Guidance

COVID-19: investigation and initial clinical management of possible cases

Updated 14 December 2020

Latest updates to this page

2 October: consolidated case definitions for inpatient and community settings into 1 list. Unusual presentations were highlighted, such as delirium in the elderly.

1. Conducting a clinical assessment

There is public advice for people with corona virus symptoms and what they should do. Nevertheless, patients will frequently present to clinicians for assessment. When conducting these assessments clinicians should:

• implement infection prevention and control measures whilst awaiting test results, including isolation and cohorting of patients in line with their GP surgery or Trust COVID operational plan

• assess the possible case individuals in a single occupancy room

• wear personal protective equipment (PPE) - as recommended in the infection prevention and control (IPC) guidance.

• ask the patient, if older than 3 years and can tolerate it, to wear a fluid-resistant (Type IIR) surgical face mask (FRSM) if they are in a clinical or communal area or are being transported. This is to minimise the dispersal of respiratory secretions and reduce both direct transmission risk and environmental contamination. A FRSM should not be worn by patients if there is potential for their clinical care to be compromised (for example, when receiving oxygen therapy via a mask). A FRSM can be worn until damp or uncomfortable

2. Definition of a possible COVID-19 case, as of 28 September 2020

Individuals with

• new continuous cough

or

• temperature ≥37.8°C

or

• loss of, or change in, normal sense of smell (anosmia) or taste (ageusia)

Individuals with any of the above symptoms but who are well enough to remain in the community should follow the stay at home guidance and get tested.

3. Other clinical situations when SARS-CoV-2 testing should be considered

A wide variety of clinical symptoms have been associated with COVID-19. When ordering a SARS-CoV-2 test it is NOT a requirement for the patient to meet the definition of a possible COVID-19 case. To access community testing, if the definition is not met and the test is considered necessary by a clinical or public health professional, the box should be ticked on the online form.

Patients with acute respiratory infection, influenza-like illness, clinical or radiological evidence of pneumonia, or acute worsening of underlying respiratory illness, or fever without another cause should have a SARS-CoV-2 test, whether presenting in primary or secondary care.

In addition, the following situations should prompt clinicians to consider SARS-CoV2 testing:

• Onset of delirium (acute confusion) in older people, or in those with dementia or cognitive impairment. Due to communication difficulties these patients may be unable to report symptoms. New infections in people with dementia may be manifest as delirium.

• When investigating a possible infection in the immunocompromised in whom atypical COVID-19 presentations may occur.

• Other factors to consider include alternative clinical diagnoses, reported exposure to other test-confirmed COVID-19 cases, and the current local incidence of COVID-19 in the community or in shared settings.

4. Actions to take if a possible COVID-19 case requires admission to hospital

4.1 Isolation

Ensure the patient is placed in respiratory isolation or within a specified cohort bay and the PPE described in the infection prevention and control guidance is worn by any person entering the room. Ensure that the patient, potentially contaminated areas, and waste are managed as per the infection prevention and control guidance.

4.2 Sampling and testing

Arrange SARS-CoV-2 diagnostic sampling for individuals who require a test. Do not wait for results of local testing for other pathogens before sending samples for SARS-CoV-2 testing.

Testing should be organised through the local hospital. How to arrange laboratory testing and the guidance for sampling and diagnostic laboratories includes an overview of laboratory investigations and sample requirements.

Testing for respiratory viruses other than COVID-19 can be guided by the current epidemiology as noted in the national flu report. Please refer to this bulletin to ensure you are informed by the latest available data.

For hospitalised patients with an acute respiratory infection, the current level of influenza activity should guide the need to screen for influenza at the same time as SARS-CoV-2 testing. Influenza testing should be considered where SARS-CoV-2 is negative, in severe infections and immunocompromised patients, and in other cases where it is relevant for clinical management.

For those patients not tested in hospital, guidelines on who can get tested and how to arrange for a test can be found in the COVID-19: getting tested guidance.

4.3 Reporting to Public Health England (PHE)

The local PHE health protection team should be informed about COVID-19 outbreaks and clusters in particular settings, including:

• non-residential settings (for example a workplace, a school, a restaurant)
• long-term care facilities and other institutional residential settings
• prisons or prescribed places of detention
• hospitals and healthcare settings
• other unusual scenarios

In addition, any case meeting the criteria for avian influenza or MERS-CoV testing should be reported to the local health protection team (HPT).

4.4 Discharge of patients

If the patient is clinically well and suitable for discharge from hospital, they can be discharged after:

• appropriate clinical assessment

• risk assessment of their home environment and provision of self-isolation advice. Isolation should be maintained until at least 14 days from their first positive test. If patients are febrile on discharge, they should extend their self-isolation until their fever has resolved for a consecutive 48-hour period without any medication to reduce their fever (unless otherwise instructed by their acute care provider- for example, if another reason for persistent fever exists). Further details can be found in the stay at home guidance

• there are arrangements in place to get them home

It is also best practice to provide written instructions on any ongoing isolation recommendations. Decisions about any follow-up should be on a case by case basis. Further guidance is available on stepdown of infection control precautions and discharging patients and in the DHSC hospital discharge guidance. Possible COVID-19 cases admitted to hospital who then test negative for SARS-CoV-2 and who have recovered from their illness, may be discharged.

5. De-escalation of infection prevention and control (IPC) measures in hospital

Decisions about de-escalation of IPC measures on admitted patients who will remain in hospital should be made on a case by case basis in discussion with local infection specialists. Further guidance is available on stepdown of infection control precautions and discharging patients.

6. Associated legislation

Please note that this guidance is of a general nature and that an employer should consider the specific conditions of each individual place of work and comply with all applicable legislation, including the Health and Safety at Work etc. Act 1974.

Cases of COVID-19 and of SARS-CoV-2 infection are statutorily notifiable. When a registered medical practitioner has reasonable grounds for suspecting a patient they are attending has COVID-19, such cases should be notified. Test-confirmed SARS-CoV-2 infections should be notified by the relevant laboratory. Guidance is available on reporting notifiable diseases. It is important to ensure suspected and confirmed cases of COVID-19 are correctly recorded in the patient’s records - see NHS Digital’s website for SNOMED codes. The Faculty of Clinical Informatics has published advice on COVID-19 clinical coding for general practice.