SKU triaging system for Covid-19:Written for HD patients but can be adapted for use in all patients attending OPD

Updated Thursday 06/08/2020 V Ingham, S Lawman, E Gillingham, J Widgery

New guidance re de-isolation, 2 negative swabs needed at day 14 and 16 if on red/amber or yellow pathways• Patients will remain in a covid red/amber /yellow area for a minimum of 14 days if they

have a positive swab /exposed• If on red/amber pathway and thought to be clinically better without temp for 48 hrs, then

re-swab on day 14• If on yellow pathway, review well and re-swab at day 14• Then repeat at day 16• If both swabs negative and clinically happy for de-isolation, de-isolate from day 17 to the

green pathway

We have 5 types of patients

Patient well Green pathway

Patient well but household or HD contact with suspected or swab positive COVID Yellow pathway (new 23.7.20)

Patient well but contact of contact Blue pathway (new 23.7.20)

Patient suspicious with COVID symptoms but swab negative or swab awaited Amber pathway

Patient known COVID positive on swab Red pathway

Swab logs: Remember to add your patients to the new swab logs which have been generated

• Log of swabs for RED, AMBER and YELLOW patients in all SKU

• Log of swabs for BLUE patients in the HD lock down cohort

• Log of swabs for GREEN patients requiring admission or theatre

• Log of swabs for pts moving HD unit, new to HD or HD in-patient weekly swabs

Algorithm 1: What to do when the triaged patient has a temperature of less that 37.8

Algorithm 4: What to do when the triaged patient HAS a temperature of 37.8 or greater

Algorithm 5: What to do when1. Triaging nurse decides patient HIGH RISK unwell and thinks patient may need isolated HD

or 2. Patient called before they arrive at dialysis and they have a positive check list of symptoms

Algorithm 6: What to do when a patient rings up in advance of their HD session to report a problem

SKU triaging system for Covid-19:Written for HD patients arriving for HD in any dialysis unit without known Covid-19

Can be adapted for use in all patients attending OPD Updated Friday 17 July 2020 V Ingham, S Lawman, E Gillingham, J Widgery

On arrival to each HD unit the patient will be triaged and asked1) Are they are unwell? Have you a new onset cough within the last 7 days or fever. Or new onset loss of taste or smell2) Do they have a household member who are self isolating because of covid-19 symptoms: There are (A) new onset continuous cough OR (B) fever3) Have you been advised to stay at home for 12 weeks as they should be shielding as they are highly vulnerable (transplant/immunosuppression)4) And have their temperature taken

Algorithm 9 : What to do when the patient has KNOWN COVID-19

Algorithm 10: Patient unwell with NON COVID illness and requires admission

Algorithm 11: Asymptomatic patient new to dialysis

Algorithm 12: Asymptomatic patient transferring to another HD unit eg satellite or DAFB

Algorithm 2: What to do when the triaged patient is well but (A) a household contact is unwell with covid/suspected covid or has a close contact with someone with covid/suspected covid at home (in line with track and trace guidance) OR (B) has a contact with covid/suspected covid on the

ward or HD unit

Algorithm 3 : What to do when the triaged patient is well but when someone in their HD cohort has had contact with a covid/ suspected positive patient (BUT YOUR PT HAS NOT HAD DIRECT CONTACT) and that covid +ve person had not been isolated on the yellow pathways for HD (contact

of contact)

Waiting areas

Advise all patients to ideally sit 2m apart (all units) and all pts should be wearing a FRSM (fluid resistant surgical mask)Aim to get HD patient into their HD room as soon as possible to minimise waiting area time

• Green ARRIVAL waiting room area: for HD pts on arrival to HD

• Green DEPARTURE waiting area: for HD pts on finishing HD

• Non HD highly vulnerable Waiting room: for non-dialysis pts advised to stay at home for12 weeks (transplant/immunosuppression)

• Yellow waiting area: ONE PATIENT ONLY USE at a time. For yellow outpatients or yellow HD pts requiring assessment prior to HD (known yellow HD pts should go directly into their HD room)

• Amber waiting area: ONE PATIENT ONLY USE at a time. For amber outpatients or amber HD pts requiring assessment prior to HD (Known amber HD pts should go directly into their HD room)

