Standard Operating Procedure for Management of Novel ......Pyrexia/ Fever - Temperature 37.8⁰C or over on tympanic, oral, rectal thermometer Red Bag - all samples/waste related to

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Standard Operating Procedure for Management of Novel Coronavirus (COVID-19) in Adults and Children

Lead executive Medical Director

Author’s details Dr James Wallace, Consultant in Emergency Medicine Dr Colin Wong, Consultant in Paediatric Emergency Medicine Dr Mithun Murthy, Consultant Respiratory Physician Dr Saagar Patel, Consultant in Acute Medicine Dr Mark Forrest, Consultant in Critical Care Dr Fraser Gordon, Consultant Geriatrician Dr Rita Arya, Consultant in Obstetrics and Gynaecology Ms Debbie Mallett, Medical Cabinet Business Manager

Type of document

Standard Operating Procedure

Target audience

All Clinical and Non-Clinical Staff who come into contact with patients eliciting symptoms consistent with COVID-19

Document purpose

To provide advice and support and guidance for the management of patients with suspected coronavirus across Warrington and Halton

Ratification meeting Appropriate governance group

Approving meeting

COVID Tactical Medical Group

Implementation date

Monday, 27 April 2020

Review date

25 May 2020

This document should be read in conjunction with national guidance which is subject to change on a regular basis

Document change history

Version 27042020

What is different? Changes to antibiotic formulary Addition of Obstetric Pathway – see appendix 22 Changes to Respiratory Deterioration flow chart

Appendices/electronic forms

Appendices outline specific treatment pathways, algorithms and action cards

What is the impact of change?

New SOP March 2020

Training requirements Any members of staff expected to work within new clinical areas will receive formal and informal bespoke ad-hoc training sessions arranged as required including in situ simulation

Keywords Coronavirus, COVID-19

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Contents

1. Process to be followed .............................................................................................................. 3

2. Purpose & Scope ....................................................................................................................... 3

3. Document Monitoring ............................................................................................................... 3

4. Glossary of Terms ...................................................................................................................... 3

5. Associated Documents .............................................................................................................. 4

6. Sources/References................................................................................................................... 4

7. Training Needs Analysis............................................................................................................. 4

Appendix 1 - Guidelines for Initial Management of Suspected or Confirmed COVID-19 .............. 6

Appendix 2 – Urgent & Emergency Department Processes for Streaming Patients 16 and

over to the ED Respiratory Cohort Area ..................................................................................... 15

Appendix 3 - Emergency Department Process for Streaming Patients under 16 ....................... 16

Emergency Department Process for Streaming Patients under 16 ............................................ 16

Appendix 4 - Pathway for potential COVID patients under 16 years old presenting to Halton

UCC .............................................................................................................................................. 17

Appendix 5 - Pathway for potential COVID patients under 16 years old presenting to Halton

UCC .............................................................................................................................................. 18

Appendix 6 to 12 - Emergency Department Action Cards .......................................................... 19

Appendix 13 – Paediatric Criteria to be ‘suspected COVID’ ....................................................... 26

Appendix 14 – COVID-19 Swabbing Criteria ............................................................................... 27

Appendix 15 - Guidance for Patients suspected of COVID-19 who routinely Use Domiciliary

CPAP for Obesity Hypoventilation Syndrome or OSA ................................................................. 28

Appendix 16 – Positive COVID Case Action Card ........................................................................ 29

Appendix 17 – Criteria for the Re-swab of Patients in Critical Care ........................................... 30

Appendix 18 – NICE Guidelines COVID-19 – Rapid Guideline: Critical Care ............................... 31

Appendix 19 – Definitions of Patient Groups Requiring Supportive Care .................................. 32

Appendix 20 – When to Use PPE Guidance ................................................................................ 33

Appendix 21 - Community Management / Referral For Patients with Suspected COVID-19 ..... 34

Appendix 22 - The Management of Unexplained Hypoxia in the Maternity Setting during

COVID-19 Pandemic .................................................................................................................... 36

Equality Impact Assessment (EIA) ............................................................................................... 37

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1. Process to be followed

Please see appendices for initial and ongoing management of adults and children with COVID-19 (coronavirus) including treatment pathways, action cards and when and how to escalate and de-escalate patients

2. Purpose & Scope

The Standard Operating Procedure details the Clinical Guidelines for the initial and ongoing management of patients eliciting symptoms of COVID-19, to include the processes for the streaming of patients attending the Urgent and Emergency Care environments within the Halton and Warrington sites, treatment pathways, escalation and de-escalation criteria, action cards relating to departmental protocols and other management guidance.

The SOP applies to all clinical and non-clinical staff involved in the care of patients with COVID-19 associated symptoms and presentations

3. Document Monitoring

**This document will be updated regularly and is subject to change** Please consider the version control

4. Glossary of Terms

AGP - Aerosol Generating Procedures

Asthma - IgE mediated reversible bronchoconstriction - Wheeze, shortness of breath, desaturation, chest pain, tightness. May respond to steroids, will respond to salbutamol / ipratropium. May be triggered by exercise, cold air, stress, allergens. May be triggered by viruses. Usually fast onset.

B10 – Paediatric Day Case Surgical Ward which will convert to Paediatric Respiratory Cohort Bay. Once PAU and B10 are both utilised as cohort bays the combined unit will be referred to as B10.

B11 - Ward B11

COVID +ve - A patient whose most recent test was positive for COVID-19

COVID Swab - x2 green viral medium swabs (one nasal, one throat) hand-delivered to the lab in red bag. There is a 24-48 hour turnaround time for verbal report. To only be done if admitting

ED Resp – Emergency Department Respiratory Assessment Unit will cohort suspected respiratory infections in ED. The location of this will remain fluid and will change depending on demand; however clear signposting, access restrictions and donning of PPE will be in place to easily identify this area.

History of Fever - Parent/carer reported fever.

LRTI - Lower Respiratory Tract Infection – can be cough, difficulty in breathing, abdominal pain, pyrexia, tachypnoea, desaturation Negative COVID - A patient whose most recent test for COVID-19 was negative

Paeds ED/PED -Paediatric Emergency Department

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PAU - Paediatric Assessment Unit which will convert to Paediatrics Respiratory Cohort Bay

PED Resp - Paediatric Emergency Department Suspected COVID Respiratory Infection are currently including Cubicle 1, Bed spaces 3, 4, 5, window

PPE - Personal Protective Equipment

Pyrexia/ Fever - Temperature 37.8⁰C or over on tympanic, oral, rectal thermometer

Red Bag - all samples/waste related to suspected COVID/ COVID+ve patients must be red-bagged and double bagged. Any samples from a suspected COVID/ COVID+ve patient must be hand delivered to the labs NOT podded.

