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?

  1. 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.

  1. 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)

  1. Record date of symptom onset (important for calculating end of isolation period)
  2. Record symptoms and note change:

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.

  1. Ask about urine output and fluid intake
  2. Note underlying chronic disease that indicates increased risk
  3. Check for red flag symptoms (see When to Refer to ED section below)
    • RESPIRATORY
      • Severe shortness of breath at rest
      • Difficulty in breathing
      • Increasing significant fatigue (reported in some patients as a marker for hypoxemia without dyspnea)
      • Blue lips or face
      • Hemoptysis
    • OTHER
      • Cold, clammy, or pale and mottled skin
      • Reduced level of consciousness or new confusion
      • Little / no urine output
      • Pain or pressure in the chest
      • Syncope

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 Click here for more detail.

  1. 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?”
  2. 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?”
  3. 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.

Temp, pulse, BP and O2 sats depending on home equipment. Interpret self-monitoring results with caution in the context of your wider assessment.

Note change from previous

Oxygen Saturation

Helpful tool to indicate disease severity when available, especially if available at beginning and can monitor change.  

If previously healthy lungs or previously documented normal O2 sat – a new consistent background reading of < 92% is a red flag

If underlying lung disease with documented low normal O2 sat at baseline – a new reading of < 90% is a red flag If patient on home oxygen normally and their O2 requirements increase with COVID illness – this is a red flag

Try to take history by phone to limit contact.

Key equipment: pulse oximeter, a thermometer, BP cuff, and stethoscope

General condition: demeanour, colour, cyanosis, the extent of respiratory effort, hydration

Vitals: temp, pulse, RR and O2 sats

Decide whether auscultation necessary

Auscultation should be carried out 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. 


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

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

Pneumonia and Hypoxemia indicate more severe illness (O2 Sats <95%. In someone with pre-existing COPD, may be lower – depends on usual sats when well)

Diagnosing pneumonia

  • 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, see When to Refer to ED in the next tab on this page.

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)

Note also

Return of cough after period of improvement may signal development of COVID pneumonia Return of fever after afebrile period may signal development of COVID pneumonia

Bacterial pneumonia more likely

  • Becomes rapidly unwell after a few days of symptoms
  • No history of typical COVID symptoms
  • Pleuritic pain
  • Purulent sputum

Consider emergent transfer to ED (unless not congruent with goals of care*) if:

  • HR >110, SPO2 consistently ≤ 92%, RR >24
  • Severe shortness of breath at rest (e.g. Breathlessness RR >30 despite normal O2 sats)
  • Difficulty in breathing (work of breathing)
  • Reducing O2 saturation (see guidance under Examination/Assessing Vital Signs on this page)
  • Pain or pressure in chest
  • Decreased oral intake or urine output (dehydrated, needing IV fluids)
  • Cold, clammy or pale mottled skin
  • New onset of confusion, becoming difficult to rouse, syncope
  • Blue lips or face
  • Coughing up blood

Other symptoms indicating severe illness, or significant or rapid deterioration including markedly increased fatigue if O2 Sats are not available * see Managing Progressive Life Limiting Conditions (COVID and non COVID)

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.

  1. Confirm date of first symptoms (if symptomatic) as well as date of positive test (for end of isolation calculation).
  2. Check whether has had public health contact. If not discuss self isolation and contacting contacts ASAP: see script for this. Instructions for Individuals who Test Positive for COVID-19 provided by Dr. Doug Sider, Hamilton Public Health.
  3. Patient can be directed to hfam guides for self isolating under patient resources tab.
  4. Check equipment patient has available. Check whether patient has or can borrow pulse oximeter. (patients can be directed to instruction YouTube video on using pulse oximeter on hfam.ca patient resources tab: found under “Self Isolation” heading).
High Risk Average Risk Low Risk
Patients with any of the safety net flags Otherwise healthy adults
Patients with symptom deterioration Pregnant women No comorbidities
Any age with medical comorbidities No safety net flags
Age > 60 40-60 years old with no medical comorbidities Age 1-39 years old with no medical comorbidities
MONITOR
Daily for 14 days
MONITOR
Every 2 days x 7 days; then recommend self-monitor for additional 7 days depending on progress
MONITOR
Consider self-monitoring only; check-ins determined by individual patient. (Consider at 7 days)

