FAQs – Clinical questions

Last updated: 30.03.2020

 

Most recently added FAQs also available in audio discussion format

Key below:

AM – Alison Moody, respiratory consultant

TC – Tim Cobby, ICU consultant

LM – Lou Mitchell, ED consultant

Q – Can you tell us what would you expect to be the typical clinical features of a COVID patient who needs to be admitted?

A –

AM: The data coming out of China is describing a fairly typical patient. 99% of them have got a fever, and by a fever they mean over 37.8°C, which we wouldn’t technically say is a fever, but 99% of them have got that. About 70% have a cough and then it gets less and less; myalgia, breathlessness. Actually people are not complaining of it particularly early on even though they’re hypoxic, because it’s easy to breathe, their lungs are compliant. They are not necessarily complaining of breathlessness. Some of them are getting rhinitis, cough/cold type symptoms, and actually interestingly, some people are getting gastric symptoms, so some people are starting off with nausea and diarrhoea.

LM: Children particularly seem to get that.

AM: Yes. Kind of typical flu like symptoms, but the fever and the cough are fairly critical and extremely common in these patients

LM: And by fever, just from an emergency medicine perspective, they haven’t always got one at the moment they come through the door, but they often describe fevers and rigors. That’s enough in my mind to trigger it.

AM: Yes, often we find they have a temperature of 38.5°C in the ambulance and they never have a temperature again when they come into hospital – that still counts!

 

Q – How would you know when a patient might be needing respiratory support or oxygen?

A –

LM: I think essentially it’s your clinical assessment and with a lot of emphasis on oxygen saturation levels actually. So probably more emphasis on oxygen sats and maybe slightly less emphasis on respiratory rate. Which goes against everything I’ve been teaching in ED for the last 15 years – which is my total obsession with respiratory rate! So it just goes to show, but I think it’s a holistic assessment: the end-of-the-bedogram has an awful lot of value and if a patient is severely hypoxic they will look a funny colour and they probably will be fairly tachyapnoeic by then. I’d want to know clinical fluid assessment as well: are they horribly dehydrated? Do they need fluid resuscitation or fluid support? But essentially, your baseline triage, global assessment and a set of obs are enough to get a fairly good picture of whether this patent is likely to need admission or not.

AM: And I think based on that, what we don’t want is every poor patient coming through having an arterial blood gas because they’re really painful. So you want to really reserve those for the people who are really ill and not for the ones who are requiring 2L of oxygen by nasal cannulae. They don’t need a blood gas if they’re normally well because it’s an invasive, painful test and probably isn’t going to add much more than any other test.

TC: No, I think sats should be a good reliable measure. A blood gas really is telling you other factors, you know are they actually septic?

AM: Yes, good for lactate but you can get that on a venous gas.

TC: And are they struggling to breathe, do they have a high CO2 or low CO2? Most patients you can get that from a clinical picture.

AM: Yes, I’m not saying we’d never do it but I wouldn’t do it as first line because I think it’s painful.

 

Q – Can you tell us a bit about when you would use or when you would think about using NIV?

A –

AM: At the moment we are not thinking about using it very much, but obviously that might change. So the situations we are going to use it in are a group of about 50 patients in the community who are on home NIV (that’s bi-level ventilation). If they end up getting admitted then they will need to continue on their bi-level ventilation. To start with they’ll have to be swapped to our ventilators because we have to use non-vented masks. The home masks have a hole in them and COVID will shoot out through the hole! If they are then COVID negative, we will put them back on their normal mask. Otherwise they will have to continue with ours. So that group of patients will get bi-level ventilation.

If somebody comes in with an exacerbation of COPD and happens to be COVID positive or not, we would be giving them bi-level ventilation if it is appropriate based on their clinical situation.

The people we are not intending at the moment to use NIV on (either CPAP or bi-level ventilation) is everybody else. So if they’re sick enough to need that, then you should be referring to intensive care for their assessment to confirm or agree a protocol in terms of: should they be going to ITU at any point? If not then we would not be giving them NIV on the ward, but the situation may change. There’s lots of debate in the respiratory community about using ward based CPAP and there is no definitive answer about that at the moment. We will have to see what our clinical need is and we will change our advice appropriately and when the time comes.

 

Q – What about patients who have sleep apnoea and bring their machine in?

A –

AM: All patients who have sleep apnoea will not be using their CPAP on the ward, they will just have to be sleepy! That is our advice: that if they come in and they have home CPAP, they will not be using it in hospital. The guidance encourages people not to use respiratory suppressing medications such as morphine, otherwise they will get really sleepy! We are just going to say a blanket no for them, it’s just easier. Obviously if they are COVID negative and they are on a clean ward they can use their CPAP machine, but not otherwise.

 

Q – You mention the hallmark clinical features in terms of COVID, when they come into the hospital emergency department, does it matter what grade you are to order a COVID test or can anyone initiate that?

A –

LM: In the emergency department we are working to a flow chart which you’ve seen on the wall and it’s changing every other day, but the one bit that hasn’t changed is that early clinical assessment of the patient needs to be by an autonomous decision maker. I don’t want to say necessarily a senior doctor, but I would say an experienced junior, a senior doctor or a junior doctor with direct senior support. I think that’s because the person who is assessing that patient ultimately is making that decision: do I think this patient clinically has COVID or not? That’s quite a weight to rest on their shoulders and they will probably occasionally get it wrong. I hope that answers your question. Yes, it’s a senior decision whether or not to swab the patient, but it’s not actually about the swab, it’s about how you cohort that patient according to what you think clinically is going on.

