Clinical guidelines

• Standard Operating Procedures (SOPs)
  • • COVID-19 - Core Principles (May 22)
    • COVID-19 SOPs – Amber/Medium Pathway - all CSUs [10/2021]
    • COVID-19 testing for adult inpatients before surgery / treatment/ attendance and whilst IP at LTHT [13/1/22]
    • COVID-19 testing of elective paediatric admissions (including resident parent) SOP [27/05/2020]
    • COVID-19 testing of non-elective paediatric admission - parent/carer SOP[27/05/2020]
    • Covid-19 testing for patients with Learning Disabilities and/ or Autism before surgery/ treatment/ attendance [19/06/2020]
    • Clinical SOP Handling, Storage and Transfusion of blood samples and compnents during COVID-19 [24/09/2020]
    • LGI Deteriorating Ward Patient Response SOP [26/11/2020 - Chris Jones]
    • Procedure for Covid 19 vaccination on in-patient wards [26/02/21]
    • Communicating with Relatives during Restricted Visiting [04/02/2021]
    • Infection prevention and control: core principles to minimise the impact of COVID-19 [12/1/22]

PPE guidelines

• • • Video: best practice when caring for patients with suspected or confirmed COVID-19 infection - March 2021
    • PPE requirements [14/01/2021]
    • Ward designation posters: Low - Green, Medium - Orange, High - Red [24/12/2020]
    • How to wear a surgical mask correctly [01/02/2021]
    • Social distancing and PPE requirements in LTHT [02/10/2020]
    • PPE FAQS [07/04/2020]
    • Re-use of eye protection guidance [14/08/2020]
    • Prevention and Treatment of skin breakdown associated with the use of facial PPE guidance [14/04/2020]
    • Caring for your skin (17/04/2020)
    • Surgical mask adaptor guidance [21/04/2020]
    • Theatres checklist [15/05/2020]
    • PPE requirements for surgery [15/05/2020]
    • PPE order form - complete the order form and email to leedsth-tr.clinicalprocurement@nhs.net [14/01/22 - Vicki Dodsworth]
    • FFP3 Mask Fit Testing SOP [04/03/2021 - Hayley Lancaster]
    • Donning, doffing, cleaning and maintenance of powered respirator hoods SOP [04/03/2021 - Hayley Lancaster]
    • Eye Protection reminder poster for clinical areas [23/09/2021]

Clinical guidelines - for internal use only

Testing

• • • Clinical / radiological diagnosis of COVID-19
    • Sampling and pathology labelling guidance for COVID-19 [14/04/2020]
    • COVID-19 test request form (E28) [02/04/20]
    • Use of POCT for patients with suspected COVID-19 [14/04/20]
    • Influenza point of care testing [12/03/20]
    • Glucose/Ketone point of care testing [14/04/2020]
    • Guidance and SOP COVID-19 Testing in NHS Laboratories [10/03/20]
    • Flow chart for testing patients who are discharged to care homes [20/04/2020]
    • Guidance on booking Covid-19 samples (05/06/20)
    • Covid-19 positive patients; virus persistence and infection risk [22/06/2020]
    • Covid-19 Swab tasks PPM+ update [09/12/2020 - Gillian Hodgson]
    • Covid-19 Swab tasks PPM+ update #2 [17/12/2020 - Gillian Hodgson]
    • Change of swab for sampling COVID-19 specimens [22/01/2021]
    • A guide for healthcare staff self-testing for coronavirus using a Lateral Flow Device (LFD) [13/1/22]
    • Registering and reporting a Lateral Flow Test Result [13/1/22]

COVID-19 patient care (internal use only)

