coronavirus

Clinical guidance for managing COVID-19

Information for RCN members

All nursing and midwifery staff are fundamental to informing the public and reassuring them about the COVID-19 outbreak.

This page provides RCN members across the health and social care workforce, including nursing support workers and students, with clinical information and key resources to support their understanding of and help them with management of COVID-19.  

Background

In late December 2019 a new (novel) coronavirus was identified in China causing severe respiratory disease including pneumonia. 

The virus causing the infection has been named - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) this is a new strain of coronavirus causing COVID-19.

Since 19 March COVID-19 is no longer categorised as a High Consequence Infections Disease (HCID) in the UK, see Public Health England for more information.

SARS-CoV-2 infections are spreading between people globally; see the WHO situation reports dashboard which is updated daily and the Johns Hopkins University dashboard which aims to present real time data uploads. The situation was declared a pandemic on 12th March 2020.

As a newly identified virus there is currently no human immunity to it and no vaccine is available to prevent infection. As a viral infection, antibiotics are not an effective treatment.

Coronavirus

Coronaviruses are a common family of viruses and one of the main causes of the common cold. In general, most infected people will present with mild to moderate respiratory like symptoms, see the WHO information. Those with underlying illness and co morbidity are the most seriously affected requiring hospitalisation and Intensive care. 

Other examples of Coronavirus include MERS Co-V and SARS both of which have prompted global collaboration to reduce spread between people and to protect healthcare workers.

Current situation

It is a fast-moving evolving situation and as with any new strain of virus, the guidance for healthcare workers and health and social care services is being developed and updated frequently. This reflects the need to take a view of the global situation as well as the situation across the UK. Alongside a growing understanding of the infection risk of this new virus; incubation time, infectiousness and severity of the infection.

All nursing and midwifery staff, including, nursing associates, and healthcare support workers, must familiarise themselves with their local policies on emergency planning, infection prevention and control. They should also keep up to date with national guidance issued by the UK governments and relevant UK Public Health agencies. 

This information is updated regularly to reflect the changing situation. It is important that members look on the web sites and check the links to ensure they are looking at the most up to date information.

UK Coronavirus response

The UK Coronavirus action plan sets out the UK plans and actions for managing the coronavirus (COVID-19) outbreak, also available from the Scottish government

The exact response to the outbreak will reflect the nature, scale and location of infection as the situation develops and members are advised to look on the links to the guidance to make sure they are accessing the most up to date information. 

Public information campaign

The Department of Health and Social Care public information campaign including the importance of handwashing and other measures to reduce the spread of coronavirus.
See: Coronavirus (COVID-19): campaign information and resources.

For health protection advice, contact your local health protection team:

Information for the public; what to do if you have symptoms, patients who are concerned should be advised to contact NHS 111

The following provide more detailed advice for the public across the UK:

Information for the public; including stay at home advice for people who are self-isolating, from the NHS

RCN position

See: RCN position on COVID-19

The RCN is not planning to develop any specific clinical guidance relating to COVID-19.

The RCN are working with national UK agencies and other key stakeholders such (for example other Royal Colleges) to support preparedness and management of the current situation providing an RCN perspective based on our role as a Royal College and Trade Union. 

The protection of healthcare workers, development and review of guidance and resilience of healthcare provision is our current key focus. Please refer back to the main RCN COVID-19 (coronavirus) resource.

RCN short life coronavirus network

To support members with communication and enable you to raise any concerns or provide feedback, a short life virtual network will be established for the duration of the outbreak. Information sent out via the network will be in addition to that posted on the webpage and may include advice and guidance relating to employment of HCW support, opportunities to comment on draft guidance or other intelligence gathering activity.

If you wish to join the virtual network and received email communication from the RCN on this issue please request to join via coronavirus@rcn.org.uk.

You may leave the network at any time by requesting to opt out of further emails and your information will only be used for the purposes of information on this issue.

RCN Infection Prevention and Control Programme

Find out more about the RCN's introductory module to infection prevention and control.

RCN hand washing poster

An A4 poster detailing the 10 steps to effective hand washing.  We recommend laminating this poster if displaying in wet areas.

Protecting staff

Employers have a duty of care under the Control of Substances Hazardous Health 2002 (COSHH) to assess and reduce the risks from exposure to biological hazards. Under COSHH employers need to identify who may be harmed by a biological agent and how they may be exposed.

