- Set expectations – similar to influenza this is most often a longer recovery than “A.Virus.” Explain that the typical symptoms are cough, fever and fatigue but they may also have breathlessness, muscle aches, sore throat, headache and loss of sense of smell / taste.
- REST – fatigue is often a marker for hypoxia, and experience with more unwell patients tells us increased mechanical work of breathing may lead to increased lung damage, so it makes sense NOT to do anything that triggers dyspnea / tachycardia. It patients have pulse oximeters they can measure after different activities and this is a way to reinforce this message.
- Change position to aid breathing (prone lying is used for inpatients, there is no evidence for outpatients either way but it makes sense to change positions including prone to move secretions and change mechanical work of breathing).
- Give clear guidance on who to contact if symptoms (such as breathlessness) get worse.
For example, give patient a self-monitoring checklist with a plan for deterioration, as well as details about the contact process:
- Call 911 if:
- You have severe trouble breathing or severe chest pain.
- You are very confused or not thinking clearly.
- You pass out (lose consciousness).
- Call clinic if:
- You have new or worse trouble breathing.
- Your symptoms are getting worse.
- You start getting better and then get worse.
- You have severe dehydration such as:
- having a very dry mouth
- passing only a little urine
- feeling very light-headed
- For patient with pulse oximeters: as outlined in the instructions for use, your care team will advise you what pulse oximetry levels are acceptable for you. Generally, an oxygen level of 93% or greater is acceptable. Call the clinic if your reading is below this level after rechecking or if your oxygen level changes by 3%.
- Call 911 if:
- Give advice to ensure adequate hydration
7. Direct patient and carers to information on mental health social supports etc. as appropriate (patient resources tab on HFAM)
- Treatment: there are NO treatment medications that have evidence for use in primary care.
- Hydroxychloroquine should NOT be used.
- Steroids should not be used in ambulant community dwelling primary care pts. As per Dr Zain Chagla there is evidence that if used in milder patients it may result in worse outcomes. If the patient is sick enough that we think they may need steroids, we should be consulting (LTC pathway aside). Think: COVID is not like a COPD exacerbation.
- Antibiotics should only be used if concomitant bacterial infection suspected, and patient can be safely managed in the community. Usual antibiotic guidelines should be followed for uncomplicated or complicated bacterial pneumonia as usual. For more information see How to Care for Ambulatory Patients with Respiratory Tract Infections: A Toolkit for Using Antibiotics Wisely in the Era of COVID-19 and Virtual Care (Choosing Wisely Canada and CFPC)
- Comfort: Acetaminophen is safer than NSAIDS (not specific to COVID but NSAIDs increase the cardiovascular risk in any viral illness). Read more here.
- ACEs and ARBs seem safe. Read more here.
- Medications for COPD and Asthma should be continued. Read more here.
- If the patient is at risk of dehydration (e.g. diarrhoea) think of acute kidney injury risk (SADMAN) if they are on an ACE / ARB plus diuretic plus aspirin these may need pausing to avoid AKI which is a significant feature of more severe COVID illness.
- If the patient is on immunosuppressant medications consult with the relevant specialist – they may need pausing.
- No specific investigations are necessary for monitoring mild – mod COVID in the community setting, except as guided by comorbidities
- CXR may be indicated to assess for bacterial pneumonia