COVID-19: Neurology service guide

May 2020

Scope

This information provides guidance on the management of patients with neurological presentations and conditions during the COVID-19 pandemic. The information is based on:

National guidance

Association of British Neurologists guidance on COVID-19 for people with neurological conditions

NICE guideline NG127: referral of suspected neurological conditions

Key messages

  • Urgent care pathways remain available
  • The Neurology Service is functioning to support social distancing to minimise risk to patients, their carers, medical staff and the population as a whole. The Neurology Team are trying to minimise COVID-19 risk, especially to vulnerable patients already under their care and patients at the point of referral. This includes older more frail patients, patients with conditions affecting their breathing or swallowing, patients with dampened immunity (either from their condition or immunosuppressive treatment), and patients with multiple morbidity.
  • COVID-19 risk needs to be balanced against risks posed by delayed / missed assessment and delayed / missed treatments. The Neurology Team are endeavouring to mitigate the above risks and be pragmatic in their approach.

2WW referrals

There is no neurology 2WW referral service.

Anyone suspected of having a brain or spinal tumour should have structural imaging organised and should be referred directly to the regional tumour MDT.

Urgent referrals

All referrals will be reviewed prior to the allocation of appointment. The Neurology Team will continue providing clinical review for urgent cases. Again, these will be prioritised on a case by case basis.

Patients will usually be telephoned, and appropriate investigations arranged. If necessary, they can be seen face-to-face.

Please ensure that a practice-based system is in place to check daily for returning referrals with A&G.

Specific Conditions

Neurology outpatient follow up and Neuro-rehabilitation active case load

Patients already on the caseload, that are due follow up, are having their follow up appointments considered on a case by case basis with possible outcomes as follows:

  • their appointment may be converted to a telephone consultation (this is the default position)
  • their appointment may be deferred (if non-urgent and teleconsultation not feasible)
  • their in-person appointment may be retained (if urgent + teleconsultation would be inadequate + risk/benefit not excessive + they wish to come to appointment)
MS
  • Many patients with Multiple Sclerosis are on immunomodulatory treatment. Their treatments have been considered according to ABN guidance and plan communicated via the MS specialist nurse team. In most cases treatment is continuing.
  • Specialist Nurse support continues by telephone
Parkinson's Disease
  • Many patients with Parkinson's disease are frail, have comorbidity or have impaired swallowing. These patients should be advised to shield.
  • Specialist Nurse Support Continues by telephone.
Neuromuscular disease (mostly this is patients with Myasthenia Gravis)
  • Patients with a recent history of breathing, swallowing or speech difficulties should be considered high risk and shield.
  • Patients on azathioprine are considered high risk and should shield
  • Patients on prednisolone > 20mg or steroid sparing drug + prednisolone >10mg should shield
Neuropathy
  • Most patients with neuropathy are not at increased risk from COVID.
  • Patients on immunomodulatory treatments may be at risk and will have had their risk status considered
Muscular Disease – myositis, muscular dystrophy
  • In many instances such patients have weak cough, swallow compromise, mobility compromise or cardiac pathology. As such they may be high risk and should shield.
Epilepsy
  • Generally, patients with uncomplicated epilepsy are not at increased risk from COVID-19
  • It is quite likely that patients referred with first seizure are offered a telephone consultation in the first instance.
Headache

Medical/immunosuppression treatment for neurology patients without symptoms of COVID-19 infection
  • People with neurological conditions should not stop or alter their medication without prior discussion with their neurology team.
  • The risk/ benefit of continuing or pausing on-going treatment is being considered on a case by case basis. In many cases the risk of stopping treatment exceeds the risk posed by COVID-19 and continuation of treatment.
  • Please follow this link for additional information: https://www.neural.org.uk/resource_library/association-of-british-neurologists-guidance-on-covid-19/

Routine referrals

All new routine referrals will be clinically triaged. Patients will either be added to a waiting list or, if appropriate, A&G will be given.

There may be some provision in the new future for telephone consultation for appropriate patients to reduce delays.

Please ensure that a practice-based system is in place to check daily for returning referrals with A&G.

In order to support secondary care to see the patients who need to be seen, please could we ask you to put as much detail in your referral letter as possible (including opinions on whether virtual consultation with your patient is appropriate) and clearly mark whether this referral is urgent or routine.

Prior to making a referral, please ensure that the appropriate CRG has been reviewed and all suggested management options have been considered.

Please ensure that a practice-based system is in place to check daily for returning referrals with A&G.

Accessing Neurological Rehabilitation
  • Patients already known to the Neuro-Rehabilitation Outpatient Service can self-refer via phone 01271 311526
  • New referrals can be made by GPs for neuro-physiotherapy or occupational therapy and spasticity management in the usual way to Neuro-Rehab via ERS
  • New referrals and self-referrals will be telephone triaged by the Neuro-Rehabilitation team with possible outcomes as follows:
    • advice and guidance given
    • signposting and/or onward referral to relevant services
    • future telephone/video consultation arranged
    • future appointments may be deferred (if non-urgent and teleconsultation not feasible)
    • future in-person appointment may be offered (if urgent + teleconsultation would be inadequate + risk/benefit not excessive + they wish to come to appointment)
  • The Stroke and Neuro Supported Discharge is operating 8am-8pm 7 days per week:
    • Referrals are made to the team via the inpatient teams. Patients are triaged and risk-assessed and access face-to-face or tele-rehabilitation as required
    • If a patient presents to primary care with a sub-acute stroke, having not accessed acute stroke services, they can be referred for rehabilitation by the GP via ERS (Neuro-Rehab)
  • Written and telephone advice to GPs is available. The Neuro-Rehabilitation Team can be contacted via 01271 311526 or ndht.neurotherapy@nhs.net

Urgent advice

Neurology Team
  • 9am-5pm, the Neurology Team can be contacted via neurology secretaries:
    • North Devon: 01271 311585
    • Exeter: 01392 408730
  • For out of hours urgent advice, the on-call consultant can be contacted via hospital switchboards:
    • North Devon: 01271 322577
    • Exeter 01392: 411611

Advice & Guidance

Neurology Team
  • Written and telephone advice to GPs is available, both for known patients and for potential referrals
  • Neurology Team can be contacted via neurology secretaries in North Devon 01271 311585 or Exeter 01392 408730,
Neuro-Rehabilitation Team
  • Written and telephone advice to GPs is available.
  • The Neuro-Rehabilitation Team can be contacted via 01271 311526 or ndht.neurotherapy@nhs.net

Please ensure that a practice-based system is in place to check daily for returning A&G.

COVID-19 High risk patient advice

All patients with neurological presentations and conditions in the presence of symptoms of COVID-19 should be discussed with the admitting team who will assess along hospital guidelines.

Patients from our caseload at high risk.

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group

Last updated: 29-05-2020

 

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