The COVID-19 pandemic has placed significant stress on the global healthcare system. While a majority of patients have a mild to moderate illness that can be managed at home, a subset of patients developed critical disease requiring intensive care and mechanical ventilation. Deterioration to the point of hospitalization typically occurs during the second week of disease.1 Differentiating patients who require hospitalization from those that do not is critical to ensuring the healthcare system is not overwhelmed. Patients who initially present with mild to moderate symptoms may be able to recover at home, but should be monitored for deterioration.
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In-home visits from community paramedics (CPs) represent one patient-centered approach to monitoring patients with COVID-19. Community paramedics are experienced 911 paramedics with additional education on disease management and social determinants of health. CPs have a unique skill set which makes them an important member of an integrated COVID-19 healthcare response. The following case report details a scenario where community paramedics cared for a patient with COVID-19.
A 69-year-old African American female presented to the emergency department (ED) and reported two days of cough, shortness of breath and left sided chest pain which was described as burning, constant and worse with deep breathing or exertion. She was found to be febrile to 101F. Her past medical history included coronary artery bypass graft surgery, COPD and pulmonary embolism. Daily medications included albuterol, Advair and warfarin. She had increased work of breathing on exam with a respiratory rate of 22 and room air oxygen saturation of 94%. There were no abnormalities on EKG to suggest ischemia, her troponin was negative and a CT scan of the chest ruled out bacterial pneumonia and pulmonary embolism. The patient was admitted to the hospital and did well overnight without the need for supplemental oxygen. Her COVID-19 test result came back positive. On hospital day two, she was discharged home in the care of four adult family members who she lived with. A community paramedicine referral was placed by the discharging physician with no changes made to her previous outpatient medications.
Four days after discharge, a home visit was performed by a community paramedic. Droplet and contact precautions were taken. The patient reported ongoing symptoms of nausea and fatigue but denied cough, fever or shortness of breath. She had no cyanosis or signs of increased work of breathing and her vital signs were: HR 78, RR 26, BP 98/66, 98.2F temperature, Sp02 90%. The patient appeared clinically stable despite a relatively low systolic blood pressure and room air oxygen saturations of 90%. She refused further evaluation at the clinic or hospital but agreed to have the CP return for reassessment the next day. Of note the patient lives with four other family members, each of whom was complaining of cough, fever or feeling “sick.” None of them had been evaluated at a clinic or hospital.
On post-discharge day five, the CP returned to the patient’s home for reassessment. Patient stated her condition was unchanged from the prior day. She continued to deny CP, SOB or fever. Vital signs were notable for oxygen saturations of 88% and a RR of 24. Physical exam showed no signs of increased work of breathing but the patient appeared weak and fatigued. The patient’s primary care physician was contacted by the CP and a telephone visit was conducted. At this point the patient was not willing to return to the hospital but she did agree to ongoing CP visits in her home. The patient’s family members were noted to have increased coughing, but none appeared seriously ill and they did not specifically request evaluation.
The CP returned for reassessment on post-discharge day seven. The patient reported worsening sore throat, severe weakness, nausea and new dizziness when standing. She continued to deny fever or SOB. Vital signs showed Sp02 of 87% at rest with RR 22. With ambulation to the bathroom patient became dizzy on standing and her Sp02 dropped to 74% with RR 30. The CP reported that the patient’s clinical condition was deteriorating. The additional family members in the home were also becoming increasingly symptomatic and unable to care for the patient. The CP contacted online medical control who performed a telehealth visit while CP was at the home.
The patient was very stoic and initially did not want to return to the hospital but together the CP and MD were able to explain the importance of hospitalization and she agreed. A direct admission was arranged by the MD and the patient was transported by the local 911 EMS service directly to the in-patient hospital ward, bypassing the ED. The patient was hospitalized for six days and ultimately was discharged to home with supplemental oxygen and additional home CP visits.
Community paramedics have a unique skill set and are ideally positioned to assist in the response to the COVID-19 pandemic. COVID-19 is primarily a respiratory virus causing mild illness in 81% of patients but which can progress to critical illness over 8-12 days.2 Differentiating between patients who require hospitalization and those who can be safely managed at home is critical to ensure that hospitals are not overwhelmed. As this case demonstrates, continued reassessment by a community paramedic experienced in assessment of respiratory status can identify patients who are becoming more symptomatic and would benefit from hospitalization.
The unique ability of CPs to conduct in-person, in-home assessments provides insight that can be critical to determining appropriate patient management. Ensuring that CPs have appropriate PPE while performing in home assessment of patients who have COVID-19 should be a priority. CPs should anticipate that in addition to their patient, other household members may be symptomatic for COVID-19. Additional precautions in these situations may include placing masks on all individuals in the household or evaluating the patient in a room separate from others. Strategies to increase ventilation such as opening windows or conducting the assessment in an outdoor space such as a garage with an open door, a patio or a backyard may also be considered.
In-home assessments of COVID-19 positive patients should include a set of key components. Initially, the CP should review the patient’s medical history including any recent hospital or clinic visits, identify any specific orders placed by the referring physician and use their knowledge of the patient’s place of residence to anticipate any social determinants of health that may complicate disease management. Reviewing medications with the patient to ensure they understand how and when to take them, especially for any medication adjustments made as a result of the COVID-19 diagnosis, is important. As a primary respiratory virus, CPs should assess the respiratory status of patients both at rest and with exertion. In the home, CPs can also evaluate other critically important aspects required for a successful patient outcome such as adequate nutrition, safe ambulation and the patient’s ability to care for others in the home. If family members are present, CPs can provide education on appropriate quarantine techniques to limit the spread throughout the home. Repeated visits both allow the CP to build rapport with the patient and also to identify subtle changes which can suggest improvement or deterioration.
