WA Health COVID-19 Framework for System Alert and Response - Version 3.2 - CHO Approved 1 February 2022
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WA Health COVID-19 Framework for System Alert and Response Version 3.2 - CHO Approved 1 February 2022
Version control
The WA Health COVID-19 Framework for System Alert and Response (SAR) is intended to be a living document
and will be reviewed and updated as changes are advised by the Chief Health Officer (CHO), Incident Controller
(IC) and other subject matter experts across the WA Health System. This will include changes to policy guidance
at national and state-wide levels, based on evolving evidence bases and best practice.
Version Last reviewed Description of changes
1.0 04/01/2021 Version resubmitted to CHO for approval, following alignment with WA Health COVID-19 Testing Guidelines v2.0. Not published.
1.1 11/01/2022 Realignment to Testing Guidelines v3.0. Minor, immaterial updates to guidance for public community dental services
2.0 14/01/2022 Version approved by CHO for internal circulation only. Inclusion of proof of vaccination requirement for all visitors
2.1 14/01/2022 Version updated to reflect it will be accessible on WA Health Corporate website
2.2 17/01/2022 Hyperlinks for supporting COVID-19 Guidelines updated
3.0 25/01/2022 Updates to PPE, outpatient, visitor guidance and alignment with publish testing guidancev3.0
3.1 27/01/2022 Interim Amber phases 1.1 and 1.2 incorporated
3.2 1/02/2022 Interim amber date of 31 January 2022 changed to 3 February 2022, Updates to the Dental Category in Amber phase
2Contents
The WA Health COVID-19 Framework for System Alert and Response (SAR) guidance for approval by the Chief
Health Officer (CHO), ahead of mobilisation in January 2022. It outlines the approach, alert levels and response
guidelines and has been developed in conjunction with key system leads and advisory groups.
Section Item Page
1 Overview of the WA Health COVID-19 Framework for System Alert and Response (SAR) 4
1.1 Overview of the Framework - context, scope, components and proposed principles for use by the CHO 5
1.2 High level structure of the Framework, including alert level definitions 6
2 SAR for CHO sign-off 7
2.1 PPE guidance 8
2.2 Service capacity management guidance (surge planning, elective surgery, outpatient and specialist day services) 9-10
2.3 Guidance for public community dental services 11
2.4 Patient screening and testing guidance, including interim amber 12-13
2.5 HCW screening and testing guidance 14
2.6 Student and volunteer access guidance 15
2.7 Visitor access guidance 16
3.0 Appendices 17
3.1 Appendix 1 - Supporting guidance materials (national and state policy and guidelines) 18
3.2 Appendix 2 - Glossary 19-20
3.3 Appendix 3 - Abbreviations 21
3.3 Appendix 4 - List of subject matter experts 22
3Overview of the SAR
Overview of the framework
A COVID-19 Framework for System Alert and Response (SAR) has been developed for use by the WA Health
system to document the different levels of risk (alert levels) and associated responses, to be applied across the
WA Health service settings, in a living with COVID-19 context.
Proposed principles for
Context and purpose Scope of the SAR Components of the SAR
use by the CHO
WA is entering a period of transition as What does the Framework cover: The SAR has two key components, that
it pivots to living with COVID-19 are based on a combination of the VIC, How will the SAR be used in practice:
(LWC), rather than continuing to aim to ● Overarching guidance for Health NSW and SA frameworks:
eliminate the virus. Service Providers (HSPs) / ● Supports CHO decision making:
hospitals 1. Alert Levels - Four risk ratings The CHO determines which alert
To support a proactive and coordinated from low (COVID READY) to very level the state or geographical
● Indicative indicators to help
risk management approach to LWC the high (SYSTEM AT CAPACITY) for region is in based on a set of
inform and group different levels of
Chief Health Officer (CHO) has advised the Department of Health to defined indicators and thresholds
risk
SHICC to: determine what the COVID-19 across the four levels of risk
● Links to relevant policy and transmission and system response
● Develop an overarching guidance documents capacity risk rating is for a ● Hospital focussed: HSPs/public
framework that informs the WA geographical region. hospitals are the primary target
Health System of actions and What is currently not in the Framework
audience. Other private hospital
interventions in response to 2. Responses - A summary of
● Public Health and prevention and non-hospital services will
changing risks of COVID-19 consistent actions and
strategies to reduce community benefit from following some of the
interventions for health services to
● The SHICC Health Operations transmission risks same guidance, and play a role in
undertake during different alert
Cell to take a lead on facilitating managing demand away from
● HSP specific procedures, including levels
the development of the framework hospitals
BAU flu season and HSP surge
using information from other Dashboards and lead indicators that
management processes ● System wide application with
jurisdictions (VIC, NSW, SA) with summarise key public health and
direction from WA Health system ● Guidance for non-hospital health system COVID-19 response region/ HSP specific risk
executives and in consultation with settings capacity measures will help inform categorisation: The framework will
subject matter experts (SMEs) the CHO (and SAR governance) in be applied at a statewide level, or
● Service preparedness actions, reviewing and determining the to different WACHS regions/
including workforce, supply and appropriate alert level metropolitan Perth geographic
logistics related support areas, which may be rated different
● Pharmaceuticals and therapeutics alert levels at a point in time. The
current intention is for the alert
● Clinical pathways/models of care levels for these regions to be
● COVID-19 testing strategies available on the WA Health website
5High-level structure of the framework
The SAR consists of alert levels with risk based thresholds, and responses. The CHO will use a range of
community, public health, and service capacity indicators to assess changing risks and determine the alert level
Alert Levels will be determined by the CHO based on lead / lag indicators that outline the current LWC situation including:
● Community transmission measures - including waste water surveillance, number of cases, number of COVID-19 deaths, new / virulent strains
Alert Level Indicators /
● Public health measures - vaccination rates, testing collection and lab capacity indicators
Criteria ●
Alert Levels and Indicators
Healthcare setting response capacity measures - hospital service capacity (ED, General, ICU) via bed availability reporting,COVID-19 home monitoring capacity
/ potential admissions, workforce capacity – via bed availability reporting
WA Health COVID-19 Framework for System Alert and Response
Green: COVID-19 READY Amber: COVID-19 ALERT Red: WIDESPREAD Black: SYSTEM AT
Nil to very limited, and stable, case Disease in community with growing TRANSMISSION CAPACITY
Alert Level numbers in community spread and risk Increasing and high rates of community Service demand exceeds COVID-19
Satisfactory vaccination rates and Concerns over vaccination rates and/or transmission of COVID-19 service response capacity
testing capacity testing capacity
HSPs / services ensuring preparedness
to respond. Usual baseline public health HSPs / services applying early HSPs / services acting to reduce HSPs/ services working together as one
Response Categories precautions precautions and on standby to respond impacts as much as possible and system to prioritise most critical care
HSPs/ services enacting early to growing service risks maintain resilience of services and create response capacity
precautions
PPE (including some
community service settings)
How will the SAR work?
