COVID-19 Response Community management of mild COVID-19

illness in rural Queensland v1.0

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For the purpose of this document virtual care includes telehealth, telephone calls and other ICT enabled communication.

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MANAGEMENT OF MILD COVID-19

VERSION 4.1PUBLISHED 4 JUNE 2020

Gene

ral

MANAGING RISK OF INFECTION

Follow national advice for use of PPE in non-inpatient heathcare settings during the COVID-19 outbreak. PP [Taskforce/AHPPC]

BASELINE ASSESSMENT

Check for signs of moderate/severe disease (refer to Assessment for suspected COVID-19 Clinical Flow Chart) Check status of oro/nasopharyngeal swab results. No baseline investigations are required for mild COVID-19. Perform CXR and/or blood tests if clinically indicated. Chest CT scan is not indicated for COVID-19, but should be performed if clinically indicated for other reasons. PP [Taskforce]

• Patients with mild COVID-19 can be managed in the community with advice on self management of symptoms and self isolation. PP [BMJ]

• Any person clinically assessed as being a likely case of COVID-19 should be managed as if they are a confirmed case until they receive a negative test for SARS-CoV-2. PP [Taskforce]

• Ensure that patients living alone have identified someone to check on them regularly, even if they are currently well. PP [BMJ]

• Assess whether or not the patient and carer(s) have the ability to manage infection control to a high standard. PP [Taskforce]

MANAGEMENT IN THE COMMUNITY

Definition of disease severity

Mild illness Person not presenting any clinical features suggesting a complicated course of illness. Characteristics: • no symptoms • or mild upper respiratory tract symptoms • or cough, new myalgia or asthenia without new shortness of breath

or a reduction in oxygen saturation

LEGEND

EBR: Evidence-Based RecommendationCBR: Consensus-Based RecommendationPP: Practice Point

Living Guidance

Prioritised for review

Not prioritised for review

Sources ACSQHC – Australian Commission on Safety and Quality in Health Care. COVID-19 Position Statement - Managing fever associated with COVID-19. Revised 29 April 2020 AHPPC – Australian Health Protection Principal Committee (AHPPC). Guidance on use of personal protective equipment (PPE) in non-inpatient healthcare settings, during the COVID-19 outbreak. 11 May 2020. BMJ – Covid-19: a remote assessment in primary care. BMJ 2020;368:m1182 doi: 10.1136/bmj.m1182 (25 March 2020)Taskforce – Current guidance from the National COVID-19 Clinical Evidence Taskforce

Trea

tmen

t

GENERAL

Ensure that people with suspected COVID-19 continue to receive their usual care for pre-existing conditions. PP [Taskforce] People advised to take NSAIDs routinely may continue with treatment. PP [ACSQHC]

DIABETES AND CARDIOVASCULAR DISEASE

TF9.1 In patients with COVID-19 who are receiving ACE-I/ARB, these medications should be continued, unless contraindicated (e.g. hypotension). CBR [Taskforce]

Do not cease or change the dose of other treatments such as insulin, other diabetes medications, or statins. PP [Taskforce]

CONDITIONS MANAGED WITH IMMUNOSUPPRESSANTS

Only cease or change the dose of long term immunosuppressants such as high-dose corticosteroids, chemotherapy, biologics, or disease-modifying anti-rheumatic drugs (DMARDs) on the advice of the treating specialist. PP [Taskforce]

ASTHMA AND COPD

TF7.1 Use inhaled or oral steroids for the management of people with co-existing asthma or COPD and COVID-19 as you normally would for viral exacerbation of asthma or COPD. Do not use a nebuliser. CBR [Taskforce]

THERAPIES FOR PRE-EXISTING CONDITIONS

SUPPORTIVE CARE

Manage mild COVID-19 in a similar way to seasonal flu and advise patients to rest and drink fluids. PP [BMJ] An antipyretic is generally not required, but paracetamol can be considered for symptomatic relief. PP [ACSQHC]

COVID-19 THERAPIES

ANTIBIOTICS

44.7 Do not prescribe antibiotics unless indicated for other reasons, such as suspected CAP. PP [Taskforce]

ANTIVIRALS AND OTHER DISEASE-MODIFYING TREATMENTS

Hydroxychloroquine TF5.1 For people with COVID-19, only administer hydroxychloroquine in the context of randomised trials with appropriate ethical approval. EBR [Taskforce]

Lopinavir/ritonavir TF5.2 For people with COVID-19, only administer lopinavir/ritonavir in the context of randomised trials with appropriate ethical approval. EBR [Taskforce]

Remdesivir TF5.3 Whenever possible remdesivir should be administered in the context of a randomised trial with appropriate ethical approval. Use of remdesivir for adults with moderate, severe or critical COVID-19 outside of a trial setting may be considered. EBR [Taskforce]

