Acute GP service
Cornwall
This is a site intended for clinicians - all guidelines must be interpreted in the context of clinical risk assessment
Primary care Acute Covid assessment guidance
Please note this updated version which tries to incorporate a more judicious use of antibiotics as per NICE guidance and is based on the Primary Care and Community Respiratory Resource pack for use during COVID-19
Using correct PPE measures when having contact with patients with suspected Covid-19 reduces the clinicians likelihood of testing postive by 33%. Healthcare worker risk is highly variable, likely based on diligent PPE and hand hygiene, local disease prevalence and level of healthcare system strain. Here is a good analysis of C19 risk to the healthcare worker
Remote Assessment/Telephone Triage with Patient or Carer
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1. Screen for symptoms of COVID-19 infection
• Do they have fever >37.8?
• If no thermometer, have they felt shivery, achy, or are they hot to touch?
• Do they have a new continuous cough, different to usual?
2. Screen for severity of illness. Suggested questions:
• “How is your breathing today?”
• “Do you have an oximeter at home or have you noticed any blue discolouration of your lips?”
• “Are you so breathless that you are unable to speak more than a few words?“
• “Are you more breathless than usual on walking or climbing stairs?
• “Do you feel dizzy, faint or have a headache?”
• “When was the last time you went to the toilet and passed urine?”
• Ask about other symptoms of severity e.g. collapse, chest pain, signs of sepsis, confusion?
3. Assess whether increased risk of severe illness with COVID-19 against the list of conditions which lead to increased risk:
• aged 70 or older (regardless of medical conditions)
• under 70 with an underlying health condition listed below (ie anyone instructed to get a flu jab as an adult each year on medical grounds):
• chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis
• chronic heart disease, such as heart failure
• chronic kidney disease
• chronic liver disease, such as hepatitis
• chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy
• diabetes
• problems with your spleen – for example, sickle cell disease or if you have had your spleen removed
• a weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroid tablets or chemotherapy
• being seriously overweight (a body mass index (BMI) of 40 or above)
• those who are pregnant
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4. Do they have an established advance care plan? Is it documented? If not, and it is appropriate, explore wishes and consider capacity.
5. Decide whether for home management (see pathway diagram 1 below)
6. Clinical judgement is crucial and overrides the pathway
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Pathway diagram 1: Categorising patients with Covid-19 symptoms in the Community
*Consideration should be given to making reasonable adjustments with telephone and videoconferencing for people who may find these interactions challenging. These groups may include people with Learning Difficulties, autism, dementia, and those for whom English is not their first language. Where possible it is suggested that interactions are supported by people who know the individual well such as the local Community Learning Disability Service, carers and relatives.
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For advice re: mild or moderate symptoms, patients / carers should be directed to the link below: https://www.nhs.uk/conditions/coronavirus-covid-19/. Categories 1 ,2a, 2b and 3 relate to the national categorisation being used by 111 services.
Pathway 2: Triaging patients with moderate symptoms of COVID-19 but NO pre-existing lung disease or significant comorbidities
Consider hot clinic review
*COVID-19 is a viral pneumonitis not commonly associated with secondary bacterial pneumonia. Therefore, it's important to try to clinically differentiate between viral and bacterial pneumonia (as per NICE; COVID‑19 viral pneumonia may be more likely if history of typical COVID‑19 symptoms for about a week, myalgia, anosmia, SOB but no pleuritic pain, COVID exposure versus bacterial pneumonia may be more likely if rapidly unwell over only few days, atypical COVID history, pleuritic pain, purulent sputum)
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If you think it is COVID-19 do not give antibiotics. If you think there is bacterial pneumonia then treat (as per CAP guidelines, currently doxycycline 5 days first line or amoxicillin 5 days second line).
Pathways for patients with PRE-EXISTING lung conditions or comorbidities
Asthma – COVID-19 can present with symptoms similar to an asthma attack such as cough and shortness of breath. However, it is worth letting patients know that it is uncommon to get a high temperature and changes in taste or smell with an asthma attack so the presence of these symptoms are more likely to suggest infection with SARS-CoV-2.
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Most patients with asthma have mild to moderate disease and normal underlying lungs. They should be treated for wheeze or bronchospasm in a conventional manner. If they have a peak flow meter at home they can monitor this themselves. They can be given one for self-monitoring if they have mild/moderate COVID-19 symptoms. The management of asthma exacerbations is unchanged and patients should NOT stop taking their ICS containing inhaler. Patients should be advised to take their medication as guided by their personal asthma action plan including oral corticosteroids and contact their GP surgery to organise a telephone, video or face-to-face consultation. If a course of steroids is clinically indicated (symptoms and signs of bronchospasm/wheeze), it should not be withheld. Antibiotics are only advised if sputum changes colour, thickens or increases in volume.
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The physiological parameters from pathway 2 should apply to asthmatic patients as to others when considering admission for COVID-19 symptoms.
