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REMEDY : BNSSG referral pathways & Joint Formulary

Long COVID

Checked: 20-10-2020 by Rob.Adams Next Review: 20-01-2021

Overview

****Long Covid is a condition that can affect patients in many different ways and our understanding of how to manage it is still evolving. A BNSSG system wide group will be meeting regularly to review recent evidence on Long Covid and assess demand and access to services. We will update this page regularly to reflect any changes.****

Following COVID-19 infection, most patients will make a full recovery or only experience mild ongoing symptoms.

Patients who have been hospitalised with severe infection or admitted to ICU are likely to be followed up by hospital teams in most cases but may still present in primary care if they need to access other services.

Patients who have not been hospitalised may also present with persistent symptoms and may need further support or referral if indicated. This page gives some guidance to clinicians on managing some of the more common symptoms that patients may present with in primary care.  We appreciate that it may not cover all scenarios so clinicians may want to consider obtaining Advice and Guidance from individual specialties if needed. 

Patient Support and Advice

The Your Covid Recovery website produced by the NHS has advice for patients on self care and managing expectations during recovery. 

Primary Care Assessment

If symptoms persist or are more severe and additional support is required then please refer to the BNSSG Primary Care Assessment and Management of Adults with Persistent Symptoms Following COVID-like Illness.

This document has been created by the STP Respiratory Board and should be used in conjunction with :

In the sections below there is also advice on management of some of the more common persistent symptoms that patients may experience.

Post-viral fatigue

Fatigue following COVID infections is quite common but most patients will make a full recovery.

The Your Covid Recovery website has some advice for patients on managing this symptom.

There is also some guidance for patients on 'Post viral fatigue - a guide to management' available from the British Association of CFS/ME which may be helpful.

If symptoms such as fatigue or cognitive dysfunction persist for more than 4 months then referral should be considered, particularly if the patient is not making acceptable progress despite following the self-management and rehabilitation advice above. Please see the CFS/ME page on Remedy for details of referral criteria which should be met prior to referral.

Psychological Support

Some patients who have had COVID-19 may suffer from psychological issues as a result of their illness.

The Your Covid Recovery website has some advice for patients.

Several resources are available to patients and further information is available on the Mental Health Support for patients page.

Respiratory symptoms

Respiratory symptoms (cough and SOB) will generally improve quickly after mild COVID-19 infections but some patients who are more severely affected may be more at risk of longer term respiratory problems - particularly if they have had COVID pneumonia or other complications such as PE.

Patients who have been hospitalised may automatically be followed up by respiratory teams.

Advice for GPs on assessing patients presenting in primary care from local respiratory teams
In the context of a normal assessment (history, examination and appropriate investigations e.g. exclusion of anaemia and other non-respiratory causes for breathlessness) without red flags, an oxygen saturation of 96% or above and the absence of desaturation on exertional tests is very reassuring. Further investigation or referral in the first six weeks after covid-19 in such patients is rarely indicated. 
Oximeter readings persistently in the 94-95% range or below require assessment and investigation. Suggested methodologies include repeated oximeter readings before and after 40 steps on a flat surface (if self-testing remotely) or  one minute doing sit-to-stand as fast as possible (if supervised on site). A fall of 3% in the saturation reading on mild exertion is abnormal and requires investigation (1, 2, 3).
 

Patient support and advice

The 'Your Covid Recovery' website  has some advice for patients who are experiencing persisting symptoms such as:

Breathlessness

Cough

 

Advice and Guidance

If further advice is required then consider initially contacting the community respiratory team or local hospital respiratory teams.

Details are available on the Remedy page below:

Advice and Guidance - Respiratory

 

References

(1) Long Term Respiratory problems of COVID-19: BMJ Editorial (3.8.20)

(2)  General Advice on wider aspects of Post-Covid Syndrome: https://www.bmj.com/content/370/bmj.m3026

(3) Statement on assessment of oxygenation in primary care: https://www.cebm.net/covid-19/what-is-the-efficacy-and-safety-of-rapid-exercise-tests-for-exertional-desaturation-in-covid-19/

Anosmia

Change in sense of smell or taste is a symptom of acute COVID-19 and in most cases this symptom will recover within 3 weeks.

In some patients anosmia may persist.

The Your Covid Recovery website has some advice for patients.

Please see the Anosmia page for advice on management and when to consider referral for this symptom.

Joint and muscle pain

Some patients will experience some joint and muscle pain or stiffness - particularly if they have been hospitalised.

The Your Covid Recovery website has some advice for patients.

Patients should be encouraged to gradually increase physical activity and/or exercise balanced with rest but if problems persist then a physiotherapy referral should be considered.

Resources

Case Definition

NICE are working on national guidelines for treatment of Long COVID and have proposed the following case definition for patients with COVID symptoms (1)

Acute COVID-19 infection: Signs and symptoms of COVID-19 for up to 4 weeks.

Ongoing symptomatic COVID-19: Signs and symptoms of COVID-19 from 4 weeks up to 12 weeks

Post-COVID-19 syndrome: Signs and symptoms that develop during or following an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis. It usually presents with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body.

Post-COVID-19 syndrome may be considered before 12 weeks while the possibility of an alternative underlying disease is also being assessed.

(1) COVID-19 guideline scope: management of the long-term effects of COVID-19 (October 2020)