New alternatives to acute care no recording
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The document discusses new alternatives to acute care that have emerged due to disruptions caused by the COVID-19 pandemic. These include providing acute care services in outpatient settings through house calls by doctors, delivering care virtually through telemedicine, and creating alternate care sites that mimic hospital care in non-traditional settings like converted hotels. Hospitals at home is also discussed as an alternative that provides hospital-level care to patients in their own homes rather than admitting them, which can lead to better outcomes and lower costs.
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New alternatives to acute care no recording
- 1. New Alternatives to Acute Care MARC EVANS M. ABAT, MD, FPCP, FPCGM Head, Center for Healthy Aging and Section of Geriatrics, The Medical City Clinical Associate Professor, Division of Adult Medicine, Department of Medicine, Philippine General Hospital
- 3. Disruptionin the provision of medical care, especially acute care
- 4. Non-communicable diseases (NCDs) increased morbidity from chronic disease and with higher all-cause mortality •Detrimental health behaviours, such as smoking and reduced physical activity may mediate over 30% of this effect https://blogs.bmj.com/bmj/2020/04/09/the-effects-of- isolation-on-the-physical-and-mental-health-of-older-adults/
- 5. Increased NCD progression •Reduced OPD access •Problems with medication supply access •Fears about going to a healthcare facility •Shifted focus of healthcare resources to COVID-19 care Aging Clin Exp Res. 2020; 32(7): 1189–1194. https://unsdg.un.org/sites/default/files/2020-05/Policy-Brief-The-Impact-of- COVID-19-on-Older-Persons.pdf
- 6. Quarantine and nutrition Change in nutritional habit • Reduced availability • Limited access • Unhealthy food • Psychological factors Weight gain and nutrition loss • Oxidative stress • Inflammation Increased NCD burden • Cardiovascular risk European Journal of Clinical Nutrition volume 74, pages 852–
- 7. Rev Panam Salud Publica. 2020;44:e81.
- 8. Solutions Process Need Provision of acute care alternatives for the outpatient setting Bring the service in person House calls Service delivery at home Provide service on a digital platform Telemedicine
- 9. Solutions Process Need Provision of acute care alternatives in for more serious and unstable patients Mimicking hospital- based care Alternative care settings
- 10. House calls
- 11. PROS Client directly seen at home Less logistical needs EMR leverage CONS Premium service Demands and legalities Risks for HCW and client
- 12. Service delivery at home • Instrumentation (e.g. NGT insertion, foley catheterization, PEG and trachestomy replacement) • IV insertion and drug administration • Nursing services, including wound care • Laboratory, radiology
- 13. PROS Client at home Provision of necessary services Relatively less costly than in- hospital care CONS Premium service Demands and legalities Risks for HCW and client
- 14. Telemedicine
- 16. PROS Client at home Adequate for simple, less toxic or visual medical concerns Less logistical concerns CONS Technology dependent Limitations in physical examination Demands and legalities
- 17. Reducing telemedicine limitations: TELEMEDICINE TECH To enable some degree of physical examination remotely
- 19. USB and mic port electronic stethoscopes
- 20. Electronic, including Bluetooth wireless stethoscopes
- 24. Alternate care sites (ACS) • where patients with [COVID-19] can remain and receive medical care for the duration of their isolation period • non-traditional environments, such as converted hotels or mobile field medical units https://www.cdc.gov/coronavirus/2019-ncov/hcp/alternative-care-sites.html https://westjem.com/articles/alternative-care-sites-an-option-in-disasters.html https://www.cms.gov/files/document/covid-state-local-government-fact-sheet-hospital- alternate-care-sites.pdf
- 25. http://www.bristol.ac.uk/media- library/sites/primaryhealthcare/documents/managing-uncertainity-PDG- evidence-report.pdf • . 5 main types of alternative to acute hospital admission have been identified for people aged 65 years and over: • Interventions initiated by paramedics and other 999 ambulance staff • Alternatives delivered in hospital A&E (Emergency) Departments • Admission to a local community hospital • Hospital-type services delivered in the patient’s own home “hospital at home” • Hospital-type services delivered in a nursing or care home
- 26. https://www.johnshopkinssolutions.com/solution/hospital-at-home/ Hospital at Home •provides hospital-level care in a patient’s home as a full substitute for acute hospital care
- 27. HaH Outcomes • better clinical outcomes: lower rates of mortality, delirium sedative medication use, restraints • Cost savings of 19% to 30% • Lower average length of stay • Fewer lab and diagnostic tests
- 28. Thank you!
