top of page

Covid-19: a remote assessment in primary care

What you need to know

  • Most patients with covid-19 can be managed remotely with advice on symptomatic management and self isolation.

  • Although such consultations can be done by telephone in many cases, video provides additional visual cues and therapeutic presence.

  • Breathlessness is a concerning symptom, though there is currently no validated tool for assessing it remotely.

  • Safety-netting advice is crucial because some patients deteriorate in week 2, most commonly with pneumonia

CASE PRESENTATION

 

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.


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.


Remote assessment of breathlessness

 

There are no validated tests for the remote assessment of breathlessness in an acute primary care setting. A rapid survey of 50 clinicians who regularly assess patients by telephone revealed some differences of opinion. For example, most but not all rejected the Roth score (which times how long it takes for a patient to take a breath while speaking) on the grounds that it has not been validated in the acute setting and could be misleading.

However, there was consensus among respondents around the following advice:

  1. Ask the patient 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. Align with the NHS 111 symptom checker, which asks three questions (developed through user testing but not evaluated in formal research):

  • “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 such as:

  • “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?”

4. 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.

  • There is no evidence that attempts to measure a patient’s respiratory rate over the phone would give an accurate reading, and experts do not use such tests. It is possible, however, to measure the respiratory rate via a good video connection. More generally, video may allow a more detailed assessment and prevent the need for an in-person visit.

Red flags

 

Red flag symptoms which indicate that the patient needs urgent assessment (either in person or by a good video link, depending on the clinical circumstances) include severe breathlessness or difficulty breathing, pain or pressure in the chest, blue lips or face, and a story suggestive of shock (such as cold and clammy with mottled skin, new confusion, becoming difficult to rouse, or significantly reduced urine output). Haemoptysis occurs in about 1% of covid-19 patients and seems to be a poor prognostic symptom.



Acknowledgments

We thank Fan-Shuen Tseng (medical student) who assisted with the search and data extraction for this paper, and Dr Eleanor Barry, Dr Michelle Drage, Dr Helen Salisbury, and Professor Simon de Lusignan along with BMJ editors (Tom Nolan, Will Stahl-Timmins, Anita Jain) and three peer reviewers (Jonty Heaversedge, Jessica Watson, Rachel Hopkins) for helpful comments on earlier drafts. TG thanks the Wellcome Trust (grant number WT104830MA), National Institute for Health Research (grant number BRC-1215-20008 and HS&DR 13/59/26), Health Foundation, and Scottish Government for funding her video consultation research.

Source: THE BMJ

77 views

Recent Posts

See All

Comments


bottom of page