Coronavirus Disease (COVID-19) Protecting You, Saving Lives

Coronavirus disease (COVID-19) Protecting You, Saving Lives

An additional chapter to the Acute and Surgical Emergencies Handbook Warwick Medical School

Prof Cyprian Mendonca Consultant in Anaesthetics UHCW, Hon Professor, WMS Prof Vinod Patel Hon Consultant in Acute Medicine & Endocrinology GEH, Professor Clinical Skills, WMS Dr Sam George Consultant in Anaesthetics and ITU Medicine, George Eliot Hospital NHS Trust

Additional Contributions and resources from

Dr Mariam George: Consultant in Palliative Medicine, GEH NHS England Coronavirus Resources Dr Rajiv Nair: Public Health England Consultant in Acute Medicine, GEH Resuscitation Council UK Prof Sailesh Sankar: Red Whale COVID -19 Director Education, UHCW ICM Anaesthesia COVID-19 Prof Saravanan Ponnusamy: Professor of Diabetes WMS Dr Lauri Simkiss: Specialist Trainee-Palliative Medicine Dr Mathew Patteril Consultant Anaesthetist Patient Perspective: Dr Asok Venkataraman

Coronavirus disease: A patient perspective

On 23rd March 2020, Dr Asok Venkataraman (Consultant Cardiologist) had an inkling that he may have Coronavirus infection. At that time, he was on clinical duty at the George Eliot Hospital NHS Trust. He had just performed two pacemaker insertion procedures, after completing his morning ward round in the Cardiology Unit. He noticed a fever and a cough. He went into self-isolation later that day. The insidious mild symptoms progressed to intermittent fever, increasing shortness of breath and cough. The intermittent fever lasted for 16 days. At the time no swab testing was being done for symptomatic healthcare professionals. He was very keen to be swabbed as he wanted to return to work as soon as possible.

The most troubling symptom was shortness of breath and bouts of coughing, which at their peak, prevented even the phone calls which have become such a key part of our social and professional contact since lockdown has been in place. His wife is a Consultant in Child Health, specialising in Asthma. She adapted her considerable clinical skills to an adult and measured his level of breathlessness. He managed to hold his breath for one minute in the early stages of the illness but with time it went down to 15 seconds at its worst just a few days later.

Subsequently, Dr Venkataraman was tested using RT-PCR, and had his diagnosis confirmed. He had never been particularly worried about his susceptibility to the virus. His concerned colleagues insisted on regular blood tests and chest x-rays. The chest x-ray done on day 7 did however show clear evidence of Covid-19 pneumonia. Repeat investigations, including a CT PA, were requested on day 14, again confirming viral pneumonia consistent with Covid-19. Antibiotics were given, orally, to combat any potential or actual superimposed bacterial infection (co-amoxiclav and clarithromycin). The extra monitoring by colleagues was fully justified as Dr Asok Venkataraman would be the one person who would under-estimate the seriousness of life-threatening symptoms and delay hospital admission.

Almost four weeks since the start of his symptoms, his primary concern is the health of those around him. He does not pinpoint a key contact or occasion when he could have contracted the virus: possibly a patient on the coronary care unit, possibly not. He traced his contacts at the hospital and was reassured by the good health of his colleagues. Without reliable testing to confirm that he is no longer infectious, he is has been advised not to return to his on-site cardiology work just yet. He feels- ‘You don’t want to be the person responsible for their infection’.

The positive tests for Covid19 pneumonia caused considerable anxiety for his family and colleagues, especially given the reported death from the infection of other health workers in the country and the wider world (Italy, Spain, France and the USA). The family were especially worried that he was in strict self-isolation and that deterioration would be unnoticed and that he would succumb. Crude monitoring was set up and included clinical parameters such as HR, respiratory rate, breath holding time. Daily phone calls and messages from multiple people from around the world confirmed the alarm and the concern caused by his infection to family and friends. A particularly touching fact was that the neighbours called to ask for his health surmising that he had picked up Covid-19, as his car had not moved for a week.

Throughout though, he never felt that he would succumb to Covid-19, despite being very breathless just walking 5 metres to the bathroom. The intermittent fever and the persistent cough has now lasted 21 days and has meant strict isolation from every one, which has been depressing. He ends on stating that he looks forward to coming back to work and being useful again.

Dr Asok Venkataraman, Consultant Cardiologist, George Eliot Hospital NHS Trust Interviewed by Lucy Townsend, Covid Assistantship WMS Medical Student

Coronavirus disease (COVID-19) Protecting You, Saving Lives

Contents CORONAVIRUS DISEASE: A PATIENT PERSPECTIVE ...... 2 BACKGROUND ...... 5 ROUTES OF TRANSMISSION ...... 6 INCUBATION AND INFECTIOUS PERIOD ...... 7

SURVIVAL IN THE ENVIRONMENT ...... 8 INACTIVATION OF CORONAVIRUSES...... 8 COVID-19 INFECTION CASE DEFINITION ...... 8

DISPARITIES IN THE RISK AND OUTCOME ...... 9 COMMUNITY CARE...... 10 STAYING AT HOME IF YOU HAVE SYMPTOMS (SELF-ISOLATION)...... 11 IN-PATIENT CARE ...... 11 DIFFERENTIATING VIRAL COVID-19 PNEUMONIA FROM BACTERIAL PNEUMONIA ...... 11 COVID-19 INFECTION CONTROL AND APPROPRIATE PPE ...... 12

PPE CLASSIFICATION ...... 12 FIT TESTING ...... 12 AEROSOL GENERATION PROCEDURES ...... 13 DONNING AND DOFFING PPE ...... 14 FFP3 MASK FITTING INSTRUCTIONS ...... 14 CARDIOPULMONARY RESUSCITATION IN A SUSPECTED OR CONFIRMED COVID-19 POSITIVE PATIENT: ALGORITHM AND PPPE ..... 15 COVID-19 SAMPLING AND TESTING ...... 16

CLINICAL SPECTRUM OF COVID-19...... 19 COVID-19 DIFFERENTIAL DIAGNOSIS ...... 20 COVID-19 INFECTION PREVENTION AND CONTROL GUIDANCE ...... 22 SCREENING AND TRIAGE ...... 23 MANAGEMENT OF A SUSPECTED CASE OF COVID-19: PHE ALGORITHM GUIDE ...... 24 MANAGEMENT OF COVID-19 ADAPTED FROM WHO GUIDELINES ...... 25

MILD COVID-19 ...... 25 MODERATE OR SEVERE COVID-19 ...... 25 TREATMENT OF CO-INFECTIONS ...... 26 CRITICAL COVID-19 WITH ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) ...... 26 CRITICAL COVID-19 WITH SEPTIC SHOCK ...... 27 THROMBOEMBOLISM ...... 28 PERI-OPERATIVE MORTALITY IN PATIENTS UNDERGOING SURGERY WITH COVID-19 INFECTION ...... 28 RECOMMENDATIONS FOR REPORTING SURVEILLANCE DATA TO WHO ...... 28 PALLIATIVE AND END OF LIFE CARE ...... 30

ISSUES IN RELATION TO COVID-19...... 30 SYMPTOM CONTROL ...... 32

3 NIV WITHDRAWAL ...... 35 COMMUNICATING BAD NEWS AND POOR PROGNOSIS...... 38 COVID-19 PATIENT: DISCHARGE ...... 40 POTENTIAL THERAPIES FOR COVID-19 MANAGEMENT ...... 40 AT: DEXAMETHASONE IN HOSPITALIZED PATIENTS WITH COVID-19. THE RECOVERY COLLABORATIVE GROUP. NEJM 2021;384:693-704 ...... 40 SUMMARY OF COVID-19 MANAGEMENT ...... 44 COVID-19 VACCINES ...... 44

RNA VACCINES...... 45 VIRAL VECTOR VACCINES ...... 46 MONOCLONAL ANTIBODIES ...... 47

CEREBRAL VENOUS THROMBOSIS ...... 47 LOOKING AFTER YOURSELF DURING THE COVID CONTINGENCY ...... 48 TOTAL CONFIRMED CORONAVIRUS CASES AND DEATH RATE ...... 51 PATIENT AND PERSONAL SAFETY TIPS ...... 52 KEY REFERENCES ...... 52 CORONAVIRUS DISEASE (COVID-19): AN OSCE ...... 55

CASE 1...... 55 CASE 2...... 57 OSCE MARKING ...... 61 CLINICAL FRAILTY SCORE...... 62 HAND-WASHING ...... 63

4 Coronavirus disease 2019 (COVID-19)

Background

Novel coronavirus 2019, also named 2019-nCoV, is a single-stranded, enveloped ribonucleic acid virus responsible for producing an influenza-like syndrome, but with many important differences in relation to virulence, morbidity and mortality. The global pandemic is thought to have originated in the final few months of 2019 in the Huanan live animal Market in the city of Wuhan, capital of Hubei Province of China.

Due to the nature of pulmonary symptoms, the virus was re-named Severe Acute Respiratory Syndrome-related Coronavirus-2 (SARS-CoV-2) and the consequent disease named coronavirus disease 2019 (COVID-19). On 13th January 2020, the first international case outside of Wuhan was reported, and on 19th January 2020, the first case outside Wuhan, but within China, was reported. By 21st January, further cases were reported in USA and Taiwan in amongst travellers returning from Wuhan. On, 30th January 2020, the World Health Organization (WHO) declared the SARS-CoV-2 outbreak a public health emergency of international concern. Since then, Covid-19 has had a major impact on human health globally; infecting a large number of people; causing severe disease and associated long- term health sequelae; resulting in death and excess mortality, interrupting routine healthcare services; and more broadly having a negative impact on peoples physical and mental health. By late March 2021 there have been over 127 000 deaths in UK with 2.8 million deaths globally. In UK it is ranked the 3rd most common cause of death after cancers and cardiovascular disease. Globally, it is 4th after cancers, cardiovascular disease and respiratory disease and higher than TB, Malaria and HIV put together.

Since the initial reports, there has been variations in the transmissibility, clinical presentations and severity of the disease. The recent reports of virus variants from the Kingdom of Denmark, the United Kingdom of Great Britain and Northern Ireland, and the Republic of South Africa have raised interest and concern in the impact of viral changes.

A variant of SARS-CoV-2 with a D614G substitution in the gene encoding the spike protein replaced the initial SARS-CoV-2 strain identified in China and by June 2020 became the dominant form of the virus circulating globally with increased infectivity and transmission. On 14 December 2020, a variant SARS-CoV-2 VOC 202012/01 was reported in the South East England. On 18 December, another variant of SARS-CoV-2 variant 501Y.V2 that was rapidly spreading in three provinces of South Africa was reported.

Virus binding to lung cells: SARS-CoV-2: Schematic PHE NHS early counter pneumocyte attachment by representation of the virus measures: to reduce number virus via ACE 2 receptor can particle. Corona, crown- of cases and fatalities and allow result in a cascade ending in a appearance due to our NHS to cope with demand cytokine storm and fatal ARDS glycoprotein spikes Images in COVID-19 Medicine

The main symptoms of coronavirus (COVID-19) are: • High temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature) • New, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual) • Loss or change to your sense of smell or taste – this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal The clinical presentation ranges from a mild upper respiratory tract infection to severe acute respiratory distress syndrome and sepsis and some people infected with the virus never develop symptoms.

While most people with COVID-19 develop mild or uncomplicated illness. In severe cases, COVID-19 can be complicated by acute respiratory disease syndrome (ARDS), sepsis and septic shock, multi-organ failure, including acute kidney injury and cardiac injury. Older age, BAME ethnicity, Diabetes (both Type 1 and 2) and cardiovascular disease have been reported as risk factors for death.

Routes of Transmission

The transmission of COVID-19 is thought to occur mainly through respiratory droplets generated by coughing and sneezing, and through contact with contaminated surfaces. The predominant modes of transmission are assumed to be droplet and contact. Respiratory droplets are >5-10 μm in diameter whereas droplets <5μm in diameter are referred to as droplet nuclei or aerosols.