Safety Net Flags

  • Socially isolated (Lives alone, unable to connect with others through technology, little to no social network)
  • Lack of caregiver support if needed
  • Inability to maintain hydration (Diarrhea, vomiting, cognitive impairment, poor fluid intake)
  • Food/financial insecurity
  • Receive homecare support
  • Challenges with health literacy or ability to understand treatment recommendations or isolation expectations
  • Unable to self-manage
  1. Assess current symptoms and change (better / worse). See symptoms / atypical symptoms in history section above.
  2. Vitals – patient to record until symptoms resolve
    • once daily T, BP (if patient has access to a cuff)
    • twice daily HR, RR, +/- SPO2
  3. Assess level of dyspnoea (see Examination/Remote Examination on this page for tips on assessing dyspnoea virtually)
  4. Check urine output and fluid intake
  5. Check for respiratory and other red flag symptoms (See When to Refer to ED section)
    • RESPIRATORY
      • Severe shortness of breath at rest
      • Difficulty in breathing
      • Increasing significant fatigue (reported in some patients as a marker for hypoxemia without dyspnea)
      • Blue lips or face
      • Hemoptysis
    • OTHER
      • Cold, clammy, or pale and mottled skin
      • Reduced level of consciousness or new confusion
      • Little / no urine output
      • Pain or pressure in the chest
      • Syncope
  6. Note underlying chronic disease that indicates increased risk. For patients with diabetes increase to daily monitoring.
  7. Assess need for regular medication changes or advice (see “management” tab below).
  8. Check mental health, access to food, support or carer, financial or housing stress.
  9. Assess whether this patient can still be managed at home (see When to Refer to ED tab: consider whether goals of care conversation is appropriate).
  10. Give detailed management advice (see management tab below)
  11. Set up time for next follow-up – If follow-up falls on weekend make plan for this.

Here is an example of a monitoring template you could use to track all your clinic patients. Download or save a copy of this template from Google Sheets.

Here is a summary sheet that can be used as a guide for a potential COVID care daily “rounds” for monitoring.

EMR Tools are available to assist with monitoring too.

HFAM has obtained a limited supply of pulse oximeters.

Pulse oximeters are available for patients you are monitoring who:

  • Do not have / cannot access a pulse oximeter in any other way;
  • Tested positive for COVID-19; and
  • Are in the high-risk category (visit HFAM website and click “Monitoring and Follow-up” for risk assessment tool) 

How to access:

Please call Anju Dalal (905-525-9140 ext. 28251), who will answer this line Monday to Friday 9 to 5, out-of-hours messages will be picked up on the next working day. Please have the following details to hand:

  • Patient full name, address and phone number
  • Family physician name and phone number
  • Arrangements for pickup or delivery of the pulse oximeter (see below)
Pick-up instructions Delivery instructions
If patient has someone who can come to the clinic to pick up the pulse oximeter:

– Name of person who will be picking it up (please confirm it is not a quarantining contact!)
– Phone number for person picking up (we will connect with them)

Pulse oximeter will be left with McMaster Family Practice clinic entry screeners on the 3rd floor of David Braley Health Sciences Centre. Package will be labeled with the names of the patient and the person picking up the unit.
If no-one is available to pick up the pulse oximeter, then a few volunteers are available to deliver it to the patient. Please include:

– Number to text or call when volunteer has arrived
– Where to leave the pulse ox (e.g. “place in mailbox” or “leave at front door”)
– Any other information that would be helpful for the volunteer (e.g. parking information, beware of dogs, etc.)

Volunteer will ring doorbell, or send a text to confirm arrival to patient.