Response Categories and Guidance
Service capacity including ICU,
ED ● Lead / lag indicators will assist the CHO in determining different alert levels
Elective surgery ● Risk alert levels indicate recommended interventions that hospital services should put in place to help maintain health service
Outpatient and specialist day setting response capacity and resilience. For example:
services ○ PPE requirements for different care and clinical risk settings
Public dental services in the ○ Thresholds for HSP led bed management and standing up the centralised patient flow command centre
community ○ Screening and streaming mechanisms for patients, workforce, visitors, students and volunteers
Patient screening and testing ● The alert level, framework categories and responses will be published online on the WA Health corporate website for health
professionals and accessible by all hospital settings. It will provide links to relevant policies and guidance (e.g. national CDNA), for
HCW screening and testing,
including volunteers and
ease of version control and to ensure advice is in line with the most up to date evidence bases. The criteria defining the alert level
students categories will not be publicly available
Student, clinical placements ● Links to relevant, up to date policy and guidance materials will be included as part of the response categories in the SAR so that further
and volunteer access detailed information is easily accessible to users of the SAR
Visitor access
6SAR
PPE guidance
Guidance for different response categories is set out below following consultation with key SME groups
Response Green (COVID-19 READY) Amber (COVID-19 ALERT) Red (WIDESPREAD Black (SYSTEM AT CAPACITY)
Category TRANSMISSION)
The following standard precautions apply, unless additional PPE guidance is recommended at certain alert levels below
● Standard precautions apply at all times i.e. PPE used as required (e.g. gowns, gloves, protective eyewear for any patient contact or procedure when there is potential for blood/body fluid exposure)
● Appropriate PPE i.e. particulate filter respirator (PFR) and protective eyewear, is to be used for all Aerosol Generating Procedures (AGPs), including cardiac compressions, as per standard
precautions as well as Aerosol Generating Behaviours (AGBs)
● Transmission based precautions e.g. negative pressure isolation room (NPIR), particulate filter respirator (PFR) when required for other diseases e.g. airborne precautions for tuberculosis,
measles etc.
PPE For management of patients confirmed to have COVID-19, symptomatic of COVID-19, meets epidemiological criteria, currently in quarantine, or patients identified as a close contact of a COVID-
19 case as determined by public health - Healthcare worker (HCW) to wear PFR, protective eyewear, gown and gloves when providing direct care. (Applicable at all alert levels)
Supporting
guidance:
In addition to the standard precautions outlined In addition to the standard precautions outlined ● All staff working in clinical areas at a As per Red Response
above: above: healthcare facility to wear a PFR and ● All staff working in clinical areas at a
CDNA Series of
● PFR (e.g. N95 or P2) and protective ● All staff working at a healthcare facility to protective eyewear on entry to the facility healthcare facility to wear a PFR and
National Guidelines
eyewear in all areas of Emergency wear a surgical mask on entry to the and for the duration of their shift, this protective eyewear on entry to the facility
Departments, for all patient facing staff facility and for the duration of their shift, includes in shared areas such as meeting and for the duration of their shift, this
MP0133/20
● All inpatients and outpatients (if this includes in shared areas such as rooms, tea rooms includes in shared areas such as meeting
Identification and
clinically appropriate), carers, and meeting rooms, tea rooms ● Physical distancing of 1.5m to apply at all rooms, tea rooms
Use of Personal
visitors* presenting to any department to ● All patient facing staff who are working in HCW breaks where possible ● Physical distancing of 1.5m to apply at all
Equipment in the
wear a surgical mask from entry to the clinical areas to add protective eyewear ● All non-clinical staff entering a HCF and HCW breaks where possible
Clinical Setting
facility, in accordance with Public Health ● PFR (e.g. N95 or P2) and protective staff working in non-clinical areas can ● All non-clinical staff entering a HCF and
During the
Safety Measures eyewear in all areas of Emergency continue to wear a surgical mask with the staff working in non-clinical areas can
Coronavirus (COVID-
Departments, for all patient facing staff addition of protective eyewear if they continue to wear a surgical mask with the
19) Pandemic Policy
*During the transition period and opening of ● All inpatients and outpatients (if transit through clinical areas addition of protective eyewear if they
borders, public health and social measures clinically appropriate), carers, and ● All inpatients and outpatients (if transit through clinical areas
Coronavirus Disease
(PHSMs) will apply, including all visitors (and permitted visitors presenting to any clinically appropriate), carers and ● All inpatients and outpatients (if
- 2019 (COVID-19):
essential visitors/ carers) to wear a surgical department to wear a surgical mask from permitted visitors presenting to any clinically appropriate), carers and
Infection Prevention
mask entry to the facility department to wear a surgical mask from permitted visitors presenting to any
and Control in
entry to the facility department to wear a surgical mask from
Western Australian
entry to the facility
Healthcare Facilities
Guideline
Australia Guidelines
for the Prevention of PPE advice for patient facing clinical care PPE advice for patient facing clinical care PPE advice for patient facing clinical care PPE advice for patient facing clinical care
Infection in in community settings, including home in community settings, including home in community settings, including home in community settings, including home
Healthcare visiting/outreach services: Refer to PPE visiting/outreach services: Refer to PPE visiting/outreach services: Refer to PPE visiting/outreach services: Refer to PPE
advice for hospital settings at Green advice for hospital settings at Amber advice for hospital settings at red, and advice for hospital settings at black, and
● All patient facing staff to wear a surgical ● Consider alternative to home visits - i.e. ● Consider alternative to home visits - i.e.
