I am especially in awe of how my primary care colleagues are dealing with Covid-19.
Primary care must be unbelievably hard right now. Not only are GPs still having to manage their normal case loads of chronic illnesses but they are also the first line of contact for many people who have been infected with SARS Coronavirus 2 (SARS Cov2). AND they are doing this remotely using telephone and videoconferencing!!! The Editor Chief in Charge (aka my wife) will tell you just how useless I would be at that… I don’t even own a smartphone; in fact I can barely use the TV remote control!
There is an increasing amount of guidance on line on the Department of Health (DoH) website but this is really all about identifying cases of Covid-19 as quickly as possible and avoiding catching the virus yourself or transmitting it to others within the practice. Only 1 of these documents is specifically aimed at primary care, and that mainly deals with how to clean up after an unsuspected patient turns up in your clinic!
I’m guessing in reality even this guidance is of limited value now; given that most consultations are happening remotely.
I think the main questions facing primary care (although as I am based in secondary care I may be far from the mark) are:
- How do you identify patients with Covid-19?
- How do you decide who should be admitted to hospital?
- Who should be tested for Covid-19?
- What Personal Protective Equipment (PPE) should be worn in primary care and nursing homes?
- Should primary care healthcare workers be tested for Covid-19?
- Are there any treatments for Covid-19 in primary care?
- What antibiotics should you start for patients with Covid-19?
How do you identify cases of Covid-19 and who should be admitted to hospital?
This has perhaps become easier as the pandemic has progressed. The more people who have Covid-19, the more likely a patient with a fever and/or cough has Covid-19. Essentially the “pretest probability” that a patient with fever and/or cough has Covid-19 is increasing with every new case in the population.
Once a patient has been diagnosed as a likely case then there needs to be some form of severity assessment to decide who needs admitting to hospital and who can be cared for at home. This is where it gets difficult.
There is no validated scoring system I am aware of for predicting who needs admission with Covid-19.
In the absence of a validated scoring system I would use CRB-65 and/or assessment of hypoxia.
CRB-65 is a modification of the CURB-65 scoring system that helps predict mortality from Community Acquired Pneumonia (CAP); the urea has been dropped as this is a lab test not available to most primary care teams. It should already be familiar to primary care and can still be used to predict mortality and therefore who to admit to hospital. It’s not specifically for use in Covid-19 but it is validated for CAP and this can be caused by viruses. It’s therefore probably the best thing available at present (unless others wish to share known validated alternatives?).
1% mortality, manage at home
1-10% mortality, consider admitting to hospital
>10% mortality, admit to hospital
I wouldn’t suggest that all patients with risk factors for severe Covid-19 should be assessed in hospital as this would put those who haven’t actually got it already at risk of acquiring it! It might be better to make sure that these “at risk” (CRB-65 0-2) patients are carefully assessed and “safety netted” at home so they quickly get back in contact with their GP if they get worse.
Remember: its 7 days home isolation from onset of symptoms for mild Covid-19 patients, 14 days for those cohabiting within the same house without symptoms.
Who should be tested for Covid-19?
At present we are NOT testing symptomatic patients who are NOT being admitted to hospital. This is not ideal, as it would be good to know everyone who has Covid-19 but it just isn’t feasible. At present we do not have the laboratory capacity to test every symptomatic patient (even if the media and government say we do!). The tests are currently reserved for hospitals where the test result is used to decide whether the patient goes to a “Covid-19 area” or whether they go to a “non-Covid-19 area”.
As testing capacity increases, and I am not in favour of volunteer labs, there may be more opportunity to start testing all symptomatic people… but I suspect by this time the incidence will be so great that there will be little need to test everyone… if you are symptomatic it is almost certain you have it and therefore a negative test is more likely to be a false negative (at which stage most Doctors will quite rightly ignore the negatives anyway).
What Personal Protective Equipment (PPE) should be worn in primary care and nursing homes?
This is proving to be a major concern for GPs and nursing home staff. I think inadequate information, fear of contracting the virus and passing it on to other patients, the feelings of being “forgotten” or of lower priority to hospitals as well as the images in the media are making the concern worse.
At present the recommendation is to wear a surgical face mask, plastic apron and gloves for contact within 2 meters of any patient with confirmed or suspected Covid-19 (adding eye protection if risk of splashing of body fluids into eyes). This means that when physically assessing (rather than video or telephone assessments) any patient with a fever or persistent cough PPE will be required.
It is therefore important for GPs to know the patients symptoms in advance, “unknown” situations make it hard for GPs to comply with PPE; but hopefully these visits are becoming less frequent with better telephone triage. The advice for GPs or nursing homes is NOT TO USE FFP3 masks, full face visors, long-sleeved gowns and gloves, as they are not performing AGPs.
