Considerations for Primary Care Based Face-to-Face Assessments of People with Suspected Covid19, in Sheffield

Version 4.2, 16.04.20 Jennie Joyce, Ollie Hart, StJohn Livesey, Prof Chris Burton, Andy Hilton, Andrew McGinty

Introduction

● This document describes the approach that Sheffield GP practices and their associated Primary Care Networks could take to the management of patients in a ‘Hot Hub’, ‘Hot Zone’ – within a practice or in a patient’s own home. The word ‘service’ in this document refers to hubs, zones and home visiting.

● The current approach in Sheffield is for each practice to have a plan for seeing patients suspected of having COVID19 in a safe environment that minimizes spread of the virus, and protects the safety of staff.

● We recognise that the scale of provision may change as the crisis develops and demand changes, with each PCN also having contingency plans prepared.

Thanks This document has many contributing authors and editors but particular thanks go to Ollie Hart, Jennie

Joyce and StJohn Livesey, without whom this documents would not exist.

Principles

● This service may be used to see patients who have been triaged by 111/CCAS (Covid Community Assessment Service – remote assessment service to assess Cat 2 patients) who are deemed to require a face to face assessment (see Appendix 1) or for Cat 1 Covid patients who are presenting with other medical problems requiring face to face assessment.

● Patients should only attend a service or be visited when there is no other means of acquiring the clinical information necessary to affect the patient’s outcome eg telephone/video consultation or the use/deployment of remote monitoring equipment.

● GP should be allocated to the service for the duration of that session where possible, to facilitate the sessional use of PPE.

● When creating a practice based or PCN based Service, those involved in its design could refer to Managing coronavirus (COVID-19) in general practice (SOP) for the most up to date advice, upon which much of the advice here is based.

● The setup of a service should never knowingly compromise the safety of its staff or patients it sees.

● Consideration should be given in the delivery of this service to vulnerable and hard to reach groups of patients including (but not limited to) learning disability, serious mental illness etc.

Each service venue will need their own specific Standard Operating Procedure (SOP), but the following factors should be considered:

Physical set up and practicalities to consider

a) Building:

● Consideration should be given to using a dedicated site or zoning within a site.

● Easily accessible, central to the population covered.

● Adequate car-parking space (solutions may involve use of carpark based assessment).

● CQC registered and account for all disability access issues.

● Good security, with methods to monitor and control entry and exit to the building.

● It should not be necessary or expected for patients to access toilet facilities (commode could be available for emergencies).

● Consider traffic light floor taping to clearly mark out zones.

b) Rooms:

● Standard consulting size, minimal room furniture and wall attachments.

● Flooring, to allow for easy cleaning/decontamination (see IPC guidance)

● Access to an examination couch if felt likely to be needed.

● Telephone for talking to the patient upon arrival and potentially when in the room, for both admin staff and the clinician.

● All computer access and note writing should occur from a separate room, ideally still within the hot zone.

c) IT /Booking:

● A service should have access to patient electronic GP record (all systems), for any patient booked in.

● A service needs to be able to operate off a list that is remotely accessible to all practices referring to the site.

d) Equipment:

● Clinicians should have access to;

o In relation to reassessment of cat2 patient a pulse oximeter (see triage guidance appendix 2)

o In relation to assessment of other medical issues in a cat 3 covid positive patient pulse oximeter, sphyg, thermometer (for assessing covid resp disease) and as needed there should also be access to other medical equipment depending on the condition- e.g. stethoscope, auroscope. The prior triage should have guided equipment should be necessary.

● PPE should be available in accordance with local latest guidance – currently; visor/goggles, face mask, apron, gloves

● All staff using PPE must be familiar with correct usage (donning and doffing) and should refer to this PHE video for visual guidance of use

e) Booking patients

● All practice reception staff / clinicians need to know how to remotely add a patient to the appropriate service list

● Appropriate slots will need to be available to outside organisations e.g. 111/ CCAS or a system that received notification of the requirement for a face to face assessment

● 111/CCAS will not give patients an appointment time they will inform them that their GP practice/Hot Hub/Zone service will contact them to arrange appropriate follow up.

f) Before the consultation

● Each service needs to have specific advice given to the patient before attending. Likely to include;

o Where the venue is.o Wait in car in the park and to contact the hub by phone

o What to bring (e.g. mobile phone)/not bring (e.g. minimize accompanying people).

o What to expect on site (e.g. no access to toilet facilities).

