Primary care & Coronavirus (COVID 19): key guidance, information and support
As a family doctor (General Practitioner, GP) we stick to a pattern: we take a history, perform an examination, make a diagnosis and instigate a treatment plan. Many appointments are face-to-face and some are on the telephone. In response to the coronavirus pandemic have adapted the way we practise medicine in the community. This document collates key guidance and much user generated content covering diagnosing coronavirus and remote consulting as well as coding diagnoses, and support for primary care staff and patients alike in this rapidly changing landscape. Last updated 25th February 2021:
NHS Vaccine Resources for Healthcare Professionals — Primary Care
NHS Vaccine Delivery Plan
Guide to coronavirus vaccinations for the public
Vaccine passports — considerations
How do vaccines work — Nature review
Setting up Long-COVID services — a practical guide
Long-COVID symptom burden
NICE Guidance on Long-COVID
Mental Health Tips during the pandemic
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Contents
1–6: Preparing for coronavirus, communication and making a diagnosis
7–10: Remote consulting
11–12: Personal Protective Equipment (PPE)
13–16: Coding and medicines (NSAIDs, ACE inhibitors)
17: Patient resources
18–19: Clinical advice for different groups and ways of working
20: Long-term consequences of COVID
21: Coronavirus vaccinations
22: Global Health and general resources
23: Support for primary care staff
24: Challenges of the pandemic and possible solutions
25: We will get through this
1. Making a diagnosis and how to manage suspected cases of coronavirus in primary care
Great guidance from the BMJ. There are lots of links to helpful guidance from British government, BMJ Best Practice and Londonwide LMCs for example. There are free templates to make a clinical diagnosis of coronavirus for British General Practice computer systems — EMIS and SystemOne. See infographic below:
2. Communicating with children and their risk
Children aren’t immune along with younger adults. They tend to have milder symptoms and probably could pass this onto more vulnerable people. They should isolate too but anyone with children knows that this is realistically very difficult especially for younger children. Use this comic and video to help explain this to the younger ones. Here’s a quick guide for parents from Sussex Partnership and a children’s guide from the Children’s Commissioner. Age specific guidance for mental health in regards to coronavirus from Public Health England.
3. Communicating uncertainty
During this pandemic, it can be an incredibly difficult and worrying time for many clinicians. Sometimes it feels like we don’t really know enough or what to say. This toolkit from Vital Talk is brilliant and goes through screening to remotely notifying patients of test results, to talking about hospital admission. It’s been translated into 8 languages.
4. Communicating to non-English speakers about coronavirus
Not everyone speaks English in the world and often our marginalised non-English speaking communities are most at risk of disease. Doctors of the World have done a sterling job of translating NHS guidance into an astounding 44 languages: Albanian and Amharic to Urdu and Vietnamese. (English, Albanian, Amharic, Arabic, Armenian, Bengali, Bulgarian, Czech, Dari, Estonian, Farsi, French, German. Greek, Gujarati, Hausa, Hindi, Hungarian, Italian, Kiswahili, Krio, Kurdish Sorani, Lithuanian, Oromo, Malayalam, Pashto, Polish, Portuguese, Punjabi, Romanian, Russian, Simplified Chinese, Traditional Chinese, Sindhi, Slovak, Spanish, Somali, Tamil, Tigrinya, Turkish, Urdu, Vietnamese, Wolof, Yiddish.)
This has been replicated by Harvard Health Publishing with 30+ languages (Creole, Filipino, Hiligaynon/Ilonggo, Japanese, Korean, Malay, Marathi, Serbian, Telugu, Ukrainian).
AskDoc have information videos in Romanian, Swedish, Kurdish Sorani, Pashto, Arabic, Polish, Panjabi, Arabic, Farsi, Urdu, German, Mandarin, Mirpuri, Spanish, Turkish, Bengali, French.
Find US guidance and posters here in many more languages such as Nepali and Haitian Creole from Eleanor Murray, Professor of Epidemiology at Boston School of Public Health.
There is a guide for children in 24 languages.
5. Not everyone presents with a cough, fever or breathlessness
Loss of smell (anosmia) was the presenting symptom 30% of South Korean patients. See advice for patients here.
Some may present with gastrointestinal symptoms such as abdominal pain & diarrhoea. I’ve seen this in clinical practice.
Other symptoms might be chilblain like symptoms commonly referred to as “COVID toe”:
https://twitter.com/DipeshGopal/status/1257412119806595072
6. Advice for pregnant women and their families
Pregnancies can be stressful at the best of times and the current pandemic adds extra layers of uncertainty. What can we say to them? What do we know?
(a) Theoretical increased risk of transmission to expectant mothers
(b) No increased risk of vertical transmission to fetuses including teratogenicity/intra-uterine infection/preterm labour/miscarriage (no cases, expert opinion)
Find patient facing information here on the Royal College of Obstetricians & Gynaecologists (RCOG) website.
