Virtual wards: caring for COVID-19 patients at home could save lives

Do you own an oximeter? If so, do you know how and when to use it? It could save your life.

COVID-19 has killed at least 60,000 people in the UK. Many who die have a sudden drop in their blood oxygen levels a day or two before their lungs fail. Unlike in many other chest diseases (asthma, for example), COVID-19 can cause a severe drop in blood oxygen level without any associated breathlessness.

Because of this, people with this “silent hypoxia” are unlikely to seek the urgent help they need, unless they regularly measure their blood oxygen level or their condition deteriorates. If they realise something is wrong, they may reach hospital just in time to receive oxygen therapy (and, if necessary, ventilation). Others are admitted too late to save – or die at home.

The blood oxygen level is one of the strongest predictors of death in COVID-19, and early oxygen improves survival. So it’s time to learn to measure yours and to know what to do if it’s low.

Oxygen is carried in the blood attached to haemoglobin (the large, iron-containing protein that makes blood red). Haemoglobin exists in two forms – oxygenated and deoxygenated – which reflect light slightly differently. An oximeter works by bouncing a beam of light against blood vessels close to the skin, typically in a fingertip, and using the reflected light to estimate the proportion of oxygenated to total haemoglobin.

To measure your blood oxygen level, turn on the oximeter and clip it on a warm fingertip (one without nail varnish). Wait five minutes until the reading has stabilised. Record the result and the time (either on paper or using an app).

You can buy an oximeter online for £15-£35 – though if you live in England, you may not need to because NHS England has just purchased 200,000 of them for distribution to eligible NHS patients as part of a new model of care.

Virtual ward

If you’re sick enough to be using an oximeter, you may not be thinking clearly. That’s why it’s best to share your oximeter readings with a healthcare professional. This is the rationale behind this new model of care called the “virtual ward”: a system for supporting patients using home oximeters through phone or video calls. The aim of the virtual ward is twofold: to fast-track you to hospital if you need to be there, and to keep you out of hospital if you don’t.

If you are a patient on a virtual ward, you’ll be given an oximeter and shown how to use it. You’ll also be asked to record your pulse, temperature and symptoms, such as breathlessness. A health professional will phone you to check these readings every day – more often if you need it.

You will be asked to take your pulse, temperature and report symptoms, such as breathlessness. Denis Prokofev/Shutterstock

Virtual ward decisions aren’t made purely on the basis of a one-off oximeter reading, but on the trend over time and associated symptoms. Generally, if your oximeter reading is 95% or above, you will probably be reassured. If it’s between 94% and 93% and there isn’t another explanation for this (cold hands being the most likely), you’ll be closely monitored and perhaps invited to come to a centre such as a “hot hub” to be examined.

If it’s 92% or lower, and especially if the trajectory is going down and you are unwell, there’s a high chance you’ll be sent to hospital. You should be given written instructions for what do to if you deteriorate in between calls (for example, call 111, call 999 or go to your local accident and emergency department).

While technical enthusiasts talk about electronic dashboards and automated safety alerts based on trends in Bluetooth-delivered oximeter data, the reality is that most patients record their readings on paper and discuss them with a doctor or nurse in an ordinary phone call. Human contact can be particularly important if your oximeter readings, rather than reassuring you, are making you more anxious.

Virtual wards (of various kinds) are up and running in many countries. But whether you can get on one depends on the arrangement where you live, and if one has been established yet. In some areas, virtual wards are used mainly for pre-hospital care (for example, your GP may refer you to one). In other areas, they are used mainly for “step-down care” (after you’ve been an inpatient, or assessed at, a hospital).

While oximeters on their own don’t save lives, good clinical care within a well-designed service may. The mortality rate of patients cared for on virtual wards in England to date is 1%-2%.

Research is ongoing to refine the virtual ward model, including establishing the best and most cost-effective way of monitoring people who are deteriorating, and the optimum cut-off levels for accepting people into the virtual ward and fast-tracking people to hospital. To avoid digital inequalities, we also need to work out how best to support people with COVID-19 who are either unable or unwilling to use an oximeter.

1. Cecilia Vindrola

   Senior Research Fellow, Applied Health Research, UCL

2.  Naomi Fulop

3. Chair Professor, Health Care Organisation and Management, UCL 

4. Trish Greenhalgh

5. Professor of Primary Care Health Sciences, University of Oxford 

6. https://theconversation.com/virtual-wards-caring-for-covid-19-patients-at-home-could-save-lives-149292
   

Cuomo to deploy National Guard to NY airports for COVID enforcement as infections rise

National Guard troops will be deployed to New York airports to make sure arriving travelers have proof of recently testing negative for COVID-19, Gov. Cuomo said Friday.

