Home and Outpatient Management

Household Assessment and PreparationCopy Link!

Updated Date: December 20, 2020
Literature Review (Ambulatory Management):
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Whether or not a patient is clinically well enough to be managed at home is addressed in:

  1. Acuity Triage
  2. Disease Severity and Disposition

Providers should then evaluate if the patient can safely isolate at home for the full duration of isolation:

  1. Home Assessment and Education: Review the requirements for home isolation with the patient. If possible, a healthcare or community health worker should have the patient talk them through the procedures in the patient’s particular environment/home and do a verbal walk through (or video call) of the place where they are isolating in order to ensure a safe environment.
  • For additional information on masks, social distancing, pets, and more see Transmission
  1. Communication: The patient and family should be provided with clear instructions of what to do and who to call if the condition worsens (see When to Seek Care).
  2. Caretakers, proxies, and goals of care: For all patients with COVID, it’s important to identify a single person who can be the primary caretaker at home. You should engage the patient in a goals of care conversation and have them designate someone to make decisions for them if they are unable to make decisions for themself (regardless of age, comorbidity, or severity). See Discussing Goals of Care. Caretakers should be trained in methods for masking, distancing, hand hygiene, and cleaning surfaces (see Transmission Prevention).
  3. Resources: Assess for and provide home care kits including food support, hygiene and cleaning supplies such as chlorine and soap and individual patient items such as plate, utensil, blanket and mask. Social/economic support, including food supplementation is critical and should be delivered in a way that is in line with infection prevention.
  4. Psychological support: See Psychosocial Support for information on mental health and psychological support.
  5. Close contacts: All symptomatic contacts should be tested and Quarantined. Depending on local epidemiology and practices, some places recommend that asymptomatic contacts also be tested(see COVID Exposures) and engage a contact tracing team where relevant.

Followup and MonitoringCopy Link!

Updated Date: December 20, 2020

Follow-Up Visit ScheduleCopy Link!

Patients on outpatient isolation or post-hospitalization require followup visits based on risk level. These visits can be performed virtually if possible (by phone, or by video). In some places, community health workers may conduct these visits physically at the home if unable to connect via phone or video.

If community health workers or clinicians conduct home visits, they should have:

  • Adequate PPE. If PPE is not available, conduct the visit outside the home (rather than entering) maintaining a distance of at least 2 meters.
  • Clear refer patients to a different clinician or a higher level of care if needed.

Tool: PIH COVID-19 Patient Intake and Symptoms Screening Data Collection Forms
Tool: BWH Telephone and Video Visit Tips
Literature Review (Virtual Care):
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Suggested Home or Phone Visit FrequencyCopy Link!

Community Health Workers:

  • For patients at low risk of complications: Visit every 2-3 days in person (or via phone or video if available).
  • For patients at high risk of complications: Visit every 1-2 days in person (or via phone or video if available). If the patient has any danger signs contact the health facility via phone or refer/accompany to the health facility.
  • After hospital discharge: Visit within 3 days of discharge (or via phone or video if available) unless the patient will return to the facility for follow up.

Clinicians:

  • For patients at low risk of complications: Day 5 of symptoms via phone or video if available (in-person if not)
  • For patients at high risk of complications: age>60, COPD, hypertension, diabetes, cardiovascular disease, chronic kidney disease, liver disease, obesity, immune deficiency or immunosuppression Days 4, 7, and 10 of symptoms by phone or video, more frequently or in-person if needed (see Acuity Triage to determine if your patient should be seen in person).
  • After hospital discharge follow-up: 2 days

When to Seek CareCopy Link!

Patients should call a healthcare provider or report to a facility if any of the following danger signs develop:

COVID-19 Danger Signs

  • Difficulty in breathing/Shortness of breath
  • Bluish lips or face
  • Gasping for air when speaking
  • Coughing up blood
  • Pain/pressure in chest (NOT associated with coughing)
  • Altered mental status (e.g. confused or severe sleepiness)
  • Inability to eat/drink or walk
  • Any other significant change in condition

Pulse OximetryCopy Link!

Literature Review: Gallery View, Grid View

Why use home oximetry: If patients or community health workers have access to pulse oximetry, this can be a helpful adjunct to symptom monitoring, since hypoxemia out of proportion to respiratory effort has been seen in patients with COVID-19. Home pulse oximetry can also be used in conjunction with awake proning.

