Telehealth outpatient coronavirus disease 2019 case management at a tertiary hospital in Sydney

Abstract

Introduction

Coronavirus disease 2019 is an acute respiratory illness caused by severe acute respiratory syndrome coronavirus 2. The coronavirus disease 2019 pandemic upended the traditional paradigm of face-to-face provision of healthcare in the Australian context; as such, a telehealth model of active case management was implemented in our public health system, even though there was little supporting data for the safety of delivering patient care remotely to home-isolation patients in the setting of a highly infectious and potentially fatal illness.

Methods

A retrospective, single-centre, observational cohort study was performed over 6 weeks commencing 12 March 2020, including patients with coronavirus disease 2019 undergoing home isolation and being actively monitored by a coronavirus disease 2019 telephone assessment clinic. Outcomes assessed comprised: duration of active case follow-up, average number of telephone calls per patient, average number of hours managing each patient, treatment required including presentation to the emergency department or admission to hospital, patient characteristics and utilisation of other health services.

Results

Of 5223 severe acute respiratory syndrome coronavirus 2 tests performed, 170 individuals (3.25%) tested positive. A total of 158 were included: 76 (47.5%) male and median age 31 years (range 18-94). Median symptom duration was 13 days (interquartile range 6, range 2-34). Median length of coronavirus disease 2019 telephone assessment clinic admission was 10 days (interquartile range 7, range 3-32). A total of 1151 telephone patient encounters were undertaken, with a median of six phone calls made to each patient (interquartile range 5, range 1-20). Ten patients required repeat clinic review; all but one returned home. Six presented to emergency department, with three of these being admitted. In total, there were six admissions: one from the clinic, three from the emergency department and two direct from home (bypassing emergency department). Only four of the six admissions (or 2.5% of all patients) required low-flow oxygen therapy; none required high-flow oxygen or assisted ventilation. The remaining 140 patients (88.6%) were safely managed at home without complications.

Discussion

A telehealth model of care is safe, efficient and cost-effective for the management of mild-to-moderate coronavirus disease-19 and facilitates home isolation, especially of a low-risk population, thus providing reassurance that this model is sound and suitable for ongoing use.

Keywords

Telehealth telemedicine teleconsulting remote consultation pandemic outpatient care

Introduction

Coronavirus disease 2019 (COVID-19) is an acute respiratory illness caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), a novel coronavirus which emerged in late 2019 in Wuhan, China.^1,2 Since its emergence, SARS-CoV-2 rapidly spread across the globe in the early months of 2020; the resulting pandemic has laid bare shortcomings in the health system of every jurisdiction worldwide, rich and poor. These failings demonstrate the need for novel means of delivering health care as we navigate this pandemic and prepare for inevitable future pandemics.³ Institutional responses have included closure of outpatient services and cancellations of elective surgeries, aimed at reducing traffic through health facilities, increasing capacity and limiting consumption of personal protective equipment (PPE).^4,5

Traditional healthcare models of face-to-face interaction have been the mainstay of healthcare provision in the Australian context. The COVID-19 pandemic upended this paradigm, and a telehealth model of active case management was implemented in our public health system. Fisk et al.⁶ noted that the intention to maintain quality safeguards in the wider context of health services has often stood in the way of significant telehealth usage; however, the pandemic may help to establish telehealth more firmly in its aftermath, particularly because of increasing acceptance amongst both patients and healthcare workers.

In order to facilitate rapid assessment of patients with possible COVID-19 whilst reducing demand on emergency departments (EDs) and general practices, the Government of New South Wales (NSW) introduced specialist COVID-19/Flu assessment clinics (CFAC), which have generally been co-located with public hospitals. Our CFAC was opened to the public on 12 March 2020, closely followed by a COVID-19/Flu Telephone Assessment Clinic (CTAC) designed to provide ongoing specialist care for positive cases. Like many healthcare systems around the world, circumstances forced our rapid and creative implementation of a new model of remote care.^7,8

To date, there has been no published study specifically into outcomes of patients with COVID-19 managed principally via telehealth in a low-prevalence community setting, like Australia. Moreover, there is little data to support the safety of delivering patient care remotely to home-isolation patients in the setting of a highly infectious and potentially fatal illness. This study therefore seeks to fill that gap, by evaluating outcomes of telehealth review of patients with COVID-19. In so doing, we aim to have a better understanding of the strengths of our programme, as well as highlight areas for improvement. We outline our modality of COVID- 19 diagnosis, risk stratification, and management at our tertiary centre, present our findings, and discuss the implications.

