Acute Covid-19 management In Primary Care - Wednesday 13th January 12:30 - 14:00 - Barnet Primary ...
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Acute Covid-19 management
In Primary Care
Wednesday 13th January
12:30 – 14:00
AGENDA
Acute covid-19 management in Primary Care Speaker Timeslot
Intro to covid assessment in Primary Care, use of SATS & Dr John McGrath, Islington GP & NCL CCG 12:30 –
Governing Body
NEWS 12:45
Experience in ED department – pressures on Acutes & Dr James Harrison, ED Consultant, North 12:45 –
Middlesex University Hospital Trust
assessing the covid pt in ED 13:00
Key updates on clinical management, any differences in Dr Tim Cutfield, ID Consultant, University 13:00 –
College London Hospitals Trust
presentation with B117 13:15
Hospital discharge and when to readmit Dr Mel Heightman, Integrated Respiratory 13:15 –
Consultant UCLH & Whittington Trusts
13:30
Covid oximetry at home pathway Dr Katie Coleman, Islington GP & Clinical Lead 13:30 –
Primary Care Development
13:40
Q&A Panel 13:40 –
14:00
2
Future events
Title Details Date & Time
Outbreaks in Primary Webinar offering practical support to practices in light of the pressures causes Thu 14th Jan 10 –
Care by rising Covid-19 infection rates. This will include IPC advice, and clear 10.45 am - see
resources and support re reporting processes. here
CAMHS support for A practical session with consultant child & adolescent psychiatrists exploring
Wed 20th Jan 1-
children & young how to support children and families through covid.
2pm - See here
people in covid times
Long covid in Primary A session with colleagues from Primary, Community & Secondary Care to Tue 26th Jan
Care and emerging explain the emerging covid f/u pathways for Long covid. 12.30 – 2pm. Invite
pathways to follow shortly
Covid vaccine training 1. Webinars by Dr David Elliman covering the 3 e-LfH materials for
for vaccinators experienced vaccinators Ongoing – see
2. Co-ordination of F2F training for staff wishing to be vaccinators (BLS, here
Anaphylaxis & IM injections)
Covid vaccine – A session to provide factual information aimed at address coming questions
Concerns & questions and concerns from staff groups TBC Coming Soon
answered
3
Thank you
Slides and recording will be shared via NCL Covid Primary Care
Bi-Weekly news bulletin
Questions?
Please email nclccg.nclth@nhs.net and the NCL Training Hubs team
will direct your query
4
Acute Covid-19
management in
primary care
Wed 13th Jan
2021
5
Previously…
https://www.youtube.com/watch?v=XMyyja9f_QM&feature=y
outu.be
http://coronavirus.ncl.nhs.sitekit.net/coronavirus-
updates/webinar-recording-ncl-clinical-knowledge-sharing-
forum/153326
6
Menti – engagement from attendees
7
Menti – engagement from attendees
8
Menti – engagement from attendees
9
Esme
• 78yr Turkish lady
• Lives with son
• Contacts extended access service
Sats probe organised
• Day 6 of symptoms – cough, appetite down, aches
Video ax
• Son has tested COVID positive
Sats 96%
• Her swab has been sent, but no result yet HR 76
10• Day 7
• Extended access call again
• Cough now productive, sats 96%
• Doxy issued and safety netting advice given
• Day 9 Monday Sats 96% resting
• Swab result positive 94% after desat test
(1MSTS)
• Feeling worse
HR 95
RR 20 What now?
T 37.1
11Lots of guidance
12NEWS2 https://www.england.nhs.uk/coronavirus/w
p-
• Spoke to NCL covid Regular paracetamol content/uploads/sites/52/2020/06/C0445-
remote-monitoring-in-primary-care-
Proning revised.pdfM
service Breathing techniques
Fluids
Patient safety netting leaflet 13• Overnight day 10
• Deterioration
Reasons for transfer to hospital
• Sats 90%
• Temp 38.2 Specialist assessment and access to diagnostics
Treatment initiation
• HR 120 Limit of professional competency
Patient safety
Criteria
Clinical judgement
Have considered existing care plan/preferences
Followed pathways and used community resources
• What’s changed? What’s actually happening?
