COVID-19 (Coronavirus disease 2019): Clinical
management of inpatients with probable or
confirmed COVID-19
Purpose of Guideline: to ensure best practice is maintained in the care of inpatients with probable or
confirmed COVID-19.
For COVID-19 case definition, please refer to
MOH guidelines. Please also refer to other ADHB guidelines relevant to COVID-19, which include
•
Screening Tool- Acute Respiratory Infection
• COVID-19 (Coronavirus disease 2019): guide to early identification, infection prevention and
management
•
Best use of Personal Protective Equipment Guide •
Shared Goals of Care •
COVID-19 Palliative Care Resources •
Resuscitation guidelines during COVID-19 response: Adult medical emergency team calls •
Influenza and Influenza-Like Illness – Prevention of In-Hospital Spread
•
COVID-19 Rapid Testing Criteria
•
“I’m sick. What should I do?”
General Information and Screening:
• This guideline applies to patients presenting with probable or confirmed COVID-19 infection.
• All patients presenting to ADHB inpatient services should be assessed using the
Screening Tool-
Acute Respiratory Infection.
o Patients with both new or worsening symptoms of acute respiratory infection and high risk
criteria (HRC) for COVID-19 should be considered to have COVID-19 and use of this guideline
considered.
o Patients with symptoms and no HRC for COVID-19: if SARS-CoV-2 negative, are unlikely to
have COVID-19 and should instead be managed as per the ADHB policy
“Influenza and
Influenza-Like Illness – Prevention of In-Hospital Spread” or other disease specific policies
and guidelines (see A-Z Communicable Diseases Table)
o Patients with neither symptoms or HRC should be managed using standard and transmission
based precautions as is appropriate for the clinical situation.
o Patients without symptoms but who have HRC for COVID-19 exposure should receive
treatment as indicated for their presenting condition, and be managed and placed in
precautions as determined by the
Screening Tool - Acute Respiratory Infection. This
includes:
Minimum of daily monitoring for the development of COVID-19 symptoms
Scheduled swabs for those inpatients from managed isolation and quarantine
facilities (MIQF) even if asymptomatic (day 0, 3 and 12 from entry to NZ) and
surveillance swabs for those who work at the border
Minimum of neutral-pressure single room, contact and droplet precautions for
routine care
Airborne infection isolation room (AIIR, or negative pressure) single room, contact
and airborne precautions for aerosol-generating procedures (AGPs)
• In addition to those with a positive contact screen, the following groups should be particularly
encouraged and supported to be tested:
o Those more likely to have severe consequences if they were to contract COVID-19. This
group includes: seniors (those who are over 70 years old), Māori, Pacific peoples, and those
who have significant pre-existing conditions.
o Health care workers and aged care residential staff. All patients in this group with symptoms
consistent with COVID-19 should be tested. Please see flow chart
“I’m sick. What should I
do?” from the COVID HIPPO webpage.
Placement of Patients with Probable or Confirmed COVID-19
Presentation
Precautions
Viral testing
Placement and Services Involved
Patients with mild ILI
Contact and droplet precautions*
SARS-CoV-2
Assess in CDU, rooms 1, 3 or 4 (neutral pressure).
Complete eReferral to Auckland Regional Public Health (ARPHS) for notification of results. Ensure up-to-
AND no ‘higher index of suspicion criteria’
For AGP, contact and airborne
date phone number on referral.
precautions
If known COVID positive or probable case, see COVID HIPPO website for discharge process (managed
AND well enough to be discharged
isolation/quarantine facility).
*Contact and airborne precautions
in Level 3 and 4
Patients with mild ILI
Contact and airborne precautions
SARS-CoV-2
Prioritise placement in CDU rooms 21, 22, 23 (AIIR/negative pressure) then 1, 3,or 4 (neutral pressure)
Complete eReferral to Auckland Regional Public Health (ARPHS) for notification of results. Ensure up-to-
AND ‘higher index of suspicion criteria’
date phone number on referral.
If known COVID positive or probable case, see COVID HIPPO website for discharge process (managed
OR COVID-19
isolation/quarantine facility).
