1. Statement and Aim - East Devon · Web view2020/05/13 · 8.2 – Telephone Triage criteria6 9....

V1.5 SMP April 17th 2020 SOP CC19

Standard Operating Procedure for RDE COVID remote monitoring service

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1. STATEMENT AND AIM.....................................................................................................................................................................32. SCOPE OF THE DOCUMENT...............................................................................................................................................................33. SERVICE OVERVIEW........................................................................................................................................................................34. STAFFING......................................................................................................................................................................................35. GOVERNANCE................................................................................................................................................................................36. LENGTH OF INTERVENTION...............................................................................................................................................................37. COMMUNITY COVID 19 (CC19) PROCESS MAP.................................................................................................................................4FOR PATIENTS THAT HAVE BEEN DISCHARGED TO HOME AND WHO ARE CONFIRMED AS COVID +VE..................................................................48. PATIENT ASSESSMENT.....................................................................................................................................................................5

8.1 – Criteria for the CC19 team referral...................................................................................................................................58.2 – Telephone Triage criteria.................................................................................................................................................6

9. ASSESSMENT OVER THE PHONE BY THE CC19 TEAM..............................................................................................................................7...................................................................................................................................................................................................... 710.PROCESS FOR REQUESTING HOME ASSESSMENT VIA COMMUNITY TEAM...................................................................................................7

10.1 Locality H&SC Teams by GP Practice Post Code................................................................................................................711. SUGGESTED GUIDELINES FOR HOME ASSESSMENT...............................................................................................................................9

11.1 Personal Protection Equipment for Home Assessment will be in line with Community Guidance.....................................911.2 Equipment required for assessment – please consider what can be left inside the property and what need to remove. Cleaning of equipment should be in line with the decontamination policy...............................................................................9

12. PROCESS FOR ADMISSION............................................................................................................................................................1013. PROCESS FOR RECORDING PATIENT DETAILS AND ADVICE....................................................................................................................1014. END OF LIFE CARE IN COMMUNITY................................................................................................................................................10

14.1 End of Life Discharge Process..........................................................................................................................................1015. PHASES OF ESCALATION..............................................................................................................................................................11APPENDIX 1 – COMMUNITY CLINICAL ASSESMENT...............................................................................................................................12APPENDIX 2 – INPATIENT ASSESSMENT................................................................................................................................................14

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1. Statement and AimThis document has been developed to outline the procedure to be followed by the COVID 19 remote monitoring team, outline Urgent Community Response Team admission and monitoring processes. The document provides indications of equipment, assessment and information governance.

2. Scope of the documentThis document applies to all members of the COVID19 remote monitoring team and UCR Teams. This Standard Operating Procedure (SOP) is a working document and it may be subject to amendment and modification as the service evolves.

3. Service OverviewThis service will seek to monitor patients who are at home with a confirmed diagnosis of COVID 19. It will aim to provide reassurance and identify patients who are deteriorating and ensure their healthcare is escalated in a safe and appropriate way. The focus will be to provide a safe means for admission avoidance and early supported discharge.

4. StaffingAllocated and experienced staff from community, general medical and respiratory teams will form the CC19 team and community response teams. Support will be accepted by relevant and approved charities. Administration support will be provided for by Medical division.

There will be a minimum staffing of 1 band 6 and admin staff member 7 days a week 8-6 mon-Fri and admin of 8-12 sat and Sunday.

5. GovernanceClinical Leadership is provided by the SDEC & Ambulatory Care Clinical Lead and the Professional Leads for Community Services. Management for the Service falls under Medical Division Governance.

The COVID 19 remote monitoring team will discuss patients with managing consultants via a ‘Virtual Ward’ round. Appropriate medical consultants are linked to the service and the caseload is regularly reviewed. In home assessment will be performed by 7 locality-based HIT teams.

Where an individual is failing to make the expected recovery and may be at risk of admission the patient will be assessed, by phone and if necessary, admitted to the Royal Devon and Exeter Hospital (RD&E) taking the appropriate COVID19 precautions

6. Length of InterventionThe team will track patients through their illness, on average 14 days.

Patients will be discharged back into the care of their GP; a discharge summary will be generated.