There is further guidance for clinicians consulting on pregnancy on the the RCOG website.
7. Key features to cover when remote consulting with a patient with suspected coronavirus.
Trying to assess a patient with a chest infection remotely can be incredibly difficult — in the past many clinicians will want to assess the patient even if these means measuring observations. However, self isolation poses new challenges. Rapid work from Prof. Trisha Greenhalgh and colleagues (shout-out to the medical student, Fan-Shuen Tseng, acknowledged here) has produced quick guidance on what primary care clinicians can do to make an assessment. See infographic:
8. How to assess breathing remotely
There has been disagreement about the best way to assess breathing remotely as oxygen saturation probes give quick answers in a face-to-face consultation. Could we confidently assess breathing over the phone or on video? Few patients have a saturation probe so what practically can we do? Many have suggested the “Roth test”. The original study asked patients to take a deep breath in and then count up from 1 to 30 in their native language. Being able to count more than 8 correlates with >95% oxygen saturation.
BUT, there is a big but…the “Roth test” is NOT validated in a patient population suffering from coronavirus and the original study performed in Israel compared 93 patients (mean age of 76 ± 13 years) requiring oxygen delivered via nasal cannulae for a variety of acute cardiorespiratory conditions (e.g. pneumonia), in an internal medicine or cardiac intensive care unit (ICU) with a control population of 103 well patients (mean age of 56 ± 18 years). There are no further follow-up studies.
A more rounded (non-peer reviewed) review of how to assess breathlessness is provided by the Oxford Centre for Evidence-Based Medicine via a team led by Prof Trisha Greenhalgh. Here is a quick summary:
We cannot rely on oxygen saturations from smartphones.
9. What considerations need to be made for video consultations?
(a) For a practice
i. Prepare the practice — the right technology, appropriate space, define workflows.
ii. Prepare our patients — set expectations, help patients prepare with appropriate pre-assessment tools, etc.
(b) For clinicians
Most of us are moving into remote consultations and using tools such as Accurx which do not require any additional software/hardware for both primary and secondary care. Accurx utilise a third party called Whereby which allows patients and clinicians to join a chat room. A text is to both the patient and the clinician which allows the video consultation to take place.
How to use Accurx with EMIS (41 minutes)
How to use Accurx with SystemOne (5 minutes)
An alternative application which I haven’t tried is Nye.
Key tips:
i. Familiarise yourself with the software.
ii. Check your environment before and during the consultation: lighting, positioning with camera, background noise and that the patient has a confidential safe space to talk. Consider landscape on a mobile phone as may be less confrontational compared to portrait.
iii. Look at the camera not the screen to maintain good rapport.
iv. Signal the end of the call clearly (speak/wave), arrange follow-up (could use text or e-prescribing) and safety-net well.
v. Document findings, the quality of video/imaging, the need for a remote consultation (due to coronavirus) and the examination not performed due to coronavirus.
Double down on video consultations with Roger Neighbour in 3 minutes
Double down on video consultations in 10 minutes
Double down on video consultations in 20 minutes
Double down on video consultations in 30 minutes (+ 30 minute Q&A)
Evidence base behind video consultations in 30 minutes
A lot of the evidence base around video consultations has been done in stable outpatient settings with a high satisfaction between clinicians and patients.
Read more in this blog covering practical considerations: appropriateness, getting set up, conducting good consultations and the research evidence base:
10. What if the video doesn’t work? How do we work around that?
Video consultations have not always worked for me due to technical errors from the patient’s side and even poor lighting so I could not see rashes. I asked patients to send me a photograph of their rash via email to our practice secure account and then called them back to contact them on the diagnosis and management strategy.
11a. Personal Protection Equipment (PPE). What works? What doesn’t?
There are big reviews coming out very soon on gloves, gowns, etc. I will update this in due course.
Which face masks work? A rough and ready answer is that there is no research looking at whether respiratory type masks (FFP/N95, the mask with a filter) are comparable to surgical masks for coronavirus specifically. However for other respiratory conditions including influenza both masks are comparable. Find the non-peer review findings here and early systematic review:
The WHO suggest gowns over aprons but there is insufficient evidence by how much gowns might be better.
11b. What if my PPE is inadequate? Am I obliged to treat patients?
The guidance from the British Medical Association (BMA, British doctors’ union) suggests that clinicians are not obliged to provide care if protection is not provided. Despite this, many clinicians will feel that they must fulfil their clinical commitments.
11c. Which PPE could I reuse if I’m running low
Guidance from Public Health England:
>> Reuse goggles, visors and FFP3/N95 masks
>> Do not reuse single use gloves/aprons.
>> Switch to re-usable gowns if possible.