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COPD – Where a patient with COPD develops increased cough or increased breathlessness in keeping with a previous exacerbation, it should be treated as an exacerbation and they should take their appropriate rescue medication. Oral corticosteroids can also be considered if known concomitant asthma and / or history of eosinophils ≥ 0.3 or known steroid responsiveness. Some patients will seek further discussion with a healthcare professional. Before prescribing steroids, ensure you are advising that the control of symptoms with increased bronchodilation, breathing exercises and pacing, for example and where appropriate. Oral corticosteroids should be avoided in COVID-19 suspected infection (fever or new cough that is different from usual).
Consider admission according to algorithm physiological parameters but if baseline O2 pulse oximetry sats are available:
• Mild deterioration would be defined as up to 2% below their baseline
• Moderate deterioration would be defined as between 3-4% below their baseline
• Severe deterioration would be defined as 5% or more below their baseline
If on Long Term Oxygen Therapy (LTOT) discuss ceiling of care and consider admission if sats <88% on their standard dose of LTOT.
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For additional guidance on Interstitial Lung Disease, Obstructive Sleep Apnoea, Bronchiectasis please see appendix 3.
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Please
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Management of hot clinics and home visits in suspected Covid-19 patients (including admission avoidance)
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Only visit at home if there is no remote alternative. Discuss need to visit with senior colleague/peer. Consider what information will be gained from it that cannot be ascertained remotely and how this will change the outcome
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Review PPE guidance daily and adhere to the recommendations
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Ask the patient to wear a mask during the consultation to protect them and the case worker- Suggest passing mask through letterbox to patient prior to entry
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Minimise physical contact with the patient and carer and keep 2m distance if possible
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Do not perform for chest physiotherapy, spirometry, PEFR, CO monitoring or FeNO or any other aerosol generating procedure
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Sputum samples for management of bronchiectasis should be discussed with specialist
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Viral swabs should not be collected, see current testing protocol here
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Monitor patients using SpO2, RR, HR (and BP if required)
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Discuss advance care plans and wishes if appropriate and seek consent to urgently document.
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Escalate by calling Acute GP or 999 if required and appropriate according to treatment escalation plans/advance care plan. Otherwise, make a plan for future monitoring e.g. telephone / video or face to face
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Dispose of all PPE at visit end according to national guidance
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PPE Requirements
For guidance on the latest advice for the use of PPE or where to get it please see:
https://www.england.nhs.uk/coronavirus/publication/guidance-supply-use-of-ppe/
Further Resources
NHSE / NHSI Primary care Covid 19 SOP
NICE guidance regarding community management here
BMJ Covid 19 remote assessment guidelines
Red Whale Clinical assessment and management of Covid-19 in the community
The following is taken from the SW CCG 'Interim Advice for Clinicians Regarding a Shared Ethical Approach to Treatment and Referral Decisions During COVID-19 Pandemic' of 7th April 2020.
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This advice note is intended to support clinicians in making ethical decisions with patients and families regarding treatment for Covid-19. It will be subjected to wider consultation and agreement and will be updated accordingly. The most up to date version will be held centrally on the South West Operational Delivery Network NHS Future Collaboration workspace.
As the COVID pandemic moves into different phases patients and caregivers will be faced with challenging decisions daily that balance the need to shield vulnerable patients from the impact of coronavirus with the needs of individual patients who present with potentially serious health conditions. These decisions, whilst difficult, are the same decisions we make daily and the principles of decision making remain the same. Each patient must be considered on an individual basis and decisions should be made based on their capacity to benefit from the treatment offered, whether that is admission to hospital for oxygen or admission to intensive care for respiratory support or palliative care at home. Wherever possible, the views of the patient and their family should be taken into consideration and due attention paid to any previously expressed wishes. Treating clinicians are responsible for the decisions they make and provider boards have responsibility for ensuring an ethical approach is taken to clinical practice throughout their services. This advice will not remove these accountabilities.
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There are current uncertainties and we will gain knowledge and experience as the pandemic progresses. In order to improve decision making, we aim to ensure that all clinicians remain abreast of new scientific evidence and current system pressures. This will not substitute guidance but enhance it.
A collaborative system-wide approach with shared responsibility for difficult decisions is more important than ever. This guidance offers a framework for decision making to support clinicians assessing patients in the community to come to the right decision regarding admission to hospital.
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Understanding of current systemwide intelligence
Background to current knowledge about COVID 19 and Admission to Hospital. This may change as we learn more about the disease. This knowledge comes from medical publications, national datasets and experience from the ITU Follow Up Clinic.
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Overall mortality from Covid-19 is 1-5%. Probably closer to 1%
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Mortality in patients over 80 years of age is 15-20%
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The move from increasing breathlessness to a sepsis-like syndrome can be potentially rapid over several hours.
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Time from onset of symptoms to need for ventilation 7 days (range 2-10 days)
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The average duration of ventilation is 7-10 days (longer in older and comorbid patients)
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Recovery from 7-10 days of ventilation in a young and fit patient is 3-6 months. Full recovery may not happen.
