The guidance includes preparations, good practice tips, infection control, management of suspected cases in ED and as inpatients, plus advice and guidance on critical care scenarios.
- Preparations for COVID-19
- Good practice
- Infection control
- Case management
- Managing suspected cases - initial investigation and management
- Presentation of possible COVID-19 at ED
- Making a diagnosis of COVID-19
- Management of admitted cases
- Discharging patients from hospital
- Notes on this guidance
- Latest updates to this page
Preparations for COVID-19
- Public Health England (PHE) guidance on infection prevention and control emphasises that staff should be familiar with local operational procedures and appropriately trained. For example, staff should be aware of where possible cases will be isolated and who to contact in their organisation to discuss possible cases.
- Staff involved in assessing or caring for confirmed cases of COVID-19 should be trained in using PPE and fit testing should be undertaken before this equipment is used. All staff in high risk areas such as emergency departments and urgent care, and other areas as agreed locally must be trained in the use of PPE.
- Staff caring for children with confirmed COVID-19 or undertaking aerosol generating procedures (AGP) should be trained in the safe donning and removal of PPE.
- Health Protection Scotland has provided advice for management of COVID-19 cases in inpatient settings in Scotland.
- NHS England has guidance to assist managers and estates teams in the rapid conversion of existing wards into facilities for COVID-19 patients, including bed layouts, infrastructure prompts, and oxygen advice.
- NHS charging guidance for COVID-19 states that there can be no charge made to an overseas visitor for diagnosis or treatment of COVID-19. Further details are available from NHS England and NHS Scotland.
- There is guidance from RCPCH to support planning paediatric staffing and rotas, which provides advice across a range of areas to support workforce decisions during the pandemic.
- Many local factors will determine how medical staff are redeployed - including staff skill mix, staff availability, services on site, patient population and the impact of coronavirus. In England NHS guidance is available to support local decision making on redeployment of medical staff. This covers supervision, principles for staff redeployment, front door streaming, and speciality specific advice, including emergency medicine, trauma & injuries, paediatrics, and critical care.
NHS England has a guide for management of paediatric patients that also describes the role that paediatric services will play during the pandemic. This guidance lists the following principles for running paediatric services during this time:
- Follow Public Health England guidance.
- Keep children out of the healthcare system, unless essential.
- Use telemedicine and other non-direct care, when appropriate.
- Plan for stopping elective procedures and treatments that may consume critical care and ward resources.
- Plan for increasing capacity for provision of oxygen and ventilators.
- Plan for admitting young adults up to 25 years of age and make contingency plans for admitting older adults.
- Comply with infection-control measures and ensure all staff have access to, and are trained in, appropriate personal protection equipment (PPE). Training should include simulation.
- Design shifts that are practical and sustainable for staff wearing full PPE.
- Use visual alerts to inform staff of symptoms on registration and reminders about respiratory hygiene and cough etiquette.
- Collaborate with hospitals and health systems on local response and to prepare for surges.
- Coordinate with regional and national networks of care to ensure that resources are used equitably, consistently and effectively.
NHS England has guidance for secondary care on management of remote consultations during the pandemic (PDF).
Note: NHS Guidance is clear that a parent/appropriate adult is permitted to visit a child requiring inpatient medical care during the COVID-19 pandemic. Wards and departments should prepare for this, and make appropriate arrangements so that no child dies alone.
Consider the following:
- How will you deal with calls from concerned parents of children with and without risk?
- Where are your quarantine areas and isolation areas for walk-in patients? Are they child-friendly as well as suitable for decontamination?
- Is your designated COVID-19 area for isolation and treatment at presentation of unwell suspected COVID-19 patients suitable for children’s care?
