Aisha Ambreen  ( Institute of Family Medicine, Jinnah Sindh Medical University, Karachi, Pakistan )
Tabinda Ashfaq  ( Institute of Family Medicine, Jinnah Sindh Medical University, Karachi, Pakistan )
Marie Andrades  ( Institute of Family Medicine, Jinnah Sindh Medical University, Karachi, Pakistan )
Fauzia Akhtar  ( Institute of Family Medicine, Jinnah Sindh Medical University, Karachi, Pakistan )
Sadaf Badiuzzaman  ( Institute of Family Medicine, Jinnah Sindh Medical University, Karachi, Pakistan )
Lubna Baig  ( APPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi, Pakistan )

Carefully developed guidelines for clinical practice serve as an important tool for desirable changes in health care of a country. They act as an important source of information for physicians as well as policy makers and educational institutions thereby improving the quality of care of patients. The outbreak of Novel Coronavirus Disease (COVID-19) in 2019 has placed a huge burden on health care system globally. The first line health care provider bears the brunt of this disease with limited and varying sources of information as most of the patients present to them. Varied presentation of disease along with limited hospital facilities for admission is a huge challenge for appropriate management and referral of these patients.  These guidelines, prepared after reviewing the interim guidelines in literature, will serve as a source of guidance for GPs to manage mild cases at home and refer those with moderate and severe disease to tertiary care hospitals.

Keywords: COVID-19, General Practitioner, Guideline, Home visit

DOI: https://doi.org/10.47391/JPMA.1526

 

Introduction

 

The outbreak of COVID-19 caused by SARS-CoV-2 virus has progressed to the status of a global pandemic, with so many countries adversely affected across all seven continents. The number of cases has approached over 93 million with over 2 million deaths (January 2021).¹ This has created a huge burden on health care system. Most of the patients presenting with COVID 19 have mild symptoms which can be managed at home while those with severe or critical disease should be referred to a tertiary care hospital for further management.²

General Practitioners (GPs) act as the frontline force in managing common problems in the community. The amount of rapidly changing information circulating on social media related to COVID 19 is overwhelming and is a cause of confusion and anxiety in primary health care providers.³ A number of interim guidelines on surveillance and management of this infection^2,4,5 have been published by several public health stakeholders. The following evidence based rapid guidelines have been specifically prepared for general practitioners of Pakistan on home management of confirmed COVID-19 patients (Table 1) as a quick reference guide.

Clinical Features: COVID-19 presents with variable symptoms ranging from non- severe to critical disease. These symptoms can appear anytime within 2-14 days after exposure to the virus.

Symptoms⁴ may include

•        Fever with or without chills (83–99%)

•        Cough (59–82%)

•        Anorexia (40–84%)

•        Fatigue (44–70%)

•        Loss of smell or taste (65%)

•        Difficulty in breathing (31–40%)

•        Myalgias (11–35%)

•        Headache <10%

•        Sore throat <10%

•        Runny nose/Congestion <10%

•        Nausea/Vomiting <10%

•        Diarrhoea <10%

Atypical presentations⁶: Can occur in immune-compromised or older patients

•        Fall

•        Delirium/confusion

•        Syncope

•        Functional decline

•        Reduced mobility

•        Bacterial co-infections

•        Absence of fever

Testing criteria: All patients who present with fever, respiratory symptoms alone or in combination with any of specified symptoms should get tested for COVID-19. The types of tests currently recommended and available in Pakistan are summarized in Table 2.

 

Home Management of COVID: The current COVID-19 situation is posing challenges to patients, their families as well as the doctors alike with high risk of infection transmission. In addition informed patients are reluctant to visit hospitals at this time due to fear of acquiring the infection. GPs being on the frontline are faced with the greatest threat of acquiring infection thus they are required to follow standard precautions for every patient they are taking care of at home as well as in clinics. Keeping this in mind, the following measures and recommendations have been proposed for GPs on infection control with particular emphasis on home management.

