COVID-19: Post (Long) COVID service

Key Messages

Although most people will recover following a COVID infection with time, a sizeable minority will continue to have symptoms lasting over 12 weeks regardless of how unwell they were or whether they were hospitalised. There is still uncertainty about the long-term effects of COVID infection and our knowledge is rapidly changing which presents a significant challenge when trying to determine best practice standards of care. What we do know is that Long COVID appears to be a multisystem disease sometimes appearing after a relatively mild acute illness and assessment requires a multisystem approach with a holistic approach around the patient. Long COVID can present with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body. It can have a significant effect on a person’s quality of life.

NICE guidance on managing the long-term effects of COVID-19 was published in December 2020.

NICE uses the following clinical definitions:

  • Acute COVID-19: signs and symptoms of COVID-19 for up to 4 weeks
  • Ongoing symptomatic COVID-19: signs and symptoms of COVID-19 from 4 to 12 weeks
  • Post COVID-19 syndrome: Signs and symptoms which develop during or following an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis. Post COVID syndrome may be considered before 12 weeks while the possibility of an alternative diagnosis is also being assessed

In addition to the clinical case definitions the term Long COVID is commonly used to describe signs and symptoms that continue or develop after acute COVID 19. It includes both ongoing symptomatic COVID-19 (from 4-12 weeks) and post COVID syndrome (12 weeks or more).

The Post COVID service aims to provide a holistic assessment of the patients around a virtual MDT and referral on for diagnostics and to specialist services as required.

Scope

  • People aged 18 and over

WITH

  • a convincing history and likely diagnosis of an acute COVID illness that doesn’t predate the COVID pandemic (evidence of a positive COVID test is NOT a requirement).

AND

  • the patient has been suffering with symptoms lasting over 12 weeks following an acute COVID illness OR a clear reason is stated in the referral letter why a review is thought to be required before 12 weeks (please note that the Post COVID syndrome service is NOT appropriate for patients who require urgent referrals)

AND

  • these symptoms have a significant impact on physical recovery, psychological wellbeing or ability to perform usual activities

AND

  • other physical causes of these symptoms have been excluded by physical examination and appropriate investigations. Details of examination findings and relevant investigation results (see the ‘Investigations’ section for specifics) must be attached to the referral to aid appropriate triage.

Please note that patients whose symptoms predate the pandemic and have not changed as a result of COVID infection are NOT appropriate for this service

Referrals submitted which do not meet the referral criteria will be returned.

Out of Scope

  • Children and young adults under the age of 18 years (please refer to paediatrics)
  • Patients with acute COVID symptoms
  • Patients with acute severe or worrisome symptoms or deterioration in physical or mental health causing clinical concern which imply need for urgent assessment
  • Patients whose symptoms predate the pandemic and have not changed as a result of COVID infection

​Assessment

Aim of assessment should be to determine the nature and severity of current symptoms and exclude alternative diagnoses. It is important that the patient is assessed holistically including assessment of physical, cognitive, psychological and psychiatric symptoms as well as affect on functional abilities and social circumstances.

History

Important to take a comprehensive history including:

  • History of suspected or confirmed acute COVID-19 infection
  • The nature and severity of current and past symptoms
  • Timing and duration of symptoms since the start of acute COVID-19
  • Investigations and treatment already received
  • Co-morbidities
  • Cognitive symptoms
  • Psychological symptoms
  • Document how a person’s life and activities, for example work or education, mobility and independence, have been affected

Examination

  • Examination should be tailored to presenting symptoms including:
    • Heart rate and rhythm
    • Temperature
    • Blood pressure including sitting and standing BP with heart rate
    • SAO2 at rest and if appropriate on exercise using an exercise tolerance tool best suited to the person’s ability e.g., the 1-minute sit to stand test. During the exercise test record level of breathlessness, heart rate and O2 saturation.
    • Assessment of cognitive symptoms using clinical assessment +/- a validated screening tool

Be aware that people can have wide ranging and fluctuating symptoms after COVID-19 which can change in nature over time.

When investigating possible causes of a gradual decline, deconditioning, worsening frailty or dementia, or loss of interest in eating and drinking in older people, bear in mind these can be symptoms of ongoing symptomatic or suspected post COVID-19 syndrome.

​Red Flags

  • Any acute severe symptoms or rapid deterioration in ongoing symptoms which could be caused by an acute or life-threatening complication should prompt an urgent referral to the appropriate acute services
  • Suicidal intent/severe mental health difficulties requiring a referral to crisis mental health services

​Investigations

Investigations should be ordered for specific clinical indications after careful clinical history and examination.

Details of examination findings and relevant investigation results must be attached to the referral to aid appropriate triage.

