A paradigm shift: It’s time to consider home-based or domiciliary care for a subset of moderately sick COVID-19 patients

This may be crucial to improve care and lighten the load on an overwhelmed healthcare system

The hurricane of COVID-19 in cities like Mumbai continues its incessant onslaught, with tragic heart-wrenching situations. For example, a senior doctor of 80 years fell sick with suspected COVID-19, with an oxygen (O2) saturation of 65 per cent (normal > 97 per cent). He and his son undertook the journey of their life, travelling all night with this life-threatening O2 saturation, as they were turned away from four hospitals. The doctor got a bed after much struggle, and finally succumbed two days later.

In another scenario, reflecting a similar care-starved situation, a patient in a CCC (COVID Care Center) in Mumbai got worse and needed transfer to a hospital but was unable to find a bed. This is happening more and more now, as the bed crisis in Mumbai worsens, with no silver lining as sick cases surmount capacity.

Need to find a solution beyond the conventional in this unprecedented crisis

Statistics show that the highest number of COVID-19 cases are in Mumbai and rising (over 45,000 cases, 20% of India’s caseload). Despite 4,700 plus beds for critical patients in the city, there is still a shortage as cases surge. Despite the government ramp up, 80% private hospital COVID-19 bed reservation and a call for healthcare workers to report for COVID-19 duty, equipped beds are still at a premium. The healthcare system is totally overwhelmed.

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What can we do to get treatment early for these patients running door-to-door at the cost of their lives? Can we use ground data from the Indian experience and world statistics to come out with out-of-the box solutions? These are the questions facing us.

As per the Maharashtra govt website, 71 per cent of COVID-19 cases are asymptomatic, and of the symptomatic cases, 5 per cent are critically ill and require ICU/ventilator management. Most importantly, about 30 per cent of symptomatic cases need O2 and medicine alone. We need to consider whether these patients can be managed without inpatient care. Or we need to ask whether we can at least initiate care promptly at the places where they are until the hospital beds become available. The premise is that early treatment can improve outcomes, free beds and reduce the burden on the healthcare system.

A solution: 'Point-of-care' treatment

This provocative thinking opens up a logical concept, namely early assessment of this category of patients and on-site care, without making them run around and potentially avoiding admission. This is called ‘point-of-care (POC) Rx’ or treatment. The POC location can be a home, or an equipped domiciliary facility (e.g. the COVID care center) in case home is not possible. The tools for this are prompt teleconsultation with an expert and supply of essential O2.

Three major aspects of this concept are as follows: 1) Early teleconsultation with an E-expert who assesses and outlines a plan of care; 2) If a hospital bed is not available, appropriate equipment at the POC is made available. This is predominantly O2 (via a concentrator) and valuable advice such as E-expert supervised prone position (lying down on the stomach) which helps in COVID care 3) Periodic monitoring by the E-expert to assess progress and escalate or de-escalate care as needed

Advantages of this strategy

The patient advantage is tremendous starting with early advice at the POC site by an E- expert, which otherwise will happen only in the hospital. This reduces the health risk related to running around, can save lives and reduce recovery time, mitigate anxiety and is extremely economical compared to inpatient care.

The system advantages include an efficient ‘POC’ triage, way earlier than the hospital triage. Genuine patients needing hospitalisation are identified earlier. If no beds are available, POC management is instituted for only O2 requiring patients, with rapid escalation to a hospital bed for borderline patients. This reduces the burden on an overstrained health care system and again is economically tremendously advantageous.

How can this be implemented?

The low hanging fruit of this proposal is the initial simplistic model, and involves a 24/7 call center where anybody can trigger help, followed by rapid consultation with an E-expert who outlines a plan of care. This is followed by system assistance with O2, and regular follow-up with the E-expert. A more comprehensive model is several steps ahead and links the above with a central bed allocation system.

To summarise, this ‘out-of-the-box’ approach to COVID-19 care for an overburdened healthcare system emphasises early E-expert advice, O2 mobilisation at the POC and shifting COVID-19 treatment to an earlier stage. This mindset change shifts the inpatient focus to the home or domiciliary setting for a subset of moderately sick COVID-19 patients. This can be planned and reproduced in any city, where a rapidly rising load overwhelms capacity. This could emerge as a win-win situation if done well.

(Dr Ravindra Mehta is Chief, Critical Care and Pulmonology, at Apollo Hospitals, Bangalore & and Dr Jatin Kothari is a Nephrologist with the Hinduja group of Hospitals and Apex Dialysis Networks, Mumbai)

Disclaimer: The views expressed above are the author's own. They do not necessarily reflect the views of DH.