  • One prospective cohort study gave pulse oximeters to 77 ED or testing site patients suspected of having COVID-19 (42% with no comorbidities) and told them to measure their O2 sat three times daily and return to the ER if it dropped to <92%. This occurred for 19 patients, and of the 17 who returned to the ER, 8 returned solely because of the oxygen saturation, and 16/17 required admission. Resting home SpO2 < 92% was significantly associated with hospitalization (RR = 7.0, 95% CI = 3.4 to 14.5), ICU admission (RR = 9.8, 95% CI = 2.2 to 44.6), ARDS (RR = 8.2, 95% CI = 1.7 to 38.7), and septic shock (RR = 6.6, 95% CI = 1.3 to 32.9) (Shah et al).

How to use pulse oximeters:

  1. A caution on reliability: Pulse oximeters are less reliable in people with darker skin tones, and may read artificially high. One study showed that pulse oximetry failed to correctly identify 11.7% of black patients with Sp02 of <88% on ABG, relative to only 3.6% of white patients (Sjoding et al). They also may not work properly in patients with blood flow abnormalities in their hands such as peripheral vascular disease or Raynaud’s syndrome (Luks et al).
  1. SpO2 trending may be more reliable than a single value (i.e. baseline 100%, now at 94%) and using dynamic measures like ambulatory saturations can help identify patients who are at risk for decompensation.
  1. How to use oximeters: Have patient’s check their saturations at home at least daily and as-needed for clinical worsening. They should take one measure while sitting and one measure while ambulating (or marching in place if they are quarantined in a small area). Instruct patients to seek care if Sp02≤94% or ≤ 92% with exertion.
  1. Use the pulse oximeter on a finger without nail polish or nail abnormalities. Hands should ideally be warm and relaxed.
  2. Wait at least 20 seconds for sampling time as the Sp02 displayed is generally the average of the last 10-15 seconds
  3. If the pulse oximeter has a visible waveform (plethysmograph), the shape should show a regular rise and fall (corresponding with the pulse) when the machine is reading correctly. If the machine is not giving a reliable reading (not registering, number not steady, number very low), try it on a different finger.

Tool: How to Use Home Pulse Oximetry

Management of Mild DiseaseCopy Link!

Updated Date: December 20, 2020
Literature Review (Ambulatory Management):
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Medical TreatmentsCopy Link!

Treatment for COVID-19 for patients with mild disease is largely supportive. A small number of places may have antibody therapies available for outpatients.

Please see Overview of Treatment by Severity of Disease, and Treatments for more details.

Symptomatic Treatments:

COVID Treatments:

  • Antibody Therapies (monoclonal antibodies, convalescent plasma)
  • Thrombosis prevention is generally not used for outpatients

Management of Existing Medications. Medications should not be discontinued without discussing with the prescriber.

Medications we DO NOT Recommend:

Vaccinations:

  • Influenza vaccination: Recommended for all patients for whom there is not a contraindication.
  • Pneumonia vaccinations: these should be given to patients who meet criteria.
  • Please note: As SARS-CoV2 vaccines become available, present guidelines do not recommend administering them to patients with acute COVID-19 (see CDC guidance).

Non-Medical TreatmentsCopy Link!

Self-proning

  • The Awake Prone position improves dyspnea and hypoxemia in some patients with severe COVID-19 illness. Proning could be used while awaiting ambulance transfer to a health facility or as part of terminal palliation.

Psychological and social support

Referral for AdmissionCopy Link!

Patients should be referred for in-person evaluation if they develop any of the danger signs above, rapidly escalating symptoms, Sp02 below 94%, or moderate to severe dyspnea.

Where to send your patient? See Acuity Triage

Inpatient treatments to be aware of: Ambulatory providers should be aware of inpatient therapies so they can refer/admit patients appropriately.

Home Oxygen CareCopy Link!

Updated Date: January 7, 2021

This section is in processPatients who require oxygen for COVID pneumonia should be cared for in a health-care facility where possible, however capacity constraints and the long course of recovery make this impossible in some circumstances. The decision to offer home oxygen therapy is complex, and should be made by a certified provider familiar with the patient’s clinical condition, resources for care at home, proximity to health care facilities, and the availability of home oxygen delivery.

