation ≥92% discharge.
Adults with another evidence-based
indication for steroids (e.g. asthma/COPD
Steroids as per usual practise.
exacerbations)
All patients enrolled in ASCOT-ADAPT trial
As per trial protocol & randomisation (in addition to
(anti-viral domain)
remdesivir, if indicated below)
Adults with mild COVID-19
Do not use remdesivir or any other anti-viral outside of a
clinical trial
UNDER
Commence Remdesivir:
ANTI-VIRAL
Adults with moderate to severe COVID-19
• Contact on-cal pharmacist - an access form needs to be
THERAPY
who do not require ventilation
completed; stock is held at Auckland Hospital
•
•
200mg IV on day 1, then 100mg q24h for a further 4 days
Note – must have ALT <5 x ULN and/or ALT
<3 x ULN and bilirubin <2 x ULN
(up to 10 days may be considered in selected severe cases)
• Dose made up in 250mL 0.9% NaCl, infuse over 30-120min
• Monitor LFTs
daily; discuss with ID if eGFR <30 or AKI
THE
Adults with critical COVID-19 who require
Do not use remdesivir or any other anti-viral outside of a
ventilation (invasive or non-invasive)
clinical trial
There are no trials of immune modulation therapies currently recruiting at CMH
Give Tocilizumab:
OFFICIAL
• ID wil need to apply to Pharmac for a ‘rapid NPPA’ but the
Adults with COVID-19:
dose can be given prior to this; stock is held at MMH
IMMUNE
• AND receiving oxygen + steroids
• 8mg/kg (actual body weight) rounded to nearest 200mg
•
(max dose 800mg), as a single dose
MODULATION
AND CRP ≥75mg/L OR other evidence of
severe systemic inflammation
• A second dose may be considered 12-24 hours later if the
THERAPY
• AND there is not another active, severe
patient’s condition has not improved
secondary infection
•
Notes:– cytotoxic precautions are not required if used for
COVID-19; risk of secondary infection is significantly
INFORMATION
increased; CRP response is inhibited.
COVID-19 not meeting the criteria above
Do not use immune modulation therapy
All patients enrolled in ASCOT-ADAPT trial
As per trial protocol & randomisation (in addition to
(anticoagulation domain)
standard VTE prophylaxis below)
Adults with mild COVID-19 plus any
Enoxaparin 40mg SC once daily
additional VTE risk factors OR al cases of
• Reduce to 20mg if eGFR <30 mL/min/1.73m2
VTE PROPHYLAXIS
moderate to severe/critical COVID-19
•
NOTE:- Higher dosing strategies, or d-dimer-guided
AND no contra-indication to anticoagulation
treatment, are not currently supported by the balance of
e.g. risk for major bleeding
evidence (outside of clinical trials)
Pregnant or postpartum women with any
Enoxaparin as above
severity of COVID-19
•
ACT
NOTE:- Discuss dosing & duration with Obstetrics
Mild or moderate COVID-19 without specific
evidence of concurrent bacterial infection
Do not use antibiotics
(which is rare in the first 7 days of il ness)
ANTIBIOTIC
Any severity of COVID-19 AND specific
THERAPY
Calculate CURB-65 score:
evidence of concurrent bacterial infection
• 0-2 = Doxycycline 200mg PO once daily for 5 days
(not routinely indicated (e.g. positive culture/antigen, purulent
• ≥3 = Ceftriaxone 2g IV once daily for 5 days
to treat COVID-19)
sputum, focal/unilateral consolidation,
unilateral pleural effusion, neutrophilia)
• Review decision/results at 48-72 hours
Severe/critical COVID-19, especial y with any Discuss with ID (in hospitalised COVID-19 it is common to
deterioration occurring >7 days post onset
develop late, severe, secondary bacterial sepsis)
Document ID:
CMH Revision No:
2.0
Service:
Infection Services / Respiratory
Last Review Date:
25/06/2021
Document Owner:
COVID-19 Response Manager
Next review date:
25/08/2021
Approved by:
Infection Services / Respiratory
Date first issued:
05/09/2020
This information is correct at date of issue. Always check on Counties Manukau DHB Control ed Documents site that this is the most recent version.
FLUID
• Use a restrictive fluid management strategy
MANAGEMENT
• Avoid: ‘maintenance’ IV fluids, high volume enteral nutrition, and repeated fluid boluses for hypotension.
Al patients
Switch nebulisers to metered dose inhalers via spacer if
possible.