● Consider the value of undertaking a further telephone/video triage. There is specific value in the clinician expected to see the patient having prior consultation with the patient.

g) Transport

● There is simple, specific Sheffield guidance for who can access CCG offered patient transport to hot sites (using fully trained taxi services).

● These are intended to prevent use of public transport (Including regular commercial taxis), and to enable access for people unable to use an appropriate private vehicle.

h) Seeing the patient

● Each service is likely to have its own approach but some core principles apply:

o Minimize time patients inside the buildingo Utilize out of building option like assessment in the carparko Patient to be given a surgical face mask to wear if entering the building.o Minimize patient contact with or touching or any hardware of the building;

▪ consider positioning of patient seating, or even the requirement for seating

▪ ask patients not touch anything

● Minimize clinician face-to-face time with the patient, use telephone as much as possible – mobile or phone in the room

● Only conduct essential examinations (e.g. try to avoid examining throat/chest)

i) Cleaning and disinfecting

● Each service needs to have a suitable cleaning plan for any spaces used for consultation. This may be different for each site depending on site specifics.

● Consider balance between minimizing the number of people exposed to a hot area, and the demand on clinician time to see other patients.

J) Indications for assessing a suspected covid19 patient face-to-face

There is emerging evidence of two distinct functions of a face to face assessment;

The assessment to recategorise Category 2 patients (see triage document appendix 2).

The assessment of other medical conditions in a suspected or confirmed cat 3 patient.

Every effort should be made to avoid face to face consulting during the COVID crisis, including use of telephone and video consulting.

Consideration needs to be given for visiting the patient in their own home where clinically necessary (depending on staff capacity and patient situation) – patient transport to services are available, see g) above.

Home visiting should not be of the traditional ‘GP home visit’ rather a very controlled episode of contact to gather whatever clinical information is required to further manage the patient that cannot be gathered by other means eg phone, triage, deployment of remote monitoring

What follows (next 3 pages) could be printed for ease of reference re the above categories of patients

The assessment of patients who have been triaged by 111/CCAS into category 2 and require face-to-face assessment

● There is emerging evidence that a proportion of patients with Covid19 clinically deteriorate very quickly over a matter of hours (see appendix 3)

● There is some anecdotal evidence from local intensivist colleagues that they feel patients could have a better outcome if they were identified and admitted to hospital sooner (by whatever means this identification of deterioration happens).

● There is emerging evidence that oxygen saturation may be the key indicator of an imminent critical deterioration, there is some evidence of patient with ‘silent hypoxia’, who are not that breathless and who have oxygen saturations in the 70-80%s.

● There is emerging evidence that ‘lethargy’ can be another significant marked of poor oxygenation

Clinical Assessment

● Assessment of these patients who only require pulse and oxygen saturation could be delivered by practices or PCNs in a ‘drive through’ model based in a practice carpark, mindful that for patients who are severely breathless or lethargic driving themselves may not be safe options, see transport/home visiting sections.

● Oxygen saturation testing should be done with the patient at rest and after a 40 pace test (the patient either walks away and back 20 paces or just over twice walking around an average size family car.

Home visiting

● A home visit for this purpose does not necessarily need to be undertaken by a GP, it could be any suitably trained health professional.

● See appendix 4 for full guidance on Primary Care Home visit Protective Equipment Pack, by Prof Chris Burton

● A home visit for a patient for this purpose would require;○ appropriate PPE, and a disposal bag to collect it in○ a pulse oximeter to be handed into the property of the patient (avoiding entry to the property if

possible)○ a bag to collect the pulse oximeter in to return it to the practice for disinfecting○ sanitising hand gel○ a phone to communicate by call or video with the patient (see appendix 5) for using AccuRx to

video consult via mobile phone without being linked to clinical system!○ A paper printout of the patient summary/drug list etc from you clinical system, to leave with

patient in case you admit them.○ or a Covid19 Advance Care plan to leave with the patient if you are to classify them as cat 3

Outcome of Assessment, whether seen in a hot hub, a hot zone within a practice or a home visit

● If either of the oxygen saturation levels is below 94% then the patient becomes a category 1 patient and should be admitted via 999 route (see triaging guidance - appendix 2).

