COVID-19 - guidance for acute settings

This page provides guidance for paediatric emergency and acute settings. It has been produced with the Association of Paediatric Emergency Medicine (APEM) and the British Paediatric Allergy, Immunity and Infection Group (BPAIIG). 

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.
Last modified
18 June 2020

Preparations for COVID-19

Good practice

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

Infection control

Case management

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.

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:

  1. Which patients should / should not be conveyed to hospital?
  2. Emergency department approach to streaming during the COVID-19 pandemic.
  3. Emergency department / AMU admission criteria for COVID-19 and non COVID-19 patients.
  4. Emergency department documentation for suspected COVID-19 patients.
  5. Radiology guidelines for COVID-19 patients.
  6. Same day emergency care 'must do / priorities'.
  7. 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 and RCPCH has published guidance on resuscitation.
  • 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


Internal transfers

  • 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

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

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). 

Association of Paediatric Emergency Medicine
BPAIIG - British Paediatric Allergy Immunology & Infection Group

Latest updates to this page

Updates in this version (18 June 2020)

Updates in version published 4 May:

  • 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 published 30 April:

  • Example inpatient discharge leaflet added to downloads section.

Updates in version published 20 April:

  • Links updated.