Suspected COVID - A patient who meets clinical criteria for COVID-19 and who does not yet have a positive swab result.

Undifferentiated Pyrexia Fever >37.8⁰C not attributable to URTI, LRTI, gastroenteritis Viral VIW / Sepsis / UTI / Viral exanthematous rash /meningitis /autoimmune

URTI - Upper Respiratory Tract Infection – presents with any or all of: cough, snuffles, coryza, stridor, sore throat, refusal to feed, fever.

VIW - Viral Induced Wheeze - Presents with wheeze, shortness of breath, desaturation, chest pain, tightness, crackles, crepitation’s. May be snuffles and pyrexia. Usually gradual onset over days.

5. Associated Documents

Please read this document in conjunction with the Trust Coronavirus Infection Control policy (current version) which can be found at https://extranet.whh.nhs.uk/workspaces/infection-control/documents

6. Sources/References These pathways are based on guidance from the Department of Health but have different criteria to defining an at risk patient based upon senior clinicians experience in ensuring all potential cases are isolated and provided with the correct PPE

https://www.gov.uk/government/collections/wuhan-novel-coronavirus

7. Training Needs Analysis

Any Staff members who find themselves working within unfamiliar areas or with unfamiliar

protocols will be offered a series of training to include formally arranged sessions and shop floor

training. This will be considered on a case-by-case basis in-line with available staffing and

demand.

https://extranet.whh.nhs.uk/workspaces/infection-control/documents


https://www.gov.uk/government/collections/wuhan-novel-coronavirus

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Staff Role Training Requirement Frequency Training Delivery

Method

All employees working in areas where patients with potential COVID 19 may present or occupy

Understanding and knowledge of the process pertinent to the area they are working in

Daily, as this changes very frequently

Read the latest guidelines as this changes too frequently for any face to face training to occur

Personal Protective Equipment

To know which PPE is required and how to doff and don it

Once, but to keep abreast of the daily changes

This document does not cover the doffing and donning of PPE but is included here for completion

All employees working in areas where patients may be transferred in

Understanding of the process of how to move a patient into their clinical area or out

Daily but this changes frequently and may differ during a single day due to demand

Read the latest guidelines as this changes too frequently for any face to face training to occur

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Adverse prognostic factors: Older age, male sex, chronic pulmonary disease, hypertension, coronary artery and cerebrovascular disease, diabetes. Pregnant and immunosuppressed considered vulnerable.

SEVERITY ASSESSMENT & PROGNOSIS

No tool is validated for use in COVID;

use NEWS2 score and CURB65 to guide management decisions in the presence of pneumonia

Use *CFS plus WHO Performance Status for aiding escalation decisions (see below)

*Ref: NICE guidance Appendix 18

See below for suggested patient grouping:

Community onset Hospital onset

Group 1 Group 2 Group 3 Group 4

Asymptomatic or mild symptoms without dyspnoea, <70, without adverse prognostic factors and negative CXR.

Mild or moderate symptoms including dyspnoea, CXR with pneumonia or mild symptoms with adverseprognostic factors

Severe pneumonia with respiratory failure/ARDS orhemodynamic instability

Variable severity of disease; may be complicated by HAP

Consider home to complete self-isolation

May be able to discharge following assessment / Admit to A7 cohort area

Hospital admission and consideration of intensive care if for escalation

Appendix 1 - Guidelines for Initial Management of Suspected or Confirmed COVID-19

Initial Management Guideline

ADDITIONAL DIAGNOSTIC WORK-UP (Lookup COVID-19 tab on ICE)

Bloods: FBC, U+Es, LFTs, CRP, VBG or ABG (if SpO2 <92% or needing oxygen), D-dimer, troponin if history of chest pain Microbiological tests: Consider blood cultures; additional tests as per CAP guidelines; send separate nasopharyngeal swab for ‘respiratory screen - extended panel’ Imaging: Chest radiograph; consider chest CT scan if diagnosis unclear or severe disease

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Clinical Frailty Score + WHO Performance Status for Aiding Escalation Decisions

1 – 3 For escalation (Critical Care – Level 2/3)

4 - 6 Clinical discussion and decision (Possible level 3 but

consider Respiratory High Care (Level 2)

>6 Not for escalation (uDNACPR and Ceiling of Care)

*both scoring systems are clinically validated and widely used; however, there is no current evidence base for the use of a combined score. Therefore this was judged to be the most appropriate and robust approach given the current situation

FEATURES THAT WOULD INDICATE HIGH LIKELIHOOD OF COVID PNEUMONIA

Use and document these features at admission:

Pyrexia >37.8’C

Loss of smell and/or taste

Lymphopaenia on FBC

Bilateral fluffy infiltrates on CXR Or ARDS picture on CXR (4 quadrant change) AND

No alternative explanation of fever

If all features present these patients have a Presumptive Diagnosis of COVID-19 pending Swab results and can be cohorted with Swab Positive patients.

An ESCALATION PLAN regarding ceiling of care and DNACPR status must be

documented on admission and confirmed on post-take ward round.

The threshold for escalation may change over time depending on demand.

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Empirical antibiotics are recommended for most patients pending results of SARS-CoV2 and other microbiological tests.

ANTIMICROBIAL THERAPY

Ongoing Management and Escalation Guideline

Community Onset Hospital Onset

Group 1 Group 2 Group 3 Group 4

Symptomatic treatment

Amoxicillin 1g PO TDS plus Doxycycline 200mg PO first day and then 100mg BD

Penicillin allergy: Doxycycline 200mg PO first day and then 100mg BD

Co-amoxiclav 1.2g IV TDS plus Doxycycline 200mg PO first day and then 100mg BD If patient unable to take oral meds: Co-amoxiclav 1.2g IV TDS plus Clarithromycin 500mg IV BD Oral Stepdown: Co-amoxiclav 625mg PO TDS Penicillin allergy: Teicoplanin IV *(see Trust Teicoplanin guideline)

plus Levofloxacin 500mg PO/IV BD

Oral Stepdown: Discuss with Consultant Microbiologist

Piperacillin/Tazobactam (Tazocin

®) 4.5g IV TDS

Penicillin allergy: Teicoplanin IV *(see Trust Teicoplanin guideline) plus Levofloxacin 500mg PO/IV BD Modify by previous microbiology results Oral Stepdown: Mild infection Doxycycline 200mg PO first day and then 100mg BD Moderate/severe infection Levofloxacin 500mg PO BD

Duration 5 days Antibiotics may be discontinued by 48 hours if no evidence of bacterial infection.

