Covid-19 BOP Community Care Clinician Guide_V2_171221

A guide for primary care clinical management of COVID-19 in the community For Bay of Plenty General Practice Providers

Version Two

1

A guide for primary care clinical management of COVID19 in the Community

Contents Summary of Changes...................................................................................................................................................... 3 Contact Numbers ............................................................................................................................................................ 5 The BOP COVID-19 Community Case Management in Adults Model ....................................................................... 7 Process for COVID-19 patient care in the community ................................................................................................ 8 Positive Test Result and Public Health Role............................................................................................................. 8 Community Management – Covid Primary Response Team (CPRT) ..................................................................... 8 Community Management - Practice Role ................................................................................................................ 8 Discharge from Hospital Care ................................................................................................................................... 9 Release from Community Monitoring .................................................................................................................... 10 Household Close Contacts ....................................................................................................................................... 11 Providing Prescriptions to Patients Isolating – No Cost Access ............................................................................... 12 Clinical Assessment and Risk Stratification ................................................................................................................ 13 Initial Assessment (part 1) Checklist for ongoing care ......................................................................................... 14 Initial Assessment (part 2) Assess Current Clinical Status ................................................................................... 15 Initial Assessment (part 3) Establish Disease Severity.......................................................................................... 16 Initial Assessment (part 4) Risk Assessment – COVID-19 Patients ...................................................................... 17 Assess Clinical Risk ................................................................................................................................................... 18 Care Framework for Pregnant Women .................................................................................................................. 19 Ordering and Delivery of Pulse Oximeters ................................................................................................................ 19 Clinical Features ............................................................................................................................................................ 20 Ongoing Assessment .................................................................................................................................................... 22 Covid-19 Treatments ................................................................................................................................................ 25 Daily Symptom Checklist (for duration of care) .................................................................................................... 27 Referring to Hospital Care ............................................................................................................................................ 28 Appendix 1: Guide to Models of Care.................................................................................................................................... 31 Appendix 2: Release letter ...................................................................................................................................................... 32 Appendix 3: Checklist for release from primary care .......................................................................................................... 33 Appendix 4: Ministry of Health Care Framework for Pregnant Women and people isolating in the community for COVID-19 – depending on gestation and clinical risk stratification ..................................................................................... 34

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Summary of Changes Version 2

Section & Page Number Contact Numbers

Pg. 5

2

10

2

Release from community monitoring Appendix 2 and 3

2

Household close contacts

11

2

15 16

New Severity Assessment matrix

17

New Risk Assessment matrix

13

Added Covid-19 illness timeline

2

Clinical Assessment and Risk Stratification Clinical Assessment and Risk Stratification Clinical Assessment and Risk Stratification Clinical Assessment and Risk Stratification Clinical Features

Summary of Changes Updated contact details for Toi Te Ora and added Community Co-ordination hub contact details Updates to guidelines for isolation period and release Added new Appendices for TTO Release letter template and release checklist New subsection with updated isolation information New Clinical Status Checklist

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2

Assess Clinical Risk

19

2

Assess Clinical risk

19

2

Care Framework for pregnant women

19

2

Ongoing Assessment

22

2 2

Ongoing Assessment Covid 19 Treatments

24 25

2

Referring to hospital care

28

2

Prescription

12

2

Contact Numbers

5

2

Appendix 4

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Added Clinical features information and Covid symptom timeline diagram Guidance for pulse oximeter use in people with darker skin All cases in pregnancy or postpartum period to be discussed with obstetrician and midwife informed Added Ministry of Health Care Framework for Pregnant Women and people isolating in the community for COVID-19 – depending on gestation and clinical risk stratification Added information about self- monitoring and what to do if condition deteriorates Added information about symptom relief Added new information about Budesonide treatment Updated Triggers for moving patient to hospital or palliative care Added process for sending Prescriptions to Isolating Patients for No-Cost Added information about the BOPDHB Virtual Ward Round Ministry of Health Care Framework for Pregnant Women and people isolating in the community for COVID-19 – depending on gestation and clinical risk stratification

2 2 2

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Overview This guidance document provides an overview of the primary care led clinical model for patients with COVID-19 in the Bay of Plenty. This is a compilation of both national and regional guidance that has been localised for the Bay of Plenty. It will be continuously updated as information develops.

This

guide

is

available

for

download

on

the

PHO

Covid

Portal

Page:

http://portal.wboppho.org.nz/covid-19/ Content for this guidance document has largely been drawn from the COVID-19 Case Management in Adults pathway provided on the Midland Health Pathways portal. This pathway can be accessed here: https://midland.communityhealthpathways.org/728651.htm Username: midlanduser Password: midlandpassword The community

care, welfare,

mental

health

and

disability

support

needs of

the

household/whānau are organised alongside the COVID-19 Primary Care Clinical Model. This is managed through the DHB Community Co-ordination hub.

This COVID-19 Case Management in Adults pathway is the current version that general practice teams in the Auckland region are using to manage COVID-19 patients in the community.

Clinical expertise and capacity in the primary care sector is utilised to keep people well in their homes (where appropriate to do so) and reduce demand on secondary care resources (e.g., hospitals). The model focuses on reserving specialist resources in primary and secondary care to manage complex conditions and cases.

The Ministry of Health is leading the ongoing development of this pathway. Work to date has been informed by overseas models such as the RPA Virtual Hospital in NSW Australia and Ontario Canada, and local models (NRHCC, CDHB, SDHB) across New Zealand.

The BOP DHB continues to work with the Ministry of Health on the supporting resources, timing, and processes required to adapt this pathway for our region’s local needs.

Consequently, it is expected this guidance document will either be shortly replaced by a national Ministry of Health guide, or continuously updated as more information comes to light.