mask and protective eyewear during telehealth alternatives telehealth alternatives
patient facing care ● Reduce number of ‘others’ attending ● No additional attendees other than
other than parent/carer parent/carer
8Service capacity management guidance
Guidance for different response categories is set out below following consultation with key SME groups
Response Green (COVID-19 READY) Amber (COVID-19 ALERT) Red (WIDESPREAD Black (SYSTEM AT CAPACITY)
Category TRANSMISSION)
Service ● Continue to ensure preparedness ● HSPs applying COVID-19 patient ● HSPs activate internal COVID-19 ● WA Health COVID-19 Patient Flow
Capacity (ED, against hospital readiness checklist pathway protocols, including local capacity management protocols Command Centre is activated
● HSPs activate COVID-19 patient HSP/service specific guidance
General Beds, pathway protocols
ICU, Mental ● Refer to local HSP guidance as per
Health) usual protocols and processes
Public and private hospitals: INTERIM Amber Testing Guidelines Public hospitals*: Public and private hospitals*:
● No restrictions (Phase 1.1) ● 100% category 1 and 2 continue ● Defer all elective surgery, except for
● COVID-19 risk assessment is From 3 February 2022 until advised: ● Reduce/defer Category 3 elective Category 1 and select category 2
required, especially for those requiring ● Screen attendees for epidemiological surgery, subject to risk assessment of procedures where clinical and
general anaesthetic and clinical COVID-19 risk factors the system by the Department of community risk assessment and/or
● Case by case consideration to defer Health Peer Review indicates a need to
care if clinically safe to do so ● COVID-19 risk assessment is required proceed. This includes consideration
for all patients to be given to impacts of delaying
Public and private hospitals*: ● RAT at home on the day of admission complex cancer surgery
● 100% Category 1, 2 and 3 elective (or on arrival). In instances where a ● Defer cosmetic surgery and non-
Elective surgery continue unless if a confirmed positive RAT is returned, case by case medical procedures
Surgery, case consideration to defer care, if clinically ● COVID-19 risk assessment is required
including ● COVID-19 risk assessment is required safe to do so for all patients
Private for all patients ● Refer to Testing Guidelines for latest ● RAT at home on the day of admission
Hospitals advice regarding asymptomatic testing (or on arrival). In instances where a
Amber Phase 1.2 (areas which have for inpatients and outpatients positive RAT is returned, case by case
been greyed) consideration to defer care, if clinically
HSPs will be provided instruction on when Private hospitals (and Day Surgery safe to do so
WA Covid-19
to proceed with the following guidance: Centres): ● Refer to Testing Guidelines for latest
Testing Guidelines
● Reduce/Defer Category 3 elective advice regarding asymptomatic testing
v3.0
● Testing 72 hours pre-admission and/or surgery for inpatients and outpatients
RAT on arrival (vaccinated and ● Defer cosmetic surgery and non-
unvaccinated). NB: Patients would medical procedures Note: Department of Health will perform
need to isolate after a pre-admission ● Screening and testing requirements as regular system assessment to determine if
PCR test until admission per above, however, COVID testing to a percentage of other Elective Surgery
● In instances where a positive PCR or be undertaken by Private Hospital categories can be permitted while the Black
RAT is returned, case by case Pathology partners (system at capacity) system alert level is
consideration to defer care, if clinically ● If a positive PCR or RAT is returned, applied
safe to do so case by case consideration to defer
care, if clinically safe to do so
*Note: to adapt to changing COVID-19 conditions, the Department of Health will perform regular system assessments to determine if a percentage of Elective Surgery categories may need to be reduced or can continue
9Service capacity management guidance
Guidance for different response categories is set out below following consultation with key SME groups
Response Green (COVID-19 READY) Amber (COVID-19 ALERT) Red (WIDESPREAD Black (SYSTEM AT CAPACITY)
Category TRANSMISSION)
● Face to face or telehealth INTERIM Amber Testing Guidelines (Phase 1.1) ● Patients should not present if ● Patients should not present if
appointments to occur as per From 3 February 2022 until advised: experiencing any symptoms of experiencing any symptoms of
normal arrangements ● Screen attendees for epidemiological and clinical COVID-19 risk factors COVID-19 COVID-19
● COVID-19 risk assessment ● Patients should not present if experiencing any symptoms of COVID-19 ● No routine asymptomatic testing ● No routine asymptomatic testing
Outpatient is required ● Outpatient clinics should all implement COVID -19 safe procedures (i.e. required, except RAT on required, except RAT on
● Outpatient COVID-19 plan in screening attendees for COVID symptoms and other risk factors via presentation for planned paediatric presentation for planned paediatric
services place questionnaires, practicing physical distancing of 1.5m within the clinical and maternity admissions and and maternity admissions and labour
including setting, frequent hand hygiene) labour ward and birth suite ward and birth suite attendances
clinics, imaging, ● Alternative triage arrangements for people with COVID-19 symptoms or attendances ● Outpatient clinics should all
pharmacy, epidemiological factors ● Outpatient clinics should all implement COVID -19 safe
● All outpatient services should return to using telehealth where possible, implement COVID-19 safe procedures (i.e. screening attendees
pathology
unless there is a critical reason why the person needs to physically procedures (i.e. screening for COVID symptoms and other risk
attend attendees for COVID symptoms and factors via questionnaires, practicing
COVID-19 Guidelines ● Refer to Testing Guidelines for latest advice and testing requirements other risk factors via questionnaires, physical distancing of 1.5m within
for Outpatient services practicing physical distancing of the clinical setting, frequent hand
(in process of being Amber Phase 1.2 (areas which have been greyed) 1.5m within the clinical setting, hygiene)
updated) HSPs will be provided instruction on when to proceed with the following frequent hand hygiene) ● Provide outpatient services by
guidance: ● Provide Outpatient services by telehealth. Defer face-to-face
WA Covid-19 Testing ● No routine asymptomatic testing required, except consider RAT on telehealth and defer non-urgent consulting, except where clinical risk
Guidelines v3.0 presentation for each paediatric and maternity patient visit, including face-to-face consulting where assessment indicates risk of harm to
maternity admissions and labour ward and birth suite attendances clinically safe the patient
● Refer to Testing Guidelines for latest advice and testing requirements ● Refer to Testing Guidelines for ● Refer to Testing Guidelines for latest
latest advice and advice and testing requirements
testing requirements
