COVID-19 Draft Guidelines for Acute Respiratory Assessment Clinics Version 1.0 13 March 2020
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COVID-19 Draft Guidelines for Acute Respiratory Assessment Clinics Version 1.0 13 March 2020
COVID-19
Guidelines for acute respiratory assessment clinics
Page 2 COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020For urgent requests or clinical advice regarding testing, the dedicated DHHS
hotline for COVID-19 is 1800 675 398.
Healthcare workers who wish to stay up to date can:
• Check this page regularly https://www.dhhs.vic.gov.au/health-services-
and-general-practitioners-coronavirus-disease-covid-19
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COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020 Page 3Contents Executive Summary ...................................................................................................... 5 Purpose and scope of an acute respiratory assessment clinic (ARAC) .................. 6 Clinic location and design ............................................................................................ 7 Location ........................................................................................................................... 7 Principles of design ......................................................................................................... 7 Staffing model of care ................................................................................................. 10 Patient flow algorithm ................................................................................................. 12 Relevant clinical guidelines ....................................................................................... 14 Staff training and PPE training requirements ........................................................... 16 Discharge information for patients ............................................................................ 17 Acknowledgement ....................................................................................................... 18 References ................................................................................................................... 18 Appendix 1 – Example of staff ARAC logbook ......................................................... 19 Page 4 COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020
Executive Summary There is presently an outbreak of a coronavirus disease (COVID-19). This is a respiratory illness with symptoms ranging from a mild cough, through to pneumonia. Many people will have mild to moderate symptoms, with a smaller proportion requiring hospitalization and intensive care. COVID-19 spreads from person to person, and there is a risk that the disease may spread in hospitals. Infection prevention and control measures, alongside public health interventions have been shown to limit the spread of the disease. The current outbreak has affected many countries worldwide and is considered a pandemic by the World Health Organisation. Travel restrictions and rapid public health responses have helped to contain the initial spread of the virus in Australia. Information about clinical assessment and public health characteristics of COVID-19 is available at: https://www.dhhs.vic.gov.au/health-services-and-general-practitioners-coronavirus- disease-covid-19 As part of the Australian government response, up to 100 private practice respiratory clinics will be established for patients with mild to moderate symptoms. The purpose of this document is to provide advice for acute respiratory assessment clinics that will complement management of patients who present to the Victorian hospital sector. COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020 Page 5
Purpose and scope of an acute respiratory
assessment clinic (ARAC)
The purpose of an acute respiratory assessment clinic is to provide safe and
streamlined assessment and management of patients who present to hospital systems
with risk factors for, or concern that they may have COVID-19.
For most patients, COVID-19 will present as a mild respiratory illness, and clinical
assessment can be safely managed in general practice.
For some patients with risk factors for, or who present with more serious illness,
assessment close to a hospital facility is most appropriate.
The function of ARACs is to:
1. Allow nearby emergency departments to function as usual by deferring patients
presenting for COVID-19
2. Provide early cohorting of patients away from the rest of the patient population,
to prevent nosocomial transmission
3. Concentrate clinical expertise
4. Provide healthcare worker testing capabilities.
During periods of significant surge, these centres may also assist general practice in
meeting the needs of the population (including the testing of healthcare workers).
Page 6 COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020Clinic location and design
The design of an ARAC is based on the principles of maximizing infection prevention
and control, and adequate distancing of patients1-4.
Location
The preferred location of ARACs for hospitals is close to, but not inside emergency
departments.
The benefits of this co-location are to:
• Allow emergency departments to safely divert into another model of care
• Provide streamlined admission for patients requiring admission
• Limit secondary transfer of patients from ARACs to hospitals using ambulance
services
• Utilise existing governance, and operations frameworks within an organisation.
Within these confines, the selected area should be:
• Low transit, well ventilated, and secure
• Minimise the distance patients travel through other clinical areas to access the
ARAC
• Make use of existing infrastructure where this is available
• Provide easy deferment of unwell or unexpectedly deteriorating patients.
Principles of design
The principles of design of clinics is to:
1. Control and limit access to patients and a potentially contaminated area.
2. Provide an early opportunity for staff to don PPE before entering areas with
potential contamination.
3. Concentrate clinical care and expertise into a designated area.
4. Maximise ability to manage high or rapidly changing patient numbers.
5. Provide a one-way flow of movement, so that patients with little risk of disease
are separated and discharged early.
