- Remote Assessment Of COVID (Phone Or Video)
- Face To Face Examination
- Assessing COVID Severity
Remote Assessment of COVID (Phone or Video)
Evidence informed advice on how to carry out a remote consultation for COVID as recently published in the BMJ. You may find the full paper and infographic useful.
Before the History
Do a quick assessment of whether the patient is sick or not sick?
- Is the patient too breathless to talk? Can you hear them gasping on the phone? Can they speak a full sentence or only a word at a time? Do they look very sick on the video (pale, cyanotic, gasping for breath)
If YES then will need an in-person assessment. If dyspnea is severe refer to ED immediately without examination.
- Do they have chest pain/pressure? If yes, then will need at minimum an in-person examination and cardiovascular risk assessment.
Refer to ED if chest pain suggestive of severe COVID or ischemia.*
Note COVID also commonly gives myalgia affecting chest wall which does not necessarily mean severe COVID
If the patient does not sound or appear SICK, clarify what they expect from the appointment.
- Do they want a sick note?
- Do they want reassurance?
- Do they want advice on self-isolation?
- Do they need a referral?
- Do they want a clinical assessment? (may need to dissuade and reassure if not unwell)
Close contact with a COVID-19 case?
Immediate family member unwell?
Healthcare worker/ at occupational risk of COVID?
- Record when symptoms began
- Record symptoms — see COVID-19 Patient Screen Guidance Updated 2020/06/11
Significant symptoms include new or worsening cough (may be productive or dry, enquire re hemoptysis), fever >37.8 (note up to 50% do not have fever at initial presentation), shortness of breath (even when not active), change in taste or smell, loss of smell or taste, new onset muscle aches, chills and fatigue. People may also report unexplained or significant headache, sore throat, difficulty swallowing, pink eye, runny nose or nasal congestion without other known cause, abdominal pain or diarrhea.
Be on the lookout for atypical symptoms in children, seniors >70 years and people living with a developmental disability. These may include delirium, unexplained or increase in falls, acute functional decline, exacerbation of chronic conditions. Symptoms and signs in young children may include lethargy and/or decreased feeding (if no other diagnosis), croup and unexplained tachycardia (using age specific tachycardia reference ranges for children). Children have also been reported as presenting with lesions on extremities resembling chilblains / pernio, and rarely with atypical Kawasaki disease. Read more about emerging evidence on the syndrome from the CEP here.
- Ask about urine output
- Check record: Is there underlying chronic disease that indicates increased risk of poorer outcome? (asthma, COPD, diabetes, CVD, immunocompromise)
RED FLAG SYMPTOMS
- Severe shortness of breath at rest
- Difficulty in breathing
- Increasing significant fatigue (reported in some patients as a marker for hypoxemia without dyspnea)
- Cold, clammy, or pale and mottled skin
- Reduced level of consciousness or new confusion
- Blue lips or face
- Little / no urine output
- Pain or pressure in the chest
- Neck stiffness
- Non-blanching rash
Assess physical and mental function as best you can
Phone: Ask patient or caregiver to describe state of breathing( see questions below) and colour of face and lips
Video: In addition, assess demeanor, colour above, the extent of respiratory effort and count respiratory rate
Should I use the Roth score? NO This performs poorly and has underestimated severe illness when used in COVID, resulting in harm. Click here for more detail.
- Ask the patient (or caregiver) to describe the problem with their breathing in their own words, and assess the ease and comfort of their speech. Ask open-ended questions and listen to whether the patient can complete their sentences.
- “How is your breathing today?”
- Then specifically check symptoms
- “Are you so breathless that you are unable to speak more than a few words?”
- “Are you breathing harder or faster than usual when doing nothing at all?”
- “Are you so ill that you’ve stopped doing all of your usual daily activities?”
- Focus on change. A clear story of deterioration is more important than whether the patient currently feels short of breath. Ask questions like
- “Is your breathing faster, slower or the same as normal?”
- “What could you do yesterday that you can’t do today?”
- “What makes you breathless now that didn’t make you breathless yesterday?”
Interpret the breathlessness in the context of the wider history and physical signs. For example, a new, audible wheeze and a verbal report of blueness of the lips in a breathless patient are concerning.
In addition, a video examination will add key detail such as whether the patient is blue, the extent of respiratory effort and the opportunity to count the respiratory rate.
Patients who are dyspneic need a face to face assessment (if severe dyspnea refer to hospital for this)
Assess vital signs
The patient or caregiver may be able to assess temp, pulse, BP and O2 sats depending on home equipment. Interpret self-monitoring results with caution in the context of your wider assessment.
(Limited Contact) in a Pandemic
History is as described here. Try to take history by phone to limit contact.
Key equipment: pulse oximeter, a thermometer, and stethoscope (if home visit consider immediate therapy pack of doxycycline, amoxycillin in case of bacterial rather than COVID pneumonia)
Assess general condition
Demeanour, colour, cyanosis, the extent of respiratory effort, hydration
Do temp, pulse, RR and O2 sats
Decide whether auscultation necessary
To Reduce Contact
Auscultation should be then be reserved for those ONLY where it is crucial to decision making.***If auscultation is performed, examine from behind the patient only
COVID Pneumonia Diagnosis
The diagnostic accuracy of “overall clinical impression” close to ruling in, in an emergency. (Systematic Review of 9 studies 2019)
Auscultation of the chest is not essential if this overall clinical judgement of CAP (partly based on temperature >=38, respiratory rate > 20, and heart rate >100, new confusion) is already met.
Hypoxemia (O2 sat <95%) should also trigger referral without further examination.*
Normal vital signs, as well as a normal pulmonary examination can rule out CAP in an emergency.
