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
• effect on functional abilities and social circumstances.

It is important to 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.
• some people may require longer assessments such as patients with learning disabilities and translation services may be required if language barriers.
• 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.

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

Prior to onward referral a face-to-face appointment is essential.

Examination should be tailored to presenting symptoms. However, some specific routine examination findings are mandated on the referral proforma.

Examinations that must be included:

• Chest Examination
• Blood Pressure
• Heart rate
• Oxygen Saturations
• Urine Dipstick

Examination to consider, include:

• Heart rhythm
• Temperature
• Sitting and standing blood pressure
• Oxygen Saturations 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 oxygen saturations.
• Assessment of cognitive symptoms using clinical assessment +/- a validated screening tool

• 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

All referrals require a minimum of:

• details of examination findings

AND

• ‘Long-COVID’ blood results (FBC, U&E, LFT, TFT, CK, CRP, Coeliac screen)

Even if the patient is not reporting fatigue symptoms

These results must be attached to the referral to aid appropriate triage.

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

If a patient has any of the symptoms below, then the results of the investigations listed for that specific symptom must be attached along with the ‘Long-COVID’ blood results and examination findings.

E.g.

• if a patient reports to have only breathlessness. The referral should include the mandated examination findings, ‘Long-COVID’ blood tests along with a BNP, pulse oximetry reading and a CXR report AND meet the other referral criteria
• If a patient report to have only fatigue. The referral should include the mandated examination findings, ‘Long-COVID’ blood tests AND meet the other referral criteria

The specific investigations which must be attached for each symptom are:

1. Fatigue
   • ‘Long-COVID’ results which must include: FBC, U&E, LFT, TFT, CK, CRP, Coeliac screen
2. Breathlessness:
   • Blood results which must include: BNP and the ‘Long-COVID’ blood tests listed above
   • CXR

CXR

• Due to the long waits for routine CXRs in some areas, it is recommended that an urgent CXR is requested for this indication. An attached CXR is essential for the appropriate triage of Long Covid referrals.
• Offer an urgent 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.

3. Tachycardia/palpitations:

• ‘Long-COVID’ blood tests listed above
• ECG (referrals where the patient has suffered these symptoms must have an ECG attached)
• Consider 24 hour/7-day loop if palpitations but do not delay referral if felt clinically necessary (not mandated)

1. Educate/Raise awareness

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

• the normal recovery trajectory (signpost to Your Covid Recovery)
  • explain that recovery time is different for everyone but for many people symptoms will resolve by 12 weeks
  • advise that if new or ongoing symptoms occur, they can change unpredictably, affecting them in different ways at different times
• what they might expect during their recovery e.g., common symptoms and self-management of these
• advise about symptoms to look out for that mean they should contact their healthcare professional

Providing/signposting to written information is especially important as the Post-COVID symptoms can have an impact on retaining information.

2. Assessment

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.

See ‘Assessment’ section.

3. Ongoing care options

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:

1. Advice on self-management
2. Signposting to supported self-management
   • via Your COVID Recovery
   • community services (including mental health)
3. Referral to Post (Long) COVID service – this referral should be made on the ‘Post (Long) COVID service’ referral form

Post (Long) COVID Service

The Post (Long) COVID service will involve initial virtual clinical triage at locality level by a designated clinician who will hold the caseload for that locality.

A screening questionnaire based on the Newcastle Screening Tool 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 aid the assessment process.

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 Criteria

People aged 16 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 not on the mandated proforma +/- do not meet the referral criteria will be returned.

Referral Instructions

e-Referral Service Selection:

Specialty: Respiratory

Clinic Type: Not Otherwise Specified

Service: DRSS-Long Covid-Devon ICB-15N

Referral Form

DRSS Long COVID referral template

DRSS Long Covid Service Referral template - EMIS

DRSS Long Covid Service Referral template - Systmone

Patient Information

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.

Publication date: January 2021

Updated: January 2022