● Consider additional INTERIM Amber Testing Guidelines (Phase 1.1) ● RAT at home prior to attendance; ● RAT at home prior to attendance;
protective measures for From 3 February 2022 until advised alert clinic if positive, before alert clinic if positive, before
Specialist day
vulnerable cohorts and high ● Consider additional protective measures for vulnerable cohorts and high attending attending
services * risk clinical care settings risk clinical care settings ● If positive RAT, case by case ● If positive RAT, case by case
e.g. patients ● Screen attendees for epidemiological and clinical COVID-19 risk factors consideration to defer care, if consideration to defer care, if
undergoing renal ● Case by case consideration to defer care if clinically safe to do so clinically safe to do so clinically safe to do so
dialysis, ● Refer to Testing Guidelines for ● Refer to Testing Guidelines for latest
chemotherapy Amber Phase 1.2 (areas which have been greyed) latest advice regarding testing advice regarding testing
radiotherapy, HSPs will be provided instruction on when to proceed with the following requirements requirements
transplant patients, guidance: ● Consider additional protective ● Consider additional protective
immunosuppressed ● RAT on presentation at each visit. This is to be reviewed with an aim to measures for vulnerable cohorts measures for vulnerable cohorts and
COVID-19 Guidelines decrease frequency dependent on patient acceptability and high risk clinical care settings high risk clinical care settings
for Outpatient services ● Refer to Testing Guidelines for latest advice regarding testing
(in process of being requirements
updated) ● If a positive PCR or RAT is returned, case by case consideration to
defer care, if clinically safe to do so
*Note: to adapt to changing COVID-19 conditions, the Department of Health will perform regular system assessments to determine if a percentage of Elective Surgery categories and specialist day services may need to be reduced or can continue
10Public community dental services guidance
Guidance for different response categories is set out below following consultation with key SME groups
Response Green (COVID-19 READY) Amber (COVID-19 ALERT) Red (WIDESPREAD Black (SYSTEM AT CAPACITY)
Category TRANSMISSION)
● Dental clinics should screen attendees INTERIM Amber Testing Guidelines In addition to pre-appointment screening Refer to guidance for red alert level
for epidemiological and clinical COVID- (Phase 1.1) questionnaire and PPE requirements set
19 risk factors via pre-appointment From 3 February 2022 until advised: out in guidance at Green alert level:
questionnaire In addition to pre-appointment screening ● Patients who meet clinical or
● Patients who meet clinical or questionnaire set out in guidance at Green epidemiological COVID-19 risk factors
epidemiological COVID-19 risk factors alert level: should not attend and alternate triaging
should not attend and alternate triaging ● Patients who meet clinical or pathways are available for emergency
pathways are available for emergency epidemiological COVID-19 risk factors dental care
dental care should not attend and alternate triaging ● Defer all routine care for all other
● For all other patients who do not meet pathways are available for emergency patients who do not meet clinical or
clinical or epidemiological COVID-19 dental care epidemiological COVID-19 risk factors
risk factors, face to face or telehealth ● For all other patients who do not meet ● If urgent care is required and cannot be
Public community appointments to occur as per normal clinical or epidemiological COVID-19 deferred, assessment and treatment
dental services arrangements for those patients who risk factors, face to face patient care may be provided. If an AGP deemed
do not meet clinical or epidemiological occurs with additional requirements of necessary, it is to occur in a closed
Risk Management COVID-19 risk factors clients performing Alcohol Based Hand cubicle with a clinical team that has
Principles for ● Appropriate PPE to include gloves, Rub (ABHR) on arrival, practice been successfully fit tested with an
Dentistry – during protective eyewear, gowns and surgical physical distancing measures in appropriate P2/N95 particulate filter
the COVID-19 masks reception and waiting areas, perform respirator (PFR)
Pandemic ● Dental COVID-19 plan is in place 30 second pre-procedural mouth rinse ● AGPs should be limited and use of
with approximately 20ml of an rubber dam and high-volume suction
Essential Oil Mouthwash (Listerine) (HVE) is highly recommended
WA Covid-19 ● Use of rubber dam and high-volume ● A 30 min fallow time is required
Testing Guidelines suction (HVE) is highly recommended ● Additional requirements of clients
v3.0 ● Appropriate PPE to include gloves, performing ABHR on arrival, practice
protective eyewear, gowns and surgical physical distancing measures in
masks reception and waiting areas, 30 second
● Other recommended public health pre-procedural mouth rinse with
safety precautions* approximately 20ml of an Essential Oil
Amber Phase 1.2 (areas which have Mouthwash (Listerine)
been greyed) ● Other recommended public health
● If an AGP deemed necessary, it is to safety precautions*
occur in a closed cubicle with a clinical ● Refer to Testing Guidelines for latest
team that has been successfully fit advice. If undertaking an AGP, RAT
tested with an appropriate P2/N95 required on presentation
particulate filter respirator (PFR) and
protective eyewear
* Other recommended public health safety precautions apply including use of detergent and disinfectant for all patient surrounds and high touch surfaces
11Patient screening and testing guidance
Guidance for different response categories is set out below following consultation with key SME groups
Response Green (COVID-19 READY) Amber (COVID-19 ALERT) Red (WIDESPREAD Black (SYSTEM AT CAPACITY)
Category TRANSMISSION)
● Screen attendees for epidemiological INTERIM Amber Testing Guidelines ● Screen attendees for epidemiological ● Screen attendees for epidemiological
and clinical COVID-19 risk factors (Phase 1.1) and clinical COVID-19 risk factors and clinical COVID-19 risk factors
● Test all patients presenting to hospital From 3 February 2022 until advised: ● Refer to Testing Guidelines for latest ● Refer to Testing Guidelines for latest
with pneumonia or acute respiratory ● Screen attendees for epidemiological advice regarding testing requirements for advice regarding testing requirements for
infection with a nose and throat PCR* and clinical COVID-19 risk factors planned and unplanned presentations planned and unplanned presentations
● PCR* testing patients/residents with ● Test all patients presenting to hospital ● Test all patients presenting to hospital
compatible clinical and/or For unplanned patient presentations with symptoms consistent with COVID- with symptoms consistent with COVID-
epidemiological risk factors including ED and emergency maternity/ 19 with a RAT as soon as possible. If 19 with a RAT as soon as possible. If
● No other testing requirements for mental health attendances: negative, repeat RAT in 24 hours. negative, repeat RAT in 24 hours.
