3.2 Managing cases
Update 7th October
An additional £10 million has been allocated this year in England to fund specialist, local clinics for patients with ‘long covid’ that are still experiencing symptoms months after contracting the virus. ‘Respiratory consultants, physiotherapists, other specialists and GPs’ will provide physical assessments to diagnose chronic health conditions as well as cognitive and psychological assessments. If needed, patients will be referred for follow-up specialist services.
These clinics will complement ‘existing primary, community and rehabilitation care’ and come in addition to other measures to support “long COVID” patients, including: the development of evidence-based NICE guidelines on the support long covid patients should receive; online rehabilitation services (‘Your Covid Recovery’); and the establishment of an NHS England long COVID taskforce. The National Institute of Clinical Excellence are also planning to release their guidance shortly and it is hoped that this will provide a formal case definition so that these cases can start to be coded in the electronic health records to create a national register. While there are plans to roll out such clinics, very few areas currently have sufficient access to care, with 67% of GP’s reporting that they are already looking after Long Covid patients and over 70% reporting a degree of psychiatric disturbance.
Source: https://www.england.nhs.uk/2020/10/nhs-to-offer-long-covid-help/ and https://committees.parliament.uk/writtenevidence/12976/html//
Update 20th June 2020
The University of Oxford’s RECOVERY clinical trial has released findings showing that a cheap and widely available steroid, dexamethasone, significantly reduced mortality in ventilated patients by one third and by patients requiring oxygen by one fifth (https://www.recoverytrial.net/files/recovery_dexamethasone_statement_160620_v2final.pdf). There were limited benefits for patients that were less unwell. In response, the UK's four chief medical officers from England, Northern Ireland, Scotland and Wales have written an urgent letter to NHS clinicians to say dexamethasone should be used "with immediate effect" for the management of people in hospital and receiving oxygen or mechanical ventilation (https://www.bbc.co.uk/news/health-53077893). The UK government has stockpiled 200,000 doses of the drug and has added it to the parallel export list, banning companies from buying medicines meant for UK patients and selling them for a higher price abroad.
The WHO has urged for production of the drug to be rapidly ramped up to meet global demand and are in the process of updating treatment guidelines to include dexamethasone or other steroids (https://www.who.int/news-room/detail/16-06-2020-who-welcomes-preliminary-results-about-dexamethasone-use-in-treating-critically-ill-covid-19-patients).
Update 16th June 2020
UK clinical trialists using hydroxychloroquine to treat COVID-19 patients have been told to suspend recruitment of further participants by The Medicines and Healthcare products Regulatory Agency (MHRA) (https://www.gov.uk/government/news/mhra-suspends-recruitment-to-covid-19-hydroxychloroquine-trials). The decision was taken following a recommendation from the Commission on Human Medicines who had reviewed evidence from two clinical trials, including the UK’s RECOVERY trial, which failed to show evidence of a meaningful mortality benefit for patients hospitalised with COVID-19.
Update 12 June 2020
People with symptoms are now advised to book a test online and if it is positive they are sent a text message and asked to update their contacts to an online secure webpage. Those who do not are telephoned by the manual contact tracers. There is currently no involvement of primary care and it is not clear what health monitoring or safety netting is taking place for these individuals. They are asked whether they will isolate and it support is supposed to be offered by the local authority if they say that they cannot. It is unclear yet how well this is working as it is early in the process.
From the outset there has been guidance for primary care providers to direct callers at risk to the national helpline for testing, to otherwise triage patients virtually and to wear appropriate PPE if there is no alternative but to see patients, with appropriate cleaning of the setting thereafter. There is triage of COVID-19 patients (https://www.gov.uk/government/publications/covid-19-guidance-for-stepdown-of-infection-control-precautions-within-hospitals-and-discharging-covid-19-patients-from-hospital-to-home-settings/guidance-for-stepdown-of-infection-control-precautions-and-discharging-covid-19-patients), which also includes the national guidance on facilitating hospital discharge. The guidance includes questions to guide admission or discharge, including:
• Whether the individual requires the care they are receiving in hospital or whether this can be provided in another setting.
• What value is being added by the admission
• ‘Why not home, why not today?’
Specific clinical treatment protocols and pathways for patients with COVID-19 have also been developed by the National Institute for Health and Care Excellence (NICE) outlining the provision of treatments for COVID-19 in various settings including in critical care and in the context of delivering kidney dialysis and systemic anticancer treatments (https://www.nice.org.uk/guidance/ng159). Evidence reviews are also underway by Public Health England and NICE for clinical treatments but at present local protocols are hospital-guidance specific.
PHE guidance for COVID-19 in the UK recommends strict hand hygiene, cohorting of patients and appropriate use of PPE to prevent transmission by droplet contact spread (https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe). In most cases, including in emergency departments and on isolation wards, this includes a fluid resistant mask (in line with WHO guidance), a plastic apron, gloves and goggles, if any splash is expected. In line with WHO guidance, the Department of Health and Social Care’s New and Emerging Respiratory Virus Threat Assessment Group (NERVTAG) have recommended that airborne precautions should be only be implemented when undertaking an aerosol generating procedure (AGP) and in clinical areas considered AGP ‘hot spots’ e.g. Intensive Care Units (ICU), Intensive Therapy Units (ITU) or High Dependency Units (HDU) that are managing COVID-19 patients. The guidance also outlines measures to prevent contact transmission by decontamination of reusable equipment, which is the most common route of transmission. PPE guidance in the UK has changed frequently and has caused much unrest among doctors and social care staff. Most recent changes advise the sessional use of PPE around asymptomatic patients.
COVID-19 patients who are not safe to return home or may now have ongoing nursing needs are expected to be discharged to care homes. This is ‘expected’ to constitute 1% of patients. Upon discharge, cases are given a single point of contact in the community to access support after discharge.
There has been much focus on pathways for people being discharged from hospital into care settings, but much less focus on those in care settings requiring hospital care. One reference is made within guidance which is largely about admission into a care home but no specific pathway set out (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/880274/Admission_and_Care_of_Residents_during_COVID-19_Incident_in_a_Care_Home.pdf). The National Institute for Clinical Excellence also published guidance on admissions for adults into acute care on 30th March, however there is no specific mention of procedures to follow in care settings (https://www.nice.org.uk/guidance/ng159/resources/covid19-rapid-guideline-critical-care-pdf-66141848681413?utm_campaign=11479390_JT%20email%202&utm_medium=email&utm_source=UKHCA&dm_i=1DVI,6U1JY,7HD23Q,RE0LH,1. Some controversy has arisen where GPs or community nurses have, in a small number of areas, imposed blanket do not attempt resuscitation (DNAR) orders on groups of people receiving social care support at home and in care homes – the Care Quality Commission along with other partners issued a statement saying that such blanket orders were inappropriate and that end of life planning should continue to be done on an individual basis (https://www.cqc.org.uk/news/stories/joint-statement-advance-care-planning).