44.7 Do not initiate corticosteroids. PP [Taskforce]

Other disease-modifying treatments TF5.4 For people with COVID-19, only administer disease-modifying treatments in the context of randomised trials with appropriate ethical approval. CBR [Taskforce]

Mon

itorin

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THINGS TO WATCH FOR

Advise the person and their carer or family members to look out for the development of new or worsening symptoms, especially breathing difficulties which may indicate the development of pneumonia or hypoxaemia. Reassure the person that 4 out of 5 people with COVID-19 will have a mild illness and will usually recover 2 to 3 weeks after the initial onset of symptoms. If symptoms do worsen, this is most likely to occur in the 2nd or 3rd week of illness. PP [Taskforce]

Nex

t ste

ps in

care

ESCALATION OF CARE

Transfer to hospital is recommended if the person develops symptoms or signs suggestive of moderate or severe COVID-19, such as: • symptoms or signs of pneumonia • severe shortness of breath or difficulty breathing• blue lips or face • pain or pressure in the chest • cold, clammy or pale and mottled skin • new confusion or fainting • becoming difficult to rouse • little or no urine output • coughing up blood PP [BMJ]

RELEASE FROM ISOLATION

• Refer to relevant State public health advice for the conditions that must be met prior to release of a person from isolation.

• Review patient Care at Home advice and provide to patient if appropriate.

PP [Taskforce]

Check the person’s wishes regarding transfer, and whether they have an Advanced Care Directive for proceeding with hospital management. If the person wishes to stay in their place of residence, discuss care arrangements with the patient, their carer(s) and family. Involve their GP, and local palliative care services if available. Be aware that out-of-hospital care will be dependent on the capacity of carer(s) and family to manage infection risk at home. If the person wishes to be admitted to hospital, advise the carer or family member to call an ambulance and to notify the paramedics that the person has suspected or confirmed COVID-19. PP [Taskforce]

TRANSFER TO HOSPITAL

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4. HistoryAdapt questions to patient’s own medical history

History of current illness

Day of first symptoms

Most common presentation

Fatigue

Short of breath

Cough Fever

Up to 50% of patients do not have fever presentation

Cough is dry but sputum is not uncommon

Exposure risk

Close contact with a known COVID-19 case

Health care worker

Travel overseas or on a cruise ship

Area of local transmission

Living in a ‘closed community’

Residential care Boarding school

Correction facilities Detention centres

Rural and remote communities Military barracks

Adapted and distributed by the Australian Department of Health. For more information and the latest Australian health advice visit www.health.gov.au

coronavirus (covid-19)Telehealth and consultations in GP respiratory clinicsThis graphic, intended for use in a primary care setting, is based on data available in March 2020, much of which is from hospital settings in China. It will be revised as more relevant data emerges

Telehealth only

Telehealth and GP Respiratory Clinics

Clinical characteristics

69% Cough

22%Temperature 37.5-38°C

22%Temperature >38°C

38% Fatigue

34% Sputum

19%Shortness of breath

15%Muscles aches

14% Sore throat

14% Headache

12% Chills

5%Nasal congestion

5%Nausea or vomiting

4% Diarrhoea

24%Any comorbidity

1. Set upPrepare yourself and decide how to connect

Review patient Care at Home advice. Provide to patient if appropriate.

Video is useful for

Anxious patients

ComorbiditiesHard of hearing

Scan medical record for risk factors such as:

Diabetes Pregnancy Smoking

Chronic kidney or liver disease COPD

Steroids or other immunosuppressants

Cardiovascular disease Asthma

6. Consider comorbidities that place patient at risk of more severe disease and need closer monitoring

Diabetes Immunocompromised Respiratory conditions

Cardiac conditions (including hypertension) Other chronic diseases

Red flags

COVID-19:Severe shortness of breath at rest

Difficulty breathing

Pain or pressure in chest

Cold, clammy or pale and mottled skin

New confusion

Becoming difficult to rouse

Blue lips or face

Little or no urine output

Coughing up blood

Other conditions such as:

Neck stiffness

Non-blanching rash

3. Get startedQuickly assess whether sick or less sick

Rapid assessment Establish what the patient wants out of the consultation, such as:

Clinical assessment Referral Certificate

Reassurance Advice on self isolation

If they sound or look very sick such as too breathless to talk, consider calling an ambulance and inform them of COVID risk.

2. ConnectMake video link if possible, otherwise call on the phone

Note patient’s phone number in case connection fails

If possible ensure the patient has privacy

Confirm the patient’s identity

Name

Date of Birth

Check video and audio

Can you hear/see

me?

