13 April 2020
The National Institute for Health and Care Excellence (NICE) has published new "rapid guidance" on symptom management in patients with suspected and confirmed COVID-19 in the community, including at the end of life, together with specific advice on managing those with pneumonia.
As part of the "rapid guidance" series that NICE is developing in response to the pandemic, additional guidelines on managing patients with severe asthma and those with rheumatological disorders in the community during the coronavirus outbreak have also been added.
Future guidelines that will form part of the series are likely to cover COPD, cystic fibrosis and people receiving immunotherapy.
NICE's recommendations are based on evidence and expert opinion, and will be reviewed and updated as knowledge develops.
The range of clinical "rapid guidelines" for GPs and their teams include:
"COVID-19 Rapid Guideline: Managing Symptoms (including at the end of life) in the Community": https://www.nice.org.uk/guidance/ng163
"COVID-19 Rapid Guideline: Managing Suspected or Confirmed Pneumonia in Adults in the Community": https://www.nice.org.uk/guidance/NG165
"COVID-19 Rapid Guideline: Severe Asthma": https://www.nice.org.uk/guidance/NG166
The guideline on managing suspected or confirmed pneumonia in adults in the community lists the signs and symptoms to be used to help make decisions about hospital admission as: severe shortness of breath at rest or difficulty breathing; coughing up blood; blue lips or face; feeling cold and clammy with pale or mottled skin; collapse or fainting (syncope); new confusion; becoming difficult to rouse; and little or no urine output.
GPs should not use the CRB65 tool, which is recommended in NICE's standard guideline on pneumonia diagnosis and management, because it needs blood pressure measurement, which may not be possible in remote consultations and also risks cross contamination.
The guidance says clinicians need to assess the benefits, risks and disadvantages of hospital admission in patients who become unwell, taking into account "service delivery issues and local NHS resources during the COVID-19 pandemic".
NICE also suggests GPs find out about whether patients have any care plans or advance decisions to refuse treatment in place.
When considering hospital admission, patients should be told of the benefits, including access to improved diagnostic testing and respiratory support but also the risks and disadvantages including spreading or catching COVID-19 and loss of contact with their family.
Patients should be advised to seek further advice if their symptoms do not improve or worsen rapidly.
NICE's "rapid guideline" on severe asthma says all patients should continue to take their medication in line with their asthma action plan, including those who have confirmed or suspected COVID-19. If a patient needs to be seen they should be screened on the telephone to assess whether they have symptoms of COVID-19 ahead of the appointment and guidance on infection prevention and control should be followed when seeing patients.
The guidance stresses how GPs should only prescribe asthma medications to meet the patient's clinical needs and for no more than 30 days, otherwise the supply chain for medication could be put at risk.
The guidance says pulmonary function tests should only be carried out for urgent cases and if the results will have a direct impact on how the patient is treated, as they have the potential to spread the virus. Advice is also given on how patients should clean all their equipment, the prevention of device sharing and use of nebulisers.
If asthma patients have any anxieties about COVID-19, GPs should signpost them to charities such as Asthma UK and the British Lung Foundation, and advise them to follow advice about social distancing and shielding if they fall into this group.
In terms of rheumatological disorders, GPs should be aware that patients having immunosuppressant treatments may have atypical presentations of COVID-19. NICE's "rapid guideline" on rheumatological autoimmune, inflammatory and metabolic bone disorders highlights examples of patients taking prednisolone who may not develop a fever, and those taking interleukin-6 inhibitors may not develop a rise in C-reactive protein.
Patients should contact their rheumatology team about any issues related to their medicines or if their condition worsens. They too should be advised to follow advice about social distancing and shielding if they fall into this group.