Respiratory droplet transmission can occur when a person is in close contact with an infected person who has respiratory symptoms (e.g. coughing or sneezing) or who is talking or singing; in these circumstances, respiratory droplets that include virus can reach the mouth, nose or eyes of a susceptible person and can result in infection. Indirect contact transmission involving contact of a susceptible host with a contaminated object or surface

6 (fomite transmission) may also be possible. This further emphasises the need for the 2- metre social distancing rule (1 meter with extra precautions such as wearing face or indoors with increased ventilation in).

Airborne transmission is defined as the spread of an infectious agent caused by the dissemination of droplet nuclei (aerosols) that remain infectious when suspended in air over long distances and time. Airborne transmission of SARS-CoV-2 can occur during medical procedures that generate aerosols (aerosol generating procedures =AGP)

In the UK, FFP3 respirators should be worn for aerosol generating procedures and must be compliant with BS EN149:200.1. During aerosol generating procedures (AGPs) there is an increased risk of aerosol spread of infectious agents irrespective of the mode of transmission and airborne precautions must be implemented when performing AGPs, including those carried out on a suspected or confirmed case of COVID-19. Coughing and sneezing are known to release aerosols, however, it is thought that aerosols generated by medical procedures pose a more significant risk to infection transmission.

In light of the above, the Department of Health and Social Care’s New and Emerging Respiratory Virus Threat Assessment Group (NERVTAG) have recommended that airborne precautions should be implemented at all times in clinical areas considered AGP ‘hot spots’ e.g. Intensive Care Units (ICU), Intensive Therapy Units (ITU) or High Dependency Units (HDU) that are managing COVID-19 patients (unless patients are isolated in a negative pressure isolation room/or single room, where only staff entering the room need wear a respirator). In other clinical areas a fluid-resistant surgical mask (FRSM) and eye protection is recommended.

Initial research has identified the presence of live COVID-19 virus in the stools and conjunctival secretions of confirmed cases. All secretions (except sweat) and excretions, including diarrhoeal stools from patients with known or suspected COVID-19, should be regarded as potentially infectious.

Incubation and infectious period

After the initial exposure, patients typically develop symptoms within 5-6 days, although about 20% of patients remain asymptomatic throughout infection

In most cases, individuals are usually considered infectious or “contagious” while they have symptoms; how infectious individuals are, depends on the severity of their symptoms and stage of their illness. The evidence suggests that SARS-CoV-2 RNA can be detected in people 1-3 days before their symptom onset, with the highest viral loads, as measured by RT-PCR, observed around the day of symptom onset, followed by a gradual decline over time. The duration of RT-PCR positivity generally appears to be 1-2 weeks for asymptomatic persons, and up to 3 weeks or more for patients with mild to moderate disease. In patients with severe COVID-19 disease, it can be much longer.

Survival in the environment

Human coronaviruses can survive on inanimate objects and can remain viable for up to 5 days at temperatures of 22- 25°C and relative humidity of 40-50% (which is typical of air- conditioned indoor environments). An experimental study using a SARS-CoV-2 strain reported viability on plastic for up to 72 hours, for 48 hours on stainless steel and up to 24 hours on cardboard. Extensive environmental contamination may occur following an aerosol generating procedure (AGP). The rate of clearance of aerosols in an enclosed space is dependent on the extent of any mechanical/natural ventilation. The greater the number of air changes per hour (ventilation rate), the sooner any aerosol will be cleared. The time required for clearance of aerosols, and thus the time after which the room can be entered without a filtering face piece respirator, can be determined by the number of air changes per hour as outlined in WHO guidance; in general wards and single rooms there should be a minimum of 6 air changes per hour, in negative-pressure isolation rooms there should be a minimum of 12 air changes per hour. Where feasible, environmental decontamination should be performed when it is considered appropriate to enter the room/area without an FFP3 respirator. A single air change is estimated to remove 63% of airborne contaminants, after 5 air changes less than 1% of airborne contamination is thought to remain.

Inactivation of coronaviruses

Surface disinfection with 0.1% sodium hypochlorite or 62 -71% ethanol significantly reduces coronavirus infectivity on surfaces within 1 min exposure time. Ethanol (78-95%), 2- propanol (70-100%), the combination of 45% 2-propanol with 30% 1-propanol, glutaraldehyde (0.5 -2.5%), formaldehyde (0.7-1%) and povidone iodine (0.23-7.5%) readily inactivated coronavirus infectivity by approximately 4 log10 or more. Sodium hypochlorite required a minimal concentration of at least 0.21% to be effective. Hydrogen peroxide was effective with a concentration of 0.5% and an incubation time of 1 min.

Ultraviolet radiation (UV) has a well-known antiviral effect. Studies have shown a total 6 inactivation of SARS-CoV-2 at a concentration of 5x10 TCID50/mL was achieved after 9 minutes of combined UVA and UVC exposure.

COVID-19 Infection Case Definition

SARS-CoV-2 infection causing Covid-19 may be manifested as asymptomatic carriage, acute mild to moderate illness or an acute severe/ critical illness. The commonly reported symptoms are a new onset of cough and fever, but may include headache, loss of smell, nasal obstruction, lethargy, myalgia, rhinorrhea, taste dysfunction, sore throat, diarrhoea, vomiting and confusion. Fever may not be reported in all symptomatic patients. Patients may also be asymptomatic.

Two types of lung phenotypes have been identified:

1. Atypical viral pneumonitis leading hypoxia with relatively compliant lungs. 2. Classic acute respiratory distress syndrome with stiff lungs. Covid-19 can be associated with other organ dysfunction such as renal failure, liver dysfunction and cardiac dysrhythmias. The risk factors for severe illness include age, male gender, obesity, ethnicity and associated co-morbidities such as cardiovascular disease, hypertension, diabetes, chronic respiratory disease, asthma and chronic kidney disease.

Disparities in the risk and outcome

Age and Gender

Current available data suggest that increasing age and male gender are significant risk factors for severe infection. However, the newer variants may cause severe infection in younger age group. In a large review of primary care records pseudonymously linked with SARS- CoV-2 status, comorbidities including diabetes, cancer and severe asthma were associated with increased risk of death.

Children

Fewer than 5% of COVID-19 cases are amongst children and in general they appear to exhibit mild disease. Although cough and fever are the main symptoms in children, a wide range of features, including fever, gastrointestinal symptoms, rash, a spectrum of multisystemic inflammatory disease, myocardial injury and shock have been reported in children.

Pregnant women

The risk to pregnant women and neonates following COVID-19 infection is generally low: more than half of pregnant women who test positive for SARS-CoV-2 are asymptomatic, and there is no increase in stillbirth or neonatal death rates associated with COVID-19 in pregnancy. It is unclear whether SARS-CoV-2 can be transmitted vertically, and only about 2% of neonates born to COVID-positive mothers in the UK test positive for SARS-CoV-2 in the first 12 hours of life. However, the risk of preterm birth is increased two to threefold for women with symptomatic COVID-19. Furthermore, a small proportion of pregnant women can have severe or fatal COVID-19.

Pregnant women are more likely to have severe COVID-19 infection if they are overweight or obese, are of Black and Asian Minority Ethnic background, have co-morbidities such as diabetes, hypertension and asthma, or are 35 years old or older

Deprivation

9 People who live in deprived areas are more likely to be diagnosed with Covid-19 and to have poor outcomes following diagnosis than those in less deprived areas. Poor outcomes remain after adjusting for ethnicity, but the role of underlying health conditions requires further investigation.

Ethnicity

The highest age standardised diagnosis rates of COVID-19 per 100,000 population were in people of Black ethnic groups. The mortality rate from Covid -19 was also higher in those in Black, Asian and Minority Ethnic (BAME) groups than in White ethnic groups. An analysis of survival among confirmed COVID-19 cases shows that, after accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity had around twice the risk of death when compared to people of White British ethnicity. People of Chinese, Indian, Pakistani, Other Asian, Black Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British.

Occupation

A high increase in all cause deaths was reported amongst those in a range of caring occupations including social care and nursing auxiliaries and assistants; those who drive passengers in road vehicles for a living including taxi and minicab drivers and chauffeurs; those working as security guards and related occupations; and those in care homes.

Health groups

There has been larger increase in deaths among people born outside the UK and Ireland. The biggest relative increase was for people born in Central and Western Africa (which includes Nigeria, Ghana and Somalia), the Caribbean, South East Asia (which includes Malaysia, the Philippines and Vietnam), the Middle East and South and Eastern Africa (which includes South Africa, Zimbabwe and Kenya).

Community Care NHS advices people in the community to look out for these main symptoms of COVID-19.

Patient Advice- Verbatim

The main symptoms of coronavirus are:

• High temperature – this means you feel hot to touch on your chest or back • New, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual) • Loss or change to your sense of taste or smell– this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal • Other atypical symptoms may include headache, loss of smell, nasal obstruction, lethargy, fatigue, myalgia, rhinorrhea, taste dysfunction, sore throat, diarrhoea, vomiting and confusion

10 Most people with coronavirus have at least one of these symptoms. People with any of the above symptoms must stay at home and arrange to have a test.

Staying at home if you have symptoms (self-isolation)

If your symptoms are mild you must not to leave your home. This is called self-isolation.

• Anyone with symptoms or a positive test must self-isolate. • Anyone who does not have symptoms must self-isolate for 10 days from when the first person in your home started having symptoms or the day their test was taken (if no symptoms but test was positive).

Clinicians should be alert to the possibility of atypical presentations in patients who are immunocompromised. Alternative clinical diagnoses and epidemiological risk factors should be considered.

In-patient Care

Patients who meet the following criteria require admission to hospital (clinical decision to admit, need to stay at least one night. • have either clinical or radiological evidence of pneumonia or • acute respiratory distress syndrome or • influenza like illness (fever ≥38°C and at least one of the following respiratory symptoms, which must be of acute onset: persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing.

Differentiating viral COVID-19 pneumonia from bacterial pneumonia

It is difficult to determine whether pneumonia has a COVID-19 viral cause or a bacterial cause (either primary or secondary to COVID-19) in primary care, particularly during remote consultations. COVID-19 viral pneumonia may be more likely if the patient: • presents with a history of typical COVID-19 symptoms for about a week • has severe muscle pain (myalgia) • has loss of sense of smell (anosmia) • is breathless but has no pleuritic pain • has a history of exposure to known or suspected COVID-19, such as a household or workplace contact.

A bacterial cause of pneumonia may be more likely if the patient: • becomes rapidly unwell after only a few days of symptoms • does not have a history of typical COVID-19 symptoms • has pleuritic pain • has purulent sputum.

COVID-19 Infection Control and appropriate PPE

Clinicians should: • Implement infection prevention and control measures: whilst awaiting test results, including isolation and cohorting of patients in line with PHE national Policy. • Wear Personal Protective Equipment (PPE): as a minimum, this should be a fluid resistant surgical mask, single use disposable apron and gloves and eye protection if blood and or body fluid contamination to the eyes or face is anticipated. • FFP3 respirator: If a patient meeting the case definition undergoes an aerosol generating procedure, then a, long-sleeved disposable fluid-repellent gown, gloves and eye protection must be worn • Patient to wear a surgical facemask: while transporting them to the treatment area- a single room or cohort area

PPE Classification

PPE should match the route of transmission. The need for use of PPE can be classified into three groups.

1. Contact precautions: Covid positive patient 2 meters away. Precautions include: surgical mask, gloves and apron. Contact precautions prevent direct or indirect transmission from contact with a suspect or confirmed COVID-19 patient and/or contaminated surfaces or equipment (i.e. contact with contaminated oxygen tubing/interfaces). If equipment needs to be shared among patients, clean and disinfect between each patient use. Health care workers should avoid contaminating environmental surfaces that are not directly related to patient care (e.g. door handles and light switches) and refrain from touching their eyes, nose and mouth with potentially contaminated gloved or ungloved hands.

2. Droplet precautions: Droplet precautions prevent large droplet transmission of respiratory viruses. Covid positive patient less than 2 meters distance. Precautions include: surgical mask, eye protection, gloves and apron.