Key websites to refer to for updates are: Midland Community Healthpathways: https://midland.communityhealthpathways.org/728651.htm Ministry of Health: https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19information-health-professionals/covid-19-primary-care

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Contact Numbers These numbers are for clinical teams only, not to be shared with patients.

Public Health – Toi Te Ora Clinical questions Non urgent: ttoimtclinicalcaseadvisor@bopdhb.govt.nz (8am - 5pm, 7 days a week) Urgent: On call COVID-19 Clinical Case Advisor: 027 336 9159 (8am – 5pm, 7 days a week).

After Hours: On call Health Protection Officer: 0800 221 555 Medical Officer of Health via Tauranga Hospital switchboard

For referrals and updates on release of people, numbers of releases etc.: TTOCRG.CCAAdmin@bopdhb.govt.nz

Toi Te Ora Welfare/Community SIQ team:

027 304 9423 or TTOIMTCommunityWelfare@bopdhb.govt.nz

PHO Covid Primary Response Team (CPRT) (For support on the clinical management of patients in the community) Email: cprt@healthbop.org.nz Phone: (07) 577 3234

Community Co-ordination Hub (for all welfare and social needs support) Email: welfare.referral@bopdhb.govt.nz Phone: 0800 798729 Note: These contact details can be shared with patients, who can contact the service directly 5

EBOP Covid Welfare Team 8am, 8pm - 7 days.

EBOPcovid@bopdhb.govt.nz Mon – Friday: 0800 633 277 EBOP CPRT - Clinical Referrals ebop.cprt@ebpha.org.nz Mon – Thurs: 021893860 (Shared Number) Weekend: Sat: 02102189119 Sun: 021 748 300

Specialist Clinical Advice or Secondary Care Referral For urgent advice contact the on call medical SMO via switchboard WBOP 07 579 8044 For non-urgent virtual advice contact the same service: on call medical SMO via switchboard WBOP 07 579 8044

BOP DHB COVID-19 Virtual Ward Round The purpose is to provide a method of discussing non-urgent exacerbations of intercurrent medical conditions due to COVID-19 infection.

Starting on Friday 17th December, GPs will be able to speak to Dr Kirsten Ramsay, respiratory physician, during dedicated sessions on Mondays, Wednesdays, and Fridays between 1pm and 2pm. Examples of conditions that may need discussion include exacerbations of heart failure or uncontrolled diabetes mellitus due to COVID-19.

To make use of the Virtual Ward Round during these hours, please telephone the DHB switchboard via 07 579 8044 and ask to speak to Dr Ramsay directly.

If your patient requires admission or urgent discussion outside of these hours, please use the usual process of speaking to the APU consultant on-call and using the acute admission electronic referral form via Best Practice.

National Telehealth Service for health professionals on 0800-177-622 Monday to Saturday 8 am to 7 pm.

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The BOP COVID-19 Community Case Management in Adults Model Pathlab notifies both Toi Te Ora AND the patient’s GP of a positive case Toi Te Ora:

-

Not safe to isolate at home

- Notifies Patient they are positive - Safety Assessment and Contract Tracing Identify where patient and household contacts will self-isolate

MIQ

Safe to isolate at home Refer to Covid Primary Response Team (CPRT)

Refer to Community Co-ordination Hub

to co-ordinate clinical response

to co-ordinate welfare care

In EBOP the clinical and welfare response will be coordinated by EBOP Community Hub

General Practice undertakes Initial Virtual Assessment.

10-14 days isolation, provided the previous 72 hours are symptom free

Identified as Level 1 (Asymptomatic / Mild), Level 2 (Moderate Symptoms / At risk of complications)

Level 1: regular virtual health check

Refer to hospital if High Risk Patient sent information pack and pulse oximeter and/or welfare supports if applicable.

Level 2: Regular more frequent virtual health check, supported by multi-disciplinary team.

Discharge and Follow Up 7

Process for COVID-19 patient care in the community The current process is for people with COVID-19 to be cared for in a Community Isolation and Quarantine (CIQ) facility, or in the community (either at home or a temporary accommodation) under Community-supported Isolation and Quarantine (C-SIQ).

Positive Test Result and Public Health Role •

When a person tests positive for SARS-CoV-2, the lab notifies Public Health and the patient’s GP.

•

Public Health then: •

contacts the patient to inform patient of positive result, assess their public health risk, initiate contact tracing and decides if the patient can isolate at home under C-SIQ or needs to go to an CIQ facility.

•

assesses household contacts (whether it is safe for the case to remain when close contacts will likely become infected).

•

assesses welfare needs, environmental and social circumstances.

•

refers the patient to the Covid Primary Response Team (CPRT) to coordinate their clinical review if they are remaining in the community.

•

refers the patient to the Community Co-ordination Hub to manage any ongoing welfare needs.

Community Management – Covid Primary Response Team (CPRT) •

The CPRT will contact the practice where the patient is enrolled, or identify a service who can deliver care to a patient that is not enrolled locally, to initiate the virtual clinical assessment process

•

Ideally, patients will be cared for by their usual primary care practitioner. Where this is not possible an alternative provider will be identified for their covid related care.

Where there are multiple patients isolating at the same address a single provider will be identified, where possible, to ensure continuity of care to the household.

•

Following virtual assessment, the practice will send an email to the CPRT confirming the Provider delivering care, the Level of Care (1 or 2), and whether a pulse oximeter is required. Note, a practice can report Shared Care if they are running a daily Doctor on Duty model.

•

The CPRT will co-ordinate delivery of the pulse oximeter to the patient if required.

Community Management - Practice Role •

Following referral from the CPRT, the practice starts the process of clinical monitoring with arrangements to cover 7 days a week • For low-risk patients, a telehealth consultation is expected at least every 2 days.

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• For at risk patients, the primary care team is required to contact the patient every

day or more if required to ensure patient safety and connect with other members of the care team regarding any new or changing needs identified.

