COVID 19 Scottish Primary Care Hub triage guide

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Scottish Government Primary Care Division has produced this quick guide to assessing and triaging patients by telephone or video call.  It is adapted from: Greenhalgh T. Koh G. Covid-19: remote assessment in primary care.  The triage guide links to information in other sections about symptoms, comorbidites, other risk factors and clinical measures associated with severe disease.

To download the pdf version click here.

Clinical course

1. Clinical symptoms and red flags

RED FLAG SYMPTOMS - SEEK IMMEDIATE MEDICAL HELP 

  • Severe SOB at rest
  • Chest Pain
  • Blue lips or face
  • Difficulty breathing
  • Clammy or cold or mottled skin
  • Poor urine output
  • Difficult to rouse
  • Haemoptysis

Clinical Symptoms:

*Atypical symptoms can be more common in the elderly*

See also Symptoms Section

3. Connect

Get prepared:

4. Clinical Triage

If the patient sounds or looks very sick such as shortness of breath, go directly to section 11 (moderate/severe), or consider 999 ambulance.

Establish what the patient wants out of the consultation:

  1. Clinical assessment
  2. Referral
  3. Certificate
  4. Reassurance
  5. Advice
5. Clinical assessment

Over the phone, ask carer/patient:

  • State of breathing?
  • Colour of face/lips?

Over video:

  • General demeanour?
  • Skin colour?
  • Respiratory rate?

Respiratory function (especially inability to talk in full sentences):

  • How is your breathing?
  • Is it worse than yesterday?
  • What does it stop you doing?
Patient may be able to take their own measurements if they have instruments at home (temperature, pulse, peak flow, BP, O2 saturation). Interpret self monitoring results with caution and in the context of your wider assessment.
6. COVID most likely diagnosis? NO

Consider differential diagnosis, especially non-COVID sepsis. 

If not likely COVID refer to GP/out of hours clinic. 

If patient is likely to have COVID assess Clinical Frailty Scale.

 

7. Clinical Frailty Scale (CFS)

To download the online version of the Clinical Frailty Score, click here.

Note: The CFS was designed to summarise the results of  a Comprehensive Geriatric Assessment. In using it as a triage tool it is essential to use it correctly (see guidance). According to NICE, “The CFS should not be used in younger people, people with stable long-term disabilities (for example, cerebral palsy), learning disability or autism. An individualised assessment is recommended in all cases where the CFS is not appropriate.”

1.  Very Fit - People who are robust, active, energetic and motivated.  These people commonly exercise regularly.  They are amongst the fittest for their age.

2. Well - People who have no active disease symptoms but are less fit than category 1.  Often, they exercise or are very active occasionally, e.g. seasonally.

3. Managing Well - People whose medical problems are well controlled, but are not regularly active beyond routine walking.

4. Vulnerable - While not dependent on others for daily help, often symptoms limit activities.  A common complaints is being "slowed up", and /or being tired during the day.

5. Mildly Frail - These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications).  Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.

6. Moderately Frail - People need help with all outside activities and with keeping house.  Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.

7. Severely Frail - Completely dependent for personal care, from whatever cause (physical or cognitive).  Even so, they seem stable and not at high risk of dying (within - 6 months).

8. Very Severely Frail - completely dependent, approaching the end of life.  Typically, they could not recover even from minor illness.

9. Terminally Ill - Approaching the end of life.  This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail.

Scoring frailty in people with dementia

The degree of frailty corresponds to the degree of dementia.

Common symptoms of mild dementia include forgetting the details of recent event, though still remembering the event itself, repeating the same question/story and social withdrawal.

In moderate dementia, recent memory is very impaired, even though they seemingly can remember their past life events well.  They can do personal care with prompting.

In severe dementia, they cannot do personal care without help.

References:

1. Canadian Study on Health & Ageing, Revised 2008.

2. K. Rockwood et al. A global clinical measure of fitness and frailty in elderly people.  CMAJ 2005: 173; 489-495.

Copyright 2007-2009 Version 1.2.  All Right Reserved.  Geriatric Medicine Research, Dalhousie University, Halifax, Canada.  Permission granted to copy for research and education purposes only.

8. COVID most likely diagnosis? YES

 

Nursing Home?
Clinical Frailty Scale of 7+?
Anticipatory Care Plan /Do Not Attempt Cardiopulmonary Resuscitation

Priority is not to move patient but assess in place.  See local protocols for services.

Assessment at home: 

  • DN
  • GP
  • ANP
  • Hospital at Home
  • Domicilliary O2
  • Anticipatory prescribing
9. Assessment of severity (non frail patients)

Mild symptoms?  Go to 10

Moderate or severe symptoms? Go to 11

10. Mild symptoms and red flags
  • Stay at home
  • Self Management
  • Fluids - 6-8 glasses per day
  • If the patient is living alone, ask someone to check on them

Advise and arrange any follow up using local protocols.

RED FLAG SYMPTOMS - SEEK IMMEDIATE MEDICAL HELP 

  • Severe shortness of breath at rest
  • Chest pain
  • Blue lips or face
  • Difficulty breathing
  • Clammy or cold or mottled skin
  • Poor urine output
  • Difficult to rouse
  • Haemoptysis
11. Moderate or severe symptoms and red flags

Patient to be assessment at COVID assessment clinic

  • Respiratory rate 20+
  • 02 saturations <92% (in COPD Sp02 <88% or below baseline)  
  • Significant clinical concern / Red flag symptoms

No?  Go back to 10

Yes? Go to 12

Link to Clinical signs

Immunocompromise or significant comorbidity?

No?  Go back to 10

Yes? Go to 12

RED FLAG SYMPTOMS - SEEK IMMEDIATE MEDICAL HELP 

  • Severe shortness of breath at rest
  • Chest pain
  • Blue lips or face
  • Difficulty breathing
  • Clammy or cold or mottled skin
  • Poor urine output
  • Difficult to rouse
  • Haemoptysis
12. Assessment at hospital and red flags

Assessment at Hospital

About this pathway

This infographic, intended for use in a primary care setting and community COVID-19 hub was last updated in November 2020 . It may be subject to change.

This has been adapted by Dr Stefanie Lip, Dr Erica Peters, Dr Michelle Watts, Dr Beth White, Dr Dan Beckett, Prof Graham Ellis from: Greenhalgh T, Koh G. Covid-19: a remote assessment in primary care. BMJ 2020;368:m1182

Editorial Information

Last reviewed: 08 December 2020

Next review: 21 February 2021

Version: 5