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REMEDY : BNSSG referral pathways & Joint Formulary

Long COVID

Checked: 09-02-2021 by Rob.Adams Next Review: 30-04-2021

Overview and Community Long COVID Single Point of Access

****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. (updated Feb 21)

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.

Community Long COVID Single Point of Access (updated 25.1.21)

The Community Long COVID SPA run by Sirona is now accepting referrals. This is a therapy service for patients with persisting Long Covid symptoms which are significantly impacting their ability to function in day to day life and who have not responded to initial self-care measures. Patients with specific physical symptoms should be investigated appropriately in primary care and referred to secondary care clinics if required.

It is particularly important that patients who are vulnerable or who can't access self -care resources are referred to this service.

The Long COVID SPA service may include,

  • a baseline assessment of Long COVID symptoms,
  • virtual or face to face clinic based assessment of needs
  • support with accessing the “Your Covid Recovery” platform and goal setting using shared decision making
  • motivational interviewing and brief intervention
  • referral or signposting to specialist services or sources of support
  • liaison with specialist MDT for more complex cases

Referral criteria for the Long COVID SPA (please be aware that these criteria may change 

  • Patients with Long Covid symptoms who are still struggling to function after 12 weeks where signposting to self-management has not led to improvement (see Your Covid Recovery above).
  • Patients should be appropriately assessed to exclude any underlying pathology before referral (see investigations below).
  • At present, we are only able to accept referrals from GPs

Please complete the referral form and send to: Sirona.longcovid@nhs.net

Investigations

Prior to referral to Long COVID SPA please check the following mandatory bloods:

  • FBC, TSH, HbA1c, U&E, LFT, CRP, TTG antibodies, Calcium, creatinine kinase

Also consider if symptoms indicate:

  • Pulse oximetry - at rest. Also consider sit/stand or 40 step test to check for desaturation.
  • Chest Xray - if there are persisting respiratory symptoms.
  • D-dimer - if there are persisting respiratory symptoms.
  • Spirometry or relaxed FVC  (FVC < 80% predicted indicative of restriction) - if this is available.
  • ECG - if there are cardiac symptoms or in patients who remain breathless.
  • NT-proBNP - in patients with suspected heart failure and who are eligible - see NT-proBNP page.
  • Echocardiogram - if NT-proBNP is raised*.
  • (*If BNP slightly raised and normal ECHO then investigate for respiratory causes (mild elevation in BNP is non-specific and can be elevated for all sorts of reasons e.g. renal impairment etc)

You may also wish to refer to the NICE guidelines:

 3 Investigations and referral | COVID-19 rapid guideline: managing the long-term effects of COVID-19 | Guidance | NICE

 

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

 

BNSSG Pathway for persistent unexplained respiratory symptoms

For patients with persistent unexplained respiratory symptoms please check the following pathway that has been developed by local respiratory teams which gives advice on diagnostics and when to refer:

 

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.

Returning to work after COVID

The Faculty of Occupational Medicine has published advice for health care professionals to help them facilitate the return to work of people who have long-COVID: :

Guidance for healthcare professionals on return to work for people with long-COVID

The guidance works on the principle that work is generally good for health and gives practical steps that health care professionals can use when making decisions about fitness to return, including certification.

Long COVID in children

At present the situation regards Long COVID in children is not clear. Most children will have mild disease and make a full recovery. 

If children present with specific symptoms following Long COVID then please use existing paediatric referral pathways.

If advice is required then please use the paediatric advice and guidance service.

For children with persistent fatigue for more than 3 months following confirmed or suspected COVID-19 infection then please consider referral to the Paediatric Chronic Fatigue Syndrome service.

Resources

NICE Guidelines

NICE guidelines (NG118) on managing the long term effects of COVID-19 were released on 18.12.20.

Case Definition

The NICE guidelines have proposed the following case definition for patients with COVID symptoms.

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.