5 days If haemodynamic instability or evidence of sepsis give a single dose of gentamicin in addition. Review need for ongoing antibiotic therapy once SARS-CoV2 and other microbiology results known.

All patients in group 3 should have a urine sample sent for Legionella antigen testing and an extended respiratory screen. These tests can also be sent for group 2 patients at the clinician’s discretion.

FLUID MANAGEMENT

• Aim to run patients on “dry-side” if evidence of ARDS type pattern on Chest x-ray. • However, without evidence of ARDS, especially in elderly or CKD, beware dehydration and maintain

normal fluid regime • For most, aim for maximum total input of 2000 ml/day (i.e. all oral and IV fluids incl. drug

volumes) unless AKI or systolic BP<90 (See Trust Fluid Therapy Guideline for Adults). • Record fluid balance carefully and insert urinary catheter if AKI or systolic BP <90. • If systolic BP <90 at presentation: give 500ml IV fluid over 30 min. Repeat if BP still <90 and check ABG. • If BP still <90, contact Critical Care if for escalation.

Patients on long-term azithromycin for chronic chest conditions should have the azithromycin withheld whilst being treated for an acute respiratory infection.

*http://thehub/Documents/Antibiotic%20Formulary.pdf

http://thehub/Documents/Antibiotic%20Formulary.pdf

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Patient Cohort Criteria for Escalation and Patient Flow

Source of patients • Acute patients in ED Resp area – management following senior (medical registrar) review or

PTWR • Current inpatients – management of move of current inpatients from other ward areas after

they are swabbed for COVID 19

Process • Use Combined score for assessment of baseline pre-morbid functional status (Clinical frailty

score + WHO performance status) as per trust wide guideline/ SOP • Actively make early decisions and documentation of ceilings of care based on above scoring

criteria • For current inpatients elsewhere in hospital, assess their ongoing need for specialist input

from their base specialty (e.g. obstetrics, orthopaedics, ENT etc.)

See Flow Chart on next page:

OTHER ASPECTS

Nutrition: refer via ICE to the Dietetic service as per usual referral criteria

VTE: Give LMWH prophylaxis unless contraindicated.

Research: Highlight all confirmed COVID-19 patients to Research teams; assist by collecting clinical specimens and data.

THINGS TO AVOID

Use of oral steroids or NSAIDs unless patient already on them or other non-COVID indication

Use of fans to cool patients

All NIV or CPAP outside of ITU/NIV locations

Routine use of antivirals

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Cohort 1 -Patients for respiratory escalation /

management

Combined functional score <=6

Swabbed for COVID-19 (can be confirmed OR suspected and awaiting swab results)

Displaying any respiratory symptoms AND requiring oxygen

therapy (or risk of type 2 respiratory

failure) AND do not require significant

input from alternative medical or surgical

specialty

Patient primarily presenting with

respiratory symptoms and / or mainly

requiring respiratory support. Would

usually be for full escalation or at least

for Level 2 respiratory support based on

above score.

Location – A7/A8 cohort wards area

Cohort 2 – Patients for supportive

management

Combined functional score of >6

May have reasonable chance of recovery / recovery uncertain, but have ceilings of

care in place for ward level care only (NOT

for level 2 or 3 escalation) based on above score. (Should

have DNACPR and CoC documentation).

May have some palliative care needs:

have anticipatory medications prescribed,

holistic care support

referred to Specialist Palliative Care Team

Location – A4/A5 cohort ward areas

Cohort 3a – Patients for supportive

management and enhanced palliative

care

Location – A4/A5 cohort wards area

Cohort 3b – Patients for advanced

palliative care management

Patient deemed to be actively dying, likely

within hours and hence, should have a

DNACPR and CoC documentation

Patients primary needs will be for palliative care:-


holistic care support

referred to Specialist Palliative Care Team

Care may be supported by use of IPOC

Location – Aim to NOT move patient

from current location

Patients in Cohorts 3 (a and b) would still need significant nursing input and may be

on high oxygen flow rates

Cohort 3a – Patients for supportive

management and enhanced

palliative care


Have high likelihood of dying / adverse

outcome – usually are NOT for MET calls

(should have DNACPR and CoC

documentation). May be on an AMBER care bundle, but still have active interventions such as antibiotics /

fluids.

Cohort 3b – Patients for advanced

palliative care management


Will have enhanced palliative care needs:-


holistic care support referred to

Specialist Palliative Care Team

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Oxygenation & Ventilation Management

Clinical Parameters for Consideration of Critical Care Referral

This is not a definitive list and is likely to change as Critical Care beds become more limited in availability. Whilst we can use many criteria, such as PaO2/FiO2 ratio etc, we have tried to keep this a simple as possible.

Oxygenation Sao2 <92% despite ward oxygen delivery at 60% FiO2 OR tiring/ intolerant on above oxygenation

SaO2 < 92% on appropriate level 2 support (e.g. NIV or HFNO* when available)

Respiratory rate Rate greater than 30 breaths / min

Exhaustion Patient becoming exhausted, reduced ability to speak

Conscious level Any evidence of reduce conscious level from respiratory cause

Rising pCO2 and falling pH pH <7.2 with pCO2 above normal for the individual patient

Increasing signs of respiratory related sepsis

Hypotension (<90 systolic for over 1 hour), lactate >4,

Peri-arrest or arrested May require crash bleep or cardiac arrest bleep, as per normal protocol

In the absence of antiviral agents with proven benefit, supportive management - in particular

oxygenation and ventilation - is the mainstay of management for COVID-19.

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Medical Team / Medical Reg Review: COVID status Level of dependency

Suspected / Confirmed COVID Perform CFAS(CFS + WHO Score)

Refer as normal to ITU (declared as non-COVID)

Critical Care Review

If accepted transferred

to Non-COVID ITU

Respiratory Consultant Gatekeeper:This small team of respiratory consultants have agreed to carry a baton phone and will discuss all potential deteriorating respiratory cases where critical care may need to be

involved. In emergency cases the ITU Team will support each patient whilst the Gatekeeper is contacted

Continue current

maximum medical

treatment

CFAS 1-3 AND requires Level 3 /

IPPV

CFAS 4-6 CFAS >6

Critical Care review – agree and retrieve patient to “COVID”

ITUFor discussion with

Gatekeeper Respiratory Consultant

Medical Registrar to refer directly to 2nd on Critical Care

Registrar (Bleep 219)

If agreed, Medical Registrar to refer to 2nd on Critical

Care Registrar (Bleep 219)

Critical Care to review and retrieve patient to Level 2 “COVID” Area for CPAP/

HFNO

Critical Care Review – Not fit for

Level 3 Care

Patient Not For Level 3 AND/OR requires Level 2 Ventilatory Support e.g.

CPAP / HFNO / NIV*

Medical Team to complete CoC Documentation (Level

2) and DNACPR

Non-COVID

*Only exception is for patients requiring standard bi-level NIV

(BiPAP) for acute Type 2 Respiratory Failure who are NOT

FOR Level 3 care – May still be managed on Ward A7 with

agreement from Respiratory Consultant with appropriate

ceilings

Referral Pathway to Critical Care for the Deteriorating Respiratory Patient

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Consultant Referral – A7 / A8 to Critical Care discussed at 0900 huddle

Patient meeting clinical referral criteria as per trust wide SOP / guideline and remains for full escalation

Refer ACT for review

Refer to Critical Care – Bleep 219

Discuss with ICU Consultant

Decision to Transfer

Discuss with Tactical Commander

Transfer Team Alerted:

Senior Airway / ODP / ACT

Appropriate PPE

Process for ITU Step-Up from Respiratory Cohort Wards – A7 / A8

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Bed Management within Each Cohort Ward Area • Aim to cohort confirmed and suspected (awaiting swab) patient in separate bays still

maintaining male and female segregation • Any acute admissions meeting “High clinical likelihood of COVID pneumonia” (see criteria

above) can be mixed with confirmed positive cases in a bay with permission from the respiratory on call consultant (REAL phone)

• Aim to cohort all asymptomatic contacts together in a bay, irrespective of date of contact. • Any contacts who subsequently become symptomatic and hence, get re-swabbed, should

be considered as a new case and follow above escalation criteria based movement facilitated by patient flow

• Patients on A7/A8 who deteriorate and are deemed to be have moved from Cohort 1 into Cohorts 2 or 3a may be moved to supportive care cohort wards.

Associated Templated Documents on Lorenzo

Combined clerking proforma – “COVID Assessment Note” searchable on Lorenzo

Positive Result Letter - ‘create a note’ and search for “COVID” to populate with the patients details and print off to give to patient

Standard Trust-wide Discharge Summary – this now has a section for COVID results

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Appendix 2 – Urgent & Emergency Department Processes for Streaming Patients 16 and over to the ED Respiratory Cohort Area

Emergency Department Process for Streaming Patients 16 and over to the ED

Respiratory Cohort Area

Stream to ED-RESP SOB, cough of chest pain suggestive

of an LRTI or pneumonia

Influenza symptoms e.g. fever, cough, muscle aches/pains

Acute COPD + fever

Acute Asthma + fever

Other presentations with associated symptoms suggesting LRTI, pneumonia or Influenza

Navigator/Triage [walking]

Hub Nurse [Ambulance]

Streaming Assessment

D/W Medical Coordinator Any presentation where there is

doubt

Any patient with an incidental finding of pneumonia on CXR

Potentially immunocompromised patients e.g. chemo/neutropaenia

Stream to other ED area Aspiration Pneumonia

Acute heart failure (no fever)

Acute COPD (no fever)

Acute Asthma (no fever)

Suspected PE

Suspected Pneumothorax

Other [respiratory] presentations unlikely to be infective in origin

ED RESP Assessment

Home Patient who can be

safely discharged home with written advice

See QR code for latest updates

Admit other ward Patients requiring

admission but not meeting A7/ICU admission criteria

Admit A7 CAP requiring

admission

HAP [recent discharge] requiring admission

Suspected influenza requiring admission

See QR code to Extranet site

Admit ICU ARDS

See ICU admission criteria and pathway on extranet – QR code

NO COVID SWABS COVID swab only after

discussion with Medical

ST [registrar] or

Consultant

COVID SWABS ON ICU Consider also deep

respiratory sample/sputum for

COVID PCR

Name: Signature: Date: Time:

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Appendix 3 - Emergency Department Process for Streaming Patients under 16

Emergency Department Process for Streaming Patients under 16

Navigator/Triage [walking]

Hub Nurse [Ambulance]

Streaming Assessment

Well

Unwell

Febrile

Afebrile

Move Resp Resus

Move to Resus

Stream to Paeds Respiratory ED

• Fever unknown source;

• Cough, coryza, wheeze, stridor, Difficulty in Breathing with or without fever;

• Asthma with fever;

• Flu-like symptoms;

• Resolved Febrile Convulsion;

• Diarrhoea/Vomiting/D&V;

• Injury w/fever/self-isolating;

Stream to Paediatric Ward (PAU/B11)

Any non-febrile illness;

Afebrile Patients with GP letter;

Surgical Patients;

Clear asthma exacerbation;

Suspected UTI;

Rash without temperature; CAMHS/OD;

Any injury non-ambulant child;

Isolated vomiting <6 months;

Afebrile seizure;

Stream to Paediatric Minors Area (primary care)

• Any Injury

• Fractures; • Minor Head injury

• Bites/Laceration; • Burns; • Limping Child; • Eye injuries (d/w

Ophthalmology)

Paeds ED Triage Assessment by clinician; Emergency Treatment;

Consider Resp Viruses Swab

Admit as ?COVID

• Bleep 885 & refer; • Bleep B11 on 286; State ?COVID 19

• COVID Swab; • Respiratory Viruses

Swab

Discharge • TTO as necessary; • Sepsis/Discharge

Advice Leaflet; • Self-Isolation advice • Fracture Clinic or PART

review as necessary; • For up-to-date

guidance scan:

After 2200 hrs to join main waiting room queue;

To be triaged by Paeds Respiratory

ED Nurse after 2200 hrs;

Move to PAU in first instance;

Admit to B11 or Discharge;

If later decided ?COVID move to Cubicles;

Admit • Bleep specialty & refer; • Bleep B11 on 286 for beds;

Notes: • Daily early Paeds/ED liaison re: staffing plan; • Clear Asthma exacerbation is well child

previously, NO FEVER, acute onset wheeze, no coryza;

• Paeds Senior available for PED/PAU 17-2100

Attempt to

notify PAU

2532/ bleep 286

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Appendix 4 - Pathway for potential COVID patients under 16 years old presenting to Halton UCC

Pathway for patients under 16 years old presenting to Halton UCC

Patient Presents at UCC

Cough

Fever

URTI/LRTI

Flu-like symptoms

Diarrhoea and Vomiting

Injury

Observations PEWS 2 or over Any tachycardia Age <12 months

Any long-term health condition Immunocompromised

Paeds ED Triage Assessment by clinician; Emergency Treatment;

Consider Resp Viruses Swab

Notify Paeds Resp ED WHH

Emergency Rx as required

Give antipyretic

Triage

Take obs, PEWS and brief history

PPE: apron, gloves, surgical mask

Observations

PEWS documented <2

excluding tachycardia

No high risk factors

Transfer to Warrington ED

Own Transport if well

Ambulance if concerns

Discharge • TTO as necessary; • Discharge Advice

Leaflet • Self-Isolation advice • (Sepsis Advice

Leaflet) • For up-to-date

guidance scan:

Discharge with or without onward referral

Information leaflet

• Refer • Speciality • Notify PAU

Arrange Transfer to PAU;

PAU notify specialty on arrival;

UTI

Any other non-febrile illness

Simple gastritis

Triage

Treat

Follow established protocols

Head Injury meeting criteria for CT but not immediate neurosurgical transfer to be managed by ED;

Specialty review;

Admit to B11 or other Trust;

Discharge with or without onward referral

Information leaflet

Admit as ?COVID • Bleep 885 & refer; • Bleep B11 on 286; State ?COVID 19

COVID Swab;

Respiratory Viruses Swab

Page 18 of 37

Appendix 5 - Pathway for potential COVID patients under 16 years old presenting to Halton UCC

Pathway for potential COVID patients over 16 years old presenting to Halton

UCC

Patient Presents at UCC

Cough

Fever

URTI/LRTI

Flu-like symptoms

Patient well

Unwell patient NEWS2 >2

Unwell Clinical concern

If requires admission or conveyance to Respiratory Assessment Unit contact • Medical Coordinator • Nurse in Charge • Patient Flow • NWAS ONLY if needs

an ambulance

Clinical review

Clinician to see as normal

Use normal clinical pathways

Triage

Take obs [NEWS2] and brief history

PPE: apron, gloves, surgical mask

Well patient

NEWS documented <2

No high risk factors

Patient well

Home

Public health advice

See QR code for latest guidance

Yes

Yes

No

Name: Signature: Date: Time:

Page 19 of 37

Appendix 6 to 12 - Emergency Department Action Cards

Appendix 6

1. Emergency Department Reception Protocols for COVID 19 This protocol is to give guidance to healthcare professionals in various areas of the Emergency

Department during the COVID 19 changes. It details most of the actions required by the

individual, but it is key that that individual keeps themselves updated with the national guidance.

Reception staff in the main waiting area – navigator present Ensuring patients move to the right area with a surgical face mask is key

When the navigator is present, book patients in as normal If the patient has been highlighted as a respiratory patient, ensure they have a

surgical mask on Book the patient into ED RESP (or Paeds waiting area if a child) on LORENZO

Reception staff in the main waiting area – navigator absent Highlighting unwell patients with potential flu like or respiratory illnesses is key

When there is no navigator ask about respiratory symptoms e.g. cough, cold, flu, breathlessness

Give the patient a surgical face mask and highlight them to the triage nurse and/or Rapid Assessment Clinician (RAC)

Book those patients in as normal in the main waiting room with the presenting complaint as “respiratory illness”

Reception staff in majors – ambulance handover

When the patient has been handed over to a nurse, book the patient in as normal

If the patient has been highlighted as a respiratory patient book them into ED RESP or Paeds waiting area on LORENZO

KEY MESSAGES Patients going to ED RESP or Paeds waiting area can have ONE relative with

them in those areas If a patient requires more than one relative/visitor, please inform the most

senior nurse or clinician in that area If the relative is unwell, discuss with the most senior nurse or clinician in that

area, they may need a surgical face mask as well

Page 20 of 37

Appendix 7

2. Emergency Department Navigation/Triage Protocols for COVID 19 This protocol is to give guidance to healthcare professionals in various areas of the Emergency



Navigator/Triage nurse in the main waiting area Ensuring patients move to the right area with a surgical face mask is key

At the beginning of your shift or at handover, check the most up-to-date criteria for screening/at risk patients – (scan this QR code with your iPhone camera/on android use an app)

If the patient has respiratory symptoms and fits the potential criteria, ensure they always have a surgical mask on

Advice the patient to book in normally at reception if they have not already done so

Stream potential respiratory patients to ED RESP, and children to the Paediatric area and direct them to the right area with their relative

Ambulance handover or navigation nurse Highlighting unwell patients with potential flu like or respiratory illnesses is key

At the beginning of your shift or at handover, check the most up-to-date criteria for screening/at risk patients – (scan this QR

code with your iPhone camera/on android use an app)


Complete the NWAS handover documentation Advice the NWAS staff to book in with the majors’ reception staff, or main

reception if out of hours Complete a set of observations and stream respiratory patients to the relevant

part of the ED RESP area, or to the Paediatric area if a child KEY MESSAGES

Patients going to ED RESP or Paeds waiting area can have ONE relative with them in those areas

If a patient requires more than one relative/visitor, please inform the most senior nurse or clinician in that area

If the relative is unwell, discuss with the most senior nurse or clinician in that area, they may need a surgical face mask as well

Page 21 of 37

Appendix 8

3. Emergency Department Rapid Assessment Clinician Protocols for COVID 19

This protocol is to give guidance to healthcare professionals in various areas of the Emergency



RAC in the main triage area Ensuring patients move to the right area with a surgical face mask is key

At the beginning of your shift or at handover, check the most up to date criteria for screening/at risk patients – (scan this QR code with your iPhone camera/on android use an app)


If the patient has a non-infective cause for their respiratory symptom such as possible PE, angina, or heart failure then they may not require the ED RESP

area Continue to rapid assess all patients appropriately, highlighting those that

require urgent treatment as usual If in doubt, discuss with the medical controller and move patients to the ED

RESP area Children with respiratory presentations go to the main Paediatric area of the

ED KEY MESSAGES

Patients going to ED RESP or ED RESP waiting area can have ONE relative with them in those areas

Early identification of potentially infected or infective patients is key to ensuring a safe dynamic approach to the COVID process

If in doubt, give the patient a surgical facemask and transfer them to the ED RESP area

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Appendix 9

4. Emergency Department Nursing staff in the ED RESPIRATORY area protocols for COVID 19




Nursing staff in the ED RESP area Ensure you wear the correct PPE and make the patients and yourself as safe as possible


At the beginning and end of your shift, change into and out of the scrubs provided in the ED RESP area

Make sure that you always wear your PPE when having contact with patients, equipment, specimens, linen and refreshments for patients

For advice on deep cleaning cubicles and equipment, check the daily COVID 19 update email and trust wide safety brief. If in doubt contact the B7 nurse

controller (or IPC team in hours) ED RESP is a smaller version of the whole ED, highlight unwell patients as usual,

escalate to the B7 and medical controller when at or nearing capacity All COVID-19 samples should go to the lab in doubled red bags; use the blue cool box and potentially allocate an external member of staff to pick up the

box from the door

KEY MESSAGES Patients going to ED RESP or ED RESP waiting area can have ONE relative with

them in those areas If the patient has respiratory symptoms and fits the potential criteria, ensure

they always have a surgical mask on If the patient has a non-infective cause for their respiratory symptom such as possible PE, angina, or heart failure then they may not require the ED RESP

area

Continue ED care as normal, complete observation charts, patient care paperwork as normal, use existing pathways where available

AGP (aerosol generating procedures) are in/extubation, open suctioning, manual ventilation, trache procedures, NIV, CPAP, nasal high flow,

bronchoscopy, CPR

Page 23 of 37

Appendix 10

5. Emergency Department Clinical staff in the ED RESPIRATORY area protocols for COVID 19




Clinical staff in the ED RESP area Ensure you wear the correct PPE and make the patients and yourself as safe as possible




See patients in the priority of clinical need then time

Patients within the ED RESP will range from resus patients to ED AMB criteria patients

If a patient requires admission, please refer as normal The decision to perform COVID 19 swabs is on the advice of an ADMITTING

team ONLY If a patient becomes unstable and requires critical care review or intervention, please follow the appropriate action card and pathway (NOTE these differ from

the usual clinical pathways)

KEY MESSAGES AGP (aerosol generating procedures) are in/extubation, open suctioning,

manual ventilation, trache procedures, NIV, CPAP, nasal high flow, bronchoscopy, CPR

If the patient has a non-infective cause for their respiratory symptom such as possible PE, angina, or heart failure then they may not require the ED RESP

area

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Appendix 11

6. Emergency Department Nursing staff in the Paediatric area protocols for COVID 19




Nursing staff in the Paediatric area Ensure you wear the correct PPE and make the patients and yourself as safe as possible



For advice on deep cleaning cubicles and equipment, check the daily COVID 19 update email and trust wide safety brief. If in doubt contact the B7 nurse

controller (or IPC team in hours)

The Paediatric area is now a smaller version, highlight unwell patients as usual, escalate to the B7 and medical controller when at or nearing capacity

All COVID-19 samples should go to the lab in doubled red bags; use the blue cool box and potentially allocate an external member of staff to pick up the

box from the door

KEY MESSAGES

Patients going to waiting area can have ONE relative with them in those areas If the patient has respiratory symptoms and fits the potential criteria, ensure

they always have a surgical mask on If the patient has a non-infective cause for their respiratory symptom then

they may not require the Paediatric area Continue Paeds ED care as normal, complete observation charts, patient care

paperwork as normal, use existing pathways where available AGP (aerosol generating procedures) are in/extubation, open suctioning,

manual ventilation, trache procedures, NIV, CPAP, nasal high flow, bronchoscopy, CPR

Page 25 of 37

Appendix 12

7. Emergency Department Clinical staff in the Paediatric area protocols for COVID 19




Clinical staff in the Paediatric area Ensure you wear the correct PPE and make the patients and yourself as safe as possible




See patients in the priority of clinical need then time Patients within the Paediatrics area will range from resus patients to primary

care patients If a patient requires admission, please refer as normal

Please follow the most up-to-date guidance on which patients to swab

If a patient becomes unstable and requires critical care review or intervention, please follow the appropriate action card and pathway (NOTE these differ from

the usual clinical pathways)

KEY MESSAGES

AGP (aerosol generating procedures) are in/extubation, open suctioning, manual ventilation, trache procedures, NIV, CPAP, nasal high flow,

bronchoscopy, CPR

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Appendix 13 – Paediatric Criteria to be ‘suspected COVID’ Any of the below will qualify a patient to be classified as ‘suspected COVID’:

Undifferentiated Pyrexia/Fever A fever where the source cannot be easily identified.

Fever/history of fever plus URTI or LRTI symptoms/signs

URTI symptoms/signs

LRTI symptoms /signs

Flu-Like Illness Headaches, Fever, Muscle ache, Coryza, malaise

Viral Induced Wheeze

Asthma with Fever/recent Hx of fever Not ‘Suspected COVID’ (list is not exhaustive) These may give you fever but should not be considered likely COVID:

?Sepsis

Urinary Tract Infection

Asthma with clear trigger/no other features of infection/recently well/acute onset

Diarrhoea and/or Vomiting bug

Viral Rash

Appendicitis/Surgical Abdomen

Cellulitis/Local Infection

Any other obvious/localised source of infection/inflammation

Page 27 of 37

Appendix 14 – COVID-19 Swabbing Criteria for Symptomatic Patients

COVID-19 Swabbing Criteria for Symptomatic Patients

Patient requires admission and:

1. Suspected Influenza Fever ≥37.8°C and at least one of the following respiratory symptoms,

which must be of acute onset: persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath,

sore throat, wheezing, sneezing

If going home – ‘Respiratory screen – extended panel’ and discharge home

If patient being admitted - ‘Respiratory screen – extended panel’ & COVID-19 swab on admission

2. Pneumonia Community acquired pneumonia

Hospital acquired pneumonia Do Not Include Aspiration Pneumonia

3. Acute Respiratory Distress Syndrome Patient will go to a resus bed with resus facility

Patient will be swabbed in ICU

NB: Document in “ED clinician/Nursing notes" or "Medical admission" note that a COVID swab has been done for ward staff to chase the swab results and

improve flow.

