Coronavirus – Top 10 tips on what to do in primary care

These top tips, issued by esteemed RCGP doctors, are for clinicians and practice employees and offer guidance on how best to tackle COVID-19 in primary care.

This is an edited version of article published on the Royal College of General Practitioner’s (RCGP) Learning portal and written Dr Toni Hazell, Dr Steve Walter and Dr Barbara Noble

1. Keep up to date

Things are changing all the time – the Public Health England (PHE) page ‘interim advice for primary care’ and the RCGPs page on coronavirus are good places to go for advice.

At first sight the PHE page looks out of date (last updated February 25th) but the advice on the page is still current and the links to things like case definitions are up to date.

Nominate one person in your practice to keep an eye on the guidance and cascade any changes. All those who would normally receive an NHS flu vaccination are being advised to practice social distancing, including working from home where possible. It remains to be seen how individual practices and trusts will interpret this for the large number of doctors who have asthma, diabetes or another condition on this list.

The NHS website currently says that ‘The NHS will contact you from Monday 23rd March 2020 if you are at particularly high risk of getting seriously ill with coronavirus. You’ll be given specific advice about what to do’ – we are not currently aware of any guidance given to practices about who to contact and what to say.

2. Triage, triage, triage

Patients who have a new persistent cough or a temperature over should not come to their GP. The temperature threshold was initially given as 37.8°C but the NHS website now just says ‘a high temperature – you feel hot to touch on your chest or back’.

Consider whether your current method of booking appointments is suitable. Many practices are suspending online booking and all patients are being triaged for these symptoms before being allowed to book an appointment. Patients with a new cough or a fever should self-isolate at home for 7 days, then can go back to their normal routine. They need only call 111 if their symptoms are worsening, or they are no better after 7 days.

3. Know where your isolation room is

Any symptomatic patient that gets past the phone triage and the notices on the door needs to be immediately isolated. You don’t want a panic about where to put them – allocate an empty room for this purpose. If a patient uses the room then they should shut the door. You should only communicate with them by phone. If they need to use the toilet then the toilet they used must be thoroughly disinfected before anyone else uses it and they should wash their hands for 20 seconds with soap.

4. Don’t expect your patients or staff to be tested

At the time of writing, only those who need admission will get a test. Petitions are springing up asking for front-line healthcare professionals to be tested (and the press conference of March 16th suggests that healthcare professionals may start to be tested soon) but you can be clear to patients who are self-isolating but not ill enough to be admitted that they won’t get a test for coronavirus.

5. If a symptomatic patient enters your room then your room becomes the isolation room

If you discover during a consultation that the patient has new symptoms then you need to leave the room and isolate the patient in it. Do not examine the patient. Follow the advice in point 3 and don’t use the room again until it has been disinfected. If guidance changes such that symptomatic patients are being seen in primary care (and there are reports that this is already happening at a local level) then practices may want to have a designated ‘dirty’ room to see these patients.

6. PPE is not just a degree in politics, philosophy and economics

Check how much PPE (personal protective equipment) you have and consider developing a protocol for how PPE is developed and for how long it is worn. You shouldn’t be examining patients with coronavirus symptoms unless they are so ill that it is an emergency, in which case you should have gloves, an apron and a fluid resistant surgical mask, all of which should be disposed in the clinical waste after use. Consider whether staff should start wearing scrubs, which can be easily washed at a hotter temperature than normal clothes.

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7. If you have a sick patient with possible coronavirus, let ambulance control and public health know asap

Patients with possible coronavirus shouldn’t use taxis or public transport so let ambulance control know and contact your local health protection team if you have such a patient in your surgery who will need hospital review. Public health will tell you where to send them.

8. Look after yourself and your staff

Anyone who actually listens to the security briefings on a plane will know that you should put your own oxygen mask on before helping others. The same principle applies here; if you get ill, you’ll be of no use to anyone. As well as using PPE if you see patients with possible coronavirus, look after your mental health if this is stressing you out. If you are pregnant or immunocompromised then talk to your employer or partners and think about what you are prepared to do; as per point 1 of this list, doctors and practice employees with a serious medical condition may have to stay home for the next 12 weeks. Doctors affected by this may be able to do telephone triage or other non-patient-facing tasks such as remote prescription signing or document management. An occupational health opinion could be sensible for some GPs with chronic conditions. If your mental health is affected, consider using some of the services available for GPs and practice employees, such as practitioner health.

9. Plan ahead; this will be a marathon, not a sprint

A sigh of relief went up when it was announced that schools would stay open for the children of NHS workers, but there may still be issues such as after school clubs and wrap around care being unavailable, so check if any of your staff are affected by this and need to change their hours.

Could they switch to doing core clinical work in the surgery and admin from home? Be aware that household contacts of anyone with symptoms are supposed to self-isolate for 14 days from the onset of symptoms, so you are likely to have significant numbers self-isolating for two weeks at short notice.

Do some forward planning at a practice level. This isn’t going away anytime soon. Make sure that what you are doing is sustainable for you and your practice. Can you do video consultations? Some of the text messaging software already in use can be adapted for this purpose. Consider what ‘routine’ work can be put off and what should still be done – some practices are delaying smears, but continuing with infant immunisations. Could you increase repeats to 2 or 3 months at a time – this will take some time now but will save time in the months to come. Do you really need to check every repeat as carefully as you always do, or could most be waved through, with proper scrutiny reserved for DMARDs, NOACS, and opiates?

10. Your core clinical skills are still important

Not every ill patient will have coronavirus. Even under pressure still allow space for patients to tell you what’s wrong with them. Keep an open mind, think laterally, and suspend your judgement as it saves time in the end.

Consider which are the relevant questions to ask; your core clinical skills are your most reliable tools. If ‘pattern recognition’ is not working, re-frame your ideas using first principles and using an analytical approach using probability. Learn to tolerate uncertainty and share this with the patient.

Make sure that you document that your triage decisions are made due to covid-19 (possibly via a template) so that if your decisions are called into question in years to come you remember what was going on.

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