Title COVID-1 Care Bundle

Lucy Lamb, Consultant Infectious Diseases and General Medicine

Primary Author Royal Free London
Used with thanks and her permission
Target audience Clinical Staff
Associated Policies /
NICE CG159, rapid guideline: critical care, March 2020
Documents
Guideline Replacement None

Issue date 20/03/20

Ratified by Medicine Board
Date of ratification 20/03/20
Date for review 31/03/20
Applicable to All sites
Significant change to
New clinical guideline
practice
Implementation plan
(including WeShare
dissemination plan and All clinical staff
audit plan if significant All clinical Boards and Site medical directors
change to practice)
Key words COVID-19 Coronavirus

Version control
Version Date Author Comment
Lucy Lamb, Consultant Infectious
1 19/03/20 Diseases and General Medicine
Royal Free London
Manreet Nijjar, Consultant Infectious Reviewed NA
1.1 20/03/20 Diseases and General Medicine,
Barts Health
Neil Ashman, Medicine Board NICE guidance included
1.2 22/03/20
Nick Bunker, Consultant Critical Care
Martina Cummins, Infection Control Infection control review
1.3 23/03/20 Dr Caryn Rosmarin, Consultant
Microbiologist

1
23/03/20 version 1.3
Confirmed COVID-1 Bundle of Care

This document should be used as a practical guide for care of patients in association with operational
guidance for the care of patients. For all patients a treatment and escalation plan MUST be
discussed and documented with patient (if possible), family and senior decision maker.
1
Clinical Syndromes

1. Mild Illness: Non-specific symptoms can include a fever, fatigue, cough (with or without sputum),
malaise, myalgia, sore throat or headache. Diarrhoea and vomiting are less common (10%).
2. Pneumonia:
I. Non-severe: Adult with pneumonia but no need for supplemental oxygen.
II. Severe: Fever or suspected respiratory infection, plus one of raised respiratory rate >30
breaths/min; severe respiratory distress or SpO2 < 93% on room air. Noting that some
2
people particularly the elderly can get “silent hypoxaemia” with minimal dyspnoea.
3. Acute Respiratory Distress Syndrome: ARDS onset is within 1 week of known insult or
new/worsening respiratory symptoms with bilateral opacities on CXR or CT and no other likely
differential (eg. fluid overload). May be significant hypoxia and other organ dysfunction.

Typical Laboratory Results:

3
FBC – can be normal, but lymphopenia often is common (80% of patients) . Note low platelets
1
(<100) can be associated with poor prognosis .

Clotting – Tends to be normal but DIC can develop associated with a poor prognosis.
4
D-dimer - >1µg/ml poor prognostic marker
1
C-reactive protein – tracks with disease severity and prognosis .

Renal function – limited AKI seen (<10%), except those with known CKD.

Liver function test – Mild transaminitis sometimes seen (ALT>AST)

5
Ferritin - > 2000 ng/ml should investigate further for secondary HLH

Radiological Findings:

Chest X-ray – patchy ground glass opacities (peripheral and basal) – can be subtle. Unilateral
1
changes can be seen. Masses, cavitation, lymphadenopathy and pleural effusions are uncommon.

Investigations for suspected COVID-19 positive patients:

FBC, clotting, U&Es, LFTs, CK, LDH, Ferritin, CRP, glucose, HIV test, β-HCG (in women of
childbearing age), troponin, D-Dimer. Consider malaria RDT and film if appropriate travel history

If pyrexial or septic, blood cultures and/or urine culture

NPS samples for SARS-CoV-2 and respiratory viral pathogens, sputum MCS if productive cough, and
Pneumococcal/ Legionella urinary antigens if consolidation on CXR.
1
ECG, CXR , ABG (if history of type 2 resp failure/COPD/failing to maintain sats >93% on room air)

1
King’s Critical Care – Evidence Summary Clinical Management of COVID-19
2
Xie et al. 2020
3
Yang et al 2/21.
4
Zhou et al Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan,
China: a retrospective cohort study
5
Mehta et al 3/20 Consider cytokine storm syndromes and immunosuppression

2
23/03/20 version 1.3
1. Mild illness COVID-19

Clinical Management Most patients do not require hospital intervention and

should follow PHE guidance to self-isolate and quarantine
family for 14 days.

