Something Seems To Be Not Quite Right Here And I Am Not Sure Why.

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16 September 2021

Remote monitoring keeps patients safe at home

By Holly Payne

As our national focus shifts away from covid-zero and toward “living with the virus”, we’re left with questions about how the hospital system will manage the increase in patients.

Virtual covid wards, where patients with milder symptoms are monitored at home, offer a shiny new solution to the issue.

But with covid patients prone to rapidly deteriorate without showing any outward distress – a phenomenon dubbed “happy hypoxia” – being able to quickly escalate care is also vital.

Given the highly infectious nature of the virus, in particular the Delta strain, clinicians have been particularly concerned about the potential for spread among vulnerable hospital inpatients.

These fears have been realised in the latest NSW outbreak, with fatal covid outbreaks at six Sydney hospitals since June 16.

Given these risks, it is unsurprising that at-home monitoring of patients with mild symptoms holds promise.

“If you’ve got 600 cases in a smallish town, but you’ve only got a couple of hundred hospital beds, then you are going to swamp that hospital very quickly,” former emergency physician and current University of New England research professor Rod McClure tells The Medical Republic.

“You can’t put covid-positive people in just for observation, you’ve got to bring them only when you need them – if you can observe them at home, that’s great.

“It keeps infectious people out of hospital, which means that the people with non-infectious diseases that need hospital care, can get it.”

In March last year, just as covid cases began to appear in Australia, Professor McClure worked with the Hunter New England local health district to establish one of the country’s first virtual covid wards at Armidale Hospital.

It was stood down when it became clear that Australia had largely avoided a first-wave outbreak, but Professor McClure says the system is simple enough to be rolled out again on short notice.

Each patient in his trial wore a unit on their wrist the size of a large watch, which measured oxygen saturation, blood pressure, temperature and even made a simple ECG reading. These measures were then transmitted continuously through a private cloud-based system to a central monitoring site set up “very much” like an ICU hospital ward, just without patients.

“It’s an ICU-quality monitoring system that can be worn very easily on the wrist of patients wherever they happen to be,” Professor McClure says.

While most hospital and health systems have community-based subacute care programs, widely known as hospital in the home (HITH), he says his virtual ward is different.

In some areas, HITH models have been souped up to create a semi-virtual ward, but these can be relatively low-tech.

“[Health services have] used existing HITH programs for home-managed covid patient wards, and they’ve done that simply by posting out or dropping off a pulse oximeter, and then giving people telephone calls once a day,” Professor McClure says.

“Pulse oximeters are really simple: you just slip a finger into a little bulldog clip and it reads your oxygen at a point in time.

“Some of the wards just rely on the reading from a thermometer which the patient has put under their tongue or under their arm, as well as a self-recorded pulse oximeter reading and a daily chat via a telehealth type model.”

While one health district in Queensland found this model easy to set up and roll out, it did acknowledge the need for enhanced visual communication and selective patient monitoring capabilities in the setting of a larger outbreak.

Professor McClure says the continuous nature of the monitoring in his trial is an especially important distinction from the low-tech HITH models, which generally only take readings once per day.

“If people were gardening or washing up, they basically just took the equipment off, and then plugged it back in twice or three times a day, allowing us to get a very reliable recording at the times that we actually needed it,” he says.

“Now, that is analogous to a hospital because patients in the wards tend to only get their observations done once a day or every four hours, depending on where the hospital they are – if they’re in intensive care, they might get their observations taken once an hour.”

More observations allow the nursing team at the hospital to better identify clinical deterioration points as they happen.

“This system will pick up the happy hypoxic, and it will pick it up before the person does,” Professor McClure says.

“If we ring the patient and ask how they were going, and they say they feel fine but we’re looking at their data and realising that they’re feeling ‘fine’ at 90% saturation, then something’s happening.

“We’re quite sensitive to that quick change because we can see it happening.

“We can call the ambulance before they know they need it – and if they live in, say, rural Australia, then we can actually notify the hospital get them in before we have a problem at two o’clock in the morning with poor transport.”

Lots more here:

https://medicalrepublic.com.au/welcome-to-the-virtual-covid-ward/53830

Reading this it seems to me that we are not trying hard enough with our remote monitoring. Each day in NSW it seems on or even more patients who are at home with COVID19 suddenly die without apparent warning. Clearly we are not getting our risk stratification right as we should not be seeing unattended deaths. With the continuous monitoring described above it is hard to believe there is not some warning of deterioration that can be picked up before deaths!

I am aware people can go downhill pretty quickly so we really need to know those in this risk category and not leave them at home!

With all the overseas experience with this virus surely we have developed ML / AI algorithms to do this risk stratification safely? Look forward to these deaths disappearing!

David.