6. Provide safe disposal of waste.
COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020 Page 7Below is an example of suitable clinic design and underlying principles, provided by the
Royal Melbourne Hospital COVID19 Response Team.
Legend Required design features5
Entrance
Design: Single entrance. Parallel ‘lanes’ of assessment can be adopted if
there is a high caseload. Under the scenario where there are significant
queues, providing access to DHHS information for the public can help
1. individuals understand their risk.
Purpose: Staged area for donning of PPE and handwashing, location of
staff logbook
Equipment required: signage, no touch handwashing facilities, secure
storage for PPE, staff logbook.
Patient registration.
Design: situated after entrance where PPE is adopted. Parallel ‘lanes’ of
assessment can be adopted if there is a high caseload.
Purpose: A staging area to assess vital signs and to triage patient, and a
2. protected location of work for triage nurses and clerks.
Equipment: computer and label printer for clerks, electronic or paper
based screening forms if these have been adopted by your institution,
equipment for physiological triage of patients (blood pressure cuffs pulse
oximetry)
3. Patient assessment waiting area
Page 8 COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020Design: Seat patients in designated areas with a minimum 1m space
between them, unless they are a cohort (family) in which case they can sit
together
Purpose: Provide space for treating clinicians to undertake initial
assessment.
Equipment: chairs for waiting patients, water for waiting patients.
Biological sampling (non aerosolised)
Design: Ideally a room that has a closed door, or a well ventilated area with
physical separation from patient assessment waiting area.
4. Purpose: take COVID swabs and perform other biologic sampling
procedures as indicated.
Equipment: chair, PPE and sample disposal bins, swabs, pathology bags,
written procedures for sampling.
Interim clinical management area
Design: Physically separated from the patient assessment waiting area,
and away from lanes of exit for patients who do not require testing.
5. Purpose: Physical location for patients who require a bed prior to transit to
an emergency department.
Equipment: Patient bed/trolleys/cots, blankets, vital sign monitoring
equipment, resuscitation transport bag.
Exit
Design: Should allow patients who do not need testing to leave without
exposure to areas where sampling or isolation of suspected patients is
6.
occurring. Handwashing facilities and space for PPE removal for staff.
Purpose: Allow patients to exit.
Equipment: handwashing facilities, PPE bins.
Water and toileting facilities available for patients in fever clinic
Food may need to be required if there are significant delays to inpatient
admission.
There may need to be a focal point for patients and carers to get
General
information and prevent patient movement.
Adequate handwashing facilities, PPE disposal areas
Where ARACs exist within an existing building, airflow optimized by
buildings and maintenance department
COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020 Page 9Staffing model of care
The following staffing model can be adapted for your needs, and a single individual
may perform more than one of the roles below.
To ensure continuity of decision making, prospective replacements for managers
should be allocated.
Role Responsibilities
ARAC • Overall responsibilities for ARAC operations
incident
• Focal point for communications with hospital executive
commander
• Focal point for communications with relevant services (e.g.
laboratory)
• Responsibility for staff rostering, monitoring staff
absenteeism.
• Responsibility of reporting public health data to DHHS.
Logistics and • Maintain structural integrity for temporary / marquee facilities.
operations
• Ensure appropriate stability of water, power, and oxygen
supervision
where temporary facilities used.
• Manage laundry, cleaning and waste management.
• Estimate the consumption of essential equipment and
supplies.
• Consult with authorities, and vendors to ensure continuous
provision of essential consumables.
• Ensure a mechanism for maintenance and repair of
equipment essential to service provision.
• Coordinate with the hospital to ensure transfer to the ED
and/or admission into the hospital where
Administration • Undertake patient registration and identification
clerks
• Depending on local procedures, notify patients of testing
results.
Medical • Undertake a daily review of DHHS prevailing case definitions,
personnel clinical presentation information, and clinical care algorithms
• Manage care according to standardised case definitions, and
clinical practice guidelines where available.
• Maintain training and competency in PPE
Nursing • Establish a triage protocol that ensures patients at risk of
personnel COVID-19 are recognised and cohorted away from the
Page 10 COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020emergency department, and that severe cases are isolated
and provided early care.
• Provide monitoring and clinical care of patients in the ARAC
• Maintain training and competency in PPE
Staff health • Manage notifications of ARAC staff illness
and
• Manage notifications of failure to wear appropriate PPE in the
psychological
ARAC, or a breach in PPE while performing an aerosolising
assistance
procedure.
lead
• Coordinate activities to recognise staff stress and burnout.