12. How to put PPE on and take PPE off?
It’s been a while since many of us have put on PPE and it can be daunting looking at the complications of coronavirus. The official guidance from NHS England has a useful diagram:
Double down on donning (putting on) and doffing (taking off) PPE for primary care in 5 minutes
13. Code suspected diagnoses of COVID-19
Now, I know this isn’t the biggest priority at the moment and we are all very busy. Coding helps chart the extent of the virus’ spread and give us data about how the disease presents and how we might be able to treat coronavirus. Read more from the RCGP here. Look at the live tracking of coronavirus cases that have been identified in British primary care.
14. ACE inhibitors and Angiotensin receptor blockers are generally safe during the coronavirus pandemic but you may wish to stop in high risk patients if they contract the infection
Correspondence in the Lancet suggested that molecular mechanisms and animals suggested that prognosis is worse in patients who take ACE inhibitors. Causality has not been demonstrated and the European Society of Cardiology advise that ACE inhibitors and other renin-aldosterone-angiotensin-system antagonists should be continued. This position is supported by the Renal Association. Read a more detailed appraisal of the research here. What should you do if your patient has a coronavirus infection and is on an ACE inhibitor or ARB? Oxford CEBM suggest (non-peer reviewed) that ACE inhibitors or ARBs should be stopped in patients with stable blood pressure who are at normal and high risk of infection AND then go on to contract the coronavirus infection. The medication could be restarted on recovery:
Column 2: advice to continue treatment will be suitable for most patients, unless they develop COVID-19;
Column 3: some patients in whom the benefits of ACE inhibitors or ARBs are small in the short term, and who have a high risk of COVID-19, may choose to stop taking their drugs until the epidemic is over. (Credit: Oxford CEBM)
15. Ibuprofen and non-steroidal anti-inflammatory drugs (NSAIDs) are safe to be taken during the coronavirus pandemic
There were initial concerns by French doctors who observed that patients on ibuprofen and cortisone was associated with a more severe respiratory illness. This was amplified by the French Health Minister. The World Health Organisation initially suggested against ibuprofen use but have not recommended against ibuprofen use currently. This is corroborated by the British Medicines and Healthcare Products Regulatory Agency, European Medicines Agency and Royal College of Paediatrics & Child Health.
16. ACE inhibitors, angiotensin receptor blockers, diuretics, metformin, NSAIDs should be temporarily stopped during symptoms with clinically significant fever, diarrhoea & vomiting for 24–48 hours.
This is not new guidance to do with coronavirus but should be adhered to in almost any situation. This position is endorsed by the British Geriatrics Society for older patients.
17. Advice for patients
Many patients can manage their own symptoms. Patients in the UK can check their symptoms online. They can get their own fit notes to sign themselves off work if they are self isolating. Extremely vulnerable patients and their carers can now get support online.
International self diagnosis of COVID-19 online
Parenting tips during the outbreak from UNICEF
Supporting children and parents/carers from Emerging Minds
Tips for teaching your children from National Geographic
Coping in Isolation from NHS Grampian
Advice on looking after your mental health during the pandemic from the Mental Health Foundation
Advice for looking after your wellbeing from the charity, Mind
Principles of Psychological First Aid from NHS Education for Scotland
NHS Every Mind Matters — keeping well at home and worries about coronavirus
Practical advice on self isolation via ‘Stop The Spread’
“Covid@home” (Staying At Home) guide in 6 languages.
Channel 4 Dispatches “How to Isolate Yourself” — expires 21st April 2020
Decreasing your risk of transmission from the World Health Organisation (WHO)
The public can volunteer to help us fight the pandemic via the Good Sam App
Volunteer via local community groups through Covid Mutual Aid
Record your symptoms via this app from ZOE (health technology company) to track the spread of the disease. (I’m not sure the exact end outcome of the data.)
18. Clinical guidance for different patient groups
[Explanatory parentheses to aid search not to explain!]
Alcohol addiction (alcoholism): advice for patients and for clinicians. Advice from Scottish Health Action on Alcohol Problems (SHAAP).
Barnet CCG guidance: assessment of patients with suspected coronavirus, confirming death and palliative care.
NHS London Networks community respiratory guidance: risk assessment for suspected coronavirus, advice with/out pre-existing conditions, palliative care.
Cancer (Oncology): advice from Cancer Research UK and C the Signs for those patients living with and beyond cancer.
Carers: advice from the British Thoracic Society to support concerns from informal carers and bereaved carers. Advice from Carers UK.
Cardiac Arrest (Resuscitation, CPR): clinical guidance for hospital resuscitation from Resuscitation Council (UK)
Cardiovascular (heart): advice for patients from British Heart Foundation.
Contraception: advice from Faculty of Sexual & Reproductive Healthcare (FRSH) and advice for patients.
Critical/Intensive Care (when to admit): advice from NICE guidance suggests to assess via Rockwood frailty score BUT there are some important caveats:
Cystic Fibrosis: for patients and families — advice from Cystic Fibrosis Trust
Death, certification of: can now occur via phone/electronically (section 4). Coronavirus can be natural cause of death. Watch this 7 minute tutorial for the rapid changes in confirmation and certification of death from the RCGP.