Methods

Objective: Ascertain characteristics of patients with COVID-19 managed by telehealth from the CTAC. Ascertain amount of time taken by staff to perform this care, and whether this care might reduce burden on other services of the healthcare organisation (ambulance, general practice, emergency, ward inpatient and intensive care).

Design and study period: A retrospective, single-centre, observational cohort study was performed over a 6-week period of patient presentations to CFAC or ED. The inclusion criterion was any patient presenting to the hospital campus and receiving a positive result for SARS-CoV-2. Patients not actively followed by our CTAC were excluded. The study reviews the first six weeks of operation of the CTAC (12 March–22 April 2020).

Clinical pathway: A standardised assessment tool (Appendix 1) was introduced for patients upon arrival to register themselves and their symptoms. They in turn underwent further questioning and examination by a doctor or nurse, and if appropriate, underwent throat and nose swab testing for SARS-CoV-2 RNA. The tests were processed on-site at the virology laboratory of NSW Health Pathology. Results were communicated by the CTAC staff to patients by telephone. Following receipt of a positive result, the patient received a telephone call from a doctor assigned to the CTAC, under supervision of an infectious diseases staff specialist. Risk of deterioration was stratified into higher versus lower risk as follows: patients were determined to be of higher risk of deterioration based on the presence of one or more of the following: age over 40 years, Aboriginal or Torres Strait Islander, pregnant, chronic lung disease, chronic renal disease, cardiovascular disease (including hypertension), malignancy, diabetes mellitus, chronic neurological disease, immunosuppression, human immunodeficiency virus (HIV) positive, drug or alcohol dependence, mental health condition, smoker, limited or no access to a carer, or limited ability to seek assistance (e.g. poor language skills). Age under 40 years and absence of any of these risk factors was deemed to carry lower risk of deterioration, and these received a second daily telephone call, whilst higher risk patients were telephoned daily. Each telephone consultation was documented in the electronic medical record (eMR). During a call, patients underwent symptom review, were counselled and provided with support, and were given ‘safety net’ advice in case of further deterioration. They were invited to telephone the CTAC if they had specific concerns, in order to reduce the burden on other healthcare services. If required, prescriptions or medical certificates were provided by mail, facsimile or e-mail. Patients deemed to require medical review were either admitted directly to a COVID-19 ward via ambulance transfer, or presented to the clinic by private transport. All patients were followed until their symptoms resolved and they met the applicable Australian criteria for release from isolation.

Data collection: Data was collected from the eMR and assessment forms used in the CFAC (Appendix 1), which had been scanned into eMR. Data collected from the file included: date of attendance, patient identifiers, age, sex, country of birth, home postcode, indigenous status, Medicare eligibility, healthcare worker status, date of symptom onset, symptoms at presentation, pregnancy and breastfeeding status, travel and cruise-ship history in past 14 days, known contact status, co-morbidities, medications, vital signs at presentation, investigations performed, overall assessment of illness (mild/moderate/severe) and risk (vulnerable/not vulnerable), number of days on CTAC, number of telephone calls, prescription provided, repeat review required in clinic, if ambulance called, ED attendance, admitted to hospital, admitted to intensive care, if died during follow up, whether illness resolved and discharge date.

Data analysis: Data was entered into a Microsoft Excel spreadsheet to perform the descriptive and statistical analysis. Outcomes studied included: number of days on CTAC, number of telephone calls made per patient, symptom duration in days, prescription provided to patient, repeat review in clinic, ambulance attendance, patient presentation to ED, admission to hospital, admission to intensive care, symptom resolution and death.

