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Nice guideline summary: COVID-19 management in community pharmacy

Nice has published a new rapid guideline, bringing together all existing recommendations for managing COVID-19 in all care settings

Unplanned learning

This article will provide a summary of the appropriate advice for community pharmacy teams to provide to patients and carers seeking advice regarding COVID-19 risks, symptoms for escalation and treatment or symptom relief, particularly as most of these queries will be carried out remotely, over the phone.

This summary reflects the National Institute for health and Care Excellence (Nice) COVID-19 rapid guideline: managing COVID-19 updates and guidance (April 2021). This summary was correct at time of publishing (March 22). Please access the full guideline for relevant updates.

Find C+D’s latest clinical updates on our COVID-19 hub.

Initial COVID-19 symptoms

The current recognised symptoms of COVID-19, which require self-isolation, have not changed much in the past year, with the primary symptoms remaining as:(1)

  • a high temperature
  • a new, continuous cough
  • a loss or change to sense of smell or taste

In addition to the main three symptoms, patients may also experience:(1)

Adults

  • breathlessness (which may cause anxiety)
  • delirium (which may cause agitation)
  • fatigue
  • headache
  • muscle aches and sore throat
  • drowsiness (particularly in older people)
  • poor appetite
  • chest discomfort or pain

Children and under 18s

  • grunting
  • nasal flare
  • nasal congestion
  • poor appetite
  • gastrointestinal symptoms
  • skin rash
  • conjunctivitis

The Nice guidance advises healthcare professionals to reassure patients that they are likely to feel better within a week if their symptoms are mild. If symptoms worsen, patients should be advised to contact NHS111 and be given advice to follow the government advice regarding self-isolation.(1,2)

Identifying severe COVID-19

In community pharmacy, it is difficult to tell when someone needs to be referred to A&E or to call 999 without being able to see the patient in person. Due to the requirement for patients to self-isolate if they display possible COVID-19 symptoms, most of these conversations will take place either with a third party or over the phone with the patient.

Adults

In adults, the main symptoms requiring referral include the following, along with tools to support the remote diagnosis:(3,4)

1. Difficulty breathing or severe shortness of breath

Ask them to describe the problem with their breathing and listen to their comfort with speech and completion of sentences:

  • “How is your breathing today?”

Ask questions that NHS111 uses:

  • “Are you so breathless that you are unable to speak more than a few words?”
  • “Are you breathing harder or faster than usual when doing nothing at all?”
  • “Are you so ill that you’ve stopped doing all of your usual daily activities?”

Ask questions to determine deterioration:

  • “Is your breathing faster, slower or the same as normal?”
  • “What could you do yesterday that you can’t do today?”
  • “What makes you breathless now that didn’t make you breathless yesterday?”

Other possible tools to assess dyspnoea:(5)

2. Reduced oxygen saturation levels

  • Finding out what a patient’s oxygen saturation levels are requires them to have access to a reliable pulse oximeter. If they have access to one at home, then utilise the results.
  • Smartphone apps should not be used for oximetry readings.
  • Keep in mind that having dark skin may result in overestimation using a pulse oximeter, especially at the borderline oxygen saturation range. Consideration should be made that nail polish and henna may also affect the reading.(1,6)
  • Refer if the readings are less than the results listed below:(1)
    • Adults – normally healthy: 94%
    • Adults – with type 2 respiratory failure: 88%
    • Children: 91%.

3. Physical observations

  • Coughing up blood.
  • Blue lips or face (note that patients with dark skin may not display this symptom easily and in these cases it is best to look at the lips, tongue, gums, under nails and around the eyes).(7)
  • Feeling cold and clammy, with pale or mottled skin.
  • Syncope.
  • New confusion.
  • Becoming difficult to rouse.
  • Reduced urine output.
  • National Early Warning Score 2 (NEWS) may be a useful tool in adults (not in pregnancy or in children) if sufficient information is available. However, patients should not be asked to come in to the pharmacy to perform this test in person.

Note that the methods above are useful, but there is currently no evidence of a conclusive tool to assess shortness of breath over the phone or via video consultation.

Children

As most children tend to present asymptomatically or with mild symptoms of COVID-19, pharmacists should be on alert for any signs and symptoms of paediatric multisystem inflammatory syndrome (PIMS), which are temporally associated with COVID-19.(1,8)

PIMS symptoms include the following:

  • persistent fever >38.5°C
  • rash
  • abdominal pain
  • diarrhoea
  • vomiting
  • swollen hands and feet
  • swollen neck
  • confusion
  • syncope

A locally approved Paediatric Early Warning Score (PEWS) can be a useful tool and includes respiratory rate, heart rate, blood pressure, oxygen saturation, temperature, level of consciousness and capillary refill time. A non-physiological parameter that can be scored is oxygen therapy.(1)

It is likely that both NEWS2 and PEWS assessment tools will be missing some information and calibrated equipment is unlikely to be available in the home.