How to return the pulse oximeters:

Please tell patients and caregivers that supply of pulse oximeters is very limited at present, so these need to be returned to the clinic as soon as they are no longer needed.  

To return the pulse oximeter, patients can call Anju at 905-525-9140 ext. 28251 to arrange for someone to drop it off at the clinic, or to have a volunteer return to the home to pick it up if there is no other option.  These instructions are included with the pulse oximeter also.

Patient instructions on using the pulse oximeter:

The instructions below are on the HFAM site, and will be included with the unit. These can also be printed and shared with patients as needed.

Pulse Oximeter Patient Instructions (ProResp)

  1. 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.

  1. 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.

  1. 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).

  1. 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:
    1. 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).
    2. 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

  1. Give advice to ensure adequate hydration

  1. Direct to latest information on self-isolation / caring for someone with COVID

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.
  • Existing
    • 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

Approach When to Use Instructions
Non-Test Based Waiting 10 days from symptom onset (or 10 days from specimen collection date if persistently asymptomatic) Mild to moderate illness AND no severe immune compromise Can discontinue isolation after 10 days from symptom onset (or 10 days from positive test collection date if never had symptoms), provided that the individual is afebrile (without the use of fever-reducing medications) and symptoms are improving for at least 24 hours. Absence of cough is not required for those known to have chronic cough or who are experiencing reactive airways post-infection. Mild to moderate illness includes the majority of cases of COVID-19, and includes all those who do not meet the definition of severe illness or severe immune compromise (below).
Non-Test Based Waiting 20 days from symptom onset (or 20 days from specimen collection date if asymptomatic and severe immune compromise) Severe illness (requiring ICU level of care) OR severe immune compromise Can discontinue isolation 20 days from symptom onset (or 20 days from positive test collection date if asymptomatic and severe immune compromise), provided that the individual is afebrile (without the use of fever-reducing medications) and symptoms are improving for at least 24 hours. Absence of cough is not required for those known to have chronic cough or who are experiencing reactive airways post-infection. Studies informing this approach did not have a consistent definition of severe illness or severe immune compromise. For the purposes of a clearance assessment:

Severe illness is defined as requiring ICU level of care for COVID-19 illness (e.g.,respiratory dysfunction, hypoxia, shock and/or multi-system organ dysfunction).

• Examples of severe immune compromise include cancer chemotherapy, untreated HIVinfection with CD4 T lymphocyte count <200, combined primary immunodeficiency disorder,taking prednisone >20 mg/day for more than 14 days and taking other immune suppressivemedications.

• Factors such as advanced age, diabetes, and end-stage renal disease are generally notconsidered severe immune compromise impacting non-test based clearance.  

See full Ministry of Health Assessment Guideline

A significant proportion (around 10%) of patients report ongoing symptoms beyond the initial acute COVID-19 infection period (so-called “long COVID”). Other estimates in a recent not yet peer reviewed cohort study from the UK appear to show significant rates of persistent abnormalities in investigations relating to different organs in low risk individuals, however it is not clear to what extent these measures represent pre-existing measurement abnormalities (as there were no premorbid measures). There is still limited understanding of the case and mechanisms underlying this, and limited evidence for management of the symptoms, however this useful paper from the UK provides some guidance for management in primary care as well as indications for referral.

Management of post-acute covid-19 in primary care
Trisha Greenhalgh, Matthew Knight, Christine A’Court, Maria Buxton, Laiba Husain.
BMJ 2020;370:m3026 | doi: 10.1136/bmj.m3026

Management of Persistent (> 2 weeks) COVID-19 olfactory disorder

  • Maintain smoke and natural gas detectors
  • Monitor food expiration dates and nutritional intake.
  • Olfactory training:
    • Deliberately smelling rose, lemon, cloves and eucalyptus for 20 seconds each twice a day, for at least 3 months.
  • A comparative study showed no evidence of additional benefit from intranasal steroids. Ref: https://jamanetwork.com/journals/jama/fullarticle/2766523

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