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7. Community COVID 19 (CC19) Process Map

For patients that have been discharged to home and who are confirmed as COVID +ve

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CC19 Team Contact Patient Establish baseline health condition & social situation

Inform GP

Triage performed into 4 categories see separate workflow

Follow up Phone Call by CC19 Nurses based on triage category

Task performed by band 6/7 Nurses

Early supported discharge from COVID wards

CC19 Team informed.Patient details and demographics recorded

Patient entered onto database

Patient Condition Satisfactory Patient deteriorating

Conduct more detailed phone consultation (Senior Decision Maker)

Continued remote

monitoring

Arrange Clinical Review in the Community by

UCR teams

Arrange for assessment in Covid-19 designated area according to Surge Plan

Task performed by Clinical Secretaries

Monitored for 14 days and assessed as stable - Discharge

Admission Avoidance From ED or AMU

Community Referral COVID +ve


8. Patient Assessment8.1 – Criteria for the CC19 team referralESD referral must meet following criteria:

a) Low NEWS <4b) No new significant organ dysfunction on lab resultsc) CURB 65 ≤2d) Respiratory rate <24e) Able to recognise and signal for help through self or familyf) No Physician concerns or specialist conditions (e.g. renal transplant) that are not included in criteria

necessitating discussion with specialist and community follow-up

Discharge on Oxygen: Stable oxygen requirements for 48hrs with Fio2 no greater than 4L and sats 94%

All patients discharged over 65, or with multiple comorbidities, need an updated TEP with COVID discussion focussing on appropriateness of readmission.

Admission Avoidance must meet: a) Low NEWS <4b) No new significant organ dysfunction on lab resultsc) Absence of hypoxia (Sats >94% unless prior known disease i.e COPD) and no overt desaturation on 1 min

exercise test (4% drop)d) No Significant imaging abnormality (i.e. chest infiltrates)e) CURB 65 ≤2f) Respiratory rate <24g) Able to recognise and signal for help through self or family h) No Physician concerns or specialist conditions (e.g. renal transplant) that are not included in criteria

necessitating discussion with specialist and community follow-up

2) All patients discharged over 65, or with multiple comorbidities, need an updated TEP with discussion focussed on admission.

OR

End Of Life Referral

Patients that have been considered for discharge home for End of Life Care and this has been discussed and agreed with the family please follow the following process:

a) Complete EOL Discharge checklist (COVID)b) Ensure accurate TEP completedc) Scan both of the above and email to [email protected] subject EOL

Please ensure all social needs are addressed and appropriate Just in Case medications are made available.

Out of Hours there is access to emergency JIC bags via Wynard.

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mailto:[email protected]


8.2 – Telephone Triage criteria

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<70 yearsMultiple ComorbiditiesSpecifically: HTN, Diabetes, CVS, Resp, Ongoing Cancer therapy / Immunosupression

Introduction Call,Provide advice leaflet/ email regarding who to call if deterioration.Provide information on what to look for

Follow up phone calls daily


Follow up phone calls daily andFace to Face assessment Day 5-7 and day 10-12Palliative Plan orLow threshold for admission

Telephone TriagePresenting Symptoms, Day of symptom onset, co-morbidities, Drug history, home circumstances including

POC, Clinical Frailty ScorePlease note ESD box at bottom of page.

<50 yearsNo Comorbidities

50 – 70 yearsNo Comorbidities

>70 yearsAll Patients on oxygenMultiple ComorbiditiesSpecifically: HTN, Diabetes, CVS, Resp, Ongoing Cancer therapyClinical Frailty score> 5



Follow up phone calls day 1,5,7,10,12More frequency if necessary

Triage for ESD

Early Supported Discharge Patients should be regarded as Orange (Cat 3) automatically.

If they have additional features from Red box please triage as Red (Cat 4).

During Visit: Perform frailty with social circumstances assessment. These patients may be identified as palliative and will likely deteriorate rapidly. The social check should be assessed in this context.

Discuss TEP / Escalation plan should be discussed and reviewed


9. Assessment over the phone by the CC19 team.

10.Process for requesting home assessment via community team1. Confirm the patients GP postcode2. Cross reference against 7 localities as listed below3. Contact care coordinator by phone to request 2 hour review.4. Care coordinator will confirm availability5. Review performed at home6. Community team contacts back CC19 with results of review.

10.1 Locality H&SC Teams by GP Practice Post CodeLocality H&SC Team Email address GP Practices and Post CodesExeter Central & EastTel: 01392 465676

[email protected] Mount Pleasant EX4 7BWClock Tower EX4 6PDWhipton EX4 8EGHeavitree South Lawn EX1 2RXSoutherhay Surgey EX1 1RXSt Leonards EX1 1SBBarnfield Hill EX1 1SRISCA EX1 2DWWonford Green EX2 6NF

Exeter South & WestTel: 01392 465614

[email protected] Ide Lane EX2 8UPSt Thomas EX4 1HJFoxhayes EX4 2BHExwick Ex4 2ADPinhoe EX1 3SYBroadclyst EX5 3EJHill Barton EX1 3ENTopsham EX3 0ENWestbank Exminster EX6 8DFWestbank Starcross EX6 8PZ

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Record symptoms and any observations possible. Note following Symptom assessment:

Low Intermediate High RiskHeadaches Productive Cough Resting SOBCough (dry) New SOBOE New OrthopnoeaLoss of appetite New PNDLoss of smell Chest Pains of Cardiac OriginExhaustion RR>24 (Will need Video Consult to

assess)Fevers Unable to complete phrases

Patients can be asked to walk while on phone to assess ability to complete phrases. If patient becomes breathless this would raise concern. This should be taken in context of any background conditions.