Check where the patient is and who else is present

7. Decision and action

Unlikely COVID-19

• Self management, paracetamol for symptomatic relief

Likely COVID-19, unwell

• Test and arrange follow up depending on clinical picture

• Self management, paracetamol, encourage fluids

Likely COVID-19, but well

• Test and follow up results

• Self management, paracetamol, encourage fluids

Consider sending to hospital if:

• Respiratory Rate >20 breaths per minute

• Heart rate >100 with new confusion

• Oxygen saturation by oximeter <= 94%

• Any Red Flag symptom or sign

Version 1 correct as at 8 April 2020

© 2020 BMJ Publishing Group Ltd. Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions, or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user’s own risk. For the full disclaimer wording see BMJ’s terms and conditions: http://www.bmj.com/company/legal-information/

!

Read the fullarticle online https://bit.ly/BMJremcon

© 2020 BMJ Publishing Group Ltd.Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions, or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: http://www.bmj.com/company/legal-information/

http://www.bmj.com/infographicsSee more visualsummaries

69%

22%

22%

38%

34%

19%

15%

14%

14%

12%

5%

5%

4%

24%

Cough

Temperature37.5-38°C

Temperature>38°C

Fatigue

Sputum

Shortnessof breath

Muscle aches

Sore throat

Headache

Chills

Nasalcongestion

Nausea or vomiting

Diarrhoea

Anycomorbidity

This graphic, intended for use in a primary care setting, is based on data available in March 2020, much of which is from hospital settings in China. It will be revised as more relevant data emerges.

Covid-19: remote consultationsVisual summaryA quick guide to assessing patients by video or voice call

Version 1.325 Mar 2020

1 Set up

2 Connect

3 Get started

4 History

5 Examination

6 Decision and action

Prepare yourself and decide how to connect

Make video link if possible, otherwise call on the phone

Quickly assess whether sick or less sick

Adapt questions to patient’s own medical history

Assess physical and mental function as best as you can

Video is useful forHave current ‘stay at home’ covid-19 guidance on hand

Over phone, ask carer or patient to describe:

Check respiratory function - inability to talk in full sentences is common in severe illness

Over video, look for:

Check video and audio

Contacts Most common presentation

History of current illness

Rapid assessment Establish what the patient wants out of the consultation, such as:

Confirm the patient’s identity

Scan medical record for risk factors such as:

Clinical characteristics

Red flags

Diabetes Pregnancy SmokingChronic kidney or liver disease COPDSteroids or other immunosuppressantsCardiovascular disease

UK government advice:

Asthma

Can you hear/see

me?NameDate of birth

Check where patient is

Note patient’s phone number in case connection fails

If possible, ensure the patient has privacy

Clinical assessmentReassurance

CertificateReferralAdvice on self isolation

Based on 1099 hospitalised patients in Wuhan, China

Severe shortness of breath at rest

Difficulty breathing

Cold, clammy, or pale and mottled skin

Becoming difficult to rouse

New confusion

Blue lips or faceLittle or no urine output

Coughing up blood

Pain or pressure in the chest

Covid-19:

Neck stiffnessNon-blanching rash

Other conditions, such as:

http://bit.ly/ukgovisol

If they sound or look very sick, such as too breathless to talk, go direct to key clinical questions

Patient may be able to take their own measurements if they have instruments at home

Interpret self monitoring results with caution and in the context

of your wider assessmentPeak flow

Temperature Pulse

Blood pressure

Oxygen saturation

Severe illnessAnxious patientsComorbiditiesHard of hearing

Whereare you

right now?

Close contact with known covid-19 case

Immediate family member unwell

Occupationalrisk group

Date of first symptoms

Fever Short of breathFatigue

State of breathingColour of faceand lips

Generaldemeanour

Skin colour

Is it worsetoday thanyesterday?

What does your breathlessnessprevent you doing?

Cough

Cough is usually dry but sputum is not uncommon

Up to 50% of patients do not have fever at presentation

How is your

breathing?

Likely covid-19 but well, with mild

symptoms

Relevantcomorbidities

Likely covid-19, unwell, deteriorating

Unwell and needsadmission

Ambulanceprotocol

(999)

Proactive, whole

patient care

Arrange follow up by video. Monitor closely if you suspect pneumonia

Self management: fluids, paracetamol

Clinical concern, such as:

Which pneumonia patients to send to hospital?

• Temperature > 38°C• Respiratory rate > 20*• Heart rate > 100†

with new confusion• Oxygen saturation

≤ 94%‡

Advise and arrange follow-up, taking account of local capacity

Reduce spread of virus - follow current government ‘stay at home’ advice

Safety netting

If living alone, someone to check on them

Maintain fluid intake - 6 to 8 glasses per day

Seek immediate medical help for red flag symptoms

* Breaths per minute † Beats per minute ‡ If oximetry available for self monitoring

5. ExaminationAssess physical and mental function as best as you can

During the consultation ask patient or carer to describe:

State of breathing

What does your breathlessness prevent you doing?

Colour of face and lips (text a photo if possible)

During the consultation look for:

General demeanour

Skin colour

Work of breathing

Self Isolate. Enable self care at home and if living alone get someone to check on them. e.g. family. Consider medical review at days 5 and 8.