This section provides a framework for providers to use when considering this treatment plan as an option for certain patients when facility-based oxygen delivery is not available. The framework below is based on published literature and an ongoing home oxygen program developed for COVID19 care in the rural United States by providers from Gallup Indian Medical Center (GIMC).

Patient SelectionCopy Link!

Patient medical selection criteria:

  1. COVID-19 diagnosis established or strongly suspected with low suspicion for alternate diagnosis
  2. Hypoxia at rest or with ambulation (O2 sat < 90% on room air)
  3. Ideally, an oxygen requirement of < 2LPM NC is needed to achieve O2 saturation (SpO2) of > 92% at rest AND > 90% with exertion
  4. Stable or improving clinical trajectory. Discharging patients with hypoxia without an observation period of 48 hours is high risk, and this is better suited to stable inpatients ready for discharge.
  1. The patient’s vital signs have normalized after addition of supplemental O2 and other clinical interventions (e.g. antipyretics and fluids)
  2. 4C Mortality Score < 9
  1. Lower risk for decompensation:
  1. In outpatients: mild severity risk features/comorbidities (See: Table 1 Sardesai et al)
  2. In inpatients: mild or moderate risk features AND stability over 48 hours of observation (See: Table 1 Sardesai et al)
  1. Patients with the following risk factors may be higher risk and not ideal candidates (Age>65, BMI>40, chronic kidney disease, liver disease, immunocompromised, diabetes, hypertension, obstructive lung disease)

Patient home-care ability selection criteria:

  1. Ability to demonstrate understanding of the risks and benefits of this discharge plan. Confusion and pre-existing cognitive impairment are absolute contraindications to discharge with home oxygen. See Capacity Assessment.
  2. Ability to use and troubleshoot pulse oximeter
  3. Ability to use and troubleshoot supplemental oxygen equipment
  4. Ability to engage in telephone (or community health worker) contact follow up (i.e. reliable phone service, language services, hearing or speech impairment does not necessarily preclude communication).
  5. Ability to Isolate Safely at Home.
  1. Household members do not have high risk comorbidities and can practice safe personal protective measures
  1. Reliable power source, if discharging with home concentrator
  2. Reliable transport or plan to provide transportation resources to medical care if the patient needs to be re-evaluated (including distance, weather, or road conditions between home and hospital)

Institutional criteria:

  1. No inpatient bed is available
  2. A provider determines the home oxygen discharge plan is safe
  3. The patient has appropriate supply of oxygen (see calculator Tool and discussion below)

Tool: Determination of Eligibility for Short-Term Home O2
Resource: Home Care for Patients with Suspected or Confirmed COVID-19 by WHO
Resource: COVID19 Home Based Quality Care by HP+

Oxygen Discharge PlanCopy Link!

Patients must receive oxygen and supporting equipment as well as the instructions for use prior to discharge. They must also be educated in-person on how to use them, and counseled on return precautions using the Teach-Back technique. It is critical to confirm a working phone number for the patient.

Equipment:

  1. Oxygen supply (Cylinders or oxygen concentrators)
  1. Calculate total oxygen need, as not all sources will be able to provide continuous oxygen. Oxygen cylinders may run out too quickly to be practical for home use in patients with high needs
  2. Cylinders:
  1. If using oxygen cylinders, an oxygen conserving (i.e. pulse dose) device may be helpful
  2. Tanks must be secured to avoid potential injury, especially with small children in the household
  1. Oxygen concentrators: Most concentrators have 5 LPM max output, though some can do 10 LPM and very few can do more than 10 LPM. Patients requiring more than 2 LPM should ideally be cared for in a facility, and risks and benefits of home treatment require careful decision-making.
  1. Pulse Oximeter (confirmed working) and instructions on use
  2. Thermometer
  3. Surgical masks to wear over nasal cannula to protect contacts at home
  4. Working phone to conference with providers

Medications:

  1. Patients receiving oxygen should get Corticosteroid Therapy unless contraindicated.
  2. Patients should be discharged with other symptomatic treatments needed. See Medical Treatments for mild disease.