The deployment follows a sweeping new entry test policy announced a week ago after the Empire State abandoned its travel advisory that mandated travelers from coronavirus hotspots quarantine for two weeks

“I want people to know we’re serious," the governor said during a conference call with reporters. “You should not land if you do not have proof of a negative test upon landing,"

Airlines, the NYPD and the Port Authority are assisting with the effort.

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Under the current rules, travelers arriving without proof of a negative test won’t be stopped from entering the state, but must quarantine for 14 days. Individuals who can prove they tested negative will still have to quarantine for three days upon arrival in New York and then must take a second test. If that’s negative, they no longer have to self-isolate.

If a test comes back positive, local health officials will issue isolation orders and initiate contact tracing to identify and quarantine other people exposed to the virus. Anyone caught violating a quarantine order could face a civil penalty of up to $10,000. The testing mandate does not apply to neighboring states.

The governor also announced Friday that COVID-19 restrictions will be lifted in some city “hot spots” while noting that the state’s overall positivity rate ticked up to 1.9% as cases continue to skyrocket across the country and Mayor de Blasio warned that New York City is “now really threatened with a second wave” of the pandemic.

The city’s daily COVID-19 count climbed by 702 cases Friday, de Blasio said, and the daily infection rate in the five boroughs is now 1.81% with a seven-day average rate of 1.96%.

“Not good,” the mayor told WNYC’s Brian Lehrer. “That’s a problem. That says that we are now really threatened with a second wave in New York City if we don’t quickly get a handle on this. And that says that we really need to emphasize the mask-wearing, the social distancing, avoiding gatherings and, sadly, avoiding travel and large family gatherings for the holidays."

De Blasio also said he would resume the city’s release of coronavirus data by zip code next week to help parents make a decision on whether they want their kids in remote or blended model learning.

The city opened a two-week window this week for parents of students who are currently enrolled in fully remote learning to opt into the hybrid curriculum.

https://www.nydailynews.com/coronavirus/ny-coronavirus-cuomo-national-guard-20201106-aydjip7mzvfxfbljyl4gkjogka-story.html

House Leaders Pan HHS Rule Review Proposal

The proposed rule from the Department of Health and Human Services (HHS) that could potentially wipe away hundreds of health and food safety regulations is "radical" and is a reflection of the Trump administration's "disdain for science and governance," House Speaker Nancy Pelosi (D-Calif.) said Friday.

"This 'lame duck' Trump rule seeks to paralyze government and generations of life-saving protections and tries to burden a new president elected by the American people right out of the gate," Pelosi said during a press conference, adding that the administration may also try to put similar rules in place at other agencies.

"We do believe that regulations should be subject to review -- that's part of the process. But there is a way to do it -- and the way to do it is not to first zero in on the FDA at a time when we're trying to achieve a vaccine for the people." The FDA's regulations, including those relating to the drug and vaccine approval process, would be among those that HHS could look at.

A Diversion of Resources

Under the proposed rule, the department will review each of its regulations -- with some exceptions -- every 10 years. Those regulations that are currently more than 10 years old must be reviewed within 2 years of the enactment of the proposed rule; regulations that aren't reviewed during that time will expire, Harrison said.

In other words, any older rules that HHS fails to review during the 2-year window would simply vanish from the Code of Federal Regulations.

Exceptions to the review requirement include regulations that are jointly issued with other agencies, those that legally cannot be rescinded, and those issued with respect to a military or foreign affairs function or addressed solely to internal management or personnel matters. A 30-day comment period began Wednesday for most of the rule, though a few parts have 60-day periods.

In addition to the other concerns raised by the proposed rule, which was announced on Wednesday, "it also diverts resources," said Rep. Frank Pallone (D-N.J.), chairman of the House Energy & Commerce Committee, who also spoke at the press conference.

"If the staff working to crush the virus has to be diverted to justify and spend time dealing with regulations they would not want to sunset, it's a question of staff time that takes away from our ability to actually deal with the virus," he said.

He noted that the comment period for parts of the rule closes on Dec. 4, so the rule could be finalized as soon as early December and the president "could put it in place and start this whole process to undermine not only regulations that are now over 10 years old, but others that might become 10 years old later, during a Biden administration."