3. Airborne precautions: Aerosol generating procedures. The precautions include: FFP3 mask, eye protection or visor, fluid repellent long sleeved gown, gloves

Fit testing

In order to protect health workers from contracting and spreading COVID-19 and to comply with the ‘duty to adequately control’ infection in the COSHH Regulations, a face fit test is required where staff are wearing tight fitting disposable respirators to ensure that they are adequately protected whilst carrying out AGPs and other specified clinical encounters. The performance of tight-fitting respirators depends on achieving a good contact between the wearer’s skin and the face seal of the face-piece. The facial characteristics of Healthcare Workers vary significantly in shape and size, so it is unlikely that one model of respirator will

12 fit everyone. An inadequate fit will significantly reduce the protection provided to the wearer.

There are two basic types of Respirator fit testing – qualitative (where the wearer needs to detect a sweet or bitter tasting solution sprayed into a hood whilst they are wearing the respirator) and quantitative (using a particle counter which measures the ratio of particles inside and outside the respirator).

Aerosol generation procedures

An aerosol generating procedure (AGP) is a medical procedure that can result in the release of airborne particles (aerosols) from the respiratory tract when treating someone who is suspected or known to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route. The following procedures are considered to be potentially infectious AGPs:

• Tracheal intubation and extubation • Manual ventilation • Tracheotomy or tracheostomy procedures (insertion or removal) • Bronchoscopy • Dental procedures (using high speed devices, for example ultrasonic scalers/high speed drills • Non-invasive ventilation (NIV); Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP) • High flow nasal oxygen (HFNO) • High frequency oscillatory ventilation (HFOV) • Induction of sputum using nebulised saline • Respiratory tract suctioning* • Upper ENT airway procedures that involve respiratory suctioning* • Upper gastro-intestinal endoscopy where open suction of the upper respiratory tract occurs • High speed cutting in surgery/post-mortem procedures if respiratory tract/paranasal sinuses involved

*The available evidence relating to Respiratory Tract Suctioning is associated with ventilation. It is the consensus view of the UK IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.

For patients with suspected/confirmed COVID-19, any of these potentially infectious AGPs should only be carried out when essential. Where possible, these procedures should be carried out in a single room with the doors shut, ideally in a negative pressure room. Only those healthcare staff that are needed to undertake the procedure should be present. A disposable, fluid repellent surgical gown, gloves, eye protection and a FFP3 respirator should be worn by those undertaking the procedure and those in the room.

13 The New and Emerging Respiratory Viral Threat Assessment Group (NERVTAG) advised that during nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles.

For patients with suspected/confirmed COVID-19, any of these potentially infectious AGPs should only be carried out when essential. Where possible, these procedures should be carried out in a single room with the doors shut. Only those healthcare staff that are needed to undertake the procedure should be present. A disposable, fluid repellent surgical gown, gloves, eye protection and a FFP3 respirator should be worn by those undertaking the procedure and those in the room.

Use of fluid resistant surgical masks and eye protection is indicated in all clinical areas.

Donning and Doffing PPE

It is important that correct procedural steps are followed during donning and doffing PPE. The key principles involve avoiding direct contact with viral load and minimising the contamination of the environment. The steps involved in donning procedure should facilitate step wise easy doffing to avoid self-contamination during the doffing procedure. Please see PHE Video link for https://www.youtube.com/watch?v=kKz_vNGsNhc.

FFP3 mask fitting instructions

A FFP3 mask should be fit tested as per the COSHH regulations 2002. Once fit tested, the mask should be fit checked during each time when the mask is worn. Fit testing may have to be repeated if there are changes like weight reduction or weight gain, substantial dental and facial work which may

Please see the video for fit testing: https://www.youtube.com/watch?v=27VKRPzkjr0 and for fit checking: https://www.youtube.com/watch?v=MCM9uMMok1M

14 Cardiopulmonary resuscitation in a suspected or confirmed Covid-19 positive patient: Algorithm and PPPE

The following steps should be followed to ensure safe clinical practice

• Ensure that DNACPR decisions are well documented and communicated • Identify as early as possible any patients with a COVID-19 like illness, who are at risk of acute deterioration or cardiac arrest. • Recognise cardia arrest. Look for signs of life and feel for carotid pulse • If a defibrillator is readily available and ready to use, defibrillate shockable rhythm prior to commencing chest compression. AGP precautions are not necessary for defibrillation. • Full AGP-PPE must be worn by all members of emergency team before entering the room • Start compression only CPR and monitor patient’s Rhythm. • Do not do mouth -mouth ventilation • Airway interventions must be carried out by experienced individuals • A viral filter must be used between the self-inflating bag and airway (tracheal tube or supragottic airway. • Ensure that all equipment are safely disposed and surfaces are cleaned appropriately. • Safe removal of PPE is essential to avoid self-contamination. For more details please refer to https://www.resus.org.uk

Resuscitation of Covid-19 patients

COVID-19 Sampling and Testing

The results of COVID-19 tests that detect different parts of the virus or immune response provide different clinical information that often overlap:

• Polymerase chain reaction (PCR) test indicates whether an individual has or recently had infectious virus. • Lateral flow device (coronavirus virus protein antigen test) indicates whether a person has the virus now and is likely to be infectious to others • Antibody test (proteins produced in response to the infection) are conducted on convalescent blood sent to a laboratory and indicates if someone has had the virus before.

Following samples can be used for testing Coivid-19.

• Upper respiratory tract sample(s): single swab used for throat, then for upper nose into one pot of viral transport medium; a viral nose swab and a viral throat swab combined into one pot of viral transport medium, or a nasopharyngeal aspirate in a universal transport pot. This is the RT-PCR Test (Real Time Reverse Transcription -Polymerase Chain Reaction). • Lower respiratory tract sample (sputum) if obtainable, in universal container. • On CRRS, using pathology request section, select Viral PCR and Covid-19 with an “ E28 form”. The form need to be printed and sent along with samples. Samples should be double bagged and clearly labelled. • Acute serology, if the patient is admitted to hospital, take a sample for acute serology. 5mL serum tube or plain (no additive) tube; for children <12 years, 1mL is acceptable. Label each sample with ID, date of birth and type of sample. Use the specific form for requesting Covid-19 acute respiratory disease testing form.

Approach to COVID-19 testing and interpretationReference: https://www.bmj.com/content/369/bmj.m1808 Watson J. Interpreting a Covid-19 test result. BMJ 2020;369:m1808 doi: 10.1136/bmj.m1808

Covid-19 clinical presentation Reference: COVID-19: epidemiology, virology and clinical features

Clinical Presentation of Covid-19: From mild illness to septic shock An algorithm prepared from the WHO Guidelines Clinical Spectrum of Covid-19

19 Covid-19 Differential diagnosis

Differential diagnosis for Covid-19

An algorithm for managing a possible COVID-19 requiring hospital admission An algorithm based on NHS England Guidance

21 Covid-19 Infection prevention and control guidance

Infection prevention and control precautions must be used by all staff, in all care settings, at all times and for all patients, to ensure the safety of patients, staff and visitors. Maintaining social distancing is considered standard practice in all health and social care areas across the UK (except when providing clinical care while wearing PPE).

Key principles of infection prevention and control measures Reference: IPC Highlights Quick Reference Guide

22 Screening and triage

All patients with suspected COVID-19 should be screened and isolated at first point of contact with health care system as per the PHE algorithm below in A&E, OPD etc

• A patient with acute respiratory infection under certain conditions (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath). • A patient with recent loss or changes in the sense of taste or smell • A patient with severe acute respiratory illness requiring hospitalisation (fever and at least one sign/symptom of respiratory disease, e.g., cough, SOB) and in the absence of an alternative diagnosis that fully explains the clinical presentation. • Covid-19 testing should also be considered in patients presenting with Acute respiratory illness and reported exposure to other test-confirmed COVID- 19 cases, and the current local incidence of COVID-19 in the community or in shared settings. Onset of delirium (in older people) or in those with dementia and cognitive impairment. When investigating possible infection in immunocompromised people. • Clinicians should suspect Covid-19 on CXR: if radiological changes are suggestive of community acquired pneumonia. • Certain blood findings should also alert a clinician to the high probability of COVID- 19. In a study 99 COVID-19 cases, patients had the following features: o Low lymphocytes: low in 35% o CRP high: not v high as in bacterial sepsis. mean 51.4 SD 41.8 (NR 0-5mg/l) o Glucose elevation: *only 12% diabetes, but 52% glucose > 6.1mmol/l o Albumin decreased: in 98%, ALT increased: in 28% o Urea only increased in 6%, Creatinine only increased in 3% o LDH increased: in 76% (lung death)

Chest X-ray of a 36 year old COVID-19 Chest X-ray of a 64 year old COVID-19 positive woman showing positive man showing Consolidation of right upper zone multiple, nodular shadowing in both Infiltrates on the right lower zone lung fields. This is especially concentrated in the lower lobes Typical Chest X-ray changes in COVID-19 Pneumonia

23 Management of a suspected case of COVID-19: PHE Algorithm Guide

Flow chart of suspected Covid-19 management

24 Management of Covid-19 adapted from WHO Guidelines

Mild Covid-19

Patients with mild disease do not require hospital interventions; but isolation is necessary to contain virus transmission.

• Symptomatic treatment with antipyretics for fever. • Counsel patients with mild COVID-19 about signs and symptoms of complicated disease. • Advice on self-isolation: must be given and safe distancing generally.

Moderate or Severe Covid-19

Patients with severe acute respiratory infection (SARI) and respiratory distress, hypoxaemia or shock require oxygen therapy to maintain target SpO2> 94%. All patients requiring any form or amount of supplemental oxygen after hospitalised should be given dexamethasone 6mg od (IV or orally) for 10 days or until discharge. Treat elevated glucose levels with local insulin protocols.

• Adults with emergency signs (obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma or convulsions) should receive airway management and oxygen therapy during resuscitation to target SpO2 ≥ 94%

• Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥ 93% during resuscitation; or use face mask with reservoir bag (at 10–15 L/min) if patient in critical condition. Techniques such high supported sitting position may help to optimise oxygenation, ease breathlessness and reduce energy expenditure. Prone position for awake, spontaneously breathing patients may also improve oxygenation and the ventilation/perfusion ratio. • Target SpO2: Once patient is stable, the target is > 90% SpO2 in non-pregnant adults and ≥ 92–95% in pregnant patients. • Patients should be closely monitored for signs of clinical deterioration: such as rapidly progressive respiratory failure and sepsis and respond immediately with supportive care interventions. • Vital Signs and NEWS: Patients hospitalized with COVID-19, require regular monitoring of vital signs and, where possible, utilization of NEWS to facilitate early recognition and escalation of the deteriorating patient. • Blood investigations: including FBC, urea, creatinine, electrolytes, CRP, liver function test and ECG should be performed at admission. • After resuscitation and stabilization of the pregnant patient: then fetal well-being should be monitored. • IV Fluids: Patients with SARI should be treated cautiously with IV fluids, because aggressive fluid resuscitation may worsen oxygenation, especially in settings where there is limited availability of mechanical ventilation. However, severe fluid restriction may lead reduced renal perfusion and acute renal failure. WHO recommends a conservative fluid management strategy for ARDS patients without tissue hypoperfusion and fluid responsiveness. • Discuss escalation plan: with family colleagues • Refer according to local policy to ITU, Respiratory physicians , Outreach team etc.

Treatment of co-infections

• Start empiric antibiotics as per the hospital guidelines to treat all likely pathogens causing SARI and sepsis as soon as possible, within 1 hour of initial patient assessment for patients with sepsis. Check antibiotic allergy status of patient. • Continue to practice good antimicrobial stewardship with regular review to stop, de-escalate or switch to oral/ enteral route based on the microbiology results.

Application of timely, effective and safe supportive therapies is the cornerstone of therapy for patients that develop severe manifestations of COVID-19.

Critical COVID-19 with acute respiratory distress syndrome (ARDS)

In Covid-19, early phase of respiratory failure primarily affects the vasculature. Pro- coagulation leading to micro- vascular pulmonary thrombosis has been observed. Lung compliance is generally good. During later phase, respiratory failure can involve ARDS and bacterial pneumonia. Hypoxemic respiratory failure in ARDS commonly results from intrapulmonary ventilation-perfusion mismatch or shunt and usually requires mechanical ventilation.

Although there is no clear evidence, HFNO and CPAP are considered as AGPs, they should be performed by a trained and experienced provider using appropriate PPE.

