Covid mgmt in Primary Care_Part 2 161221

BOP Covid Management in Primary Care Part 2 16 December 2021

Whakataka te Hau

Karakia Timatanga (opening) Whakataka te hau ki te uru Whakataka te hau ki te tonga Kia mākinakina ki uta Kia mātaratara ki tai E hī ake ana te atakura He tio, he huka, he hau hū Tīhei mauri ora!

Cease the winds from the west Cease the winds from the south Let the breeze blow over the land Let the breeze blow over the ocean Let the red-tipped dawn come with a sharpened air A touch of frost, a promise of a glorious day

A little Zoom housekeeping For Questions please go to https://www.sli.do/ and enter code 595146. You can ask your question there.

OR you can use the Chat function.

Please ensure your audio is Muted during the session.

These slides and session recording will be shared via the PHO Covid Alert.

Agenda Speaker Dr Claire Isham, Clinical Director, WBoP PHO

Session An update on current BOP response and services

Dr Claire Isham, Clinical Director, WBoP PHO

Updates to Version Two of the Clinical Guide

Catherine Warren, COVID Performance, Quality and Design Lead, BOP DHB

Community Co-ordination Hub for welfare support Q&A session

Dr Johnnie Walker, Respiratory Consultant, BOP DHB Dr Kirsten Ramsay, Respiratory Consultant, BOP DHB

What to expect when caring for people with Covid and how to manage end of life from Covid in the community Q&A session

Dr Vanessa Muller, Papamoa Pines Medical Centres Dr Kiran Singh, Fifth Avenue Family Practice

Insights from local GPs currently looking after Covid positive patients Q&A session

Current Cases in the Bay of Plenty Total Case Breakdown (Volume)

W BOP E BOP TOTAL

Active Cases

63

7

70

Close Contacts

100

8

108

Total Active Referrals

163

15

178

Hospital Care

2

-

2

Completed

44

8

52

Total Cases

207

23

230

Total Case Breakdown (Percent) W BOP E BOP TOTAL Active Cases 30% 30% 30% Close Contacts 48% 35% 47% Total Active Referrals 79% 65% 77% Hospital Care 1% 0% 1% Completed 21% 35% 23% Total Cases 100% 100% 100%

Source: WBOP PHO CPRT Database as at 2.40 PM 16/12/21

Cases by Vaccination Status TOTAL ACTIVE CASES BY VACCINATION STATUS 50 45

61%

40 35 30

Volume

Active Case Breakdown by Vaccination Status W BOP E BOP TOTAL TOTAL % Unvaccinated 38 5 43 61% Vaccinated - One 16 16 23% Dose Vaccinated - Two 7 2 9 13% Doses Vaccinated - Three Doses Vaccinated - Two Doses Plus Booster Yet to determine 61 7 68 Yet to grade in 2 2 3% database Total Active Cases 63 7 70

25 20 23% 15 13%

10 5 Unvacci nated Vaccinated One Dose

Vaccinated Two Doses

-

-

-

Vaccinated Three Doses

Vaccinated Two Doses Plus Booster

Yet to determine

Yet to grade in database

Source: WBOP PHO CPRT Database as at 2.40 PM 16/12/21

Cases by Ethnicity

Yet to grade in database Total Current Cases

TOTAL W BOP E BOP TOTAL % 8 8 4% 41 1 42 24% 101 11 112 63% 3 3 2% - 2 2 1% 155 12 167 8 3 11 6% 163 15 178

TOTAL CASES (ACTIVE AND CLOSE CONTACT)

BY ETHNICITY 120

63%

100

80

Volume

Total Current Cases Breakdown by Ethnicity Asian NZ European Māori Pacifika Other Unknown

60 24% 40

20 4%

2%

Asian

NZ European

Māori

Pacifika

-

1%

Other

Unknown

Yet to grade in database

Source: WBOP PHO CPRT Database as at 2.40 PM 16/12/21

Version 2: A guide for primary care clinical management of Covid -19 in the Community Version 2 includes updates to local processes and new additions to the Midlands HealthPathway Covid-19 Case Management in Adults model. https://midland.communityhealthpathways.org/728651.h tm Username: midlanduser Password: midlandpassword

Summary of Changes Section & Page Number Contact Numbers Release from community monitoring