14The NMUH ED perspective
James Harrison
15The NMUH story so far
16Beds required at NMUH
17ITU Outcomes
1St wave (6 months) 2nd wave (4 months)
COVID cases in 176 182
ITU
ITU mortality 72% 22%
ITU transfers 39 94
Overall hospital 27% 9%
mortality
18Patients in ED, sent by GP
1920
COVID-19 2021:
A brief update from UCLH
Tim Cutfield
Infectious Diseases Fellow
Thanks to Sarah Logan, Michael Marks, Peter Shakeshaft
and rest of UCLH COVID-19 team
21CPAP
CPAP
22What are we doing
• Investigations:
• Oximetry
• Bloods (esp. CRP > 50 early, ‘high’ D-dimer if worsening SOB / new CP)
• CXR
• Lots of CTPA’s…
• Admission almost exclusively driven by need for oxygen treatment
• Treatment
• Oxygen (individualised targets); CPAP trial / ITU if required (see later)
• Dexamethasone 6mg daily (max 10d) with PPI
• Enoxaparin (minimum dosing prophylaxis, sometimes higher)
• (Discharge – will leave for Mel)
2324
25
CRAID remote clinic numbers
• Mix of post-ED and post-Ward discharges
• 490 appointments for 306 patients, 2 Nov – 31 Dec
• From Jan 2021: 15-30 / day
• 74 ED reattendances (64 patients, 20%) – [not all for COVID-19]
• 40% admitted from ED
70
60
50
40
First Attendance
Telephone First Attendance
30
Telephone Follow-up Attendance
20
10
0
02-Nov-20 09-Nov-20 16-Nov-20 23-Nov-20 30-Nov-20 07-Dec-20 14-Dec-20 21-Dec-20 28-Dec-20 26CRAID what we are doing
• [Inform of positive result]
• Establish contact, build relationship and offer reassurance (if necessary)
• Assess severity, risk factors for deterioration
• Offer contact details (9-5 7 days a week)
• Take patient-activated calls (infrequent..)
• Reinforce indications to call 111/999
• Answer questions (e.g. isolation requirements, repeat tests )
• Referral for follow-up CXR and post-COVID clinic
• Offer inclusion in outpatient trials
2728
Is the new variant / 2nd wave different?
• Clinically, probably not (much) aside from impact of bigger numbers
• (Non-evidence-based) observations:
• Higher proportion of ‘entire household’ sick
• More middle-aged / working aged admissions
• ?Quicker improvement post-Dexamethasone in febrile cohort
• ?Lower mortality (too soon to be accurate)
• 1 Dec – 9 Jan 401 patients admitted
• 44/401 (11%) died (12 t/f from other hospitals)
• Median age 80, CFS 4, high ISARIC 4C scores
29Hospital Discharge and when to readmit
Dr Mel Heightman’s slides to follow
30Covid oximetry@home Dr Katie Coleman NCL Clinical Lead Primary Care Development31
Undertaking a comprehensive clinical
assessment
32ADULT PRIMARY CARE COVID ASSESSMENT PATHWAY
TRIAGE
Non-COVID/other pathologies Patient referred to practice on initial presentation Mild COVID symptoms
Triage to determine if remote or F2F consultation is required Clinician telephone/video triage if cough or breathless Patient instructed to
Ensuring that unwell non-COVID conditions are not ignored Decides when/in whom oximetry would be helpful self manage –
paracetamol, fluids,
NHS 111 website
Face to face or Virtual Assessment
Watch for ‘silent hypoxia’ With pulse oximetry +/- rest of observations
Asymptomatic presentations with low O2 sats
(often with normal RR, HR & other obs)
COVID symptoms ranked
by severity SEVERE MODERATE MILD
predictiveness
O2 92%* or lower O2 93 - 94%* O2 95% or higher
BREATHLESSNESS Or any of RR 21-24, HR 91-130 Or any of RR ≤ 20, HR ≤ 90
Or any of RR ≥ 25, HR ≥ 131, new confusion
Myalgia ≈ NEWS2 ≥ 5 ≈ NEWS2 3-4 ≈ NEWS2 0-2
*Or if O2 sats >4% less than usual *Or if O2 sats 3-4% less than usual *Or if O2 sats are 1-2% less than usual
Chill
Severe Fatigue CONSIDER URGENT ADMISSION CONSIDER Hospital CONSIDER MONITORING
Sputum ADMISSION / ASSESSMENT
Dizziness
Cough if considering discharge, do exertion test (40 step walk or 1 min sit-to-
Nausea/vomiting
Hospital stand tests & consider admission if concern or if ≥ 3% reduction
Diarrhoea
Headache
Sore throat
COVID REMOTE MONITORING / VIRTUAL WARD
GP issues COVID diary (inc. admission/CPR status)
Nasal Congestion
Monitoring: symptoms & trend of O2 saturation
Modality & frequency of monitoring as directed by GP
Some patients may be suitable for purely verbal/written safety-netting, others may require call
Shared Decision-making points
Continuing community/palliative Care where appropriate
33
https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0445-remote-monitoring-in-primary-care-revised.pdfKeeping Covid +ve people at home
• Numbers of Covid +ve patients increased due to increased transmission of new
variant putting significant strain on all local providers:
• LAS
• NHS 111
• Emergency departments
• In patient beds
• NCL GP practices skilled in undertaking remote monitoring via pulse oximetry to
support admission avoidance – Covid Oximetry@home
• NCL acute trusts offering enhanced supported discharge (variation present across
NCL) – Enhanced Covid Ward (greater complexity, remote care, consultant oversight)
• Greater understanding of those at greatest risk of silent hypoxia ensuring clear
eligibility criteria for above services
34How does it all fit together?
