Published: 1 April, 2020
A round-up of the news for primary care
Contents
New Zealand interactive case map
This graphic shows a daily update of cases around the country, with an interactive feature showing details of cases in
each DHB region.
World data including interactive graphs to compare countries is available here.
The case definition for testing is due to be updated: check the Ministry
of Health website. We
will cover this in the next Bulletin.
High-risk patients
Patients who meet any of these criteria are regarded as being at a higher risk of
complications from COVID-19:
- Aged 70 years or over
- Aged under 70 years with any of the following:
- Established cardiovascular or renal disease. Expert opinion is that well-controlled hypertension is not considered
to be a risk factor alone for people aged under 70 years.
- Chronic respiratory disease, e.g. moderate to severe asthma*, COPD, bronchiectasis
- Chronic kidney disease
- Diabetes; type one or two
- Chronic liver disease e.g. hepatitis
- Chronic neurological disease e.g. Parkinson’s disease, MND, MS, cerebral palsy
- Under active treatment or within four weeks of completing treatment for cancer
- Leukaemia, lymphoma, myeloma at any stage of treatment
- Immunocompromised due to organ/bone marrow/stem cell transplant, conditions such as HIV or medicines such as steroids
or biologicals, e.g. for rheumatoid arthritis, inflammatory bowel disease, psoriasis
- Severe obesity (BMI > 40)
- Pregnancy – increased risk from severe viral illness although no data to date suggests increased risk from COVID 19
N.B. People in close contact/living with those that meet the above criteria should take additional precautions to
avoid virus transmission, i.e. minimise all contact with others.
* Asthma severity is subjectively determined by the level of treatment required to maintain good control. For example,
mild asthma is well controlled with infrequent use of a SABA or with a standard daily ICS dose. Moderate asthma requires
a “step up” in treatment to achieve good control, e.g. replacing an ICS with a combination ICS/ LABA. Severe asthma
is when symptoms are uncontrolled despite the patient being adherent to optimal treatment, taken correctly.
Medicines information
The Christchurch Medicines Information Service has put together a web page containing regularly updated information
about medicines reported to worsen COVID-19 and medicines reported as treatment for COVID-19. The bottom-line is that
there are currently no clinical studies demonstrating increased harm from any medicine use in relation to COVID-19 and
patients should not be advised to stop any regular medicine for this reason. Treatment for COVID-19 is supportive; there
are no medicines which should be prescribed for the direct treatment of COVID-19 outside of a clinical trial.
The Medicines Information web page is available here
ACE/ARBs in people with COVID-19
A consensus statement from the Specialist Hypertension Research Network of the North Island of Aotearoa, supported by the Heart Foundation of New Zealand,
states that patients currently taking ACE inhibitors or angiotensin receptor blockers (ARBs) should continue to do so unless a change in treatment is clinically
indicated. The evidence that has been reported to date about worse outcomes in patients with COVID-19 who have hypertension and are taking ACE inhibitors or
ARBs is considered to be inadequately adjusted for confounding factors, and therefore inconclusive. This viewpoint is consistent with international advice.
Read more about the consensus statement here
Asthma management during COVID-19 pandemic
Advice from GINA (Global Initiative for Asthma) is summarised in a
one-page document.
In general, patients should continue on their
usual treatment, i.e. inhaled corticosteroid should not be stopped. In the event of an acute asthma attack, short course oral corticosteroids can be
prescribed if required. Patients with severe asthma who are on longer-term oral corticosteroids should continue these but ideally at the lowest possible
dose. Biological treatments should also be continued as they may reduce the need for additional oral corticosteroids.
The Asthma and Respiratory Foundation of New Zealand states that: "Our advice to those with
severe asthma, COPD, bronchiectasis, or other respiratory conditions is that they should self-isolate and seek to
minimise contact with others as much as possible."
COPD management during COVID-19 pandemic
Brief advice from GOLD (Global Initiative for Chronic Obstructive Lung Disease) is
available on their website.
They recognise that people with COPD are among the worst affected by COVID-19 and strongly encourage
them to isolate to minimise the chance of becoming infected and to continue on their regular medicines. They state that they are “not aware of any
scientific evidence to support that inhaled (or oral) corticosteroids should be avoided in patients with COPD during the COVID-19 epidemic”.
Ten tips for assessing patients for COVID-19 during a telephone consultation
- Use a checklist to guide the consultation and record your notes. Use a keyword code for the notes, e.g., TCCov (standing
for “Telephone consultation due to COVID-19 restrictions”)
- Before you make the call, check the patient notes for any pre-existing conditions/long-term medicines that
may put them in a higher risk group or explain any of their symptoms
- Check who you are talking to (i.e. is it actually the patient?). Ask for and then document consent for the consultation.
- Double-check that the patient is at home in case they are acutely unwell and urgent assistance is required. Also
ask what support they have at home.
- Establish what the patient is calling about - what is their main concern? The “why did they choose to call today”
question.
- Check what their symptoms are and how severe. Fever and cough are two key COVID-19 symptoms, but presentation is
variable. Has the patient any equipment at home for assessing temperature, pulse, BP, peak flow, blood sugar or other
vital signs that may be relevant? Determine if testing is required.
- Ask about specific signs of deterioration such as difficulty breathing or shortness of breath, e.g., can the patient
complete a sentence without needing to take a breath?
- Check what medicines the patient is taking, consider if they increase their risk (e.g. immunosuppressants) or if
they need any temporary adjustment (e.g. if dehydration is present) and advise what they should take for symptomatic
relief.
- Always safety-net and document that you have done so. Provide clear advice on the signs of deterioration and what
to do if that happens. Reinforce advice about staying at home unless further assessment is needed.
- Consider a face-to-face consultation with appropriate PPE if there is uncertainty about the diagnosis or the severity
of symptoms.
Adapted from:
- Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ 2020;368:m1182 doi: 10.1136/bmj.m1182
(https://www.bmj.com/content/bmj/368/bmj.m1182.full.pdf)
- Neighbour R, Stockley S. Ten tips for telephone consultations about COVID-19.
BJGP, 2020. (
https://bjgplife.com/2020/03/19/neighbours-ten-tips-for-telephone-consultations-about-covid-19/)
PPE
There is clear advice for PPE (i.e. hand hygiene, surgical mask, eye protection, gloves and gown) when caring for people with suspected or confirmed COVID-19,
however, there is a lack of pragmatic guidance on the use of PPE in a community setting for other scenarios, e.g. patients without respiratory symptoms. The
current Ministry of Health advice for community health professionals providing face-to-face care for people who are presumed “non-COVID” is “standard
precautions” i.e. hand hygiene. A gown or apron and gloves should also be worn if there is a risk of contact with bodily fluids. The majority of front-line
health care workers feel that this level of PPE is now insufficient to reduce the risk of infection and that all direct patient contact poses some risk.
We are monitoring this issue and will keep you up to date as any new information becomes available.
Link for MoH guidance
This Bulletin is supported by the South Link Education Trust
If you have any information you would like us to add to our next bulletin, please email:
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