Dermatology (skin): referral management & isolation guidance from British Association of Dermatologists. Patients with psoriasis controlled by immunosuppressants who are diagnosed with coronavirus should discontinue their immunosuppressant medication — advice from International Psoriasis Council.
Diabetes: sick day rules and insulin — advice from Primary Care Diabetes Society.
Endocrinology: adrenal pituitary insufficiency to follow sick day rules. Advice from the Society of Endocrinology.
Geriatrics/Older people: managing delirium during suspected and confirmed cases of coronavirus and managing the pandemic in care homes. Advice from British Geriatrics Society.
Further advice re pandemics in care homes from Oxford CEBM: hand hygiene, cleaning hard surfaces, allocating staff to the same areas, limiting visitors, community testing.
Gynaecology: abnormal uterine bleeding remote consulting guidance from British Society for Gynaecological Endoscopy, RCOG & British Gynaecological Cancer Society.
Menorrhagia: refer to secondary care if oral treatment is not working, assess/treat anaemia or assess causes
Inter-menstrual bleeding: assess face-to-face if risk of sexually-transmitted infection, and if cervical cancer
Post-menopausal bleeding: 2 week wait
Haematology (blood): for patients and family — advice from Sickle Cell Society. Hydroxycarbamide and iron chelation therapy currently require regular monitoring. No current evidence that hydroxycarbamide therapy increases risk of coronavirus. Advice from British Society of Haematology (BSH). INRs for warfarin therapy can be postponed during isolation and where stable for >60% time: advice from BSH. Patient resources for ITP — advice from the ITP Support Association.
HIV: advice for patients from British Human Immunodeficiency Virus Association (BHIVA). No current evidence to suggest that patients with HIV at increased risk of coronavirus.
Inflammatory Bowel Disease (Crohn’s disease/Ulcerative colitis, gastroenterology): for patients and family — advice from Crohn’s & Colitis UK. Immunosuppressants do not increase risk of infection but possible increased risk of complications — ideally continue. Advice from British Society of Gastroenterology (BSG). Patients with inflammatory bowel disease can register via the COVID-19 portal.
Inherited Metabolic diseases: advice for patients, families and carers from British Inherited Metabolic Diseases Group.
Lesbian, Gay, Bisexual and trans (LGBT): advice for GPs from the LGBT foundation:
Mental Health (psychiatry): guide for supporting people with autism and learning disabilities from Sussex Partnership. Guidance for supporting people with intellectual disabilities is pending from the Royal College of Psychiatry. Supporting children with learning disabilities from Sunshine Support.
Neurology: increased risk of viral infections for patients on infliximab, rituximab, and ocrelizumab — discuss with neurologist re starting/stopping. Advice from Association of British Neurologists.
Obstetrics (pregnancy): advice for patients. Advice for clinicians from RCOG. Register women who have been infected with coronavirus in the International COVID registry in pregnancy — will need informed consent.
Ophthalmology (eyes): eye examinations could be performed with breathguards for slitlamps if PPE not used. Advice from Royal College of Ophthalmologists.
Orthopaedics (bones): advice for patients. Advice from British Orthopaedics Association.
Paediatrics: general guidance for vulnerable children (safeguarding). General guidance from Royal College of Paediatrics & Child Health (community paediatrics). One page spread on helping children cope with stress from the World Health Organisation (WHO).
Much discussion has been about a hyperinflammation syndrome in children. Persistent fever, tachypnoea and hypotension should signal rapid referral to hospital.
Paediatrics/ENT (tonsillitis): AVOID tonsillar examination UNLESS absolutely necessary specifically to avoid risk of transmission. Advice from the Royal College of Paediatrics and Child Health & British Paediatric Allergy, Immunity & Infection Group. The more holistic FEVERPAIN score has been suggested as an alternative but high FEVERPAIN scores should not warrant antibiotics — antibiotics should be considered (e.g. via delayed prescription).
Agreed expert opinion from mostly British & North American clinicians (n=195) suggested some observed behaviours were reassuring, e.g. active movement, eating and drinking which may be useful for video consultations where the oropharynx may not be adequately visualised. I am unaware of higher quality evidence. It’s impossible to determine type of virus affecting children from symptoms alone.
Pain: hold off steroid injections due to potential increased risk of coronavirus infection. Advice from Faculty of Pain Medicine.
Palliative Care: symptom management, spiritual care and arrangements to be made before and after death. Advice from Association of Palliative Medicine for Great Britain & Ireland. Difficult conversations around dying/death from Scottish Quality & Safety Fellows. Advice from NICE guidance.
Domestic violence/abuse in palliative care advice from RCGP/Marie Curie/IRIS.
There are alternatives to syringe drivers (off label) if we run short of staff to operate syringe drivers or short of syringe drivers from Future Planning.
A simple way for patients to document their holistic wishes and preferences for end of life care from Future Planning.
Ramadan: if patients become unwell they should discontinue their fasting and adequate hydration. Detailed information from British Islamic Medical Association.