AND well enough to be discharged
Patients requiring admission with ILI
Contact and droplet airborne
SARS-CoV-2
Assess in CDU, preferred rooms 21, 22 or 23 then 1, 3 or 4.
precautions*
Admit to the COVID ward, Purple General Medicine team.
AND no ‘higher index of suspicion criteria’
Additional respiratory
Discuss with COVID coordinator (021 195 6238) or ID consultant on-call afterhours.
For AGP, contact and airborne
panel (SARS-CoV-2,
If pre-existing lung disease, or Non-invasive ventilation (NIV) for another condition (e.g. OSA) discuss with
AND SpO2 ≥ 92% on room air
precautions
influenza and RSV) may be
Respiratory Service. A non-vented mask and viral filter should be used on machine.
Confirmed COVID-19 positive patients may be cohorted in multi-bed room if required. Prioritise AIIR
*Contact and airborne precautions
requested
AND haemodynamically stable
(negative pressure room).
in Level 3 and 4
If COVID-19 negative and low clinical suspicion of COVID-19, maintain Contact and Droplet precautions
until respiratory symptoms have resolved for ≥24 hours.
Patients requiring admission with ILI
Contact and airborne precautions
SARS-CoV-2
Prioritise placement in CDU rooms 21, 22, 23 (AIIR/negative pressure) then 1, 3,or 4 (neutral pressure)
Placement dependent on clinical stability. If haemodynamically stable and SpO2 ≥ 92%, admit to the
AND ‘higher index of suspicion criteria’
Additional respiratory
COVID ward, Purple General Medicine team.
panel may be requested
Discuss with COVID coordinator (021 195 6238) or ID consultant on-call afterhours.
OR COVID-19
Discuss and notify DCCM regarding ward placement and escalation plan.
Document escalation plan and ceiling of treatment.
If pre-existing lung disease, or Non-invasive ventilation (NIV) for another condition (e.g. OSA) discuss with
Respiratory Service. A non-vented mask and viral filter should be used on machine
Prioritise AIIR (negative pressure room)
If requiring ≥4L/min oxygen via nasal prongs or reservoir mask to maintain SpO2 ≥ 92%, or CXR changes,
may be best placed on ward 7A (which may be the COVID ward) and discussed with Respiratory, with
consideration given to non-invasive ventilation (NIV)
Patients presenting with a primary issue under
Contact and droplet precautions
SARS-CoV-2
Admit under service most appropriate to main presenting issue.
another service but who also have ILI
until respiratory symptoms
resolved for 24 hours
Additional respiratory
AND no ‘higher index of suspicion criteria’
panel (SARS-CoV-2,
For AGP, contact and airborne
influenza and RSV) maybe
precautions
E.g. abdominal pain for surgical review but also have
requested
a cough and sore throat
*Contact and airborne precautions
in Level 3 and 4
Patients presenting with a primary issue under
Contact and airborne precautions
SARS-CoV-2
Admit under service most appropriate to main presenting issue.
another service but who also have ILI
Prioritise placement in CDU rooms 21, 22, 23 (AIIR/negative pressure) then 1, 3,or 4 (neutral pressure)
Additional respiratory
AND ‘higher index of suspicion criteria’
panel (SARS-CoV-2,
Ideally admit to the COVID ward, may require assistance from Purple General Medicine team.
influenza and RSV) maybe
Discuss with COVID coordinator (021 195 6238) or ID consultant on-call afterhours.
E.g. abdominal pain for surgical review but also have
requested
a cough and sore throat and MIF worker
Symptoms of COVID-19
• The mean incubation period is 5-6 days (or shorter for the Delta variant) but can be
up to 14 days.
• Symptoms include
o Fever 45-98%
o Rhinorrhoea 5%
o Cough 65-80%
o Sore throat 5-15%
o Fatigue 45-70%
o Nausea/vomiting 5%
o
Shortness of breath 20-65%
o Diarrhoea 5%
o
Sputum 25-55%
o Anosmia 25-40%
• Most cases are mild but approximately 15% of adult cases develop severe disease
requiring hospitalisation and 5% require ICU admission.
