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Evidence Check - Clinical models of care

Triage, virtual care, temporary hospitals, ethics.

Models of emergency department mental health care evidence check

Added: 15 Oct 2020

Q1 What innovative models or redesign of emergency department mental health care have been reported in response to the COVID-19 pandemic?
Q2 What is the evidence for different models of mental health care in the emergency department setting?
  • Q1 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.
  • Q1 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.
  • Q1 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.
  • Q1 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.
  • Q1 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.
  • Q2 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.

Conducting virtual respiratory assessments and monitoring via telehealth evidence check

Added: 2 May 2020

What is the current evidence for conducting virtual respiratory assessments and monitoring in adults via telehealth?
  • Conducting physical examinations remotely by telehealth is recognised to be a challenge in clinical practice.(1-3) However, there is evidence that telehealth assessments and monitoring can be carried out for a variety of respiratory illness, including chronic obstructive pulmonary disease (COPD), acute exacerbations of COPD (AECOPD), asthma, cystic fibrosis, pulmonary hypertension, interstitial lung disease and most recently, COVID-19.
  • A previous Critical Intelligence Unit evidence check reported on a rapid review conducted by the Centre for Evidence-based Medicine (CEBM) at the University of Oxford, which found no validated tests for assessing breathlessness in acute primary care settings. The review identified insufficient evidence for the clinical accuracy of the Roth score test for breathlessness. It also advised against the use of smartphone apps to assess oxygen saturation.(4)
  • A systematic review found that forced expiratory volume, assessed daily by using a spirometer, was the most common modality of remote respiratory assessments in people with COPD. Other measurements included resting respiratory rate, respiratory sounds and end-tidal carbon dioxide level. When combined with machine learning algorithms, remote assessments were found to be highly predictive of AECOPD. Daily remote respiratory assessments were found to be feasible and well tolerated in most people with COPD and had consistently high user satisfaction.(5)

Preserving consumer and patient partnership during COVID-19 evidence check

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.

Virtual care and telehealth for specific conditions evidence check

Added: 28 May 2020

What is the available evidence about the effective use of telemedicine or virtual care in different clinical areas?
  • Telehealth has been shown to improve access to care, is acceptable to patients and clinicians, and available technology can provide high-quality and secure information transfer.
  • The application of telehealth spans from the highly technical to the person centred and from time-limited acute encounters to ongoing episodes or series of care.
  • Strongest evidence is available for the acute management of ischaemic stroke via telestroke and for monitoring and management of chronic conditions such as diabetes and heart failure.
  • Tele-ICU, tele-mental health and tele-rehabilitation have also been associated with positive outcomes.
  • Much of the available evidence is of low quality.

Reducing adverse impacts of people with a lived experience of severe mental health issues during COVID-19 evidence check

Added: 27 May 2020

What guidance is available to support health systems respond to COVID-19 and reduce adverse impacts on people with a lived experience of mental health issues during the pandemic?
  • Extensive evidence shows premature mortality and significant morbidity for people living with severe mental health issues, compared to the general population. They are six times more likely to die from cardiovascular disease and four times more likely to die from respiratory disease. Health issues are exacerbated by homelessness and other social determinants.
  • Expert opinion is that COVID-19 will adversely and disproportionately impact people with a lived experience of mental health issues, and if infected, they will have poorer outcomes.
  • Several factors are considered to increase the risk of COVID-19 infection, mortality and mental health symptom relapse, including: o Person-related factors such as existing poor physical health and difficulty following strict quarantine precautions. o Provider-level factors such as structural design of facilities, communal spaces for in-patient activities, long lengths of stay in mental health facilities and infection control practices. o System-level factors such as limited access to community care either virtually or in-person, risk of interrupting medications and public health interventions that raise psychological distress.
  • The peak advocacy body for mental health consumers in NSW (BEING) conducted consultations at the onset of COVID-19. It recommended a clear mental health plan for NSW, with provisions for people in inpatient units to access leave and to host visitors, and activities focused on web-based communication and skill-building strategies.
  • Several clustered outbreaks have been described in the US and China. One study reported COVID-19 transmission to 50 patients and 30 medical staff in a mental health facility in China. The authors suggest that closed and crowded wards and limited space in which to implement social distancing measures were contributing factors in the outbreak.

