This guide is written by Roger Neighbour and Simon Stockley.

Dr Roger Neighbour (OBE MA DSc FRCP FRACGP FRCGP). He qualified in 1971 from King’s College, Cambridge, and St Thomas’ Hospital, London. He is the author of The Inner Consultation (1987), The Inner Apprentice (1992), and The Inner Physician (2016).

Dr. Simon Stockley is the RCGP Clinical Champion for Sepsis, and represents the RCGP on the NHS England Cross-systems Sepsis Prevention Programme Board and the Academy of Royal Colleges Sepsis Group. A GP for 30 years, he has prepared multiple sepsis teaching and support aids for clinicians working in general practice.

This guide is an aide-memoire for clinicians conducting telephone consultations to assess and advise patients concerned they may have coronavirus.

Pre-planning

1. Choose a good time for making the calls. Calls under these circumstances can be stressful. For everyone’s sake, try not to squeeze them in at a time during the day when you are already under more than usual pressure.

Consider using a checklist of questions or a template to guide and record your conversation.

Beginning the conversation

2. Establish early on who you are talking to and what the purpose of the call is.

Are you talking to the patient, or to a relative or carer? (If it’s not the patient, remember there may be issues of confidentiality.)  You could say something like:
“Let me see if I have got this right – you are worried that you may have coronavirus? … OK, in that case I’ll need ask you for a bit more information.”

Try not to let the call sound routine or a chore. Patients are more likely to accept reassurance or follow advice if the conversation feels ‘personal’.

Information needed

3. Check where the patient is at the moment. They may not be at the address you think they are, and this could be important if they need to be seen or are acutely unwell.

4. What are the symptoms? Are they consistent with coronavirus?

Does the patient have any pre-existing conditions such as COPD or asthma that could be causing the symptoms, or that could place the patient at increased risk of deterioration?

Do they have any facilities for taking temperature, measuring pulse, peak flow, blood sugar or other relevant physiology?

5. Actively ask about specific signs of deterioration.

Is the patient able to go about their normal activities? Have they stopped doing anything they usually do? Or are they well enough to do most of their usual daily activities?

When talking, does the patient sound breathless or unable to complete sentences without pausing for breath?

Take the concerns of parents or family seriously. They are in the best position to know if a child or loved one is behaving ‘uncharacteristically unwell’, i.e. not in the way they usually do when they’re ill.

Decide if telephone management is appropriate

6. Telephone management is appropriate if, and only if:

  • the diagnosis is fairly clear;
  • the duration of illness is short (Most patients should show some improvement over a 7-day period);
  • there are no ‘red flags’, and the patient seems in reasonable condition, and
  • the caller is willing to accept reassurance and advice.
Red flag warning signs include: • Difficulty in breathing / shortness of breath • Persistent pain or pressure in the chest • Pale and clammy • New confusion or becoming difficult to rouse • Blue lips or face. • Non-blanching rash

7. Give clear advice about staying at home

Government advice for people with possible or probable COVID-19, and their families and contacts, can change significantly at short notice. Before you make calls to patients, it is worth reading and/or printing-out the latest ‘stay at home’ guidance, which can be read and downloaded from:
https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance-for-people-with-confirmed-or-possible-coronavirus-covid-19-infection°

You could also offer to send this link to the patient by text or email.

8. Check what other medications the patient is currently taking, in case any might need to be altered or suspended during a period of fever and possible dehydration e.g. metformin, ACE inhibitors, NSAIDs, diuretics or steroids. Familiarise yourself with the Sick Day Rules, and offer to call the patient back later if you need to double-check your advice.

Safety netting

9. Always give clear safety netting advice, explaining what would be signs of getting worse, and what to do in that event. You could say something like:

‘Let me tell you what signs to look out for, that might indicate things were getting worse. If you start to:

  • become significantly breathless,
  • or develop pains in your chest,
  • or become pale and clammy ‘like someone who is about to vomit”,
  • or seem muddled or confused

‘then you should seek urgent medical advice.’

Finally, ask ‘Do you have any questions about what I’ve told you?’

Face-to-face consultations.

10. These should be used where there is diagnostic uncertainty either about the cause or the severity of the symptoms.

Make sure you know what the arrangements are for doing this in your practice or service, and how patients are to be segregated or isolated. If the patient needs to be seen face-to-face, tell them what to expect.