 

Standard Precautions for GPs:

•        Rigorous hand washing and hygiene

•        Appropriate use of personal protective equipment (PPE)

•        Needle-stick injuries prevention

•        Safe management and disposal of waste

•        Equipment disinfection and cleaning

•        Environment cleaning

•        Maintaining safe distance from patients and examination only if necessary with full PPE

 

Infection control measures to be followed by GPs during home visits:

•        Use of PPE is mandatory before entering the house. A new gown, gloves and surgical cap should be used as per donning procedure for each home visit if visiting multiple houses to prevent infections.

•        Avoid unnecessary touching of surfaces or eating/drinking during consultation at patient’s house.

•        After leaving the patient’s house and before entering your car/transport, PPE should be removed as per doffing procedure and hand hygiene should be performed.

•        Used PPE should be sealed in a plastic bag and disposed off or washed for reuse where applicable.

•        All the used instruments should be disinfected using a disinfectant containing 70% Alcohol 

•        On reaching home, shower is advised before meeting and greeting any household members

Table 3 provides an approach to the diagnosis and management of COVID-19 patients. The severity criteria have been adopted from already published guidelines by World Health Organization, Center of Disease Control and recently updated guidelines of National Institute of Health (NIH) Pakistan.^2,4-6

Symptom based management of mild disease: Our guidelines focus on management of non-severe clinical presentation of COVID. Most of the patients recover and can be managed at home, however the risk of hospitalization should not be ignored, therefore frequent and efficient monitoring is essential. The decision to shift the patient to an inpatient setup should be made on a case to case basis. This decision depends not only on the clinical presentation but additionally on potential risk factors for severe disease, the ability of the patient to self-isolate at home or any requirement for supportive care. Patients at high risk of complication for severe illness should be monitored closely because of the risk of progression to severe illness, specially seen in the second week after symptom onset. Strict watchfulness is mandatory at home as some may develop severe disease even earlier.

Enhancing the body’s immunity plays an important role in maintaining optimum health. Following general measures should be ensured at home and suggested to the patients.

General measures: Advice patients to

•        Stay at home in a well-ventilated room

•        Eat healthy meals and keep well hydrated

•        Get plenty of rest and sleep

•        Get involved in physical activity as tolerated

•        Encourage mental relaxation techniques to help cope with anxiety and panic

•        Keep a pulse oximeter at home if possible and stay vigilant in case the oxygen saturation drops and stays below 95% as this may require hospital admission

Table 4 highlights a brief management plan for the commonly reported symptoms at home. To date, there is no specifically approved treatment for COVID-19 i.e. no cure yet, although various treatments are currently under investigations and trials.

Table 5 shows the evidence based recommendation for the various therapeutic and adjunctive treatments being investigated and tested.

 

Home visit advice by GPs for mild category COVID-19 patients

 

Advice given by GPs for self-isolating COVID-19 patients at home

•        Patient should be quarantined in a well-ventilated single room with limited movement. Ideally, they should have access to a separate toilet else it should be disinfected after every use.

•        Patient should be advised to wear a surgical mask to prevent contamination especially during care giver presence in the room or when leaving room for any reason. 

•        Separate eating utensils should be advised for patient; and after use these should be washed with soap and water by the patient him/herself if stable otherwise by care giver with all precautions.

•        Surfaces which are frequently touched like tables, door handles and any other bedroom furniture should be disinfected daily using any household disinfectant that contains 0.1% sodium hypochlorite (equivalent to 1000 ppm).

•        All clothes, bed linen, towels under patient use, should be either washed with laundry soap and water or it can be machine washed at 60–90 °C (140–194 °F) using household detergent

•        Patients should limit contact with others through social distancing

 

Advice given by GPs for caregivers of COVID-19 patients at home

•        Household members should be advised to stay in a separate room from the patient. If this is not possible, then a minimum distance of at least 2 meter (6 feet) should be maintained. Ideally patient should be advised to use a separate washroom. If not possible then disinfect toilet after every use.

•        The number of caregivers should be limited. Ideally, assign one person who is in good health and has no medical problems.

