Date: April 8th – What is the best evidence on care pathways for patients with COVID-19? What care pathways or models of care have been implemented internationally for COVID-19 suspected or confirmed positive patients? [Keywords: Care Pathways]
Key themes emerging from the literature:
- The importance of optimising community delivered care
- Increased utilisation of telehealth/telemedicine
What does the World Health Organization say?
Key action steps to be taken are presented by transmission scenario to enable timely surge of clinical operations. Strategic priorities are outlined by scenario, including the 7 recommended steps to deal with community transmission. Referral pathway overviews are provided for:
- Screening and Triage
- Hub and Spoke Model [community transmission]
What does the international literature say?
Health Protection Surveillance Centre and HSE
The HPSC has made available specific pathways such as: COVID-19 Assessment and testing pathway for use in a hospital setting. The current HSE Operational Pathway of Care is also available here.
The European Centre for Disease Prevention and Control
ECDC provide guiding principles for contingency planning in primary care, hospital and long-term care settings. This features modifications to community care, inpatient and outpatient care which may be useful to consider when developing care pathways.
This report provides a detailed outline of how care should be planned, organised and delivered:
- Community Assessment and Referral to Secondary Care [Section 4] and includes a 2-page clinical assessment tool for assessment at hospital or community management
- Anticipatory Care Plans in COVID-19 [Section 5]
- Hospital Admission and Management [Section 6]
- Critical Care [Section 7]
- Management of Special Populations [including flowcharts for Paediatric and Obstetric patients in Section 8]
- End-of-Life Care [Section 9]
The importance of Scotland’s community hubs and assessment centres is emphasised. They will triage patients presenting with suspected COVID-19 to ensure that the best possible location of care is identified. It is vital they are adequately resourced and supported. New pathways of care for patients are clearly described.
The report also describes how care should be delivered in surge conditions:
- Prioritisation of active treatment for those acutely ill from all conditions
- Redeployment of staff and resources to deliver maximum level of care service, potentially in non-standard acute settings;
- Curtailment and suspension of non-emergency work such as elective surgery
- Utilisation of primary and community care to reduce demand on acute care settings and support patients discharged to home or to the community
It recommends a focus on best practice in alignment with the principles of realistic medicine:
- Identification of those who will benefit from medical interventions
- Provision of supportive or end-of-life care for all acutely ill patients in whom extensive medical interventions are futile
- Discussions with patients about their preferences in the event of becoming acutely unwell with COVID-19 or other illnesses
- Ensuring cohesive working across health and social care in Scotland to reduce unwarranted variation in care
Much has been written about the evolving pathways of care in England for COVID-19 patients, with changes to primary care and the establishment of a dedicated temporary hospital, the NHS Nightingale London Hospital.
This discussion paper describes the reorganisation of general practice into ‘cold’ and ‘hot’ sites to reduce the rate of spread, optimise use of critical care beds and ensure high quality care for those choosing not to be admitted. It outlines the practical considerations, such as:
- Site location and configuration
- Electronic health record systems and digital solutions
- Preventing staff illness and PPE
- Practicalities of each potential point of assessment/pathway
- Professional education and learning
- Patient education
The discussion paper features a COVID-19 Hub Generic Model (5).
Greenhalgh and colleagues determined that:
- Most patients with COVID-19 can be managed remotely with advice on symptomatic management and self-isolation
- Although such consultations can be done by telephone, in many cases video provides additional visual cues and therapeutic presence
- Breathlessness is a concerning symptom, though there is currently no validated tool for assessing it remotely
- Safety-netting advice is crucial because some patients deteriorate in week 2, most commonly with pneumonia
This practical guide for GPs describes when to suspect COVID-19 and how to respond. Regarding care pathways it suggests that: “GP surgeries should develop protocols for managing patients with possible infection, including triaging remotely, postponing non-urgent services, isolation procedures, PPE provision, seeking specialist advice, decontamination, and collaborating with community services.”
The BMJ also provides infographics for GPs:
Twitter posts from Irish and British GPs:
Dr Trisha Greenhalgh:
Dr Craig Seymour:
Dr Mark Murphy:
NHS Nightingale London, opened on April 3rd 2020, is a specially built hospital to care for patients who have already been intubated and ventilated at a London hospital and require further intensive care treatment for COVID-19. It provides up to 4,000 beds, fully equipped with ventilators and oxygen. These are a mixture of intensive care and recovery beds and it will use a multidisciplinary team approach.
According to the BBC three more temporary hospitals are to be built, in Birmingham, Manchester and Glasgow, and NHS England said other sites were being considered.
The Italian Network for Safety in Healthcare (INSH) has compiled key lessons on the optimal environment, team, equipment and staffing for COVID-19 patient care. It outlines ‘reliable’ pathways of care that they recommend for: diagnosis; hospital treatment; surgery; pregnant women; paediatric patients; hospital discharge; home isolation; quarantine; oncology and immunosuppressed patients; mortuary procedures; mental wellbeing of staff and patients.
In includes sample outcome measures which can support healthcare providers in monitoring their response to the pandemic and capacity to treat other commonly presenting conditions.
Italian clinicians suggest that:
§ Western health care systems have been built around the concept of patient-centred care but they recommend a move to epidemic community-centred care.
§ Hospitals may be the main COVID-19 carriers, facilitating transmission from infected to uninfected patients.
§ Massive deployment of outreach services is required. Home care and mobile clinics avoid unnecessary movements and release pressure from hospitals. Early oxygen therapy, pulse oximeters, and nutrition can be delivered to the homes of mildly ill and convalescent patients, setting up a broad surveillance system with adequate isolation and leveraging innovative telemedicine instruments.