● You may have seen other guidance (national or otherwise) using different oxygen saturation levels but in Sheffield we have agreed the oxygen saturation threshold for admission is below 94%, this is a higher level to admit at than the other guidance.

● The outcome may be the recategorisation to Category 3 (see triaging guidance, appendix 2) and the conclusion of the ‘consultation’ can happen either outside the building with appropriate 2m social distancing or by phone/video call ensuring appropriate safety netting - 111/GP services/999 if emergency.

● The outcome may also be the diagnosis of a secondary pneumonia (see triaging guidance, appendix 2) - the diagnosis of which does not require chest auscultation and prescribing guidance is different from usual community acquired pneumonia. Again the ‘consultation’ should be concluded outside the building with appropriate 2m social distancing or by phone/video call. Prescriptions should be issued using electronic transfer by default. Again there should be appropriate safety netting - 999 if any deterioration

● All patients who do not become cat 1 (call 999) patients should be given a ‘Covid19 advance care plan’ form and guidance for them to complete and retain (see appendix 6)

● Patients should be advised to continue isolation for themselves and their household as per current guidance and this visual aid may be helpful

The assessment of other medical problem requiring face to face assessment in a cat 3 suspected or confirmed Covid19 positive patient

● If the patient's history is not clear enough to the consulting clinician from the 111/CCAS (or even in practice) triage then the GP consulting should remotely, via phone/video call take a fullest history possible, this may negate the need for the face to face assessment

● If face to face assessment is still required the minimal equipment necessary should be taken into the consulting room/the presence of the patient.

● Efforts should be made to use equipment that is cleanable by disinfectant and reusable where possible (for equipment that would normally be reused!)

● This should include measuring pulse oximetry due to the potential for ‘silent hypoxia’, already described (see appendix 3 for more detail and appendix 2 for actions on results). If oxygen saturation below 94% (at rest or after 40 pace test) call 999

● The conclusion including outcomes should be done by phone/video call (or outside the building observing 2m social distancing, and mindful of patient confidentiality - if necessary)

● The outcome of the assessment may involve a prescription, which should be sent electronically by default

● It may be necessary to make onward management plans and these should be confirmed with the patient informing them that their practice will make contact with them to make necessary arrangements.

● All patients who are not admitted to hospital should be given a ‘Covid19 advance care plan’ form and guidance for them to complete and retain (see appendix 6).

● Appropriate safety netting for both covid and any other conditions should be given to patients.

● Patients should be advised to continue isolation for themselves and their household as per current guidance and this visual aid may be helpful

k) Safety netting, feedback to practice and non-negotiable actions

● Usual standards of safety netting should be practiced but clinicians should be mindful where they advise the patient to seek future medical attention from (not usually the hot hub itself).

● If hot hubs formed at PCN level consideration should be given, and agreed between the practices, how the outcome and any actions for the patient’s practice are fed back to that practice

● Some outcomes and actions will require immediate feedback to the practice eg issues of safeguarding, patients meeting 2ww criteria etc practices in a PCN based hub model must agree a mechanism that will allow this eg access to and contact with their on-call GP.

l) Referring a patient to hospital

● Each hub needs to be clear about the current process, and thresholds for referral to hospital, these could change on a daily basis.

● Check with local triaging guidance re Cat2 patients who may need admitting as either 999 or otherwise (see appendix 2)

● Until otherwise notified the criteria for admission to hospital in Sheffield remains consistent with usual standards for clinical safety.

● There needs to be adequate capacity to safely manage patients awaiting transfer (e.g. onsite oxygen, room availability to continue seeing other patients)

Adapting as the situation changes

● Each hub will need a clear daily management structure to maintain, including but not limited to;o Daily staffing rotaso Updates to protocols and SOPs if change in local guidance or conditions.o Supply of appropriate equipment o Operational functions of the facilities in all situation

Appendix 1

Appendix 2 – Primary Care Covid Triage GuidanceThis pathway was created for GPs in uncertain times, using clinical judgement, and are not currently evidence based. HR, RR and O2 sats are taken from sepsis and NEWS2 score—these may not be sensitive for COVID19 and should be taken as part of overall assessment.