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Mortality in patients over age 70 who require ventilation may be as high as 75%
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Some patients may develop hypoxemia and respiratory failure without dyspnea – ‘Silent Hypoxia’
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Hospitals have adapted their acute pathways and criteria for admission for non-covid conditions have changed.
Be aware of the current system-wide pressures and latest knowledge on coronavirus presentation and trajectory. During the pandemic, systemwide leaders of critical care / A&E / IUC / SWAST and primary care will meet regularly and share intelligence on current system pressures, and experience of disease presentation and progression. This information will be made available on the NHS futures website in the form of a ‘30 second brief’, which will be regularly updated. Taking this information into account will help inform difficult decisions by refining the assessment of the likely risks and benefits to the patient, of the various clinical options.
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We recognise that there may come a situation where resources are limited and decisions may need to be made based on assessing and prioritising patients for treatment. These decisions will be made by multiple intensive care physicians with assistance from colleagues and will be documented. By making decisions as a system that take the evolving pandemic into account, we hope to mitigate this situation and possibly avoid it altogether. The steps being taken to respond to the pandemic such as increased capacity and social distancing are intended to avoid this situation arising.
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2. Assessment of respiratory distress
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All patients should be considered for hospital transfer in particular:
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Patients with signs of increasing respiratory distress
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Patients whose symptoms cannot be satisfactorily controlled
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Physical examination is generally non-specific. For many patients, a decision on further treatment will be possible with video/telephone assessment. Face to face assessment should be offered if there is a clear rationale that it will influence decision making.
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Patients with signs of respiratory distress could benefit from hospital admission for oxygen therapy without needing ventilation. The parameters below are a guide and should be interpreted in the context of the situation and comparing any knowledge from the patient or medical record of baseline parameters. Trust your clinical judgement.
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Unable to complete full sentences
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Sitting up, leaning forwards with arms on legs, not able to lie flat
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Breathing differently: flared nostrils, pursed lips.
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Restlessness or anxiety can be a sign of early hypoxia
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Changes in skin colour to bluish or grey
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Respiratory rate >24 at rest
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Saturations <93% if available
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Tachycardia at rest*
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Excessive sweating
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Significant deterioration of SOB over the last 2-6 hours
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Alteration of consciousness or new delirium
* Patients may know their pre-morbid resting heart rate or an estimation of their baseline can be based on physical activity/medication such as beta-blockers etc.
3. Supporting patients at home
For patients with no signs of respiratory distress advise on self-care and safety-netting.
​https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-advice/
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4. Safety Netting
For people with some respiratory distress where admission is not felt necessary it will be important to provide specific advice on the deterioration of breathlessness that would warrant re-contacting health care professionals. Including deterioration in symptoms and symptoms that have not resolved within 7-10 days.
If patients are not well supported and/or not able to comply with safety-netting advice, or you are concerned about the potential for rapid deterioration, consider a planned follow-up.
5. Assessment of co-morbidity
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6. Discussion with patient and/or family
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Acknowledge where the care you can offer deviates from your usual high standard of care.
Depending on co-morbidities supplemental oxygen may offer benefit whilst mechanical ventilation may be recognised as causing suffering without an expected benefit.
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Decision making on admission to ITU has not changed. If patients will benefit from ITU and they want to be ventilated the treatment is available.
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Patients should be treated fairly; all patients (Covid and Non Covid) should be offered intensive care admission and ventilation based on the likelihood of a successful outcome for them as an individual.
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The expected benefit for patients is a return to health and to resume their lifestyle in the community with a quality of life that is acceptable to the patient.
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Patients who are frail or have serious comorbidities may have their death prolonged but not prevented by ventilation in ITU.
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Ventilation in ITU comes with a burden of suffering, pain and distress. Psychological and physical morbidity is significant.
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Hospitals are operating a policy of no visitors for reasons of infection control. This may be distressing for dying patients and their family and may influence a decision to stay at home, where supportive care can be offered, including non-injectable, just in case medication.
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7. Record Keeping
Document the decision you have made, parameters contributing to decision and communication with patient/family.
Make it clear in the notes when your preferred options are not available.
Keep records that demonstrate the circumstances at that moment including information from the ’30 second brief’.
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8. Multi-professional Decision making
If after considering the above, you are not clear on the best course of action or you and the patient/ family are not agreed– i.e. patient declining admission when you think they may benefit, or patient seeking admission that you do not agree is clinically appropriate or necessary;
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Discuss with colleagues / senior member of your team
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Discuss with hospital acute care team
Most importantly, get up each morning knowing that you are human, and can only do your best. This guide has been designed to help support you. Please document your rationale and decision-making process. It is important to retain a record should there be a future review or challenge.
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Please send back any comments, suggestions or reflections you have regarding this guidance to england.swcovid19-clinical@nhs.net