Guidance for patients from the Muslim Council of Britain and WHO.
Renal/Kidney: for patients and families —advice from Kidney Care UK.
Respiratory (not pneumonia): Inhaled corticosteroids in asthma do not increase risk of coronavirus infection, nebulisers are safe (not aerosol generating), use oral steroids where clinically appropriate (asthma exacerbation), those with severe asthma should be shielded — advice from British Thoracic Society. No evidence to avoid inhaled or oral steroids in treatment of COPD — advice from GOLD. What inhalers are equivalent from NW London prescribing group? Patient guidance for those with asthma —advice from Asthma UK. Patient guidance for those with respiratory conditions — advice from British Lung Foundation and European Lung Foundation. There are videos for patients with asthma and COPD on how to safely exercise. NICE guidance on cystic fibrosis — increased risk of coronavirus.
Respiratory (pneumonia): avoid steroids for routine treatment of viral pneumonia — advice from WHO. For both non-older and older adults, use CRB65 to assess severity and ensure that you clean equipment between patients. In a care home environment, you may consider early antibiotics given than viruses cause 50% of pneumonia. NICE guidance suggests either amoxicillin and doxycycline, This may increase antimicrobial resistance. It may be worth supplying rescue packs of antibiotics to residential/nursing homes for early use in suspected pneumonia.
Rheumatology: for patients and families from Versus Arthritis. Managing patients with rheumatological conditions, urgent referrals and advice about shielding from British Society of Rheumatology.
Safeguarding (domestic violence/abuse): for survivors and victims of domestic abuse from SafeLives and find services near you from Domestic Violence UK. Guidance from Royal College of General Practitioners (RCGP).
Most vulnerable: shielding advice from NHS England — who and how to help
19a. Clinical ways of working
There are rapid changes to the ways of working in primary care. The RCGP and BMA have suggested which services that primary care should continue to be provided and which services should be temporarily suspended given the pandemic. It is possible that especially that lack of annual reviews may cause long-term conditions to be at risk of neglect but many will have been done in time for this year’s Quality & Outcomes Framework (QOF) deadline in April 2020.
Suggested practice centre plans are from the Maltings Surgery, Cleveland Medical Centre, Surrey Heartlands, and Ivy Grove Surgery.
Shorter length repeat prescriptions are recommended to prevent supply chain issues in future.
GP surgeries are being ask to identify and shield the most vulnerable patients. For queries regarding this, please email england.covid-highestrisk@nhs.net. Vulnerable patient search advice from Ardens.
Record staff absence with this NHS tracker.
Request a volunteer from NHS Volunteer Service
If you have not yet received personal protection equipment (PPE) contact the National Supply Disruption line on 0800 915 9964 or email supplydisruptionservice@nhsbsa.nhs.uk (Monday to Friday 0800–1800).
What if you don’t have PPE? How could you improvise? Could you print your own PPE on a 3D printer? See this Pulse article from Dr Dave Triska. Or using this Montana Mask blueprint.
Dr Marco Nardelli asked some Italian colleagues for the blueprints to pulse oximeters that can be printed using 3D printers.
Find support for community pharmacists and pharmacies here.
Returning doctors frequently asked questions (FAQs) from NHS England.
Disclosure and Barring Service (DBS) checks are now free and fast tracked.
How can Clinical Commissioning Groups (CCGs) support their Primary Care Networks (PCNs) during the pandemic from NHS Confederation.
Guidance for NHS Workforce Leaders from NHS Employers.
Leaders planning for psychological distress for staff from Academy of Medical Royal Colleges: 1⃣ Don’t force debriefs, 2⃣ Look after vulnerable folk on your team. Our team uses daily meetings at midday so we can air pluses/negatives/lessons learnt etc.
Put these posters up in and around your practice.
Physiotherapist safe practice guidance
As teams move more to remote working in case of isolation/sickness, many GP teams move to use a collaborative platform such as Microsoft (MS) Teams.
Get set up with Microsoft (MS) Teams in 6 minutes
Navigate Microsoft (MS) Teams in 29 minutes
19b. Hot hubs or Red hubs for coronavirus
(i) A suggested generic model on setting up hot hubs can be found in this paper from South Peninsula NIHR ARC.
(ii) Brent CCG hot hub 6 minute experience video and set-up.
(iii) Advice from Dr David Lloyd from Harrow CCG on running hot hubs.
(iv) Advice from Nanterrian hot hubs, France
20. Long-term consequences of COVID
Managing the long-term consequences of coronavirus infection can be difficult. Perhaps the most difficult thing to determine is what is long COVID? Greenhalgh and colleagues define this as ≥ 3 weeks after the onset of symptoms and it seems that severity of the initial illness is independent of long-term consequences, i.e. mild illness could result in long-term symptoms and vice-versa. The article is brilliant as it has links to patient support groups and forums.