Sheffield’s PCN Hot Hub Service setting within the wider system

Telephone Triage—Patient with COVID19 Symptoms (Most common symptoms cough, fatigue, fever, shortness of breath) **Think about other possible causes for symptoms—not everything is COVID**

Category 3 Category 2 Moderate

symptoms: Category 1

Category 2B

Treat temperature: paracetamol, fluids https://www.nice.org.uk/guidance/ng163

Consider secondary bacterial pneumonia (see box 1)

Doxycycline 200mg day 1 then 100mg/day for 5 days OR amoxicillin 500mg tds for 5 days

See: https://www.nice.org.uk/guidance/ng165

If known asthma/COPD ensure SABA continued and follow usual plan for exacerbations.

Advise patients to seek urgent medical attention/dial 999 if any deterioration.

Category 2A

Treat temperature: Paracetamol, fluids.

(See https:// www.nice.org.uk/ guidance/ng163)

Safety netting— advised to call practice or 111 if symptoms are

worse

Tell patients if SOB or rapidly unwell to call 999 or go to A&E—potential to deteriorate rapidly, especially insecond week of illness

Box 1

Bacterial cause of pneumonia more likely in second week of illness and if patient:

• does not have a history of typical COVID-19 symptoms

(in particular, they are not breathless)

• has typical pleuritic pain

• has purulent sputum

• becomes rapidly unwell after only a few days of symptoms

• new confusion

• RR>20, pulse >100, temp >38

Consider abx if fits above, diagnosis of viral v bacterial uncertain or high risk of complications.

Ask patient: how is your breathing today?

THEN Ask patient: are you so breathless that you are unable to speak more than a few words?

Ask patient: are you breathing harder or faster than usual when doing nothing at all?

Ask patient: are you so ill that you’ve stopped doing all your usual daily activities? If YES to any,

THEN Ask patient: is your breathing faster, slower, or the same as normal?

Ask patient: what could you do yesterday that you can’t today?

Category 2B

Basic Assessment

Completing full sentences

New SOB on exertion

Mild chest tightness

Able to do ADLs but lethargic

Advanced Assessment

Adults RR 21-24

Adults HR 100-130

Adults O2 Sats >93%

Adults:

RR >24, HR >130, Sats <94%

AND/OR

Cardiac chest Pain, Unable to complete sentences due to SOB, Drowsy/unconscious, Unable to get out of bed or stand due to dizziness, Confusion, Reducedurine output, Cold extremities or Skin mottling

N.B Higher risk if male, Afro- Caribbean/Asian, type 2 DM, asthma or hypertension

Category 3 Category 2 Moderate

symptoms: Category 1

Category 2A

Basic Assessmen t

Completing full sentences

No SOB or Chest Pain Able to do ADLs

Able to get out of bed

Advanced Assessment Adults RR 14-20

Adults HR 50-100 Adults O2 Sats >96%

USEFUL LINKS

NICE Guidance:

On managing symptoms including cough, fever and breathlessness and end of life:

https://www.nice.org.uk/guidance/ng163

On diagnosis, assessment and treatment of suspected pneumonia in COVID:

https://www.nice.org.uk/guidance/ng165

Assessing breathlessness remotely: https://www.pcrs-uk.org/mrc-dyspnoea-scale

Guidance in Respiratory Conditions:

Sheffield guidance: https://www.intranet.sheffieldccg.nhs.uk/Downloads/Medicines%20Management/COVID%2019/Covid% 20advice%20-%20Respiratory%20.pdf

BTS Guidance: https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/

Guidance in Rheumat ology Conditions:

https://www.intranet.sheffieldccg.nhs.uk/Downloads/Medicines%20Management/COVID%2019/Sheffield% 20Rheumatology%20Covid%20Primary%20Care.pdf

Sheffield CCG COVID Updates: https://www.intranet.sheffieldccg.nhs.uk/updates-for-practices.htm

Sheffield CCG intranet medicines and covid: https://www.intranet.sheffieldccg.nhs.uk/COVID-19/

Appendix 3

Identifying the severely unwell Covid-19 PatientGuidance for Primary Care Clinicians

The following guidance has been produced with Secondary Care colleagues in Sheffield Teaching Hospitals due to concerns that some patients with Covid-19 are presenting to hospital in severely unwell state.