•

Ideally the initial assessment should be undertaken by an NP or GP, ongoing assessment can be delegated to the nursing team with NP/GP oversight as required.

•

Clinical care and assessment tools, based on Midland HealthPathways are provided in this document.

•

Inform the CPRT team via email confirming the Provider delivering care (this could be a shared care model), the Level of Care (1 or 2), and whether a pulse oximeter is required.

•

Patients identified over the weekend will be managed by an alternate provider until formal handover can be made.

•

If your patient is also under the care of other services, e.g., Hospice, District nursing please can you let these teams know, where possible.

•

If a COVID-19 positive patient contacts you before being contacted by Public Health, take interim measures.

Advise the patient: • of their positive test result.

• that they are now required to isolate at home.

• that all their household members should get an immediate COVID-19 test and stay home. Household members can leave isolation to get tested.

As long as there is no immediate need for COVID-19 care, advise the patient that Public Health will contact them about what will happen next and what they need to do.

•

If you identify unmet social or welfare needs, contact the Community Co-ordination Hub.

•

For non-urgent virtual advice contact the on call medical SMO via switchboard WBOP 07 579 8044

Discharge from Hospital Care 1. Following hospitalisation with COVID-19 a patient may be discharged back into community self-isolation to complete their recovery. The hospital will inform Public Health and the CPRT at discharge. The CPRT will liaise with the relevant general practice to ensure ongoing care in the community.

2. These patients are automatically COVID-19 Care 2 for the remainder of their review period. The referring clinician will advise where the patient is in their illness. ToC is done at discharge, the patient will have a copy and the GP will be sent this electronically. Patient’s will also be provided with information packs for community care at point of discharge.

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Release from Community Monitoring TTO Guidelines: Managing cases and household close contacts in primary care Version 03, 2 December 2021

Given the rapidly moving nature of COVID-19 and public health response, this document will change and be updated as necessary.

Toi Te Ora contacts: Non urgent: ttoimtclinicalcaseadvisor@bopdhb.govt.nz (8am - 5pm, 7 days a week) Urgent: On call COVID-19 Clinical Case Advisor: 027 336 9159 (8am – 5pm, 7 days a week).

After Hours: On call Health Protection Officer: 0800 221 555 Medical Officer of Health: via Tauranga Hospital switchboard

Covid-19 Cases Cases are referred from Toi Te Ora via referral form to PHO Single Point of Contact. Every referral includes household contacts (statistically about half of all household contacts become cases).

Isolation time period: Fully vaccinated* cases: 10 days isolation (and symptom free for 72 hours before release) Unvaccinated cases: 14 days (and symptom free for 72 hours before release) Day 0 is the first day of symptoms. If the case has been completely asymptomatic, Day 0 is the day of the swab. The clinical referral from Toi Te Ora includes the day 0 date.

Testing: Once a person returns a positive swab result there is no point in having a further swab as the individual is likely to remain PCR positive for up to several months

Release: Occurs the day after the isolation period to ensure completion of isolation.

Primary care releases case (letter template available see Appendix 2).

Email Covid Primary Response Team: cprt@healthbop.org.nz with completed release checklist (Appendix 3) CPRT will inform TTO so that they can update national records.

Note: Both the letter template and release checklist are available to download from the PHO Covid portal page http://portal.wboppho.org.nz/covid-19/

Please contact Toi Te Ora if: Case is going to hospital or for palliative care Any public health concerns, i.e., compliance, questions about isolation/testing.

Case remembers a new location of interest they attended, especially if high risk, e.g., marae, hospital, prison, aged care facility. *Fully vaccinated: 7 days since second COVID-19 vaccination

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Household Close Contacts These are people that live with the case and have ongoing exposure with the case. Primary care is responsible for following up household close contacts.

If household contacts can isolate completely away from case (i.e., in a room with separate bathroom, separate building, or caravan), their follow up will be by a public health provider (e.g., Healthline) who will do daily follow up and release phone calls.

Isolation and testing requirements are outlined in document POL-002 (available via the PHO Covid portal page http://portal.wboppho.org.nz/covid-19/ ), i.e., isolate for 10 days following the last exposure to the case, and test immediately, on days 5 and 8 post exposure.

The only acceptable reasons for a contact to leave their place of isolation are • to get one of the required follow-up swabs, or • to access urgently needed health care.

A contact cannot attend a vaccination clinic during their period of isolation.

Isolation time period: Close contacts isolate during the case’s isolation PLUS for 10 days after the case is recovered and released from isolation.

Testing of Household members: Test immediately when case is identified and on case’s day 5 Test on days 5 and 8 after case released If symptoms develop at any time, get an additional test immediately

Release: Occurs the day after the 10 days of isolation that started when the case left isolation, provided no new or worsening symptoms AND negative day 8 test Note that a day 7 test is not acceptable for release, it must be day 8 or later.

Primary care releases contacts.

If there are new cases in the household: If a household contact becomes a case, Toi Te Ora will investigate the new case and send a referral for the new case to the PHO Single Point of Contact. The entire management plan is then repeated for the household contacts, i.e., everyone must isolate for another 10 days and require additional swabs (immediate, days 5 and 8). In other words, the ten-day isolation clock for household contacts is reset to zero.

Primary care continues to follow up contacts and to ensure swabs are taken on the required days.

Q&As Who takes the clinical lead if an isolating case/contact moves out of their DHB region and away from their usual GP due to accommodation issues?

Currently the referral goes to the PHO/GP where the case/contact usually lives. The PHO decides if this is appropriate as they have best clinical knowledge and rapport with the case/contacts. If the PHO recommends follow up by the PHO of new location, Toi Te Ora can help facilitate this.

Who takes the lead for an elderly close contact isolating at home with welfare and medical needs?

If the contact is isolating with a case, they are included with the case for follow up.

