Covid-19 HSE Clinical Guidance and Evidence

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| NEWS in Acute Mental Health Services Index

Guidance on the use of Irish National Early Warning System (NEWS) in Acute Mental Health Services (CD19-105 / 20.04.20)

• Early identification of cases of COVID-19

• Clinical Investigations supporting COVID-19

• Clinical Monitoring Using NEWS with Patients with suspected or confirmed COVID-19 status

• Decision algorithm in regards to escalation reflecting anticipatory guidance

• HSE Mental Health Services Covid-19 Escalation algorithm

• Red flags which indicate Critical Illness in COVID-19 

• NEWS Escalation and Response Protocol​

Early identification of cases of Covid-19

It is essential to have systems in place for the early identification of cases of Covid-19. This includes:

• Ensuring staff and residents are aware of the symptoms of Covid-19
• Twice daily review of residents for symptoms especially temperature and respiratory rate.
• Early identification of staff absenteeism which may be due to Covid-19infection or restricted movements as close contact of a case
   

Clinical Investigations supporting Covid-19

Throat and nose swab virology are the commonest form of diagnosis. Where there is a high clinical index of suspicion for COVID- 19 (e.g. during facility outbreak), non-detectable viral load through nose / throat swab does not exclude possibility of COVID -19 infection. It is not necessary to wait for laboratory test results before beginning initial investigations or implementing control measures.

• On confirmation of a positive diagnosis of Covid-19 further investigations may be considered appropriate to assist with management. E.g. FBC, UEC, LFTs, CXR if possible
• Investigations to out rule underlying non-Covid-19   related conditions may be appropriate
• Clinical discretion and judgement should be used regarding further investigation and in particular in identifying whether same will alter overall patient management and risks posed by transfer to and from acute hospital facilities for same.
• Vital signs with an emphasis on respiratory rate and temperature should be monitored at least every four hours if the patients are suspected of having Covid-19. This should be done using the Irish National Early Warning System (NEWS)  observation sheet where possible
   

Clinical Monitoring Using NEWS with Patients with suspected or confirmed Covid-19 status

• Complete a full set of NEWS observations for the patient.
  • A full set of NEWS observations is as follows: Respiratory rate, peripheral oxygen saturation, FiO2 (room air or supplemental oxygen), blood pressure, heart rate, neurological responsiveness using scale for alert, verbal, pain, unresponsive  i.e. ACVPU scale  and temperature.
• Calculate baseline NEWS score as per the NEWS observation chart. Please clink on links to see presentation and factsheet which explains how to use NEWS.
  How to complete the NEWS observation chart
  Presentation to provide information about how to use NEWS for staff in acute settings
  Patient observation chart                                                                                                          

Links can be found on the HSE webpage Physical-health-supports-for-mental-health-services Record the normal baseline health and NEWS score of the patient.

• Be alert to any changes of the normal baseline in the patient.
• Commence twice daily monitoring for symptoms of Covid-19 for all patients in acute mental health adult inpatient approved centres for the duration of the Covid-19 outbreak.
• If patient requires more frequent observations continue with same.
   

Decision algorithm in regards to escalation reflecting anticipatory guidance

• The following anticipatory decision log is to offer guidance to doctors and nurses who may not be familiar with the Service User as to what approach to take in the event of their acute deterioration. This document cannot cover all clinical eventualities but it may act as a guide in deciding the appropriateness of certain interventions. It is not prescriptive. The treating clinician should use their discretion to provide whatever treatment they see fit, depending on the clinical scenario.

Decision algorithm in regards to escalation reflecting anticipatory guidance

HSE Mental Health Services Covid-19 Escalation algorithm

(In-patient services-Adult Acute Approved Centres including admission, continuing care and special care or secure wards)

Nebuliser usage should be discouraged in favour of Metered Dose Inhaler (MDI) and spacer where possible. Use of a nebuliser should be in a well-ventilated room and Health Care Worker should vacate if at all possible. If Health Care Workers remain they should follow PPE protocols.

Red flags which indicate Critical Illness in Covid-19

Complete patient observations on the NEWS observation chart. Please see form here: Patient observation chart    and score using the NEWS scoring key below.

NEWS Escalation and Response Protocol

• Please ensure the NEWS Escalation and response protocol in your service is in line with the NEWS escalation and response protocol in use in the acute general service to which you refer patients to; check with the acute service to make sure this is still current practice and is still in use.
• The score sheet below was written for acute general services. A NEWS score equal to or greater than 3 in a COVID-19 patient requires urgent transfer from mental health services to acute general hospital if appropriate. Deterioration of the patient’s condition can be quite rapid beyond this point.

A score of less than 3 with other triggers may also require transfer.

• Ensure that the ISBAR tool is prepared before corresponding with acute service where possible as this ensures clear and prompt communication with acute services.
• The NEWS observations chart and Escalation and Response protocol are tools to assist healthcare professionals with clinical decision-making.  They are an adjunct to clinical judgement – they do not replace clinical judgement