asymptomatic patients ● Group 1: Confirmed COVID-19 case. No Positive RAT* should be considered Positive RAT* should be considered
further testing required confirmed COVID-19 case confirmed COVID-19 case
● Group 2: Suspect COVID-19 infection. ● For paediatric and maternity patients: ● For paediatric and maternity patients:
Patient (i) if patient has clinical and /or consider RAT test on presentation for consider RAT test on presentation for
epidemiological criteria consistent with planned paediatric and maternity planned paediatric and maternity
screening and
the case definition for COVID-19, then admissions and labour ward and birth admissions and labour ward and birth
testing for should receive RAT test on arrival +/- suite attendances suite attendances
unplanned PCR test ● RAT on presentation for AGPs ● RAT on presentation for AGPs
emergency ● Group 3: patients who do not have
presentations symptoms of, or epidemiological risk
factors for COVID-19 infection, no For unplanned patient presentations, For unplanned patient presentations,
routine RAT or PCR testing including ED: including ED:
● If supplies of RAT adequate, test all ● If supplies of RAT adequate, test all
Note: Amber phase 1.2 on page 13 patients presenting to emergency patients presenting to emergency
departments with RAT to assist with departments with RAT to assist with
patient management patient management
WA Covid-19
● If RAT limited: ● If RAT limited:
Testing Guidelines All patients to be managed as probable All patients to be managed as probable
v3.0 COVID-19 COVID-19
● If symptoms consistent with COVID-19 ● If symptoms consistent with COVID-19
then RAT test then RAT test
For planned patient presentations: For planned patient presentations:
● RAT at home prior to attendance (or on ● RAT at home prior to attendance (or on
presentation); alert service if positive, presentation); alert service if positive,
before attending (vaccinated and before attending (vaccinated and
unvaccinated) unvaccinated)
Positive RAT* should be considered Positive RAT* should be considered
confirmed COVID-19 case confirmed COVID-19 case
*If a positive PCR or RAT is returned, case by case consideration to defer care, if clinically safe to do so
12Patient screening and testing guidance
Guidance for different response categories is set out below following consultation with key SME groups
Response Green (COVID-19 READY) Amber (COVID-19 ALERT) Red (WIDESPREAD Black (SYSTEM AT CAPACITY)
Category TRANSMISSION)
Amber Phase 1.2 (areas which have been greyed)
HSPs will be provided instruction on when to proceed
with the following guidance:
● Screen attendees for epidemiological and clinical
COVID-19 risk factors
● Refer to Testing Guidelines for latest advice
regarding testing requirements for planned and
unplanned presentations
● Test all patients presenting to hospital with
pneumonia or acute respiratory infection with a
nose and throat PCR* until testing capacity is
reached then consider rapid antigen test (RAT)
for diagnostic purposes
● For paediatric and maternity patients: consider
RAT test for planned paediatric and maternity
Patient admissions, including admissions and labour
ward and birth suite attendances
screening and ● RAT on presentation for AGPs
testing For unplanned patient presentations, including ED,
recommend triaging:
● Group 1: Confirmed COVID-19 case. No further
testing required
● Group 2: Suspect COVID-19 infection. (i) if
patient has clinical and /or epidemiological
criteria consistent with the case definition for
WA Covid-19
COVID-19, then should receive RAT test on
Testing Guidelines arrival +/- PCR test; (ii) if patient unable to use
v3.0 PPE effectively (e.g. agitated patients, patients
with dementia, paediatric patients), then should
receive RAT test on arrival; or (iii) if patient
unable to provide sufficient information on their
symptoms or risk factors for COVID-19, then
should receive RAT testing on arrival
● Group 3: patients does not have symptoms of, or
epidemiological risk factors for COVID-19
infection
No RAT or PCR testing needed
● If patient will be admitted to hospital, RAT and
PCR (collected at same time)
For planned patient presentations:
● PCR Testing 72 hours pre-admission and/or RAT
on arrival (vaccinated and unvaccinated)*. NB:
Patients would need to isolate after a pre-
admission PCR test until admission
*If a positive PCR or RAT is returned, case by case consideration to defer care, if clinically safe to do so 13Healthcare worker screening and testing guidance
Guidance for different response categories is set out below following consultation with key SME groups
Response Green (COVID-19 READY) Amber (COVID-19 ALERT) Red (WIDESPREAD Black (SYSTEM AT CAPACITY)
Category TRANSMISSION)
● Refer to Testing Guidelines for latest INTERIM Amber Testing Guidelines (Phase ● Refer to Testing Guidelines for ● Refer to Testing Guidelines for latest
advice regarding testing 1.1) latest advice regarding testing advice regarding testing requirements
HCW staff requirements from 3 February 2022 until advised requirements ● HCWs are to seek immediate testing if
screening and ● HCWs are to seek immediate testing ● Refer to Testing Guidelines for latest advice ● HCWs are to seek immediate they develop any symptoms
testing, if they develop any symptoms regarding testing requirements testing if they develop any compatible with COVID-19 with a RAT
includes compatible with COVID-19 - all to be ● HCWs are to seek immediate testing if they symptoms compatible with COVID- as soon as possible. If negative,
volunteers and tested with nose and throat PCR develop any symptoms compatible with 19 with a RAT as soon as possible. repeat RAT in 24 hours. Positive
COVID-19 - all to be tested with nose and If negative, repeat RAT in 24 hours. RAT* should be considered
student/ clinical throat PCR, until testing capacity is reached Positive RAT* should be confirmed COVID-19 case
placements then consider RAT for diagnostic purposes considered confirmed COVID-19
(assumes HCW case
are fully For asymptomatic HCW working Amber Phase 1.2 (areas which have been
vaccinated) within a hospital area including greyed) For asymptomatic HCW working For asymptomatic HCW working within
Intensive Care Unit, High Dependency HSPs will be provided instruction on when to within healthcare settings managing healthcare settings managing very
WA Covid-19 Testing Unit, respiratory ward, a COVID-19 proceed with the following guidance: very high risk patients (e.g. high risk patients (e.g. transplant ward,
Guidelines v3.0 clinic, or other units at the discretion of For asymptomatic HCW working within transplant ward, haematology unit, haematology unit, oncology ward, renal