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If the contact is isolating alone, they will be followed up by a public health provider, e.g., Healthline, with daily phone calls. If welfare and medical needs are identified, the provider notifies Toi Te Ora and Toi Te Ora refers as required.

If clinical concerns, Toi Te Ora will refer for PHO/GP assessment. The public health provider or Toi Te Ora will continue to follow up (i.e., isolation, testing and release information) unless the PHO/GP advises or is requested to do daily follow up for clinical reasons. This will be referred as required.

When a household contact leaves the house, what should the GP do?

Advise Toi Te Ora via email (ttoimtclinicalcaseadvisor@bopdhb.govt.nz) so that follow up can be organised (either by Healthline, Toi Te Ora, or another public health provider).

What do I do if I can’t contact a Patient for their daily check?

Contact the Community Co-ordination Hub (WBOP) Phone: 0800 798729 or EBOP Co-ordination Hub Phone: 027 257 9108 They will continue to try and contact the patient including home visiting if needed.

What do I do if I have concerns a patient and their close contacts are not following the isolation requirements?

Advise Toi Te Ora via email (ttoimtclinicalcaseadvisor@bopdhb.govt.nz) or 027 336 9159 (8am – 5pm, 7 days a week).

Providing Prescriptions to Patients Isolating – No Cost Access Please note there is an agreement in place between the Welfare Team and Chemist Warehouse Bethlehem.

GPs/NPs issuing prescriptions to covid-19 patients isolating at home can notate the script with the following text: ‘Covid patient isolating at home’ and use the code “H” (instead of A4) as a single occasion entry to remove the prescription co-payment for these patients.

If there is not an option to amend the A4 code (e.g. e-script) then practice can add the text information and add H Code into the ‘Comments/Notes’ section to let the pharmacy know. They are aware of the scenario.

This will address some access barriers and ensure continues medication adherence.

The script can cover medications the patient has been regularly prescribed and additional medication specific to managing symptoms of Covid-19.

Please email DHB Welfare Team: Welfare.Referral@bopdhb.govt.nz to let them know you require a script collected and delivered. The pharmacy can call the DHB Welfare Team on 0800 798 729 once collection is available.

Long Term Management of Covid-19 Patients Long term Management Following Covid Infection Long term care following Covid-19 infection is not covered within this guide. It is recommended that any patient who required hospital admission has a telephone or in-person follow-up within 6 weeks of discharge for patients to assess trajectory of recovery.

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Clinical Assessment and Risk Stratification This pathway is about remote clinical assessment of patients with COVID-19 aged 15 years or older who are isolating in the community, where the primary care team has accepted handover of clinical care via Public Health and the Covid Primary Response Team (CPRT).

Welfare needs will be addressed by the Covid Co-ordination Hub. 1. Establish Covid-19 illness timeline 2. Assess current clinical status (Part 1 and 2) 3. Assess Clinical Risk / disease severity 4. For severe cases arrange acute COVID-19 assessment if escalation to hospital care is required, including assessment for any non-COVID condition. Consider in person assessment1 when escalating to hospital care. (See red flags below and triggers for moving patients to hospital or palliative care.)

5. Assess whether non COVID-19 health care and social supports have been addressed.

This is managed by the Covid Community Co-ordination Hub 6. Liaise with public health and secondary care as needed

Red flags for ED Assessment • • • • • • • • • •

HR >110, SPO2 consistently ≤ 92%, RR >24 Severe shortness of breath at rest (e.g. Breathlessness RR >30 despite normal O2 sats) Difficulty in breathing (work of breathing) Reducing O2 saturation (<92% or down 3%) Pain or pressure in chest Decreased oral intake or urine output (dehydrated, needing IV fluids) Cold, clammy or pale mottled skin New onset of confusion, becoming difficult to rouse, syncope Blue lips or face Coughing up blood

COVID-19 illness timeline • • •

Date of positive swab result Date the patient first became unwell Day of illness the patient is at now. If they are: • symptomatic, day 0 is date of initial symptoms.

• asymptomatic, day 0 is date of test

In-person assessments. Based on overseas experience, in-person assessment is not usually required to decide management and is only indicated: if it will change management, or when the treating clinician is not confident, they can adequately assess the patient remotely. Consider in-person assessment when escalating to hospital care.

1

The key elements of an in-person assessment are: 1. taking the history by phone to limit contact, 2. preparing for in-person examination, using: space for examination with good airflow; full personal protective equipment (PPE) and infection prevention and control (IPC) measures; key equipment – pulse oximeter, a thermometer, blood pressure (BP) cuff, and stethoscope.

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Initial Assessment (part 1) Checklist for ongoing care

Checklist for Ongoing COVID-19 Care Planning Confirm the following:

Telehealth access and preferences, including: the best contact number and secondary contact number the patient's preferred method of telehealth (Doxy.me, telephone call). If data access is limited, phone the patient.

Language preference. Arrange an interpreter if necessary.

Patient's home address and where they are currently (e.g. in managed isolation, at a relative's address), if it is not at home.

Who is caring for the patient while they are unwell, consent to contact them, and that person's best contact number.

Next of kin is recorded in the patient management system (PMS).

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Initial Assessment (part 2) Assess Current Clinical Status

Clinical Status Checklist – COVID-19 Patients Date of assessment:

Day of illness: Ask

Describe main symptoms: Are you feeling:

□ better

□ same

□ worse If worse,

details: Is there anything you can’t do today that you could do yesterday? If yes, details: Record (if able) Respiratory rate:

O2 saturation:

Heart rate:

Temperature: Appears confused or drowsy:

□ yes

□ no

Respiratory assessment Is your breathing: If worse:

• •

□ better

□ same

□ worse

Ask what makes them breathless today that didn’t yesterday Assess for signs of respiratory compromise: • Severe fatigue or lethargy • Talking with single words or short sentences • Pausing between sentences to catch their breath • Respiratory rate greater than 24 breaths per minute

If O2 saturation normal but any of the above features present, obtain O 2 saturation reading post exercise.