Infection • Provide training and exercises for PPE
prevention
• Coordinate vaccination of staff if vaccine becomes available
and control
adviser (if • Ensure PPE easily available to staff and visitors
available)
• Liaise with building management for optimised airflow (where
existing structures are used).
• Provide a logbook of staff members who are working in the
ARAC.
• Ensure the cleaning of reusable equipment between patients.
• Advise on breaches in PPE
• Maintain a database of staff competencies and training
completed
Security (if • Identify potential security constraints
required)
• Optimise control of facility access, patient flow, traffic, and
parking.
COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020 Page 11Patient flow algorithm The next page shows an example of a patient flow matrix that can be adapted for your service, according to your local resources. This can either be circulated as an electronic or paper document, or placed on a white board. Because case definitions (and therefore indications for testing) change frequently, and maintenance of a ‘live’ version of this matrix requires continued vigilance regarding government communication. DHHS and Safer Care Victoria are working to have a centralised and frequently update version of this document suitable for statewide use. Page 12 COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020
COVID-19 Clinical Assessment Framework
What is the patient’s clinical reason for presentation?
Fever or Acute Respiratory Fever or Acute Respiratory
Severe Acute Respiratory infection
Is the patient in a high risk group?
Asymptomatic No COVID-19 symptoms but Infection* Infection* Severe Acute Respiratory Infection
(requires Aerosol Generating
requires admission for other (not requiring admission) AND requires (requires Admission)
Procedure + Admission)
condition 1 Admission for other condition 1
Sort/triage: e.g. to assessment clinic Sort/triage: Sort/triage: Sort/triage: Sort/triage: Sort/triage: e.g. to resus
Staff PPE: e.g. CDE Staff PPE: Staff PPE: Staff PPE: Staff PPE: Staff PPE: e.g. RPP
Travelled Patient PPE: e.g. Surgical Mask & HH Patient PPE: Patient PPE: Patient PPE: Patient PPE: Patient PPE: e.g surgical mask & HH
Swab: e.g. No Swab: Swab: Swab: Swab: Swab: e.g. Yes
overseas Disposition: e.g. Self-Isolate as Disposition: Disposition: Disposition: Disposition: Disposition: e.g. ICU
within 14 days required
#
Sort/triage: Sort/triage: Sort/triage: Sort/triage: Sort/triage: Sort/triage:
No international Staff PPE: Staff PPE: Staff PPE: Staff PPE: Staff PPE: Staff PPE:
travel but Patient PPE: Patient PPE: Patient PPE: Patient PPE: Patient PPE: Patient PPE:
close contact Swab: Swab: Swab: Swab: Swab: Swab:
with confirmed Disposition: Disposition: Disposition: Disposition: Disposition: Disposition:
case
Sort/triage: Sort/triage: Sort/triage: Sort/triage: Sort/triage: eg.g Triage to ED cubicle Sort/triage:
Staff PPE: Staff PPE: Staff PPE: Staff PPE: Staff PPE: e.g CDE Staff PPE:
Any other Patient PPE: Patient PPE: Patient PPE: Patient PPE Patient PPE: e.g. surgical Mask and HH Patient PPE:
patients Swab: Swab: Swab: Swab: Swab: e.g.Yes Swab:
Include HCW* Disposition: Disposition: Disposition: Disposition: Disposition: e.g. Admit Disposition:
Glossary
HH: Hand Hygiene
CPE (Contact + Droplet + Protective Eyewear): Surgical mask, gown, gloves, protective eyewear
Respiratory Precautions Plus: Fit tested N95/ P2 mask, gloves, gown, googles
Aerosol Generating Procedure are defined as: Tracheal intubation, non-invasive ventilation, bronchoscopy, High flow nasal cannula, suctioning, manual ventilation, CPR, sputum induction. Nebuliser use is discouraged.
HCW: Health Care worker
Acute Respiratory Infection definition in non HCW*: Fever & cough or increased respiratory rate
Acute respiratory infection definition in HCW *: Health Care Worker indication for testing are Fever or cough or sore throat or SOB
#
Isolate as required : Patients returning from China, Iran, South Korea and Italy must self- isolate for 14 days irrespective of the test result.
