A larger than normal number of letters have been received this month, so it has only been possible to select a few for publication.
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Many medical bodies have issued guidance over the 4 months since COVID-19 was identified. By my reckoning there are at least 12 National Institute for Health and Care Excellence COVID-19 rapid guidelines and at least 20 other sets of national guidance from clinical leaders in many fields. The Royal College of General Practitioners and British Medical Association among others have resource hubs, and local systems are doing their best to interpret this information and apply it with more guidelines and system changes.
As each new guidance hits my inbox I feel a mixture of slight irritation and a spark of interest to see if there is a nugget of information that I can apply in my day-today decision making.
Some things however have occurred to me:
We can’t know that much about an illness that is only 4 months old and it is amazing that it is possible to write so much guidance about it.
I get a sense that people are sometimes trying to fill the knowledge gap too soon (the Roth score being used in triage of patients with COVID-19 being an example of this). We should be prepared to say sometimes, ‘I’m afraid that you are on your own here with your clinical judgement because we really don’t have an evidence-based approach yet.’
In GP Out of Hours (OOH) work in particular it currently feels like there is a lot of pressure placed on us to triage away from face-to-face consultations. One is aware that you are potentially putting a colleague’s life at risk and systems are being put in place to put bureaucratic hoops in the way of seeing patients face to face. Patients also are strongly resisting face-to-face assessments. The ‘Stay at home’ mantra is very hard to overcome.
Yet telephone or video triage for COVID-19 patients has little or no evidence base, and I have certainly been surprised by finding a number of frailer patients who don’t look or sound too bad, with oxygen saturations well less than 90% or other observations consistent with sepsis.
In general practice we have a tendency to discriminate against the inconvenient (for example, OOH work) and the unpleasant. Of course we need to minimise the risks to clinicians in assessing patients with possible symptoms of COVID-19 but we need to acknowledge our own discomfort when making triage decisions on the telephone or by video link, and also the lack of an evidence base for this work currently.
If in doubt, recognising the challenges of limited supplies of personal protective equipment (PPE), isolation rooms, and challenges of cleaning rooms and equipment, we need to have systems in place where people can be seen if they need to be. If nothing else, to try to reduce the number of anxious hyperventilating patients that I am currently seeing from ending up inappropriately in a hospital COVID-19 assessment unit.
Excessive pressure to avoid face-to-face consultations might risk an unnecessary complaint or an adverse medical outcome.
- © British Journal of General Practice 2020