 

Q – We’ve had a few debates around this on the wards: patients who have come in with a diagnosis of pneumonia, they’ve reached the ward and they haven’t had a COVID swab. So what evidence can we have for justifying not swabbing or swabbing the patient?

A –

AM: Everybody with pneumonia should be swabbed. There is very clear guidance on that, and the difficulty is diagnosing pneumonia which can be variable between clinicians. As you probably know the respiratory consultants are quite strict on diagnosing pneumonia and other people are less strict. I haven’t seen anybody coming in without a COVID swab recently. Obviously in that transition there were some, but currently ED are swabbing everybody with pneumonia or respiratory symptoms.

LM: Currently we’re thinking about it in anybody with a new respiratory type presentation, or an exacerbation of an existing respiratory type presentation, or a fever and/or a cough. So I was thinking about the patients I saw last night. They were both children who I saw and said ‘no we’re not going to swab them’ because I didn’t think they had COVID. One of the kids was a very young baby who was having hypoxic episodes, but there was no fever and there was no cough. We changed our mind later but that’s going to happen. The other child was a 3 year old who quite clearly had a high fever but no cough, no real respiratory symptoms and had infected eczema, so it’s like well there’s clearly an alternative diagnosis for that child. It made a huge impact because, as is always the way, that child’s parents were healthcare workers who up until then had been told to self isolate.

TC: I think we will get the odd one coming through. Someone who presents with diarrhoea and fevers and two days later develops a cough, they won’t have had their COVID swab done, but then that probably should be a senior person to decide that and saying we need a swab.

AM: It’s getting the balance isn’t it, between doing way too many tests and running out of tests, slowing up the ones we really need back, versus missing out on tests in the right people and I don’t get the impression at the moment that ED are unnecessarily swabbing or missing people out. I haven’t had that feeling at all. I think we had a few at the beginning; people were already on a ward when the government changed the guidelines (anyone with a cough or a fever), but since then I don’t think it’s going to be a major issue. As Tim says there will always be somebody who doesn’t quite present in the right way that we think about that straight away.

 

Q – Do these patients need antibiotics?

A –

AM: Sometimes…The evidence that getting a superadded bacterial infection isn’t as strong as it is in the normal seasonal flu, but there is no doubt people are, so I think we have to use our clinical skills to some extent. If someone’s got significant consolidation on their chest x-ray and high inflammatory markers, then I think none of us would say this is all viral and not give antibiotics. But if they’ve got a clear chest x-ray and they’re otherwise relatively well, I’m not sure any one of us would give antibiotics. We are using calcitonin on ITU to try to help with that decision making, but not elsewhere at the moment.

 

Q – And for those patients who have asthma and COPD that come into the hospital, and they have a wheeze as well, can you give them steroids? Are steroids ok to give in those patients?

A –

AM: The advice is to avoid them if possible, but I think if you’ve got someone who’s wheezy and is compromised by that and you’ve given them nebulisers, then we would expect steroids to be part of their treatment. They shouldn’t be automatic in COPD patients who present with pneumonia, which is often the case now. If they’re not wheezy and they’ve got pneumonia we shouldn’t be giving them steroids: you should just treat their pneumonia and give them nebulisers if they need it, but you shouldn’t be giving them steroids. If in doubt ask!

 

Q – Are we still recruiting to clinical research?

A – No – except for trials where patients may come into harm and for any trials relating to COVID-19.

 

Q – Are we repeat swabbing?

A – We are not routinely repeat testing at the moment. The decision to keep in isolation and reswab should be made by a consultant.

 

Q – Who swabs patients?

A – The decision to take an initial swab needs to be made by middle tier clinical staff – SHOs or above. The decision to keep in isolation and reswab should be made by a consultant.

If poor technique is used there is a higher risk of false negative, so staff should confirm that they have had training to take a swab before doing it.

Areas at NDDH where the majority of swabs are taken are all trained. If an inpatient ward needs a swab taken but nobody on the ward is sure how to take the swab, then bleep 500 can facilitate.

 

Q – Can we have clarification on our approach to the CPR guidance issued by the Resuscitation Council?

A – The guidance from the Resuscitation Council presents a few options depending on the situation, which is entirely appropriate for some healthcare professionals in some healthcare settings.

For staff first responding in our settings, we have decided to adopt the same procedure (performing compression only resuscitation) for all patients whether admitted with COVID-19 or for another reason, although PPE need only be used in patients who are suspected of having or confirmed to have COVID-19.

Only anaesthetists should be performing airway interventions. This includes the insertion of guedel or nasopharyngeal airways.
No airway manoeuvres of any sort should be performed on patients with suspected or confirmed COVID.

Please be assured that there is lots of research to support that hands-only CPR is very effective.

 

Q – Non-cardiac arrest situations e.g. respiratory arrest. Can I insert a basic airway?

A – No, only ICU team should at this point. In theatres, only anaesthetics teams should support with airways.

 

Q – Will junior doctors still be rotating to the next specialty on 1 April?

A – We very much agree with national guidance that to rotate junior doctors into a new environment in these current circumstances puts them at professional risk – particularly as the level of senior support we normally provide for inductions will not be available. The safest action is for junior doctors to continue to work in their current environment.
We will be working with the clinical tutors to ensure we are making the best use of all junior doctors and some may be redeployed as needed.

 

Q – Are there plans for August when a lot of us/junior doctors? are expecting to move on?

A – Not yet. The answer will depend on a variety of factors that are currently unknown, and we will need to address this at a later date.

 

 

Last updated: March 30, 2020