For example, specific investigations which may be considered include:

  • Fatigue:
    • Bloods including FBC, U&E, LFT, TFT, CK, CRP, coeliac screen
    • Urine dip
    • Pulse oximetry
  • Breathlessness:
    • Bloods including FBC, D-dimer, BNP
      • Pulse oximetry
      • Offer a CXR by 12 weeks after acute COVID if the person has not already had one and they have continuing respiratory symptoms. Please note if patient had a previous CXR indicative of COVID pneumonia this should have been repeated at 12 weeks as per British Thoracic Society Guidance for Management of patients with clinical-radiological diagnosis of Post-COVID pneumonia.
      • Be aware that a plain CXR may not be sufficient to rule out lung disease
  • Tachycardia/palpitations:
    • ECG
    • Consider 24 hour/7-day loop if palpitations but do not delay referral if felt clinically necessary

​Management

People who have had suspected COVID or confirmed acute COVID-19 should be given advice and access to written information on:

  • the most common new or ongoing symptoms after acute infection
  • what they might expect during their recovery
  • explain that recovery time is different for everyone but for many people symptoms will resolve by 12 weeks
  • ensure patients understand that the likelihood of developing ongoing symptomatic COVID-19 or post COVID syndrome is not thought to be linked to the severity of their acute COVID-19 including whether they require hospitalisation
  • advise that if new or ongoing symptoms occur, they can change unpredictably, affecting them in different ways at different times
  • direct patients to resources how to self manage ongoing symptomatic COVID-19 or post COVID -19 syndrome such as Your COVID recovery
  • advise about symptoms to look out for that mean they should contact their healthcare professional

For people who are concerned about new or ongoing symptoms 4 weeks or more after acute COVID should be offered an initial consultation in primary care by telephone or video consultation or face to face if deemed appropriate and available.

A screening questionnaire based on the Newcastle Screening Tool (Post (Long) COVID Pre-assessment questionnaire) will be shared with individuals accepted onto the service. They will complete this prior to assessment, to support them in thinking about previous and current symptoms to aide the assessment process.

Based on the initial consultation, shared decision making should be used to discuss and agree with the person whether they need a further assessment and whether this should be by phone, video or in person.

For people with ongoing symptomatic COVID 19 or suspected post COVID syndrome who have been identified as needing an assessment, a person-centred, holistic approach with a comprehensive history and examination as detailed above.

Recognise that some people may require help in describing their symptoms and may require the support of a carer or family member in their assessment.

Recognise that some people may require longer assessments such as patients with learning disabilities and translation services may be required if language barriers

Offer tests and investigations tailored to people’s signs and symptoms as suggested above. Do not delay referral awaiting results of tests if likely to be significant delays

After the holistic assessment, use shared decision making to discuss and agree with the person what support and onward care they need and how this will be provided. This may include:

  • Advice on self-management
  • Signposting to supported self-management via YourCOVID recovery
  • Referral to Post COVID service – this referral should be made on the ‘Post COVID service’ referral form.

The Post COVID service (Pathway flow chart) will involve initial virtual clinical triage at locality level by a designated clinician who will hold the caseload for that locality. Following initial triage patients may be directed to self-management pathways including referral to ‘Your COVID Recovery’ digital platform, IAPT self- referral or potential signposting to access social prescribing. Alternatively, for individuals who require diagnostics or specialist opinion, they will be presented to a multidisciplinary virtual panel (meeting weekly) which will include representatives of the following specialisms: Respiratory, Cardiology, Neurology, Psychology, Rehabilitation and a GP. Alternative specialisms may be requested where appropriate according to individual patient needs. Decisions made at MDT will be actioned by the locality case holder. As Long COVID is a multisystem disease it is envisaged that a person may require several discussions at the MDT and review by multiple specialities and the aim will be to complete a full assessment before discharge back to primary care therefore avoiding the need for multiple referrals.

​Referral

Referral Criteria

  • People aged 18 and over

AND

  • a convincing history and likely diagnosis of an acute COVID illness that doesn’t predate the COVID pandemic (evidence of a positive COVID test is NOT a requirement). Details of this illness must be clearly stated in the referral letter

AND

  • the patient has been suffering with symptoms lasting over 12 weeks following an acute COVID illness OR a clear reason is stated in the referral letter why a review is thought to be required before 12 weeks (please note that the Post COVID syndrome service is NOT appropriate for patients who require urgent referrals)

AND

  • these symptoms have a significant impact on physical recovery, psychological wellbeing or ability to perform usual activities. Details of this impact must be clearly stated in the referral letter

AND

  • other physical causes of these symptoms have been excluded by physical examination and appropriate investigations. Details of examination findings and relevant investigation results (see the ‘Investigations’ section for specifics) must be attached to the referral to aid appropriate triage.

Please note that patients whose symptoms predate the pandemic and have not changed as a result of COVID infection are NOT appropriate for this service

Referrals submitted which do not meet the referral criteria may be returned.

A referral form (please see below) is available to use but is not mandated.

Referral Instructions

e-Referral Service Selection:

Specialty: Respiratory

Clinic Type: Not Otherwise Specified

Service: DRSS-Northern-Long Covid Referral-Devon CCG-15N

Referral Form

DRSS Long COVID referral template

​Supporting Information

GP Information

To best equip clinicians to help patients with post-COVID syndrome:

and

Patient Information

ANY PATIENT INFORMATION/LINKS SHOULD GO IN HERE

MyHealth Devon website - Long COVID

Evidence

BMJ article: Management of post-acute COVID-19 in primary care

British Thoracic Society Guidelines on follow up of patients with clinico-radiological diagnosis of COVID-19 pneumonia

NHSE National Guidance for Post COVID syndrome assessment

NICE guidance NG188: COVID-19 rapid guideline: Managing the long term effects of COVID-19

Pathway Group

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

Publication date: January 2021

Updated: April 2021

Pathway Group

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

Publication date: January 2021

Updated: April 2021

Last updated: 06-04-2021

 

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