the hospital operator: healthcare settings managing very high risk oncology ward, renal dialysis units, IV dialysis units, IV lounge/similar day units):
Coronavirus Disease ● Voluntary nose and throat PCR test patients (e.g. transplant ward, haematology lounge/similar day units): ● Daily RAT for all staff if feasible – but
- 2019 (COVID-19): on day 5 and 12 after first contact unit, oncology ward, renal dialysis units, IV ● Daily RAT for all staff if feasible – consideration may be given to limiting
Infection Prevention with a COVID-19 patient and then lounge/similar day units): but consideration may be given to to symptomatic staff only
and Control in
every 7 days until 14 days pass from ● Twice weekly RAT with a minimal interval of limiting to symptomatic staff only ● RAT for visitors a each visit
Western Australian
last contact 72 hours apart ● RAT for visitors a each visit
Healthcare Facilities
● If an HCW who has had contact with No routine testing required for
Permissions and a positive COVID-19 patient is For asymptomatic HCW working within a No routine testing required for asymptomatic HCW working within
restrictions for involved in a breach of infection hospital area including Intensive Care Unit, asymptomatic HCW working within other hospital settings
workers in Health control practices or PPE, then seek High Dependency Unit, respiratory ward, a other hospital settings
Care Settings - Public Health advice to decide if any COVID-19 clinic, or other units at the discretion
Interim Guidance additional COVID-19 testing in of the hospital operator:
addition to the above is required, ● Voluntary twice weekly RAT with a minimal
Health Worker and undertake breach assessments interval of 72 hrs apart
(Restrictions on at the HSP level, in accordance with ● Any breach of infection control practices or
Access) Directions policy personal protection equipment should be
managed by the health service infection
Proof of Vaccination For asymptomatic, HCWs not control team
Directions mentioned above:
● No routine asymptomatic testing For asymptomatic, HCWs not mentioned
above:
● No routine asymptomatic testing
14Student and volunteer access guidance
Guidance for different response categories is set out below following consultation with key SME groups
Response Green (COVID-19 READY) Amber (COVID-19 ALERT) Red (WIDESPREAD Black (SYSTEM AT CAPACITY)
Category TRANSMISSION)
● Access for students/ clinical ● Access for students/ clinical ● Access for students/ clinical ● Access for students/ clinical
placements continue as per normal, placements where possible, placements (as per amber advice) placements (as per amber advice)
noting restrictions on access with placements to be maintained. Noting ● Where possible student placements to ● Where possible student placements to
vaccination requirements access with vaccination requirements be maintained, but formal teaching be maintained, but formal teaching
● Placement of students into areas of sessions will be unlikely sessions will be unlikely
Student, clinical ● Access for volunteers permitted, higher risk of contact with COVID-19, ● Students may be deployed to support ● Students may be deployed to support
placement and follow HCW guidelines as considered such as COVID-19 clinics, EDs or the response in appropriate ways the response in appropriate ways
volunteer part of staff group isolation wards, should be reviewed however must be vaccinated, PPE however must be vaccinated, PPE
access and subject to a risk assessment trained and fit tested prior to attending trained and fit tested prior to attending
● The exclusion of secondary (high health sites health sites
Work Permissions school) students undertaking work ● Placement of students into areas of ● Placement of students into areas of
and Restrictions experience is at the discretion of HSPs higher risk of contact with COVID-19, higher risk of contact with COVID-19,
Framework for such as fever clinics, EDs or isolation such as fever clinics, EDs or isolation
Workers in Health
Care Settings
wards, should be reviewed and subject wards, should be reviewed and subject
● Access for volunteers permitted, to a risk assessment to a risk assessment
Coronavirus Disease - providing they are vaccinated and ● The exclusion of secondary (high ● The exclusion of secondary (high
2019 (COVID-19): appropriately trained in PPE, school) students undertaking work school) students undertaking work
Infection Prevention particularly if located within clinical experience is at the discretion of HSPs experience is at the discretion of HSPs
and Control in environments - follow HCW guidelines
Western Australian
as considered part of staff group. ● Access for volunteers - where ● Access for volunteers - where
Healthcare Facilities
Guideline Refer to PPE guidance possible, volunteers to be maintained, possible, volunteers to be maintained,
providing they are vaccinated and providing they are vaccinated and
Health Worker appropriately trained in PPE, appropriately trained in PPE,
(Restrictions on particularly if located within clinical particularly if located within clinical
Access) Directions environments. Follow HCW guidelines environments. Follow HCW guidelines
as considered part of staff group. as considered part of staff group.
Proof of Vaccination Refer to PPE guidance. Refer to PPE guidance.
Directions ● Consideration should be given to any ● Consideration should be given to any
COVID-19 risk factors that volunteers COVID-19 risk factors that volunteers
may have, such as chronic disease or may have, such as chronic disease or
respiratory illness, in determining what respiratory illness, in determining what
role and duties each person role and duties each person
undertakes undertakes
● Consider pre-shift screening ● Consider pre-shift screening
15Visitor access guidance
Guidance for different response categories is set out below following consultation with key SME groups
Response Green (COVID-19 READY) Amber (COVID-19 ALERT) Red (WIDESPREAD Black (SYSTEM AT CAPACITY)
Category TRANSMISSION)
● Visitors welcome however proof of INTERIM Amber Testing Guidelines ● Proof of vaccination required ● No visitors (exceptions for essential
Vaccination required (Phase 1.1) ● Limitations on visitor hours and and essential carers/parents/
● All visitors and essential From 3 February 2022 until advised: numbers of visitors to each patient guardians )*
carers/parents/guardians to be risk ● Proof of vaccination required ● Controlled visitation of fully vaccinated ● RAT for exempt visitors and essential
assessed for wearing a surgical face ● Limitations on visitor hours and visitors in emergency situations only, carers/parents/guardians each visit if
mask* numbers of visitors to each patient as per exemption process in a very high risk setting (e.g.