I think PPE is really hard for nursing homes. A possible and prudent way to help detect signs of Covid-19 early would be to take residents temperatures at least twice a day during this pandemic. If a patient has a temperature of 38oC or more then repeat the temperature 1 hour later. If this 1 hour temperature is raised (or two consecutive daily temperatures are raised) then the residents should be treated as presumed Covid-19, isolated and PPE used even if they don’t yet have a cough. This early intervention might help prevent other residents being infected. In practice early isolation might be really difficult as some nursing homes have over 100 residents and, as PPE should be disposed of after every contact, you can see how nursing homes could rapidly run out of PPE. When coupled with the fact that almost all nursing home residents are in the high risk groups for severe Covid-19 then running out of PPE is a recipe for disaster. This certainly appears to have been the case in Italy and Spain.
It is essential that nursing homes continue to have access to PPE… the tricky thing is who pays for this? Some argue that many nursing homes are private businesses and therefore they are responsible for their own supplies and costs of equipment. That might be the case but I personally think that this is wrong; this is an unprecedented crisis especially for this patient group and if PPE is available it should go to where it will do the most good… and this includes ALL nursing homes in my book.
Whatever PPE you are using the last thing to do when taking off PPE is wash your hands! You may contaminate your hands taking off PPE, so give them a good scrub with soap and water before doing anything else. Here are posters and video education tools for standard Covid-19 PPE.
It does concern me to see just how many doctors, nurses and healthcare workers worldwide are wearing PPE when being interviewed by the media. This may be “for effect” and “asked for” by the news reporters but it is 1) wasteful 2) inappropriate 3) fuels further fears amongst healthcare workers and the public. PPE is worn with the patient and then removed. Wearing it outside the immediate “patient environment” is an incorrect use of PPE.
There will come a time when there will be more patients and residents in nursing homes who have Covid-19 then don’t, and at that time it will be necessary for PPE to be worn in all patient contacts. It will no longer be single use per patient. This is apparently already happening in some hospitals and I suspect it won’t be long before the same happens across all healthcare settings.
I hope there will be adequate supplies of PPE BUT I hope even more that the PPE is used correctly. Many of the pictures I see on the television show just how bad many people are at using PPE. I even saw one Head of an Emergency Department in Italy in his scrubs talking on the BBC news whilst his facemask was looped around his ears and folded under his chin!!! If that had been used near a patient that Doctor has now contaminated his face with whatever was on the outside of the mask… please don’t do this!!
PPE not only protects you, but also protects the other patients and residents. Use it correctly.
AGPs are procedures that might generate small particles of suspended material which may then be inhaled, exposing people in close proximity to infectious material. The current list of official AGPs includes the following list as of 27/03/2020:
- Intubation, extubation and related procedures e.g. manual ventilation and open suctioning of the respiratory tract (including the upper respiratory tract)*
- Tracheotomy/tracheostomy procedures (insertion/open suctioning/removal)
- Bronchoscopy and upper ENT airway procedures that involve suctioning
- Upper Gastro-intestinal Endoscopy where there is open suctioning of the upper respiratory tract
- Surgery and post mortem procedures involving high-speed devices
- Some dental procedures (e.g. high-speed drilling)
- Non-invasive ventilation (NIV) e.g. Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
- High Frequency Oscillatory Ventilation (HFOV)
- Induction of sputum
- High flow nasal oxygen (HFNO)
*Chest compressions and defibrillation (as part of resuscitation) are not considered AGPs.
None of these AGPs are normally done in primary care which is why FFP3 face masks, long sleeved disposable gowns, gloves and disposable eye protection are not required.
What Personal Protective Equipment (PPE) is being worn in hospital and why?
When caring for most hospital patients with Covid-19 the current PPE is a surgical face mask, plastic apron and gloves (adding eye protection if risk of splashing of body fluids into eyes). Yes, the same as recommended in the community! This prevents “unintentional” contamination e.g. you are rolling a patient for care needs and they cough; the initial aim was not to roll the patient to treat their chest, as chest physiotherapy is “induction of sputum” (AGP above). The PPE for AGPs (see above) is FFP3 face mask, long sleeved disposable gown, gloves and disposable eye protection. The media portray that ALL hospital care is done in AGP PPE but this is not the case, it’s just the media’s portrayal; it is true ITU wear APG PPE but generally their patients are intubated or might need intubating at a moment’s notice. A good summary page can be found on the Public Health England website. Addendum: On the 2nd April PHE added "Table 2" for clear concise guidance on PPE in Primary Care.
I hope this is coming. I suspect that primary care is suffering the same shortages of staff due to self-isolation as the hospitals.
