North Shore Hospital Campus
Shakespeare Road, Takapuna
Private Bag 93-503, Takapuna
Telephone: 09 489 0527
22 October 2021
Via email: [FYI request #16919 email]
Re: OIA request – COVID-19 treatment protocols
Thank you for your Official Information Act request received 28 September seeking information from
Waitematā District Health Board (DHB) about COVID-19 treatment protocols.
Before responding to your specific questions, it may be useful to provide some context about our
Waitematā is the largest and one of the most rapidly growing DHBs in the country, serving a
population of around 650,000 across the North Shore, Waitakere and Rodney areas. We are the
largest employer in the district, employing around 8,600 people across more than 80 locations.
In addition to providing care to our own resident population, we are the Northern Region provider of
forensic mental health services and child rehabilitation services, plus the metro Auckland provider of
child community dental services and community alcohol and drug services.
In response to your request, we are able to provide the fol owing information:
1. What is the Covid-19 treatment protocol for hospitalised cases?
Our COVID-19 Clinical Guide is attached – Attachment 1
2. Are some DHBs fol owing different treatment protocols from others?
Yes, some protocols differ from DHB-to-DHB.
3. Are DHBs free to make decisions about treatments for individuals with COVID-19?
While DHB protocols are based on the individual needs of each DHB, we are subject to Ministry of
Health overview. In addition, the metro Auckland DHBs (Auckland, Counties Manukau and
Waitematā) have a Clinical Technical Advisory Group (CTAG) to guide the treatment of COVID-19-
4. To what extent are patients able to participate in decision-making about their treatment
Treatment cannot be provided unless patients give informed consent, except in certain limited
circumstances, such as emergencies. Patients are able to fully participate in decision-making about
their treatment programmes. We comply with the Health and Disability Commission (HDC) Code of
Health and Disability Services Consumers’ Rights, including:
Right 6 - Right to be fully informed
(1) Every consumer has the right to the information that a reasonable consumer, in that consumer's
circumstances, would expect to receive, including—
(a) an explanation of his or her condition; and
(b) an explanation of the options available, including an assessment of the expected risks,
side effects, benefits, and costs of each option; and
(c) advice of the estimated time within which the services wil be provided; and
(d) notification of any proposed participation in teaching or research, including whether the
research requires and has received ethical approval; and
(e) any other information required by legal, professional, ethical, and other relevant
(f) the results of tests; and
(g) the results of procedures.
(2) Before making a choice or giving consent, every consumer has the right to the information that a
reasonable consumer, in that consumer's circumstances, needs to make an informed choice or give
(3) Every consumer has the right to honest and accurate answers to questions relating to services,
including questions about—
(a) the identity and qualifications of the provider; and
(b) the recommendation of the provider; and
(c) how to obtain an opinion from another provider; and
(d) the results of research.
(4) Every consumer has the right to receive, on request, a written summary of information provided.
5. If a patient requests a blood test for Vitamin D and/or the administration of high-dosage
Vitamin C, are hospital staff able to provide these?
Clinicians are only able to provide treatment as clinically indicated. If their clinical view is that
Vitamin D and/or the administration of high-dosage Vitamin C will not benefit the patient and,
therefore, is not clinically required, they are not required to provide it.
Patients have a right to care of an appropriate standard, taking into account their clinical
6. Do hospital staff have the right to refuse a patient's request and, if so, is there a process for a
patient to appeal the decision?
Hospital staff have the right to refuse a patient’s request if their clinical view is that the treatment
requested is not indicated for the patient’s condition or there is insufficient scientific evidence
supporting its use for the patient’s condition.
Where a patient requests a second opinion, this is facilitated where possible.
Clinical staff discuss treatment options and pathways with each patient, providing the information
necessary for the patient to provide informed consent. If the patient does not agree with the
proposed treatment(s), they have the right to refuse treatment.
They also have the right to obtain honest and accurate answers to their questions and to seek a
second opinion from another provider.
I trust that this information is helpful.
Waitematā DHB supports the open disclosure of information to assist community understanding of
how we are delivering publicly funded healthcare. This includes the proactive publication of
anonymised Official Information Act responses on our website from 10 working days after they have
If you consider there are good reasons why this response should not be made publicly available, we
wil be happy to consider your views.
Executive Director Hospital Services
Waitematā District Health Board
SURNAME: ____________________________________ NHI: _____________
COV I D -1 9
FIRST NAMES: ____________________________________________________
Date of Birth: _______ /_______ /_______ SEX: _____________
C O V I D - 1 9 C L I N I C AL G U I D E
At Waitematā District Health Board, patients are screened via the COVID Screening and Clinical Assessment
to determine an appropriate management stream based on clinical criteria and epidemiological risk
(higher index of suspicion).
