Assessment of COVID-19 in the community setting

Summary of NICE guideline [NG191].COVID-19 rapid guideline: managing COVID-19

Communication and shared decision making

• Communicate with people with COVID-19, and their families and carers, and support their mental wellbeing to help alleviate any anxiety and fear they may have. Signpost to charities and support groups (including NHS Volunteer Responders), to UK government guidance on the mental health and wellbeing aspects of COVID-19 and UK government guidance on supporting children and young people's mental health and wellbeing, and to Royal College of Paediatrics and Child Health resources for parents and carers
• Give people information in a way that they can use and understand, to help them take part in decisions about their care. Follow relevant national guidance on communication, providing information (including in different formats and languages) and shared decision making, for example, NICE's guideline on patient experience in adult NHS services.
• The Royal College of Obstetricians and Gynaecologists has produced information on COVID-19 and pregnancy for pregnant women and their families.

For adults with COVID-19, explain:

• that the typical symptoms are cough, fever, and loss of sense of smell or taste, but that they may also have breathlessness (which may cause anxiety), delirium (which may cause agitation), fatigue, headache, muscle aches and sore throat
• that other symptoms may be drowsiness (particularly in older people), poor appetite, and chest discomfort or pain
• that they and people in close contact with them or in the same household (including those caring for them) should follow the UK guidance on self-isolation and the UK guidance on protecting vulnerable people
• that they are likely to feel much better in a week if their symptoms are mild
• who to contact if their symptoms get worse, for example, NHS 111 online.

For children and young people under 18 years with COVID-19, explain:

• that additional symptoms (to those found in adults) may include grunting, nasal flare, nasal congestion, poor appetite, gastrointestinal symptoms, skin rash and conjunctivitis
• that they and people in close contact with them or in the same household (including those caring for them) should follow the UK guidance on self-isolation and the UK guidance on protecting vulnerable people
• that they are likely to feel much better in a week if their symptoms are mild
• who to contact if their symptoms get worse, for example, NHS 111 online
• that the presence of fever, rash, abdominal pain, diarrhoea or vomiting may indicate paediatric inflammatory multisystem syndrome (PIMS)
• how and when to seek medical help if PIMS is suspected

In the community, consider the risks and benefits of face-to-face and remote care for each person. Where the risks of face-to-face care outweigh the benefits, remote care can be optimised by:

• offering telephone or video consultations (see BMJ guidance on Covid-19: a remote assessment in primary care for a useful guide, including a visual summary for remote consultation)
• cutting non-essential face-to-face follow up
• using electronic prescriptions rather than paper
• using different methods to deliver medicines to people, for example, pharmacy deliveries, postal services and NHS volunteers, or introducing drive-through pick-up points for medicines.

Assessment

Use the following signs and symptoms to help identify people with COVID-19 with the most severe illness:

• severe shortness of breath at rest or difficulty breathing
• reduced oxygen saturation levels measured by pulse oximetry (see the recommendation on pulse oximetry levels that indicate serious illness)
• coughing up blood
• blue lips or face
• feeling cold and clammy with pale or mottled skin
• collapse or fainting (syncope)
• new confusion
• becoming difficult to rouse
• reduced urine output.

Be aware that different pulse oximeters have different specifications, and that some can under- or overestimate readings especially if the saturation level is borderline. Overestimation has been reported in people with dark skin.

For people with severe respiratory symptoms associated with COVID-19 (for example, suspected pneumonia) being managed in the community, see the recommendation on venous thromboembolism in hospital-led acute care in the community.

Care planning

• Discuss with people with COVID-19, and their families and carers, the benefits and risks of hospital admission or other acute care delivery services (for example, virtual wards or hospital at home teams)
• Some benefits and risks may be similar for all patients (for example, improved diagnostic tests and access to treatments, or better contact with families in the community), but others may be personal to the individual (such as loss of access to carers who can anticipate needs well in someone unable to communicate themselves, or risks of spreading COVID-19)
• Explain that people with COVID-19 may deteriorate rapidly. Discuss future care preferences at the first assessment to give people who do not have existing advance care plans an opportunity to express their preferences

For full details then see:

NICE guideline [NG191].COVID-19 rapid guideline: managing COVID-19