Dr Sharon Raymond describes the pathway and protocols for giving patients oxygen saturation monitoring equipment for use in their homes
Patients at greatest risk of poor clinical outcomes from Covid-19 are best identified by oxygen levels.1 Last summer NHS England issued guidance on pulse oximetry to measure oxygen levels in patients with confirmed or suspected Covid-19, in order to identify silent hypoxia and to detect early deterioration when monitoring patients remotely in primary and community care.2
In November 2020, NHSE stipulated that all CCGs should implement the Covid oximetry at home model (Covid Oximetry @home).3 This facilitates the prompt identification of patients needing further treatment, including admission to hospital. This earlier detection improves mortality rates and reduces the numbers requiring ICU and ventilation. Each CCG should have a named person responsible for the service. National support, including the supply of oxygen saturation probes (meeting standard ISO 80601-2-61:2017) is intended for patients in the entry criteria group. The Covid-19 primary care standard operating procedure supports the guidance.4
Running in conjunction with this, the Covid virtual ward model is a secondary-care-led initiative to support early and safe discharge from hospital for Covid patients. It has been shown to reduce emergency admissions and builds on Covid Oximetry @home.5
Oximetry @home entry criteria
Patients with suspected Covid-19 should be assessed for alternative diagnoses before being put on the remote monitoring pathway. Current evidence suggests the patient groups that will benefit most are those:
• Diagnosed with Covid-19, either clinically or with a positive test result
• Showing symptoms
• Aged 65 years or older
• Under 65 and clinically extremely vulnerable (CEV) to Covid-19.
The CEV serves as a guide to eligibility, and clinician discretion may be used and multiple other Covid-19 risk factors can be considered. Many practices have gone beyond the national guidance to include groups such as those aged over 50 years. Other vulnerable groups that could be included are homeless patients,6 and those with learning disabilities (who have a 3.6 times greater mortality risk if they develop Covid-19 compared with the general population).7
The patient journey
Stage 1 – referral
This model is predominantly instigated in primary care. Referrals may also come via the 111 Covid Clinical Assessment Service (CCAS), and from NHS Test and Trace, A&E and secondary care discharge. Patients presenting directly to general practice should be assessed and not redirected to NHS 111, in order to prevent delay in their care.
Stage 2 – triage
Patients referred to the service require clinical assessment by the GP if this was not done at stage 1, with a face-to-face consultation if appropriate. Shared decision-making is required before entry to the pathway, with a discussion about support for patients or carers. A risk assessment is needed to evaluate the safety of onboarding a patient remotely. A face-to-face route, which may involve carers or relatives, may be safer. Figure 1 on page 30 outlines the pathway with reference to oxygen saturation levels.
Exertion oximetry at triage, if clinically appropriate, can help identify suitability for entry into this monitoring pathway. Clinician-supervised exertion oximetry (including the 40-step walk and the one-minute sit-to-stand tests) should be done with patients who have a minimum saturation of 93% to detect desaturation and facilitate identification of those at risk of deterioration.2,8 These tests are important in identifying silent hypoxia, but should be attempted with caution. In remote assessments they should only be used where the patient has a minimum resting saturation of 96%.8
Stage 3 – onboarding
Patients should be given a pulse oximeter and supporting information,9,11 including a paper diary, or an app or regular call system. There should be contact details to report oximetry readings and symptoms, and safety netting instructions (see figure 2, right). This information should be supplied immediately if the patient is seen face to face or within 12 hours if assessed remotely. Different local systems operate for delivery of oximeters to patients’ homes, including the national NHS volunteer responders.9
Stage 4 – monitoring
Text/email prompts or check-in calls to the patient should be used as agreed at onboarding. A suggested message and phone script is available on the NHS At Home platform.11 Communications with the patient should confirm correct oximeter and diary use, and that oxygen saturations are 95% or above.
