MUST ATTACH PATIENT LABEL HERE
SURNAME: ___________________________ NHI: ______________
S
FIRST NAMES: ________________________ DOB: ______________
C
Screening Tool
Acute Respiratory Infection
R
Please ensure you attach the correct patient label
F
E
E
1.
Screening questions for all patients on entry to hospital or prior to visit
Inpatients must be screened daily and outcome recorded on the back of this form and the clinical record
N
Screening Date/Time: Designation: Initials:
I
N
Ⓐ
High Risk Criteria: In the last 14 days have you: (tick any that apply)
G
*
Locations of interest and QFT zones change frequently, check the Ministry of Health website if unsure
Had a
positive COVID test (if yes, go straight to red stream)
T
Identified by public health as a contact of a COVID case or
been at a known location of interest
O
O
Travelled internationally (excluding travel by air from a country New Zealand has quarantine free travel (QFT*).
L
Had direct contact with a
person who has travelled internationally outside of a QFT* Zone
(e.g. staff in customs, immigration, quarantine/isolation facilities)
A
Exited a managed isolation or quarantine facility
C
Worked on an international aircraft, shipping vessel or maritime port (excluding on aircrafts from a QFT* zone)
U
Cleaned at an international airport or maritime port visited by international arrivals (excluding areas used by travellers
T
from *QFT)
E
Worked in a cold store facility that receives chilled or frozen imported items directly from an international airport
R
Ⓑ
Symptoms: Any new or worsening symptoms of an acute respiratory infection? (tick any that apply)
E
If
under 12yrs: Diarrhoea
S
Fever Cough Shortness of breath Sore throat Runny nose Loss of smell or taste Vomiting
P
I
Ⓐ + Ⓑ
Ⓐ
Ⓑ
Ⓐ + Ⓑ
R
BOTH ‐ YES
YES ‐ ONLY
YES ‐ ONLY
BOTH ‐ NO
A
AIIR
Single room
Single room
Routine Bed flow
T
(Door closed or
(Negative Pressure Room)
(Door closed)
*variance to room placement)
O
Contact +
Contact +
Contact +
Medical Mask +
R
Airborne precautions Airborne precautions
Airborne precautions Standard Precautions
Y
Unless other transmissible
for 14 days from last exposure
infections
I
Red Stream
Orange Stream A
Orange Stream B
Green Stream
N
Medical masks
F
All patients must wear a medical mask for the duration of the visit or until advised by a health care worker to remove it
E
Time critical intervention or those who are unable to complete screening:
C
Assess for an acute respiratory infection and care for in airborne precautions until criteria for COVID risk down grade can be made
T
*Variance to room placement: Orange B stream only
I
Variance must be agreed by the responsible clinician or patient flow manager and documented in the clinical record
O
No single rooms available: Patient in cohorted room with curtains drawn.
Staff to wear N95 mask and maintain
N
airborne transmission based precautions until safe down grade of COVID risk has occurred. Patient/whanau should
wear a medical mask.
Child is under 2yrs with a single symptom, whanau are asymptomatic and no high risk criteria has been identified:
Consult with senior decision maker regarding safe down grade to contact and droplet precautions
2. Confirmation of Streaming or Isolation Requirements after Clinical Assessment:
To be completed by
responsible or delegated clinician
Is this patient’s history and clinical assessment consistent with risk of COVID‐19 or acute respiratory infection?
YES
YES
YES
NO
DD3400
Confirmed or probable COVID
High risk criteria but
consistent with
not consistent with an acute
Page 1
asymptomatic
an acute respiratory infection
respiratory infection
Red Stream
Orange Stream A
Orange Stream B
Green Stream
07/09/2021
Assessment Date/Time:
Designation:
Initials:
MUST ATTACH PATIENT LABEL HERE
S
SURNAME: ___________________________ NHI: ______________
C
FIRST NAMES: ________________________ DOB: ______________
R
E
Screening Tool
Please ensure you attach the correct visit patient label
E
Acute
Respiratory Infection
N
Down Grading COVID Risk: Decision to down grade must be documented in the clinical record.
I
N
Red Stream
Orange Stream A
Orange Stream B
G
Ⓐ + Ⓑ
Ⓐ
Ⓑ
T
Contact +
Contact +
Contact +
Airborne precautions Airborne precautions
Airborne precautions
O
High risk criteria AND
High risk criteria ONLY
Respiratory symptoms ONLY
O
respiratory symptoms
▼
L
▼
▼
First SARS CoV‐2 test
negative
It has been
14 days from the
and
A
last exposure event
COVID or Infectious Disease
A clear alternate diagnosis has been made
C
Clinician has advised
or
to down grade COVID risk
A high risk exposure event
U
DOWN GRADE
has been excluded
T
▼
E
Contact +
Droplet precautions
R
A clear alternate diagnosis has been made
E
or
Respiratory symptoms have resolved for more than 24hrs
S
or
P
Patient is back to baseline of chronic respiratory illness
I
No to any criteria: Remain in current stream until all criteria is met or patient is discharged
R
YES to
all criteria
YES to
all criteria
YES to
all criteria
A
T
DOWN GRADE
DOWN GRADE
DOWN GRADE
O
▼
▼
▼
R
As per COVID or ID
Green Stream
Green Stream
Y
clinician advice
I
Record of Daily Symptom Checks: Any new or worsening symptoms of an acute respiratory infection? (tick if
any apply)
. If any new symptoms are identified, review streaming and commence appropriate level of precautions
N
Loss of
High
Date
Fever
Cough
Shortness
Sore
Runny
taste
Risk
Action Taken
Initials
Designation
F
of Breath
Throat
Nose
or
smell
criteria
E
C
T
I
O
N
DD3400
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