Ethics: The study design and access to clinical data was approved by the Local Health District Human Research Ethics Committee (HREC Reference Number 2020/ETH01006). Patient information was kept confidential in line with the National Statement on Ethical Conduct in Human Research 2007 and the Australian Code for Responsible Conduct of Research 2007.^9,10

Results

During the 6-week period of study, 5223 tests were performed for SARS-CoV-2 across the hospital campus. Of these, 170 individuals (3.25%) were positive. A total of 158 individuals were followed by the local CTAC and were included in this analysis; 12 were excluded as they lived in another local health district and were followed by another service (see Figure 1). Key demographics of the 158 patients included in the study are shown in Table 1. Of these, 76 (47.5%) were male and the median age was 31 years (range 18–94). None of the patients identified as Aboriginal or Torres Strait Islander. Almost one-third (30.1%) of patients were Medicare-ineligible overseas visitors (care was provided free of charge).

Figure 1.

Case cascade.

Table 1.

Baseline characteristics of patients managed by COVID-19 telehealth assessment clinic.

	n = 158
Sex (male)	76 (47.5%)
Medicare eligible	111 (69.6%)
Healthcare worker	13 (8.2%)
Age at presentation; median (range)	31 (18–94)
Country of birth	Australia	74 (46.8%)
	Chile	11 (7.0%)
	United Kingdom	10 (6.3%)
	Spain	9 (5.7%)
	Argentina	7 (4.4%)
	Germany	5 (3.2%)
	Italy	4 (2.5%)
	South Africa	4 (2.5%)
	Ireland	4 (2.5%)
	United States of America	3 (1.9%)
	France	3 (1.9%)
	Other	24 (15.2%)
Postcode of dwelling (see Figure 2)	2026	48
	2031	12
	2035	11
	2024	10
	2022	9
	2036	8
	2032	6
	2019	5
	2020	5
	2030	5
	2023	5
	2010	4
	Other Sydney	26 (16.5%)
	Other NSW	1 (0.6%)
	Other interstate	3 (1.9%)
Travel history	Travel abroad in preceding 14 days	57 (36.1%)
Travel history	Travel on a cruise	4 (2.5%) of all patients 7.0% of all travellers
Source of infection as determined on review	Known contact	93 (58.9%)
	Overseas	51 (32.3%)
	Unknown community transmission	14 (8.9%)
Co-morbidities	None reported	123 (77.8%)
	Heart disease	9 (5.7%)
	Hypertension	8 (5.1%)
	Lung disease	5 (3.2%)
	Malignancy	2 (1.3%)
	Diabetes mellitus	2 (1.3%)
	Neurological disease	2 (1.3%)
	Obesity	2 (1.3%)
	HIV/AIDS	1 (0.6%)
	Liver disease	1 (0.6%)
	Haemoglobinopathy	1 (0.6%)
	Kidney disease	0 (0.0%)
	Other	22 (13.9%)

The most common identified risk factor for a positive case was contact with a known case (60.8%). Of those with a contact history, 84.4% were defined as ‘close contacts’ – i.e. face-to-face contact for more than 15 min, or sharing a closed indoor space for more than 2 h.¹¹ More than one-third (36.1%) had travelled abroad in the 14 days preceding their presentation to the CFAC. Of these, 7.0% had been on a cruise ship. Figure 2 depicts the geographical distribution of cases based on postcode of residence.

Figure 2.

Incidence by post code of dwelling.

The majority of cases (77.8%) did not report significant co-morbidities (see Table 1) and the rate of medication usage was low (15.2%). The most frequent co-morbidities encountered were cardiac (5.9%), hypertension (5.1%), pulmonary (3.2%) and unspecified other (13.9%). Only three patients (1.9%) were on immunosuppressive medication (adalimumab, imatinib and hydroxyurea). In terms of risk stratification at time of enrolment, those deemed to be of lower risk were the majority (n = 108, 68.4%). The remainder were either aged 40 years or over, had background medical problems, or social factors rendered them potentially vulnerable (see Table 2). No case was deemed severe.

