Evidence Check - Clinical models of care

Triage, virtual care, temporary hospitals, ethics.

Post acute and subacute COVID-19 care

Added: 30 Sep 2021
Updated: 11 Feb 2022

What published advice and models of care are available regarding post-acute and subacute care for COVID-19 patients?
  • The burden post severe COVID-19 and prolonged ICU stay is considerable in patients, affecting both functional status and biological parameters, suggesting the need for close follow-up for critically ill COVID-19 survivors.
  • Emerging evidence suggest that age, hospitalisation, a higher number of onset symptoms, history of asthma bronchiale, distinct immunoglobulin signature and an increase of certain inflammatory markers during primary infection are associated with an increased risk of developing post-acute sequalae of COVID-19. A pre-print study suggests that COVID-19 infection may cause microscopic damage to the lungs which may explain the breathlessness experienced by post-acute COVID-19 patients.
  • National COVID-19 Clinical Evidence Taskforce recommendations for the care of people with post-acute COVID-19 encompass assessment, managing infection, diagnosis, red flags and symptoms, as well as goals of care such as communication, access and coordination.

Acute mental health inpatient unit risk mitigation and models

Added: 8 Oct 2021

What are the published risk mitigation and models of care for COVID-19 positive people in an acute mental health inpatient unit or in the community?
  • A systematic review identified four themes for reorganising psychiatric facilities to reduce transmission risk: addressing people’s higher risk of infection, organising to prevent clusters, implementing multiple adaptions in facilities and setting up extra-psychiatric care structures.
  • International examples of care delivery models for COVID-19 positive people with a lived experience of mental health issues include: - In the United States, a free-standing psychiatric hospital was re-purposed for treating COVID-19 in people requiring inpatient psychiatric treatment. Bed capacity, source of referral, personal protective equipment, admitting process, team structure, medical and psychiatric management, disinfecting the unit and other factors are described in how to operationalise the psychiatric COVID-19 unit. - Also in the United States, a medical centre created a stand-alone unit to care for COVID-19-positive people with acute psychiatric needs, while minimising the risk of exposure to other patients and staff using a three phase approach: identifying an existing unit, moving patients, and creating the administrative, staffing, and clinical infrastructure.- A case report in the United States described a COVID-19 positive person, who presented to the emergency department, who had his psychiatric treatment conducted via phone and through a glass wall. - In Israel, a dedicated psychiatric hospital has 16 beds specifically dedicated to treating people with both acute psychiatric needs and COVID-19. Two-way communication technology was installed, enabling people to speak to therapists and family members from a safe distance. - A dedicated setting was established in India. They considered several factors to reduce transmission risk, including modifications to admission procedures, criteria for admission and discharge, logistics of management while admitted, transfer and discharge and readmission.6 Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health. - An inpatient unit in Turkey for people with COVID-19 included measures such as cameras in rooms for observations, hospitalisation with a companion, daily visits and medical treatments for people with COVID‐19 being conducted after daily consultations with the Department of Infectious Diseases.
  • The American Psychiatric Association Committee guidance suggests vaccines should be prioritised for people with substance use disorders and serious mental illness.8 People should be provided with information about the benefits of vaccination, and vaccination rates in people with mental illness can be increased with targeted strategies such as vaccination programs in clinics.
  • Uptake of COVID-19 vaccination in a medium secure psychiatric hospital population in the United Kingdom was high (85 of 92 patients).10 However a mental health hospital in Israel had 51 of 196 people sign the informed consent for vaccination.11 A large university psychiatric hospital in Belgium found COVID-19 vaccination rates in people with mental disorders, admitted to or residing in a psychiatric hospital, were as high as in the general population with a targeted prevention program.

