Guidance

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

Updated 22 May 2020

Latest updates to this page

18 May: updated case definition in section 2 with addition of a loss of, or change in, normal sense of taste or smell (anosmia).

1. Preparing for an assessment

Clinicians should:

• implement infection prevention and control measures whilst awaiting test results, including isolation and cohorting of patients in line with your Trust seasonal influenza operational plan

• assess individuals in a single occupancy room

• wear personal protective equipment (PPE) - as a minimum, this should be a fluid resistant surgical mask, single use disposable apron, gloves and eye protection. If a patient meeting the case definition undergoes an aerosol generating procedure, then an FFP2/FFP3 respirator, long-sleeved disposable fluid-repellent gown/coverall, gloves and eye protection must be worn; refer to infection prevention and control (IPC) guidance and PPE guidance

• ask the patient to wear a fluid-resistant (Type IIR) surgical face mask (FRSM) if they are in a clinical or communal area or are being transported if the patient can tolerate it. The aim of this is to minimise the dispersal of respiratory secretions, 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). An FRSM can be worn until damp or uncomfortable

2. Case definitions: possible case, as of 18 May 2020

2.1 Patients who meet the following criteria (inpatient definition)

• requiring admission to hospital (a hospital practitioner has decided that admission to hospital is required with an expectation that the patient will need to stay at least one night)

and

• have either clinical or radiological evidence of pneumonia

or

• acute respiratory distress syndrome

or

• influenza like illness (fever ≥37.8°C and at least one of the following respiratory symptoms, which must be of acute onset: persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing

or

• a loss of, or change in, normal sense of taste or smell (anosmia) in isolation or in combination with any other symptoms

Note: Clinicians should consider testing inpatients with new respiratory symptoms or fever without another cause or worsening of a pre-existing respiratory condition.

2.2 Patients who meet the following criteria and are well enough to remain in the community

• new continuous cough

or

• high temperature

or

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

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.

Clinicians should be alert to the possibility of atypical presentations in patients who are immunocompromised.

Alternative clinical diagnoses and epidemiological risk factors should be considered.

3. Action to take if inpatient definition is met

3.1 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.

3.2 Sampling and testing

Arrange diagnostic sampling for individuals meeting the inpatient definition. 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. As of 19 March 2020, influenza positivity in GP surveillance was low. Therefore, seasonal influenza testing may not be routinely required for non-hospitalised influenza-like illness patients. In the future, please refer to this bulletin to ensure you are informed by the latest available data.

For hospitalised patients with an acute respiratory infection, whilst influenza activity remains low and international travel is minimal, there is no need to screen every case for influenza at the same time as SARS-COV2 testing. Influenza testing should be considered where SARS-CoV2 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.

3.3 Reporting to Public Health England (PHE)

The local PHE health protection team should be informed of cases or situations relating to the following contextual settings:

• 2 or more cases (meeting the definition of a possible or confirmed COVID-19 case) from a long-term care facility
• any case from a prison or prescribed place of detention
• any outbreak in a hospital or healthcare setting
• schools
• 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).

3.4 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 advice about staying at home
• there are arrangements in place to get them home

People in hospital who are not confirmed to have COVID-19 can be discharged. Decisions about any follow-up will 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.

4. 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.

5. 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.