• Atypical symptoms may be seen, particularly in the elderly and children
• New variants may present atypically
• In severe cases, the median time from onset of symptoms to acute respiratory
distress syndrome (ARDS) is 8-12 days, and from onset to ICU admission 10-12 days.
• Risk factors for more severe disease include:
o Age >55 years
o Chronic kidney disease
o
Chronic respiratory disease
o Malignancy
o Cardiovascular disease
o Immunocompromised states
o
Hypertension
o Obesity
o
Diabetes
o Smoking
o
New onset SOB and fever >3 days
Investigations for Inpatients with Probable or Confirmed COVID-19:
• Nasopharyngeal swab.
o For patients being discharged with mild symptoms in the absence of
confirmed disease, send swab for COVID-19 only, give isolation advice, and
make eReferral to ARPHS to enable an automated text message result to be
sent.
o For patients being admitted, send for SARS-CoV-2. For patients without HIS
criteria, ARPHS referral is not required if the patient is likely to have their
result communicated to them as an inpatient.
o The FilmArray respiratory PCR panel (which includes many viral and some
bacterial pathogens but not SARS-CoV-2) should only be requested if it will
materially change management. This occurs in liaison with the on-call
Microbiologist.
o Rapid testing is available for critically unwell patients and other selected
situations (e.g. urgent surgery required).
See COVID-19 Rapid Testing Criteria
in the LabPLUS Test Guide on HIPPO.
• Routine blood testing
o FBC – lymphopenia and mild thrombocytopenia are common.
2+
o U&E, LFT, Mg – electrolyte disturbances can occur with COVID-19.
o CRP – if <40, associated with a lower risk of progression to severe disease.
o CK, LDH, D-dimer, ferritin – not routinely required but high values may be
associated with a higher risk of progression.
o Troponin, BNP – if myocarditis is thought possible. Consider echocardiogram
if elevated.
o Arterial blood gas (ABG) – if oxygen saturations <92%.
o Consider HIV test.
• Tests for alternate diagnoses – blood cultures, urinary antigens for
S. pneumoniae,
sputum for culture and atypical organism PCR.
• CXR.
o Mild cases not requiring hospital admission may not require a CXR.
o Patients being admitted for ILI, or probable or confirmed COVID-19 should
have a portable CXR performed in their room.
May be unremarkable in early stages.
Unilateral changes may occur in mild or early disease.
The typical picture of COVID-19 is patchy ground glass opacities,
predominantly peripheral and basal. May coalesce into more dense
consolidation with increasing severity of illness.
Pleural effusions, masses, cavitation and lymphadenopathy are rare.
o Repeat CXR only if clinically indicated.
• CT scanning.
o Should not be used to screen for or diagnose COVID-19. Use only if it is
expected to change management. Most COVID-19 patients do not need a CT.
o If CT it is felt to be necessary or is required to exclude an alternative
diagnosis, inform radiology that COVID-19 is suspected. The patient needs to
wear a surgical mask with radiology staff wearing appropriate PPE, and
appropriate cleaning required (see
COVID-19 (Coronavirus disease 2019):
guide to early identification, infection prevention and management).
• ECG.
o Mild cases not requiring hospital admission may not require an ECG.
o Patients being admitted for ILI, or probable or confirmed COVID-19, should
have an ECG performed as cardiomyopathy and arrhythmias can occur.
• Bronchoscopy is aerosol generating and should be avoided
in probable or confirmed
COVID-19.
• Point of Care Ultrasound Scan (POCUS).
o Not generally useful as POCUS findings are not specific to COVID-19.
o POCUS may be useful for differentiating other causes (e.g. pleural effusion).
o Infection Prevention and Control recommendations should be followed for
safe use and disinfection of the POCUS machine.
Management of Inpatients with Probable or Confirmed COVID-19:
• Supportive care and close monitoring is key.
o Monitor for complications, which may include hypoxaemic respiratory
failure/ARDS, sepsis, cardiomyopathy, arrhythmia, acute kidney injury,
secondary bacterial infections, and thrombotic complications including
pulmonary emboli.