Oxygen saturation monitors/pulse oximeters for COVID-19

Added: 29 Sep 2021

Evidence on oxygen saturation monitors/pulse oximeters for COVID-19
  • Remote home monitoring models for COVID-19 aim to manage high-risk patients at home to avoid unnecessary hospital admissions and escalate cases of deterioration in a timely way. Oxygen (O2) saturation monitors, or pulse oximeters, can be used at home to detect COVID-19 associated hypoxia.
  • Home oximetry requires clinical support, such as regular phone contact from a health professional in a virtual ward setting.
  • Symptoms of COVID-19 can range from mild illness to pneumonia. Most people experience mild illness and can recover at home. Treatment is aimed at relieving symptoms and includes rest, fluid intake and pain relievers. However, there are a variety of COVID-19 disease trajectories, and care at home requires assessment of risk and monitoring of changes in clinical parameters.
  • Oximetry has been identified as an important element in providing home care for COVID-19 patients and monitoring the need for escalation.
  • The UK Medicines and Healthcare Products Regulatory Agency does not recommend the use of oximeters at home unless under the advice of a qualified clinician. Pulse oximeters are regulated as medical devices.
  • The NHS recommends ensuring any pulse oximeter used at home has a valid CE, UKCA or CE UKNI mark. They have a patient leaflet on how to use a pulse oximeter.
  • In the US, pulse oximeters are regulated by the Food and Drug Administration (FDA).5 Pulse oximeters reviewed by the FDA are only available with a prescription and may be prescribed for home use. Over-the-counter oximeters do not undergo FDA review.
  • There is limited data on the accuracy of inexpensive pulse oximeters, including stand-alone finger oximeters and phone-based products.
  • An observational study during COVID-19 found that low-cost pulse oximeters sold to consumers may produce inaccurate readings, although some perform similarly to more expensive options.

Organisation of emergency departments during COVID-19

Added: 20 Sep 2021

What is the evidence to support surging the capacity of emergency departments (EDs) during the COVID-19 pandemic in terms of: infrastructure, staffing, processes and patient flows, including flows out of ED
  • International examples of hot and cold zones are well described. Core characteristics of designated (hot and cold) zones include designated physical areas, certain personal protective equipment requirements, staffing models and screening areas to separate patients with known or confirmed COVID-19 from those without suspected COVID-19.
  • Temporary hospitals such as tents and marquees as well as repurposing other buildings and COVID-19 designated hospitals have been used internationally for triage and treatment.
  • Restructuring of teams and dedicated shifts have been used to reduce the number of staff exposure to COVID-19, while using other specialties has been implemented for surge capacity.
  • Patient flows and patient cohorting have been used in triage and to alleviate bed shortages.

