Suspected child – mildly-moderately symptomatic requiring admission (level 0–1)
Level 0 is a standard ward paediatric patient.
Level 1 refers to level 1 paediatric critical care.
- Children with mild to moderate symptoms and are admitted for observation/feeding support. This advice may change for those with mild symptoms during a pandemic stage.
- Possible interventions:
- Nasogastric feeding
- Supplemental oxygen to maintain saturations over local criteria (90– 92%)
- IV fluids
- Humidified high flow nasal cannulae oxygen (HHFNCO) – note this is a high risk procedure only if absolutely necessary and appropriate infection control measures in place see PHE guidance PICS revised guidance
- Monitoring as required by level of care.
- These children should be nursed in a single side room. A parent/carer who is admitted with the child must stay in the room at all times until discharge or confirmed negative screening test. Both child and parent should wear surgical mask for transfer from ED to the designated room and if leaving for any reason.
- Staff should minimise time in the room as far as possible.
- The process must be explained to families requesting their compliance to infection control procedures. Ways of doing this but minimising contact need to be identified.
- Aerosol generating procedures (HHFNCO, suctioning, performing NPAs) should be avoided unless absolutely essential. NPAs are also aerosol generating procedures but may be clinically helpful.
- Where AGPs are medically necessary, they should be undertaken in a negative-pressure room, if available, or in a single room with the door closed.
- Waste should be managed appropriately. If there is no en-suite toilet in the side room, a dedicated commode (which should be cleaned as per local cleaning schedule) should be used with arrangements in place for the safe removal of the bedpan to an appropriate disposal point.
- Room will need chlorine clean following discharge if screening results pending or confirmed positive.
Suspected child - requiring moderate intervention (level 2 critical care eg CPAP)
- Children who require respiratory support should be discussed with PICU. If they are undergoing high risk procedures (suction, HHFNCO, CPAP, etc.) they should be managed in a single side room and should take priority over other inpatients.
- All attending staff should wear appropriate PPE.
- If subsequently confirmed to have COVID-19, the patient may warrant transfer to an appropriate paediatric HCID centre if there are concerns regarding clinical deterioration; these decisions will be made on a case by case basis depending on capacity within the designated paediatric HCID centres.
- The parent/carer who is admitted with the child must stay in the room at all times until discharge or confirmed negative screening test.
- Room will need chlorine clean following discharge if screening results pending or confirmed positive.
Suspected child – requiring PICU level 3 care
- The Paediatric Intensive Care Society (PICS) have put together detailed practical guidance specific to the management of critically ill children, including flow diagrams for suspected and confirmed cases of COVID-19 infection
- Details regarding the levels of paediatric critical care can be found here.
- Level 3 care includes intubation and ongoing ventilation. Management and referral pathways for level 2 and 3 patients are described in PICs guidance, along with intubation guidance if a child needs intubating in a DGH due to respiratory failure.
- Children requiring level 3 care should be referred to PICU as per normal protocol, highlighting on referral that there is a suspicion of COVID-19.
- All staff involved in their care prior to transfer to intensive care should wear appropriate PPE.
- If the child is confirmed to have COVID-19, assuming that we are still in the containment phase, they should ideally be transferred to an HCID PICU centre.
- Following transfer, the room should be chlorine cleaned.
Child needing resuscitation
More information on resuscitation is available from our COVID 19 resuscitation guide.
Note: reference to PPE levels in these scenarios are based on Resuscitation Council guidance.
- Level 2 PPE: disposable gloves, disposable apron, fluid resistant surgical mask and disposable eye protection
- Level 3 PPE: disposable gloves, disposable gown, filtering face piece (FFP3) respirator and disposable eye protection / visor.
1. The child with prolonged seizure
The emergency department (ED) is alerted by the paramedics that a 2-year-old boy with Dravet Syndrome is en-route with a prolonged seizure. He has had one dose of benzodiazepine with no effect.
The call is put out for paediatric emergency in ED which brings the paediatric registrar, paediatric SHO and the ED paediatric nurse to ED before the patient arrives.
The arriving paediatric team are aware that COVID-19 cannot be excluded and don level 3 personal protective equipment (PPE) for an aerosol generating procedure (AGP) as risks may be airway obstruction or need for bag-valve-mask. The registrar ensures the SHO has completed a fit check for his mask (NHS video). Both the registrar and paediatric nurse complete their fit check. Also in attendance are an ED SHO and ED nurse in level 2 PPE.
The boy arrives without his family who are following and is still seizing with oxygen being administered.
Shortly after arrival in ED he is administered a second dose of buccal midazolam. His seizure terminates but he desaturates and then stops breathing. The paediatric registrar confirms the absence of breathing by observing the patient from the side of the bed.
The paediatric team ask the ED SHO and ED Nurse to leave the area with instructions for the SHO to act as gatekeeper at the door and the ED Nurse to put out the 2222 call and then return with level 3 PPE donned and bring the COVID-19 resuscitation trolley, which he subsequently does.
The registrar positions the airway and prepares the bag-valve-mask with heat moisture exchanger (HME) filter and high flow oxygen attached. Once the ED SHO and ED Nurse have left the paediatric team follow APLS protocol and deliver five inflation breaths via bag-valve-mask. The child also needs some airway suctioning and his saturations and heart rate respond.
The anaesthetist arrives having donned level 3 PPE and takes over the airway from the registrar.