Remote care

Remote care for the patient should include conversations over the telephone (or possible video consultations if the technology is available). Further guidance can be found at British Medical Journal guidance on COVID-19: a remote assessment in primary care.(9)

Consideration for reduction in face-to-face contact includes supporting patients with EPS prescriptions, reordering medication virtually and home-delivering medication.(1)

Advice to self-manage mild-to-moderate COVID-19 symptoms at home

Managing cough(1)

  • Patients should avoid lying on their back: coughing is less effective.
  • First line children and adults over one year: one teaspoon of honey (although consider dietary requirements).
  • Second line adults >18 years only – to suppress coughing if it is distressing: codeine linctus/tablets followed by morphine sulfate oral solution (see C+D’s Nice summary article Nice guideline summary: Managing symptoms).

Managing fever(1)

  • Drink fluids regularly: fluid intake needs can be higher than usual because of fever, and caution is required where dehydration could cause serious harm.
  • Adults and children may use ibuprofen or paracetamol at appropriate dosages: continue only while both the symptoms of fever and the other symptoms are present.

Managing breathlessness (supportive care at home once other risk factors are excluded)(1)

  • Keep the room cool (fans can spread the virus and are not encouraged).
  • Encourage relaxation and breathing techniques, and changing body positioning – signpost to the NHS advice, which includes a video.(10)
  • Improve air circulation by opening a window or door while self-isolating.

Managing anxiety, delirium and agitation(1)

Pharmacological advice regarding medication in the community

Home therapeutics

  • Although Vitamin D is not currently recommended to prevent COVID-19, the government advice to continue to take regular vitamin D to support bone and muscle health remains and was updated in December 2020 (see C+D’s article Vitamin D supplements for at risk groups).
  • Antibiotics are not recommended for the prevention or treatment of COVID-19.(1) Evidence of an additional bacterial infection is needed first, ruling out other causes for symptoms of pneumonia including fungal infection or other viruses.(1) For secondary bacterial pneumonia antibiotic choices, prescribers should follow the Nice antimicrobial prescribing guideline on community-acquired pneumonia. Managing pneumonia advice can be found in this previous C+D summary article Nice guideline summary: Managing pneumonia

Hospital therapeutics

  • Corticosteroids in the form of dexamethasone as first line, (second line hydrocortisone or prednisolone) are only advised where supplemental oxygen is required or in cases of hypoxia. They are not advised in cases where supplemental oxygen is not needed.
  • Remdesevir, tocilizumab, sarilumab are therapies that may be used in the hospital setting.
  • Further trials are ongoing on other therapies and the guidance will be updated as this becomes available.(1)
Non-pharmacological COVID-19 advice - signposting

Further to the Nice advice, it is advisable to maintain a current list of signposting links as support tools. You may find the following links useful in consultations for COVID-19 support:(1)

Advice for hospital discharge is due to be added to the Nice guidelines as they develop, and this will be useful for community pharmacy teams to utilise once they are available.

References
  1. Nice (2021) COVID-19 rapid guideline: managing COVID-19
  2. Gov.uk (2021) COVID-19 stay at home guidance
  3. The Centre for Evidence-Based Medicine - CEBM (2020) Are there any evidence-based ways of assessing dyspnoea (breathlessness) by telephone or video
  4. British Medical Journal (2020) COVID-19: a remote assessment in primary care
  5. The Primary Care Respiratory Society (2021) Medical Research Council dyspnoea scale
  6. Balaraman, K; Rausch, D; Bellomy, R; Chong, K; Kameoka, A; et  al (2020) Effect of nail polish on oxygen saturdation readings. Critical Care Medicine: Volume 48 - Issue 1 - p 561 doi: 10.1097/01.ccm.0000643592.11619.5c
  7. NHS (2020) Blue skin or lips (cyanosis)
  8. Royal College of Paediatrics and Child Health (2020) Guidance: Paediatric multisystem inflammatory syndrome temporally associated with COVID-19
  9. British Medical Journal (2020) COVID-19 a remote assessment in primary care
  10. NHS (2021) How to look after yourself at home if you have coronavirus.
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