Note: formal exertional desaturation tests not evaluated for safety in COVID-19 and should not be performed routinely. Asking the patient to walk around the room may suffice.

Other symptoms Diarrhoea, nausea, or vomiting:

If yes, details:

□ yes

□ no

Faints or falls:

If yes, details:

□ yes

□ no

Any other medical concerns:

If yes, details:

□ yes

□ no

Hydration status:

Reduced oral intake and minimal urine output in 12 hours:

□ yes

□ no

Mood and mental wellbeing: Other COVID-19 symptoms: Other (describe):

□ headache

□ sore throat

□ muscle aches

□ loss of taste and smell

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Initial Assessment (part 3) Establish Disease Severity

Severity Assessment – COVID-19 Patients Mild

Moderate

Severe

Symptoms •

Feeling tired

Mild symptoms plus one or more of:

•

Headache

•

Constant fatigue

•

Cough

•

Worsening headaches

•

Sore throat

•

•

Muscle aches

•

Intensifying symptoms or any of: •

Difficulty breathing at rest, talking in short sentences or single words

Worsening cough

•

Chest pain or pressure

•

Becoming short of breath with effort

•

Coughing up blood

Runny nose

•

Constant aches

•

Confusion, altered mental state or becoming difficult to rouse

•

Nausea

•

Diarrhoea (frequent loose bowel motions)

•

Cold, clammy, mottled, or pale skin

•

Loose bowel motion

•

Chills, fever

•

Worsening fatigue, profound exhaustion, fainting, falls

•

Loss of taste or smell

•

Abdominal pain

•

•

Vomiting

Dehydration (reduced oral intake and minimal urinary output in 12 hours)

•

Rashes, swelling or blistering of toes

•

Rapid deterioration of any sign or symptom

•

Dropping oxygen saturations by 3% from baseline, or SpO2 < 92%, or blue lips or face

•

Fever > 40 degrees

•

Respiratory rate > 24, unexplained heart rate > 100

Signs Mild fever < 38 degrees

•

SpO2 > 93%

•

Fever of 38-39.9 degrees

•

Rising heart rate from normal baseline

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Initial Assessment (part 4) Risk Assessment – COVID-19 Patients

Risk Assessment – COVID-19 Patients At risk = Any positive factors listed below Low risk = Absence of any of the factors listed below COVID-19 vaccination status

Unvaccinated, or second vaccination received less than 2 weeks before testing positive

Risk of complications

Pasifika > 39 years, Māori > 44 years, other ethnicities > 65 years Medical history: •

pregnant, or within six weeks or giving birth

•

immunocompromised

•

active malignancy

•

CVD: hypertension or ischemic heart disease

•

diabetes

•

chronic kidney disease

•

chronic obstructive pulmonary disease (COPD) or asthma

•

stroke (CVA)

•

epilepsy

•

liver disease

•

mental health or addiction

•

frailty

•

smoker (tobacco or cannabis)

•

BMI > 30

•

CPAP use for sleep apnoea

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Complex or dynamic circumstances

•

social isolation

•

geographical isolation (rural)

•

lack of transport

•

unreliable phone or internet connection

•

housing insecurity

•

housing crowded or damp and cold

•

requires carer support

•

absence of a suitable caregiver

•

disability support required

•

family harm notifications

•

health literacy support required

•

requires an interpreter

Assess Clinical Risk The clinical risk profile of an individual is determined by their individual clinical risk and the most vulnerable/at-risk member of their household. Check whether any household members have risk of complications.

COVID-19 Care 1 Case has mild symptoms and low risk of complications: •

Telehealth clinician contact every other day

•

Daily self-monitoring of symptoms, more frequent if there are emergent concerns

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) COVID-19 Care 2 Most patients in COVID-19 Care 2 have risk factors putting them at higher clinical risk of deterioration and requiring daily monitoring.

Ask the patient to self-monitor (including pulse oximetry if required) and record observations at least twice daily.

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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.

A patient with a clinically lower risk may be stratified to COVID-19 Care 2 due to having a high-risk household member. Stratification to COVID-19 Care 2 indicates clinical risk of deterioration if the household member becomes COVID-19 positive and therefore a need for awareness of the household.

Pulse Oximeter Patient Instructions will be supplied with the pulse oximeter to the patient. Advise that deteriorating respiratory function should be notified irrespective of the pulse oximeter reading, especially in those with darker skin. https://www.healthnavigator.org.nz/health-a-z/p/pulse-oximeter-adult/

Care Framework for Pregnant Women If the patient is pregnant, seek obstetric advice to discuss multidisciplinary management plan and inform the patient's midwife. See Appendix 4: Care Framework for pregnant women and people isolating in the community for COVID-19 – depending on gestation and clinical risk stratification.

Ordering and Delivery of Pulse Oximeters Email or phone the Covid Primary Response Team cprt@healthbop.org.nz (07) 577 3234 with the pulse oximeter request, following the virtual assessment.

The CPRT will then submit the pulse oximeter request to the Community Co-ordination Hub team who will organise delivery. Please also request pick up of pulse oximeter at point of release via the CPRT team.

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Clinical Features About 85% of unvaccinated patients experience a mild illness with spontaneous recovery, while the remaining 15% experience more severe disease.

The clinical course is often prolonged (2 to 4 weeks) and patients at risk of deterioration need daily or more frequent assessment.

Clinical deterioration typically occurs between days 5 and 10 from symptom onset, and (rarely) can be followed by rapid progression to acute respiratory distress syndrome, requiring intensive support.

Māori have 2.5 times greater risk of hospitalisation (95% CI 1.39 – 4.51) than non-Māori, non-Pacific people. Pacific people have 3 times greater risk (95% CI 1.39 – 4.51).

2

Despite rapid improvements in care, about 1% of unvaccinated people with COVID19 die from the disease.