§ Hospitalisation should be limited by disease severity.
§ Measures to prevent infection must be widely implemented, in all locations and including vehicles. Dedicated COVID-19 hospital pavilions and operators are required, separated from virus-free areas.
§ This outbreak is a public health and humanitarian crisis and requires a broad response such as social scientists, epidemiologists, experts in logistics, psychologists, and social workers.
§ A long-term plan for the next pandemic is required.
This article highlights the importance of a shift from patient-centred models of care to a community-system approach that offers pandemic solutions for the entire population with a specific emphasis on home care. A comparison of Lombardy and Veneto’s approaches to COVID-19 is outlined. Veneto’s strategy was multi-pronged and more effective:
- Extensive testing of symptomatic and asymptomatic cases early on.
- Proactive tracing of potential positives: families and neighbours.
- A strong emphasis on home diagnosis and care. Whenever possible, samples were collected directly from a patient’s home and then processed in regional and local university labs.
- Specific efforts to monitor and protect health care and other essential workers.
The authors highlight the importance of learning from strategies and policies in Italy and elsewhere and of collecting and disseminating accurate data.
This handbook which outlines experience from Chinese clinicians emphasises the importance of personalised, collaborative and multidisciplinary patient care (18-19): “A comprehensive multidisciplinary diagnosis and treatment mechanism has been established in which doctors both inside and outside the isolation wards can discuss patients’ conditions every day via video conference … The goal of MDT discussion is to achieve personalized treatment. The treatment plan should be adjusted to each person when considering the differences among individuals, courses of disease, and patient types. Our experience is that MDT collaboration can greatly improve the effectiveness of the diagnosis and treatment of COVID-19.”
Suggested lessons using Chinese data with a view to directing the US approach:
- Centralised quarantine is effective, reducing household and community transmission
- Provision of accommodation for healthcare workers will help protect their families
- Undiagnosed community cases, some of which are asymptomatic, will infect others which underscores the importance of widespread testing
- A multi-pronged approach is necessary: screening; mitigation and suppression
- Protect vulnerable groups: healthcare workers; elderly people; family members and close contacts; children [as their risk may increase with time periods]
- Early diagnosis and early medical care are essential
[i] World Health Organization. 19th March 2020. Operational considerations for case management of COVID-19 in health facility and community. https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf [Accessed 7 April 2020].
[ii] Health Protection Surveillance Centre. 2020. Assessment and testing pathways for COVID-19. https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/algorithms/ [Accessed 7 April 2020].
[iii] European Centre for Disease Control and Prevention. March 2020. Guidance for health system contingency planning during widespread transmission of SARS-CoV-2 with high impact on healthcare services. https://www.ecdc.europa.eu/en/publications-data/guidance-health-system-contingency-planning-during-widespread-transmission-sars [Accessed 7 April 2020].
[iv] Scotland (3 April 2020). Coronavirus (COVID-19): Clinical Advice: Guidance from the Chief Medical Officer (CMO) on treating patients with COVID-19. https://www.gov.scot/publications/coronavirus-covid-19-clinical-advice/ [Accessed 7 April 2020].
[v] National Institute for Health Research (6 April 2020). COVID-19 and the rapid reorganisation of general practice: Triage, hubs and pathways to care in hospital and the community: a discussion paper. Version 2. 6/4/20 https://www.arc-swp.nihr.ac.uk/general-practice-hubs [Accessed 7 April 2020].
[vi] Greenhalgh T, Koh GCH, Car J. COVID-19: a remote assessment in primary care. BMJ. 2020;368:m1182. Published 2020 Mar 25. doi:10.1136/bmj.m1182.
[vii] Razai MS, Doerholt K, Ladhani S, Oakeshott P. Coronavirus disease 2019 (covid-19): a guide for UK GPs [published correction appears in BMJ. 2020 Mar 11;368:m989] [published correction appears in BMJ. 2020 Apr 7;369:m1398]. BMJ. 2020;368:m800. Published 2020 Mar 5. doi:10.1136/bmj.m800.
[published correction appears in BMJ. 2020 Apr 7;369:m1398]. BMJ. 2020;368:m800. Published 2020 Mar 5. doi:10.1136/bmj.m800.
[ix] Italian Network for Safety in Healthcare (7 April 2020). White Paper: Patient Safety Recommendations for Covid19 Epidemic Outbreak: Lessons from the Italian Experience. Version 1.2
[x] Nacoti et al. 21 March 202. At the Epicenter of the COVID-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0080 [Accessed 7 April 2020].
[xi] Pisano et al. 27 March 2020. Lessons from Italy’s Response to Coronavirus. Harvard Business Review. https://hbr.org/2020/03/lessons-from-italys-response-to-coronavirus
[xii] The First Affiliated Hospital, Zhejiang University School of Medicine. “Handbook of COVID-19 Prevention and Treatment”. https://www.alibabacloud.com/universal-service/pdf_reader?spm=a3c0i.14138300.8102420620.dreadnow.6df3647fNEnE3r&pdf=Handbook_of_COVID_19_Prevention_en_Mobile.pdf. [Accessed 7 April 2020].
[xiii] Xihong Li, Harvard. Learning from 26,000 cases in Wuhan https://docs.google.com/presentation/d/1-rvZs0zsXF_0Tw8TNsBxKH4V1LQQXq7Az9kDfCgZDfE/mobilepresent#slide=id.p2 [Accessed 7 April 2020].