NB: In addition to standard paper requesting form, also use ‘dummy request’ for COVID-19 swab under COVID tab on ICE to allow tracking of sample.

*This is a rapidly changing situation*

and guidance is likely to change

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Appendix 15 - Guidance for Patients suspected of COVID-19 who routinely Use Domiciliary CPAP for Obesity Hypoventilation Syndrome or OSA

Guidance for Patients suspected of COVID-19 who Routinely Use Domiciliary CPAP for Obesity Hypoventilation Syndrome

Advise Patient to bring CPAP machine into hospital with them

Do not use CPAP unless instructed by Medical Staff.

CPAP should not be used on an open ward if you have suspected or confirmed COVID-19 Until screening results are back. If patient is on CPAP for OSA/OHV Obesity Hypoventilation syndrome requiring CPAP to maintain ventilation, this should continue after discussion and advice from a respiratory consultant. The CPAP will need to be in an isolation area (such as

side room or negative pressure area) on ward A7 and staff will need full PPE.

To decrease any risk of infection from CPAP while the patient is in hospital, replace patients own mask with a hospital mask , which will have to be a non-vented mask with a viral filter

added to the exhalation port.

DO NOT USE your humidifier with the CPAP machine in hospital due to increased droplet spread

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Appendix 16 – Positive COVID Case Action Card

Positive COVID Case Action Card

This protocol is to give guidance to healthcare professionals if a patient has a positive confirmed case of COVID. It details most of the actions required by the individual, but it is key that that individual keeps themselves updated with the national guidance.

Tick All Staff

Ensure you wear the correct PPE and make the patient and yourself as safe as possible

Action for Laboratory:

Inform consultant microbiologist of result

Action for Microbiologist:

If patient is an inpatient, inform COVID consultant on-call on 07876 373 694

Otherwise, contact relevant carer (e.g. care home manager if in a care home)

Action for COVID-consultant:

Inform Ward Manager of result (preferably face to face)

Inform medical team of result (preferably face to face)

Inform Trust Executive Team, Emma Blackwell, IPC team of positive result

Action for ward manager:

Minimise contact with patient to essential staff only

Wear normal PPE to close curtains around other patients and their visitors in the cohorted bay

Any current visitors for the confirmed case should be asked to move to the identified isolation room meant for the case

Move confirmed COVID-19 patient to designated isolation area – patient to wear surgical face mask for transfer, staff to wear PPE as per trust policy. If patient is already in isolation, keep in isolation.

Signage on patient’s door (COVID signage and PPE signage)

All staff to wear appropriate PPE for all contact with the confirmed patient

Other patients and their visitors in the same bay should be informed of contact with a positive case and provided with an information leaflet

Action for medical team:

Inform patient of result, ensuring appropriate PPE is worn

Give patient information leaflet

Medical review

If evidence of bacterial superinfection, prescribe 7 days of antibiotics for severe community acquired pneumonia as per trust policy (e.g. PO/IV co-amoxiclav with clarithromycin)

Notification to Public Health via email [email protected] or by completing Notification of Infectious Diseases Form on Lorenzo and faxing form to 01512362488 (PHE would prefer not to notify by telephone unless patient is from a long term care facility, prison, hospital outbreak. If so telephone details are 03442250562 (option 0, then option 1) in hours 0151 434 4819 out of hours)

Action for infection control team:

Obtain a list of patient contacts if confirmed case was in a bay

If the other patient contacts within the bay are negative, and to be discharged home, then they should be advised to self-isolate for 14 days from the date of contact. If they subsequently become symptomatic, then to follow usual guidance (isolate for 7 days if well, or if unwell seek medical assessment) – see QR code below for guidance.

If the other patient contacts within the bay are negative but require continued admission to hospital, they should remain cohorted till discharge or for 14 days from date of last contact, whichever is soonest.

Scan for UK Government ‘Stay at Home’ Guidance

mailto:[email protected]

Page 30 of 37

Appendix 17 – Criteria for the Re-swab of Patients in Critical Care As the COVID swab test is not completely accurate and the potential for false negatives is considered to be up to 30%, we are unable to step down patients from isolation after a negative swab as they may be positive or they may have become positive during their isolation when exposed to others with the virus. In view of this, respiratory medicine, med-micro, infection control and critical care have agreed a simple process for these patients:

Criteria for the Re-swab of Patients in Critical Care

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Appendix 18 – NICE Guidelines COVID-19 – Rapid Guideline: Critical Care

Page 32 of 37

Appendix 19 – Definitions of Patient Groups Requiring Supportive Care

Page 33 of 37

Appendix 20 – When to Use PPE Guidance For up-to-date information the latest Infection Control Guidance and PPE, please refer to the Trust Infection Control Policy on the Trust intranet



Page 34 of 37

Appendix 21 - Community Management / Referral For Patients with Suspected COVID-19

Clinical Symptoms / Examination

‘The Well Patient’ ‘The Unwell Patient’

Cohort Zero- Well- Ambulant- Fit to stay at home

Advice Self-care, self

isolation for 7 days (other family

members 14 days) and safety net advice

Consider diagnostics if clinical concern:

Bloods: FBC, U&E’s, LFT’s, CRP

symptomatic treatment +/-

antibiotics where clinically indicated (see antimicrobial

formulary overleaf)

COVID-19 PRESENTATION IN ADULTSFever > 37.8⁰C Often high and sustained for 10 daysMay be intermittentAbsence of fever does not rule out diagnosis

Breathless 3-64%Onset around day 6Silent hypoxia (especially elderly)No increased work of breathing – seem ‘comfortable’ with low sats

Cough 68-82% Sputum 14-56%

Loss of sense of smell and taste Unknown prevalence but seems to be very common

Less common:GI (diarrhoea, nausea without vomiting, may precede fever) (1-10%) Runny nose – (4-24%)Sore throat – (14%)Myalgia – (11-15%)Headache – (6-34%)

Hypoxic / abnormal observations Significant or prolonged symptoms Requirement of any additional tests e.g. CXR / US Exacerbation of existing respiratory co-morbidities

Perform Combined Functional Assessment Score (assessment of baseline pre-COVID) (PTO)

NB: CXR requested by primary care may not be helpful in the decision for hospital referral and is therefore discouraged.

