Managing non-hospitalised COVID patients
Having some evidence-based guidelines on when a COVID-positive patient needs hospitalisation is likely to be welcomed by the GP currently managing these self-isolating patients.
The advice outlining the distinction between mild, moderate and severe disease is part of the new government-sponsored ‘living guidelines’1, put out by a coalition of Australian expert professional groups that include organisations such as Cochrane Australia, the Australian College of Emergency Medicine, the two GP colleges (RACGP and ACRRM) as well as many others.
The idea is to have a single, regularly updated reference site based on a review of the best available evidence for doctors managing people with COVID-19.
According to the guidelines, most patients who will ultimately develop severe disease will experience clinical deterioration on days five to eight after the onset of symptoms.
A person is categorised as having moderate disease if they continue to have a fever higher than 38˚C, have a persistent cough or xray changes. Affected patients are also classed as moderate if they are able to maintain oxygen saturation above 92% with 4L/min O2 – just in case you happen to have an oxygen cylinder and pulse oximeter on you when you do a home visit. A patient is moving into the severe category if their respiratory rate is 30 breaths/minute or more – by this stage they should not be at home.
Guidelines on other aspects of the disease are expected in the coming weeks, with one of the areas under review being the management of mild cases of COVID-19 in general practice.
One of the major issues with regard to mild cases of COVID-19 is actually confirming the diagnosis. Most states have reasonably strict criteria for who is eligible for COVID-19 testing, so people with milder symptoms who have not travelled or been in contact with an affected patient are often self-isolating just in case.
However, as the number of community-acquired cases of the disease grows, people (and their families) are often keen to have a definitive yes or no to the question of whether they have been affected or not.
Testing criteria have now been expanded to include people with symptoms in COVID-19 hotspots, but there are still restrictions, and according to the Royal College of Pathologists of Australasia there are no shortcuts, you need to swab to get the diagnosis.
In a media release, the RCPA has reiterated that the deep nasopharyngeal is the current test of choice for acute COVID-19.
New serological tests that check for antibodies may have a high rate of false negatives, as patients only make antibodies to COVID-19 infection a week to 12 days after they become sick. And if the patient is elderly or immunocompromised they make take even longer, if at all.
So serological tests aren’t likely to be of use early, but they may prove to have a role in the future to help determine previous infection and therefore possible immunity.
As Dr Michael Dray, President of the RCPA says, ‘the new serological antibody tests may have a place in detecting unrecognised past infection and immunity but that role still needs to be vigorously evaluated.’
- National COVID-19 Clinical Evidence Taskforce. Caring for people with COVID-19 [Internet]. 2020 Apr 4 [updated 2020 Apr 8]. Available from: https://covid19evidence.net.au/#living-guidelines