Executive Order on Civil Service Panned

Experts also have questioned whether the rule may violate the Administrative Procedures Act, which requires that any rule that is substantially changed must go through a notice and comment period. In addition, they say that 2 years is an extremely tight time frame to try to review the 2,480 rules that HHS said it would have to review during that period.

Pelosi and Pallone also criticized the president's Oct. 21 executive order creating a new class of civil service employee. "This includes people at the FDA and CDC and basically says over the next month or so, the president and his administration are going to put out a new schedule classifying career civil servants -- for example, somebody like Dr. Fauci -- essentially as non-civil-service employees who could be fired," said Pallone, noting that Trump has suggested he might fire Fauci after the election.

"Dr. Fauci is an example of the type of person who could be fired under this executive order, and possibly be replaced by people like Dr. Atlas who are not qualified to actually deal with this virus effectively because of their lack of background or their policies -- and all of this before he leaves office on January 19th," Pallone said.

"Some have said, 'Is he really going to fire these people?' I don't know, but the very fact this is in place is a threat," Pallone continued. "It's either 'I'm going to fire them' or 'I'm going to threaten them with the fact that if they speak out and do things contrary to what I want to do with regard to COVID-19, they'll know they might lose their civil service job,' which is really basically the same thing."

"Civil service is a very important part of democracy," said Pelosi. "It takes the politics out of the performance of civil service.... But if those civil servants are directed by certain political appointees to make certain scientific decisions or they'll lose their jobs, that undermines the purpose of safety and efficacy in term of the FDA but also the health and well-being of the American people."

She added that the executive order can be undone, "but it takes a great deal of time and effort to undo."

Call to "Crush the Virus"

"Why is the president doing things to undermine the ability to crush the virus, rather than working with the speaker and trying to put together a plan like the HEROES Act that would make a difference and actually effectively crush the virus?" Pallone said. "We need the scientists and we need the public health experts. We need to scale up testing, contact tracing, and treatment."

"Unfortunately, this is likely to be a dark winter, and it just doesn't make any sense for the president to use the short time he has left to undermine the national response, and it's also an insult to the civil servants," he added.

"And one thing we're certainly going to do is spend our time at Energy & Commerce and the other committees trying to shore up these agencies like HHS and CDC and FDA that he has been trying to dismantle for the last 4 years. Morale is very low, but I want everyone who works at these agencies to know that we as Democrats -- we're on their side," Pallone said. "We're committed to crushing this virus, and we're going to support public servants ... We're going to work to ensure civil service protections remain in place and we have a national response."

https://www.medpagetoday.com/publichealthpolicy/healthpolicy/89539

Big box stores called top source of COVID-19 spread in El Paso

With repeated high numbers of new coronavirus cases being reported in the Sun City, El Paso city leaders said they’re doing as much as they can to work with one of the top reported sources of the spread: big box stores.

Despite a recent mishap of more 3,000 cases being reported on Wednesday, city leaders are still raising awareness of where the virus is mostly infecting the community and sharing how it’s being handled.

“Shopping in El Paso, given our culture and our nature, is a family event. We have stressed and said please. Don’t take your family to go shopping if you can do it with one person,” Mayor Dee Margo said during a news conference on Thursday.

Margo said contact tracing data has been continuing to show big box stores as the leading source of where the virus has been infecting community members. “The main retailers — the Walmart, Target, Home Depot, Lowes — and all those fall under federal guidelines. As determined by Homeland Security, we have no legal oversight control over any limitations to those stores.”

Although the city cannot overstep these company’s current measures, Margo shared that the request to take more action has already been made. “So what we have done is my office has reached out to corporate at Walmart, Target and all of the major big box retailers, and ask that they take proactive action to try and limit the occupancies in their various stores. So far as what I recall, the feedback has been positive.”

Some big retailers in El Paso have already chosen to temporarily shut their doors to the public in efforts of further sanitizing the stores to keep shoppers and the community safe.

“They do notify us to let us know if they are closing the stores, so they are rotating. They’re closing them one at a time. They close on a day and then they open at 6 a.m. two days later. So again, the closings have no public health orders or implications up to now,” said Angela Mora, director of the El Paso Department of Public Health.

The Mayor added that family gatherings are also a big reason for the ongoing spread in El Paso, and said it’s very similar to what was happening during the high spread of COVID-19 in the Rio Grande Valley. Margo said that it’s imperative for El Pasoans to stop having mass gatherings.

https://www.ktsm.com/news/big-box-stores-top-source-of-covid-19-spread-in-el-paso-officials-say/