Vaccination reduces the risk of hospitalisation and death 10-fold.

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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.

21

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. See the Covid-19 illness timeline.

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.

Clinical review cycle •

Patients in COVID-19 Care 1 are reviewed by a suitable clinical practitioner on alternate days (including weekends) or as clinically appropriate, unless escalated to COVID-19 Care 2. 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.

Self-monitoring •

•

Advise the patient to: • record symptoms and observations 3 times a day.

• watch for worsening symptoms.

• only seek medical care outside the home on the advice of their medical care team. what to do if their condition deteriorates.

What to do if their condition deteriorates Advise the patient to call 111 if acute care is consistent with their wishes and they experience any of the following: •

Severe trouble breathing or severe chest pain 22

• • •

Confusion or not thinking clearly Feeling faint or passing out (losing consciousness) Haemoptysis

Advise the patient to inform the ambulance service that they are COVID-19 positive.

Reassure them they will still receive care.

If acute admission is not consistent with the patient's wishes, advise them to contact their clinical team.

Advise the patient to contact their clinical team if they experience any of the following: • • • •

New or worse trouble breathing Symptoms getting worse Start getting better and then get worse Symptoms of severe hydration, e.g.:

• • •

having a very dry mouth passing only a little urine feeling very light-headed

The likely time course of the illness.

How to seek help for unwell household members Advise to seek medical advice: • •

Between 8 am and 5 pm, contact the household member's usual general practice clinic.

After hours, contact the COVID-19 Healthline – phone 0800358545 or (09) 3585453.

Advise not to self-present to any medical clinic or emergency department.

If they need to call an ambulance, ensure they inform the ambulance service of COVID cases in the house. Assure them the service will still be provided if appropriate.

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.

23

•

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.

Symptom relief • •

Provide medications for symptomatic relief if required, e.g. paracetamol, antiemetic, antidiarrhoeal, electrolyte replacement.

Ask about allergies before providing any medications.

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 24

the day, if possible. An SpO2 above 93% would be consistent with moderate severity.

Covid-19 Treatments Budesonide Therapy Studies have shown inhaled budesonide (Pulmicort) has a modest benefit in reducing illness duration and need for admission.

If available, offer to patients who are within 14 days of onset of COVID-19 symptoms and are not taking other inhaled or systemic corticosteroids, and are either: • aged 65 years or older, or • any age with any of the following: • diabetes • heart disease and/or hypertension asthma or lung disease • immunocompromised • mild hepatic impairment • stroke or other neurological problem • obesity.

Dose: 800 microgram twice daily.

Duration of therapy: up to 14 days.

Due to world-wide demand, supply may become a problem. Only supply one inhaler per patient. Consider clinical review if further inhalers are requested.

Provide patient instructions on how to use a turbuhaler device (includes instructional video). https://www.healthnavigator.org.nz/medicines/b/budesonide-for-inhalation/ Do not start inhaled budesonide/formoterol (Symbicort) in place of budesonide (Pulmicort) for this indication. The unnecessary LABA is likely to induce unwanted side effects.

Patients already using an inhaled corticosteroid for a different indication (either alone or in combination with long acting beta agonist [LABA]) should continue to use their regular medication and not switch budesonide.

Ask about allergies before providing any medications.

25

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.

Community-based investigations are rarely required for COVID-19 positive patients. Seek specialist advice if considering.

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.

•

If taking angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensinII receptor antagonists, encourage good hydration and consider stopping or dose reduction 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.

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Daily Symptom Checklist (for duration of care)

Clinical Status Checklist – COVID-19 Patients Date of assessment:

Day of illness: Ask

Describe main symptoms: Are you feeling:

□ better

□ same

□ worse If worse,

details: Is there anything you can’t do today that you could do yesterday? If yes, details: Record (if able) Respiratory rate:

O2 saturation:

Heart rate:

Temperature: Appears confused or drowsy:

□ yes

□ no

Respiratory assessment Is your breathing: If worse:

• •

□ better

□ same

□ worse

Ask what makes them breathless today that didn’t yesterday Assess for signs of respiratory compromise: • Severe fatigue or lethargy • Talking with single words or short sentences • Pausing between sentences to catch their breath • Respiratory rate greater than 24 breaths per minute

If O2 saturation normal but any of the above features present, obtain O 2 saturation reading post exercise.

Note: formal exertional desaturation tests not evaluated for safety in COVID-19 and should not be performed routinely. Asking the patient to walk around the room may suffice.

Other symptoms Diarrhoea, nausea, or vomiting:

If yes, details:

□ yes

□ no

Faints or falls:

If yes, details:

□ yes

□ no

Any other medical concerns:

If yes, details:

□ yes

□ no

Hydration status:

Reduced oral intake and minimal urine output in 12 hours:

□ yes

□ no

Mood and mental wellbeing: Other COVID-19 symptoms: Other (describe):

□ headache

□ sore throat

□ muscle aches

□ loss of taste and smell

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Referring to Hospital Care Most confirmed COVID-19 cases will be mild and uncomplicated and can safely be managed via telehealth.

Deteriorating respiratory function is the primary indicator for hospital admission. Do not rely exclusively on pulse oximetry, especially in those with darker skin.

Triggers for moving patient to hospital or palliative care Escalate care if the patient develops: Respiratory compromise, indicated by any of the following: Talking with single words or short sentences Pausing between sentences to catch their breath Respiratory rate greater than 24 breaths per minute Profound exhaustion where pulse oximeter not available to exclude silent hypoxia Haemoptysis Change in oxygen saturation (SaO ): No baseline – SaO less than 92% Baseline greater than 94% 2

2

Baseline greater than 94% Any of: • SaO less than 92% • Drop of 3% or more from baseline • Drop of 3% from resting to after exercise • Exercise Note that the safety of formal exertional desaturation tests such as the 1 minute sit-to-stand test have not been evaluated for COVID-19 and should not be performed routinely. Asking the patient to walk around the room may suffice.

