What's an acceptable respiratory exacerbation telephone or video patient assessment now we are trying harder to keep a distance?
What do we think is currently reasonable practice for assessing a suspected COPD or asthma exacerbation? In the best of times ( which we don't necessarily always have anyway) we would prefer to see them , get all vital signs and examine. What now? What about next week or next month if pressures worsen? Maybe our rural colleagues have some tips for the urban GPs ?? Daryl Freeman How are video consults helping? Katherine Hickman How is it for patients on the receiving end Barbara Preston Amanda Roberts
A patient's perspective:
It depends on the asthma patient's understanding of and familiarity with their own asthma. For those of us with a good relationship with our doctor's practice and so that they know us and we trust them, speaking to someone who knows us is useful - on the phone or whatever. So many practices are large and impersonal. An excerbation can be scarey - so any port in a storm is better than none - but I would be warey about the possibility of cross contamination with Covid19 if I attended face to face anywhere.
Naturally any contact will be far more reassuring than nothing, particularly if the patient isn’t used to self-management. I suspect video would be best especially if it’s an unfamiliar doctor . And presumably it would be better for you too from that point of view, plus you’re more likely to be able to pick up some signs of the severity of the patient’s condition. At the moment my main concern would be to find out if I had Covid 19 or not and so do I take my antibiotics as usual or not? So, whilst I take Amanda’s point about avoiding the surgery, what we urgently need are quick tests - and that means back to face to face with all it’s difficulties.
I have started using AccuRx which integrates with SystmOne and allows video consultations. At least this allows you to assess RR better and how the patient looks as well as opportunity to assess inhaler technique. I am trying to be as proactive as possible and every COPD or asthma patient I talk to regardless of what they are phoning about I discuss importance of ICS for asthmatics, using SABA more than 3x a week as a sign of worsening symptoms and importance of getitng in touch with us sooner rather than later. For COPD patients focus on recognising when they are starting to deteriorate early, avoiding deconditioning and signposting to exercise videos etc. Also I have been talkign them through rectangular breathing over the phone which they have found really useful. This was useful advice from our local respiratory consultant. Interesting to note that he suggests examining the chest will have little to add so don't bother.....
A GP asked on the Covid Facebook group when she should be sending pts with Covid in and when to keep at home and this was one of the replies:
Email from secondary care colleagues re C19 case presentation:
Clinical presentation of the cases we have had so far has varied: some have a dry cough, others productive, most have been febrile, although not always at presentation; which has caught us out. Descriminating COVID from bacterial pneumonia is not easy, and we are giving the majority antibiotics in case they have a superinfection. This will not be as relevant for the less unwell patients. Examining the chest will have little to add, don't bother.
Deciding who to admit: There is a lot to be said for respiratory rate. RR > 21 is a useful cut off. Most patients reach the steep part of the oxygen haemoglobin dissociation curve at SpO2 of 90%, so would tolerate anything above that if they are otherwise looking OK.
Progress: a lot of patients do get worse about a week in. So it would be worth having some safety net in place. If they are presenting later, that in some ways is reassuring.
Immunosuppressed are at greater risk of severe disease, but may still have milder infection. Decisions about admission should probably be the same as others, as risk of catching coronavirus are probably greater in hospital.
We should be avoiding NSAIDS and steroids where possible. COPD exacerbations with historical eosinophil counts of <0.3 probably don't benefit from oral steroids with exacerbations. Avoid nebulisers, instead use MDI with spacer, they should be as effective and lower risk.
Pts presenting having not taken on oral fluids and paracetamol: turning them around at triage. The public health messages seem to be more about when to self-isolate but if we can get the drink drink drink message out , that would help a lot
Sick day rules for diuretics and ACE-inhibitors would be good to disseminate, so they don't all end up with AKI.