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Evidence Check - Clinical models of care

Triage, virtual care, temporary hospitals, ethics.

Pulmonary rehabilitation and COVID-19 evidence check

Added: 7 May 2020
Updated: 12 May 2020

What is the guidance for the provision of pulmonary rehabilitation for people recovering from COVID-19?
  • A small quasi-randomised trial of elderly patients with COVID-19 showed respiratory rehabilitation can improve respiratory function, quality of life and anxiety.
  • Recommendations from international researchers for physiotherapy in acute hospital settings cover post COVID-19 mobilisation, exercise and rehabilitation interventions. They recommend early rehabilitation after the acute phase of acute respiratory distress syndrome, which is of particular value to those admitted to intensive care unit (ICU) to limit the severity of ICU-acquired weakness and promote rapid functional recovery.
  • Expert opinion suggests pulmonary rehabilitation could relieve the symptoms of dyspnoea, anxiety and depression, and eventually improve physical function and quality of life.
  • One article lists a range of common practices used in respiratory physiotherapy that are not recommended in with patients with COVID-19 in the acute phase including diaphragmatic breathing, pursed lips breathing, manual mobilisation or stretching of the rib cage, respiratory muscle training, exercise training and mobilisation during clinical instability. Other guidance suggests early mobilisation and physical exercises to improve respiratory and diaphragmatic muscle strength and promote recovery.
  • A living guideline for allied health professionals recommends that case prioritisation consider the potential impact on critical outcomes of a patient not receiving immediate rehabilitation.
  • Guidance suggests continuing rehabilitation care in the outpatient setting, and at home through ongoing therapy either in-person or via telehealth.
  • The American Thoracic Society does not endorse a specific approach to pulmonary rehabilitation during COVID-19. However a patient education factsheet has been published suggesting some ways to continue pulmonary rehabilitation at home. The British Thoracic Society released a resource kit with guidance to support pulmonary rehabilitation remote assessment during COVID-19.
  • The Lung Foundation Australia is facilitating an at-home exercise series through the initiative COVID-19 - Maintaining Movement.

Diabetes care during COVID-19 evidence check

Added: 4 May 2020
Updated: 7 May 2020

Are there risk stratification approaches to identify diabetes patients that are high, intermediate and low risk during COVID-19?
Which clinical pathways and modalities can support diabetes management and service delivery during COVID-19?
  • Recent evidence reviews and meta-analysis have shown: o People with diabetes appear to be at increased risk of more severe COVID-19 infection, however the factors that moderate this relationship are unclear. o Self-management tools based on text messages and increased blood glucose monitoring have shown benefits to patients. There are algorithms for triaging care for diabetes patients during COVID-19, which guide the use of delivery options including urgent face-to-face, virtual care and deferral of appointments. There are no validated risk stratification tools to identify high risk patients.
  • Expert advice from Australian Diabetes Society, NHS Clinical Networks and Association of British Diabetologists recommend services during COVID-19 should include: o For inpatient services increased staff capacity, provision of remote support, teamwork and facilitation of early discharge. o For outpatient services minimising investigations, utilising virtual clinics and conducting remote consultations. The models outline pathways of care for type 1 and type 2 diabetes and diabetes in pregnancy, according to clinical needs and risk factors.
  • Evidence for telehealth application of diabetes in COVID-19 is emerging, including a case study of a new onset of type 1 diabetes via a combination of emails, Zoom and telephone calls during COVID-19. Telehealth has previously been demonstrated to be successful in delivery of diabetes services.
  • Specialist guidance around managing diabetic foot clinics and diabetes in pregnancy screening is also available.

Intubation in the emergency department during COVID-19 evidence check

Added: 1 May 2020
Updated: 7 May 2020

What is the evidence for the safe practice of intubation in the emergency department during the COVID-19 pandemic?
  • Australian and New Zealand medical societies and colleges have endorsed a consensus statement from the Safe Airway Society on the principles of airway management and tracheal intubation specific to COVID-19. Guidance currently suggests early intubation and that principles of airway management are the same for patients with mild or asymptomatic disease requiring urgent surgery or critically unwell patients with acute respiratory distress syndrome. The statement suggests negative pressure ventilation rooms with an anteroom are ideal to minimise exposure to aerosol and droplet particles. Where this is not feasible, normal pressure rooms with closed doors are recommended.
  • Consensus guidelines from the UK suggest if critical care is expanded to areas outside of the intensive care unit, airway management may take place in rooms with positive pressure with reduced air exchanges. The guidelines suggest this may have implications for transmission risks and there needs to be consideration of what constitutes appropriate personal protective equipment (PPE).
  • Expert recommendations are for a rapid sequence induction technique (or a modified version) for emergency intubation. The use of video laryngoscopy is suggested to improve first-attempt success. Video laryngoscopy enables a reduction in the proximity of intubator and patient airway.
  • Clinical data on 202 patients on emergency tracheal intubation by anaesthetists from two hospitals in Wuhan China with COVID-19 showed that using rapid sequence induction resulted in first-attempt intubation in 89% of cases and 100% overall.
  • Guidance consistently suggests that airway management needs to be performed quickly and the number of healthcare workers at the bedside kept to a minimum, and adherence to airborne precautions, hand hygiene and donning of PPE.
  • Most guidance features a recommendation that airway management plans, including backup techniques, are to be agreed upon before starting the procedure.
  • The evidence and guidance reflects a range of PPE recommended and used.