• Covid positive waiting room: MULTIPLE OCCUPANCY POSSIBLE. For red covid positive pts (HD pts should go directly into their HD room)

Other satellite HD units will develop their green arrival and departures waiting rooms and waiting room for patients they have acutely discovered to be high risk (amber, yellow or red)

Accurate recording HD sessions on CV5HD patient to keep to regular slot, room, location wherever possible

• All HD pts having HD must use a programmed card even if visiting or having just one session of HD in that unit. This helps identification of patients having HD in case there is a positive COVID case and contacts can be easily identified

• HD patient must remain whenever possible on the same HD shift and within the same room/ satellite unit

• Other procedures/scans etc need to be arranged around the HD sessions so that they don’t need to move the HD session

• HD patient should remain to have single person only transport

• HD pts must move directly to the arrival/departure waiting room before or after HD and must not stop in other waiting rooms to talk to other patients outside their am/pm/twilight group

Patient had NO symptoms and no contacts

Algorithm 1: What to do when the triaged pt has a temperature of less than 37.8oC

Patient states they have been unwell at home

Designated amber single person use isolated waiting room

Patient WELL with no symptoms BUT household member unwell

Patient states they have:

• New onset cough

• New onset fever at home (>37.8) but not documented today or feeling unusually hot at home but no thermometer to check temp

• Patient has evidence of pneumonia/ chest infection or respiratory distress with breathlessness and unable to do normal activates because of this

• New onset confusion

No swabs

Regular Green arrival waiting room

Single patient transport with PTS home

Dialysis or clinic as usual

LOW RISK HIGH RISK

On arrival to each HD unit the patient will be triaged and asked1) Are they are unwell? Have you a new onset cough within the last 7 days or fever or new onset loss of taste or smell2) Do they have a household member who are self isolating because of covid-19 symptoms: These are (A) new onset continuous cough OR (B) fever3) Have you been advised to stay at home for 12 weeks (transplant/immunosuppression)4) And have their temperature taken

NON dialysis pts: Patient had NO symptoms but has been advised to stay at home for 12 weeks (shield) (transplant/ immunosuppression/ chemotherapy)

Dedicated non HD vulnerable waiting

room

LOW/ IS RISK

Dialysis pt CKD 3-5/ Hypertension or other non-dialysis pt not on immunosuppression

Identify if household contact has definite covid +ve or only suspected. Identify date of +veswab or start of symptomsAdd to the log

Swab our well pt with a household contact.

Yellow single person use waiting room or cohorted HD group if

contact with +ve HD pt

Follow algorithm 2

Bleep 8808 to discuss the case. • If in MRDU and well enough to start HD: isolated HD

in MRDU and medical review. If too unwell to start HD: do not start HD until medical review.

• If in satellite HD unit: decide whether person can have HD in some degree of isolation in the base unit if well enough and then MRDU next time. If not well, transfer for isolated HD in MRDU and medical review

(A) BUT household member unwell or another close contact

Identify if contact has definite covid +ve or only suspected. Identify date of +ve swab or start of symptomsAdd to the log ‘log of swabs Yellow

Swab our well patient at time 0 ie upon discovering contact. Tell pt they need to self isolate at home for 14 days

Yellow single person use isolated waiting room

Patient had NO symptoms

Algorithm 2: What to do when the triaged patient is well but (A) a household contact is unwell with covid/suspected covid or has a close contact with someone with covid/suspected covid at home (in line with track and trace guidance) OR (B) has a contact with covid/suspected covid on the ward or HD unit

MRDU HD, not in satellite. In

isolation NOT WITH AMBER

OR RED PT Sessional check by dr to

ensure our pt well

If our pt unwell: re-swab and adopt amber or red pathway straight away. Otherwise re-swab at 7 AND 14 AND 16 days

Our pts swab at 14 and 16 days negative and our ptremains well ANDcontact well with no fever for 48hrs AND negative swab:Our pt can return green and to usual hd unit

If our pts unwell: amber/red pathway

If household contact positive still: our pts to remain yellow and review in 1 week

Swab our if household contact swab unknown, chase and our pts remains yellow

Yellow pts who are a household contacts must remain isolated from one another (B) BUT a person on the HD

shift they have HD with has or is suspected of COVID

Identify if contact has definite covid +ve or only suspected. Identify date of +ve swab or start of symptomsAdd to the log ‘log of swabs Yellow’

Cohort this group of HD patients . (Positive pt moves out to red

pathway). This will include all pts that the positive patient had transport

with, were in the waiting room with or HD room with. So effectively will be

the WHOLE HD SHIFT.