• Baseline 94% or less 2

Baseline 94% or less Any of: • SaO less than 88% • Drop of 3% from baseline • Drop of 3% from resting to after exercise 2

28

Features suggesting respiratory compromise are independent of SaO levels for seeking admission. SaO readings can be falsely high in darker skinned people.

2

2

Non-respiratory features: Rapid deterioration of any sign or symptom Falls in a frail person Fever greater than 40°C. New onset of confusion or drowsiness.

Unexplained heart rate greater than 100 beats per minute Dehydration – reduced oral intake and minimal urinary output in 12 hours.

Other factors indicating need for management in hospital.

Chest pain or breathing with concerning features Cold, clammy, mottled, or pale skin If escalation to hospital care is required call on call medical SMO via switchboard WBOP 07 579 8044 and submit ereferral as per usual referral but mark as Covid Positive.

Inform the patient that they are to wear a mask when arriving at the hospital.

Transport to hospital If ambulance transfer is required, then refer though the normal process. It is vital that the dispatch team is aware that the patient is covid positive Alternate transport – if the patient is clinically stable and able to be transported by a household member then this can occur, only if it is clinically safe to do so

Funding Information on funding and the claiming process has yet to be released. Please log all activity so you can claim for it when the funding model is issued.

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Further Information

•

Ministry of Health – Interim Guidance – Clinical Management of COVID-19 in Hospitalised Adults

•

Dee Mangin, Hamilton Family Medicine, Canada: •

Assessment, Monitoring and Management of COVID

•

COVID-19 Management of Mild to Moderate COVID in the Community: Learnings from Canada [video 55 minutes 58 seconds, hosted by Canterbury Primary Response Group (CPRG)]

•

COVID-19 Management of Mild to Moderate COVID in the Community: Learnings from Canada [slides]

•

General Practice Monitoring and Management of Mild to Moderate COVID19 Illness – Learnings from Canada [summary of unanswered/text Q&A from webinar]

•

Centre for Evidence-Based Medicine (CEBM) – Are There any Evidence-based Ways of Assessing Dyspnoea by Telephone or Video?

•

NZ Telehealth Forum & Resource Centre – Providers

•

World Health Organization – Home Care for Patients with COVID-19 Presenting with Mild Symptoms and Management of Their Contacts

•

BMJ – Remote Management of Covid-19 Using Home Pulse Oximetry and Virtual Ward Support

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Appendix 1: Guide to Models of Care Level 1 / Low:

Level 2 / Medium:

Asymptomatic or mild symptoms

Moderate symptoms / At risk of complications

Key Components

Key Components

• Self-monitor symptoms • Telehealth health check monitoring every other day • Referral for other health and social supports

• Self-monitor symptoms • Telehealth health check monitoring every other day • Referral for other health and social supports

Providers

Providers

• General practice, telehealth services, Māori and Pasifika

• Whānau at the center of a general practice virtual

clinical providers, community pharmacy

Workforce (may include) • Clinical workforce for monitoring and management: Nurses,

nurse practitioners, GPs, telehealth services clinical team, clinical support through Māori and Pasifika providers, community pharmacists, physiotherapists, counsellors • Non-clinical workforce for support: HIPS & Health Coaches, Māori and Pacific providers, translation services, community support workers, kaiāwhina, cultural support workers, service navigators Decision-making framework Triage and escalation pathway, testing and results for consults Training / Guidance COVID-19 Community HealthPathways, clinical webinars, 0800 COVID-19 Positive Line for cases, Clinician to Clinician helpline

multidisciplinary team providing shared care approach for daily virtual/telehealth monitoring and supportive management of COVID, co-morbidities and chronic care.

• Virtual team ‘hub model’ for the coordination of health services to be regionally determined across primary, community and secondary care Workforce (may include) • Clinical workforce for monitoring and managing care: GPs and

Urgent Care doctors, nurse practitioners, nurses, clinical support through Māori and Pasifika providers, community pharmacists, secondary care clinicians and nursing, telehealth services clinical team, paramedics, physiotherapists, counsellors • Non-clinical workforce for support: HIPS & Health Coaches, Māori and Pacific providers, and Pasifika providers, translation services, community support kaiāwhina, cultural support workers, service navigators Decision-making framework Triage and escalation pathway, testing and results for contacts Training / Guidance

IT Integration with shared care record between NCTS, public health, primary care (PMS), telehealth and secondary care providers Equipment Patient access to cell phone with data or landline (video capability if available), testing kits, PPE Escalation Via telehealth or 111 if symptoms deteriorate

COVID-19 Community HealthPathways, clinical webinars, 0800 COVID-19 Positive Line for cases, Clinician to Clinician helpline IT Integration with shared care record between NCTS, public health, primary care (PMS), telehealth and secondary care providers Equipment Pulse Oximeters, thermometers, cell phone with data or landline (video capability if available), testing kits, PPE, 02 (in exceptional circumstances Escalation Via telehealth or 111 if symptoms deteriorate

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Appendix 2: Release letter

Toi Te Ora Public Health PO Box 2120 TAURANGA 3140 Date

To Whom It May Concern

Reference: Case Clearance

RE: [Name] [name] has been identified by Public Health as having had a notifiable infectious disease as listed in the Health Act 1956.

They were placed in isolation to prevent spreading the illness to others. [name] has completed the required period of isolation and is now released by Public Health from isolation. They are now able to return to their usual activities.

Should you have any questions please feel free to call your GP or local health provider or Toi Te Ora Public Health on 0800 221 555 between 0800 - 1630hrs.