● Pre-attendance health screening for ● All visitors and essential ● Permitted visitors and essential transplant ward, haematology unit,
Visitor access all visitors and essential carers/parents/guardians presenting to carers/parents/guardians presenting to oncology ward, renal dialysis unit)
carers/parents/guardians based on any department to wear a surgical mask any department to wear a surgical
COVID-19 Public
clinical and epidemiological factors, ● Pre-attendance health screening for all mask
Hospital Visitor at a minimum visitors and essential ● Pre-attendance health screening for all
Guidelines ● All visitors and essential carers/parents/guardians based on visitors and essential
carers/parents/guardians are to be clinical and epidemiological factors, at a carers/parents/guardians based on
Coronavirus Disease - encouraged to perform hand hygiene minimum clinical and epidemiological factors, at
2019 (COVID-19): on entry to the healthcare setting ● Restrictions for unvaccinated visitors* a minimum
Infection Prevention prior to entering the patient room and ● RAT for permitted visitors and
and Control in at regular intervals during their visits Amber Phase 1.2 (areas which have essential carers/parents/guardians
Western Australian been greyed) each visit if in a very high risk setting
Healthcare Facilities *During the transition period and opening HSPs will be provided instruction on when (e.g. transplant ward, haematology
Guideline of borders, PHSMs will apply, including all to proceed with the following guidance: unit, oncology ward, renal dialysis unit)
visitors and essential ● RAT testing for visitors and essential ● Restrictions for unvaccinated visitors*
Health Worker carers/parents/guardians to wear a carers/parents/guardians to high risk
(Restrictions on surgical mask areas/vulnerable patient
Access) Directions cohorts. Hospital operator to determine *Clear exemptions process and pathway
high risk area for that hospital (e.g. for unvaccinated visitors to be in place for *Clear exemptions process and pathway
Proof of Vaccination oncology wards, ICU) short, controlled, ushered visits in for unvaccinated visitors to be in place for
Directions ● RAT every third day for long term emergency/ end of life situations, and/or for short, controlled, ushered visits in
regular visitors appropriate maternity or parent/guardian emergency/ end of life situations, and/or for
WA Covid-19 Testing *Clear exemption processes and pathways access. Refer to Testing Guidelines for appropriate maternity or parent/guardian
Guidelines v3.0 for exempt unvaccinated support person/s to advice and consideration for use of RATs access. Refer to Testing Guidelines for
be in place. Refer to visitor guidelines. in some situations advice and consideration for use of RATs
Refer to Testing Guidelines for advice and in some situations
consideration for use of RATs in some
situations
16Appendices
Appendix 1 - Supporting guidance materials
The following guidance materials provide detail to the high level advice which has been mapped and collated into
the SAR. Updated links will be provided as updated WA Health COVID-19 guidelines are signed-off
Document name Link or location Comments
National guidelines
https://www1.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-novel-
CDNA National guidelines for public health units Version: 6.3, published 24 December 2021
coronavirus.htm
Work Permissions and Restrictions Framework for https://www.health.gov.au/resources/publications/work-permissions-and-restrictions-
Dated 8 October 2021
Workers in Health Care Settings framework-for-workers-in-health-care-settings
Australian Government Department of Health:
Permissions and restrictions for workers in Health Permissions and restrictions for workers in Health Care Settings – Interim Guidance Published 18 January 2021
Care Settings – Interim Guidance
Coronavirus (COVID-19) – Testing Framework for https://www.health.gov.au/resources/publications/coronavirus-covid-19-testing-
Dated 16 December 2021
COVID-19 in Australia, (24/02/2021) framework-for-covid-19-in-australia
Guidance on the use of personal protective
https://www.health.gov.au/resources/publications/guidance-on-the-use-of-personal-
equipment (PPE) for health care workers in the Dated 10 June 2021
protective-equipment-ppe-for-health-care-workers-in-the-context-of-covid-19
context of COVID-19
https://www.ada.org.au/Covid-19-Portal/Dental-Professionals
Risk Management Principles for Dentistry – During
Dated 22 October 2021
the COVID-19 Pandemic
Australian Guidelines for the Prevention and Control
https://app.magicapp.org/#/guideline/Jn37kn Version: 11.9, published 20 July 2021
of Infection in Healthcare
State guidelines for WA
COVID-19 Public Hospital Visitor Guidelines COVID-19 Public hospital visitor guidelines (health.wa.gov.au) Published 31 January 2022
Health worker (restrictions on access) Directions (No
https://www.wa.gov.au/government/publications/health-care-workers-directions Published on 29 January 2022
4)
Identification and Use of Personal Protective https://ww2.health.wa.gov.au/~/media/Files/Corporate/Policy-Frameworks/Public-
Equipment in the Clinical Setting During the Health/Policy/Identification-and-Use-of-Personal-Protective-Equipment/Identification-
MP 0133/20 - Effective from: 19/07/2021 - Update in Progress
Coronavirus (COVID-19) Pandemic Policy and-Use-of-PPE-in-the-Clinical-Setting.pdf
Infection Prevention and Control in Western
COVID-19 Infection Prevention and Control in Hospitals (healthywa.wa.gov.au) Published 24 January 2022
Australian Healthcare Facilities Guideline
COVID-19 Guidelines for outpatient services COVID-19 guidelines for outpatient services (health.wa.gov.au) Update in progress
Furloughing of Healthcare Staff – Interim Guidance Furloughing of Healthcare Staff – Interim Guidance Updated 18 January 2021
Proof of Vaccination Directions (No 2) Proof of Vaccination Directions (No 2) Published on 29 January 2022
WA COVID-19 Testing Guidelines WA Covid-19 Testing Guidelines v3.0 Current version: 3.0 Final draft, approved 21 January 2022
18Appendix 2 - Glossary (1 of 2)
The below outlines some high level definitions for terms used in the SAR and provides some links for further
clarification and information (i.e. in relevant policy guidance)
Term High level definition Reference for further information
Population cohorts / groups
Carer including essential visitors such as a Labour support person, parent or designated guardian of an admitted child WA Health COVID-19 Public Hospital Visitor Guidelines
Carer/Essential visitor/
(including a neonate), designated guardian for a patient living with a disability, an end-of-life support person, a family
support person
member or friend required to visit a patient in the case of an emergency. Health Worker Directions No. 4
A person who provides health, medical, nursing, midwifery, pathology, pharmaceutical, social work or allied health
Health Care Worker services to a patient at the health care facility (irrespective of whether those services are provided for consideration or
Health Worker Directions No. 4
HCW on a voluntary basis and irrespective of whether that person is employed or engaged.
Including: Volunteer, student in placement, health support workers and ambulance officer.
Patients who access certain care procedures and treatments, or who may be considered immunocompromised or at
Informed by subject matter experts and WA COVID-19 Testing
High risk clinical care greater risk of complications from contracting COVID-19, such as: dialysis patients, high risk cf endoscopy group (in
Guidelines, v3.0
most cases), cancer treatment, organ transplant, immunology, haematology, ICU
Statutory Personnel Mental Health Advocates are not considered visitors and have a statutory right to access mental health units under the
including Mental Health Mental Health Act 2014. Other Statutory Personnel may also be required to undertake legal, safety, Industrial relation WA Health COVID-19 Public Hospital Visitor Guidelines
Advocates and emergency functions.
