The number of new cases of Covid-19 continues to fall in the UK, but there is ongoing concern about the long-term effects of Covid-19 infection and how the symptoms of so-called ‘long Covid’ should be managed.
The National Institute for Health and Care Excellence (NICE) has published a guideline entitled ‘Covid-19 rapid guideline: managing the long-term effects of Covid-19’. This aims to provide guidance for healthcare professionals in relation to the care of long Covid patients, with long Covid being defined as ‘signs and symptoms that continue or develop after acute Covid-19’ including ‘symptomatic Covid-19 (from 4 – 12 weeks) and post-Covid syndrome (12 weeks or more)’. A ‘living approach’ has been adopted as regards the guideline such that it will be continuously reviewed and updated as evidence emerges.
It is noted that common symptoms of long Covid include respiratory, cardiovascular, neurological, gastrointestinal, musculoskeletal, psychological/psychiatric, ENT and dermatological issues as well as the more generalised symptoms of fatigue, fever and pain.
The guideline recommends that individuals with suspected or confirmed acute Covid-19 are given advice on the most common new or ongoing symptoms that occur after acute Covid-19, as well as what they might expect during their recovery. Patients will also need information as to how to self-manage ongoing symptoms; what symptoms to look out for which should lead to them contacting a healthcare professional; and who to contact in the event of new, ongoing or worsening symptoms. Such information should be given in a way that is accessible and can be easily understood. People who are concerned about new or ongoing symptoms four weeks or more after acute Covid-19 should be offered an initial consultation (after consideration of whether this should be by video, phone or in person), with healthcare providers potentially using a screening questionnaire to capture all of the reported symptoms in conjunction with a clinical assessment.
Thereafter, there should be discussion and agreement as to whether further assessment and investigation is required or if an urgent referral needs to be made to an appropriate service. In the context of planning care, it is noted that ‘prompt referral is needed to avoid delays in getting people the support they need’ on the basis that the earlier people receive help, the more effective the intervention is likely to be. Support to enable access to assessment and care should be provided, particularly to those in vulnerable groups, with follow-up by primary care or community services offered to those in vulnerable or high-risk groups who have been self-managed in the community after suspected or confirmed acute Covid-19. A healthcare professional in secondary care should arrange a video or phone follow-up consultation at six weeks after discharge to those previously hospitalised with acute Covid-19 ‘to check for new or ongoing symptoms or complications’.
The assessment of patients with new or ongoing symptoms after acute Covid-19 should entail a ‘holistic, person-centred approach’ with comprehensive clinical history taking, an appreciation that symptoms can be wide-ranging and change over time and an acknowledgment of how these may impact the person’s life and activities. Concerns should be listened to with empathy, involving a family member or carer if this is of benefit and the patient agrees.
Where the long Covid symptoms could be caused by an acute or life-threatening complication (for example severe hypoxaemia or oxygen desaturation on exercise; signs of severe lung disease; cardiac chest pain; or multi inflammatory syndrome in children), urgent referral should be made to the relevant acute services. Tests and investigations should be tailored to rule out acute or life-threatening complications and to establish if such symptoms are likely to be due to ongoing symptomatic Covid-19, post-Covid syndrome or a new, unrelated diagnosis. Once acute or life-threatening complications and alternative diagnoses are ruled out, referral to an integrated multidisciplinary assessment service should be considered, even if a positive Covid-19 test has not been obtained.
The planning of care for affected individuals should be discussed and agreed in terms of the support and rehabilitation they need and how this should be provided, whether self-managed; with support from integrated and coordinated primary care, community, rehabilitation and mental health services; via referral to an integrated multidisciplinary assessment service; or via referral to specialist care for specific complications. The guidance also sets out recommendations with regard to follow-up and monitoring.
It is of note that many of the symptoms of long Covid are poorly understood and more research is needed. In the specific context of cardiovascular symptoms, Dr Sonya Babu-Narayan, associate medical director at the British Heart Foundation, has commented that there is a need for ‘ambitious, larger scale research into the potential for lasting cardiovascular consequences of coronavirus infection’. She also stresses that those who develop ‘new or worsening heart-related symptoms should still seek medical advice’ and that it is important that those who are diagnosed with a heart or circulatory condition attend the follow-up care they are offered.
Alison Appelboam Meadows, partner in the clinical negligence team at Penningtons Manches Cooper, comments: “Whilst the symptoms associated with long Covid are potentially wide-ranging, the key is to ensure that such symptoms are assessed appropriately and that acute or life-threatening complications - including those evidencing lung and cardiac complications - are identified and urgent referrals are made to relevant services so that treatment can be put in place. The impact of long Covid, although not well understood, should not be underestimated and those affected are entitled to appropriate, holistic and empathetic assessment, care, management and monitoring in line with the NICE guideline.”