• HFNO (≥ 30l/min): The use of high-flow nasal oxygen in COVID-19 is the subject of much debate, relating to the benefits and harms that may result for patients and healthcare. HFNO may be an appropriate therapy for many patients for whom tracheal intubation has not yet become a necessity but for whom low- flow nasal oxygen or facemask oxygen is not providing adequate respiratory support. A careful decision must be made based on high oxygen usage and spread of infection by aerosol generation. WHO recommends a trial of HFNO, non-invasive ventilation – continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) in patients with mild ARDS. The joint guidance issued by the Faculty of Intensive Care Medicine, Intensive Care Society, Association of Anaesthetists and Royal College of Anaesthetists on 27.03.2020 states that “high-flow nasal oxygen or similar devices should be avoided,” remarking that there is “no survival benefit compared to conventional oxygen therapy, and the risk of environmental viral contamination may be higher.” • NIV (BiPAP): The use of NIV (BiPAP) should be reserved for those with hypercapnic acute on chronic ventilatory failure. • Early application of CPAP may provide a bridge to mechanical ventilation. Appropriate PPE precautions and strict hygiene precautions must be used. Response to CPAP should be assessed at regular intervals for 30 to 60 minutes. It is recommended that CPAP is delivered in a negative pressure room with air exchanges more than 10 cycles/ hour. A full-face non-vented mask with expiratory viral filter with a good mask seal is the preferred choice for delivering CPAP. Immediate intubation and ventilation facility should be available for patients treated with CPAP. Prone position can help ventilation.

26 PEEP increase should be discuss with seniors and considered if patient’s respiratory rate is above 30 or failure to maintain target oxygen saturation. • WHO recommends that patients receiving a trial of HFNO or NIV should be used in a monitored setting and cared for by personnel experienced with HFNO and/or NIV and capable of performing endotracheal intubation in case the patient acutely deteriorates or does not improve after a short trial (about 1 hour). Intubation should not be delayed if the patient acutely deteriorates or does not improve after a short trial. • Mechanical ventilation: The initial tidal volume of 6 mL/kg predicted body weight is adequate for majority of patients. The plateau airway pressure should be maintained <30 cm H2O. Permissive hypercapnia is permitted. However, at early stages when lungs are compliant, low tidal volumes may lead to atelectasis. The use of deep sedation may be required to control respiratory drive and achieve tidal volume targets. • Prone Ventilation: In adult patients with severe ARDS, prone ventilation for 12–16 hours per day is recommended. • Proning patients should be considered early to support the vasculature. A P/F (PaO2/ FIO2) ratio of <16 should be used as cut off for proning. • Careful fluid management strategy to ensure euvolaemia and adequate perfusion. • PEEP: PEEP titration requires consideration of benefits of improving alveolar recruitment vs risks of end-inspiratory overdistension leading to lung injury and higher pulmonary vascular resistance. A High PEEP may be required in patients with moderate or severe ARDS. At early stages, lungs are likely to be compliant and high PPEP may not be required. A PEEP of 10 cm H2O appears to be satisfactory. • Regular alveolar recruitment manoeuvres may have benefit in improving alveolar oxygenation. • Disconnection of ventilator breathing system increases the risk environmental contamination with aerosols. • Use in-line suction catheters for airway suctioning (closed system suctioning). • Clamp the endotracheal tube or disconnect distal to the HME filter (after the filter) when disconnection is required (for example, transfer to a transport ventilator). • Severe upper airway swelling in some patients may make extubation difficult.

Critical COVID-19 with septic shock

In adults when infection is suspected or confirmed AND vasopressors are needed to maintain mean arterial pressure (MAP) ≥ 65 mmHg AND lactate is ≥ 2 mmol/L, in the absence of hypovolaemia a diagnosis of septic shock should be considered.

Standard care includes early recognition and initiation of sepsis six care bundle within 1 hour of recognition. WHO recommends administration of fluid bolus of 250–500 mL crystalloid .in first 15–30 minutes. If there is no response to fluid loading or signs of volume overload appear then reduce or discontinue fluid administration. This step is particularly important in patients with hypoxaemic respiratory failure. Vasopressors should be used when shock persists during or after fluid resuscitation with a target blood pressure of MAP ≥ 65 mmHg.

Thromboembolism

Coagulopathy is common in patients with severe COVID-19, and both venous and arterial thromboembolism have been reported. WHO recommends pharmacological prophylaxis when not contraindicated and use of mechanical prophylaxis for those with contraindications.

During hospital stay If the patient needs advanced respiratory support: consider increasing anticoagulation from standard dose to an intermediate dose (double the standard dose) of low molecular weight Heparin. Therapeutic dose of either unfractionated heparin (UFH) or subcutaneous low molecular weight heparin (LMWH) should not be offered in the treatment of patients with COVID-19, unless there is a standard indication like pulmonary embolism.

Peri-operative mortality in patients undergoing surgery with COVID-19 infection

Patients having surgery are at risk of SARS-CoV-2 exposure in hospital and might be particularly susceptible to subsequent respiratory complications, due to the pro- inflammatory cytokine and immunosuppressive responses to surgery and mechanical ventilation. An international multi-centre study reported that postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Men aged 70 years and above, those with comorbidities (ASA grades 3–5), those having cancer surgery, and those needing emergency or major surgery are most vulnerable to adverse outcomes.

Strategies to minimise in-hospital SARS-CoV-2 transmission and mitigate the risk of postoperative pulmonary complications in SARS-CoV-2-infected patients whose surgery cannot be delayed are essential.

Recommendations for reporting surveillance data to WHO

WHO requests that national authorities report probable and confirmed cases of COVID-19 infection within 48 hours of identification, by providing the minimum data set outlined in the “Revised case reporting form for 2019 Novel Coronavirus of confirmed and probable cases” through the National Focal Point and the Regional Contact Point for International Health Regulations at the appropriate WHO regional office.

Generic approach to management of Covid-19 patients on the ward

Escalating phases of Covid-19 disease state and potential therapies Siddiqi HK, Mehra MR. COVID-19 illness in native and immunosuppressed states: A clinical–therapeutic staging proposal J Heart Lung Transplant. 2020 May; 39(5): 405–407.

Palliative and End of Life Care

Issues in Relation to COVID-19

Patients who are elderly, frail, have underlying serious illness or comorbidities have a higher mortality associated with COVID-19 infection as it has the potential to exacerbate their co- existing illness or place significant pressure on their lack of physiological reserve. Patients may continue to deteriorate despite optimum management and sufficient exploration of all reversible conditions. All clinical professionals should provide palliative and end of life care symptom control in irreversible situations and also support honest conversations about goals of care and treatment escalation (utilising the ReSPECT process).

It is important to have discussions about treatment escalation options as early as possible, to enable the involvement of patients in the decision making process. Where possible, patients must be supported to communicate what their preferences may be around medical interventions as well as ongoing care when they stop responding to treatment. In the

30 context of COVID-19, patients are likely to become ill and deteriorate quite quickly so the opportunity for discussion and involving them in decision making may be limited or lost. If patients lack capacity according to the Mental Capacity Act 2005, then the principles of best interest decision making apply. There must be clear documentation of all the discussions associated with the decision making process, including that of a formal Mental Capacity assessment if this has been undertaken.

Families and those close to them may be shocked by the suddenness of these developments and may also be ill and / or required to self-isolate. There may be multiple members of the family ill at the same time. Being kept honestly informed helps to reduce anxiety, even if the health care professionals do not have all the answers and even if the conversations need to be conducted behind PPE or, in the case of families who are self-isolating, by telephone or by using other technology solutions. The Palliative Care Team will be able to provide additional advice and guidance to support patients and their loved ones as well as staff. Specialist Palliative care teams have been working collaboratively across Coventry and Warwickshire to provide consistent standards in the delivery of End of Life (EoL) care service for patients across the region. The following guidance is an adaptation of the document developed by the UHCW Palliative Care Team in conjunction with local and national publications, particularly the Association for Palliative Medicine’s ‘COVID-19 and Palliative, End of Life and Bereavement Care in Secondary Care’(May 2020). The aim of this guidance is to help deliver the best care possible for patients and their families.

31 Symptom Control

For any symptom control, adopt the general approach of: • Correct the correctable • Non-pharmacological approaches • Pharmacological approaches Experience so far suggests the most common symptoms encountered in COVID-19 are breathlessness, cough, symptoms of delirium and fever. The table below outlines the drug options for management of symptoms in patients dying with COVID-19 infection. Consider renal and hepatic impairment when prescribing. Patients may require a continuous subcutaneous infusion of medication to gain control of symptoms. Seek specialist palliative care advice if symptoms are not controlled with the medications listed in the guidance or if further support is required. (Note some medications used in palliative care are unlicensed for their indication but have been agreed for use through local guidance.)

Non-Pharmacological and Pharmacological Approaches for Symptom Control

Symptom Usual Management Other Management PAIN If opioid naïve: Treat any contributory o Step 1: Paracetamol 1g PO/IV/PR qds symptoms such as cough (reduce if weight <50kg or if severe renal/liver impairment) o Step 2: Codeine 30-60mg PO qds o Step 3: Morphine IR 2.5mg PO qds OR If previously taking Codeine 240mg/24hrs, start Morphine MR 10mg PO bd with Morphine IR 2.5mg PO 1-hourly PRN and titrate appropriately. Max up to 6 doses/24h (seek advice if requiring multiple PRNs)

If unable to take oral medication: o Morphine injection 2.5mg SC 1-hourly o Consider syringe driver if on Morphine MR PO or requiring multiple PRNs

When prescribing opioids consider prescribing laxatives

If eGFR <30, give ½ normal Morphine PRN dose. Avoid Morphine MR and Codeine. Seek specialist advice regarding syringe drivers. Seek Specialist palliative care advice if: o Pain remains uncontrolled o Already on opioids or on Buprenorphine/Fentanyl patch

32 FEVER Paracetamol 1g PO/IV/PR qds (reduce to 2-3g/24 Reduce room hours if weight <50kg or if severe renal/liver temperature impairment) Wear loose clothing Consider NSAIDs as adjunct (avoid if concerns of Remove blankets, cool renal impairment)’ face with cloth Oral fluids, avoid alcohol BREATHLESSNESS Consider oxygen therapy only if hypoxic Positioning Relaxation techniques Morphine IR 2.5-5mg PO PRN hourly up to 6 Reduce room doses/24 hours (1.25mg in renal failure)(seek temperature advice if using multiple PRNs) OR Morphine MR Cool face with cloth 5mg PO bd (Use of fans during outbreaks of infection If associated anxiety, Lorazepam 500 micrograms not recommended) PO/SL qds PRN

If unable to take oral medication: o Morphine injection 1.25-2.5mg SC PRN hourly up to 6 doses/24 hours (seek Specialist advice if using multiple PRNs) o Midazolam 2.5mg SC PRN 1-hourly up to 6 doses /24h (seek Specialist advice if using multiple PRNs) o Consider a syringe driver with Morphine +/- Midazolam If acutely distressed (ARDS), SEEK SPECIALIST ADVICE: - Give *5mg Midazolam + *5mg Morphine SC/IV stat; if ineffective, one off Midazolam crisis dose (10mg IM/SC/IV) may be needed. *Use 2.5mg in frail/opiate naïve/renal failure patients COUGH Simple linctus 5ml PO qds, if ineffective: Humidification Codeine linctus 15-30mg PO qds OR Morphine IR Drinking fluids 2.5mg PO qds Honey & lemon warm drink If unable to take oral medication: Sucking cough/hard o Morphine injection 1.25mg SC PRN qds sweets o Consider a syringe driver with Morphine Elevate head when injection asleep Avoid smoking NAUSEA & Establish likely cause and treat with appropriate Treat reversible causes VOMITING anti-emetic Suppress smells If unable to take oral medication o Consider syringe driver with appropriate Sips of water antiemetic Eat and drink small o Haloperidol* 500micrograms-1mg SC 2- amounts slowly hourly (max 5mg/24 hours) if cause is uncertain *Avoid in Parkinsonism, seek Specialist advice DELIRIUM & Haloperidol* 0.5-1mg PO/SC 2-hourly (max Treat reversible causes AGITATION 5mg/24 hours)

33 Ensure adequate lighting If ineffective, add Lorazepam 500 micrograms- 1mg PO/ SL bd and prn Reassurance

If unable to take oral medication Reduce stimuli o Midazolam 2.5mg SC 1-hourly prn o Haloperidol* 0.5-1mg SC 2-hourly (max Minimise transfers to 5mg/24 hours) new environments o Consider a syringe driver if frequent prn are needed *Avoid in Parkinsonism, seek Specialist advice If acutely distressed, SEEK SPECIALIST ADVICE o Haloperidol higher starting dose 1.5-3mg PO/SC; o if ineffective may need Levomepromazine 12.5mg -25mg SC +/- Midazolam RESPIRATORY Glycopyrronium 200microgram SC 2-hourly PRN Repositioning SECRETIONS (max 1.2mg/24 hours) Reassurance of patient OR and family

Hyoscine Butylbromide 20mg SC 2-hourly PRN (max 120mg/24 hours) Consider early use of either Glycopyrronium 600micrograms/24 hours OR Hyoscine Butylbromide 60mg/24 hours in a syringe driver (after first PRN dose)

Care in the Last Days of Life For patients thought to be in the last days of life, it is recommended to consider the Coventry and Warwickshire Unified Holistic Assessment and Individual Plan of Care for the Dying Person (‘I-Plan’).