Testing to see if either healthcare workers or their symptomatic contacts have Covid-19 appears to be starting this week but this will only answer the question of whether someone who is symptomatic actually has the infection. The asymptomatic person (often the healthcare worker) in self-isolation will STILL need to stay in isolation for the 14 days, just in case they develop Covid-19. Think about it: they could be tested on day 3 and be negative but by day 5 (or day 7 or day 12 etc.) be positive! A negative test before 14 day of an asymptomatic self-isolator does not make them completely safe to return to work. Sorry, unhelpful but true! This may change as the risk of having no staff might outweigh the risk of a healthcare worker with a negative test returning to work but potentially still being infectious; this will have to be assessed by locally healthcare providers on a case-by-case basis.
What we really need is an antibody test that tells us who has already had Covid-19 and is therefore safe to be at work. This would take the form of a test for SARS Cov2 IgG, a measure of past exposure and immunity. This is likely to be some form of blood test, either a rapid screening test a bit like a pregnancy test or a more formal serum test in a laboratory (or combination of both!). WE WANT THIS TEST and hopefully this will be coming soon (NB must send a memo to Government officials, voluntary start-up labs, Dyson and formula 1 to concentrate on an IgG test!).
Are there any treatments for Covid-19 in primary care?
At present there are no routinely available treatments for Covid-19 anywhere, primary care or in hospitals.
In hospitals any treatment used has to be part of a registered clinical trial. This is understandable as some of the treatments have already been shown to be potentially harmful; steroids have increased mortality, and Kaletra has shown no clinical benefit whilst increasing the risk of spread. The most promising drug is Remdesivir, made by Gilead, who are currently recruiting worldwide for a clinical trial.
Remember the quote from Chris Hadfield, a NASA astronaut, “there is no problem so bad that it cannot be made worse”. I believe making an already sick patient worse through uncontrolled experimental treatments is unforgiveable in medicine, so bring on the clinical trials.
What antibiotics should you start for patients with Covid-19?
At present I’m not recommending any routine antibiotics for patients with Covid-19.
Covid-19 does not appear to be particularly prone to secondary infections in the same way as influenza would be. This is probably because infection with SARS Cov2 appears to primarily be a problem with thickening of the alveolar wall with resulting hypoxia rather than inflammation.
If patients do appear to have a secondary infection, or where from a clinical perspective the diagnosis of Covid-19 is in doubt, then I would give normal Community Acquired Pneumonia (CAP) antibiotics. The causes of any mild secondary infections would be the normal CAP suspects such as Streptococcus pneumoniae, Haemophilus influenzae and a bit of Staphylococcus aureus. More severe secondary infections are likely to need hospital care.
In primary care I would recommend using PO Amoxicillin, PO Clarithromycin or PO Doxycycline.
Addendum: NICE now have produced guidelines on antibiotic use in Covid-19
How long is this going to go on for?
I suspect this question is one that is on everyone’s minds right now… and perhaps the hardest question of all to answer.
In my opinion we are likely to be working like this for 3-6 months. I know this sounds alarming and awful (and is quite a wide timescale) but let me explain…
It is likely to take 2-3 months at least before we are over the hump of severe cases. Many of the sick patients admitted during this time will remain in hospital for some time after this. There will also still be susceptible people in the community who have not yet had Covid-19 because they have been effectively self-isolating and therefore they will be at risk of acquiring SARS Cov2 in another wave. In addition there will be countries around the World who are still struggling to cope with the pandemic and could be a source of reintroduction of SARS Cov2 back into the UK.
All of this means there will be an ongoing risk of outbreaks and a worsening of the pandemic if restrictions are relaxed too early. So we need to stand fast together as a profession, keep getting clear simple messages out rather than media lead “news” and at least “look” calm even if we are all paddling like swans. The public expect it of us, I think the NHS staying calm actually keeps the public calm too; and a calm public will abide by restrictions (and reduce their panic buying!) and social distancing will reduce the spread dramatically, which in turn helps us! (But I could just be naïve…)
I remain in awe of my frontline colleagues, both in primary care and in hospital, who are dealing with Covid-19… I will continue to support my local colleagues both via telephone and face-to-face in MDTs; they tell me this helps. We all have our roles to play, we are all doing an amazing job and my wife tells me people on the streets appreciate that… in a socially distant way!
Useful Primary Care Resources
These videos are rather basic but I think they are useful resources to train and reassure community teams, those suddenly responsible for self-isolating and those caring for at risk groups; it’s all good stuff, easily digestible and presented in a non-sensational way!
- Respiratory and cough hygiene
- Standard Infection Control Precautions (SICPs)
- Covid-19 Guidance for Residential Care, supported living and home care
- COVID19 Guidance on Cleaning Poster
- A useful patient-friendly summary for care homes and those self-isolating
These are useful guides and videos for Primary Care Physicians to use or share:
- Guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19
- Posters and video for non-AGP PPE
Got more questions?... see last week's blog FAQ on Covid-19