This clinical guide is recommended for use in probable
or confirmed COVID-19 cases
patients who have had a confirmed COVID diagnosis in the community and are presenting for acute
assessment in ED or ADU. It has been adapted from the Australian National COVID-19 Clinical Evidence
and the National Institute of Health COVID-19 Treatment Guidelines,
and aligns with clinical
guidance across the Auckland region.
The COVID/ID physician on call would expect to be involved at an early stage in the management of
START OF CLINICAL GUIDE - PPE AND ISOLATION
Ensure appropriate PPE and isolation measures are in place at the time of assessment
The guidelines on recommended PPE for different clinical settings is located on the intranet here.
RELEVANT HISTORY TO BE DOCUMENTED AT TIME OF ASSESSMENT AT WDHB
CLINICAL CRITERIA - (RECENT ONSET
Ensure a full interrogation of current locations
Until the extent of community transmission is
identified, all adults with respiratory symptoms with
Anosmia or dysgeusia
onset after 12 August wil be initially managed as
New or worsening cough
Note that patients with clinical criteria who have
Shortness of breath
exited a MIF within 2 weeks will be Blue stream
Relevant comorbidities known to confer high risk of severe disease - Chronic respiratory disease,
cardiovascular disease, obesity, age >65, diabetes, active malignancy or chronic organ failure
1. Patients meeting the clinical criteria for COVID-19 should be tested. Some people may present with
less common symptoms such including diarrhoea, headache, myalgia, nausea, vomiting, or
confusion/irritability. If there is not another more likely diagnosis, perform SARS-CoV2 testing
Authorised by: COVID-19 IMT
Issued Date: 02/09/2021 v7
Classification #: COV-016
TIPS FOR RE-STREAMING TO LILAC
Consider vaccination, community
- contact Laboratory 42326 if result required urgently
prevalence, exposure history (Locations of
- add extended viral PCR panel if compatible illness
interest, family primary contacts),
alternative cause for symptoms
Lower respiratory sample (sputum) -
Consider testing if >1-2 weeks into illness
Test for SARS-CoV-2, M/C/S, viral respiratory panel
PCR sensitivity highest (90-94%)
and atypical respiratory panel
first 1-2 weeks of illness
Full blood count
CXR reduced specificity in low
Serum chemistry - Electrolytes, Renal function, Liver
Function, Ferritin, CRP
Coagulation studies and D-dimer
Repeat NP swabs are not routinely
required but may be requested by ID
Consider ABG if hypoxia or concern re: hypercapnoea
Screen for alternative infective aetiology as
indicated -consider blood cultures, urinary legionella
and pneumococcal antigens
IDENTIFY PATIENTS ABLE TO BE STREAMED FROM BLUE TO LILAC
If no exposure or incompatible timing of symptom onset, negative PCR (conducted ≥1d but <7-14d of
symptoms) or alternative source found - can change stream from blue to lilac
If you are not confident to exclude COVID-19 based on negative SARS-CoV2 PCR result for the above or other
reasons please contact COVID ID SMO. The patient will remain Blue Stream ‘under investigation’
ID wil advise on streaming and additional investigations. Possible work up may include repeat NP PCR,
sputum (prolonged illness or specific CXR changes), additional imaging including CT chest, serology (if >14d
of symptoms). ID wil review and advise on change of stream in these cases.
COVID CONFIRMED: ASSESS CURRENT SEVERITY OF COVID DISEASE
Consider the current stage of the disease and the potential trajectory.
Note - patients have the potential to deteriorate in the second week of illness.
SIGNS AND SYMPTOMS
Symptoms and signs consistent with COVID-19 but no symptoms or signs
of pneumonia and normal (or unchanged) oxygen saturation
COVID-19 disease with pneumonia or dyspnoea but not meeting criteria for severe
illness (SpO2 ≥ 92% on room air at rest)
COVID-19 pneumonia with one of the following: RR ≥30/min, oxygen saturation <92%
on room air at rest, or PaO2/FiO2 ≤ 300.
Respiratory failure, shock, impairment of consciousness, or multiple organ
Authorised by: COVID-19 IMT Issued Date: 02/09/2021 v7
Classification #: COV-016
ANAGEMENT RECOMMENDATIONS FOR CONFIRMED COVID CASES
Discuss whether this patient should be admitted with the ID/COVID physician. Patients
with severe or critical COVID-19 should be admitted to hospital as should some patients
with mild or moderate COVID-19 but who are vulnerable or need admission for other
reasons (e.g. infection prevention and control if from an Aged Residential Care facility).
Goals of Care
Establish ceiling of care and resuscitation decisions. Discuss with patient and whānau,
documenting the outcome. Check whether the patient has an advanced care plan or
Give supplemental oxygen if hypoxic. This should be prescribed on MedChart.