• • • Management of adult patients with suspected Covid-19
    • Covid-19 Feeding Protocol - Critical Care
    • Covid-19 on Neonatal Unit
    • Covid-19 PPE Step-down & Discharge Guidance
    • Covid-19 Physiotherapy Rehabilitation Guide
    • Covid-19 Vaccination on in-patient wards
    • Diagnosis and Management of Covid-19 Coagulopathy - Prevention and Management of Venous Thromboembolism in Covid-19 Pneumonia
    • Ethical Guidance in a Pandemic
    • Handling, Storage and Transfusion of Blood Samples and Components during Covid-19
    • Pathology Standards for Covid-19 Samples in Secondary Care
    • Protocol for the Management of an Inoculation Incident (Body Fluid Exposure Incident Including Needlestick Injury) - Leeds Covid-19 Vaccine Centre
    • Transfer of Adult Critical Care Patient from HOT to COLD Critical Care Unit

Nutrition

• • • COVID-19 Nutrition learning and resources - please note that you will need to be on the LTHT network to view this page.

Shielding

• • • Sources of shielding information for clinicians [30 May]
    • High risk patient letter [30 May]
    • Sources of information for people who are shielding [30 May]

Respiratory guidelines

• • • Blood gas results form guidelines [17/04/2020]

Palliative care

• • • Communicating difficult conversations by telephone during Covid-19 pandemic (12/10/2020)
    • Managing common end of life symptoms in patients with COVID-19 (10/05/2021)
    • Guidance for visiting patients approaching the end of life in hospital (13/01/2021)
    • West Yorkshire & Harrogate Grief & Loss Support Service
    • Leeds Palliative Care Network - thank you letter

Visiting

• • • Visiting guidance [28/4/22 - Jo Regan]
    • Screening questions for visitors entering the ward [25/08/2020]

Estates and Facilities

• • • COVID-19 waste guidance [08/04/2020]
    • Converting wards for intubating COVID-19 patients. This document contains: bed layouts infrastructure prompts and oxygen advice for COVID-19 patients.
    • Receiving an infectious patient from YAS (Estates and Facilities card)
    • Use of portable electric fans [24/06/2020]
    • Electric fans - risk assessment non-clinical areas [25/06/20]
    • Electric fans - risk assessment clinical areas [24/06/20]
    • Temporary staff shuttle timetable [08/07/20]
    • Disinfectant Guide [12/2020]

Management

• • • Workstream leads [20/03/2020]
    • Guidance for CSUs relating to existing governance processes [27/08/2020]
    • Interim quality and safety framework for CSUs [19/11/2020 - Sarah Johnson]

IT

• • • ED Records on PPM+ [08/06/2020]
    • Xero image viewer FAQ [15/07/20]
    • Xero image viewer How-to guide [15/07/20]
    • Emergency Care Plan Alert ppm+
    • ppm swab tasks (9/11/20)
    • ppm update [18/12/20]
    • Swab alerts and screening questionnaire PPM update [26/03/21]
    • Bed rails [25/1121]

Patients on Warfarin

• • • Guidance for clinicians on new measures to help reduce the number of patients being discharged on Warfarin. [27/03/2020]

Specialty guides for patient management

• • • The latest guides can be downloaded from the NHS England website
    • Principles for intimate clinical assessments under remote consultation - NHS England guidance [15/07/20]
    • Inpatient Diabetes Advice: Dexamethasone and hyperglycaemia [04/11/20]

NICE Guidance

NICE have published the following rapid guidelines in response to COVID-19 relating to:

• • • Critical Care
    • Delivery of Systemic Anticancer treatments
    • Dialysis Service Delivery
    • Severe Asthma
    • Rheumatological autoimmune, inflammatory and metabolic bone disorders
    • Delivery of Radiotherapy treatment
    • Haematopoietic stem cell transplantation

We have produced a summary of the guidance outlining key recommendations, which are attached for easy reference. Please can you consider this in relation to service delivery in these specified areas.

Please note the Clinical Frailty Scale (CFS) score is a key determining factor in the provision of critical care and assessment must be completed when adult patients are admitted to hospital, irrespective of age and COVID-19 status. Please refer to the critical care algorithm.

Details of the full guidance can be found on the NICE website.

Paper based health records

Provision of paper-based health records for medical specialties - more info here

Alert notice

Scope handle issue - 16/06/2020