Stage 5 – recovery and discharge
Patients who do not show signs of clinical deterioration within 14 days of symptom onset are discharged with safety netting advice, and arrangements made for the return of the oximeter device.11 Patients may be discharged sooner if they have tested negative for Covid-19, or if clinically appropriate. Patients with persistent symptoms at 14 days will require clinical assessment. Once the oximeter is returned, it must be decontaminated12 and checked.
Dr Sharon Raymond is a GP in London
Figure 2: Safety-netting instructions
Attend your nearest A&E or call 999 immediately if you have one or more of the following, and tell the operator you may have coronavirus:
• You are unable to complete short sentences when at rest due to breathlessness.
• Your breathing suddenly worsens within an hour.
• Your blood oxygen level is 92% or lower, following two checks, immediately after one another.
OR if these more general signs of serious illness develop:
• You are coughing up blood.
• You feel cold and sweaty and have pale or blotchy skin.
• You develop a rash that does not fade when you roll a drinking glass over it.
• You collapse or faint.
• You become agitated, confused or very drowsy.
• You have stopped peeing or are peeing much less than usual.
Give your oxygen saturation reading to the 999 operator.
Ring your GP or 111 as soon as possible if you have any of the following, and tell the operator you may have coronavirus:
• You slowly start feeling more unwell or more breathless.
• You are having difficulty breathing when getting up to go to the toilet or similar.
• Your blood oxygen level is 94% or 93% when sitting or lying down, and remains at this level after being rechecked within an hour.
• You sense that something is wrong (general weakness, extreme tiredness, loss of appetite, reduced urine output, unable to care for yourself – simple tasks like washing and dressing or making food).
If your blood oxygen level is usually below 95% but it drops below your normal level, call 111 or your GP surgery.
Many hospitals have developed step-down facilities to discharge Covid-19 patients from acute beds into their own homes if they show significant improvement – the Covid virtual ward (CVW).
Who is setting up virtual wards?
More than 60% of acute trusts in England have a CVW. The CVWs are normally operated by secondary care with clinical intervention from the hospital team. Academic health science networks and patient safety collaboratives are supporting the implementation in every region.
Which patients are suitable?
Patients must have an improving trajectory:
- Improving symptoms, function and oxygen saturations, and blood tests.
- Stable NEWS2 score of less than 3.
- No fever for 24-48 hours without antipyretics.
Discharge to the CVW can be considered if a patient is stable with mild exercise desaturation and they have been fully investigated.
Any patients who are being considered for discharge on oxygen therapy must be discussed with the respiratory department and home oxygen team.
The virtual ward is suitable for monitoring people whose oxygen saturations are not yet back to baseline but who have been stable for 48 hours.
The virtual ward could be considered for anyone of clinical concern: those over the age of 65, especially with comorbidity; those with long-term conditions or obesity; people of BAME origin; those with a learning disability; and those living alone.
What is the GP’s involvement?
Patients remain under the care of their local hospital until actively discharged.
Who do patients contact if they have problems?
Patients are taught how to respond to oximetry readings in association with their symptoms, using safety-netting guidance available in many languages. They will have clear escalation and treatment plans. In case of deterioration they have a direct line to the hospital and may need to be reassessed or readmitted without recourse to the GP, perhaps via 999 depending on severity.
Many patients are managed safely in the community with 5.5% requiring emergency readmission.
Dr Karen Kirkham is a senior GP partner in Dorset
Fulop N, et al. Rapid evaluation of remote home monitoring models during Covid-19 pandemic in England. 2020. tinyurl.com/2n5ngypp
NHS. Novel coronavirus (Covid-19) standard operating procedure: Covid virtual ward. 2021. tinyurl.com/1trbqa05
Wessex Academic Health Science Network. Covid Virtual Ward (secondary care). 2021. tinyurl.com/nr6ekb3n
For further guidance and support see the NHS @home Future NHS platform: https://future.nhs.uk/NHSatH/grouphome.