There have been a number of people who have lost their smell after a COVID-19 like illness (not everyone was tested at that time). This is a great resource for patients who are struggling to regain their sense of smell:
In reality, how might you set up your long-COVID service — what should it have? It’s no surprise that it should be multi-disciplinary.
There is some NICE Guidance on managing Long-COVID too. The burden of Long-COVID is thought to be far reaching with a higher symptom burden for women.
21. Coronavirus vaccinations
NHS Vaccine Resources for Healthcare Professionals — Primary Care
There are huge ethical and legal considerations for vaccine passports nto only in the UK but worldwide.
22. Global Health Resources/General References
NHS England Primary Care Guidance — and recent webinars
UK case map from Public Health England
NICE Guidelines — mostly secondary care for now (30/03/2020)
Academy of Medical Royal Colleges — mental health, education, clinical, governance
Digital contact tracing paper published in Science (13 pages)
Intensive Care National Audit & Research Centre (ICNARC) 27 March 2020 report on characteristics of patients admitted to critical care
The British GP trainee voice video (24 mins) and podcast (35 mins)
Ali Baba COVID-19 Global handbook
Secondary care hospital speciality guidance from USA
Live global data of cases and deaths worldwide
Interactive global case map from John Hopkins University & Medicine
Interactive global case map from the WHO
Infographics on COVID-19 from Information is Beautiful
Coronavirus Tech Handbook: collaborative Google document made by doctors worldwide
World Health Organisation (WHO) technical guidance — they do daily updates on their YouTube channel. They have a free training resource too.
Australian strategy against coronavirus
Oxford Centre of Evidence Based Medicine (CEBM)
Oxford COVID-19 Government Response Tracker
“The Hammer and the Dance” — why early aggressive social distancing works (29 minute read)
Should we all wear masks? (12 minute read) and BMJ review of the evidence Should we all wear masks? (4 page read)
Is it just about social distancing and masks? Ventilation and occupancy too! (4 pages)
When running or cycling should we keep more than 2 metres distance? (3 pages)
Does viral dose matter in coronavirus (4 pages)
Why do conspiracy theories arise in a pandemic? (3 pages)
WHO Mythbusters: 5G, pepper, houseflies, bleach, sun, breath holding, alcohol, cold, hot, baths, mosquitoes, hand dryers, UV light, nasal saline, garlic, antibiotics.
The British Coronavirus management strategy from Imperial College London (20 pages)
Flattening the curve for the 1918 flu from National Geographic
Mental Health Consequences of Infectious Disease Outbreaks from University of Rochester, New York (28 pages)
NB Medical Podcast — recent episodes have focussed on lessons from coronavirus for primary care
London School of Hygiene and Tropical Medicine (LSHTM) podcast and free online course (free, 3 x 4 hours) on “Understand the emergence of COVID-19 and how we respond to it going forward”
St George’s, University of London (SGUL) free online course (free, 2 x 2 hours) on “Managing COVID-19 in General Practice”
Newest research papers on coronavirus from the Geneva Centre for education and research in humanitarian action.
Living map of the evidence behind COVID-19 — look at the emerging body of evidence behind coronavirus as it happens at a glance
Meta-Evidence: Upcoming therapeutics and evaluating evidence quality
New England Journal of Medicine (NEJM) resource centre
The British Medical Journal (BMJ) resource centre
Journal of the American Medical Association (JAMA) resource centre — fantastic 30 minute updates via video on their YouTube channel.
Cambridge Open Access journal centre
Royal College of General Practitioners resource centre
Links to coronavirus pages for all medical specialties advice
23. Healthcare professional help: how can we look after ourselves during this difficult time?
Share problems and find solutions on the RCGP Coronavirus forum.
Connect with other family doctors worldwide on the “Family Doctors International Coronavirus Task Force” Facebook Group
Free Coaching for all healthcare professionals from Hult Ashridge Business School
Sustaining healthy workplaces from the Intensive Care Society
Priority Shopping times and discounts for NHS workers
Lifestyle advice on diet, exercise, sleep and nutrition from the BEAT COVID team
Mental Health Tips from Dr Andy Knox
A — sk for help. Reach out to healthcare professionals as we are here for you.
B — reathe 4 sec in, hold, out, hold
C — onnect: with friends and family with a phone-call/online
D — evelop a daily routine
E — at well & exercise if you can. This can be walk.
F — ocus on today’s activities
G — ratitude — 3 things daily before you sleep.