This whole cohort should be in one waiting room and no-one new can move in or out of this cohort. They must not enter the HD room until people from the other shift have

moved out.

If this happens in a satellite HD unit, the cohort of HD pts must stay in the

HD unit but the positive pt moves out to red pathway on MRDU

Swab our well patients at time 0 ieupon discovering contact. Tell pt they need to self isolate at home for 14 days

Sessional review by

team to ensure pt well

If HD cohort pt unwell: re-swab and adopt amber or red pathway straight away. Otherwise re-swab at 7 AND 14 AND 16 days

If all HD cohort ptswabs at 14 and 16 days are negative and pts well , pts can return green

If any pt in HD cohort has a day 14 or 16 +ve swab, whole cohort remains yellow and repeat for further 2 weeks , removing the positive pt to red pathway

Who would be contacted by Track and Trace : 1. If household contact has covid2. If you have contact with a covid +ve person up to 48hrs before they developed symptoms and you were

• having face-to-face contact with then (at less than 1 metre away)• spending more than 15 minutes within 2 metres of them• travelling in a car or other small vehicle with them (even on a short journey)

or close to them on a plane

The other patients who dialysed with this contact person, must now form a lock down group So patients on the same HD shift as they may have used the same waiting room, been at a chair <2m apart form the contact in the HD room or shared transport must form a lock down cohort,

All identified patient should be added to the lock down blue log

All identified patient must from now on dialysis in a cohort, with no other patient at the same time. Swab cohort at day 0, 7 and 14 Nursing staff to check at the start of HD that patients remain well and if not, request a medical review or discuss with 8808 if in a satellite unityIf symptomatic : move into isolation and follow the amber pathway

Would need clear strict waiting room plan. This cohort group would need to wait in their waiting room before all the people in their HD room have vacatedThe lock down cohort could continue to have HD in the satellite unitThis cohort, AS NO-ONE HAS HAD DIRCET CONTACT WITH A POSITIVE CASE, does NOT need to self isolate for 14 days and we do not need to inform transport

This is about someone who should be on the yellow pathway having HD next to someone else/a group of other people. So these people become contacts of a contact. The definite contact moves to the yellow pathway

If at day 14 patients asymptomatic and negative swabs, de-isolate to green pathway

If symptomatic or positive swab: move into isolation from the cohort on the amber or red pathway Then the whole cohort to move from blue to yellow n pathways as they have NOW had contact with a definite positive pt, and follow yellow pathway

Algorithm 3 : What to do when triaged patient is well but when someone in their HD cohort has had contact with a covid suspected/+ve patient and that patient had not been

isolated (on yellow/amber pathway for HD). Therefore this is NOT direct contact, but a contact of contact. See Renal ward IP Covid BLUE pathway for managing inpatients.

Algorithm 4: What to do when the triaged patient HAS a temperature of 37.8 or greater

Follow algorithm 4: What to do when triaging nurse decides patient is HIGH RISK and

thinks patient may need isolated HD

HIGH RISK

Designated amber single person use isolated waiting room

All patients need a medical review Patient

Ask particularly about the following symptoms:

• New onset cough

• New onset fever at home (>37.8) or feeling unusually hot at home but no thermometer to check temp

• Patient has evidence of pneumonia/ chest infection or respiratory distress with breathlessness and unable to do normal activates because of this

• New onset confusion

Bleep 8808 to discuss the case. • If in MRDU and well enough to start HD: isolated HD

in MRDU and medical review. If too unwell to start HD: do not start HD until medical review.