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

Appendix 2 and 3

Added new Appendices for TTO Release letter template and release checklist

Household close contacts

New subsection with updated isolation information

Clinical Assessment and Risk Stratification Clinical Assessment and Risk Stratification Clinical Assessment and Risk Stratification Assess Clinical Risk Assess Clinical Risk

New Clinical Status Checklist New Severity Assessment matrix Added Covid-19 illness timeline Added Clinical features information and Covid symptom timeline diagram Guidance for pulse oximeter use in people with darker skin

Assess Clinical risk Ongoing Assessment Ongoing Assessment Ongoing Assessment

All cases in pregnancy or postpartum period to be discussed with obstetrician and midwife informed Added information about self-monitoring and what to do if condition deteriorates Added information about symptom relief Added new information about Budesonide treatment

Referring to hospital care

Updated Triggers for moving patient to hospital or palliative care

Toi Te Ora guidelines for isolation period and release Included in the Clinical Guide v2 but also available via the Practice Resources Covid-19 Clinical Management in Primary Care section http://portal.wboppho.org.nz/covid-19/ PHO Covid Portal page in the General Key messages: • 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) • Release occurs the day after the isolation period to ensure completion of isolation • Email cprt@healthbop.org.nz with completed release checklist. The team will inform Toi Te Ora. • Primary care is responsible for following up household close contacts.

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

New Toi Te Ora resources Included as Appendices the Clinical Guide v2 but also available via the Practice Resources - Covid-19 Clinical Management in Primary Care section http://portal.wboppho.org.nz/covid-19/

Release Letter Template

Checklist for release

New Clinical Status Checklist Included in the Clinical Guide v2 but also available via the Practice Resources Covid-19 Clinical Management in Primary Care section http://portal.wboppho.org.nz/covid-19/

New Severity Assessment Matrix

COMMUNITY CO-ORDINATION HUB Eastern Bay of Plenty ebopcovid@bopdhb.govt.nz 0800 633 277

Western Bay of Plenty welfare.referral@bopdhb.govt.nz 0800 798 729

8am – 8pm Receiving referrals from TTO (positive cases + household members), General Practice, Community Providers and self-referrals

WELFARE SUPPORT • Kai • Clothing • Accommodation • Transport • Education packs for children • Building relationships between whānau and GPs • Support for patients with compliance – this can be unique for each whānau • Pharmacy delivery

JKR Walker, December 2021

Docherty et al, 15 May 2020

Docherty et al, 15 May 2020

Docherty et al, 15 May 2020

o

o

o

o

• Oxygen and Pressure Support

o

• Proning • Steroids

COVID End of Life Care Dr Kirsten Ramsay

COVID vs Non-COVID Death • Most people die from respiratory or cardiac failure • Breathlessness, agitation, drowsiness and delirium are commonest symptoms • Pain and retained secretions are not so common • Benzodiazepines and opioids commonest medications used (then antipsychotics) • Syringe drivers are useful and should be started early (ARC vs home)

The P’s

Person

Puff

Cough

Panic Puke

Pain Poo

Preliminary • Shared Goals of Care

• The goal is curative or restorative • The goal of care is primarily improving quality of life • The goal of care is comfort whilst dying

• Prepare: • ACP • EPOA

• Discuss

• Patient and whanau understanding

• Recommendation https://midland.communityhealthpathways.org /Resources/SharedCareGoalsForm.pdf

Person • Location • Whanau • Discussion • How much info do they wish?

• Patient/whanau priorities/ expectations • Patient/whanau fears/ anxieties • Patient/whanau cultural/ spiritual needs

https://www.uruta.maori.nz/ https://www.health.govt.nz/publication/te-ara-whakapiri-principles-andguidance-last-days-life

Specific Challenges with COVID • Distance • Medical Practitioner/patient • https://www.hospice.org.nz/wp-content/uploads/2019/04/4.-Giving-serious-news-COVID19-resource-V2-23-August-2020.pdf

• Family/patient • Family/ Medical Practitioner

• Speed • Rapid deterioration

PUFF (out of) • Non-pharmacological (best used early when breathlessness not severe) • Breathing techniques

• Smell the roses, blow out candles • Slow breathing from tummy- rise tummy with inspiration, focus on long relaxed breaths out • Pursed lipped breathing (esp if COPD)