Instructions and education:

  1. Self Proning Handout
  2. Oxygen self titration guidance
  1. Oxygen saturation readings consistently less than 92% on flow rates prescribed at initiation of home oxygen therapy (regardless of symptoms).
  1. Return Precautions:
  1. Return criteria for worsening symptoms and danger signs (see followup)
  2. Handout with instructions specific to the healthcare setting and available resources
  1. Oxygen management instructions
  1. Oxygen Supplier Contact
  2. Phone Number for Help Line
  3. Action plan for equipment failure, low supplies, or power failure
  1. Fire safety plan at home (Table 3 from Sardesai et al)
  2. Plan for food security

Resource: How to Use an Oxygen Concentrator

Tool: Oxygen Supply Calculator and Cylinder Duration Calculator

Tool: Tools for Home Oxygen Therapy

Follow-UpCopy Link!

Below is a sample protocol modified by one developed at GIMC.

For inpatients observed for >48 hours and then discharged on oxygen:

  1. Should be called daily for at least 2 days after discharge
  2. If remaining on 2L or less x 2 days may consider discharge from phone follow-up program, otherwise the same criteria above apply. For those on >2L, follow at least 10 days from oxygen initiation.

For patients sent home on oxygen with < 48 hours of observation (not preferred):

  1. Should be called daily for at least 6 days unless weaned off oxygen sooner
  2. After day 6, patients on 2L or less at rest x 2 days with improving trajectory may be discharged from phone follow-up
  3. After day 10, patients on stable oxygen x 2 days (even if >2L) and an improving trajectory may be considered for discharge
  4. High risk patients may remain in the program longer at provider discretion

Triggers to Consider Sending to ER

  1. Please see Home Acuity Triage. In addition to the danger signs listed there:
  1. O2 sat less than 90% at rest on >3L (depending on local practice)
  2. Increase in oxygen requirement of more than 2L in <24hr
  3. Inability to walk 5 steps without becoming severely short of breath
  4. Resting heart rate over 120 or Respiratory rate >28 at rest
  5. Inability to toilet, eat, or navigate the home using bedside devices

Tool: Provider Note Template for Telephone Follow-up with Home Oxygen Patients

Community Health WorkersCopy Link!

Updated Date: December 20, 2020

While Community Health Workers (CHWs) are in a unique position to help with COVID response, they are also at risk of exposure. Programs that deploy CHWs should consider how COVID will impact their work and assess risk tolerance. This is particularly applicable for CHWs who have frequent patient contact (e.g. routine home visits) and may not have access to PPE. Workflows should be evaluated, and in some instances changed, in order to adequately protect CHWs. This may include measures such as remaining outside and at a distance greater than 2 meters during routine home visits and avoiding activities requiring close physical proximity and/or contact.

Below we outline two strategies for CHW engagement in the fight against COVID. These strategies should be adapted to the local context as well as CHWs’ training, availability, funding, compensation, and access to PPE.

Strategy 1: AdvisingCopy Link!

Most CHWs should be capable of implementing this strategy which does not require them to enter homes, meet in groups, or touch patients.

Intervention

Activities

Community education

Disseminate information, answer questions, encourage social distancing, inform when to seek care. Specific measures could include distributing fliers at houses; village communication using bullhorns; assess potential cases from a distance; distribution of paracetamol and oral rehydration solution generously (i.e. treatment and trust)

Strategy 2: AccompanimentCopy Link!

This requires sufficient funding, staffing, PPE, data systems, and integration with local health systems. Teams should map catchment areas, divide areas, and relay information systematically. Known cases should be communicated with the coordinating authorities.

Intervention

Activities

Case finding

Screening in communities at risk. Some CHWs may also be able to do home testing (see below).

Contact tracing

Tracing contacts and household members of known cases. Following up and assessing for symptoms. Facilitating referral to a facility when necessary.

Home testing

Performing Rapid Tests for contacts or other community members meeting testing criteria (typically a Positive Symptom Screen) may be possible for some CHWs. This depends on training and local regulations. Some tests will be similar to rapid malaria tests (which may require little additional training for CHWs familiar with these tests), and some may be nasal swabs (this may require some additional training).

Home based care

Ensuring understanding of quarantine, hygiene, and distancing protocols. Conducting routine check-ins (at least twice a week) to monitor for worsening symptoms and need for referral to a facility. Facilitating transport when severe cases are identified