Table 2.

Illness characteristics.

COVID-19 risk stratification	Higher risk	50 (31.6%)
	Lower risk	108 (68.4%)
Fever (T > 37.5 °C) at presentation	20 (12.7%)no temperature was recorded in 13 cases (8.2%)
Oseltamivir prescribed at presentation	5 (3.2%)
Given a prescription during period of telehealth (not at presentation)	6 (3.8%)
Required repeat review in CFAC	10 (6.3%)
Ambulance called to patient’s dwelling	4 (2.5%)
Presentation to emergency department	6 (3.8%)
Admitted to hospital from home	6 (3.8%)
Required oxygen therapy	4 (2.5%)
Required admission to intensive care	0 (0.0%)
Deceased during follow up	1 (0.6%)
Symptom duration in days, median (IQR)	13 (IQR 6), range 2–34
Phone calls, median	6 (IQR 5), range 1–20
Symptoms resolved at discharge	155 (98.1%)
	Details of ongoing symptoms	2 (husband and wife) with ongoing post-viral symptoms 1 with ataxia persisting at 6 weeks

Ten patients required repeat in-person clinic review; all but one returned home. Of these, two had worsening symptoms around 2–3 weeks into their illness, and were diagnosed and treated as mild secondary bacterial pneumonia; two suffered sore throat; four with persisting/post-viral symptoms at 4 weeks; one simply returned for repeat swab after an initial negative result. The remaining patient was admitted for investigation of new-onset cerebellar ataxia during COVID-19 recovery. Six presented to ED with three of these being admitted. One of these presented to ED without first seeking advice from CTAC, and was discharged direct from ED with a diagnosis of globus secondary to reflux. Hence, there were six admissions in total, one from clinic, three from ED and two direct from home (bypassing ED). One of these patients was admitted directly to the COVID-19 ward from home in order to facilitate end-of-life care, and subsequently died (mortality rate 0.6%). Only four of the six admissions (or 2.5% of all patients) required low-flow oxygen therapy; none required high-flow oxygen, non-invasive or invasive ventilator support (see Figure 1). No patients were admitted to the intensive care unit. The remaining 140 patients (88.6%) were safely managed at home without complication. Six (3.8%) of these had prescriptions sent to their local pharmacy and medications delivered to their door – these included antibiotics for possible secondary bacterial pneumonia, analgesia, and proton pump inhibitor for reflux.

Median symptom duration was 13 days (interquartile range (IQR) 6, range 2–34). Median length of admission to the CTAC was 10 days (IQR 7, range 3–32). During this time, a total of 1151 patient contacts were made by telephone. Given an average call duration of 15 min, this equates to an estimated 23 h and 45 min (or 1425 min) of telephone contact with patients. The median number of phone calls made to each patient was six (IQR 5, range 1–20).

Discussion

This study delineates the natural history of the disease in a geographical cohort in which all known cases were followed up by a specialist hospital telehealth clinic. Unlike some international studies of a similar nature, every case in our cohort had infection proved by polymerase chain reaction (PCR),¹² whereas direct comparison against a high-prevalence demographic is not comparable.¹³ Our findings have shown that provisioning care in this model is safe, reduces burden on alternative avenues of health care, and enables quarantining of known positive cases in the comfort of their own home environment. When appropriate, patients with progressive symptoms were able to be reviewed remotely and/or in person, and receive appropriate and timely admission to hospital (including admission to hospital for end-of-life care).