35*The COVID virtual ward describes an enhanced package of monitoring
Covid-19 Clinical (of symptoms and O2 sats) for patients at risk of future
deterioration/admission, provided within a patient’s own home (or usual
Pathway residence) and can be managed by either community or hospital teams.
Diary &
Admit RECOVERY
COVID Virtual Ward*
Active follow up
e.g. SatsNuts and bolts of Covid Oximetry@ Home
3738
Identification of appropriate patients
for Covid Oximetry@home
• Diagnosed with COVID-19: either clinically or positive test result AND
• Symptomatic AND EITHER
• Aged 65 years or older OR
• Under 65 years and clinically extremely vulnerable to COVID. (The Clinically Extremely Vulnerable to
COVID list should be used as the primary guide. Clinical judgement can apply and take into account
multiple additional COVID risk factors)
Patients should be considered to join the Oximetry @Home pathway if they do not meet the above criteria
but have:
• oxygen saturations of ≥95% with additional risk factors, having been assessed by a GP
• oxygen saturations of 93-94% and no additional risk factors, having been assessed by a GP with an
exclusion of other risks and consideration of the need for additional diagnostics
Patients who have oxygen saturations of 93-94% and additional risk factors should be assessed
within an ED/SDEC before the appropriate pathway is selected – the senior clinical decision maker
will determine if they are suitable for the community @home pathway or whether they should join
the acute-based pathway via the COVID Virtual Ward.
39Patients onboard to Covid Oximetry@Home are advised: • Undertake 3 x daily readings – breakfast, lunch and dinner • Active follow up on day 2,5,7,10,12 and 14 or at clinical discretion • agree how to be actively followed up • text (use Accurx template - Covid-19 Remote monitoring questionnaire) • email • non-clinical check in via phone • check knows when to call if deterioration in readings and less
Now for the resources:
• Safety netting letter
• How to use your oximeter and diary
• Videos in different languages
• Covid oximetry@home register and data collection
spreadsheet
• Accurx florey Covid-19 remote monitoring
• Email text
• Non-clinician follow up script
• Advice sheet for non-clinician monitoring
• NCL acute covid service
41Safety netting COVID Diary
210k +/- 150k
Pt instruction youtubes
COVID virtual ward apps Interoperable
digital systems
analogue COVID virtual ward resources
https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0445-remote-monitoring-in-primary-care-annex-2-diary.pdf
digital
42Covid Oximetry@home register
Advice sheet for non-clinician monitoring
patients on Covid oximetry@home
pathway
Patients will be followed up on the Covid
Oximetry@home pathway.
They will be asked a series of questions on day
2,5,7,10, 12 and 14.
If the answers to the questions are abnormal the
patient should be advised that a clinician will call
them back. The answers below should trigger a call
with a clinician.
How do you feel today compared to yesterday
- worse
Do you feel more breathless today? - yes
Temperature - >37.8
Blood pressureCovid Oximetry@Home: Self-monitoring
non- clinician follow up script
• Flowchart produced as a guideline only
• Please adapt and use as needed.
• For self-monitoring service only
44FIRST CONTACT B Explain that they thy will be prompted to send
in their readings via text, email or phone.
on day 2,5,7,10 & 12 – more frequent for
Confirm the persons Explain process of self- clinically indicated
identity monitoring and safety netting
This is to let the person know you are from
Hello my name is ## the COVID Oximetry @Home support team.