If High risk features present patient should be discussed with senior decision maker if possible or admitted directly for assessment.

If Orange symptoms present or concerns discuss with senior decision maker +/- community assessment see process.




Crediton, Moretonhamstead & Okehampton (CMO)

Tel: C 01363 771070 M 01647 442071 O 01837 658047

[email protected] Cheriton Bishop EX6 6JAChiddenbrook EX17 3JJNew Valley EX17 2ARBow EX17 6FBOkehampton Medical Practice EX20 1AYNorth Tawton EX20 2EXHatherleigh EX20 3HZMoretonhampstead TQ13 8LWChagford TQ13 8BW

Honiton & Ottery St Mary (HOSM)Tel: 07794070053Or Hannah 07814296179

[email protected] Honiton EX14 2NYColeridge EX11 1EQCranbrook EX5 7DR

Woodbury, Exmouth & Budleigh Salterton (WEB)Tel: 01395 282111

Rde-tr.web.urgentcommunityresp [email protected] Budleigh Salterton HC EX9 6LSClaremont EX8 2JFRolle EX8 2JFHaldon House EX8 1DQImperial EX8 1DQRaleigh EX8 1DQWoodbury EX5 1NZ

Tiverton & Cullompton (TCU)Tel: 01884 235520

[email protected] Bampton Surgery EX16 9NB Castle Place Surgery EX16 6NP Clare House Surgery EX16 6NJ Mid Devon Practice Morchard Bishop EX17 6NZ Witheridge EX16 6EZ Cheriton Fitzpaine EX17 4JBBlackdown Practice EX15 3SF Bramblehaies Surgery EX15 1TZ College Surgery EX15 1FT New Valley Practice EX5 5NT Wyndham House Surgery EX5 4HZ

Seaton, Axminster & Seaton (SAS)Tel: 01297 300450

[email protected] Axminster EX13 5AGSeaton & Colyton EX12 2DUSid Valley EX10 8ETTownsend EX12 2RY

Out of Hours Nursing TeamTel: 07855 133636

7 days a week 1600-0800

Weekend Co-ordinator – 0345 600 7878

** Please note locality teams are 7 days a week, 9am-5pm – outside of these hours, contact the Out of Hours Nursing Teams**

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mailto:Rde-tr.web.urgentcommunityresp%[email protected]




11. Suggested guidelines for home assessment Home Assessment (use clinical judgement) – if positive findings found (right hand column) consider admissionStandard Clinical exam Observe for cyanosis etcNEWS2 Above 4QSOFA Score (1 point for each of the following: Altered mentation; Systolic Blood Pressure<100; Respiratory Rate >22) to monitor for Sepsis.

2 or above

Respiratory Rate >24 If found patient should be considered for admission independent of other findings

Oxygen Desaturation test Assuming normal sats at beginning – ask patient to walk for 1 min and observe for drop of saturations to <92%

Clinical Frailty Score 6 or greater Assess home care/ circumstances are adequate

Look for other relevant pathology relating to other conditions

The contact number for the consultant on duty will provided to the team at time of referral. The team can call this number during or post assessment for advice.

If a community team has assessed a patient they will need to communicate the findings to CC19 team by telephone who will then document the findings against the patient. This can be communicated to consultant at same time if seeking advice.

Any items from above criteria or general concerns not mentioned above patient should be admitted for assessment or if in doubt contact CC19 consultant.

11.1 Personal Protection Equipment for Home Assessment will be in line with Community Guidance Home assessment with COVID +ve will require 2 people. 1 person will remain clean wearing standard PPE and remain outside the property, they will support the ‘the clinician who has doffed the PPE. The doffed team member will perform the assessment and relay the information the clean member of staff, who will record on the proforma attached to this SOP.

11.2 Equipment required for assessment – please consider what can be left inside the property and what need to remove. Cleaning of equipment should be in line with the decontamination policy.

Saturations monitor (to be left with patient) Automated blood pressure monitor and disposable cuff. (Cuff and/ or machine to be left with patient, if

machine retrieved they should be cleaned. ) Ear thermometer (cleaned post assessment) with probes Observation paper and pen for the doffed clinician (disposed post assessment). Record for the clean person

to relay the information required to the CC19 team. Stethoscope (cleaned post assessment) Wipe clean watch Plastic container PPE gear in line with current recommendations

Additional equipment not to enter home: Plastic container, Chlorhexidine wipes, Laminated protocol, phone, Orange disposal bag and clip.