Cohort 1Combined

functional score <=6

Hospital referral for treatment

and full escalation

Cohort 2Combined functional score of >6 and self-

ambulant.

Hospital or community management – Referral to Specialist Palliative

Care

May benefit from hospitalisation or community

management with PO/IV antibiotics and

oxygen.

For supportive management and enhanced palliative care in hospital / community

Referral to Specialist Palliative Care

DNACPR and CoC in place.

These patients should NOT be moved from current care setting

unless symptoms cannot be managed

Cohort 3aCombined functional

score of >6

Cohort 3bCombined functional

score of >6

Usually NOT for escalation, but may benefit from having

antibioticsAlmost always have a

DNACPR in situ

Avoid:- Use of oral steroids or

NSAIDs unless patient already on them or other non-COVID indication

- Use of fans to cool patients- Routine use of antivirals

Prescribe anticipatory medicines for these patients

Recovery may be uncertain.

Significant nursing care and high likelihood of

dying

Significant nursing care and dying within

hours

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Combined Functional Assessment Score =Clinical Frailty Score + Word Health Organisation Performance Score

Cohort 0If a bacterial infection

may be present, consider the following

antibiotic choices:

Amoxicillin 500mg PO TDS for 5 daysOR

*Doxycycline 200mg PO stat and then 100mg OD for 5 days(if unable to tolerate amoxicillin)

ANTIMICROBIAL GUIDELINES

Respiratory Consultant On-Call – via Switchboard 01925 635911For advice on clinical management of pneumonia / respiratory symptoms

COVID Consultant On-Call – via Switchboard 01925 635911For advice on community management versus escalation to hospital or palliative care

Microbiologist On-Call – via Switchboard 01925 635911

Specialist Palliative Care Support - For advice on symptom management, complex discussions and decision making, including decision on community, hospital or hospice-based supportive and palliative care.

In Hours 7/7 - to contact Specialist Palliative Care Nurses and Community Palliative Medicine ConsultantHalton: 0844 225 0677 / 01928 714927Warrington: 0333 366 1066 / 01925 570781

Out of Hours - Palliative Medicine Consultant On-Call Rota with telephone numbers distributed weekly to GPs, OOH GPs, NWBH Doctors, Hospice Doctors and Community Specialist Palliative Care CNSs (available via Warrington switchboard: 01925 635911)

Remember: Testing for COVID is available for cases in residential

care facilities, and for key workers and their household contacts.

NB: *Clinical Frailty Score is not applicable where function is limited by long-term stable disability such as Cerebral Palsy, Learning Disability etc.

Score Description0 Fully active, able to carry on all pre-disease

performance without restriction

1 Restricted in physically strenuous activity, but ambulatory and able to carry out work of a light and sedentary nature(e.g. housework, office work)

2 Ambulatory and capable of all self-care, confined to a bed or a chair more than 50% of waking hours

3 Capable of only limited self-care, confined to a bed or a chair more than 50% of waking hours

4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair

+

Cohorts 2 & 3aIf a bacterial infection may be present, consider the following antibiotic choices:

Mild to moderate symptoms:Amoxicillin 1g PO TDS for 5 daysOR

*Doxycycline 200mg PO stat and then 100mg once/day for 5 days (for penicillin allergy / intolerance)

Moderate to severe symptoms:Co-amoxiclav 625 mg PO TDS + *Clarithromycin 500mg PO BD for 5 daysOR

*Levofloxacin 500mg PO BD for 5 days(for penicillin allergy / intolerance)

If patient cannot take enteral antibiotics use:Ceftriaxone 1g IV once/day (via OPAT Team)(In severe Penicillin-allergic patients, contact microbiologist on-call)

Pregnancy*Not Indicated In Pregnancy - Use Erythromycin 500mg PO QDS for 5 days(For moderate / severe infections, contact microbiologist on-call and liaise with on-call Obstetric Registrar / Consultant)

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Appendix 22 - The Management of Unexplained Hypoxia in the Maternity Setting during COVID-19 Pandemic

- Silent hypoxia has been noted in COVID 19 infection- Respiratory function in young, fit women can compensate with relatively normal

oxygen saturations, thus masking sudden deterioration- This flowchart has been designed to apply in both antenatal and postnatal settings

All women should have oxygen saturations performed on admission and hourly during labour

Oxygen saturations should be part of ALL antenatal & postnatal observations

Signs of decompensation include: Respiratory rate >30 Drowsiness, exhaustion, inability to complete sentences Unable to maintain saturations >94% Hypotension or other signs of shock such as reduced urine output

If saturations are <94% give 4Litres per minute oxygen via nasal specs and escalate to obstetric team for review

In cases with explained hypoxia eg. PE/PPH

Treat as per protocol and administer 15L oxygen via non rebreather mask

If unexplained hypoxia and other causes ruled out, perform combined throat – nose swab for Covid-19 and escalate to anaesthetist on call for the maternity unit

Perform urgent basic investigations

- CXR

- Urgent bloods (D-Dimers unhelpful in pregnancy)

Consider additional investigations to rule out differentials eg. ECG, CTPA, ECHO (after medical advice)

Management

If pyrexia, perform full sepsis 6 screening and send Covid-19 swab. Use paracetamol.

Fluid management - COVID 19 can cause ARDS

- perform hourly input/output.

- Caution with IV fluids – aim to achieve neutral fluid balance in labour

- when giving IV fluids, give a bolus of 250 – 500 ml and then assess for fluid overload before prescribing more fluid

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Equality Impact Assessment (EIA) Initial assessment Yes/No Comments

Age

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

Gender reassignment

Race

Religion or belief

Sex

Sexual orientation including lesbian, gay and bisexual people

Marriage and civil partnership

Pregnancy and maternity

No No No No No No No No No

The policy covers all ages however there are separate sections relevant to adults and children

Is there any evidence that some groups are affected differently?

No The only differentiation is in regard to age segregation from an adults and paediatric perspective

If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable?

No N/A

Is the impact of the document likely to be negative?

If so can the impact be avoided?

What alternatives are there to achieving the document without the impact?

Can we reduce the impact by taking different action?

No N/A

Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the Human Resource Department together with any suggestions as to the action required to avoid /reduce this impact. For advice in respect of answering the above questions, please contact the Human Resource Department.

Was a full impact assessment required?

No

What is the level of impact? N/A