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Home treatment as a solution to hospital overcrowding

11 Aug 2021

  • Caregivers responsible for identifying warning signs and seeking professional assistance
By Sumudu Chamara The Covid-19 pandemic has continued long enough for us all to learn that knowledge and resources alone are not sufficient to contain its spread; well-planned strategies are equally important. Especially with the increasing demand for resources, it has become vital that health care facilities such as hospitals manage limited resources for maximum results – which is the newest strategy employed by nations battling the pandemic. In a bid to ensure these limited resources are not overtaxed, the avenues of home-based care and quarantine were first highlighted in Sri Lanka early this year, when health authorities realised the risk of being overwhelmed by the increasing caseload. After months of discussion, the health authorities first decided to quarantine asymptomatic Covid-19 infected persons in their homes. However, the influx of infected persons being admitted to hospitals has now compelled them to take a further step and implement a plan of home-based care for such persons. Sri Lanka’s plan The Health Ministry, on 4 August, issued guidelines for integrated home-based isolation and the management of asymptomatic and mildly symptomatic Covid-19 infected persons, with the aim of detecting infected persons who need early hospital admission, providing patient-centric safe home care, reserving hospital care for symptomatic infected persons, and reducing unwanted hospital admissions. Adding that appropriate early risk assessment will allow for timely intervention to prevent complications and detect infected persons with deteriorating clinical symptoms and signs of the disease during the period of home stay, the Ministry statement noted that they will be admitted for institutional health care for further management, if needed. According to the Ministry’s definitions, asymptomatic infected persons are “polymerase chain reaction (PCR) or rapid antigen test (RAT) positive cases that  are not experiencing any symptoms with oxygen saturation of more than 96%”, while mildly asymptomatic cases are “PCR or RAT positive cases with upper respiratory tract infections (with or without fever) and other associated symptoms, and no shortness of breath at rest or after mild exertion, and having oxygen saturation of more than 96%”. The statement added that while the Medical Officer of Health (MOH) in charge of the respective area will be responsible for the triaging of infected individuals who need home-based care and institutional health care services, there is a set of eligibility criteria that should be taken into account when opting for home-based care: The infected person should be between two and 65 years old; have a well ventilated, separate room with adequate washroom facilities; have no conditions such as morbid obesity (body mass index above 30), diabetes, hypertension, and chronic heart/lung/renal diseases; not be suffering from immunocompromised status, or not on long-term immunosuppressive therapy; have adequate self-care or caregiver support at home; have proper communication facilities and the ability to communicate; and has given informed consent. The health authorities have also introduced a system called the “Patient Home Isolation and Management System (PHIMS)”, which will be used by the area MOH to register eligible individuals, and after registration, the MOH will hand over the responsibility of the infected person’s care to the relevant call centre and medical care team through the PHIMS. The call centre will co-ordinate with the patient and a medical care team assigned for home based care management, while an assigned medical officer in the medical care team will conduct an initial assessment and daily monitoring of the infected person. This remote assessment and daily monitoring are to be carried out through telephone consultations via a method called the standard screening tool, and the findings will be recorded in the PHIMS. Preparation and guidelines Home-based care for Covid-19-infected persons is an option many countries in the world are considering owing to the rapidly increasing Covid-19 cases, and the World Health Organisation (WHO) has published guidelines for home-based care with a focus on the safety of both the infected person and the caregiver (in cases where a caregiver is necessary). Stressing the importance of keeping everyone safe in the event a Covid-19-infected person has been advised to care for themselves at home, or in the event a person becomes a caregiver for an infected person who is being cared for at home, the WHO Public Health Specialist Medical Officer Dr. April Baller noted that such situations arise due to two situations, both of which Sri Lankan health authorities too have stressed based on recent developments. The first situation is the lack of, and/or exhausting of, the resources of a country’s health care system due to, among other reasons, a sudden increase in Covid-19 cases, which Sri Lanka started experiencing during the past few weeks. The second situation highlighted by Dr. Baller, which she said was the “ideal scenario”, is when infected persons do not show any or severe symptoms, and at the same time, do not have any underlying diseases such as cardiovascular diseases or chronic lung diseases, and are not elderly. She extensively explained the basic factors that need to be taken into consideration: “The first and important point is that the infected person, or the patient, should stay in a separate room. If this is not possible, then, they should have a designated part of the home, and their movements around the house should be limited. Also, there should be at least one-metre distance between them and anyone else. Secondly, it is critical to have good ventilation in that patient’s room and any shared spaces. So, this means to really have fresh, clean air coming through as much as possible, which can be just by opening the windows.  “Thirdly, there should only be one person, who is the caregiver for that patient, and that caregiver should have no underlying conditions. Fourthly, whenever patients receive care, they should wear a medical mask, as should the caregiver, and as soon as the caregiver leaves the room, they need to make sure to wash their hands. Also, the patients should have their own designated, or personalised, dishes and cups, towels, and bed linens, which can be washed with soap and water at least once a day. Also, importantly, any frequently touched surfaces by the patient have to be cleaned and disinfected every day, and any waste generated from that patient should be packed safely. Finally, there should be no visitors allowed during the time that the patient is ill.” Emphasising the importance of proper preparation, the US national public health agency, the Centres for Disease Control and Prevention (CDC) said that caregivers are advised to wear a mask and ask the infected person to do the same before entering the room or the part of the house in which the latter lives, and wear gloves when touching or having contact with the infected person’s blood, stool or body fluids such as saliva, mucus, vomit or urine. Gloves and masks should be disposed of immediately after dealing with the infected person and hands or any part of the body that may have been exposed to the environment should be washed with soap or infected with sanitisers. When to seek help Opting for home-based care for infected persons is a decision that needs to be taken carefully after taking into account the infected person’s health situation. In most cases, it is only for asymptomatic persons, or those who do not show severe symptoms and complications. However, there is a possibility that this situation may change, and a need to hospitalise the infected person may arise. In this case, the caregiver’s role is crucial, as they are expected to identify when to seek help, and ensure that they do so before the infected person’s situation becomes critical. According to Dr. Baller, in addition to ensuring the aforementioned safe environment, it is of utmost importance that the caregiver is aware of how to monitor the infected person’s condition for complications or red flags, i.e. signs and symptoms, which, according to Dr. Baller should take place at least once a day. She added: “The important point here is that red flags can vary slightly depending on age. So, for adults, these include complaining of feeling lightheaded, shortness of breath, heavy breathing, chest pains, and looking dehydrated. For children, it can often be them suddenly appearing confused, the lack of appetite, and having blue lips or face. When it comes to infants, it involves the inability to be breastfed. In any of these cases, urgent care needs to be given.  “While at home, some patients may be asked to measure their oxygen saturation with a pulse oximetre (a medical device that monitors the blood oxygen level). However, it is important that the user has clear instructions on how to use it, and also to know what an abnormal reading or normal measure is; and when this takes place, they need to urgently call their health care provider.” Moreover, the CDC explained simple steps that caregivers can take to ensure the well-being of the infected person. Among them are ensuring that the infected person consumes a lot of fluids and receives rest, that the process of looking after the infected person is done in accordance with health care professionals’ instructions for care and medicine, that the infected person receives all the supplies they require including medicines and hygiene and disinfectant products, and limiting their interaction with pets. With regard to the importance of identifying the warning signs to decide as to when to seek professional medical assistance, the CDC said that if an infected person shows breathing difficulties, persistent pain or pressure in the chest, are unable to wake or stay awake, or have pale, grey, or blue skin, lips, or nail beds (depending on the person’s skin tone), the caregiver must seek emergency medical care immediately. Even though these are merely the most common warning signs, according to the CDC, there may be other symptoms and complications which only a medical professional can identify. In the Sri Lankan context, according to the health authorities, the parametres that will be assessed and recorded in the PHIMS by the medical care team include the date on which they tested positive in a PCR or RAT test, or the date of initial symptoms, and whether they have fever, breathing difficulties upon rest or mild exertion and symptoms of mild dehydration, or are feeling unwell or experiencing any other significant symptoms (body aches), symptoms of uncontrolled underlying co-morbidities, or any further issues such as isolation and communication-related matters. In the event of warning signs such as progressively worsening or persisting symptoms, difficulty  in breathing at rest or after mild exertion, oxygen saturation (SpO2,a measure of the amount of oxygen carrying haemoglobin in the blood, relative to the amount of haemoglobin not carrying oxygen) at rest being below 96% or less than 94% after mild exertion (if a pulse oximetre is available), persistent chest pain or heaviness, symptoms of dehydration or altered mental state (confusion, drowsiness, or irritability), infected persons registered in the PHIMS requiring hospitalisation will be identified early by a medical care team supervised by a consultant family physician, and will be handed over to a specialist medical officer or a medical officer nominated by the Regional Director of Health Services (RDHS). They will arrange transportation for the patient to be taken to the hospital, in co-ordination with the relevant hospitals which have adequate and necessary facilities. Infected persons who violate health instructions during home-based care will be admitted to the intensive care units (ICU) or a hospital by the MOH, and in the event a person refuses to be admitted to such an institution, the MOH has the authority to evacuate the infected person without obtaining consent, and even take legal action according to the Quarantine and Prevention of Diseases Ordinance. If a need arises, the area MOH could seek the assistance of the area Police to hospitalise the infected person. The guidelines added that symptoms of possible post-Covid-19 syndrome should be explained to every infected person upon discharge from home-based care, while the patient should be asked to report to the area’s MOH without delay if any such symptom appears. Home-based care for Covid-19 infected persons is not new to the world, and according to foreign media, many countries have already started this method and have been able to reduce the burden on their health care systems. Also, this method has been identified as an effective way to reduce the mental trauma an infected person may experience, as they get to live with their families at their homes, instead of in a crowded hospital.  However, the responsibilities it involves are immense. The role of the caregiver, or the infected person’s family, is crucial in this process, especially when it comes to identifying the warning signs and taking prompt measures to seek the additional professional assistance they may require. It all comes down to proper planning, which will allow this system to reduce the burden on the health care system, as well as the people.  

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