- How will you manage family members of suspected cases in the Emergency Department (ED) area during this time? See isolation plans for parent-child combinations
You should identify:
- Your lead clinician / lead nurse to lead on policies and procedures for COVID-19 (this may be a paediatrician in ED or ED link paediatrician
- Your paediatric cardiac arrest team and management of infectious risk team
- Your paediatric ward isolation cubicles
- Your ward cohorting areas, if needed
- Your hospital’s negative pressure cubicles, and prepare for use for children
- Suitable areas for donning and doffing PPE and its disposal in paediatric areas
- Staff to maintain isolation rooms and ensure quarantine areas remain clean, stocked and ready for use
And ensure that:
- If there is no ensuite toilet in the isolation room, a dedicated commode (which should be cleaned as per local cleaning schedule) should be used with arrangement in place for the safe removal of the bedpan to an appropriate disposal point
- In emergency departments, barrier signs and infection control precaution signs are in place
- Access to isolation cubicles is only via one entrance
- Establish a process for communicating positive results from swabs taken in the quarantine area. Including repeat risk assessment by telephone triage if positive
- Ensure families and patients have advice on self-isolation (stay at home)
- Have your suite of patient information ready specifically written for parents and children, including written information for admitted patients and posters in waiting areas
- PHE has extensive guidance on infection prevention and control for inpatient settings that should be used alongside local operational policies. Note this guidance is issued jointly by public health agencies across the UK.
- The guidance covers:
- staff considerations
- PPE and hand hygiene
- mobile equipment
- critical care, and
- Guidance by PHE on use of PPE for non-aerosol generating procedures.
- Health Protection Scotland has produced a checklist designed for the control of incidents and outbreak in healthcare settings and can be used within a COVID ward or when there is an individual case or multiple cases.
- NHS England has advice on supply and use of PPE, including FAQs on using FFP 3 Respiratory Protective Equipment (RPE)
- Guidance on the infection control implications of tonsillar examination, by the RCPCH and BPAIIG, is available. The guidance gives clinical recommendations to minimise the risk of transmission from asymptomatic children to ear, nose and throat (ENT) healthcare professionals.
- The Government has stay at home guidance.
- Children will be told to remain at home unless the child unwell and requires urgent hospital review.
- There is current advice for the public on NHS111 testing.
Managing suspected cases - initial investigation and management
- PHE guidance on the investigation and initial management of potential cases defines a possible COVID-19 case as an individual that requires admission to hospital and has: either clinical or radiological evidence of pneumonia; or acute respiratory distress syndrome; or flu-like illness regardless of epidemiological links.
- PHE has guidance on steps to take when a patient with suspected COVID-19 presents to ED.
- PHE has guidance providing a priority order of testing for periods when triaging of requests is required. It also advises on priorities for repeat testing given demand for testing
NHS England guidance describes approaches to streaming at the 'front door', with rapid assessment and triage, to help ensure safe management of increased patient numbers. For example, streaming of patients by directing: well COVID-potential patients home to access services via NHS 111 online/remote primary care; well non-COVID presentations to primary care services/home as appropriate (including all minor illness presentations traditionally seen by UCC and GPCOOPs); COVID-potential patients to ‘hot assessment’ zones; non-COVID patients to ‘cold assessment’ zones; and patients being seen directly by the specialty, without prior ED assessment (other than rapid assessment and triage).
NHS England has produced a reference guide for emergency care settings covering the following topics:
- Which patients should / should not be conveyed to hospital?
- Emergency department approach to streaming during the COVID-19 pandemic.
- Emergency department / AMU admission criteria for COVID-19 and non COVID-19 patients.
- Emergency department documentation for suspected COVID-19 patients.
- Radiology guidelines for COVID-19 patients.
- Same day emergency care 'must do / priorities'.
- Discharge of inpatients - reasons to reside in an acute hospital bed.
Presentation of possible COVID-19 at ED
- If a child with possible COVID-19 presents directly to ED, they should be redirected to your COVID-19 quarantine area. See PHE guidance on managing infection control risks in ED.
- If the child has severe respiratory compromise, they will need to be transferred immediately to your designated isolation cubicle for management. In most hospitals this will be in your ED areas, other solutions may exist.
- Any cases phoned in by Ambulance services as “sick” and likely to require resuscitation will be managed in your designated isolation room. The Resuscitation Council has guidance.
- Complete your COVID screening documentation as per guidance.
- A record should be kept of all staff in contact with a possible case, and this record should be accessible to occupational health should the need arise.
- Healthcare staff should wear PPE as per PHE guidance
- PPE should be disposed of in line with infection control procedures
Making a diagnosis of COVID-19
- Follow PHE’s guidance on sample requirements for laboratory investigations.
- Follow HPS guidance for Scotland.
- The sample sets required for diagnostic testing are listed here.