Latest guidance from Public Health England, Health Protection Scotland and the Health and Safety Executive will inform the COSHH assessment and what steps need to be taken including the identification of potential patients with COVID-19, isolation procedures and precautions such as negative pressure ventilation and the provision and safe use of appropriate personal protective equipment (PPE).

Staff may be anxious by what the read in the media and employers should ensure that all nursing staff are provided with factual information on COVID-19, the steps that their employer is taking to identify and manage suspected cases and what nursing staff can do to protect themselves, including reinforcing hand hygiene. Staff who may be required to deliver clinical care to affected patients, should have the necessary skills and experience and be provided with training and information on any additional infection prevention and control measures needed to work in such environments including the safe donning and removal of PPE.

RCN safety representatives should be kept informed of measures being taken to protect staff and there should be mechanisms in place that allow safety representatives to raise concerns with senior managers/health and safety/infection control leads on behalf of staff. To also ensure there are appropriate safeguarding measures in place for staff and patents/ service users.

Members who are concerned should speak to their local safety representative and/or contact RCN Direct on 0345 772 6100 see the RCN get help guide. Also see the RCN COVID-19 employment advice.

See also NHS Employers: Joint statements and papers on COVID-19 and NHS Providers national guidance

UK governments are working to develop guidance and information:

Department of Health and Social Care, Public Health Wales, Public Health Agency (Northern Ireland), Health Protection Scotland and Public Health England joint UK advice.

Also see:

Please see the COVID-19 (coronavirus) FAQs for information about personal protective equipment (see the PPE (personal protective equipment) section).

NICE COVID-19 rapid guidelines

Critical care and emergency department nurses are likely to be looking after more acutely and critically unwell patients. Nurse to patient ratios may be much higher than usual and they may require support from colleagues from other specialties not necessarily related to emergency or critical care. Therefore, they may have to supervise non-emergency/critical care colleagues moved to support the care delivery to the critically ill patients in their departments.

Please see:

Cancer and Coronavirus (COVID19)

Guidance has been produced by the One Cancer Voice* charities in partnership with NHS England.

Macmillan Cancer Support: frequently asked questions for people with cancer.

Please refer in the first instance to wider Government guidance on:

Royal College of Psychiatrists guidance for psychiatrists and other healthcare professionals working in mental health settings. Developed with NHS England and Improvement (NHSE/I) and the Royal College of Nursing.

The National Association Psychiatric Intensive Care and low secure units (NAPICU) have developed advice on restrictive practices and managing acute disturbance.

See also:

Royal College of Nursing: Redeployment guidance for pregnant staff (under 'What are the occupational health / health and safety factors?')

Royal College of Obstetricians and Gynaecologists: National guidance on managing COVID-19 infection in pregnancy

Royal College of Obstetricians and Gynaecologists: Guidance for pregnant health care staff

Alongside European colleagues, the BFS (British Fertility Society), supported by the Human Fertilisation and embryology Authority (HFEA) have agreed to cease all fertility treatments. Those in progress will continue and services will maintain storage banks but new patients will not be taken on at this time, see here for further information. 

Community Nursing in all forms is pivotal to the nation’s health and social care. We have put together some useful UK guidance. However, it is important that the nursing team familiarise themselves with their local policies on emergency planning, infection prevention and control and national other guidance.

You may find useful information on the Queens Nursing Institute website: See: Coronavirus Information Centre. A collection of resources and links for community nurses and allied health professionals

People living with dementia may find changes in patterns of life difficult to manage. It is important to explain to people living with dementia why there are changes are occurring and what is being done to keep them safe. Writing reminders, reinforcing details at each visit and encouraging virtual community support will all be helpful. 

Alzheimer’s society: Coronavirus: Information for people affected by dementia  

Dementia UK: Coronavirus (COVID-19): information for families looking after someone with dementia 

We need to be aware that people may experience considerable stress during this outbreak and be in closer contact with household members for longer periods of time, which may increase issues related to safeguarding. 

Children

With infants and young children spending more time indoors it is important that we all remind parents of potential hazards in the home, including hazards such as blind cords. There have been one or two deaths recently of young infants/children getting tied up in blind cords. Info can be found at CAPT and NHS advice for new parents.