Yours faithfully, [Name]

On behalf of the Medical Officer of Health Toi Te Ora Public Health

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Appendix 3: Checklist for release from primary care

Checklist for release of COVID case from Primary care

1. NHI number: 2. Date: 3. Case has completed required isolation period: Y/N 4. Case has been symptom free for 72 hrs: Y/N 5. For cases who were asymptomatic at time of diagnosis, did the case develop any symptoms later? Y/N

If Yes, date of onset of symptoms: What where the symptoms? List all:

6. Was the case hospitalised? Y/N If yes, date of hospitalisation: Name of hospital: Date of discharge:

Please email to Covid Primary Response Team: cprt@healthbop.org.nz

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Appendix 4: Ministry of Health Care Framework for Pregnant Women and people isolating in the community for COVID-19 – depending on gestation and clinical risk stratification Care Framework for pregnant women and people isolating in the community for COVID-19 – depending on gestation and clinical risk stratification Gestation <28 weeks Low risk of complications from COVID-19

• • •

• •

<28 weeks Mod/High risk of complications from COVID-19

COVID-19 Designated Clinical Lead (may be GP, Nurse Practitioner or other provider)

LMC

• • •

•

•

Referral for consultation to Obstetrics Clinical responsibility for Maternity care remains with LMC / Midwife Continue to provide routine care by phone or video where appropriate, keeping in -person physical assessment <15 minutes if possible, where it cannot be reasonably or safely postponed In-person acute care continues Any concerns about worsening COVID 19 condition should be escalated to the COVID 19 clinical lead and the obstetric team - See Health Pathway COVID- 19 pregnancy pathway Referral to Obstetrics for clinical transfer of care for duration of illness Three-way discussion to negotiate LMC involvement in care including responsibility for in- person acute care Clinical responsibility for care is returned to the LMC when the woman/person has recovered from Covid-19 Routine visiting schedule is provided (if LMC remains involved in care) by phone or video where appropriate, keeping in -person physical assessment <15 minutes if possible, where it cannot be reasonably or safely postponed Any concerns about worsening COVID 19 condition should be escalated to the COVID 19 clinical lead and the obstetric team - See Health Pathway COVID-19 pregnancy pathway

• • •

• • • •

DHB Obstetric and Maternity Units

Manage COVID-19 care depending on woman’s clinical situation Escalate as clinically required- See Health Pathway COVID-19 pregnancy pathway Communicate any changes in management with LMC / Midwife.

•

Consultation with Obstetric Team is indicated, a case review will take place and a plan of on-going and follow up care will be made and communicated as part of the three-way consultation with the woman and the LMC, an in-person visit may not be required.

Manage COVID-19 care depending on woman’s clinical situation Escalate as clinically required Increased monitoring as clinically indicated – See Health Pathway COVID19 pregnancy pathway Communicate any significant changes in management with LMC / Midwife and the local maternity unit obstetric service.

•

Transfer of care to Obstetric Team is indicated, a case review will take place and a plan of on-going and follow up care will be made and communicated as part of the three-way consultation with the woman and the LMC, an in-person visit may not be required.

34

•

>28 weeks

• •

• •

• •

Intrapartum

•

•

Postpartum

• • •

Referral to Obstetrics for clinical transfer of care for duration of illness Three-way discussion to negotiate LMC involvement in care Clinical responsibility for care is returned to the LMC when the woman/person has recovered from Covid-19 Routine visiting schedule is provided (if LMC remains involved in care) Any concerns about worsening COVID 19 condition should be escalated to the COVID 19 clinical lead and the obstetric team - See Health Pathway COVID-19 pregnancy pathway Referral to Obstetrics for clinical transfer of care Three-way discussion to negotiate LMC involvement in care Escalate as clinically required- See Health Pathway COVID-19 pregnancy pathway

•

Clinical responsibility transferred to LMC on discharge from hospital Referral to Paediatrics if new infection in the postnatal period Routine visiting schedule is provided Any concerns about worsening COVID 19 condition should be escalated to the COVID 19 Clinical lead and the assigned clinical lead for COVID care (GP) and paediatric teams - See Health Pathway COVID-19 pregnancy pathway

•

• • •

Manage COVID-19 care depending on woman’s clinical situation Escalate as clinically required Increased monitoring as clinically required – See Health Pathway COVID19 pregnancy pathway Communicate any changes in management with LMC / Midwife and the local maternity unit obstetric service.

• •

• •

•

•

Manage COVID-19 care depending on situation Escalate as clinically required- See Health Pathway COVID-19 pregnancy pathway Communicate any changes in management with LMC /Midwife.

• •

Clinical responsibility for Maternity care to be transferred to Obstetric Team for duration of illness Three-way discussion to: o negotiate LMC involvement in care o plan follow up care for post infection depending on the woman’s clinical situation.

Clinical responsibility for Maternity care to be clinically transferred to Obstetric Team until discharge from hospital.

Three-way discussion to plan: o follow up care for post infection depending on the woman’s clinical situation.

Consultation with Obstetric and Neonatal Teams Three-way discussion to plan: o follow up care for post infection depending on the woman’s clinical situation.

Further information 1. This diagram is to be read alongside the Health Pathway for providing clinical care to COVID-19 confirmed pregnant women and people, to determine the pregnant woman or person’s risk stratification.

2. Three-way discussions: the groups involved in these conversations are expected to include the pregnant woman or person, the 3.

4.

5.

6.

Midwife/LMC and Obstetricians as per the Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines).

Robust processes will be needed that enables information sharing between Midwives, COVID Clinical leads, DHB Obstetric and Maternity Units and the COVID-19 hub.

DHBs COVID Care Coordination Hubs will need to establish processes that enables coordination and triaging of women’s/people’s care requirements.

If a clinical transfer of care to Obstetric Teams takes place, it is expected that the care will be returned to the LMC once clinically appropriate to do so.

LMCs will be paid for the care they provide. From 28 February 2022, if they are not involved in providing care, they will not be able to claim for that module of the Notice.

35