Assessing blood pressure significantly increases contact time so consider only in those in whom it contributes to essential decision making to admit or not. low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg) is a concerning sign
Document that on examination a ‘limited examination’ was performed (abbreviated to O/E LE).
Remember: DISINFECT all equipment used between patients
*A pulse oximeter provides a simple way to also measure heart rate without contact and can aid the assessment of the deteriorating patient. The patient can be instructed on how to put this on to reduce contact.
Assessing COVID Severity
Mild or moderate cases have been generally defined based on less severe clinical symptoms (low grade fever, cough, discomfort) with no evidence of pneumonia. 6,10
More Severe Illness
There was some difference in myalgia / chills /fatigue between severe and non severe.
Pneumonia and Hypoxemia also indicate more severe illness (O2 Sats <95%. In someone with pre-existing COPD, may be lower – depends on usual sats when well)
- T > 38
- RR > 20 breaths/ minute
- HR > 100
- New confusion
Plus clinical impression: The diagnostic accuracy of “overall clinical impression” is close to ruling in pneumonia, in an emergency. (Systematic Review of 9 studies 2019)
Other distinguishing symptoms and signs that help identify patients with more severe illness to make the decision about hospital admission:
- Severe shortness of breath at rest of difficulty breathing
- Cyanosis (lips / face)
- Feeling cold or clammy with pale or mottled skin
- Syncope (collapse or fainting)
- Becoming difficult to rouse
- Little or no urine output or other signs of dehydration needing IV fluids
Distinguishing from bacterial pneumonia
It is difficult to distinguish between viral and bacterial pneumonia. However, as community prevalence becomes higher patients will be more likely to have a COVID viral pneumonia than a bacterial pneumonia. The UK National Institute for Clinical Excellence suggests these things may help:
COVID Pneumonia more likely
- Patient has had typical COVID symptoms for about a week
- Has severe muscle pain (myalgia) including chest wall myalgia
- Has recent onset loss of sense of smell / taste
- Feels breathless but has no pleuritic pain
- Has a history of potential COVID exposure (this may become less important as community prevalence increases)
Bacterial pneumonia more likely
- Becomes rapidly unwell after a few days of symptoms
- No history of typical COVID symptoms
- Pleuritic pain
- Purulent sputum
There will normally be a brisk return to normal of vital signs in bacterial community acquired pneumonia, so review of the decision with repeat assessment at 72 hours is also helpful.
ED Referral Decision
The patients risk factors for more severe illness should be considered in making the decision to refer to ED: age (>65), comorbidities as above, immunocompromised, higher frailty score. In addition inability to self-isolate or lack of support at home may be other reasons to consider ED referral.
Refer to ED if severe illness, for example:
- O2 Sats <95%
- Breathlessness RR >30 despite normal O2 sats
- Deterioration with confusion
- Dehydration needing IV fluids
Other symptoms indicating severe illness, or significant or rapid deterioration deterioration (see above) including markedly increased fatigue if O2 Sats are not available. (Fatigue may be a marker for hypoxemia without dyspnoea.)
Send the patient to the ED
Call the ED ahead and arrange for safe transfer to minimize contact
Note decisions should consider the patient’s wishes and any Advanced Care Plan.
- 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.
- That they should follow current public health guidance on self-isolation, including from household members. Self-isolation must be strict even if symptoms are mild.
- That if the symptoms are mild they are likely to feel much better in a week.
- Give clear guidance on who to contact if symptoms (such as breathlessness) get worse.
- Discuss antipyretic use (antipyretic not as a routine but prefer acetaminophen if must use medication for symptom relief – avoid NSAID) see Evidence Reviews on antipyretics and on NSAIDs in viral illness.
- Consider whether SADMANS medication advice is indicated if there is concern about dehydration, to prevent acute kidney injury: https://www.rxfiles.ca/rxfiles/uploads/documents/SADMANS-Rx.pdf
There is no indication for antibiotic treatment for viral COVID. Do not offer antibiotics in clear COVID illness with mild symptoms for treatment or prevention of pneumonia.
Antibiotics should only be initiated if bacterial infection is suspected. There is concern in other countries that antibiotics are being prescribed too frequently early in early COVID illness, and that this will increase antibiotics resistance, reducing treatment effectiveness for bacterial superinfection later in the illness.
Consider Oral antibiotics only if:
- The likely cause is bacterial and that patient can be safely managed in the community
- It is unclear whether it is bacterial or viral and symptoms are more concerning (closely monitor)
- The patient is at high risk of complications (older, frail, other comorbidities such as significant heart or respiratory disease, immunosuppression, previous severe pneumonia)
Usual antibiotic guidelines should be followed for uncomplicated or complicated bacterial pneumonia as usual, but sparing macrolides where there is a choice to preserve supply for inpatient management.
Safety net all patients with mild illness:
- Advise patients to seek help without delay if their symptoms do not improve as expected or worsen significantly or rapidly (this may occur 6-7 days after onset)
- Plan to actively reassess those with higher risk and reconsider whether patient has mild or more severe signs of illness and whether to admit to hospital as above
Higher risk patients include those with existing cardiovascular disease, respiratory disease, diabetes or hypertension. Older patients (>65) and males are also at higher risk than younger patients and women.
When to Discharge from isolation or consider “resolved”
- Ministry of Health Assessment Guideline
- OMA Assessment Guidelines
- Oxford Centre for Evidence Based Medicine COVID-19 Evidence Service
- National Institute for Clinical Excellence Guidelines for COVID Assessment and Management
- COVID: A remote assessment in primary care Greenhalgh T, Koh G, Car J BMJ 25 March 2020;368:m1182
See links throughout for more references.