Adults

Changes in patterns of day to day life may result increased safeguarding events as people spend longer periods of time together without access to recreational activities and other opportunities to socialise, Community nurses need to be aware that they may be an increase in abuse, harm or neglect and understand their role for both adults and any children that may be involved.

Many of the usual options for respite care, such as day centres and home support, may not be available during this COVID-19 outbreak. This is likely to increase the stresses placed on family carers. Additionally, people with high levels of need may be exposed to unscrupulous persons who may contact them offering services or financial advice which may result in abuse.  We recognise that community nurses will often be the only people who are entering the homes of many adults with high level of care need and will demonstrate their usual vigilance to identify safeguarding concerns. It is important you are familiar with any different ways of working in your locality in order to protect people. 

The novel coronavirus (COVID-19) outbreak will have major implications for health and care services in the UK, and for health and care staff. This briefing is to support members making difficult decisions during this challenging time. 

Background 

Health and social care staff are faced with difficult decisions every day. However, planning for and responding to COVID-19 will require nurses and other staff to make difficult decisions under new and exceptional pressures, with limited time, resources and information.  

These decisions could relate to the care we provide, how we provide it and who we can provide it to and could have wider impacts on the delivery of our health and social care services.

RCN Position 

Making these difficult decisions should be based on our professional judgement, in accordance with the law, relevant guidance and evidence, and statutory duties.  

This resource is designed to direct RCN members to the relevant resources designed to support specific areas of care but also provide some overarching principles. 

It is critical that our decisions are made with transparency and are free from unlawful discrimination and personal bias, commensurate with the spirit of the Human Rights Act 1998 and Equality provisions operating across the UK.   

  • The right to life must be preserved wherever possible  
  • The protected characteristics of a patient such as their age, ethnicity, gender, sexual orientation, should not influence our clinical decision making without a clear evidence base for doing so. 
  • Decisions must be taken in consultation and discussion with the patient during this pandemic, wherever possible. 
  • Health and care workers must be supported including with relevant and adequate guidance and resources, in order to provide the best possible care in the context of this emergency.  

Guidance 

Wherever possible decisions must be taken in consultation and discussion with the patient. If treatment is available (subject to resources), and there is a real prospect that the patient would benefit, then the treatment should be offered. 

A patient with capacity should be given sufficient information to make a real choice of which available treatment, if any, to consent to. If the patient lacks capacity, then the clinician should decide which, if any, available treatment is in the best interests of the patient, but should normally consult with the patient’s family and carers, or an independent mental capacity advocate (if appropriate), before making this decision.  

A record of the decision and the discussion should be made.   

If a treatment is likely to be futile, or harmful, then it need not be offered. For example, if there is no real prospect that mechanical ventilation will benefit the patient, then it should not be offered. The clinician should explain to the patient why it would not be appropriate. Ultimately, the patient does not have the right to insist on a treatment that would not be beneficial. 

Resources to Support Practice 

For more information about this visit: 

RCN COVID-19 guidance on DNACPR and verification of death

Joint NMC/RCN statement regarding Decisions Relating to Cardiopulmonary Resuscitation (CPR) (updated March 2020)

RCP joint statement on ethical guidance for front line staff

Equality and Human Rights Commission

Equality Commission 

Northern Ireland Human Rights Commission 

With recognition of the increasing pressures and demand on staff and on the health and care system, it might become necessary to make challenging decisions about how to direct resources to where they are needed most, and to prioritise individual care needs.  

The NICE COVID-19 rapid guideline includes a decision tree algorithm and tools to support clinical decision making: 

See also The Joint statement on developing immediate critical care nursing capacity  

The Ethical guidance: Department of Health and Social Care Adult Social Care Ethical Framework; provides support for ongoing response planning and decision-making to ensure that sufficient consideration is given to ethical values and principles when organising and delivering social care for adults.

The framework intends to serve as a guide for these types of decisions, and that consideration of any potential harm that might be suffered and the needs of all individuals are central to decision-making. 

Due to coronavirus infection (COVID-19) there will be an increase in numbers of people with Palliative and end of life care needs. This will include those who have also become palliative during the pandemic with COVID-19 and also unrelated conditions and be impacted by changes to health and care services in this time of unprecedented demand. This briefing is to support members at a time of unprecedented numbers of deaths due to COVID-19.