Much attention has been drawn on international experience of patients suffering a severe phenotype of COVID-19, featuring a fulminant type of acute respiratory distress syndrome (ARDS), which is the most feared and fatal complication of COVID-19.^14,15 It has also been demonstrated that the mortality rises with age, particularly age greater than 65 years.² However, the majority of cases do not result in death and in fact often do not require hospitalisation. Any deteriorations in our cohort were detected in a timely manner, with none of the patients presenting in extremis; our sole mortality was an expected death of a patient receiving community palliative care at the time of admission. The low median age (31 years) of the cases in this district of Sydney, coupled with the low rate of reported co-morbidity (nil reported in 77.8%), help to explain our low case-fatality ratio of 0.6% (1/158). Moreover, it is worth noting that the preponderance of cases in the Bondi area (Figure 2) was partly explained by an outbreak associated with young backpackers.

Our examples of patients being admitted direct to the ward from home and bypassing the ED illustrates the potential our model has to reduce unnecessary exposure to healthcare workers, as well as saving precious cleaning and PPE resources:¹⁶ our model had the potential to avoid hospital admissions, and countless general practitioner (GP) or ED visits may have been averted thanks to regular contact with the CTAC.

Telehealth or telemedicine have been defined as the use of information and communications technologies to provide care to patients outside the traditional healthcare context.^17,18 Prolonged need for physical distancing during the pandemic and limiting the exposure of vulnerable patient populations to the hospital environment (including their journey to and from) are likely to necessitate broadened utilisation of telehealth solutions; where this is done well, it may have lasting impacts on the way we deliver care in the future. Moreover, limiting the need for possibly highly contagious COVID-19 sufferers (and suspect cases) to attend physical healthcare facilities is a particular need that our model has addressed. Importantly, telehealth has the potential to assist in ‘flattening the curve’ of current and future outbreaks.¹⁷ As noted by various commentators, telemedicine in the pandemic era can facilitate rapid access of patients to specialists who would otherwise be unavailable in person. Additionally, the added benefits of modern technology and a contemporary network infrastructure allow for a ‘multi-modal paradigm’ incorporating smartphone apps, consumer-grade pulse oximeters and thermometers, in addition to traditional modes of telephony.¹⁹ Additionally, as seen at our own hospital, staff forced into isolation due to exposure to people with COVID-19 are able to continue to provide valuable telehealthcare from home quarantine.¹⁶

In addition to these benefits, telehealth has the potential to mitigate the negative psychological impact isolation has on patients. It has been found that isolation measures correlate with psychological distress, in particular due to prolonged isolation, financial concerns, fear of infection, shortcomings in government communications, and inadequate food and medical supplies.²⁰ Whilst the lack of regular in-person access to the conventional healthcare system may compound these issues, telehealth may be a mitigating factor. Augmenting our model to provide greater aid to patients suffering from the mental hardships of isolation, telehealth can play some part in combating loneliness felt by isolated patients, especially those at risk of or suffering from depression and/or anxiety.^6,18 Since the period under review in this study, our CTAC now benefits from a social worker as well as individual and group support psychology sessions.

Limitations of this study include the vast predominance of younger and non-comorbid patients, the retrospective nature of the study, and reliance on clinical data entered at patient registration without secondary confirmation. In spite of such limitations, the study outcomes are unlikely to have been affected, given that no patients were lost to follow up.

Future studies will be able to assess the added benefits of app-based home monitoring with pulse oximetry as an additional objective marker of illness severity. We would expect such a study to strengthen the findings of the present study and assist healthcare workers in making safe clinical decisions while maintaining a high standard of clinical outcomes. Feedback has also highlighted the need to assess patient satisfaction and utilise self-reported mood scales. Further assessments of patient satisfaction will also be required to ensure that patient expectations are known and able to be met. It is increasingly apparent that telehealth will continue to be a cornerstone of healthcare delivery in the pandemic era and is proving an unavoidable linchpin to which we must adapt and seek to refine.²¹

In conclusion, we found that mild-to-moderate adult cases of COVID-19 can safely be managed in home isolation with regular telephone review from a specialist hospital clinic. Moreover, this reduces the logistical and financial burden on the public health system and on GPs, reserving hospital capacity for severe cases, minimising wastage of PPE, and reducing the risk of exposure to healthcare workers.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Milton Micallef

Rebekah Cook

Appendix

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