An individualised approach is needed for each Spiritual needs may be very important to patient for the prevention and relief of some patients. The Hospital chaplaincy suffering. team can access help for all the main religions in the local community

34 NIV Withdrawal Temporary guidelines for COVID -19 in Non ICU settings This guidance is for use by clinicians caring for adults with proven or suspected COVID-19 who have been on NIV but where the decision to withdraw NIV has been made. For the purposes of this document, NIV includes both continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) support, the latter is more commonly referred to as NIV.

Whilst invasive mechanical ventilation is preferred over NIV in COVID-19, invasive mechanical ventilation may not be appropriate in many patients and at times not available. In these situations, NIV may be used. Prior to starting NIV, discussions should ideally be had with the patient and family regarding: o Goals of care and treatment escalation o Potential need for NIV to be withdrawn

A ReSPECT form should be completed with clear goals of care and treatment escalation.

When to consider withdrawal of respiratory support: • A patient deteriorating despite respiratory support and burdens are outweighing benefits.

• A patient with capacity who requests withdrawal of respiratory support.

• A patient with a valid advance care plan/ Advanced Decision to Refuse Treatment (ADRT) declining respiratory support.

• A patient who is agitated or distressed due to ongoing use of their respiratory support.

A decision to withdraw ineffective or unwanted medical treatment including respiratory support is good clinical practice. Withdrawal of respiratory support is not assisted dying/ suicide or euthanasia. This should be carefully communicated to patients, loved ones and MDT colleagues, with opportunities to discuss wherever possible.

The decision to withdraw NIV should be multi-disciplinary wherever possible and led by a senior clinician. Once the decision has been made to withdraw NIV, this should be communicated to the patient, if they have capacity, and to their loved ones. Some patients will have strong feelings and beliefs about what they wish to happen both before and after withdrawal, for example with regards to communicating families or whether they wish sedation and these must be considered fully.

Considerations

Withdrawal of NIV can be distressing in ‘normal’ circumstances and is likely to cause emotional distress for patients with capacity, their families and staff caring for COVID-19 patients. It is particularly challenging as patients’ families and loved ones may not be able to

35 be with them and to say goodbye. Good communication is key when withdrawing NIV and can be particularly challenging as it may be over the telephone rather than in person. Staff caring for these patients, especially in a hospital setting, need to consider ways that families can see their loved ones before they die, often with technology to support video calls.

Key professionals required to be present at the time of NIV withdrawal should include the registered Nurse and senior Doctor responsible for the patient and Specialist Palliative Care Team. If this is not achievable, the responsible Consultant for the team should be contacted - remote senior support may be appropriate in exceptional circumstances. All patients, where possible, should be referred to the Specialist Palliative care team for support. Aim for all withdrawals to be in working hours with staff as above available.

Medications Prior to withdrawal of NIV ensure adequate medications are prescribed and available to control any symptoms during the process of withdrawal. At a minimum the following medications should be available in injectable form:

• Morphine Sulphate (or alternative strong opioid) – breathlessness or pain • Midazolam – agitation • Haloperidol – nausea/vomiting or agitation • Glycopyrronium or Hyoscine Butylbromide – upper airway secretions

Patients should be given doses of medication before withdrawal occurs and may also require a continuous infusion of medication. Patients with COVID-19 may need large doses to ensure they do not become distressed. Medication can be given either via the intravenous or subcutaneous route. The palliative care team can provide support with the use of medications to prevent and control symptoms.

NB: A patient who has already been on opioids, benzodiazepines or other sedatives may need a significant increase to their regular dose of medication.

36 PLEASE REFER ALL PATIENTS TO THE SPECIALIST PALLIATIVE CARE TEAM

Ensure the patient, carer/family and the members of the MDT are aware of the plan for withdrawal and ensure key professionals are in place and medications are available including oxygen (if planned to be used)

If there are 2 hours or more before the withdrawal of 1. Give STAT doses of Morphine Sulphate 5- NIV will commence, start a continuous subcutaneous 10mg IV/SC and Midazolam 5-10mg IV/SC infusion with a minimum of Morphine Sulphate 10mg 2. Repeat step 1. at 10-15 minute intervals if and Midazolam 10mg over 24 hours required until patient settled 3. If the patient has upper airway secretions, give Glycopyrronium 200micrograms OR Hyoscine Butylbromide 20mg STAT IV/SC 4.

Switch off ventilation and removal of mask by designated person

Remember the doses given above are a Change over to 28% Oxygen if planned minimum. Patients already taking opioids, benzodiazepine or other sedatives may require higher doses.

Give IV/SC Morphine Sulphate and Midazolam PRN to Contact the specialist palliative care ensure that patient is completely settled and team for advice on medications and comfortable dosages if required.

Ensure ongoing review - if survival for over 1 hour and continuous subcutaneous infusion not in place, commence one after discussion with specialist palliative care team

Key staff involved in the process should remain until confident that patient is settled or death occurs and the family have the support that is needed.

An algorithm for complete withdrawal of NIV

37 Communicating bad news and poor prognosis

Do not underestimate the value of regular communication with patients and families. Due to visiting restrictions telephone conversations maybe the key mode of communication with families. Communicating bad news face-to-face can be difficult and it can be even trickier over the phone. o Be sensitive to the varied reactions to bad news – anger, upset, questions. o Be kind to colleagues – It is an incredibly difficult time for staff. o Be kind to yourself – Be aware of personal reactions and emotions. Identify and engage with sources of support available to you, for example, colleagues, mentors, health and wellbeing support teams, local chaplaincy, useful resources on self-care.

When breaking bad news:

• Don’t make things more complicated than they need to be; use a framework such as SPIKES: o Setting / situation: read clinical records, ensure privacy, no interruptions o Perception: what do they know already?; no assumptions o Invitation: how much do they want to know? o Knowledge: explain the situation; avoid jargon; take it slow o Empathy: even if busy, show that you care o Summary / strategy: summarise what you’ve said; explain next steps • Be prepared for anger / upset / questions o These are usually not aimed directly at you, but you may have to absorb these emotions and react professionally, even if they are upsetting / difficult at the time o Patients or those close to them may request a ‘second opinion’ – this should be facilitated wherever possible • Be honest and clear o Don’t use jargon; use words patients and those close to them will understand o Sit down; take time; measured pace and tone; use silences to allow people to process information o Avoid using phrases such as “very poorly” on their own – is the patient “sick enough that they may die”? If they are – say it.

Supporting Patients and Visitors In view of the current COVID-19 pandemic, visiting is significantly restricted. It is therefore very important that patients are supported, and other ways of them keeping in touch with those close to them, such as through phone calls and video conferencing apps, should be recommended.

Communicating bad news to relatives A poster from patient safety learning hub

39 COVID-19 Patient: Discharge

If the patient is clinically well and suitable for discharge from hospital, discharge them after: o Appropriate clinical assessment o Risk assessment of their home environment o Provision of advice about staying at home o Treatment of symptoms such as cough, fatigue, mild SOB. These may last for several weeks and should not be a barrier for discharge. Potential Therapies for COVID-19 Management

There are many non-evidenced-based therapies that are being considered for COVID-19. The main ideas in the field expand daily- there are currently 200 clinical trials registered. A few are presented below. We will use the AT-A-GLANCE to summarise high quality published trials. This is: AT- Acronym, Title and reference, A- Aim and Method, GL- Group studied, Limbs of the trial eg X vs Y, AN- main results, Absolute risk reductions, NNT, CE- Clinical conclusion, Educating patients.

Results from Clinical Trials

Dexamethasone Corticosteroid therapy: The World Health Organization (WHO) strongly recommends systemic corticosteroid therapy (low- dose intravenous or oral dexamethasone 6mg) for 10 days in adults requiring supplemental Oxygen. UK RECOVERY trial shows that that systemic corticosteroids reduce 28-day mortality in patients with severe and critical disease. They also reduce the need for invasive ventilation.

AT: Dexamethasone in Hospitalized Patients with Covid-19. The RECOVERY Collaborative Group. NEJM 2021;384:693-704 A: To study the effect of Dexamethasone vs Placebo in hospitalised adults with COVID-19 GL: Covid-19 patients in UK 2104 were assigned to receive dexamethasone and 4321 usual care. Dexamethasone was given at a dose 6mg od (IV or oral) for 10 days maximum. AN: Primary Endpoint: 28 day mortality. Significant results as below. • Overall Dexamethasone reduced deaths by 17%: From 25.7% to 22.9%- NNT 36 • In ventilated patients: Deaths reduced by 36%, From 41.4% to 29.3% - NNT 8 • Oxygen Therapy no Ventilation: Deaths reduced by 18%. From 26.2% to 23.3% - NNT 34 • No benefit in those not receiving respiratory support at randomisation: Number Needed to Treat (NNT): Based on these results, 1 death would be prevented by treatment of around 8 ventilated patients or around 34 patients requiring oxygen alone CE: Dexamethasone clearly improves survival in COVID-19 pneumonia, especially in patients requiring ventilation or oxygen therapy without ventilation.

Remdesivir: Is a prodrug of an adenosine analogue that has a broad anti-viral spectrum including coronaviruses, filoviruses, paramyxoviruses and pneumoviruses. It vitro, it inhibits SARS-CoV-2. In animal models, inhibits both SARS-CoV-1 and MERS-CoV viruses.

Trial 1: AT: Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo- controlled multi-centre trial. Wang Y etal. Lancet 2020;395:1569-78 A: To study the effect of Remdesivir vs Placebo in adults with COVID-19 GL: Adults with radiologically confirmed pneumonia in 10 hospital in Hubei, China. Random allocation IV Remdesivir (Day 1 200mg, then Days 2-10 100mg). Use of other agents allowed. 237 patients, AN: Primary Endpoint: time to clinical improvement up to 28 days (1= discharged alive, 6= death). Remdesivir not associated with a difference (HR 1.23, CI 0.95-2.43). Mortality no benefit: Remdesivir 14% at day 28 vs Placebo 13%. CE: Remdesivir does not have Clinically significant benefits in COVID-19 pneumonia.

Trial 2: AT: Remdesivir for the treatment of COVID-19- Preliminary Report. Beigel JH et al. NEJM 2020. DOI 10.1056 A: To study the effect of Remdesivir vs Placebo in adults with hospitalised COVID-19 respiratory infection. GL: Adults in 60 centres: USA (45), Demark, UK, Greece, Germany, Korea, Mexico, Spian, Japan. Remdesivir (Day 1 200mg, then Days 2-10 100mg). 1063 patients. AN: Primary Endpoint: time to recovery. Remdesivir median time recovery 11 days vs 15 days placebo (significant, rate ratio 1.32). Mortality 0.70 for Remdesivir (not significant). CE: Remdesivir shortens time to recovery from 15 days to 11 days. No mortality benefit found.