Experience from secondary care suggests the three symptoms most likely to indicate the possibility of developing severe disease are:

1. Breathlessness 2. Persistent fever3. Prolonged illness (5-7) days without feeling better. Severe disease before day 4 is rare.

Breathlessness is probably the clearest symptom of concern, but unfortunately patients can be profoundly hypoxic and tachypnoeic without realising it. The “end of the bed” doctor eyeballing can also be very misleading- people can look really fine with O2 sats of 80%. Oximetry is essential.Primary care clinicians should consider threshold for admission being O2 saturations below 94%.

Importantly however there are a range of presentations and the above is only a guide and cannot replace clinical judgement. Have greater clinical suspicion of the possibility of severe disease if the patient is male, Afro-Caribbean, Asian, has type 2 DM, asthma or hypertension.

In summaryIf a patient complains of breathlessness, continuous fever, or has felt unwell for 5 days and is not improving, they need to be seen (either visit or hot hub). The key investigation is oximetry- this is the equivalent of the meningococcal rash. If their sats are below 94%, admit. 94% and above, in the context of clinical judgement, it is likely that they can be safely kept at home, on the understanding that if they deteriorate they seek urgent medical attention or dial 999 if they’ve already seen a GP.

If in doubt admit.

Appendix 4Primary Care Home Visit Protective Equipment PackPACKING LIST – All packs.

S M L Gloves (2 pairs)[ ] Apron[ ] Mask[ ] Orange waste bag[ ] Sealed clear bag with 3 wipes For used equipment[ ] Alcohol gel In dispenser / disposable container

Packed by Date BEFORE THE VISIT

Choose eye protection & collect

This may be separate from pack and may vary according to nature of visit. Reusable eye protection must be taken in a separate sealable bag

Check equipment Limit to what you will need, keep separate from usual medical bag, check batteries for electronic devices

Call ahead Inform you will need space to don PPE Cleanse hands and arms. Prepare clothing if possible

Consider whether you can travel without extra layers and bare to elbow. Consider separate spectacles for travel & site.

ON ARRIVALSelect donning and doffing space

Tell family / carer to stay at least 2m. Remove all items from your pack.

Prepare for doffing Open up the orange disposal pack, unseal the bag with wipes and place the wipes on top of it.

Check bare to elbow Secure any loose sleeves, check watch etc removedDon Equipment in order APRON

MASKEYE PROTECTION (if appropriate)GLOVES

***Before going into the patient’s room, remind yourselves of the items below, then turn this checklist over and put it close to the disposal bag ready for coming out of the room ***

IN THE PATIENT’S ROOMKeep 2m distance when talking

No need to repeat all questions from earlier triage. Check critical answers

Observe from 2m General appearance and count Resp RateFit oximeter / check pulse at arms’ length

Minimise other examination, only collect information which will change your management.

Step back to 2m For any further discussion with the patient. Consider leaving now and calling back from the practice.

Leave the room If you wish to speak with family / carers then use a different room, keep 2m distance and keep your PPE on.

PREPARING TO LEAVE

Return to your donning / doffing point

Ensure family / carer stay keep 2m distance

Remove GLOVES (if double glove, outer pair only)

(remember different technique for removing first and second gloves of a pair) place in bag

Now clean your hands (only if had been single gloved, see below for 2nd pair)Remove EYE PROTECTION Keep head straight and lift up to avoid catching clothing.

Place separate from the disposal bagRemove APRON Tear apron waist strap then tear at neck and roll from

top down. The apron will have to be quite tightly rolled / scrunched or it will fall back out of the bin bag

Remove MASK Untie / tear the bottom strap first then the top one. As with eye protection, keep head straight, lift up and away.