An intra-osseous is inserted by the paediatric registrar assisted by the paediatric SHO. A nasopharyngeal swab is taken for COVID-19 testing before intubation. He is then transferred to where further monitoring and management can continue, which in this service is a cubicle in paediatric HDU where he is successfully extubated an hour later. There is an HME filter between patient and exhalation valve, transferring team wear level 3 PPE and the procedure occurs as per their hospital policy on patient transfer during COVID-19 pandemic.
2. The child with confirmed COVID-19
A previously fit and well 5-year-old is admitted to the COVID area of the children’s assessment unit. She has had 8 days of fever and cough and is now short of breath. Her nasopharyngeal swab on admission was positive for COVID-19.
Despite humidified high flow nasal cannulae oxygen (HHFNC) she is deteriorating and her nurse, who is in level 3 PPE for AGP, pulls the emergency call bell. The first responder is a paediatric SHO who dons her level 3 PPE for AGP from the preprepared trolley outside the red area and enters the room. The nurse in charge of the ward is alert to the call and tasks a second nurse to act as gatekeeper and communicator.
When the paediatric SHO arrives, the nurse has already started bag and mask ventilation with an attached HME filter, the SHO calls to the gatekeeper to request a 2222 call stating ‘confirmed COVID-19’ and requesting emergency equipment. The SHO and the nurse then rapidly reassess the patient. The absence of breathing is confirmed by observing the patient from the side of the bed and a pulse check is performed after five inflation breaths, CPR is not required.
The paediatric arrest team arrive and don level 3 PPE for AGP. The gatekeeper’s role is to ensure only essential team members enter the room and that communication flows from the room to the ward. The gatekeeper and a second SHO help team members don PPE quickly and effectively and complete their fit check before entering the room.
The registrar and SHO follow APLS protocol. Following further ventilation breaths via bag-valve-mask with good positioning, and an orophyryngeal airway, her heart rate responds and rises to 100 beats per minute. The registrar is aware he needs to ensure the mask is a good fit with a good seal to reduce aerosolisation. The paediatric anaesthetist arrives, dons level 3 PPE for AGP and takes over the airway from the paediatric team. The patient already has a cannula in situ. She is stabilised and the decision to intubate is made and is carefully rehearsed before the actual procedure, referring to the paediatric intensive care guidelines (intubation guidelines).
3. Unexpected collapse in a cubicle
A 3-month-old infant is admitted for nasogastric tube feeding with very poor feeding, an increased respiratory rate and saturations of 94% in air. COVID-19 is suspected and a swab is awaited. A healthcare assistant (HCA) competent in nasogastric feeding, wearing level 2 PPE is halfway through a feed when the infant becomes very distressed and then limp. The HCA pulls the emergency cord.
Two nurses and the paediatric registrar run to the preprepared trolley at the entrance to the cubicle. The first arriving nurse dons level 2 PPE and enters the cubicle whilst the remaining nurse and registrar assist each other donning level 3 PPE for AGP, ensuring a fit check is completed. The ward emergency AGP PPE boxes contains thumb loop gowns, gloves, clearly sized goggles and FFP3 masks and are well marked.
The first nurse assists the HCA, she confirms slow laboured breathing, the saturations are 60% and a face mask delivering high flow oxygen is placed on the patient. She calls to the team by the door to put out a 2222 call, stating ‘suspected COVID-19’ and she prepares the bed-side bag with suitable mask and HME filter with high flow oxygen. She also sets the wall suction and yankauer sucker.
The second nurse and registrar enter the room wearing level 3 PPE for AGP and get a rapid handover from the nurse. They ask her to leave the room with the HCA, ensure the 2222 has been called and that emergency equipment is arriving. The HCA will act as gatekeeper communicating to arriving teams.
The registrar confirms slow breathing and delivers careful ventilation breaths followed by a pulse check whilst the nurse removed the original nasogastric tube and resizes for a replacement tube. The heart rate increases with airway suctioning and ventilation breaths. A normal respiratory pattern then resumes.
Outside the room the arriving arrest team don level 3 PPE for AGP and plan the actions needed in the room. This includes requesting rapid sequence induction. Medications are prepared from standard weight charts and the correct sized advanced airway and circulatory equipment is collected from the emergency trolley before entering the room. In the room the infant is now breathing spontaneously with saturations of 94% in 8L of oxygen. A decision will be made if intubation with escalation of care to PICU is needed.
4.Unexpected collapse in a non-ward area
A 9-year-old girl is eating with her father in the hospital restaurant after attending for a blood test when she begins to choke. She collapses and the restaurant staff put out a 2222 call.
A surgical registrar eating at the next table attempts choking manoeuvres without success. The paediatric arrest team arrive together with an anaesthetist. They are wearing fluid resistant surgical masks only. The SHO rapidly dons’ gloves, plastic apron and eye protection from the grab bag they have brought with them and assesses the patient whilst the registrar and anaesthetist don level 3 PPE for AGP.
The SHO confirms a respiratory arrest and prepares the bag-valve-mask, HME filter and an appropriately sized mask and connects it to the portable oxygen cylinder.
Restaurant staff are asked to clear the area. The rest of the team are now in level 3 PPE and take over from the SHO. She is asked to leave the area and act as gatekeeper.
Bag-valve-mask ventilation fails to move the chest. On inspection of the airway the anaesthetist is able to remove the food item and subsequent inflation breaths move the chest successfully. The girl’s heart rate responds and after a further minute of ventilation breaths she begins to make respiratory effort.
The bag-valve-mask is replaced with an oxygen facemask and she is transferred to the nearby ED for further assessment and stabilisation.