Archive Mental health models to support children and young people

Added: 10 Feb 2021

What innovative models have been described for children and young people with mental health issues as a result of the COVID-19 pandemic?
What are the key elements for an effective mental health service responding to a surge in mental health presentations, such as following pandemics or disasters, in this age group?
Are there any specific issues that need to be addressed for different age subgroups?
  • The review included children and young people from birth to 25 years. Within this age range, however, the mental health and wellbeing needs, treatment and care responses are distinctly different.
  • Models of mental health care for children and young adults as a result of COVID-19 Models of mental health care for children and young people in response to COVID-19 predominantly describe transitioning from face-to-face care to telehealth models. Most peer-reviewed and grey literature describe a decline in face-to-face presentations and service utilisation during pandemic waves.(1-8)
  • Transition to telehealth was reported at various levels of service provision, including tertiary hospital psychiatry departments, outpatient specialist clinics, and school counselling.(1-6, 9-11) Telehealth was used for assessment, counselling and therapy sessions for individuals, parentchild dyads or groups of parents or adolescents.(1-3, 9, 10) In one study, group telepsychology was found to be comparable to face-to-face group sessions in terms of content and process fidelity, acceptance and satisfaction.(10)
  • Challenges identified in transitioning to telehealth included: parent, child and provider unfamiliarity with the technology, concerns about privacy, confusion, resistance to transition, administrative level challenges in rapid and large-scale transition and training, and difficulties in determining financial eligibilities.(1, 2, 4, 10) Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health. COVID-19 Critical Intelligence Unit 10 Feburary 2022
  • Opportunities or benefits of transitioning to telehealth included: improved access to specialised mental health services for children and families that live in geographically disadvantaged areas, enhanced synchronous and asynchronous mental health support and continuation of care.(1-3, 11)
  • In Australia, according to a survey by non-profit organisation headspace, 94% of young people (n=1348) reported a positive experience with telehealth.(7) 45% (n=592) of headspace staff said their therapeutic relationship and the young person’s therapeutic progress were about the same using telehealth, as compared with in-person, and 44% said it was worse.(8) The phone counselling service, Kids Helpline, received funding to develop the first digital mental health practice model to offer online peer support for young people 13 to 25 years.(12)
  • In New Zealand, a digital ecosystem for school students was used to provide safe and secure platform to host a wide range of interventions, including chatbot, online fantasy games designed for depression, and apps for youth and parents, and screen and identify users who might benefit from interventions and refers users to urgent care when needed.(13)
  • In Canada, a Virtual Innovation in Care grant program was initiated to evaluate and scale virtual services in youth mental health in response to COVID-19.(14)
  • Models and interventions of mental health care in the events of pandemic and disasters Search included studies described models of care and mental health interventions for children and young people following natural disasters (such as hurricanes, tsunamis, tornados, earthquakes, flooding, war, terrorism events, and pandemics).
  • Interventions such as mass screening, wellbeing and resilience building, psychological debriefing, storytelling, psychoeducation, trauma-informed mental health interventions in schools and other community settings delivered by either the schoolteachers, professionals or paraprofessionals, and stepped care approach where children are matched to intervention levels through assessment, screening and clinical evaluations.(15-19) Post-disaster interventions were found to be beneficial, even when delivered a considerable period after the disaster, and to have a long-lasting impact on children and young people.(19)
  • School-based programs have been identified as a core implementation site for child and family mental health interventions post-disaster.(20-22) School-based interventions in either natural disaster or conflict settings were found to significantly reduce post-traumatic stress disorder, depression and anxiety symptoms compared to controls.(15, 17, 23, 24) A Sri Lankan, posttsunami project, the Happy/Sad Letter Box, was found to be effective, non-stigmatising, relevant, and helpful in catering to children’s mental health needs during the recovery process.(22)
  • Digital programs, including an online cognitive behaviour therapy program, introduced for children and adolescents experiencing anxiety following the Canterbury earthquake in New Zealand was found to be feasible and acceptable in improving mood and anxiety symptoms.(25) A web-based intervention for adolescents following tornado disaster in the United States of America (USA) was feasible, effective and scalable in reducing depressive and post-traumatic stress disorder symptoms.(26)
  • Bridging resources and building partnerships between local academic, health, community, media and school sectors in developing culturally sensitive and locally suitable psychological response interventions were identified as key components of comprehensive trauma-and resiliency-focused programs.(27-33)Q3. Are there any specific issues that need to be addressed for different age subgroups?
  • Preschool hildren: Assessing and screening for mental health problems with preschool children can be challenging due to their limited verbal abilities. One review article recommended that screening activities to be integrated into normal institutional activities and professional who interact with children to be trained in trauma assessment and care.(34) One study described implementing play-based activities which aimed to alleviate fear and manage aggressive behaviours.(27)
  • School children (kindergarten to grade 12): Schools are identified as critical sites for mental health assessment and interventions during and after a disaster.(15, 20, 21, 23, 30, 35-37) Interventions were mainly delivered in the form of classroom-based and teacher delivered group sessions.(24, 35, 38)
  • Adolescents, youth and young adults: Specific interventions for this group included text-based crises support, online therapy, web-based intervention, and a resilience-based leadership program.(25, 26, 29, 39)

Archive Models of emergency department mental health care

Added: 15 Oct 2020

What innovative models or redesign of emergency department mental health care have been reported in response to the COVID-19 pandemic?
What is the evidence for different models of mental health care in the emergency department setting?
  • Adaptations to the mental health services in the emergency departments (EDs) during COVID-19 sought to minimise the risk of infection and transmission in hospital settings and to convert space and divert resources to provide critical COVID-19 related services.
  • Within Australia, various models have been developed. In Victoria, a framework for mental health care during COVID-19 outlines staged actions for reducing bed-based admissions and increasing community-based mental health services. An intensive mental health community care service model was proposed as an alternative to bed-based mental health services during the COVID-19 outbreak. In South Australia, an urgent mental health care centre within close proximity to a major hospital is currently being developed to divert mental health patients from the emergency department. A mental health co-responder program reduced ED presentations by emergency service call-outs by two-thirds.
  • In UK, the Royal College of Psychiatrists recommends that where possible, patients who present with mental illness should be moved to a separate area away from the high-risk areas in emergency departments. A survey of ED clinicians from 68 EDs in the UK found 82% of EDs established an alternative care pathway for mental health assessment in response to COVID-19. A range of assessment locations were used in the pathways, including: 38 (68%) on a separate site which has existing mental health services, 9 (16%) away from the emergency department but within the hospital, 5 (9%) within the emergency department, 3 (5%) at home via telehealth, 1 (2%) at another clinic site.
  • Studies in US settings describe: o conversion of psychiatric emergency care areas to COVID-19 assessment and management areas providing psychiatric emergency assessment to multiple emergency departments from one crisis response centre located in one of the hospitals.
  • In Spain, mental health home care and home hospitalisation care models were proposed. In Italy, new admissions into day hospitals, day centres, short and long-term residential care facilities and in-patient units were either suspended or strictly restricted.
  • Models with potential to reduce the ED presentations and boarding by patients experiencing mental health crises include: central acute community team, community based psychiatric emergency service, mobile assessment team, rapid response team, assertive outreach care model, home acute care and crisis resolution team. emergency department follow-up team, child guidance model, emergency department initiated case management model, and mental health liaison nurse model.