As prehospital professionals, CPs are uniquely positioned to integrate knowledge of neighborhoods into their care plan. Obstacles to care a CP may identify include food deserts, personal safety/crime, transportation challenges, language barriers or cultural differences such as requiring a family elder be consulted before decisions are made. Having medical discussions occur in the patient’s home, as opposed to a clinic or hospital, can be empowering for individuals and can help guide medical providers to develop care plans which are most in line with the patient’s beliefs. In the case presented here it was the relationship the CP built with the patient and family over a series of visits which allowed the CP to explain the importance of returning to the hospital in a manner consistent with the patient’s beliefs. Involving online medical control to reinforce to the patient the medical abnormalities identified by the CP, and the importance of transport to a hospital to address these, is an excellent example of the physician-paramedic relationship that is core to successful CP programs.
As this case demonstrates, patients diagnosed with COVID-19 can deteriorate after hospital discharge and CPs can play a vital role identifying changes in patient condition that require hospitalization. By having CPs conduct in-home reassessments of high risk COVID-19 patients, hospital beds are able to remain open and patients are able to recover at home as long as it remains safe to do so. This approach is patient centered and is an effective management of high risk COVID-19 patients who initially present with mild to moderate illness that may progress over time.
- Clinical Questions about COVID-19: Questions and Answers. U.S. Centers for Disease Control and Prevention. [Internet]. Atlanta. [2020 Aug. 4; cited 2020 Sept 14]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html.
- Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19). U.S. Centers for Disease Control and Prevention. [Internet]. Atlanta. [2020 Sept 10; cited 2020 Sept 14]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html.
Tips & Tricks for COVID-19 Patient Visits
- Bring a visit checklist on laminated paper and a dry erase pen for note taking.
- Use a designated bag for COVID+ visits containing: BP cuffs, stethoscope, pulse ox, glucometer, thermometer, gloves (in baggie) and foam sanitizer.
- Make up a PPE bag (large Ziploc) containing: Gown, mask with shield (or N95 & face shield or goggles), head cover, shoe covers, mask for patient and one family member, bio bag, Sani-Wipe. Prep garbage bag and sanitizer in vehicle for after visit clean up.
- Call patient and prep them about what to expect. Advise patient that you will be wearing full PPE and will need to put this on prior to coming into their home or apartment building. Ask if they have a garage or other location you can use to discreetly don PPE outside of their home. Inform them that you will be disposing of used PPE in their garbage. If that is not possible, place in the back of your vehicle and dispose of in base dumpster.
- Request that only one additional person be in the room with the patient if needed, and that both patient and family member wear a mask.
- Talk through some social determinants over the phone with patient to lessen in-home time. Topics include: access to food, diet concerns, medications, housing, mobility, insurance and financial resource needs, transportation and follow-up appointments.
*** Taking the time to prep prior to your visit is very helpful and important to minimize handling of items and possible contamination of equipment. Attempt to keep anything outside of the home that does not need to be brought in (i.e. paperwork, extra bags or equipment). Paper reference or educational materials can be left with the patient.
- Upon arrival to home:
- Don PPE outside of home
- Double glove
- Place bag and supplies on a disposable pad. Open a large disinfecting wipe to wipe down each piece of equipment as it is used.
- Do not sit down inside the home
- Try to assess patient in a separate room from family members
- Respiratory status at rest and with exertion (RR, work of breathing, Sp02)
- Review and reconcile meds
- Collect labs
- Provide COVID-19 education to patient and family
- When to involve MD for consultation: Utilize phone or tele-visit
- SpO2 <92% at rest or <90% with ambulation
- RR >30 breaths/min
- CP assessment and intuition that patient’s overall clinical status is declining
- New findings/signs/symptoms that are concerning
- Determining if patient is able to be maintained at home or needs to be seen in ER
*** Be aware of cross contamination. Do not rush as this is when errors can happen.
- Take a picture of your notes prior to leaving home if using secure device. This helps in case there is any smudging or rain outside.
- Doff outside of the home or apartment. At the end of doffing, take off first set of gloves and throw in the bag with other PPE. Then continue cleaning your equipment with the second set.
- Place everything in a bio bag with top tied closed. Discard in patient’s garbage if possible.
- Wash hands well before getting into your vehicle to leave.
Extra Tips & Tricks
- If you are using an interpreter by phone, be sure to let them know you will be wearing layers of PPE and check that they can hear you clearly. It is ok to repeat yourself and confirm understanding.
- Rain and inclement weather can make donning and doffing challenging. Having a vehicle with a hatchback is helpful as it gives you a place to stand under and also working space for donning and doffing.
- Try to don & doff in an inconspicuous place (garage, between your vehicle and the home, behind your vehicle in the driveway), if possible.
- Mask fogging can be frustrating. Use of alcohol preps to clean reusable goggles and shields can help, as well as anti-fogging treatment for your glasses. Make sure your mask is tight across the bridge of your nose and cheeks.
- If you feel you will need to use your phone for a tele-visit, you can cover it in plastic wrap and it will still work. Remember to also wipe it down afterward.
- Don’t forget to use sanitizer on your gloved hands for cross contamination precautions. Look for sanitizers that will dry well over your gloves. We find that the foam sanitizer dries the best.