Supply patient information leaflet

AVOID NSAID’S at this time.
Ensure patients know to contact NHS111 or 999 if
symptoms change.

2. Pneumonia – COVID-19

On admission, assess all adults for frailty, irrespective of age and COVID-19 status. Consider
comorbidities and underlying health conditions. Use the Rockwood score below, and record the frailty
assessment in the patient's medical record.

3
23/03/20 version 1.3
Clinical Management
Physiological targets (Based on NEWS)
 Maintain oxygen saturations >94% (unless
COPD)
 Monitor for clinical deterioration using NEWS
score and call 2222 if required. Inform team that
patient is COVID-19 confirmed before entering
the room
 Consider medical co-morbidites to tailor
management
 Conservative fluid management of patients when
no shock (BP>100 systolic). Use crystalloid
(Plasmalyte 148). If patient well encourage oral
intake

Observations  NEWS-led frequency of obs

 Record fluid balance
 Stool chart
Investigations  Investigations on admission (see p2), consider
ABG and lactate if concern regarding sepsis
 Repeat daily if severe otherwise only if clinically
indicated
Interventions Consider:
 Supplementary Oxygen to maintain Sats >94%
(unless COPD)
 Optiflow to < 30L/min has low aerosolization risk
and may offer benefit
 Antimicrobial therapy (MicroGuide) as Co-
amoxiclav + Clarithromycin. Duration of
therapy should be individualised
 Influenza treatment (MicroGuide) as Oseltamivir
until covid-19 positive result, at which point stop.
 Peripheral cannula
 VTE prophylaxis (Enoxaparin 40mg sc od and
TEDs) and complete chart
 Paracetamol for fever (NOT NSAID’s)
 Nutrition chart

Discuss the risks, benefits and possible likely outcomes of the different treatment options with
patients, families and carers using decision support tools (where available) so that they can make
informed decisions about their treatment wherever possible.

Sensitively discuss a possible 'do not attempt cardiopulmonary resuscitation' decision with all adults
with capacity and a CFS score suggestive of increased frailty (for example of 5 or more). Include in
the discussion:

 the possible benefits of any critical care treatment options

 the possible risks of critical care treatment options

 the possible likely outcomes.

Useful aids:

https://www.nice.org.uk/guidance/ng159/resources/information-to-support-decision-making-pdf-
8708913901

4
23/03/20 version 1.3
3. Management of Critical Care COVID-19 Acute Respiratory Distress Syndrome (ARDS)
6,8
Clinical Management  Recognise severe hypoxaemic respiratory failure:
RR>30, despite FiO2 0.60
 Non-invasive ventilation is not advised in the
treatment of COVID-19. There may be patients
with co-existing disease who should still be
considered for NIV (eg sleep apnoea/COPD)
 Consider early endotracheal intubation, using
COVID-19 specific intubation check list
 Critical care interventions to be considered
include; neuromuscular blockade, lung protective
ventilation, high PEEP, prone positioning,
Negative fluid balance
 NGT & feeding
 VTE Prophylaxis
 PPI
Physiological targets
 Hb >70 g/dL
 Vt 6 ml/kg IBW
 Plat Press < 30 cmH20
 Sats 94 - 96%
 PaO2 > 8.0 kPa
 PaCO2 < 6.0 kPa
 MAP > 60 mmHg
 UO > 0.5 ml/kg/hr
 K+ 4.0 – 5.0 mmol/L
 Mg+ > 1.0 mmol/L
 Glu 6.0 – 12.0 mmol/L
Observations Hourly: O2 Sats, EtCO2, ECG, Invasive BP monitoring,
Temp, Neuro obs, RASS score, BM, consider CO
monitoring
Investigations CXR, ECG, FBC, U&Es, LFTs, Clotting, Fibrinogen, Blood
Film, Ferritin, CK, LDH, CRP, triglycerides, troponin, Blood
Cultures, Sputum Cultures, CSU if indicated
Consider repeat viral NPA/ETA for SARS-CoV-2 viral PCR
Consider echo
Interventions Antibiotic treatment guided by MicroGuide
At this time there are no specific therapies advised for the
treatment of COVID-19.
Currently we advise against the use of steroids, IVIG,
chloroquine/hydroxychloroquine, remdesivir and Kaletra
outside of a clinical trial.
In patients with evidence of cytokine storm/HLH treatment
with an anti-cytokine agent such as Tocilizumab may be
consider on a named patient basis.

