How do you monitor patients who have COVID-19 symptoms but are not ill enough to come to the emergency department? And how do you help those patients feel cared about and less frightened while convalescing at home?
That was the dilemma facing Dr. Jeffrey Linder, Northwestern Medicine chief of general internal medicine and geriatrics.
The solution: mount a massive, new, daily home-monitoring program of patients presumed positive for COVID-19 with the assistance of nurses, nurse practitioners, a large workforce of medical students, physicians' assistants and daily questionnaires delivered through the Electronic Health Record portal.
The results: 7,604 patients monitored, of whom about 500 were sent to the emergency department.
We were able to catch these patients before their condition dangerously deteriorated, which improved our ability to treat them."
Dr. Jeffrey Linder, Professor of Medicine at Northwestern University Feinberg School of Medicine
The development of the program, its feasibility and early results will be published June 16 in New England Journal of Medicine Catalyst.
"We started the program to address the needs of the 80% of patients who would spend their entire course of COVID-19 at home," Linder said. "We knew from early COVID-19 experience patients could deteriorate quickly. We also suspected they may have a lot of questions about quarantine, the course of the disease and lots of social needs."
"We had no models for addressing a large-scale pandemic for outpatients, so we had to create one based on our best understanding of COVID-19, public health approaches and care in the home," said Gayle Kricke, an assistant professor of medicine at Feinberg, who implemented the monitoring program.
Linder and Kricke believe the program improved the care of patients physically and emotionally.
One team member reported: "I just spoke with a patient who is very grateful for our calls. She has been sick for six weeks. She said that there were some nights when she didn't feel like she could take another breath. But knowing we would be calling to check on her helped her to get through those nights. She is finally starting to feel better, but she told me over and over again how very grateful she is for all of the people who have been calling to check on her."
"Bless whoever came up with the idea of this program calling patients," said another patient.
How monitoring worked
The idea of the program is to proactively reach out to patients to ensure they are safe in their homes rather than waiting for them to identify a worsening of their condition. Patients fill out an online patient portal questionnaire and a monitoring team member calls the individual to follow up on any concerning symptoms they report, such as shortness of breath, chest pain or confusion
Team members also call any individuals who do not report symptoms via the patient portal or who simply don't use it. On the call, health care providers assess and triage individuals for urgent medical care if they report severe symptoms like confusion, trouble breathing or bluish lips or face. They also refer patients to social work for non-medical challenges, such as difficulty with finances or accessing food.
"This model could be used for other acute conditions where quick deterioration is likely," Linder said. "The program has been especially helpful for giving our physicians something to offer a patient when there is really no treatment available. For example, could we see changes in antibiotic prescribing habits for other respiratory infections if physicians had the option to enroll a patient in a monitoring program rather than send a patient home with nothing?"
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