Patients returning from other countries must self-isolate until test result is known
COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020 Page 13Relevant clinical guidelines
There are a number of relevant clinical guidelines for management of patients in an
assessment clinic. The following links provide DHHS advice for:
Up to date case definitions https://www.dhhs.vic.gov.au/health-services-
and-general-practitioners-coronavirus-disease-
covid-19
Specimen collection process Coronavirus disease 2019 (COVID-19)
Guideline for health services and general
practitioners - Version 12 - 9 March 2020
(Word)
Environmental management Coronavirus disease 2019 (COVID-19)
(signage, cleaning, and disinfection, Guideline for health services and general
waste management) practitioners - Version 12 - 9 March 2020
(Word)
https://www.safetyandquality.gov.au/our-
work/healthcare-associated-infection/national-
infection-control-guidelines
Checklist of key actions for positive Coronavirus disease 2019 (COVID-19)
cases Guideline for health services and general
practitioners - Version 12 - 9 March 2020
(Word)
Notification of patient test results Coronavirus disease 2019 (COVID-19)
Guideline for health services and general
practitioners - Version 12 - 9 March 2020
(Word)
Advice on transfer to other Coronavirus disease 2019 (COVID-19)
healthcare facilities Guideline for health services and general
practitioners - Version 12 - 9 March 2020
(Word)
Criteria for inpatient discharge Coronavirus disease 2019 (COVID-19)
Guideline for health services and general
Page 14 COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020practitioners - Version 12 - 9 March 2020
(Word)
Release from isolation of a Coronavirus disease 2019 (COVID-19)
confirmed case Guideline for health services and general
practitioners - Version 12 - 9 March 2020
(Word)
Signage for healthcare facilities Coronavirus disease 2019 (COVID-19)
Guideline for health services and general
practitioners - Version 12 - 9 March 2020
(Word)
COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020 Page 15Staff training and PPE training requirements
The expectation of staff working in the ARAC is that they
1. Undertake daily review of the case definitions and changes in clinical
management flowcharts.
2. Understand the symptoms and relevant epidemiology of COVID-19
3. Are compliant with IPC policy
Regarding PPE, At a minimum, all staff who work in the assessment clinic should:
• Have watched relevant PPE donning and doffing videos
• Been fit tested for a N95/P2 mask.
• Renew training once a year, or following a period of more than 6 months of non-
clinical work.
The following links on PPE resources are provided by the Department of Health and
Human Services:
How to put on and fit check a P2 respirator (PDF)
How to put on your PPE (PDF)
How to take off your PPE (PDF)
Further resources will become available with time, and released via:
https://www.dhhs.vic.gov.au/health-services-and-general-practitioners-
coronavirus-disease-covid-19
The following incidents should be notified to the psychological and staff health lead.
1. Notification of a failure to wear appropriate PPE in an assessment clinic.
2. Suspected breach of PPE during undertaking of aerosolosing procedures.
Page 16 COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020Discharge information for patients Iinformation sheets are currently available for patients who meet various category of risk for COVID-19, available at the following site: https://www.dhhs.vic.gov.au/health-services-and-general-practitioners-coronavirus- disease-covid-19 Home Isolation Guidance - Australian Federal Government Culturally and linguistically diverse resources are available here: https://www.dhhs.vic.gov.au/translated-resources-coronavirus-disease-covid-19 COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020 Page 17
Acknowledgement
These state guidelines (including layout for ARACs, and clinical flow matrices) are
adapted from guidelines first developed by the Royal Melbourne Hospital COVID-19
response team. Dr. Martin Dutch has provided technical expertise regarding ARAC
operations.
References
1. McDonald LC, Simor AE, Su IJ, et al. SARS in healthcare facilities, Toronto and Taiwan. Emerg
Infect Dis. 2004; 10(5):777.
2. Varia M, Wilson S, Sarwal S,et al. Investigation of a nosocomial outbreak of severe acute
respiratory syndrome (SARS) in Toronto, Canada. CMAJ. 2003;169(4):285-92.
3. Booth CM, Matukas LM, Tomlinson GA, et al. Clinical features and short-term outcomes of 144
patients with SARS in the greater Toronto area. JAMA. 2003; 289(21):2801-9.
4. Zhang J, Zhou L, Yang Y, et al. Therapeutic and triage strategies for 2019 novel coronavirus
disease in fever clinics. Lancet Respir Med. 2020. February 13.
5. Rojek, AM, Dutch M, Camilleri, D., et al. Early response to a high consequence infectious
disease threat at the Royal Melbourne Hospital Emergency Department – insights from COVID-
19. MJA (preprint, under review)
Page 18 COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020Appendix 1 – Example of staff ARAC logbook Name Organisation Patient Time in Time out COVID-19: Guidelines for acute respiratory assessment clinics, 12 March 2020 Page 19
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