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Covid-19 Primary Care Resources


What you need to know to triage and assess suspected cases of Covid-19



An updated synthesis of all relevant guidance for primary care

This information is sourced from NHS London clinical networks, the BMJ, the Centre for Evidence Based Medicine (CEBM)PHE, NHSE, the MHRA and the PCDS:

Key points

  • Covid-19 can produce rapid deterioration in respiratory function, especially in the second week
  • Patients with moderate symptoms who do not meet criteria for a 999 call, need assessment via video, hot zone review or home visit
  • Only visit at home if there is no alternative and if 2 clinicians agree this is the only option (eg patient shielding or very frail)
  • Patients with moderate symptoms who meet medium risk criteria (see table below) should be followed up with daily phone calls and pulse oximetry
  • Deterioration in these patients requires referral to secondary care
  • Follow up should continue until symptoms and signs have improved for 48 hrs
  • Serious differential diagnoses such as bacterial pneumonia, meningitis, or sepsis should be considered
  • Comorbidities such as asthma or diabetes may need active management
  • Covid-19 can trigger new-onset diabetes in previously healthy people
  • Patients may be able to take their own measurements if they have instruments at home/if supplied with a pulse oximeter but interpret self monitoring results with caution and in the context of your wider assessment. 
  • The use of oximetry to monitor and identify ‘silent hypoxia’ and rapid patient deterioration at home is recommended
  • Exertion oximetry (under the supervision of a clinician) is used to pick up desaturations and for better early identification of those at risk of significant deterioration. It is particularly useful for identifying ‘silent hypoxia’
  • Evidence suggests that pulse oximeters may be less accurate in people with darker skin pigmentation
  • Inhaled budesonide can be considered (off-label) on a case-by-case basis for symptomatic Covid-19 positive patients aged 65 and over, or aged 50 or over with co-morbidities

Steps

1. Review a patient’s notes before calling them:

  • Look for conditions/medications which put someone at increased risk for serious illness
  • If they have COPD or Interstitial lung disease review their baseline oxygen saturations so that you can grade deterioration accordingly (details on embedded links)
  • Do they have an advanced care plan documented on Coordinate My Care? If not, and it is appropriate, consider exploring wishes and capacity when you call

2. Screen for symptoms of Covid-19 infection and severity of illness

Focus on change. A clear story of deterioration is more important than whether the patient currently feels short of breath:

  •  Date of first symptoms
  •  Do they have fever >37.8 or have the felt shivery, achy, or are they hot to touch?
  •  Do they have a new continuous cough?
  •  Do they have a loss of/change in their normal sense of taste or smell?
  •  “How is your breathing today?”
  •  “Do you have an oximeter at home or have you noticed any blue discolouration of your lips?”
  •  “Are you more breathless than usual on walking or climbing stairs?”
  •  “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. Categorise symptoms and assess risk for patients with likely Covid 19

CategorySymptoms Risk Assessment  Action
Mild symptomsNo moderate or severe symptomsSats ≥ 94%
HR ≤ 90
RR ≤ 20
– Add to practice list of known/suspected Covid 19 patients (and notify public health)
Self management advice
Antigen testingStay at home advice & safety netting
– Consider eligibility for inhaled budesonide if over 50
Moderate symptoms
MEDIUM RISK
New breathlessness on walking
Dizzy/faint on walking
Severe headache
Not passing urine
Moderate tight chest/wheezy
MEDIUM RISK SIGNS
No Desaturation with exertion on desaturation test or ≤ 2% from resting values
Sats = 93-94
HR =91-130
RR=21-24
Speaking full sentences
Deteriorating symptoms
– Currently medium risk
Add to practice list of known/suspected Covid 19 patients (and notify public health)
– Consider trial of treatment at home
– Consider eligibility for inhaled budesonide if over 50
– Consider treatment to prevent secondary bacterial pneumonia (the MHRA have advised that azithromycin and doxycycline should no longer be used in the management COVID-19 infection within primary care, unless indications for which its use remains appropriate are shown)
– Treat an exacerbation of asthma or COPD IF known steroid responsive
– Consider high dose bronchodilators (4-8 puffs salbutamol via large volume spacer (or nebuliser)
Antigen testingStay at home advice & safety netting
– Arrange daily follow up call via hot site or GP to assess breathlessness at rest/with usual activity and daily pulse oximetry
– Follow up until 48 hours of improvement in symptoms and O2 Saturations
– Refer to secondary care if deteriorating saturations 
– Patient to call 999 if deteriorating
Moderate symptoms
HIGH RISK
New breathlessness on walking
Dizzy/faint on walking
Severe headache
Not passing urine
Moderate tight chest/wheezy
HIGH RISK SIGN
Sats ≤ 92%
HR ≥ 131
RR ≥ 25
Unable to speak full sentences
Signs of sepsis
Other emergency signs
– 999 Hospital Admission unless:
– Advance Care Plan/plan on CMC. Refer to local primary and palliative care teams
– Assess comorbidities and underlying health conditions in conjunction with Clinical Frailty Score 
SEVERENew breathlessness on walking
Dizzy/faint on walking
Severe headache
Not passing urine
Moderate tight chest/wheezy
– 999 Hospital Admission unless:
– Advance Care Plan/plan on CMC. Refer to local primary and palliative care teams
– Assess comorbidities and underlying health conditions in conjunction with Clinical Frailty Score