3 Investigations and referral

3 Investigations and referral

These recommendations are for healthcare professionals carrying out initial investigations in primary care or community services for people with new or ongoing symptoms 4 weeks or more after the start of suspected or confirmed acute COVID-19.

3.1 Refer people with ongoing symptomatic COVID-19 or suspected post-COVID-19 syndrome urgently to the relevant acute services if they have signs or symptoms that could be caused by an acute or life‑threatening complication, including (but not limited to):

  • severe hypoxaemia or oxygen desaturation on exercise

  • signs of severe lung disease

  • cardiac chest pain

  • multisystem inflammatory syndrome (in children).

3.2 Offer tests and investigations tailored to people's signs and symptoms to rule out acute or life‑threatening complications and find out if symptoms are likely to be caused by ongoing symptomatic COVID‑19, post‑COVID‑19 syndrome or could be a new, unrelated diagnosis.

3.3 If another diagnosis unrelated to COVID-19 is suspected, offer investigations and referral in line with relevant national or local guidance.

3.4 Offer blood tests, which may include a full blood count, kidney and liver function tests, C‑reactive protein test, ferritin, B‑type natriuretic peptide (BNP) and thyroid function tests.

3.5 If appropriate, offer an exercise tolerance test suited to the person's ability (for example the 1‑minute sit‑to‑stand test). During the exercise test, record level of breathlessness, heart rate and oxygen saturation. Follow an appropriate protocol to carry out the test safely (see the rationale section on investigations and referral for suggested protocols). For advice on sharing skills between services to help community services manage these assessments, see the recommendation on sharing skills and training in the section on service organisation.

3.6 For people with postural symptoms, for example palpitations or dizziness on standing, carry out lying and standing blood pressure and heart rate recordings (3‑minute active stand test, or 10 minutes if you suspect postural tachycardia syndrome, or other forms of autonomic dysfunction).

3.7 Offer a chest X-ray by 12 weeks after acute COVID-19 if the person has not already had one and they have continuing respiratory symptoms. Chest X-ray appearances alone should not determine the need for referral for further care. Be aware that a plain chest X-ray may not be sufficient to rule out lung disease.

3.8 Refer people with ongoing symptomatic COVID-19 or suspected post‑COVID‑19 syndrome urgently for psychiatric assessment if they have severe psychiatric symptoms or are at risk of self‑harm or suicide.

3.9 Follow relevant national or local guidelines on referral for people who have anxiety and mood disorders or other psychiatric symptoms. Consider referral:

  • for psychological therapies if they have common mental health symptoms, such as symptoms of mild anxiety and mild depression or

  • to a liaison psychiatry service if they have more complex needs (especially if they have a complex physical and mental health presentation).

3.10 After ruling out acute or life-threatening complications and alternative diagnoses, consider referring people to an integrated multidisciplinary assessment service (if available) any time from 4 weeks after the start of acute COVID‑19.

3.11 Do not exclude people from referral to a multidisciplinary assessment service or for further investigations or specialist input based on the absence of a positive SARS‑CoV‑2 test (PCR, antigen or antibody).

For a short explanation of why the panel made these recommendations see the rationale section on investigations and referral.

Full details of the evidence and the panel's discussion are in evidence review 4: investigations, evidence reviews 6 and 7: monitoring and referral, and evidence review: views and experiences of patients, their families and carers.