• Numerous risk stratification tools using demographic, clinical, laboratory, and
radiological measures have been suggested to identify patients suitable for early
discharge in an epidemic setting.
o A period of monitoring in hospital for 24-48 hours will be suitable for most
patients in the current setting or dependent on where they are in illness
trajectory
o Certain patients, such as those <50 years old without comorbidities may be
suitable for early discharge
• Probable or confirmed COVID-19 patients who are considered for discharge should
firstly be discussed with ARPHS and then the Regional Isolation and Quarantine
Coordination Center (RIQCOORD) to arrange isolation in a managed quarantine
facility with discharge. See the MIFQ patient discharge process on the COVID HIPPO
webpage
• Request early DCCM review for deteriorating patients. Discuss any patient with
DCCM who has a RR>30, oxygen saturation <92% on air, or hypotension refractory to
initial fluid boluses.
o Aim to ascertain the appropriate ceiling of treatment and avoid inappropriate
escalation of care. This must be reviewed regularly by the medical team.
o The ADHB Goals of Care form (available in the clinical forms library) should be
used as a basis for discussion with the patient and/or whanau and for
documentation of appropriate treatment in the event of deterioration.
o See th
e Shared Goals of Care webpage on HIPPO
• Resuscitation - Refer to th
e Resuscitation Guidelines during COVID-19 response.
o Safe PPE use must be prioritised for staff involved in resuscitation.
• IV fluids – use IV fluids as you would in any unwell patient.
o e.g. 1-2L IV fluid per day if no oral intake.
o Avoid maintenance fluids where possible.
o If hypotensive, administer small fluid boluses (e.g. 250mL) and refer to DCCM
for consideration of vasopressor therapy if not responding after 2-3 boluses.
• Supplemental oxygen
o See th
e ‘Key Points when Prescribing Supplemental Oxygen to patients with
probable or confirmed COVID-19’ guideline on the COVID HIPPO webpage
o If saturations <92% on room air, check an arterial blood gas (ABG).
o Titrate oxygen therapy to target oxygen saturation of 90-92% if no underlying
chronic lung disease or ≥86% if known COPD.
o Place a surgical mask over any oxygen delivery device, if possible.
o Initiate oxygen therapy with low-flow nasal prongs (0.5-3L/min).
o If oxygen target not met with nasal prongs, escalate to Hudson mask, or mask
with reservoir bag (non-rebreather) at up to 10L/min.
o Discuss with DCCM and Respiratory SMO for consideration of options for
escalation including high-flow nasal prong oxygen (“Airvo”), non-invasive
ventilation, and intubation for invasive ventilation. These therapies should
not be initiated without discussion with DCCM and Respiratory.
o Non-invasive ventilation is aerosol generating and must be provided in an
AIIR (negative pressure).
o Patients established on non-invasive ventilation (NIV) at home for underlying
conditions (e.g. COPD, OSA, obesity hypoventilation) need to be discussed
with the Respiratory SMO and managed in an AIIR (negative pressure room).
A non-vented mask and viral filter should be used on their machine.
o Avoid nebulisers and high flow nasal oxygen devices if possible, as these are
potentially aerosol generating – use metered dose inhalers via spacer as an
alternative. If required they should be provided in an AIIR (negative
pressure).
• Self-proning
o Some experts are encouraging that hospitalized patients with COVID-19
spend as much time as is feasible and safe in the prone position, while
receiving oxygen or non-invasive modalities of support, such as high-flow
oxygen via nasal prongs or NIV. This should only be attempted by patients
who are able to self-prone under verbal supervision from staff.
o Data remains limited on the optimal indications for and duration of
pronation, and assessment of response. Use of prone positioning should not
delay intubation and mechanical ventilation in a deteriorating patient. It also
may be difficult and potentially harmful in the elderly, those who are frail, or
those with cognitive impairment. Please discuss with the COVID Co-ordinator.