NOW CLEAN UP!Clean your hands and armsPut the second pair of gloves on (if not originally double gloved)Use the wipes to clean any medical equipment, reusable eye protection and personal spectaclesPlace equipment in sealable bags, place wipes in the disposal bagNow remove second pair of gloves into disposal bag, empty air from it and seal it. You are ready to pick up your things and leave.

BACK AT THE PRACTICEPut the orange disposal bag in the appropriate waste areaRemove equipment and clean it again so ready for re-useWash your hands a final timeReflect on the process, go back through the checklist what did you miss, what do you need to do better? Are there lessons to learn for the team?

Appendix 5

Using your mobile phone for an AccuRx video consultation with a patient without going through your clinical system

● open your internet browser and search for ‘accurx fleming’ or enter the webpage https://fleming.accurx.com/

● click the link to log into your nhs.net email page (usual email address and password)

● click the link for ‘video consultation’ or follow prompts to use test patient

● enter 7777777777 as the nhs number and any random date of birth this will bring you accurx test patient, then confirm patient

● enter the actual patients mobile phone number and it will send the patient a text with link to start video consultation

● Click the link to open the video consultation as you usually would and off you go!

● bear in mind that this will not embed a read code in the patients records so you will need to record your video consultation once you are back into you clinical system

Appendix 6 – Covid Advance Care Pan – Following pages printable for patientCovid 19 Advance Care plan document

● What is a COVID-19 Advance Care Plan?

○ A page of information developed by you, with your family or friends (or somebody else if you need help).

○ It outlines the decisions you have made about your treatment and the support you need if you develop severe COVID-19 symptoms and need to contact emergency services or be admitted to hospital.

○ In these circumstances you are likely to be separated from people who usually support you or speak on your behalf, or COVID-19 may make you too breathless to speak.

○ This plan is a way to capture and share, in an urgent situation, the advance decisions you have made around the care and treatment you would like

● What information is required for a COVID-19 Advance Care Plan?

○ You only need to note down brief information about the key things you want people to know under the following headings.

Example plan

My name, NHS number, I like to be known as

Basic information about your name, NHS number and what you like to be known as.

Summary of my health conditions Briefly list any underlying health conditions you have.

Who am I? Let us know a few things about you as a person, for example, things you do when you are well, like drawing and painting or cycling. Or you are a mother of three and a grandmother of five, or whether you are generally very active etc

Three important things I want you to know

This is one of the most important sections as it is a place for you to indicate the preferences you have for treatment if you have COVID-19. • If you do not want to be admitted to hospital, please record this at number 1 in this section.

• You can indicate here if your priority is comfort i.e. managing symptoms, rather than prioritising sustaining your life, which may involve more invasive treatment. • Other things to record under this section might be • that you usually have low blood pressure or body temperature, (tell us what they are) • or that you have a phobia of needles or sickness. • Other helpful information would include how you react if you are very stressed as well as treatment that you have decided to decline.

Medication I take A list of your medication, doses and frequency

How my medication is administered How you take your medication, eg orally or through a PEG etc

How I communicate It may be that you don’t usually use words to speak, or English isn’t your first language and a family member interprets for you. It might be useful to know how you would indicate distress or discomfort if you are unable to speak.

My emergency contacts List the names and numbers of people you would like us to contact in an emergency.

Who has a copy of this plan? Please tell us who knows about your plan and who we can contact about you if we need to

On the next two pages are a blank plan for you to complete and keep somewhere safe and obvious.

Please think about who you want to tell about your plan and put their details on the plan.

If you have any other Sheffield Care Plan eg an ‘OK to Stay Plan’ please keep all your plans together.

Covid19 Advance Care Plan

My name; My NHS Number;

I like to be known as;

Summary of my health conditions;

Who am I? Things I do when I’m well, something about me as a person…

Three important things I want you to know

1.

2.

3.

Medication I take, or attach a copy of your repeat prescription list;

How my medication is administered;

How I communicate

My emergency contacts .

Name:

Relationship to me:

Phone number:

Name:

Relationship to me:

Phone number

Who has a copy of this plan?

Do I have any other Sheffield Care Plans eg ‘OK to Stay Plan’ and where are they;

Anything else I think the NHS should know about me…………...