The guidance for treatment of patients with COVID-19 is continually evolving and as it does so
the evidence is being assessed by a multi-disciplinary group. When the evidence changes this
document will evolve. This is the assessment of the current position at version 1.2.

6
World Health Organisation. Clinical Management of severe acute respiratory infection (SARI) when
COVID-19 disease is suspected. Interim guidance dated 13 March 2020.
8
Clinical guide for the management of critical care patients during the coronavirus pandemic dated 16
March 2020 version 1.

5
23/03/20 version 1.3
Basic Rules for Managing Confirmed COVID19 patients:

- Change into scrubs or uniform on arrival to work.

- Keep personal property (bags/coats) off the main ward or unit.
- When going home change into personal clothing.
- Scrubs or uniform must be changed if they become soiled.
- Consider showering at end of shift before leaving work.
- No eating or drinking in the clinical area
- Washing your hands with soap and water is important. If you cannot access a hand wash
basin, use alcohol hand sanitizer
- Inpatients with suspected or confirmed Covid-19 are treated in isolation and not able to
receive visitors.
- Where possible do not take notes, observations charts or drug charts into the patient room.
- Stethoscope (only essential use as risk of contamination and should be thoroughly cleaned
with 1,000 ppm hypochlorite after use), observation machine and peak flow meter to stay in
patient room or cohorted bay
- For further details on infection prevention and control principles and appropriate personal
protective equipment, staff should refer to the Public Health England guidelines

Daily review of COVID19 patients on the wards (ABCDEFIL)

Appropriate PPE. Equip yourself and check your colleagues before entering the patient environment.
Minimise number of staff exposed. Don’t take equipment/notes/personal belongings into the room.

Breathing: is RR rising? Are sats falling? Does pt have a new 0 2 requirement? Sputum? If concerned
consider need for repeat CXR/ABG and senior/ICU review.

Circulation: assess cap refill, JVP, BP and pulse. Is patient passing adequate urine? If known heart
failure, review fluid balance and consider need for diuresis. AVOID IV FLUIDS where possible.

Cardiopulmonary resuscitation: Check treatment escalation plan is documented and appropriate.

Disability: Assess GCS. Check blood glucose if diabetes or decreased GCS. Discuss with diabetes
team if BMs >15. Consider patient’s psychological state – are they coping with isolation and anxiety?

Exposure: check pressure areas, assess for signs of DVT. Review CVC/peripheral cannula
site/urinary catheters. Remove or change if inflammation at site.

Feed/Family: Can the patient drink? Eating adequately? Bowels open? Consider need for laxatives,
nutritional support or supplements. Is the patient able to communicate current status to family/friends
by telephone independently or do team need to call next of kin to update?

Infection: Review drug chart – are antibiotics indicated? IV to po switch? Any drug interactions? Send
further samples if indicated (eg. blood cultures if febrile, sputum if cough now productive).

Lab: review results available. Are further routine bloods required for monitoring? (If on antibiotics,
FBC/U&E/LFTs/CRP at least every 72hrs).

6
23/03/20 version 1.3