• Medical therapies
o Secondary bacterial infection is uncommon in confirmed COVID-19 but
antibiotic therapy should be provided in cases where an alternate diagnosis,
such as community-acquired pneumonia is being considered. There is
evidence that unnecessary antibiotics can cause harm in COVID-19. See
ADHB Script guidelines and review at 48 hours.
o Inhaled budesonide 800 µg bd for 14 days may be used in patients >65 years
who do not require oxygen or dexamethasone; or in patients >50 years with
comorbidities (eg, hypertension, heart disease, diabetes, obesity, asthma or
lung disease, hepatic impairment, stroke or neurological impairment,
immunosuppression) who do not require oxygen or dexamethasone.
o Dexamethasone 6mg once daily, IV or oral, should be given to patients with a
requirement for oxygen (SpO2 <92% on room air), or invasive or non-invasive
ventilation, until discharge or up to 10 days. Steroids are not indicated in
patients with mild disease or those not requiring oxygen. Consider PPI
prophylaxis with use.
o
o Do not use therapies proven to be of no benefit including
hydroxychloroquine, chloroquine, oseltamivir, lopinavir-ritonavir or
azithromycin.
o Continue ACE inhibitors and angiotensin receptor blockers if already on
these, and no other reason to stop (e.g. hypotension, AKI).
o Interleukin 6 receptor antagonists (e.g. tocilizumab) have been shown to
improve outcomes in critically unwell patients, and may also have benefits in
hospitalised patients with an oxygen requirement who are not critically
unwell. Tocilizumab may be accessed via a NPPA to Pharmac prior to release
of the widened access via special authority. All of the following criteria for
use are required:
Patient has confirmed (or strongly clinically suspected) COVID-19; and
Oxygen saturations of <92% on room air, or requiring supplemental
oxygen; and
Patient has laboratory markers of significant inflammation (eg, raised
CRP, ferritin or procalcitonin); and
Patient is receiving adjunct systemic corticosteroids, or systemic
corticosteroids are contraindicated; and
Tocilizumab is administered as a single dose of 8mg/kg IV (actual body
weight) with maximal dose of 800mg.
o Remdesivir (200mg IV on Day 1 then 100mg IV q24h on Days 2 – 5) may
reduce time to recovery with moderate COVID-19. Patients must meet
PHARMAC eligibility criteria, essentially requiring supplemental oxygen
(oxygen saturations <92% on room air) without organ dysfunction or need for
ventilation, dialysis or ECMO. Supply is available from Auckland Hospital
Pharmacy on receipt of a signed Access Form
(link here).
o There is no clear evidence that convalescent plasma improves outcomes in
hospitalised patients with COVID-19. The RECOVERY trial has reported no
difference in 28 day mortality. The REMAP-CAP trial has reported no benefit
in severely unwell patients.
o Consideration of all other alternative treatments should be in the context of a
clinical trial.
Consider enrolment in ASCOT study once open.
Consider enrolment in REMAP-CAP for patients in DCCM/CVICU.
• Thrombosis management.
o Patients with COVID-19 have an increased risk of thrombosis.
o Moderately unwell patients (hospitalised but not in ICU) should receive full-
dose therapeutic anticoagulation with low-molecular weight heparin (e.g.
enoxaparin 1mg/kg twice daily, adjusted for renal function if necessary –
equivalent to VTE treatment) as there is a mortality benefit.
o Severely unwell patients (in ICU or similar severity) should NOT receive full-
dose therapeutic anticoagulation as there is no benefit and high likelihood of
harm. The current evidence supports standard low-dose thromboprophylaxis
(e.g. enoxaparin 20-40mg once daily) in this situation. Enrolment in a clinical
trial (e.g. the anticoagulation arm of REMAP-CAP) is advised if available.
o Patients who receive therapeutic anticoagulation on the ward and
subsequently deteriorate to the point they require ICU care could be
discussed with the Haematology and COVID teams. The current evidence
supports continuing therapeutic anticoagulation in these patients but this
may be the subject of future research; consider trial enrolment if available.
o Critically ill COVID-19 patients may have laboratory evidence of mild
coagulopathy on laboratory testing. This can be due to a coagulopathy or the
presence of an inhibitor. In the absence of bleeding, therapeutic
anticoagulation should be continued if established.
o Haematology opinion is recommended in patients with low platelet count
9
(<50 x10 ), low fibrinogen level (<1.0g/L) or significant renal impairment
(creatinine <30mL/min).
o For patients unable to receive chemical therapeutic anticoagulation or
thromboprophylaxis, intermittent pneumatic compression (IPC) should be
used, providing there are no contraindications. There is no added benefit of
combining IPC with pharmacological thromboprophylaxis in critically ill
patients.