• If in satellite HD unit: decide whether person can have HD in some degree of isolation in the base unit if well enough and then MRDU next time. If not well, transfer for isolated HD in MRDU and medical review

If too unwell to go home: Dr to contact on call medical team following medical management algorithm

Is pt unwell and would usually: call 999 to send to local A+E. Inform 8808 via bleep

Would NOT normally call 999: So bleep 8808 and run through check list of symptoms above in order to decide what to do next

In satellite HD unitIn MRDU

Designated isolated waiting room

Algorithm 3: What to do when1. Triaging nurse decides patient HIGH RISK unwell and thinks patient may need isolated HD

2. Patient called before they arrive at dialysis and they have a positive check list of symptoms

Designated HIGH RISK isolated waiting room

YES, NOT that unwell: initiate dialysis in a covidamber HD area. FOLLOW

protocol for tests required

NO, UNWELL: seek medical help before initiating dialysis in a covid amber HD area

Is patient well enough that you would usually start HD

Covid-19 swab

If well to go home at the end of dialysis, home and tell them and household contacts to self isolate for 14 days

If UNWELL: transfer to RSCH MRDU for

dialysis with a medical review and

dialysis in an isolated amber HD area

If too unwell to go home: Dr to contact on call medical team following medical management algorithm

In satellite HD unitIn MRDU

Designated isolated single person use waiting room

PT: apply FRSM

Algorithm 5: What to do when:1. Triaging nurse decides patient HIGH RISK unwell and thinks patient may need isolated HD 2. Patient called before they arrive at dialysis and they have a positive check list of symptoms

Add patients to the ‘Red. Amber, yellow’ log

Designated amber isolated waiting room

YES, NOT that unwell: initiate dialysis in an

isolated amber HD area. FOLLOW protocol for

tests required

NO, UNWELL: seek medical help before

initiating dialysis in an isolated amber HD area

Is patient well enough that you would usually start HD

If well to go home at the end of dialysis, home and tell them and household contacts to self isolate for 14 days

If NOT unwell and able to have HD in some degree of isolation in the base unit: initiate dialysis in satellite unit.

BUT discuss with 8808 BEFORE initiating this and need MRDU HD

next session. If cannot isolate, transfer to MRDU that day

AMBER pts cannot be cohorted, they must remain isolated from one another

HD staff to wear FFP3/Eye protection/Full-length fluid repellent gown and gloves. They must not HD anyone else other than amber and red pts THAT DAY

Algorithm 6: What to do when a patient rings up in advance of their HD session to

report a problem

Patient calls HD before they arrive to say very unwell

Advise they call 999 as they would usually to go to AE

If any of the above: Contact 8808 for more advice detailing the problem.

Will need check list symptoms as may need MRDU HD

Patient states they have:• Household/ other known contact with covid patient

or been told to isolate by Track and Trace system

• New onset cough

• New onset fever at home (>37.8) but not documented today or feeling unusually hot at home but no thermometer to check temp

• Patient has evidence of pneumonia/ chest infection or respiratory distress with breathlessness and unable to do normal activates because of this

• New onset confusion

• SWAB negative: a senior decision maker (JW or spr/consultant) need to decide of the patient can come out of isolation

• This would be for pts who have a reliable alternative diagnosis and no worsening of symptoms

• If this cannot be determined they remain on the amber route for 14 days and then reviewed again as per protocol . STAY SAFE

Algorithm 7: What to do when a patient is on the amber pathway and has a negative swab

Swab results

If • swab negative at day 14 AND 16AND • clinically well De-isolate to green pathway

If • clinically remain unwell OR • swab positive at day 14 or 16Review again in 1 week and remain RED

At day 14 after the symptoms began a senior decision maker (JW or spr/ consultant) to decide if the patient can come out of isolationSwab at day 14 and 16Review symptoms: need to have been free of fever for 48hrs and had no ongoing worrying symptoms (still may have cough)

Medical review each session in isolated amber HD area

Algorithm 8: What to do when a patient is on the amber pathway and has a positive swab

SWAB positive: HD in positive Corona cohort area in MRDU

and follow red corona +vepathway algorithm 7

Swab results

Algorithm 9: What to do when the patient had KNOWN COVID-19

Options for where you an dialyse a Covid positive patient:• Isolated HD in MRDU side room• Cohorted HD side room with all + pts • Bay in HD with all +ve cohort• Trafford ward SR/ ward cohorted bay with all +ve pts• RRT on ITU

