Ongoing Assessment

Ongoing Assessment

Establish what day this is in the course of the patient's COVID-19 illness and continue the clinical review cycle until at least day 10. The counting of the days starts from the day of diagnosis which is day 0. Day 0 is the first day of symptoms, or day when positive covid test was done, whichever comes first.

For vaccinated cases, the isolation time is 10 days, provided the previous 72 hours were symptom free.

Unvaccinated cases, the isolation time is 14 days provided the previous 72 hours were symptom free.

The handover from public health will include day 0 date for each case.

Clinical review cycle

• At COVID-19 Care 1, patients self-monitor symptoms daily and receive alternate day (or as clinically indicated) remote clinical assessment from an appropriate practitioner. This can be a nurse, NP or GP (if this is provided by a nurse, then NP or GP support must be available if required). • At COVID-19 Care 2:

• higher risk patients are reviewed by a suitable clinician daily (including weekends), with additional checks as clinically indicated. Patients should have access to a pulse oximeter if they have personal risk factors for

COVID-19 Care 2.

• lower-risk patients self-monitor symptoms daily and may receive lower frequency of clinical assessment, but the household is contacted frequently.

Review symptoms and perform remote examination

Monitor trends over time and take account of the full clinical picture. The symptom complexity and changes in features over time may be more significant than isolated responses.

• Assess breathing and general symptoms. See Daily Checklist. • Include video observations, if available.

• To minimise exposure, only perform an in-person examination if it will change clinical management or when you are not confident that remote assessment is adequate. • Consider important acute complications of COVID-19. • Ask about mood and mental wellbeing. • Consider whether symptoms are due to a different new diagnosis or a preexisting condition.

Triggers for moving from COVID-19 Care 1 to 2

• Escalate care if the patient develops features indicating moderate severity: • worsening pattern of general symptoms. • mild symptoms with one or more of: • constant fatigue • worsening headaches • worsening cough • becoming short of breath with effort • constant aches

• diarrhoea (frequent loose bowel motions) • chills, fever

• abdominal pain • vomiting • rashes, swelling, or blistering of toes • Fever greater than 38°C • Rising heart rate from normal baseline • Arrange delivery of a pulse oximeter with instructions to the patient or caregiver on how to use. Reassess the patient when the pulse oximeter is available later in the day, if possible. An SpO2 above 93% would be consistent with moderate severity.

Important acute complications of COVID-19

Besides pneumonitis, patients with COVID-19 have increased incidence of other complications:

More common complications

• Delirium in older patients • Anorexia • Orthostasis/dysautonomia • Gastrointestinal upset

Less common complications

• Venous thromboembolism (VTE) • Cardiac complications, e.g. myocarditis, acute coronary syndrome, heart failure • Acute kidney injury See BMJ Best Practice – Coronavirus Disease 2019 (COVID-19) Complications.

Investigations

Do not routinely perform blood tests or chest X-ray on community patients for COVID-19 as the benefits of obtaining this information are generally not significant enough to warrant the risk of increased COVID- 19 exposure in the community.

Consider deferring any non-urgent or routine checks until the self isolation period has been completed.

If blood tests or chest X-ray are deemed essential for management, hospital admission is likely to be appropriate.

• If unsure, seek COVID-19 advice. If other investigations are required (e.g. relating to other illness or injury), seek COVID-19 advice about appropriate investigation and venue.

Management of co-morbid conditions

Review status of co-morbidities and medication compliance. Ensure the patient has their usual medications and advise about non-contact delivery from pharmacy.

• Encourage good hydration and consider stopping or dose reduction of medications for example, Empagliflozin, angiotensin-converting enzyme inhibitors

(ACE inhibitors) or angiotensin-II receptor antagonists to prevent acute kidney injury if at risk of dehydration. • Plan sick day management in patients with diabetes, including those on insulin. Consider whether the household is known to the community nursing or other community healthcare team and advise them of the patient's COVID-19 positive status.