Rehabilitation needs of post-acute COVID-19 patients evidence check

Added: 4 May 2020
Updated: 7 May 2020

What are the rehabilitation needs of post-acute COVID-19 cohort?
What is the appropriate timing of rehabilitation interventions?
  • COVID-19 can affect respiratory, cognitive and motor functioning.
  • A small quasi-randomised trial of elderly patients with COVID-19 showed respiratory rehabilitation can improve respiratory function, quality of life and anxiety.
  • Recommendations from international researchers for physiotherapy in acute hospital settings cover post COVID-19 mobilisation, exercise and rehabilitation interventions. They recommend early rehabilitation after the acute phase of acute respiratory distress syndrome, which is of particular value to those admitted to ICU to limit the severity of ICU-acquired weakness and promote rapid functional recovery.
  • Italian guidelines recommend rehabilitation both in the acute phase, when patient has reached a minimum clinical stability, and in the post-acute phase.
  • Even with rehabilitation, Recovery time is variable - depending upon the degree of normocapnic respiratory failure, and the associated physical and emotional dysfunction.
  • A living guideline for allied health professionals recommends a case prioritisation process that explicitly considers for each patient, the potential impact of not receiving immediate rehabilitation on critical outcomes (i.e., risk of hospitalisation, extended hospital stay).
  • The British Society of Rehabilitation Medicine recommends rehabilitation pathways provided by coordinated networks, starting service provision in intensive care units, followed by an acute rehabilitation programme with the opportunity for further triage into post-acute pathways in the network.
  • Tele-rehabilitation tools are available to observe and communicate directly with patients and/or staff already in isolation areas (e.g., use of data-secure cameras, such as iPads and baby monitors). Models for cardiac rehabilitation in COVID-19 have also been described.

Conducting virtual respiratory assessments and monitoring via telehealth evidence check

Added: 2 May 2020

What is the current evidence for conducting virtual respiratory assessments and monitoring in adults via telehealth?
  • Conducting physical examinations remotely by telehealth is recognised to be a challenge in clinical practice.(1-3) However, there is evidence that telehealth assessments and monitoring can be carried out for a variety of respiratory illness, including chronic obstructive pulmonary disease (COPD), acute exacerbations of COPD (AECOPD), asthma, cystic fibrosis, pulmonary hypertension, interstitial lung disease and most recently, COVID-19.
  • A previous Critical Intelligence Unit evidence check reported on a rapid review conducted by the Centre for Evidence-based Medicine (CEBM) at the University of Oxford, which found no validated tests for assessing breathlessness in acute primary care settings. The review identified insufficient evidence for the clinical accuracy of the Roth score test for breathlessness. It also advised against the use of smartphone apps to assess oxygen saturation.(4)
  • A systematic review found that forced expiratory volume, assessed daily by using a spirometer, was the most common modality of remote respiratory assessments in people with COPD. Other measurements included resting respiratory rate, respiratory sounds and end-tidal carbon dioxide level. When combined with machine learning algorithms, remote assessments were found to be highly predictive of AECOPD. Daily remote respiratory assessments were found to be feasible and well tolerated in most people with COPD and had consistently high user satisfaction.(5)

Management of acute behavioural disturbance and COVID-19 evidence check

Added: 28 Apr 2020

What is the guidance on the management of acute behavioural disturbance during COVID-19?
Specifically, what are the: a) inflection control and personal protective equipment, b) pharmacotherapy and c) non-pharmacological management considerations during COVID-19?
  • There is limited evidence on the specific management of acute behavioural disturbances during COVID-19.
  • Expert opinion is that people with severe mental illness may find it difficult to understand, accept and follow isolation protocols. This may increase the risk of COVID-19 transmission to others.

Validated tools to diagnose respiratory illness via telehealth evidence check

Added: 22 Apr 2020
Updated: 28 Apr 2020

Which tools are validated to diagnose respiratory illness via telehealth?
  • A Centre for Evidence Based Medicine (CEBM) review of methods to assess dyspnoea by telephone or video found no validated tools, and recommended against the use of the Roth score.
  • In this review, a rapid survey of 50 clinicians gave the following advice: ask the patient to describe their breathing in their own words, align with the NHS111 symptom checker which asks three questions, focus on change to identify if there has been deterioration and interpret the breathlessness in the context of the wider history and physical signs.
  • A rapid review on the accuracy of self-monitoring of heart-rate, respiratory rate and oxygen saturation in patients with symptoms suggestive of COVID-19 infection found no studies on remote monitoring of respiratory rate and cautioned against use of smartphone apps for measuring oxygen saturation.
  • A rapid evidence synthesis from CEBM found it is not physically possible to measure blood oxygen saturation (SpO2) using current smartphone technology.

Triage tools for ICU admission during COVID-19 evidence check

Added: 13 Apr 2020

What triage tools are available to guide decisions about admission to ICU during COVID-19?
  • There is considerable guidance around general principles for triaging patients to intensive care units during COVID-19. Key themes include, have decisions made by at least three physicians, multidisciplinary, shared and ethical decision making, documentation and transparency, reserving ICU admission for patients requiring ICU-specific interventions and not using age, on its own, as criteria.
  • For COVID-19 specifically guidance is available including
  • NICE rapid guidance including a critical care referral algorithm (which were updated on 31st March), and the Swiss Academy of Medical Sciences released guidelines for ICU triage. Criteria from opinion sources and other organisations were also identified
  • Triage criteria is generally based on clinical criteria and probability of survival, with a recently published triage tool also including criteria on likely duration of stay
  • Some of the guidance specifies that criteria apply to all patients potentially in need of ICU admission not only to COVID-19 infected patients

Daily Evidence Digest

Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health.

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