• Positioning

• Sit upright, legs uncrossed, let shoulders droop, head up • Lean forward

• Distraction • Relaxation • Cool

• Reduce room temperature if possible • Cool face

• Anxiety reduction

Puff Pharmacology 1. PRN oral opioids 1. Morphine 2. Fentanyl sc if renal failure

2. PRN benzos (for anxiety) 3. If PRN frequent start regular opioid /benzo and continue PRN

Halve doses in frail or elderly

PRN

Regular

• Morphine PO 2.5-5mg q1h PRN • Morphine SC 1-2.5mg q1h PRN

• Morphine SR (m-Eslon or Morphine LA) 10mg (or 20mg) PO BD, or • Morphine 10 or 20mg/24hours via CSCI • Lorazepam 0.5-1mg PO BD • Clonazepam 3-5 drops (0.3-0.5mg) SL BD • Midazolam 10mg/24hrs via CSCI

• Lorazepam PO/SL 0.5mg tds PRN • Clonzepam 2-3 drops (0.2-0.3mg) SL q8h PRN • Midazolam SC 1-2.5mg q1h PRN

Severe Out of Puff (extremis) last hours/days of life Goal of Care

• relief of suffering without major sedation

last hours/days of life Pharmacology

• Stat SC morphine 5mg + SC 5mg midazolam, or • Stat IV morphine 2.5mg + IV 2.5mg midazolam • Start CSCI or CIVI/24hours Morphine 10mg + midazolam 10mg

Puff: oxygen • Not beneficial if non-hypoxic breathlessness • Not routinely used in community setting with COVID + patients • Hypoxaemia common in COVID infection • Patient may not be breathless even when low oxygen saturations • Air hunger • Common • first line treatment is opioids

• If oxygen therapy considered: contact Respiratory Medicine physician on call (Tauranga) or General Medicine physician on call (Whakatane)

Panic 1 (anxiety) • An element of anxiety or panic is almost universal when acute breathlessness is present. The anxiety is usually because of the breathlessness (not vice versa) • Remain calm, reassure, stay with the person if resource allows • Utilise non-pharmacological management strategies when the level of anxiety is low enough to allow this (above) • Mainstay of pharmacotherapy is benzodiazepines • Avoid midazolam nasal spray as little evidence for effectiveness

Panic 2 (delirium) • Delirium may occur in any patient with acute illness and is a poor prognostic sign • Non-pharmacological management at end of life include treating reversible causes • urinary retention, constipation, and hypoxia

• Manage in a low stimulus environment where possible.

• Having a family member present if possible • In a low-resource setting eg community, medication may be required to manage symptoms • Use pharmacological therapy only if the patient • has distressing thoughts, hallucinations and/or • is agitated and a danger to self, or others

Panic Pharmacology First line benzodiazepine: Lorazapam/ Clonazepam (as per dyspnoea) midazolam (delirium) 2.5mg SC Q1H prn to max 10mg/24hrs First line antipsychotic: haloperidol 0.5mg PO/subcut q1h PRN to max 5 mg/24hr Second line antipsychotic or where sedation required: levomepromazine 12.5 q4h PRN to max 50 mg/24hr (more sedating) • A continuous infusion may be required for intractable symptoms combining both antipsychotic and benzodiazepine: seek palliative care advice

Pain • Oral first • S/L second line • COVID-19 for health professionals – Hospice New Zealand • Support doc- sublingual (under the tongue) and buccal (cheek) instruction for carers, Support doc- Sublingual –medication order- for – family- carer

• Paracetamol (mild) • Opioid (moderate to severe)

Cough • Treat GORD, asthma, hayfever and post nasal drip • Opioids • Avoid nebulisers (saline /SABA) • Terminal secretions • Hyoscine Butylbromide SL/SC 20mg q2h PRN (max 120mg/24h) • Hyoscine/ Scopolamine patch, change 72 hours (SA1998)

Puke • Cyclizine oral/ SL • Metoclopramide oral • Haloperidol SL • Levomeprazine SL • Ondansetron wafer

Insights from local GPs currently looking after Covid positive patients Dr Vanessa Muller, Papamoa Pines Medical Centres Dr Kiran Singh, Fifth Avenue Family Practice

Final Q and A Time .

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Kia tau Karakia whakamutunga (closing) Kia tau kia tātou katoa Te āio, te aroha me te marutau Tīhei Mauri Ora

May peace, love and safety Be upon us all Let there be life