Health Worker Vaccination Directions No 4
Those who may have an increased likelihood of current COVID-19 and meet the following criteria (i.e. both clinical and
epidemiological criteria);
Clinical evidence (in the past 14 days): Fever (≥37.5 °C) or history of fever (e.g. night sweats, chills); or Acute
respiratory infection (e.g. cough, shortness of breath, sore throat)1; or Loss of smell or loss of taste.
Coronavirus Disease 2019 (COVID-19): CDNA National Guidelines for
Suspect COVID-19 case Epidemiological evidence (in the past 14 days): Close contact with a confirmed case, international travel, workers
Public Health Units
supporting designated COVID-19 quarantine and isolation services, International air, maritime and border staff, health
care workers with potential COVID-19 patient contact, or people who have been in areas with COVID-19 community
transmission Note - Terminology expected to change to asymptomatic and symptomatic, or probable COVID-19.
Awaiting confirmation from CDNA
A family member or friend who is not a carer, or someone with a statutory role. Refer to Visitor Guidelines for additional Proof of Vaccination Directions (No2)
Visitor definitions of essential visitors, ad hoc visitors, ad hoc volunteers, in reach service providers and visitors in quarantine
that have a modified quarantine direction to visit a health care facility in exceptional circumstances. Health Worker (Restrictions on Access) Directions
Essential HCWs who are at higher risk of serious illness and, where the risks cannot be sufficiently mitigated e.g. using
PPE, should not work in high risk settings. Vulnerable HCWs are more likely to be, at higher risk of serious illness if
Coronavirus Disease - 2019 (COVID-19) Infection Prevention and
Vulnerable HCW they acquire COVID-19 - Aboriginal and Torres Strait Islander people 50 years and older with one or more chronic
Control in Western Australian Healthcare Facilities
medical conditions - people aged 65 years and older with chronic medical conditions - people aged 70 years and older -
people with compromised immune systems
19Appendix 2 - Glossary (2 of 2)
The below outlines some high level definitions for terms used in the SAR and provides some links for further
clarification and information
Term High level definition Reference for further information
Population cohorts / groups continued
In addition to people accessing high risk clinical care, other patients who may be considered vulnerable patient cohorts
at higher risk of serious illness if they acquire COVID-19 include maternity and neonates, geriatric patients, or some
Vulnerable / at risk Informed by subject matter experts and WA COVID-19 Testing
mental health patients, Aboriginal and Torres Strait Islander people 50 years and older with one or more chronic
clinical patient cohorts Guidelines, v3.0
medical conditions - people aged 65 years and older with chronic medical conditions - people aged 70 years and older -
people with compromised immune systems
Care settings
Clinical and Epidemiological risk factors include the number of cases of COVID-19 in the local community, geographical location
Coronavirus Disease 2019 (COVID-19): CDNA National Guidelines for
Epidemiological risk (low vaccination coverage vs. high vaccination coverage), travel history, indigenous status and poverty.
Public Health Units
factors Clinical risk factors include age, comorbidities, having one or more chronic conditions, or vaccination status.
Includes patient facing care in community based settings run by HSPs, including for example Child and Adolescent
Community based Informed by subject matter experts and
Community Health Clinics, WACHS remote area clinics and nursing posts, public community dental services, home
clinical care WA Covid-19 Testing Guidelines v3.0
based settings and outreach care
As per definition for Prolonged episodes of care: direct face to face contact with a patient when duration is 15 minutes or Coronavirus Disease - 2019 (COVID-19) Infection Prevention and
Long episodes of care
more and where physical distance cannot be maintained Control in Western Australian Healthcare Facilities
Includes clinics, imaging, pharmacy, pathology etc. May include examination, consultation, treatment or other service WA Health: Specialist Outpatient Services Access Policy
Outpatient services provided to non-admitted non-emergency patients in a specialty unit or under an organisational arrangement
administered by a hospital WA COVID-19 Testing Guidelines, v3.0
Includes planned frequent/ regular patient presentations for services such as dialysis, chemotherapy, haematology (i.e. WA Health: Specialist Outpatient Services Access Policy
Specialist day services frequent transfusions) or short stay admission (Appendix 3 - Abbreviations
The below table sets out abbreviations and acronyms used throughout the SAR
Abbreviation High level definition Abbreviation High level definition
AGPs Aerosol-Generating Procedures NSW New South Wales
AGBs Aerosol-Generating Behaviours NPIR Negative Pressure Isolation Room
BAU Business As Usual PAPR Powered Air Purifying Respirators
CAHS Child and Adolescent Health Service PFR Particulate Filter Respirator
CDNA Communicable Diseases Network Australia PHLN Public Health Laboratory Network
CHO Chief Health Officer PHSM Public Health and Social Measures
COB Close of Business PPE Personal Protective Equipment
DG Director General PSP Purchasing and System Performance
DoH Department of Health PCR Polymerase Chain Reaction
ED Emergency Department RAT Rapid Antigen Testing
HCW Healthcare Worker SA South Australia
HEC Health Executive Committee SAR WA Health COVID-19 Framework for
System Alert and Response
HSPs Health Service Providers SHICC State Health Incident Control Centre
ICEG Infection Control Expert Group SMEs Subject Matter Experts
IC Incident Controller TB Tuberculosis
ICU Intensive Care Unit TBC To be confirmed
IDPAG Infectious Diseases Physicians Advisory VIC Victoria
Group
LWC Living with COVID-19 WA Western Australia
MfH Minister for Health WACHS Western Australian Country Health Service
21Appendix 4 - Key SMEs
The SAR has been developed by SHICC Health Operations Cell, with significant input from SMEs across the WA
Health System. The below lists key contributors and groups consulted during the development of the SAR
Key SMEs (roles) Key Advisory Groups
Chief Health Officer (Sign-Off) WA Health Executive Committee
COVID-19 HSP Executive Lead (and CE, EMHS) SHICC Planning teams (Public Health, including Infection Prevention and Control)
previously Public Health Emergency Operations Centre (PHEOC) team/s
Assistant Director General, Clinical Strategy and Planning, DoH Health Service Provider COVID-19 Leads
State Health Incident Controller Infection Prevention and Control Clinical Advisory Group
Deputy Chief Health Officer (Office of the CHO) Infectious Diseases Physicians’ Advisory Group
Deputy Chief Health Officer (Public Health)
Deputy Incident Controller (Public Health)
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