Do not mix unconfirmed amber pts with positive red covid patients

If confirmed COVID-19HD staff to wear FFP3/Eye protection/Full-length fluid repellent gownand gloves

HD staff must not HD anyone else other than amber and red pts THAT DAY

If cardiac arrest or AGP:Staff PPEFFP3 mask or hoodFull-length fluid repellent gownEye protectionGloves

Confirmed Covid positive

Positive covid

Pt PPE: Sessional FRSM

HD in RSCH MRDU only

Dedicated covid positive waiting area

Medical review each HD session. FOLLOW protocol for tests required

If well to go home at the end of dialysis, home and tell them and household contacts to self isolate for 14 days then review as below

If too unwell to go home: Dr to contact on call medical team following medical management algorithm

This would be for pts who had been free of fever for 48hrs and had no ongoing worrying symptoms (still may have cough)

They should have a repeat swab on day 14 and day 16

If • swab negative day 14 AND 16AND • clinically wellDe-isolate to green pathway

If • clinically remain unwell OR • swab positive day 14 or 16Review again in 1 week and remain RED

At day 14 after the symptoms began a senior decision maker (JW or consultant) to decide if the patient can come out of isolation

Algorithm 10: Patient unwell with NON COVID illness and requires admission

Regular waiting room and HD

Send covid swab but remain on the green route and do not await result to determine IP

ward allocation, should be green

Add patient to the ‘Log of green patient swabs for admission or theatre’

Algorithm 11: Asymptomatic patient new to dialysis

Swab at day 0

Algorithm 12: Asymptomatic patient transferring to another HD unit eg MRDU to satellite OR satellite to MRDU

Swab within 72 hrs of planned transfer and only transfer if negative

If emergency transfer to MRDU (when usually have HD elsewhere) swab on day 0 on arrival

Algorithm 13: HD patient inpatient

If HD patient IP in BSUH need to ensure have weekly swabs

If HD patient IP in another non RSCH hospital need to ensure have weekly swabs

Algorithm 14: Asymptomatic patient planning DAFB

Swab within 7 days or travel and then again within 72 hrsAdvise not to travel if positive COVID patient in DAFB unit or if COVID within our unit

Isolated HD in MRDU for 2 weeks on return from DAFBSwab at day 0 , 7 and 14 and again day 16

If well and asymptomatic and swab negative at day 0, 7, 14 and 16: return green unless BBV issue requiring longer isolation

Patient PPE: vulnerable/ shielding pts (Dialysis, TX, immunosuppressed) • Must wear a FRSM (fluid resistant surgical mask)

• This is at all times they are outside their house including in patient transport to and from their home

• They will wear this throughout their time in the department ie in clinic or on dialysis

• Dialysis pts will be given a face mask to take home to wear on their next HD session and should put it on when they leave their home from home

• Dialysis pts will be advised that the mask if for their personal use and no for other family members and must remember to wear it and not loose if for their next session as they are a scarce resource and need to be looked after

Staff PPE: As per PHE and the local Trust guideline, updated as per the RA 1 Aug 2020Masks• Wear a FRSM (fluid resistant surgical mask) at all times when with our vulnerable and shielded for the whole

session ie this is in all our areas unless in the back office with no patient contact . This includes reception staff. • Wear an FFP3 mask if a patient is on the amber or red pathway or has as a cardiac arrest/ intubated for pts in the

renal block

Eye protection • Wear sessional eye protection when doing HD for all pts as is policy• Wear sessional eye protection if working with suspected or covid positive pt

Gowns and Aprons• Single use apron and gloves for all pt contacts• Wear long sleeved full length gown if HD pt on the red or amber pathway

PPE

Where to send COVID-19 for HD patients to:MRDU to RSCH lab for in house processing

Worthing HD samples to Chichester.

Polegate and Bexhill HD samples to Eastbourne Hospital and then processed in Southampton

Crawley HD samples to RSCH via the laboratory at PRH