Background

Palliative care is the care people receive when their treatment is no longer considered curative. The Palliative care philosophy promotes holistic care looking after all the domains in life that makes us individual and important to ourselves and those around us. It is recognised that for some people, curative interventions for COVID-19 may be inappropriate and/or ineffective and a palliative approach to care may be implemented. 

Palliative and end of life care is delivered by a range of healthcare professionals across the health and social care workforce. Community nursing caseloads will have a large proportion of people who have palliative and end of life care needs, and this is likely to increase. Palliative may need to be given in settings which do not normally care for people at the end of life.

People with current palliative care needs may fall within the vulnerable group criteria and should they contract COVID-19 they may find that they decline more rapidly than would have been expected. Advance care planning is critical to ensuring that people who are or who may become palliative during this pandemic have opportunity to discuss their wishes.

Conversations with people who are approaching the end of their life are not always easy, but they are necessary. Opportunities to discuss Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) with the person or their advocate/family if they lack capacity, are important and should be initiated as early on within the illness as possible.  Advance Care plans including advance directives to refuse treatment should be discussed and support put in place to complete, should the person decide that this is what is important to them. 

Where a person lacks capacity then a decision in their best interests (a best interests decision implies a formal legal decision under MCA) should always be made supported by the people that know them the best. Or who have powers of attorney

As a result of COVID 19, life expectancy may be shorter than previously expected and people and their families should, as far as possible, be prepared for this.  Sensitivity and kindness must prevail even in these challenging situations. 

Hospices and specialist palliative care providers may change the way they are working during this pandemic. 

Guidance

Dignity, respect and compassion must remain at the core of the delivery of end of life care.  

People approaching the end of their lives should still be engaged in conversations about their treatment during this pandemic, wherever possible. This may form a part of advanced decision-making conversations. See section on DNACPR and advanced decision making

As far as reasonably possible, people’s cultural and religious beliefs should be explored and respected. However, as the pandemic increases, this may not always be possible.

Health and care workers in all relevant settings must be supported including with relevant and adequate guidance and resources, in order to provide the best possible end of life care in the context of this emergency.  

Resources to support practice

Further protocols and guidance are currently being produced to support care of the dying in the community, and in mental health. This will be added to this resource as they become available.

RCN: Guidance on advance care planning 

RCN: COVID-19 guidance on DNACPR and verification of death

APM: COVID-19 and Palliative, End of Life and Bereavement Care in Secondary Care

COVID EoLC Community Charter

e-Learning for Healthcare: End of Life Care for All

Hospice UK: Coronavirus Guidance (COVID-19)

Hospice UK: Caring for your dying relative at home with COVID-19

Marie Curie: Coronavirus (COVID-19) if you’re affected by terminal illness

NHS England: Clinical guide for the management of palliative care in hospital during the coronavirus pandemic

RCGP: Community Palliative, End of Life and Bereavement Care in the COVID-19 pandemic

RCGP: End of life and palliative care toolkit

RCGP: End of life quality improvement resources

 

Bereavement Support

It is likely that people who may become bereaved during this time may need extra bereavement care and support, local hospice websites may have local information.

You can also access information here.

It is likely that people who may become bereaved during this time may need extra bereavement care and support, local hospice websites may have local information. See: Coronavirus: dealing with bereavement and grief.

Nurses work closely with many community and staff groups. Set out below are the links to guidance covering different sectors that may be helpful to you in managing day to day interaction with colleagues and will inform your own practice. 

Care home providers should stop visits to residents from friends and family. Healthcare professionals and delivery couriers can still visit.

Further details can be found below:

England

Department of Health and Social Care & PHE: New adult social care guidance to protect the most vulnerable against COVID-19

Department of Health and Social Care, PHE & NHS England, Admission and care of residents during COVID-19 incident in a care home

Hospice UK: Caring for your dying relative at home with COVID-19

COVID-19: guidance on residential care provision:

Scotland 

Scottish Government guidelines COVID-19 - information and guidance for social or community care & residential settings and letter from the Chief Medical Officer, Chief Nursing Officer and Chief Social Worker. Care home new admissions or transfer form and clinical guidance on COVID-19 for the management of clients accessing care at home, housing support and sheltered housing.

Northern Ireland 

HSC Public Health Agency: COVID-19 (coronavirus)

Wales

Social Care Wales: The latest information on coronavirus (COVID-19)

Page last updated - 08/04/2020