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12. Process For Admission1. PATIENT/ COMMUNITY TEAM CONTACTS either CC19 or AC (dependent on in hours / OOH)2. CC19/ AC ASSESSES PATIENT AS NEEDING ADMISISON or ASSESSED BY COMMUNITY TEAM AS NEEDING

ADMISSION3. CHECK PATIENT DETAILS AGAINST REGISTER4. NOTIFY ON CALL SITE M ANAGEMENT THAT PATIENT NEEDS ADMISISON5. CC19 / AC CONTACTS MEDCIAL REGISTRAR AND ALERTS PATIENT COMING TO TORRIDGE OR DESIGNATED

LOCATION6. SITE MANAGEMENT ORGANISES BED AND SWAST

13. Process for Recording patient details and advice1. Email sent to CC19 email address2. The patient should be entered onto patient first – Site S. Email should be moved to upload folder.3. Nurse should contact the patient and perform triage moving the patient to relevant box on patient first.4. Each phone call on patient first should be transcribed into notes section on patient first.5. A letter should be sent from CDM to the GP confirming the patient is being followed up by CC196. At the end of follow up period the patient should be discharged from patient first.

The patient lists should be saved everyday onto the shared hard drive.

Access to Site S will be made available to CC19 team, Band 6/7 nurses of AMU, CD urgent Care, AMD Medical Division.

If a community team has assessed a patient they will need to communicate the findings to CC19 team by telephone who will then document the findings against the patient. This can be communicated to consultant at same time if seeking advice.

14. End of Life Care in Community

There will be times when admission into hospital is not appropriate and/ or not in line with patient wishes. Management of these patients will be shared by RD&E community staff and Hospiscare nurses. Where possible standard care will continue however should extreme pressures be placed on community teams assessment maybe performed by telehealth. Carers and families may have to provide greater support than normally expected.

It is considered that access to Just in Case (JIC) bags may become difficult based on pharmacy supplies and syringe driver availability. Patients should be assessed on symptom need and alternative routes of administration should be considered including buccal, transdermal and rectal. Where these are not sufficient consideration of informal carer training should be considered for subcutaneous administration – this will be assessed case by case. Please see separate Endo of Life documentation.

Access to Urgent JIC bags will be made available in community and ambulatory sites that have 24hr access. It is recognised that there may be an increase in need. This will be covered in greater detail within Palliative care proposals.

14.1 End of Life Discharge Process

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Some patients will be seen in hospital and the decision made with themselves and loved ones that it be best they are transferred to community for EOL care.

To expedite this documentation has been created to ensure best possible care is continued into the community. This is in the form of the Acute Care EOL checklist. This is includes a medical transfer covering communication, patient wishes and ongoing management; TEP form; JIC prescription; Patient needs form; Nursing handover.

Each patient discharged will be referred to the CC19 team with the following process:

1. Email to CC19 with subject heading EOL – notes transferred to CC19.2. CC19 team cross reference postcode against locality team and email copies of information including TEP to

appropriate community team. Include in this any urgent need for community assessment.3. CC19 Contact EPACCS register and add patient.4. CC19 add patient to hospital end of life register in Patient First.5. CC19 contact patient or carer to assess safe return and adequate symptom control.

This process will be sufficient to allow Verification of Expected Death in community.

Support for community teams in EOLC advice will be provided by Hospiscare call centre. Face to face support will be provided by primary care and Devon Docs out of hours. Emergency advice where all above unavailable can be through CC19 consultant.

15. Phases of EscalationAHAH (CC19) Community ESD

Green <15 follow ups – Standard follow up

Prioritise green to go patients

Community assessments initiated and monitored for numbers

Extended role to include Pulmonary Fibrosis / Nursing Home >15 Follow ups – ACP

added to team

Orange

50 Patients being actively managed in AHAH

Review pressure pointsDiscuss with AMU clinical leads and Senior NurseDiversion of Band 7 from ESD to support CC19AMU Matron to support AHAH coordination

As aboveCommunity review of working practiceBusiness contingency plansLead checks capacityReview staffing levelsDivert services to aid home reviews

Take all COVID +ve patients with chronic respiratory background

Or >25 Pts being actively managed in community

Further review every 25 referrals

RED 100 Patients on AHAH

AC’s diverted to support CC19Clinical secretaries to take AMU referralsRegistrar diverted from ambulatory/ SDEC.

Review monitoring plan to

Review BCPDaily morning huddles to assess capacity (AND and CC19 clinical Lead)

Review capacity to take over community referrals or add to capacityOr Community

unable to receive new referralsRDE in full escalation

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step down non-essential processes

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APPENDIX 1 – Community clinical assesment

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Appendix 2 – Inpatient Assessment

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1. Statement and Aim - East Devon · Web view2020/05/13 · 8.2 – Telephone Triage criteria6 9....

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