Walk through step by step how to use the
Confirm that they have had an assessment pulse oximeter-may need video call to talk
and that benefits, risks and alternative Go through process of taking through the process as per competency doc
options have been discussed. If not, stop Look @ documents in front of the person and
the call as the pathway may not be
pulse oximeter readings and talk through them –important that the
Explain why they are being
appropriate. how they put this data into a person knows they don’t have to wait until
asked to self-monitor at home
diary and send to COVID next call if worried about number reducing
or their usual place of They are being asked to self-monitor at and needs to contact the number on the
home or their usual place of residence
Oximetry @Home support
residence and emphasise they Person information leaflet sooner than
because they have either had a positive team waiting for call.
will be supported 24/7
COVID test or have a high suspicion of Ensure aware when they will be called & they
COVID and that they may be of a certain have all contact numbers
group of people who are more susceptible
to complications from COVID (CEV etc). Walk through process of
They will be supported to self-care 24/7 by taking reading and recording
a range of trained professionals. this
Have they
received the
patient leaflet If they haven’t got pack or Pulse Oximetry
package and organise for equipment to be delivered..
oximeter and do Ask patient to summarise their understanding
they know how Summarise of conversation (teach back if helpful).
to use this
A END
45ONGOING CONTACT
Confirm the persons B
identity Ask them to show you how they take their pulse ox,
Do you have any
questions or concerns revisit the video and try and alleviate any concerns if
This is to let the person know you are from the COVID have video access
Hello my name is ## Oximetry @Home support team. about using your
oximeter or diary ? If unable to seek help from supervisor
How are you Establish the patients well-being – is anything worrying Oximeter readings three times a day and enter readings
managing? them, do they feel sufficiently supported to self-monitor? into the diary.
• Patients will be asked to attend ED within an hour or
Do you know
call 999 if reading is 92% or less, or to contact 111/GP if
what to do if 93-94% .
• Have we received any via email/text confirm those your readings
Pulse ok? with person? drop below
Review • Remind them of which day they are on at the moment 95%
readings for 2, 5 , 7, 10 ,12
past few days • If pulse oximetry between 93-95% consistently then
advise clinician will call patient within the hour.
Ensure person knows to call the practice back in hours
• At all times, remain calm to help the patient Any concerns over equipment or
How are you • We are asking about COVID related symptoms and NHS 111 out of hours
condition of equipment and
feeling today breathing etc. what to do if stops working?
better, same, • If person complain of any other symptoms then you
worse? must stop the call and advised either GP /111/999 or
seek help from supervisor
Ensure aware when they will be called & they have all
Review booked for x days if
contact numbers
If worse, then get the person to self-monitor whilst on any problems ring the
Is your
telephone/video and record details practice. Please keep sending in readings
breathing
better, Same, If persistently less then 93 % then advise that a GP will
worse? call them back immediately. Alert GP.
A 46END CONTACT
B
Confirm the persons identity
Any further
questions? Allow person time to ask further questions
Explain this is the last planned call from about stopping self-monitoring.
If in doubt seek help from supervisor
Hello my name is ## the COVID Oximetry @Home support
Long Covid symptoms etc. INSERT
team.
Persons who do not show signs of END
deterioration within 14 days of onset of
symptoms should be actively discharged
Final reading and supplied with leaving information,
safety netting. A person who remains
symptomatic should receive a further Contact NHS 111
clinical assessment. If you experience any the following COVID-19 symptoms, you should contact 111 as
soon as possible. You can access 111 online at www.111.nhs.uk, by telephoning 111 or
via your GP
• Feeling breathless or difficulty breathing, especially when standing up or moving
• Severe muscle aches or tiredness
• Shakes or shivers
Safety Netting • If you use a pulse oximeter and your blood oxygen level is 94% or 93% or
consistently lower than your usual reading and you feel unwell
• Sense that something is wrong (general weakness, severe tiredness, loss of
appetite, peeing much less than normal, unable to care for yourself – simple tasks
like washing and dressing or making food)
Returns process as per local policy, either You should tell the operator you have recently been seen in A&E and have been told
Returning of Oximeter through drop of point or pick up by you might have coronavirus.
voluntary service INSERT
A
47Resources
http://coronavirus.ncl.nhs.sitekit.net/coronavirus-
updates/covid-19-oximetry-at-home-resources-for-
practices/201645
https://future.nhs.uk/NHSatH/view?objectID=23346672
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