• Target saturations of 92-96% or 88-92% if Type 2 Respiratory Failure
Oxygen via High-Flow Nasal Prongs can be considered in a negative pressure room
with appropriate PPE if required to maintain SaO2 ≥ 92%. Link here [Paul’s doc]
Discuss enrolment in the ASCOT trial (liaise with Dr Bhal y).
Use treatment dose enoxaparin (1 mg/kg bd) for patients with moderate / severe
COVID-19 disease who are not admitted to ICU/HDU with normal renal function and
no risk for major bleeding. Consider therapeutic anticoagulation 1 mg/kg once daily in
renal impairment with a CrCl <30 ml/min. Discuss with haematology if platelets <50 or
fibrinogen <1. Discuss dosing and duration of enoxaparin in pregnancy with obstetric
Consider giving five days of remdesivir (protocol here)
to patients who meet the
following Pharmac inclusion criteria:
Oxygen saturations ≤92% on air and requiring supplemental oxygen
ALT <5x the upper limit of normal
Do not give remdesivir to patients who meet any of the exclusion criteria (e.g.
multiorgan failure, renal impairment with an eGRF <30 ml/min or requiring dialysis,
requiring mechanical ventilation for > 48 hours, receiving ECMO)
Give 200 mg IV on day one and then 100 mg IV daily for four more days.
Give dexamethasone 6 mg IV/PO daily for up to 10 days in patients requiring oxygen
and/or ventilatory support to maintain oxygen saturation ≥92%.
Steroids can be given for another evidence-based indication (e.g. asthma/COPD
exacerbations) as per usual practice.
Give tocilizumab (protocol here)
8 mg/kg (up to 800 mg) as a single dose to patients
receiving dexamethasone (or where dexamethasone is contraindicated) with a
persistent oxygen requirement, evidence of systemic inflammation (e.g. CRP ≥75mg/L),
and no evidence of an active and severe secondary infection.
Low threshold for regular supplementation – liaise with dietitian if required
Take a conservative approach to fluid if there are no signs of shock,
aiming for SBP >100mmHg.
• Use crystal oid solutions for fluid replacement e.g normal saline or plasmalyte
• If the patient is able to drink, encourage oral fluids
If not, maintenance fluids are 30mls/kg/day + 500-1000mls
Antimicrobials are not routinely recommended
• Give empiric antibiotics if clear signs of pneumonia on chest x-ray (refer to W
. Note - bacterial co-infection with COVID is relatively uncommon
compared to other viral respiratory illnesses
Regular medications should be continued as appropriate for the clinical setting
• Patients who are already taking ACEi / ARB medications should continue on these
unless there are other contraindications e.g. hypotension, AKI etc
• Regular paracetamol should be used for all patients as the anti-pyretic of choice but
NSAIDs are not contraindicated in COVID patients.
Authorised by: COVID-19 IMT Issued Date: 02/09/2021 v7
Classification #: COV-016
PALLIATIVE CARE RECOMMENDATIONS
The Palliative Care Service have developed COVID-19 Palliative Care
pages on the WDHB intranet for
guidance around symptom management, shared goals of care, communication, compassion, and care of the
Symptoms should be assessed and managed for all patients regardless of
prognosis, alongside active and supportive therapies for COVID infection.
• There is a stepwise protocol for symptom management a
vailable on the
Shared Goals of Care Conversations about goals of care
and treatment escalation should
be initiated early, involving patient, family and whānau when
Care of the dying
Information about care of the dying patient is
outlined in detail on the intranet
• Inform family and whānau of what to expect when their loved one is dying
• Ask what practices are important for them.
• Ask if they would like additional support e.g. chaplain or social worker
• Be aware of particular changes in care around death e.g. family unable to
remain with the body or changes to funeral arrangements
Any patient discharge must be discussed with both the COVID/ID physician and ARPHS
Please refer to the latest guidance from the Ministry of Health - a
dvice for health professionals
Admit all COVID patients with severe or critical illness
Consider admission of vulnerable adults regardless of their current severity of illness
Vulnerable adults are patients at risk of rapid deterioration. They are defined as:
• Older adults (aged 65 years or older)
• Patients who live in residential care facilities
• Patients with underlying medical conditions: Chronic respiratory disease, Cardiovascular disease, Diabetes, Cancer,
Chronic organ failure(s)
Note - Repeating nasopharyngeal swabs to document ‘clearance’ for confirmed cases is not generally
recommended and should be discussed with the ID SMO on a case-by-case basis.
Useful additional clinical resources include:
The World Health Organisation case management guide
Australian National Covid-19 Clinical Evidence Taskforc
e living guidelines
(endorsed by the Australasian
Society for Infectious Diseases)
uthorised by: COVID-19 IMT Issued Date: 02/09/2021 v7
Classification #: COV-016