Podcast - NICE News - January 2024
10m | Feb 5, 2024The video version of this podcast can be found here: https://youtu.be/0r2kJQNzHME?si=hwG9mG3jNVaXRQEq
This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through new and updated guidelines published in January 2024 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
There is a podcast version of this and other videos that you can access here:
Primary Care guidelines podcast:
· Redcircle: https://redcircle.com/shows/primary-care-guidelines
· Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK
· Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148
There is a YouTube version of this and other videos that you can access here:
The Practical GP YouTube Channel:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The Full NICE News bulletin for January 2024 can be found here:
The links to the update guidance covered can be found here:
Suspected sepsis: recognition, diagnosis and early management:
· https://www.nice.org.uk/guidance/ng51
National early warning score information:
· National Early Warning Score (NEWS) 2 | RCP London website:
§ https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2
· eLearning:
§ https://newslms.ocbmedia.com/login
· The NEWS2 observation chart, score card and clinical responses can be downloaded from the main NEWS2 page at
§ https://news.ocbmedia.com/resources
·
COVID-19 rapid guideline: managing the long-term effects of COVID-19:
· https://www.nice.org.uk/guidance/ng188
COVID-19 rapid guideline: managing COVID-19:
· https://www.nice.org.uk/guidance/ng191
Skin cancer:
· https://www.nice.org.uk/guidance/qs130
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Transcript
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.
Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in January 2024, focusing on what is relevant in Primary Care only.
And to be honest, there have not been any major changes, only minor tweaks in the guidelines on sepsis and COVID19.
Today’s episode is not very long so let’s jump into it.
The first clinical area is sepsis. We can’t really look at the whole sepsis guideline here so let’s just look at the update, which points out four aspects:
· First, that temperature may not rise in cases of spinal cord injury. We know that some groups of people with sepsis may not develop a raised temperature. These include:
o people who are older or very frail
o young infants or children
o people having cancer treatment
o people severely ill with sepsis and after this update
o people with a spinal cord injury
· Second, we should suspect neutropenic sepsis also in immunosuppression which is not related to cancer.
o That is, we should now suspect neutropenic sepsis and send them to hospital if they become unwell and:
§ Are having or have had systemic anticancer treatment within 30 days or
§ Are receiving or have received immunosuppressants for reasons unrelated to cancer, obviously using our clinical judgement
· Third, we should give early antibiotics when the person is at high risk from sepsis.
o This means that if the transfer time to the emergency department is likely to be more than 1 hour, we should give antibiotics if high risk criteria are present. And,
o If meningococcal disease is specifically suspected, we will give appropriate doses of parenteral benzyl penicillin in the community.
· And finally, we should use a national early warning score for sepsis. And this is the most interesting part of the update, so let’s have a look at it in a little more detail.
NICE says that the national early warning score should be done in ambulances and secondary care but it is not expected in primary care.
So, let’s have a look at what NICE says that we have to do in Primary Care.
Firstly, we should always ask ourselves 'could this be sepsis?' if there are infection symptoms, taking into account that these symptoms may be non-specific, like feeling very unwell.
As part of the initial assessment in Primary Care, we will carry out a thorough examination, examining the skin for a mottled appearance, cyanosis and rashes and checking the temperature, heart rate, respiratory rate, oxygen saturation and level of consciousness for everyone. For those aged 12 and over, we will also check the blood pressure, and for the under 12s we will check the capillary refill and, if it is abnormal, we will check the BP if we have the equipment, including a correctly-sized blood pressure cuff. We will also enquire about urine output in the previous 18 hours.
If we are worried about sepsis, we should send the patient to hospital. Like stated earlier, if, in addition, there are high risk features, we should also consider early antibiotics if there is going to be more than one hour’s delay.
So, what are these high-risk features? Well, for those aged 12 and over they are as follows:
· New altered mental state
· Respiratory rate: 25 breaths per minute or more
· New need for 40% oxygen or more to maintain saturation more than 92% (or more than 88% in known COPD), being aware that pulse oximeters can underestimate or overestimate oxygen levels, and that overestimation has been reported in people with dark skin.
· Systolic BP < 90 mmHg or more than 40mmHg below their normal
· Heart rate: more than 130 beats per minute
· Not passed urine in previous 18 hours.
· Mottled or ashen appearance of skin
· Cyanosis and a
· Non-blanching petechial or purpuric rash- when we will consider meningococcal disease.