Triage tools for ICU admission during COVID-19

Added: 13 Apr 2020
Updated: 16 Sep 2020

What triage tools are available to guide decisions about admission to ICU during COVID-19?
  • There is considerable guidance around general principles for triaging patients to intensive care units during COVID-19. Key themes include, have decisions made by at least three physicians, multidisciplinary, shared and ethical decision making, documentation and transparency, reserving ICU admission for patients requiring ICU-specific interventions and not using age, on its own, as criteria.
  • For COVID-19 specifically guidance is available including
  • NICE rapid guidance including a critical care referral algorithm (which were updated on 31st March), and the Swiss Academy of Medical Sciences released guidelines for ICU triage. Criteria from opinion sources and other organisations were also identified
  • Triage criteria is generally based on clinical criteria and probability of survival, with a recently published triage tool also including criteria on likely duration of stay
  • Some of the guidance specifies that criteria apply to all patients potentially in need of ICU admission not only to COVID-19 infected patients

Archive Preserving consumer and patient partnership during COVID-19

Added: 28 May 2020

How can we preserve consumer and patient partnership approaches during COVID-19? Specifically, what guidance is available for patient experience and person-centred care in renal care?
  • In response to the COVID-19 pandemic, organisations are using initiatives and programs to preserve patient experience and person-centred care. NSW Health is expanding the ‘Patient Experience Program’ to COVID-19 clinics. This initiative involves four key strategies: patient experience officers, information technology, waiting room enhancements and staff support and development. The Point of Care Foundation in the UK has implemented ‘Team Time’, online reflective practice sessions for health professionals to share experiences of their work in health and social care. Patient partnership champions have called for the immediate recognition of families as ‘essential partners in care’ not ‘visitors’ in response to COVID-19 visitor policies. The Beryl Institute further suggests the need to reinstate responsible access and visitation policies that balance clinical and personal needs. Hospitals are using virtual visiting solutions, apps and smart devices to support communication between patients and families. McMaster University and the National Hospice and Palliative Care Organisation have developed patient decision aids to support shared decision making during COVID-19.
  • A May 2020 Beryl Institute survey on US patient experience in healthcare found despite lower engagement in healthcare activities in the context of COVID-19, consumers were more positive about overall healthcare quality and their own care experiences compared to the previous survey in January 2020.
  • Evidence based guidance on the introduction and use of video consultations during COVID-19 notes that technology can alter the quality of clinical encounters and outcomes. Expert opinion is that video consultation is preferable to telephone as it supports relationship building and allows patients to feel more comfortable.
  • Australia’s Health Panel asked 95 panellists about their views and perceptions on the use of telehealth in Australia during March 2020. Only one third (n=32) had ever been offered a telehealth service and the majority found it to be of excellent or good quality. When compared to regular face-to-face consultations, 11 panellists believed it was better than face-to-face, 9 thought it was worse and 8 thought it was more or less the same.
  • In renal care during COVID-19, opinion recommends transparency when disclosing information to patients in dialysis units. This includes communicating what patients can and cannot expect from the service during COVID-19.
  • Broader evidence base for renal care. o A systematic review found person-centred integrated care may have little effect on mortality or quality of life. o Evidence from a number of studies suggests patient education and shared decision making can help achieve person-centred care for people with chronic kidney diseases. o Expert opinion suggests a collaborative approach, using shared goals rather than prescribed targets, a greater understanding by the individual of their condition and their treatment can lead to better decision-making and a more positive experience of care.

Daily Evidence Digest

Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health.

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