5 Management: patients not known to have COVID-19

5.1 If patients have to attend a face-to-face appointment, on the day of the appointment first screen them by telephone and then again on arrival at the outpatient setting to make sure they have not developed symptoms of COVID‑19.

5.2 Ask patients to help reduce the risk of contracting or spreading COVID‑19 by:

  • following the relevant parts of government advice on social distancing (this differs across the UK)

  • coming to the appointment alone

  • having only 1 person accompany them if they cannot come alone

  • avoiding using public transport if possible.

5.3 Check patients' temperature when they arrive, ideally before they enter reception.

5.4 Minimise time in the waiting area by:

  • careful scheduling

  • encouraging patients not to arrive early

  • texting or phoning patients when you are ready to see them, so that they can wait outside, for example, in their car

  • providing a 'clean route' through the hospital to the department

  • delivering clinical assessment and treatment promptly

  • dispensing prescriptions rapidly.

Starting and continuing treatment

5.5 When deciding whether to start or continue an immunosuppressant, discuss the risks and benefits with the patient. Take into account the following in the context of the current prevalence of COVID‑19 infection and the services that are available at the time.

  • Is the patient's clinical condition stable?

  • If treatment is needed, is there an alternative with a better risk profile?

  • Is the required monitoring and review feasible?

  • Will it be safer to delay starting the drug?

  • Does the patient need to continue the drug?

  • Can monitoring be done remotely or at a frequency that minimises the risk to the patient's safety and wellbeing?

  • Are there any changes to the dose or route of administration that could make hospital attendance less likely?

  • If continuing treatment, can the patient tolerate a reduction in the dose?

  • If the patient has rapidly progressive interstitial lung disease, is intravenous therapy an option?

    Involve all relevant members of the hospital specialist team in the decision and record the reasoning behind the decision.

5.6 Advise patients on immunosuppressive therapy to continue to take their treatment as prescribed to minimise the risk of their condition worsening.

5.7 For patients who have been advised to shield, making blood monitoring difficult, assess whether it is safe to increase the time between blood tests for drug monitoring if their clinical condition is stable on treatment.

5.8 Discuss with the patient the risks and benefits of being on an immunosuppressant with blood monitoring requirements. For patients with a condition that is responsive to immunosuppressants who are unable to attend for blood monitoring, think about offering prednisolone alone.

5.9 Offer the lowest dose of prednisolone possible. If patients have been on prednisolone before, use the last dose that controlled their symptoms.

5.10 Offer antifibrotic therapy as usual if:

5.11 Advise patients already taking antifibrotic drugs that they should continue their treatment because there is no evidence they increase the risk of getting COVID‑19 or make more severe disease more likely.

Oxygen assessment

5.12 Decide whether to carry out or defer an assessment for ambulatory or long-term oxygen therapy based on clinical need. Carry out oxygen assessments in the patient's home if possible.

5.13 For patients already on ambulatory or long-term oxygen therapy, decide whether to carry out or defer an updated oxygen assessment, taking into account if their symptoms are worsening. Carry out oxygen assessments in the patient's home if possible.

Pulmonary rehabilitation

5.14 Continue to offer pulmonary rehabilitation services to patients if available, including local services offering remote individualised education and exercise advice.

5.15 If remote pulmonary rehabilitation services are not available locally, think about using online pulmonary rehabilitation resources, such as the British Thoracic Society pulmonary rehabilitation resource pack. This covers self-management, home exercise and educational materials.

5.16 When face-to-face pulmonary rehabilitation services become available, discuss the risks and benefits of attending with the patient, taking into account the current prevalence of COVID‑19.

Lung transplantation referral

5.17 Continue to refer patients for lung transplant assessment following the usual protocols.