Now, let’s go back to the national early warning score or NEWS2 that we were talking about earlier.
The National Early Warning Score or NEWS 2 tool was designed by the Royal College of Physicians to be used in adults in addition to clinical judgement to assess a person's risk of deterioration. It is not advised in children or pregnant women or in cases of spinal cord injury.
The NEWS2 tool scores the same things that we already measure in Primary care, that is, temperature, heart rate, respiratory rate, oxygen saturation, blood pressure and level of consciousness. A score is given to each value where the high-risk criteria that we have just mentioned, score 3 points and other abnormal but less severe criteria only 2 points. I will not go through the score chart today but, if you want to look at it in more detail, I have put relevant links in the episode description.
And when interpreting the risk from sepsis using the NEWS2 score we will recognise that:
· a score of 7 or more suggests high risk from sepsis and we should arrange immediate admission.
· a score of 5 or 6 suggests a moderate risk from sepsis and we should arrange an urgent hospital assessment
· a single parameter scoring 3 points, is a red flag and we should discuss it with the hospital medical team.
· a score of 1 to 4 suggests a low risk from sepsis but we should still use our clinical judgement
A score of 0 should not be interpreted as indicating that there is no risk from sepsis and the patient will still need to be monitored.
In summary, while a formal NEWS2 assessment is not mandatory in Primary Care, in practice, by measuring all relevant parameters and recognising high-risk values, we are effectively applying the NEWS2 system. That is why it is a good idea for us to have a good understanding of it.
Let’s now move to the second clinical area, which refers to the COVID-19 rapid guideline, both in managing COVID-19 itself and also managing the long-term effects of COVID.
The update is presentational only and the recommendations are largely unchanged. But since we are here, I will give you a very brief summary.
In respect of the acute COVID-19 guideline, I will keep it extremely brief. We will assess the severity of COVID checking what we have just discussed in the sepsis guideline, that is temperature, heart rate, respiratory rate, oxygen saturation, blood pressure and level of consciousness and we will consider using the NEWS2 tool here too, sending the patient to hospital when necessary.
In terms of managing cough in the community, we will encourage people to avoid lying on their backs, because this makes coughing less effective. And to manage fever, we will advise paracetamol or ibuprofen explaining that there is insufficient evidence to link non-steroidal anti-inflammatory drugs and worsening COVID-19.
Now let’s address the long-term effects of COVID.
And let’s remember that:
· Acute COVID19 refers to the first 4 weeks.
· Ongoing symptomatic COVID19 to between 4 and 12 weeks
· And post-COVID-19 syndrome to more than 12 weeks
· The term 'long COVID' is commonly used and it includes both ongoing symptomatic COVID‑19 and post‑COVID‑19 syndrome, that is, anything that is longer than 4 weeks
Examples of the most commonly reported symptoms in long COVID are:
· Respiratory symptoms like Breathlessness and a Cough
· Cardiovascular symptoms like Chest tightness, chest pain or Palpitations
· General symptoms like Fatigue, Fever and Pain
· Neurological symptoms like 'brain fog', loss of concentration or memory issues, Headache, and Dizziness
· Gastrointestinal symptoms like Abdominal pain, Nausea and vomiting and Diarrhoea
· ENT symptoms like Tinnitus, Sore throat, Loss of taste and/or smell and Nasal congestion
· Dermatological symptoms like Skin rashes and Hair loss
· Mental health symptoms like depression, anxiety and PTSD Symptoms and
· In addition, absence or reduced performance in education, work or training.
In terms of investigations, we will offer tests and investigations tailored to the symptoms. If clinically indicated, we will offer blood tests, which may include a full blood count, kidney, liver and thyroid function tests, HbA1c, CRP, ferritin, and BNP.
For people with postural symptoms, for example, palpitations or dizziness on standing, we will check lying and standing blood pressure and heart rate and we will offer a chest X-ray for continuing respiratory symptoms.
After ruling out severe complications and alternative diagnoses, we will refer to a long COVID clinic.
Their management includes a personalised rehabilitation plan with fatigue management being a key component of this. Breathlessness, fatigue and 'brain fog' are among the most commonly reported long‑term symptoms, so support for these symptoms is also essential.
We will explain that it is not known if over-the-counter vitamins and supplements are helpful, harmful or have no effect in long COVID situations.
We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
