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Home-based Care For COVID-19 Patients – Expert Reaction

At present, more than 1500 people with COVID-19 are isolating at home in New Zealand.

Almost half of them have not been given pulse oximeters, used to monitor oxygen levels and signal when hospital treatment may be needed. The US and UK are looking into whether these devices are equally accurate for all people.

Ministers announced policy changes on Thursday to boost health and social support for COVID patients in the community with a new ‘Care in the Community’ model.

The SMC asked healthcare experts about home isolation currently – and what the new changes may mean.

Dr Kyle Eggleton, Associate Dean – Rural Health, Department of General Practice and Primary Health Care, University of Auckland, comments:

What is your response to the just-announced health and social support for people with COVID-19?

“It is reassuring to see financial support being provided to community organisations to support people isolating. The detail of how that funding is accessed by organisations is less transparent.

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“Also it’s reassuring to see the pivot towards primary care leading the health support. However, there is no detail on the additional resourcing that primary care will need. In rural areas, with significant workforce issues, it may become difficult to undertake business-as-usual plus a COVID-19 response.”

How is the existing home isolation policy working?

“The current home isolation policy relies on a risk stratification by Public Health as to whether a person can safely isolate at home or whether they need to isolate in a MIQ – and if they can isolate at home, how frequently they need to be contacted. A list of conditions that places people at risk of complications and requirements are checked off.

“Although the current policy does not involve notification to primary care of cases isolating at home, a new policy is being formulated that will notify primary care as well as social service providers (in order to ensure that people’s social needs are met). This proposed policy is an improvement on the old, existing policy.

“However, there are some significant issues that we need to be mindful of. One issue relates to thinking about risk as being a little more nuanced than ensuring that a checkbox list is completed. Health is complex with multiple intersections, and a greater deal of flexibility should be applied to risk stratification. I also question whether public health are in the best position to understand a person’s risk, and would think that the primary care team would understand an individual’s circumstances a lot better. One reason for this is that public health do not have access to the GP’s notes and are only reliant on the history taken from individuals as well as any hospital records.”

How ready is the health care system to care for rising numbers of patients in the community?

“The short answer is that it is not. While DHBs have been able to redistribute resources and allocate people to designing hospital flow, the major impact is going to be felt in primary care, where DHBs have had little involvement. Primary care consists of a range of different providers from small solo GPs to large corporate general practices. Some larger practices might be more prepared than others. Smaller practices might not have the resources to design plans.

“The burden is going to be greatest in rural communities, which have the lowest vaccination rates and often high levels of socioeconomic deprivation. Many practices and communities are remote from ambulance services. It is not unheard of for ambulances to take 5 hours to attend to a call in a rural community. Oxygen supplies are limited and a small oxygen cylinder will quickly run out of oxygen if used to treat a COVID-19 patient. Rural hospitals also have limited oxygen supplies and may not have enough oxygen to last more than 24 hours. In addition, rural hospitals do not have adequate negative pressure rooms required to keep infection risk down, or are old and not designed in such a way to have infectious and non-infectious zones. Helicopters are not able to transport COVID patients by air, and so an acutely sick person in a rural or remote setting who deteriorates will need transporting by road for a number of hours.”

Can you give any examples of innovative approaches emerging in communities?

“I am aware of a number of rural communities designing COVID-19 plans. These include lists of volunteers who can look after and check on ill people, identifying empty homes in the area that can be used for isolation, and the use of marae to house people.”

What methods of communication are used by health authorities to check in with people? How could this improve?

“Communication is mostly by phone. Email is not timely enough and will not pick up subtleties in a person’s condition or how they present. Video consultations are not widely used and require a reasonable familiarity with technology to set up.

“When you are ill you will want the most convenient and easily-used technology i.e. phone. However, phone coverage is patchy in many rural areas and sometimes totally absent. For these locations health providers will probably have to physically visit – which is resource-intensive, takes people away from other tasks, and places the health provider at risk of infection. Some things to consider include providing phones and data packages to people who have limited income, and ensuring that lots of resources go into rural primary care for physical monitoring of patients who have limited communication or fragile health.”

What are the challenges with using pulse oximeters at home?

“Most people would have limited understanding of oximeters. Obviously YouTube videos can be watched to understand their use but this would require data/WiFi, which many people may not have.

“Oximeter use is important for health professionals to decide the threshold for admitting a person to hospital. However, there can be a tendency to focus on the technology rather than assess the person in their entirety. I have been made aware of anecdotal stories of patients with COVID-19 relying on what the numbers of the oximeter are saying – despite being very sick and the oximeter probably malfunctioning.”

What are the issues for people isolating in crowded homes?

“Overcrowding is such a problem in New Zealand and is a sad indictment on a failed capitalist system. Obviously overcrowding is going to lead to greater infectivity i.e. more people are going to get sick.

“Advice includes: Ventilation – such as opening a lot of windows – might help reduce spread, wearing masks inside and maintaining good hygiene with frequent hand washing important. Keep the positive people together in a separate room and try as best as possible to isolate people with negative tests elsewhere in a different room. Prepare now with supplies of food, essential items, cleaning products, games to play.

“Think about mental health and social needs – and individual strategies to cope, such as meditation or doing breathing exercises to relax. If individuals in the home have drug dependency issues how is the household going to cope and how is the person going to maintain their drug supply without endangering other people and spreading the virus? What about cigarette supplies and making sure there is enough if you are a smoker?

“Talk to Public Health as soon as possible about your circumstances and ensure that a social service provider or Māori health provider is informed who can assist you as much as they can. The best defence is of course vaccination.”

No conflict of interest declared.

Associate Professor Lynn McBain, Head of Department of Primary Health and General Practice, University of Otago Wellington, comments:

How is the existing home isolation policy working?

“Primary health practitioners in parts of the country where there is no or minimal COVID-19 have little practical experience or examples to discuss re COVID home isolation. We are however actively preparing with meetings and discussions at a practice, locality, PHO, DHB, regional and national level.

“Many practitioners (I can’t speak for everyone) are wishing to be actively involved in the care of their practice patients if those patients are at home with COVID-19. Their knowledge of, and relationship with, the patients and families means that the care is likely to be reassuring to the patient – and also a bit more customised to the known patient needs. Local practices may also know the preferred method of contact for their own patients.

“It is difficult to know about numbers / modelling for future community cases given the daily rise in vaccine rates. I am concerned that there will be a steady rise in COVID-19 cases towards the end of December – right at the time when general practices are minimally staffed.”

What is your advice for patients isolating at home?

“If people are isolating at home – no matter what the size of the home – there is a high chance that others in the home will contract COVID-19. Ensuring high immunisation rates will reduce this risk. I understand that part of the response for home isolation is a support package which can be customised to the home, again the primary care practice will have a good idea about the household’s needs. Personal preparedness includes: planning ahead and thinking about who might shop for a family, or who could drop off other needed supplies.”

Conflict of interest statement: Dr McBain owns a general practice in Wellington.

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