•        Caregivers should at least wear a surgical mask and gloves when with the patient. Mask handling should be minimized during use. If it gets wet from secretions, replace immediately with a new and dry mask using appropriate technique (Avoid touching the front of mask). Mask and gloves should be discarded in a closed container immediately after use and hand hygiene carried out.

•        Avoid coming in contact with patient’s skin, clothes or any other contaminated materials. Perform hand hygiene after handling all items.

•        Visitors should not be allowed until patient’s complete recovery and all signs or symptoms of COVID-19 have resolved.

•        Care giver should perform hand hygiene after any contact with patients or their environment or use an alcohol-based hand rub if hands cannot be washed.

•        Those who cannot tolerate a mask should be advised to use rigorous respiratory hygiene; They should cover their mouth and nose with a disposable paper tissue on coughing or sneezing which should be discarded after use.

•        Gloves, masks, and other waste should be placed into a waste bin with a lid before disposing off.

•        Avoid other types of exposure to all items from immediate environment of patient (like toothbrushes, dishes and utensils, towels or bed linen etc.).

 

Conclusion

 

These guidelines will assist as a resource for GPs to differentiate the different categories of COVID-19 according to severity. Additionally, this will serve as a guide for appropriate home management of non-severe disease, appropriately identifying and referring those with severe or critical disease thereby easing the burden on tertiary care hospital.

 

Disclaimer: None.

Conflict of interest: None.

Funding Disclosure: None.

 

References

 

1.      World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard. [Online] 2020 [Cited 2021 January 19]. https://covid19.who.int/?gclid=EAIaIQobChMIsvron7Lg6gIVGIXVCh2RFgiNEAAYASAAEgLsVPD_Bw

2.      Government of Pakistan, Ministry of National Health Services, Regulations & Coordination. Guidelines: Clinical Management Guidelines for COVID-19 Infections. [Online] 2020 [Cited 2021 January 14]. Available from URL: https://storage.covid.gov.pk/new_guidelines/11December2020_20201211_Clinical_Management_Guidelines_for_COVID-19_infection_1204.pdf

3.      Centers for Disease Control and Prevention CDC. Healthcare Personnel and First Responders: How to Cope with Stress and Build Resilience During the COVID-19 Pandemic. [Online] 2020 [Cited 2021 January 19]. Available from URL: https://www.cdc.gov/ coronavirus/2019-ncov/hcp/mental-health-healthcare.html

4.      Centers for Disease Control and Prevention CDC. Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19). [Online] 2020 [Cited 2021 January 19]. Available from URL: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

5.      World Health Organization. Clinical management of COVID-19: interim guidance. [Online] 2020 [Cited 2021 January 19]. Available from URL: https://www.who.int/publications/i/item/clinical-management-of-covid-19

6.      BMJ Best Practice. Coronavirus Disease 2019 (COVID-19) – Symptoms, Diagnosis and Treatment. [Online] 2020 [Cited 2021 January 19]. Available from URL: https://bestpractice.bmj.com/topics/en-us/3000168/pdf/3000168/Coronavirus%20disease%202019%20%28COVID-19%29.pdf

7.      COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. [Online] 2020 [Cited 2021 January 19]. Available from URL: https://www.covid19treatmentguidelines.nih.gov/

8.      Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, et al. Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report. N Engl J Med 2020:NEJMoa2021436. doi: 10.1056/NEJMoa2021436. [ahead of print]

9.      Bauer SR, Kapoor A, Rath M, Thomas SA. What is the role of supplementation with ascorbic acid, zinc, vitamin D, or N-acetylcysteine for prevention or treatment of COVID-19? Cleve Clin J Med 2020. doi: 10.3949/ccjm.87a.ccc046. [ahead of print]

10.    Greiller CL, Martineau AR. Modulation of the immune response to respiratory viruses by vitamin D. Nutrients 2015;7:4240-70. doi: 10.3390/nu7064240.

11.    Martineau AR, Jolliffe DA, Hooper RL, Greenberg L, Aloia JF, Bergman P, et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ 2017;356:i6583. doi: 10.1136/bmj.i6583.

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