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Get help from Help Them Help Us for NHS workers (unsure what it will be at the moment)
British Medical Association (BMA) Wellbeing Service — 24-hour counselling and peer support phone lines and online resources
Practitioner Health Programme — confidential mental health help for doctors via self-referral and upcoming events
Looking after our mental health and wellbeing (1 page) from NHS Confederation
Managing stress and burnout module from Royal College of Psychiatrists
Mental health hacks from NHS In Mind
Home workouts from Joe Wicks on YouTube (30 minutes)
Free app based home workouts from Fiit (for 3 months)
Home Yoga classes with Adriene on YouTube (20–30 minutes)
Free Yoga classes at specific US times (60 minutes)
Free virtual physiotherapy — book an appointment from Pure Sports Physiotherapy
Entertaining the kids: indoor activities with the Scouts, drawing with Rob, colouring in with Quentin Blake, national park tours from home, children’s authors reading out loud, bedtime stories read by astronauts, free audiobooks from Audible, family activities with Home Huddle, free children’s programs/games from Azoomee for 3 months.
Free childcare via Bubble for NHS staff.
Entertaining the adults: cooking classes by chefs online, university art classes online, free audiobooks from Audible, free plays from the National Theatre starting every Thursday 1900 GMT from Thursday 2nd April 2020
Exercise/yoga app from Down Dog (until 1st July 2020, use NHS email)
Find accommodation at no discount via AirBnB
Free JUMP e-bikes across London for NHS staff
Free Santander cycle hire across London for NHS staff with code “THANKSNHS”
Free Men’s Gillette Razor for NHS staff
Free AA breakdown cover
Free Car Parking Spaces for NHS Staff from Your Parking Space (use NHS email)
Free parking at NCP
Free unlimited data from EE until 9th October 2020
Headspace App — free mindfulness for NHS professionals (until 31 December 2020)
Unmind App — free mental health support for NHS professionals (until 31 December 2020). Use the organisation name as NHS.
Daylight App — free mental health support for NHS professionals (until 31 December 2020)
Sleepio App — free sleep cognitive behavioural therapy (until 31 December 2020)
(app information from NHS Employers)
24. Challenges of the pandemic and possible solutions
Challenges:
Rehabilitation needs for those hospitalised
Worsening of chronic disease due to neglect
New and worsening mental health problems
Exacerbation of socio-economic problems — homelessness, poverty
Worsening domestic abuse
Possible solutions:
Prioritise chronic disease checks by most deprived first
Think about using a trauma based approach
Mobilise existing momentum of voluntary and third sector to help support the most vulnerable. Don’t forget link workers/social prescribers. We need them more than ever.
Advocate against local inequality and write to your local MP: socio-economic problems needs socio-economic solutions.
Sources: FairHealth, Krist et al, 2020; Victor Tseng, BMJ.
25. We will get through this
This is a trying time for us all and we sometimes feel overwhelmed with great uncertainty. Dr. Sonia Tsukagoshi has been interviewing different family physicians (GPs) globally who are struggling to manage the pandemic in a variety of different healthcare systems. Read accounts from family doctors in Hong Kong, North Italy, Japan, Germany, Spain, Indonesia, the Philippines, Australia, India, USA, Taiwan, Turkey, Zambia, Kenya, Brazil and New Zealand. Read this account from a paramedic, a paediatrician and geriatrician.
But knows this — we are all in this together AND we will get through this. As my patients have been saying — stay safe.
Just as the fate whispers to the warrior, coronavirus whispers to us “You cannot withstand the storm” we must whisper back to coronavirus “We are the storm”.
Limitations: Apologies in advance as this is primarily British guidance and its applicability may not be global.
Acknowledgements: thank you to the hundreds of colleagues who have all written guidance to inform this article. Special mention to Primary Care Pathways, the numerous Royal Colleges and patient charities, Prof. Trish Greenhalgh, the Oxford Centre of Evidence-Based Medicine, Dr. Hussain Gandhi, eGPlearning, Dr. Simon Tobin, Dr. Sonia Tsukagoshi, Dr. Crunch, the BMJ, Sussex Partnership and the numerous WhatsApp group members who have given a wealth of ad hoc resources. Thank you for your tireless work.
Competing interests: I am a salaried general practitioner (GP, family physician) who has an unpaid (honorary) research fellow post at Queen Mary, University of London. I am a non-funded member of the Royal College of General Practitioners (RCGP) and non-funded trainee on the Late Effects Clinical Studies Group of the National Clinical Research Institute (NCRI). I am not funded by industry or any other healthcare company.
Disclaimer: this article does not constitute medical advice and does not claim any responsibility from any harm or damage. I will do my utmost to update any guidance.
Updates:
Saturday 29th August 2020:
Managing the long term consequences of COVID-19 in primary care
Patient resources for long-term anosmia
Lessons from around the world:
Zambia: what if there is no GP?
Kenyan GP and community health workers
Brazilian GP and the emotional toll
What can we learn from New Zealand??
Social isolation and social determinants in COVID
Conspiracy theories in a pandemic
Is it just social distancing and masks? — what about ventilation, exposure, occupancy?
What happens to children who are admitted to UK hospitals?
Saturday 16th May 2020:
Read about the experience of an American GP, experience of a Taiwanese GP, experience of a Turkish GP and a paramedic,
Apply for healthcare worker grants here
Spotting hyper inflammatory syndrome in children
Chilblain like symptoms (COVID-toe) as a presentation of coronavirus.
