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Communique

Weekly Communique # 20

27 August, 2020

WEEK IN REVIEW

The Care of Older People and Palliative Care Panel has published a clinical flowchart for the Management of people with COVID-19 who are older and living with frailty and/or cognitive impairment.

The flowchart has been developed to reinforce the overarching principles of care and provide a consolidated resource for healthcare professionals working with this special patient population. The panel is currently developing a second flowchart for the Management of People with COVID-19 receiving Palliative Care.

Update to prone positioning recommendation

This week several panels (Hospital and Acute Care, Critical Care and Care of Older People and Palliative Care) contributed to an update to the prone positioning recommendation for non-intubated patients, addressing how long to place patients in a prone position, together with notes regarding further considerations around this intervention for vulnerable people. There is no change to the direction or strength of the consensus recommendation (see below).

Our congratulations to Taskforce colleagues Professor Allison Tong and the COVID-19-Core Outcomes Set (COS) Workshop Investigators on publication of their landmark work in Critical Care Medicine. The paper reports the findings of four international workshops and a survey of almost 10,000 clinicians and people with lived experience of COVID-19. The study concluded that “Mortality, respiratory failure, multiple organ failure, shortness of breath, and recovery are critically important outcomes to be consistently reported in COVID-19 trials.” 

 

CORE OUTCOMES

 

Taskforce contribution commended by Victorian Government

Victorian Premier Daniel Andrews this week highlighted the state’s support for the work of world-leading medical researchers, making significant strides in the battle against Coronavirus. Taskforce Executive Director, A/Prof Julian Elliott was invited to speak to the media about the role of the Taskforce in developing world-first living guidelines for COVID-19.

Julian emphasised the critical importance of being guided by evidence in a time of great uncertainty and conjecture, and acknowledged the tireless contributions of Taskforce members and contributors to deliver reliable, up to-date, evidence-based guidance for clinicians during a time of fast-paced research and swirling media interest.

Highlights from of the media conference can be seen below or view the full conference here.

 


QUICK STATISTICS

COVID-19 research pipeline

  • 17,789 studies published or registered in Cochrane COVID-19 Study Register, 1,010 added this week
  • 1,667 randomised controlled trials registered (data from Covid-nma site), 93 added this week
  • 2,009 systematic reviews registered in PROSPERO, 40 added this week
  • 43 randomised controlled trials published (data from Covid-nma site), added this week

 


NEW OR UPDATED RECOMMENDATIONS

Version 19.0

Colchicine
The evidence base has been updated with no change to the strength or direction of the recommendation.

Favipiravir
The evidence base has been updated with no change to the strength or direction of the recommendation.

Interferon Gamma
New consensus recommendation

For people with COVID-19, do not use interferon gamma outside of randomised trials with appropriate ethical approval.

Telmisartan
New consensus recommendation

For people with COVID-19, do not use telmisartan outside of randomised trials with appropriate ethical approval.

High-flow nasal oxygen therapy (HFNO) / Non-invasive ventilation (NIV)
The recommendations have been updated and are now separated by different settings for use. Use in negative pressure rooms has been changed to a conditional recommendation (previously a strong recommendation). There are no other changes to strength or direction of the other HFNO or NIV recommendations.

Prone positioning for adults (non-ventilated)
The wording of the recommendation has been updated around the duration of the intervention, with no change to the direction or strength of the recommendation.

For adults with COVID-19 and respiratory symptoms who are receiving any form of supplemental oxygen therapy and have not yet been intubated, consider prone positioning for at least 3 hours per day as tolerated. When positioning a patient in prone, ensure it is used with caution and accompanied by close monitoring of the patient. Use of prone positioning should not delay endotracheal intubation and mechanical ventilation in patients with COVID-19 who are deteriorating despite optimised less invasive respiratory therapies.

Vulnerable people who are treated outside the ICU, for example people who are older and living with frailty, cognitive impairment or unable to communicate, may particularly be at increased risk of harm from proning. Despite the potential risks of awake proning associated with frailty, there may be benefits for this group. The net clinical benefit for each individual patient should be considered on a case-by-case basis.

Currently, there is limited evidence to suggest prone positioning could be effective in improving oxygenation in patients with COVID-19. This should be done in the context of a hospital guideline that includes suitable personal protective equipment (PPE) for staff and which minimises the risk of adverse events.

Child and adolescent care
The information box with the definition of Paediatric Multisystem Inflammatory Syndrome (PIMS T-S) has been updated to reflect more clearly that this definition is endorsed by the
Taskforce.

The Taskforce is continually monitoring research to update recommendations weekly as new evidence accumulates.

 


CLINICAL FLOWCHARTS

Six clinical flowcharts have been developed by the Taskforce to cover:

  • Assessment for suspected COVID-19
  • Management of adults with mild COVID-19 UPDATED
  • Management of adults with moderate to severe COVID-19 UPDATED
  • Management of adults with severe to critical COVID-19 UPDATED
  • Respiratory support for adults with severe to critical COVID-19 UPDATED
  • Management of people with COVID-19 who are older and living with frailty and/or cognitive impairment NEW

 

  • New recommendations on use of interferon gamma and telmisartan
  • Modification of wording and structure of respiratory support recommendations (HFNO, NIV and prone positioning)
  • Format change to A3 printable PDF

 


 EVIDENCE UNDER REVIEW

We are currently reviewing evidence to develop recommendations and flowcharts to guide practice in areas including:

  • Disease modifying treatments NEW
  • Antenatal corticosteroids
  • ACE-I/ARBs in pregnant women
  • Anticoagulants for pregnant women
  • Respiratory support for children and adolescents
  • Paediatric Multisystem Inflammatory Syndrome (PIMS-TS)
  • Overarching principles of care for people who are receiving palliative care or older people living with frailty
  • Cardiac arrest

 


NEWS & EVENTS

Cochrane
A Cochrane Diagnostic Test Accuracy Review on the accuracy of rapid tests performed during health-care visits for diagnosing COVID-19 was published this week in the Cochrane Library. The authors wanted to know whether rapid point‐of‐care antigen and molecular tests are accurate enough to replace RT‐PCR for diagnosing infection, or to select people for further testing if they have a negative result. Read here.

NPS MedicineWise
NPS MedicineWise CEO, Steve Morris, is joined by Prof Michael Kidd AM, Deputy Chief Medical Officer, Australian Government Department of Health in their latest podcast, Episode 12: An insight into the national COVID-19 response. They discuss the role of the National Incident Room, the Taskforce, the challenges of managing chronic disease during this pandemic, and some of the ways health professionals are ensuring continuity of care and access to medicines to patients in this rapidly changing environment. Listen here.

RANZCOG
RANZCOG’s recent webinar: Fireside Chat – Pregnancy & COVID-19, featuring several members of the Taskforce Pregnancy & Perinatal Panel, is now available to view here.

 


NEW TOPICS & QUESTIONS

It is a core mission of the Taskforce to engage with frontline clinicians to rapidly identify and address priority clinical questions.

Each week we collect suggestions for new clinical questions or topics for consideration by the Taskforce. A document that lists all of the suggested questions, topics and new patient groups that we have received to date is available here.

Please encourage your clinical colleagues to provide their insights via the website.

 


 

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