Evidence Check - Clinical models of care

Triage, virtual care, temporary hospitals, ethics.

Archive Rehabilitation needs of post-acute COVID-19 patients

Added: 4 May 2020
Updated: 7 May 2020

What are the rehabilitation needs of post-acute COVID-19 cohort?
What is the appropriate timing of rehabilitation interventions?
  • COVID-19 can affect respiratory, cognitive and motor functioning.
  • 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 ICU to limit the severity of ICU-acquired weakness and promote rapid functional recovery.
  • Italian guidelines recommend rehabilitation both in the acute phase, when patient has reached a minimum clinical stability, and in the post-acute phase.
  • Even with rehabilitation, Recovery time is variable - depending upon the degree of normocapnic respiratory failure, and the associated physical and emotional dysfunction.
  • A living guideline for allied health professionals recommends a case prioritisation process that explicitly considers for each patient, the potential impact of not receiving immediate rehabilitation on critical outcomes (i.e., risk of hospitalisation, extended hospital stay).
  • The British Society of Rehabilitation Medicine recommends rehabilitation pathways provided by coordinated networks, starting service provision in intensive care units, followed by an acute rehabilitation programme with the opportunity for further triage into post-acute pathways in the network.
  • Tele-rehabilitation tools are available to observe and communicate directly with patients and/or staff already in isolation areas (e.g., use of data-secure cameras, such as iPads and baby monitors). Models for cardiac rehabilitation in COVID-19 have also been described.

Archive Conducting virtual respiratory assessments and monitoring via telehealth

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)

Archive Management of acute behavioural disturbance and COVID-19

Added: 28 Apr 2020

What is the guidance on the management of acute behavioural disturbance during COVID-19?
Specifically, what are the: a) inflection control and personal protective equipment, b) pharmacotherapy and c) non-pharmacological management considerations during COVID-19?
  • There is limited evidence on the specific management of acute behavioural disturbances during COVID-19.
  • Expert opinion is that people with severe mental illness may find it difficult to understand, accept and follow isolation protocols. This may increase the risk of COVID-19 transmission to others.

Archive Validated tools to diagnose respiratory illness via telehealth

Added: 22 Apr 2020
Updated: 28 Apr 2020

Which tools are validated to diagnose respiratory illness via telehealth?
  • A Centre for Evidence Based Medicine (CEBM) review of methods to assess dyspnoea by telephone or video found no validated tools, and recommended against the use of the Roth score.
  • In this review, a rapid survey of 50 clinicians gave the following advice: ask the patient to describe their breathing in their own words, align with the NHS111 symptom checker which asks three questions, focus on change to identify if there has been deterioration and interpret the breathlessness in the context of the wider history and physical signs.
  • A rapid review on the accuracy of self-monitoring of heart-rate, respiratory rate and oxygen saturation in patients with symptoms suggestive of COVID-19 infection found no studies on remote monitoring of respiratory rate and cautioned against use of smartphone apps for measuring oxygen saturation.
  • A rapid evidence synthesis from CEBM found it is not physically possible to measure blood oxygen saturation (SpO2) using current smartphone technology.

Archive Telemedicine in intensive care units

Added: 20 Mar 2020

What telemedicine models or interventions are associated with improved outcomes for people in the intensive care unit?
  • In the setting of intensive care units (ICU), telemedicine generally uses audio visual technologies to assist in patient care by connecting an intensive care specialist who is not on site
  • There are two models of telemedicine in ICUs that are most commonly described. hub-and-spoke model and virtual consultations.
  • Hub-and-spoke models describe a model which uses a single remote centre (hub) in a fixed location to provide tele-critical care services to multiple local locations (spokes) simultaneously. Differences in definitions of the model make it challenging to draw conclusions on outcomes, but some studies show a reduction in hospital mortality
  • Virtual consultations involves a remote intensivist virtually reviewing one patient at a time using audio-video connectivity. It has shown some improvement in reducing ICU and total hospital mortality, but no significant difference in length of stay in pre/post studies

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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