Thursday 30th April 2020:
Advice for Ramadan for clinicians from British Islamic Medical Association, CEBM.
Advice for patients from Dr Gandhi, Muslim Council of Britain and WHO.
Fight disinformation with WHO Mythbusters (5G, pepper, houseflies, bleach, sun, breath holding, alcohol, cold, hot, baths, mosquitoes, hand dryers, UV light, nasal saline, garlic, antibiotics)
Quick 16 page contraception guide from FSRH.
Face masks for the public from BMJ — read the responses too!
The Atlantic “Don’t Wear a Mask for Yourself”
Mitigating the effect of the coronavirus pandemic from BMJ
Sunday 19th April 1700 BST:
Older adults may present ‘atypically’ without fever/cough
Containing pandemic spread in care homes: hand hygiene, cleaning surfaces, allocating staff to the same area, limiting visitors, community testing where available
Guidance on re-using PPE: reuse goggles, visors and FFP3/N95 masks; do not reuse single use gloves/aprons. Switch to re-usable gowns if possible.
Gowns over aprons if possible recommended by CDC/WHO but not sure by how much they are beneficial.
Staff offers — the most comprehensive list
Thursday 16th April 0900 BST:
Compassionate telephone consultations in COVID-19, Advice for parents for children with a fever, using the frailty scale properly.
Free parking from NCP, free Gillette Men’s Razor Gift Set, free AA breakdown cover for NHS staff, free unlimited EE data, free children’s games/programs from Azoomee, free virtual physiotherapy for NHS staff, free £20 Deliveroo meal.
Learn about an Australian GP and Indian GP experience
How do we respond after the pandemic? with infographic & research paper
Friday 10th April 1800: Print your own PPE, face masks or pulse oximeters using a 3D printer. Hot hub special with guidance from SW SAPC, Brent CCG, Harrow CCG and Nanterre.
Londonwide LMC guide on managing COVID-19, Information videos in different languages from AskDoc (search for your language…can you find it?), patient facing guidance for those living with and beyond cancer from C the Signs, safe exercise videos for those with lung conditions, NICE guidance on cystic fibrosis, guidance from the LGBT foundation, changes to death certification in 7 minutes, should the public wear face masks, should we be more than 2 metres apart from runners and cyclists, or get free childcare via Bubble for NHS staff, get accommodation if needed via AirBnB, record staff absences.
Tuesday 7th April 2200: finding domestic violence services near you, domestic violence and abuse in end of life care, end of life care alternatives to syringe drivers, help patients make their wishes clear, vulnerable patients searches, upcoming mental health support events online, international secondary care guidelines, does viral dose matter.
Sunday 5th April 2020 1630: Brent CCG hot hubs set up and experience, guide to safe practice for physiotherapists, coronavirus sanity guide (talks/meditation) from Ten Percent, quick mental health hacks from NHS In Mind; WeWork pilates/yoga/meditation/HIIT, activities for families with Home Huddle.
Saturday 4th April 1700: NICE coronavirus guidelines for palliative care & diagnosing pneumonia, do not use smartphones to measure oxygen saturations, extra language resources, self help with wellbeing and work prioritisation from Red Whale, paediatric remote consultation support, SE London CCG Guideline collection, abnormal uterine bleeding (gynaecology) section added, exercise/yoga app from Down Dog.
Thursday 2nd April 2000: Why we shouldn’t use the Roth score, which PPE and when, assessing the respiratory system via the video consultation, 3 minutes with Roger Neighbour on video consultations, discussing care plans/palliative care with Dr Andy Knox, setting up hubs.
Wednesday 1st April 2020: How to request an NHS volunteer, international self-diagnosis of COVID-19, death certification during the pandemic, self-register for IBD coronavirus database, should we all wear masks article, digital contact tracing article [previous updates listed at foot of document].
Tuesday 31st March 2020: living map of the evidence on COVID-19, free clinical diagnostic templates for coronavirus, primary care guidance on asthma/COPD
Monday 30th March 2020: age specific guidance for children’s mental health, formal data from systematic review re PPE masks, International COVID pregnancy registry looking at outcomes, upcoming NICE guidance, the GP trainee voice via video and podcast, a reflection before you leave, managing stress/burnout module, advice for leaders for managing psychological stress in teams, free coaching for staff worldwide.
Sunday 29th March 2020: What is severe asthma and who therefore should be shielded, vulnerable patient support, dedicated section on pneumonia, advice for home visits, supporting patients with alcohol addiction (alcoholism), free DBS checks, online courses from SGUL/LSHTM, LSHTM podcast, characteristics of patients admitted to British critical care, decontamination before getting home, staff support (BMA).
Saturday 28th March 2020: advice for non English speakers, tonsillitis in children, safeguarding, NHS England webinars, ethics of not working without PPE, suspending non-urgent services, getting set up with Microsoft Teams, advice for patients, staff support.