• Administer dry oxygen (1-4 L/min) via standard nasal
prongs
• Aim for SpO2 92–96% (88–92% for those at risk of
SpO
hypercapnic respiratory failure)
RELEASED 2 <92% or significantly below baseline
RESPIRATORY
• Use Hudson mask (5-10 L/min) if higher flow rates
SUPPORT
required
• Consider use of self-proning after consulting with
Respiratory Physiotherapy
• Consider High Flow Nasal Oxygen (HFNO)
Unable to maintain SpO2 ≥92% on
•
Note that this is a potential aerosol-generating procedure
conventional oxygen at 6 L/min
• Consider use of self-proning after consulting with
Respiratory Physiotherapy
Hypercapnic patients with underlying COPD
• Discuss with Resp about Non-Invasive Ventilation (NIV)
or OHS
•
Note that this is a potential aerosol-generating procedure
UNDER
Patients with any of the fol owing signs of deterioration should be discussed with ICU:
• Increasing oxygen requirement (requiring FiO2 of 0.4 to maintain SpO2 >92% on HFNO, or 10-15L/min
conventional O2 therapy)
ICU CARE
• Increased work of breathing with impending respiratory failure
• Haemodynamically unstable
• Rapidly worsening tachypnoea or hypoxaemia
THE
Detailed clinical guidelines for ICU care of COVID-19 is beyond the scope of this guideline.
• ACE-inhibitors / ARBs
• Oral contraceptive pill (with or without
• Usual care (i.e. may be continued in COVID-19 unless
THERAPIES FOR
oestrogen)
otherwise contra-indicated)
OFFICIAL
EXISTING
• Antenatal steroids for high risk of preterm birth
INDICATIONS
• Corticosteroids for asthma/COPD (inhaled or
• Usual care
oral, with or without bronchodilators)
• Do not use a nebuliser
• Oral menopausal hormone therapy / HRT
• Consider stopping until after recovery
• Do not routinely perform elective surgery within eight weeks of recovery from COVID-19 infection, unless
SURGERY
outweighed by the risk of deferring surgery, such as disease progression or clinical priority.
• For people undergoing elective surgery fol owing COVID-19 infection, consider carrying out multisystem
preoperative assessment in consultation with ID and/or Respiratory.
INFORMATION
PREGNANCY &
• Out of scope for this local guideline; detailed guidance is included in t
he Australian COVID-19 guidelines
PERINATAL CARE
• Input from Obstetrics, in discussion with ID and/or other relevant specialties, is essential.
Discharge Planning:
Patients with Suspected, Probable or Confirmed COVID-19 who are being considered for discharge need to have specific
decisions made about the following aspects of post-discharge care:
1. Further investigations (for Suspected)
2. Discharge destination:
• Suspected cases being discharged before results are available should be notified to the Medical Officer of
Health, who may request discharge to a quarantine facility.
ACT
• Most Probable/Confirmed cases who remain in isolation wil be discharged to Jet Park.
3. Clearance from isolation:
• Mild cases can be released from isolation after ≥10 days have passed since the onset of symptoms AND there
has been resolution of the acute symptoms for ≥72 hours.
• Most hospitalised moderate & severe cases wil require a further 10 days of isolation after discharge.
• Patients with prolonged il ness, long hospital stay, or major immunosuppression wil require case-by-case
review by ID.
• Note – repeat swabs are general y discouraged (but may be requested by ID on a case-by-case basis).
4. Appropriate follow-up:
Document ID:
CMH Revision No:
2.0
Service:
Infection Services / Respiratory
Last Review Date:
25/06/2021
Document Owner:
COVID-19 Response Manager
Next review date:
25/08/2021
Approved by:
Infection Services / Respiratory
Date first issued:
05/09/2020
This information is correct at date of issue. Always check on Counties Manukau DHB Control ed Documents site that this is the most recent version.
• Patients who have had significant respiratory failure and/or persistent dyspnoea or hypoxia may require
respiratory fol ow up and support on discharge e.g. pulmonary rehabilitation, short-term oxygen.
Al cases should be discussed with ID in advance to individualise the plan.
RELEASED
UNDER
THE
OFFICIAL
INFORMATION
ACT
Document ID:
CMH Revision No:
2.0
Service:
Infection Services / Respiratory
Last Review Date:
25/06/2021
Document Owner:
COVID-19 Response Manager
Next review date:
25/08/2021
Approved by:
Infection Services / Respiratory
Date first issued:
05/09/2020
This information is correct at date of issue. Always check on Counties Manukau DHB Control ed Documents site that this is the most recent version.
Document Outline