- Ideally only one parent / carer should accompany child to isolation cubicle. Decide who that will be and manage other members appropriately to reduce risk of infection and request they self isolate.
- NHS England has guidance on visitors to inpatients, outpatients and diagnostics.
- HSC NI has guidance on visiting in Northern Ireland (PDF).
- Follow isolation plans for admitted patients - see isolation plans for parent-child combinations
- The attending parent must wear PPE equipment defined by PHE at all times within the hospital buildings and grounds
- It is not advisable to move suspected patients and their families internally until an infectious risk assessment is performed. This covers absolute risk of family members being infected, risk to family members themselves of being secondarily infected by case, risk of family members infecting others within the hospital ( ie not wearing PPE/ poor compliance to infection risk reduction measures), including management of asymptomatic parent / carer who themselves be a potential infection risk when entering or exiting the unit. The risk assessment needs to be standardised and recorded.
Note: guidance is available from NHS England on clinical management of emergency department patients during the pandemic. As at 18 March, this does not discuss paediatric emergency care specifically but outlines different categories of patients and clinical presentations not requiring admission.
Further guidance and advice can be found on the Royal College of Emergency Medicine website.
Management of admitted cases
- Many people with confirmed COVID-19 may be managed at home as per PHE guidance.
- Follow isolation plans for admitted patients - see isolation plans for parent-child combinations
- Visitors should be restricted to essential visitors only, such as parents of a paediatric patient or an affected patient’s main carer. It is recommended that only one parent is in attendance.
- NHS England has guidance on visitors to inpatients.
- HSC NI has guidance on visiting in Northern Ireland.
- NICE is producing rapid guidelines and evidence reviews around COVID-19.
- British Association for Paediatric Nephrology is issuing updates for renal specialists working in paediatrics.
- NHS England has issued guidance on care for people with learning disability and autism aimed at clinicians working in other fields (PDF).
Alder Hey Children’s Hospital, the British Paediatric Respiratory Society, the British Paediatric Allergy, Immunity and Infection Group and RCPCH have developed guidance for the clinical management of children admitted to hospital with suspected COVID-19 for general paediatrics.
NHS England has guidance for care of paediatric critical care patients. This clinical and operational guidance is for paediatric intensive care units (PICUs; level 3) and paediatric high-dependency units (HDUs; level 2). It is also relevant to children's wards with high dependency capabilities (level 1).
Discharging patients from hospital
- NHS England has guidance on discharge of patients with suspected COVID-19 that covers: discharge criteria; stay at home guidance; and discharge advice to patients.
- PHE has guidance on stepdown of infection control precautions within hospitals and discharging COVID-19 patients from hospital to home settings.
- For other inpatients, on 19 March 2020, NHS England issued guidance and requirements on discharge arrangements, with the aim of freeing up inpatient capacity. The default pathway will be 'discharge home today'.
- The COVID-19 Hospital Discharge Service Requirements outline all the details.
- Acute providers need to rapidly update their processes and ways of working to deliver a discharge-to-assess model.
- There should be at least twice daily review of all patients in acute beds to agree who is not required to be in hospital, and will therefore be discharged.
- NHSE has published criteria to aid decision making (see Annex B on p.32 of this PDF).
- Based on these criteria, acute and community hospitals must discharge all patients as soon as they are clinically safe to do so. Transfer from the ward should happen within one hour of that decision being made to a designated discharge area. Discharge from hospital should happen as soon after that as possible, normally within two hours.
- Health Protection Scotland has guidance on discharge arrangements in Scotland.
- An example of inpatient discharge leaflet (kindly shared by Airedale Hospitals) can be found in the downloads section at the bottom of this page.
Notes on this guidance
This section has been produced with the Association of Paediatric Emergency Medicine (APEM), the British Paediatric Allergy, Immunity and Infection Group (BPAIIG), and the British Paediatric Respiratory Society (BRPS).
Latest updates to this page
Updates in this version (4 May 2020)
- Added link to Health Protection Scotland checklist designed for the control of incidents and outbreak in healthcare settings
- Updated link to NHS England reference guide for emergency care settings.
Updates in version 30 April 2020
- Example inpatient discharge leaflet added to downloads section.
Updates in version published 20 April:
- Links updated.