Trial 2: AT: Remdesivir for the treatment of COVID-19- Final Report. Beigel JH et al. NEJM 2020, 383:1813-26. A: To study the effect of Remdesivir vs Placebo in adults with hospitalised COVID-19 respiratory infection. GL: Total 1062 patients were randomised (541 to Remdesivir and 521 to placebo). AN: Primary Endpoint: time to recovery. Remdesivir median time recovery 10 days vs 15 days placebo (odds ratio 1.5, 95% CI 1.2 -1.9). Estimated mortality 6.7% with Remedesivir and 11.9% with placebo by day 15 (-27%, not significant). CE: Remdesivir was superior to placebo in shortening the time to recovery.

Trial 3: Tocilizumab in patients hospitalised with Covid-19 pneumonia AT: Salama et al. NEJM 2021; 384:20-30. A: To study the effect of anti-interleukin-6 receptor antibody vs Placebo in adults with hospitalised COVID-19 pneumonia. GL: Total 388 patients were randomised (259 to Tocilizumab and 129 to placebo).

41 AN: Primary Endpoint: mechanical ventilation or death by day 28. The cumulative percentage of patients who had received mechanical ventilation or who had died by day 28 was 12.0% in the tocilizumab group and 19.3% in the placebo group. (hazard ratio for mechanical ventilation or death, 0.56; 95% CI, 0.33 to 0.97; P=0.04). CE: Tocilizumab reduced the likelihood of progression to the composite outcome of mechanical ventilation or death, but it did not improve survival.

Other Therapies being evaluated in Clinical Trials o Chloroquine and hydroxychloroquine: Widely approved for the treatment of malaria, lupus and rheumatoid arthritis. Preliminary research in human and primate cells suggests that the drugs could effectively treat COVID-19. Chloroquine disrupts the ability of the SARS-CoV virus to enter and replicate in human cells by blocking the ACE2 receptor. Hydroxychloroquine undermines the novel virus' replication in a similar way. There are important side effect including cardiac toxicity (prolong QTc). One recent study showed that after high-risk or moderate-risk exposure to Covid-19, hydroxychloroquine did not prevent illness compatible with Covid-19 or confirmed infection when used as postexposure prophylaxis within 4 days after exposure.

o EIDD-2801 Oral: promising data in vitro with human lung and airway cells. This drug might even be more efficient at blocking the novel coronavirus, SARS-CoV-2, than remdesivir. EIDD-2801 introduces genetic mutations into the virus’s RNA. As the RNA makes its copies, so many damaging mutations accumulate that the virus is no longer able to infect cells. Japanese trials. o Favipiravir (Avigan): Japanese influenza drug showed promising outcomes in treating at least mild to moderate cases of COVID-19. In Japan, it is approved as an experimental treatment for COVID-19 infection tested in 340 individuals in Wuhan and Shenzhen. "It has a high degree of safety and is clearly effective in treatment," Zhang Xinmin, of China's science and technology ministry (March 2020). It shortens the duration of the virus as well as improves lung conditions (as seen in X-rays) in tested patients. Research yet to be published in a peer-reviewed science journal. o Favipiravir (Kaletra): An HIV anti-viral drug combination. However, data from China, published in NEJM, could not detect benefit when patients took the drug. A total of 199 people with low oxygen levels were randomized to Kaletra or placebo. Fewer people taking kaletra died, but difference was not statistically significant. Both groups had similar levels of virus in their blood over time.

o Losartan: A generic BP-lowering drugs acts on the Renin-Angiotensin system. University of Minnesota has launched two clinical trials. The first would evaluate whether losartan can prevent multi-organ failure in COVID-19 pneumonia. The second would evaluate if the drug can prevent hospitalizations in the first place. Losartan might block the ACE2 receptor to prevent the virus from infecting cells. Aliskerin may block production of the ACE2 receptor by down regulating the renin-angiotensin axis. Losartan might also

42 feasibly make matters worse by increasing the number of ACE2 receptors and increase the ability of the virus to infiltrate cells. An Italian report showed that of 355 who died from COVID-19, 75% had hypertension and may would be on ACE-I or ARBs such as losartan. o Recovery phase serum: Convalescent plasma from people who have recovered from COVID-19 infection. The NHS Blood and Transplant Authority in UK has started recruitment for this trial. Other trials have reported no benefit.

43 Summary of COVID-19 Management

Covid-19 is a Severe Acute Respiratory Syndrome caused by SARS-Coronavirus-2. The clinical features are fever, fatigue, myalgia, anorexia, cough with or without sputum, shortness of breath, nausea and diarrhoea.

Immunocompromised and elderly patients can present with atypical features. Important investigations include throat and nasal swab, bloods for FBC, CRP, U&Es, LFT and blood culture.

Management is mainly supportive with supplementary oxygen therapy, empirical antibiotics for suspected bacterial pneumonia and ventilator support for hypoxic respiratory failure. ARDS, respiratory failure, sepsis, septic shock, DIC and heart failure are the complications associated with Covid-19. Deamethasone 6mg od for 10 days in all patients requiring supplemental oxygen.

Consider critical care: Patients requiring more than 60% oxygen to maintain SpO2 > 92%, require critical care admission and ventilator support. Those patients who are suitable for discharge should have appropriate risk assessment of home environment.

Covid-19 Vaccines The COVID- 19 pandemic is the greatest public health crisis of the 21st century. Many pharmaceutical companies and countries are involved in the fight against this, and few vaccines have been approved for use.

Coronaviruses are single-stranded enveloped RNA. SARS-CoV-2, the pathogenic factor for COVID-19, is a novel zoonotic RNA beta coronavirus. While the exact source of the virus remains a mystery, it is widely reported to have originated from a bat and made its way to humans via an intermediate animal host, the pangolin, a mammal that is traded for the medicinal properties. The virus enters human cells through its Spike (S) protein, and binds to the angiotensin I converting enzyme 2 (ACE2) receptor. ACE2 is a type 1 transmembrane aminopeptidase seen mainly in the lungs especially in the Type 2 alveolar cells. ACE regulates the Renin- Angiotensin System (RAS) and plays a significant role in neurohumoral regulation of the cardiovascular system. When the virus binds to ACE2, it alters signaling pathways, causing acute myocardial and lung injury. When the over activated immune system is engaged in destroying the virus, there is a sharp spike in the production of inflammatory factors, such as IL-2, IL-6, GCSF, MCP-1, TNFα, etc. This, in turn, causes the cytokine storm and eventually lead to ARDS, secondary infections and multi-organ damage, ensuing death. Vaccines Vaccines should pass through different levels of clinical trials to test for immunogenicity, effectiveness, safety, dose levels and adverse effects. Currently there are 66 Covid vaccine candidates in clinical research. The effectiveness of the vaccine is defined by its efficacy. For the Covid -19 a vaccine efficacy of > 50 % is deemed to slow down the pandemic. The sterilizing immunity is what is necessary to prevent transmission. There are 10 vaccines currently approved by one regulatory body for public use. They are

44 • 2 RNA vaccines (Pfizer- BioNtech vaccine storage at -70oC and Moderna mRNA 1273 vaccine sored at -20 oC) • 3 Conventional inactivated vaccines (BBIBP -CorV, Covaxin, Chinese CoronaVac) • 4 viral vector vaccine (Russian SputnikV, Oxford AstraZeneca vaccine, Convidecea, Johnson and Johnson vaccine) • 1 peptide subunit vaccine (Epivaccorona)

RNA vaccines Strands of genetic material mRNA which encodes for the antigen are synthesised in a cell free system using a DNA template. They are covered by a lipid nanoparticle which protects the mRNA from body enzymes. They enter the macrophages and dendrite cells near the vaccination site. This mRNA will deliver instructions to the cell to make spike protein which are like the Coid-19 spike protein. The mRNA doesn’t enter the cell nucleus or affect the genetic material. Once the spike protein is presented on the cell surface, it will activate the T cells and produce antibodies.

Mechanism of action of RNA vaccine

45 The Pfizer vaccine is stored at -70oC. After removal from the frozen storage the undiluted vaccine can be stored at 2-8oC for 120 hours. Once removed from the fridge it should be diluted within 2 hours and used in 6 hours. The recommended dosage for the vaccine is two doses at 21-day interval.

Viral Vector vaccines These vaccines are examples of non-replicating viral vectors, using an adenovirus shell containing DNA that encodes a SARS-CoV-2 protein. The viral vector-based vaccines against COVID-19 do not make new virus particles, but rather produce only the antigen which elicits a systemic immune response.

Mechanism of action of viral vector vaccines

Inactivated viral vaccine These consist of virus particles that have been grown in culture and then are killed using a method such as heat or formaldehyde thereby loosing disease producing capacity, while still stimulating an immune response.

Peptide subunit vaccine These present one or more antigens without introducing whole pathogen particles. The antigens involved are often protein subunits but can be any molecule that is a fragment of the pathogen.

Formulation Most vaccines use adjuncts to increase the immunogenicity of the vaccine. Aluminum “Alum” were the first used in vaccines to enhance immunogenicity. The alum adjuvant produces molecular and cellular mechanisms.

Monoclonal Antibodies

Monoclonal antibodies (MAbs) are synthesised in laboratory to mimic natural antibodies. This has a similar mechanism of action as that to natural humoral immunity. MAbs may be useful for patients with compromised immune systems who may not be good candidates for receiving a vaccine. In a pandemic setting they are useful because of a lack of natural immunity. MAbs are expected to diminish viral load, reduce symptoms, and prevent hospitalization. Barriers for the use of MAbs include high costs and the requirement for parenteral administration.

There are about 70 MAbs currently in development to treat COVID-19.

BLAZE-1 trial: A phase 2 randomised trial comparing three doses of bamlanivimab for outpatients having mild to moderate COVID-19. Four of 136 participants (2.9%) in the pooled bamlanivimab arms versus seven of 69 participants (10.1%) in the placebo arm were hospitalized or had emergency department visits. In November 2020, the FDA issued an emergency use authorization for the investigational mAb bamlanivimab (700 mg given over 60 min) for the treatment of outpatients with mild-to-moderate COVID-19. Monoclonal antibodies, such as bamlanivimab, may be associated with worse clinical outcomes when administered to hospitalized patients with COVID-19 requiring high flow oxygen or mechanical ventilation.

A randomized controlled Phase 1 and 2 trial comparing two doses of casirivimab plus imdevimab to placebo was undertaken. An interim analysis of this study suggested a potential clinical benefit of casirivimab plus imdevimab for outpatients with mild to moderate COVID-19 who received an infusion of the drug combination a median of 3 days after symptom onset. Eight of 434 participants (2%) in the pooled casirivimab plus imdevimab arms versus 10 of 231 participants (4%) in the placebo arm were hospitalized or had emergency department visits within 28 days of treatment.

Cerebral venous Thrombosis

The rates of cerebral venous sinus thrombosis (CVT) have been noted to be significantly higher among the people with Covid-19 than in general population. CVT and thrombocytopaenia has also been reported following Covid-19 adenovirus vectored vaccines. Using electronic health records, researchers at Oxford University examined the incidence of CVT among roughly 500,000 patients diagnosed with COVID-19, nearly 500,000 who'd received the first dose of a COVID-19 mRNA vaccine, and roughly 175,000 with influenza diagnosed between January 2020 and March 2021. In patients with Covid-19, the absolute risk of cerebral venous thrombosis was higher than the risk among mRNA vaccine recipients and among AstraZeneca adenovirus vaccine recipients.

47 Looking after yourself during the COVID Contingency

Look after yourself to an even higher standard than before during these very stressful times. For your own and your families and friends you must not develop any additional physical or mental disorder due to your great help with the COVID-19 pandemic.

• Wash your hands regularly: use hand gel between patients and use soap and water often. Wash hands for 20 seconds or more and more often. Clean from below the elbows to clean off any invisible droplets. Wash and clean your stethoscope in between all clinical uses.

• Obsessive PPE: Please take all necessary PPE precautions. There are adequate supplies national and you should never compromise with respect to national guidance. You are of no use to anyone if you get sick.

• Resuscitation: Airline safety briefings tell you to put your own oxygen mask on before helping others, and the first step in in any clinical setting and especially resuscitation is to ensure that the area is safe and that you have the correct PPE.

