The BMJ have published guidance on how to give a remote assessment for a patient with suspected COVID-19
A 37 year-old healthcare assistant develops a cough. Next day, she wakes with a fever (which she measures at 37.4°C) and shortness of breath. She manages her condition at home for several days, experiencing increasing tiredness, loss of appetite, and a persistent dry cough. On the fifth day of her illness, she develops mild diarrhoea, and her chest feels quite tight. She takes her temperature, which has gone up to 38.1°C. Feeling unwell, she contacts her GP surgery for advice. She would like someone to listen to her chest, but the receptionist tells her not to come to the surgery and offers her the choice of a telephone or video consultation. She was previously well apart from mild asthma (on occasional salbutamol). Five years ago, she took citalopram for anxiety. She is a single parent of three children.
Novel coronavirus disease 2019 (COVID-19) is an urgent and spreading threat whose clinical and epidemiological characteristics are still being documented. With a view to containing COVID-19, a shift from in-person to remote consulting is occurring; clinicians are, thus, faced with a new disease and a new way of interacting with patients.
This article will present some guiding principles on how to choose between telephone and video appointments, how to conduct a ‘query covid’ consultation remotely, and considerations when arranging follow-up and next steps.
It does not cover remote triage or how to set up video consulting in your practice. This article is intended as a broad orientation to a COVID-19 consultation. It does not cover every clinical eventuality, and should not be used as an official guideline for the management of a COVID-19 patient. National and local guidance are being urgently produced, and further research is being undertaken on specific aspects of management such as use of antibiotics.
Telephone or video?
The telephone is a familiar, and dependable, technology which is adequate for many COVID-19 related conversations. Patients who just want general information about COVID-19 should be directed to a telephone message or online symptom checker such as NHS 111 online or other online resources. Those with mild and uncomplicated symptoms, and those consulting for administrative reasons, can generally be managed by telephone. In the UK, sickness certificates can be downloaded directly from NHS 111 online.
However, video can provide additional visual information, diagnostic clues and therapeutic presence; hence, video may be appropriate for sicker patients, those with comorbidities, those whose social circumstances have a bearing on the illness, and those who are very anxious. Patients who are hard of hearing may prefer video to telephone.
Note that many countries, including the US, are formally relaxing privacy and data protection regulations for video and other communications technologies during the crisis; the General Data Protection Regulations, which apply in the UK and European Union, already include a clause excepting work in the overwhelming public interest.
Before you connect
Open the patient’s medical record, preferably on a second screen if using video. Check for risk factors for poor outcome in COVID-19, including immunocompromised states (such as frailty, diabetes, chronic kidney or liver disease, pregnancy, or taking chemotherapy, steroids, or other immunosuppressants), smoking, cardiovascular disease, asthma, or chronic obstructive pulmonary disease (COPD). Enter a code for a video or telephone consultation and perhaps also ‘in the context of COVID-19 pandemic’. Have your current ‘Stay at home’ COVID-19 guidance on hand.
Establishing a technical connection for a video consultation
Research shows that if the technical connection is high quality, clinicians and patients tend to communicate by video in much the same way as in an in-person consultation. When you are ready to connect, follow your local procedure (in some cases, for example, the link will be via a fixed URL and in others, a new URL will be generated for each appointment). When connected, check video and audio (‘Can you hear/see me?’) and ask the patient to do the same. If necessary, prompt the patient to unmute and adjust their microphone (you may need to call them on an ordinary telephone to troubleshoot this). Make sure you have a record of their ‘phone number in case you need to call them.
Beginning the consultation
Check the patient’s identity (for example, if they are not known to you, ask them to confirm their name and date of birth). Speak to the patient, if possible, rather than their carer or family member. Ask where they are right now (most patients will be at home, but they may be staying somewhere else). Then, begin with a ballpark assessment (very sick or not so sick?). What are they currently doing (lying in bed or up and about)? Do they seem distressed? Too breathless to talk? If you are using video, do they look sick? If the patient seems sick, go straight to key clinical questions as appropriate – otherwise, take time to establish why the patient has chosen to consult now (for example, are they or a family member very anxious, or are they concerned about a comorbidity?). Find out what the patient wants out of the consultation (for example, clinical assessment, certification, referral, advice on self isolation, reassurance).
Taking a history
Note the approximate incidence of key symptoms and signs listed in the infographic (right hand column), with the caveat that this list was generated in a different population and may not reflect your own case mix. The infographic guidance should be used flexibly to take account of the patient’s medical history and issues that emerge during the conversation. The vignette describes a typical mild to moderate case of this disease; more serious cases – typically develop worsening respiratory symptoms, which may indicate pneumonia. Elderly and immunocompromised patients may present atypically.
Note the date of first symptom to date-stamp the onset of disease. Many, but not all, patients will have a thermometer at home. Ask how high their temperature is currently, how long the fever has lasted, and what the highest reading so far has been. The fever in COVID-19 is often, but not always, >38.0°C and tends to persist beyond five days; note that up to half of all patients with COVID-19 have no fever at initial presentation.
Most, but not all, patients with COVID-19 have a cough. It is usually dry, though a substantial proportion of patients have sputum production, and typically persists for more than five days. Fewer than half of patients with COVID-19 have shortness of breath or difficulty in breathing, but if they do this tends to indicate more serious disease (especially pneumonia). It is, therefore, important to assess respiratory symptoms carefully, though the evidence base on how to do this is weak and expert opinion divided). If the patient has asthma, ask how many puffs of their reliever they are currently taking per day and whether this has increased recently. Systemic symptoms include fatigue and muscle pain, though many patients have neither.
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