• Symptom control and Palliative Care
o Patients who are for active ward management but for whom DCCM
admission is not likely to be in their interests or feasible should have
symptom control available as appropriate (see
Palliative Care Webpage –
COVID-19 pink tile for symptom control advice).
o Patients who are deemed to be in the last few days to hours of life should be
managed to a high standard – please follow the guidance in th
e Last Days of
Life Care plan to ensure high quality care.
o Referral to specialist Palliative Care services should be made in the usual way
via the e-referral on th
e palliative care webpage. Urgent advice should be
sought through the palliative care triage phone 29163/021 227 3529.
Version: 5, 18 August 2021
Document owner: Service Clinical Director, Infectious Diseases
Authors: Mark Hobbs, Annabelle Donaldson, Rebekah Lane,
Thomas Hills, Mitzi Nisbet, Eamon Duffy, Colin McArthur
Approver: Ian Dittmer, COVID Clinical lead,
Alex Pimm, COVID-19 Incident Controller
References
Interim guidelines for the clinical management of COVID-19 in adults. Australasian
Society for Infectious Diseases Limited (ASID).
www.asid.net.au/documents/item/1873
• Clinical management of severe acute respiratory infection (SARI) when COVID-19
disease is suspected. Interim guidance. 13 March 2020.
• https://www.who.int/publications-detail/clinical-management-of-severe-acute-
respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected
• Interim clinical guidance for management of patients with confirmed coronavirus
disease (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-
guidance-management-patients.html
• ANZICS COVID-19 Guidelines. https://www.anzics.com.au/coronavirus/
• Kings Critical Care – evidence summary clinical management of COVID-19.
www.nwpgmd.nhs.uk
• Massachusetts General Hospital. Department of medicine COVID-19 treatment
guidance. https://www.massgeneral.org/news/coronavirus/treatment-guidances
• National COVID-19 Clinical Evidence Taskforce. Caring for people with COVID-19.
https://covid19evidence.net.au/
• EDguidelines.com. COVID-19 Emergency Department assessment and management
guideline. https://www.edguidelines.com/covid-19-resources/covid-19-emergency-
department-assessment-and-management-guideline/
• THANZ Thrombosis and Haemostasis Society of Australia and New Zealand
Guidelines.
https://www.thanz.org.au/resources/thanz-guidelines
The RECOVERY collaborative Group. Dexamethasone in hospitalized patients with
Covid-19 – Preliminary report. DOI: 10.1056/NEJMoa2021436.
Beibel JH, Tomashek LE, Dodd, LE et al. Remdesivir for the treatment of Covid-19-
preliminary report. DOI: 10.1056/NEJMoa2007764.
Ding L,Wang L,MaW, He H. Efficacy and safety of early prone positioning combined
with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort
study.
Crit Care. 2020;24(1):28. doi:10.1186/s13054-020-2738-5
Beigel J, Tomashek K, Dodd L et al. Remdesivir for the treatment of COVID-19 – Final
report. N Engl J Med 2020; 383: 1813-26.
The REMAP-CAP Investigators. Interleukin-6 Receptor Antagonists in Critically Ill
Patients with Covid-19 – Preliminary report. doi:
https://doi.org/10.1101/2021.01.07.21249390 [Pre-print]
The WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group.
Association Between Administration of Systemic Corticosteroids and Mortality
Among Critically Ill Patients With COVID-19 – A Meta-analysis. JAMA.
2020;324(13):1330-1341. doi:10.1001/jama.2020.17023.
Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a
randomised controlled, open-label, platform trial. Lancet 2021; 397: 2049–59
Inhaled budesonide for COVID-19 in people at high risk of complications in the
community in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive
platform trial Yu, Ly-MeeYu, Ly-Mee et al. The Lancet, August 10, 2021.
DOI:https://doi.org/10.1016/S0140-6736(21)01744-X
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