Assessment and management of COVID-19 patients in the emergency department (ED) evidence check

Added: 25 May 2020

What is the evidence for the assessment and management of suspected or confirmed COVID-19 patients presenting to the Emergency Department (ED)?
  • Guidance on the assessment and management of patients with suspected or confirmed COVID-19 in the ED consistently prioritises limiting the spread of infection, identifying all cases, and estimating disease severity.
  • Consistent with other guidance, the European Society for Emergency Medicine recommends that access to ED should be limited to those with severe respiratory symptoms or other organ compromises. Current World Health Organization guideline states that where possible, mild to moderate cases without other known risk factors can be managed in the community with advice on self-management of symptoms and self-isolation.
  • The Australian Medical Association recommends that patients and healthcare professionals alert the hospital prior to the arrival of suspected cases to facilitate the preparation of appropriate safety controls and patient management. When patients directly present to the ED, it is recommended they are given a surgical mask, and screened and triaged away from other patients.
  • Guidance consistently prescribe that assessment of suspected COVID-19 patients should occur in a dedicated single isolated room, to screen for the presence and severity of clinical symptoms (e.g. fever, coughing, shortness of breath), epidemiological risk factors (e.g. illness onset, travel history, previous contact with cases), potential known risk factors for more severe illness (e.g. old age, comorbidities), and differential diagnoses such as influenza.
  • From the ED, patients are triaged and transferred based on their severity of illness to appropriate care settings, such as the community, in the general ward or intensive care unit (ICU).
  • The Australian National COVID-19 Clinical Taskforce recommends that staff refer to local diagnostic testing criteria for SARS-CoV-2, noting that they may differ between states and territories. Diagnostic tests that have been shown to be informative in the ED, including nasopharyngeal or oropharyngeal swab polymerase chain reaction (PCR) tests. The Taskforce recommends performing further testing on all cases admitted to hospital, including laboratory testing, haematology, electrocardiogram (ECG) tests, and chest X-rays.

Homelessness and COVID-19 evidence check

Added: 22 May 2020
Updated: 25 May 2020

What guidance is available to support health systems respond to COVID-19 and associated risks for people experiencing homelessness?
  • Homelessness is a significant social determinant of health. Expert opinion is that people experiencing homelessness may find it difficult to effectively quarantine, practice distancing measures or perform proper hand hygiene. This may exacerbate and amplify the spread of COVID-19
  • Opinion suggests that people experiencing homelessness often have pre-existing medical conditions and limited access to healthcare, which may increase the impact of COVID-19 compared to general populations.
  • Evidence suggests that infection control, isolation and quarantine were challenges in previous pandemics and epidemics. Lessons can be applied from HIV/AIDS, Tuberculosis, H1N1 and SARS, including the need to establish rapid communication between public health and homelessness service providers, ensuring providers have access to personal protective equipment, and identifying where and how people will be isolated and treated.
  • Centers for Disease Control and Prevention (CDC) reported high proportions of positive COVID-19 test results upon universal testing in some shelters in the USA, suggesting the need for broader testing to prevent the spread of COVID-19 in these settings. Two USA studies also saw high proportions of people positive for COVID-19 after testing in homeless shelters.
  • Guidance from CDC includes implementing infection control practices, applying distancing measures and promoting use of cloth face coverings within homelessness services.
  • Guidance based on expert opinion suggests: - widespread distribution of accessible and up-to-date information on COVID-19 for people experiencing homelessness. Distribution can be through community partners including law enforcement. - providing providers of homelessness services with training to ensure effective screening and implementation of infectious disease protocols. - prioritising testing and flagging older people accessing services as a high risk for COVID-19.
  • Western Australia State Government is conducting scenario planning to develop strategies to respond to potential outbreaks of COVID-19 in people experiencing homelessness including cluster outbreaks.

Pulmonary rehabilitation and COVID-19 evidence check

Added: 7 May 2020
Updated: 12 May 2020

What is the guidance for the provision of pulmonary rehabilitation for people recovering from COVID-19?
  • A small quasi-randomised trial of elderly patients with COVID-19 showed respiratory rehabilitation can improve respiratory function, quality of life and anxiety.
  • Recommendations from international researchers for physiotherapy in acute hospital settings cover post COVID-19 mobilisation, exercise and rehabilitation interventions. They recommend early rehabilitation after the acute phase of acute respiratory distress syndrome, which is of particular value to those admitted to intensive care unit (ICU) to limit the severity of ICU-acquired weakness and promote rapid functional recovery.
  • Expert opinion suggests pulmonary rehabilitation could relieve the symptoms of dyspnoea, anxiety and depression, and eventually improve physical function and quality of life.
  • One article lists a range of common practices used in respiratory physiotherapy that are not recommended in with patients with COVID-19 in the acute phase including diaphragmatic breathing, pursed lips breathing, manual mobilisation or stretching of the rib cage, respiratory muscle training, exercise training and mobilisation during clinical instability. Other guidance suggests early mobilisation and physical exercises to improve respiratory and diaphragmatic muscle strength and promote recovery.
  • A living guideline for allied health professionals recommends that case prioritisation consider the potential impact on critical outcomes of a patient not receiving immediate rehabilitation.
  • Guidance suggests continuing rehabilitation care in the outpatient setting, and at home through ongoing therapy either in-person or via telehealth.
  • The American Thoracic Society does not endorse a specific approach to pulmonary rehabilitation during COVID-19. However a patient education factsheet has been published suggesting some ways to continue pulmonary rehabilitation at home. The British Thoracic Society released a resource kit with guidance to support pulmonary rehabilitation remote assessment during COVID-19.
  • The Lung Foundation Australia is facilitating an at-home exercise series through the initiative COVID-19 - Maintaining Movement.

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.