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Covid-19 HSE Clinical Guidance and Evidence

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Consensus Statement of Neurological Care during COVID-19 Crisis (CD 19-027 001/30.03.20)

General Statements
Irish Neurologists are fully supportive of the HSE emergency response to Covid-19.  Each Neurology service has engaged with colleagues within General Medicine, and has agreed to the following:
  • Provide full ED support for neurology patients attending with non-COVID related neurological emergencies, including early triage and discharge where safe
  • Provide support to the acute stroke service, including where feasible, contribution to the on call stroke rota
  • Provide support to those presenting with TIAs where necessary
  • Provide emergency in house consultations and expediate discharges 
  • Provide an enhanced outreach service to prevent neurological  presentations to the ED / hospital services 
  • Provide additional support for  vulnerable patients with neurological conditions in the community 
Irish Neurologists agree to the release of non-specialist NCHD staff to support the GIM COVID service, but will  require a core staff of specialist NCHDs, key nurse specialists and core clinical professionals to maintain essential services .
However, In the event of a significant exacerbation of the COVID crisis to a point in which there is a risk of overwhelming the GIM service, Neurologists will without question be available to support clinical colleagues. 
Neurological Capacity During the COVID-19 Crisis

Currently the capacity across neurological services has been significantly  curtailed due to re-deployment of NCHD and some nursing staff. 
While neurologists recognize the need for capacity for acute management of COVID related illness, it is vital that frontline neurological services are also retained to permit delivery of essential neurological care as specified, including enhanced care for vulnerable populations.  The need to retain frontline neurological services  particularly pertains to Specialist Nursing (MND, MS, Parkinsons Disease, Epilepsy and General Neurology nurses) , Specialist Registrars, and core Clinical Professionals (Physiotherapy, Occupational Therapy, SLT, Dietetics and Psychology) 

Vulnerable Neurology Populations that will Require Support

Eight categories of particularly vulnerable patients have been identified, for which core clinical, nursing and allied professional services must be retained /expanded to prevent / limit hospital attendance and to reduce the risk of COVID infections. 

 These are as follows:

  1. MND and related neurodegenerative conditions requiring NIV ventilation  (e.g. muscular dystrophies, SMA, Myotonic dystrophies etc), and /or rapidly progressive conditions  requiring high levels of integrated care (e.g. CBD, FTD, FTD/ALS , atypical Parkinsons Disorders and early onset dementias)
  2. Vulnerable groups with high levels of disability requiring ongoing neurological support. These include Secondary Progressive Multiple Sclerosis, Parkinsons Disease , Recent CVA and other acquired disabilities with high levels of burden 
  3. Neurological conditions requiring immunomodulatory therapies (Relapsing Remitting Multiple Sclerosis, Myasthenia Gravis, Inflammatory Neuropathies, Vasculitis etc.)
  4. Those with intellectual disabilities and complex needs including complex epilepsies
  5. Neurological patients receiving support /treatment /infusions on an ongoing basis in specialist units and  day wards including VNS services (Epilepsy) and DBS services (Parkinson’s Disease). 
  6. Those requiring essential prescriptions through the Hi-Tech Hub (MS, MND, Myasthenia Gravis, Vasculitis etc.) and those with conditions that require frequent adjustment of meds (later stage PD, complex epilepsies etc) 
  7. Emergency neurological presentations, including CNS infections, status epilepticus, TIA/stroke, acute inflammatory neuropathies etc.
  8. Those with acute vascular events / unstable cerebrovascular disease, who currently are managed by Neurology-supported Rapid Access clinics.
Current Recommendations for Neurological Services During the COVID-19 Crisis
  • Face to face out-patient services have been discontinued at the majority of Neurology sites.  However, all centres should provide facilities for telephone consultations & virtual clinics.  This is essential to maintain high quality safe services for those with serious neurological illness. 
  • For urgent new referrals  a telephone / video linked assessment should be performed.  Where clinically necessary, as defined by a Consultant /SpR, provision for follow up face to face consultations should be made available by the hospital in a COVID free area, observing all of the required social distancing protocols where feasible / practical.
  • Essential day services (infusions, etc.) should be moved to COVID free facilities, while observing appropriate social distancing etc. 
Recommended Essential Services provided by Specialists Nurses 
Specialist nurses should not be re-deployed as they are essential to the management of vulnerable neurology patients.  
Essential activities that should be protected include the following:
  • Nurse led Specialist clinics 
  • Nurse Prescribing  and troubleshooting/ medication adjustments 
  • Phone based advice & crisis management including  liaison with community services 
  • Nurse led Emergency triage to avoid A+E attendance
  • Outreach /Community based / domiciliary care 
Recommended Essential Serv‚Äčices provided by Core Clinical Professionals

Core Clinical Professionals

Core clinical professional staff should be retained where feasible to support:

  • Rehabilitation following acute neurological deterioration (e.g. stroke)
  • Management of respiratory decline (MND)
  • Management of acute deterioration in swallowing & communication
  • Management of nutritional decline

Discontinuation / attenuationof these services will lead to a significant breakdown in care and a high likelihood of extended hospitalizations

Summary of Neurological Services that Require Immediate Ring-fencing

While the Neurology Services across the country recognize the need to re-deploy staff, we strongly urge that 

  • AT LEAST ONE SPECIALIST NURSE within each discipline in each hospital  be retained to manage patients, and that in some instances (MND, Epilepsy, MS ) that at least 2 nurses  are retained to provide adequate care for vulnerable patients, including outreach services (e.g. see section of those using NIV  below) . 
  • In addition to the existing commitments to on call services within each of the larger Neurology sites,  AT LEAST  2 SPRS / EXPERIENCED  REGISTRARS should be designated for provision of expert  neurological care.  These SpRs /Registrars should not be re-deployed to provide COVID based care unless the health service is overwhelmed.
  • Priority should be given to the provision of facilities for telephone based advice, including virtual clinics. 
  • Access to safe  clinic space will also be required for urgent face to face reviews
  • Infusion suites and day services should be retained and managed off site with designated staff. 
  • Core clinical professional staff should be identified and allocated to neurological services within each centre.  The commitment of these professionals will depend on the specific requirements of neurological patients managed within each centre.     Examples include the requirement of expert physiotherapists for MND and Parkinson’s Disease, Occupational Therapists & Speech and Language therapists for those following stroke and those with MND and neuropsychologists for those with cognitive /behavioural changes. 
Current Specialist Nursing staff by hospital & recommended non-deployment

The current complement of Nurses across the country as of 20/03/2020  is as follows:

Health Library Ireland, Health Service Executive. Dr. Steevens' Hospital, Dublin 8. Tel: 01-6352555/8. Email: