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Innovative Appendix-Oxygen Saturation Measurement.

 The global pandemic means that practices or GPs working at scale are using innovative ways to deliver care whilst we co-exist with Covid-19.

This appendix lists innovative ideas/pilots from across General Practice to give examples of the opportunities that exist to deliver care differently.  

We would like this to be a developing electronic resource moving forwards and would value your input and ideas to share with colleagues across Wessex. Please complete this   link   with the details of your innovation. If you encounter any issues with the link or to discuss an innovation further please email: office@wessexlmcs.org.uk

Oxygen saturation probe work for remote Covid-19 monitoring and how to move equipment safely around your community for remote monitoring  

Background 

Following the recommendation that the ROTH score is not used in primary care and the University of Oxford findings that smartapps cannot be reliably used as indicators of hypoxia in the Covid-19 pandemic, this document sets out the background to monitoring and the steps GPs can take to assess patients remotely with some ideas about how oxygen saturations could be performed dependent on setting. 

Which patients could this apply to? 

What new evidence has emerged about saturation monitoring?  

A rapid systematic review(1) was undertaken to review the efficacy and safety of exertional desaturation tests in Covid-19. This is was performed as it is becoming clear that some patients have normal pulse oximetry at rest but their readings deteriorate on exertion (unpublished data).  

Indeed, front-line clinicians have identified the late transfer of patients with exertional desaturation (i.e. a fall of 3% or more in pulse oximetry reading on exercise) as a possibly remediable cause of poor outcome. In other words, if we could better identify those with exertional desaturation and escalate their care more promptly, we could reduce mortality. (1) 

Two tests have potential: the 1-minute sit-to-stand test (in which the patient goes from sit to stand as many times as they can in one minute) and the 40-step test (in which the patient takes 40 steps on a flat surface). The former correlates well with the validated 6-minute exercise test. The latter is less demanding (hence safer) and in more widespread use, but does not appear to have been validated. (1) 

Conclusion: There is no evidence of harm (e.g. precipitation of cardiopulmonary compromise) from either test, but neither is there firm confirmation of their safety. Neither test has been studied in the context of covid-19; they were validated on patients with chronic interstitial lung disease and airways obstruction. An exertional desaturation test should be used with clinical judgement, and only on patients whose resting oximetry reading is 96% or above unless they are in a supervised care setting. It should be terminated if the patient experiences adverse effects. (1) 

What benefits might an oxygen saturation assessment in addition to a remote consultation provide? 

What models of care have been used elsewhere? 

It is important to remember that these are new models of care delivery, with little known about the effectiveness/outcomes and are based upon many factors which need to be considered at a local level. 

Factors to consider: 

Potential pathways: 

Cleaning the equipment: 

The recommended decontamination of equipment is shown  here

Patient information and resources: 

What to do with the results that you are given 

How to safety-net patients: 

Follow your local guidance on the frequency of monitoring and calls dependent on the patient risk features and also clinical parameters. Safety-net on progressive symptoms such as confusion, dizziness and shortness of breath when walking and in activities of daily living. Other red flags are highlighted in the remote assessment of Covid patients. (3) 

Resources list to help triage/add decision making and used in the production of this document 

1.https://www.cebm.net/covid-19/what-is-the-efficacy-and-safety-of-rapid-exercise-tests-for-exertional-desaturation-in-covid-19/ (last accessed 23/4/2020)

2.https://www.nwlondonccgs.nhs.uk/application/files/4915/8763/5676/Primary_and_Community_Care_Respiratory_Resource_Pack_during_COVID-19_V3final_160420.pdf  (last accessed 23/04/2020) 

3. https://www.bmj.com/content/368/bmj.m1182  (last accessed 23/04/2020) 

 

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Updated on Tuesday, 16 June 2020 240 views