• Medical conditions: If you are pregnant, immuno-compromised or any significant medical condition, consider seeking advice from occupational health.

• Mental Health: Try not to get so stressed that you aren’t effective at work or at home. If stress about coronavirus is affecting you on a day to day basis, seek help – there are online resources that you can turn to and a chat with a supportive colleague can be invaluable.

• Personal Decontamination: At the end of your shift consider a personal decontamination protocol o Minimise on-site dress paraphernalia- such as watches, rings, other jewellery o At the end of shift, wash arms below the elbow and hands with soap and water. o Sanitise Stethoscope (after every patient encounter), Phone, Badge o Arrive home – consider leaving “clinical” jacket or coat in car o Wash Hands at Home- straight to sink or shower without touching anything. o Change clothes and place into laundry basket o Relax!

• Use wider resources: there are several useful resources that can help manage and cope with stress and anxieties in relation to clinical work and especially COVID-19. BMJ learning resources are particular high quality in this regard. A table from the RD Whale Survival guide is attached below- we recommend the whole article to you.

• Personal Reflections: You are doing a very important job during some of the most difficult times in the modern history of our country and the world to some extent. Life will be different after COVID-189 that is a certainty. Reflect on your contribution and know that it is appreciated by your colleagues, friends, family and the public.

Early Stage Anxieties Not understanding what will enfold with the Pandemic. Understanding the effects on our thoughts, feelings, behaviours and physical symptoms

Summary of Helpful Strategies Creating a contextual understanding of how COVID impacts on your life and strategies on how to mitigate and overcome these impacts

Red Whale: COVID-19 An emotional and psychological survival guide Please consult the whole article

Total confirmed coronavirus cases and death rate

Month end UK total UK deaths World total World deaths cases cases January 2020 0 0 11,950 259 February 2020 23 0 86,604 2,977 March 2020 25,150 1789 858,361 42,309 April 2020 171,253 26,771 3,299,603 233,824 May 2020 274,762 38,489 6,259,250 373,695 June 2020 283,253 40,391 10,916,034 526,730 July 2020 303,181 41,030 18,474,396 694,505 August 2020 335,873 41,501 26,260,157 871,520 September 2020 465,125 42,143 34,878,457 1,027,055 October 2020 1,011,660 46,555 47,139,653 1,203,654 November 2020 1,629,656 58,448 64,484,967 1,478,526 December 2020 2,488,780 73,512 83,925,956 1,833,978 January 2021 3,817,176 106,158 103,466,727 2,246,139 February 2021 4,176,554 122,849 114,626,932 2,543,393 March 2021 4,350,266 126,713 129,468,030 2,828,139

First Fatality UK 5 March 2020 China 11 January 2020 https://www.worldometers.info/coronavirus/country/uk/

COVID -19, a viral pandemic is causing global crisis. Currently there are 108, 700,500 with 2,396,400 deaths across the world. Present specific and supportive treatment strategies include respiratory management, use of steroids, antibiotics, antiviral medications and immune modulating drugs. As for the preventative measures, WHO guidance of hand washing, personal protective equipment, restrictions of travel etc. helps in the restriction of transmission of this contagious disease. Vaccines are the mainstay in the long- term prevention of diseases. Normally vaccine production takes few years, but in the case of COVID-19, it has taken less than 10 months for an approved vaccine to be in use.

Patient and Personal safety tips o PPE and Hand-washing: there is a dual purpose in protecting yourselves but also the patient. PPE on the patient when they are being transferred will protect others, including patients and the public, from contracting COVID-19. Ensure that you have appropriate personal protection before approaching a Covid-19 known or suspected patient o Early detection of symptoms and isolation is key in minimising the spread of Corona virus. o Social distancing and self-isolation Advice: offer this whenever needed to friends, family and patients. Avoid all non-essential social contact to minimise the spread of the disease. Unfortunately, social distancing measures are poorly observed in many hospitals by HCPs and other employees. o Careful triage and transfer of patients within hospital: Care should be taken to minimise the transmission of infection whilst transferring patients within the hospital. o Infection prevention and control measures must be initiated whilst waiting for test results. o Clinical Management should be guided by timing of onset of symptoms to understand where in the trajectory of the disease the patient is. Basics must be in place urgently: oxygen therapy, investigations, antibiotics, fluids with caution. o Early recognition of deteriorating respiratory symptoms and supportive measures are essential. o Proning the patient should be considered at early phase of ventilatory support. o Severe upper airway oedema may complicate weaning and extubation in the ITU. o Mental Health: There is good evidence of deterioration in the mental health of patients, general public and staff in clinical settings. There is also some evidence that suicide rates are increasing with a distinct increase in domestic violence, in part, due to social isolation measures. Anxiety, stress, depression and other mental health issued needed to be picked early and managed professionally in a supportive environment.

Key References

Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance V 1.2. May 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory- infection-when-novel-coronavirus-(ncov)-infection-is-suspected

Information, guidance and resources supporting the understanding and management of coronavirus (Covid-19) New multidisciplinary website

Intercollegiate General Surgery Guidance on COVID-19 UPDATE. Rcsed.ac.uk

Ireland, N. (2020) ‘ICNARC report on COVID-19 in critical care’, https://www.icnarc.org

Covid-19 rapid guideline: critical care in adults. https://www.nice.org.uk/guidance/ng159

52 https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial- investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible- cases-of-wuhan-novel-coronavirus-wn-cov-infection-accessd 03.03.2021 https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection- prevention-and-control/covid-19-personal-protective-equipment-ppe#section-7 https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/specialty- guide-NIV-respiratory-support-and-coronavirus-v3.pdf https://www.who.int/docs/default-source/coronaviruse/coping-with- stress.pdf?sfvrsn=9845bc3a_2

Disparities in the risk and outcomes of Covid-19. PHE. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/ file/889195/disparities_review.pdf

Boulware DR. A Randomized Trial of Hydroxychloroquine as Postexposure Prophylaxis for Covid-19. https://www.nejm.org/doi/full/10.1056/NEJMoa2016638

Red Whale: COVID-19 An emotional and psychological survival guide

Chen N et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China. Lancet 2020; 395:507-13.

Kampf, G. et al. (2020) ‘Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents’, Journal of Hospital Infection, 104(3), pp. 246–251. doi: 10.1016/j.jhin.2020.01.022.

Sorbello, M. et al. (2020) ‘The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice.’, Anaesthesia, (March), pp. 1–9. doi: 10.1111/anae.15049.

Wang, W. et al. (2020) ‘Detection of SARS-CoV-2 in Different Types of Clinical Specimens’, JAMA - Journal of the American Medical Association. doi: 10.1001/jama.2020.3786.

Watson, J., Whiting, P. F. and Brush, J. E. (2020) ‘Interpreting a covid-19 test result’, BMJ (Clinical research ed.). doi: 10.1136/bmj.m1808.

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31182-X/fulltext

Wong, J. et al. (2020) ‘Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore’, Canadian Journal of Anesthesia. Springer International Publishing. doi: 10.1007/s12630-020-01620-9.

WHO: Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. March 2020.

Palliativedrugs.com: https://www.palliativedrugs.com/download/Palliative_care_collated_COVID_resources_V07 _200411.pdf

GEH Trust Intranet Specialist Palliative Care and End of Life webpage http://geheasyweb/clinical-services/palliative-care-specialist/.

Guidelines for the use of drugs in symptom control (West Midlands Palliative Care Physicians Guidelines): http://www.wmcares.org.uk/wmpcp/guide/ and COVID-19 specific page. http://www.wmcares.org.uk/covid-19/

Association for Palliative Medicine COVID-19 guidance: https://apmonline.org/wp-content/uploads/2020/04/COVID-19-and-Palliative-End-of-Life- and-Bereavement-Care-20-April-2020-2.pdf e-ELCA COVID-19 learning path: https://portal.e-lfh.org.uk/Component/Details/604722

NHSE specialty guide: https://www.england.nhs.uk/coronavirus/wp- content/uploads/sites/52/2020/04/C0081-AMENDED-Speciality-guide-Palliative-care-and- coronavirus-v2-2020-04-22.pdf

NICE rapid guideline: https://www.nice.org.uk/guidance/ng163

Guidelines for withdrawing Non-Invasive Ventilation (NIV) at End of Life. Version 3 April 2018. UHNM

Withdrawal of Assisted Ventilation at the Request of a Patient with Motor Neurone Disease. Association for Palliative Medicine Of Great Britain and Ireland. 2015

University Hospitals Leicester guideline: Withdrawal of NIV/ CPAP/ HFNO (“respiratory support”) when proven/ suspected COVID-19

Coronavirus disease (COVID-19): An OSCE

Notes on how to conduct and mark the OSCE at end of the section. Questions in darker shaded rows. Additional case information in lighter shaded row. Model answers in row immediately below the question.

Case 1 Mark Gabriel: DoB: 10/11/1961, Hospital Number: BTS9875, NHS No: 170537053 1 2 100 Solitude Drive, Coleraton, Coventry. Mark is admitted in the medical assessment unit with history of myalgia, fever, continuous cough and increasing shortness of breath. He says: “I have heard a lot about Coronavirus, it can cause a nasty chest infection and even death in some people”. He lives with his wife. Active social life went to Cruft’s a few weeks ago on all 3 days. There is a son who visits regularly. Mr Gabriel feels that his son may have had a ‘flu-like illness on return from skiing in Italy, but this was several months ago.

He has been triaged and you are asked to move him to the side room of the Covid bay of the admission unit. You have been asked to perform initial assessment of this patient. What PPE is required for you and the patient? Wash hands or alcohol gel to hands Outlines Donning of PPE procedure in the correct order. Apron, surgical mask, a face visor or goggle and two pair of gloves. Make sure the patient wears a surgical mask. What additional history is needed, what other symptoms could be asked about? Ensure correct patient by checking name, address, date of birth. All other symptoms should be explored. PMH, Drug history, allergies. Home circumstances, history of smoking, alcohol use, occupation will all be relevant. His ideas, Concerns and Expectations should also be explored to produce an individualised management plan. Other symptoms for Coronavirus infection would include: Cough: 69% Temp. > 37.4 C: 44% Fatigue: 38% Sputum: 34% SOB: 19% Myalgia: 15% Sore throat: 14% Headaches: 14% Chills: 12% Nasal congestion: 5% Nausea/Vomiting: 5% Diarrhoea: 4% Anosmia and dysgeusia are also included Additional information: Cough present for 3 days- also noted loss of sense of smell. PMH: Diabetes (Type 2) and Hypertension DH: Metformin 500mg bd, Alogliptin 25mg daily, Atorvastatin 20mg nocte, Losartan 100mg od, Indapamide 2.5mg od He is an ex-smoker having stopped 10 years ago. Lives with his wife. He is a recently retired Council Gardener. He wonders whether he has coronavirus and is concerned about ending up on ICU and dying. He would like to be considered for a chest x-ray. What additional examination would you undertake? Vital signs and a full A to E assessment is required. Specific systems should be examined in detail. In this case a full cardiorespiratory examination is indicated. General Examination: Alert, orientated, no shortness of breath, no distress Vital Signs: BP 132/72, Pulse 84 regular, Temp. 38.1, Resp. rate 18, Sats. 96% Room Air,

55 Cardio-Resp. Examination: Clear, no crackles or wheeze. Heart Sounds are normal. JVP normal. No peripheral oedema. No rashes Glucose level 7.3 mmol/L and negative for ketones. Does this patient fit in for a diagnosis of Coronavirus infection? Yes. It is consistent with the COVID-19 Infection Case Definition for Community Care 1 2 Patients who meet the following criteria and are well enough to remain in the community: new continuous cough and/or high temperature Individuals with cough or fever should now Stay at Home and call NHS 111 for advice or present to A&E or via emergency call 999 if significantly unwell. There is no indication for this patient to have Covid-19 swabbing or any other form of testing. Basic blood tests and chest x-ray may be needed dependant on advice of senior clinician input. Outline a management plan for this patient. • Patient will need to self-isolate at home for 7 days • His wife will need to self-isolate for 14 days, son should not visit. • Standard treatments for cough. Specific ally, paracetamol for pyrexia and muscle pain. Encourage good fluid intake, nutritional balance, adequate physical activity. • Red flag symptoms to be discussed for return to A&E What are the Red Flags symptoms that the patient should look out for? Severe SOB at rest Difficulty breathing Pain or Pressure in chest Cold, clammy, pale mottled skin New confusion Becoming difficult to arouse Blue lips or face Little or no urine output Neck-stiffness, rash Outline of Doffing of PPE procedure: Ensure consultation is finished with the patient having had an opportunity to ask questions. Carefully remove and dispose the outer pair of gloves soon after clinical examination. Using Sani cloth 70% alcohol clean the equipment used (Stethoscope). Remove apron, under gloves, face visor, wash hands, remove surgical mask. Alcohol gel to hands. Leave room and wash hands with soap and water. The senior clinician does decide on a chest Xray and blood tests prior to discharge with advice. What do these results indicate ? FBC Results Normal Range

Hb (g/l) 129.8 130-175

WCC (x109/l) 8.5 3.5-9.5

Neutrophils (x109/l) 5.0 1.8-6.3

Lymphocytes (x109/l) 1.9 1.1-3.2

Platelets (x109/l) 214 125-350

CRP (mg/l) 11 <3

U&Es normal

Chest Xray: There some evidence of hyper-inflation in keeping with his ex-smoking status. There are no focal lesions suggestive of chest infection and specifically pneumonia. Normal gastric bubble is noted. FBC: Very slightly anaemic, WCC elevated, lymphocytes normal and CRP elevated.

56 Patient stable at present and can go home. Case 2 Philip Rothman: DoB: 11/11/1941, Hospital Number: BTS11245, NHS No: 112358132 1 2 11 Polo Drive, Nematon, Coventry. 11 days after Mark’s review in the medical assessment. His father-in-law is triaged for review in the Acute Medical Unit at the local hospital. There is a history of severe shortness of breath for the last 6-8 hours, hacking cough, exhaustion and fever. He has not passed urine overnight. History is given over the phone by Mark and his wife Maria. Mr Rothman lives alone. He is a retired engineering worker who spend some early years of his working life as a miner. You are asked to assess him in the side room of the Covid bay of the admission unit. You have been asked to perform initial assessment of this patient. He is coughing continuously. He has been placed on 15 l/min Oxygen. What PPE is required for you and the patient? Wash hands or alcohol gel to hands In view of the continuous cough, FFP3 respirator mask is indicated and justified under current guidance. FFP3 mask, face visor or goggles, apron, water repellent gown and two pair of gloves. Describes Donning of PPE procedure. Considers a surgical mask for the patient. What additional history is needed, what other symptoms could be asked about? Ensure correct patient by checking name, address, date of birth. Maria, his daughter will be providing additional information. All other main symptoms should be explored. PMH, Drug history allergies. Home circumstances, history of smoking, alcohol use. His ideas and expectations in relation to ITU care or resuscitation may have been explored already. Check whether a Respect Form is already in place. Additional information Cough present for 5 days. Productive of whitish brown sputum. PMH of Diabetes (Type 2), Hypercholesterolemia, COPD, Heart Failure. DH: Novomix 30 Insulin bd (24 + 16 units), Dapagliflozin 10mg od, Atorvastatin 20mg, Bisoprolol 10mg od, Furosemide 40mg od, losartan 50mg od. He is an ex-smoker having stopped 10 years ago. Lives alone and has carers twice a day for bathing, dressing, meals and housework. He rarely leaves the houses apart from special occasions. There is no evidence of cognitive dysfunction. What additional examination would you undertake? Vital signs and a full A to E assessment is required. Specific systems should be examined in detail. In this case, a full cardiorespiratory examination is indicated. General Examination: Disorientated, confused, shortness of breath, distress o Vital Signs: BP 102/72, Pulse 114 regular, Temperature 38.6 C, Respiratory rate 24, SPO2 Sats. 91% on Room Air, CVS Examination: Crackles at both bases with scattered wheezes, Heart Sounds: systolic murmur at the apex radiating to the neck. JVP normal not visible. Marked peripheral oedema. No rashes- glucose level 13.3 mmol/l and ketones 1.2 mmmol/l. Pupils are equal and reactive to light.

Does this patient fit in for a diagnosis of Coronavirus infection? Yes. It is consistent with the In-patient COVID-19 Infection Case Definition 1 2 Patients who meet the following criteria (inpatient definition) requiring admission to hospital (clinical decision to admit, need to stay at least one night) and • have either clinical or radiological evidence of pneumonia or • acute respiratory distress syndrome or • influenza like illness (fever ≥37.8°C and at least one of the following respiratory symptoms, which must be of acute onset: persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing How is the PPE removed in the Doffing Procedure? 1. Carefully remove the gown along with outer pair of gloves and discard 2. Apply alcohol gel to the under gloves 3. Remove face visor (do not touch outer side visor) and discard 4. Remove the under gloves 5. Remove respirator mask- discard 6. Wash hands with soap and water. Investigations are ordered. What could these be? Chest X-ray Blood Tests: arterial blood gases, FBC, U&Es, LFTS, CRP, Blood Cultures, INR Covid-19: swab from throat and then nose Outline a management plan for this patient. • Administer 40% oxygen • Complete E28 form and send nasal and throat swabs for viral PCR • Insert intravenous cannula (wide bore 16 gauge if possible) and give IV Antibiotics. • Take blood samples for FBC, U&Es, CRP, LFT, INR, urea and creatinine • Blood samples for culture • Arrange for chest x-ray • Prescribe paracetamol 1 gram IV, 6 hourly. The initial investigations are now available FBC Results Normal Range Urea & Electrolytes Results Normal Range

Hb (g/l) 99.8 130-175 Na+ mmol/l 131 133-146

WCC (x109/l) 9.7 3.5-9.5 K+ mmol/l 5.0 2.5-7.8

Neutrophils (x109/l) 9.0 1.8-6.3 Urea mmol/l 25.4 2.5-7.8

Lymphocytes (x109/l) 0.6 1.1-3.2 Creatinine umol/l 276 65-105

Platelets (x109/l) 112 125-350 Glucose mmol/l 15.4 Usually 4 to 6

CRP (mg/l) 67 <3

Real Time PCR: Covid-19 Positive. Blood Cultures: results awaited

Blood Test Results FBC: Anaemia, elevated WCC, elevated neutrophils, low lymphocytes, low platelets. All indicated severe sepsis U&Es: urea and creatinine elevated (ideally compare with previous data). Indicates AKI especially as history indicates reduced renal output.

Further Assessment 1 2 3 hour later, on further review, SPO2 is 92%, on 40% oxygen, heart rate is 106 beats per minute. His blood pressure is 104/62 mmHg, respiratory rate is 28 breaths per minute. Further results are now available FIO2 =0.4, venturi mask

LFTs- other data Pts Results NR Arterial Blood Pts Results NR Gas Total Protein g/l 54 60-80 pH 7.28 7.35-7.45 Albumin g/l 31 35-50 PaO 9 kPa 11-12 kPa Bilirubin umol/l 21 4-25 2

PaCO2 5.6 kPa 4.7-6 kPa Alk. Phos. U/L 74 40-130 HCO - 18 m mol/L 22-26 m mol/L ALT U/L 46 10-50 3 Base excess -5 m mol/L -2 to 2 m mol/L CRP mg/L 51 < 3 Lactate 3 m mol/L < 2 m mol/L Blood Results LFTs: Low albumin and total protein, raised ALT. Poor prognosis markers in severe ARDS. ABG: pH is low, PaO2 is very low (remember patient is on 40% oxygen, so with normal gas exchange PaO2 >25 KPa is expected), bicarbonate is low, lactate is mildly elevated. This patient has hypoxia and metabolic acidosis (secondary to hypovolaemia and under perfusion of organs). Outline Further Management • Increase the inspired oxygen concentration by using facemask with reservoir and increasing the flow to 10L/ min • ABG analysis and lactate • Start IV fluids with an initial bolus of 250 mL of Hartmann’s solution • Catheterise the bladder and monitor urine out put • Assess the response to fluid bolus and repeat another bolus of fluid if no response. • Request immediate senior help- review from Registrar or consultant Likely to need ventilatory support. Who would a clinician need to communicate with and how? • Communicates with senior using SBAR • Inform the patient regarding further management Telephone patient’s next of kin, confirm and explain the current condition and possible transfer to critical care ward The ICU Consultant asks you for the Clinical Frailty Score on this patient- what is it? In the patient it appears to be 5 or 6- some guidelines would indicate that the patient would need to be more carefully considered for ICU due to high likeliness of no clear benefit on prognosis and outcome. The Clinical Frailty Score is given below after the OSCE. Do you know of a scoring system that can help identify those at highest risk of death from viral pneumonia?

Can you please discuss the MuLBSTA score further? Understands the role of scoring system in predicting mortality in viral disease Understands the role of scoring system in predicting mortality in viral disease Clinical Features Mortality at 90 days 1 2 Multilobe infiltrate on CXR: No = 0, Yes = 5 5 points: 2% Mortality

59 Lymphocytes ≤ 0.8 x 109/L: No = 0, Yes = 4 10 points: 9% Mortality Bacterial infection: No = 0, Yes = 4 15 points: 32% Mortality Smoker: Yes = 3, Ex-smoker: Yes = 2 17-18 points: 50% Mortality ‘Tension- Hypertension: No = 0, Yes = 2 20 points: 69% Mortality Age: ≥ 60: No = 0, Yes = 2

The ITU Consultant decided to move the patient to ITU for a trial of ventilatory support. Patient was transferred to ITU, following an initial trial of CPAP for 6 hours, he required mechanical ventilation and proning for 14 to 16 hours/day. Further radiological images are now available to review. What do these radiological images show?

Chest Xray: AP chest radiograph for CVC position shows the presence of extensive bilateral ground-glass opacities as demonstrated on the recent CT. Also, right IJV catheter and ETT noted. CT: There are bilateral large areas of ground-glass opacities with crazy paving and, more evident at both bases, areas of consolidation. Enlarged mediastinal lymph nodes. Images and Report from Radiopaedia: F Macori Despite a poor prognosis being given at transfer to ITU the patient improves quickly with eventual discharge. Personal Reflections: Please write notes on a “conversation” with yourself or peer colleagues. What have you done to enhance your own safety and improve or maintain good infection control practice? What have you learnt from working with colleagues during these times? What have you learnt from patients? How will your future professional practice be different because of your experience of the coronavirus pandemic?

Assessment 1 Completed by Overall Grade Ex (Excellent), G (Good), P (Pass), B (Borderline), F (Fail) Assessment 2 Completed by Overall Grade Ex (Excellent), G (Good), P (Pass), B (Borderline), F (Fail)

OSCE Marking

This OSCE can be used initially for self-assessment then by assessment by a peer or tutor. The questions in the shaded rows should be read out and the candidate will then provide an answer. The assessor will check against the answer provide and award a score.

These will be A, B, C+, C-, D or E for each section of the OSCE (see criteria below).

Then give a final grade in the last rows of the OSCE (Excellent, Good, Pass, Borderline or Fail)- please criteria below.

Score for each component of the OSCE

A Consistently demonstrates mastery of all components B Competent in almost all components to a high standard and to a satisfactory standard in all. No significant omissions. C+ Competent in a large majority of components. Few minor omissions. (This will equate to the threshold standard of a new FY1 Doctor) C- Competent in a bare majority of components. A number of omissions D Some major omissions. Competent in a minority of components E Many major omissions. Competent in only a few testable components

Overall Grade for the OSCE

Excellent: Consistently demonstrates mastery of all components

Good: Competent in almost all components to a high standard and to a satisfactory standard in all. No significant omissions.

Pass: Competent in a large majority of components. Few minor omissions

Borderline: Competent in a bare majority of components. A number of omissions

Fail: Some major omissions. Competent in a minority or only a few testable components

61 Clinical Frailty Score

This can be useful in assessing a patient as more frail patients are less likely to benefit from escalation of therapy.

Clinical Frailty Score

62 Hand-washing

Hand wash Technique The most critical infection prevention strategy for Healthcare Professionals and the Public