Notas del editor
- Good day. I am Dr. Marc Evans Abat. Thank you to the our organization, the Philippine College of Geriatric Medicine for having me over as one of the speakers today. We will be discussing new alternatives in acute care. Although the theme of the convention involves navigating the digital world, we shall include in the discussion options that may be more traditional but relevant nonetheless in this current environment.
- The COVID-19 pandemic has placed the entire world in a huge conundrum, and the Philippines, for the past 1 year and 7 months, has been burdened by the huge challenge of managing this situation. Of course, there are other events that can pose a great concern for our country, including disasters like typhoons, earthquakes, or even armed conflict. In fact, next year will be the Philippine National and Local elections, and honestly, I am greatly concerned as to what kind of promise or even catastrophe this may bring.
- In all of these situations, there is either a localized or a more widespread disruption in the provision of many vital services, especially health care. This includes acute care, wherein patients, especially older persons, will have great difficulties seeking acute medical care for a wide spectrum of conditions, either mild or severe.
- The pandemic has placed the older person in a corner wherein non-communicable diseases, for example, can worsen and have acute decompensation, leading to an increased need for frequent utilization of acute care services, especially in-hospital services. Some of the acute events may be mediated by an increase in detrimental health behaviors like smoking, reduced physical activity and alcoholic beverage excursions. These can eventually lead to unnecessary increased morbidity and mortality.
- Several aspects leading to NCD progression, have been affected by the COVID-19 pandemic. There is reduction in the OPD access, especially for follow-up of patients. It is also related to other challenges like public transportation issues, and granular lockdowns. Income and mobility issues also caused problems in medication supplies. There is still a general fear or concern in going to bigger healthcare facilities due to fear of contracting COVID-19, especially with the dominance of the Delta variant. In many facilities, there is also a shift of resources to manage COVID-19, limiting influx of non-COVID acute patients.
- Part of the unwanted behaviors perpetuated by quarantines and lockdowns, is the change in the nutritional habits of many older persons. There is either a volitional choice of unhealthy food or reduced availability or access to more nutritious food. Psychological factors also trigger unhealthy eating habits. All of these lead to diet-related deterioration in non-communicable diseases.
- There is also an increase in stress and mood disorders among the older population. These can be risk factors for worsening of the NCDs, increased morbidity and mortality.
- There is therefore a need to provide acute care service alternatives for the outpatient setting. The processes should either bring the acute care services to the patient, or provide a consultation service using a digital platform. For the 1st process, solutions can be either house calls or service delivery at home. For the 2nd process, the solution is telemedicine.
- Obviously, in the previous slide, these services are ideal only for mild and stable acute needs, or for monitoring of health parameters like blood sugar control. For more serious and unstable patients, there should be alternatives that mimic hospital-based care. These solutions are lumped together under alternative care settings.
- House calls used to be a regular physician practice in the older days. When I was a child, I remember several doctors who visit us in the house for our medical needs, especially for my grandmother. Currently, there is a resurgence of this practice in many countries, including here in the Philippines, and mainly targets the older person who benefits from this service the most. Basically, a physician is contracted to go to the house of the older person on a scheduled day and time. During this COVID-19 pandemic, this process has become complicated in terms of the need for PPE and modification of processes to reduce the possibility of transmission of COVID-19
- There are certain advantages to house calls. The patient is seen personally at home, and the consultation process is similar as if the patient went to the clinic of the physician. There is less logistical needs for the older person, who does not need to prepared and transported outside the house. It is especially advantageous if this older person is bedridden. In certain situations where the patient is a long-term patient of a healthcare facility with an EMR that is accessible remotely, this asset can leverage the availability of healthcare information of the patient for the physician. There are some drawbacks however. House calls are premium services, and entails higher costs for the patient and family. This comes out usually as out-of-pocket expense in most situations. Here in the Philippines, local HMOs will not compensate the house call. Some foreign insurance policies are available to reimburse the family for these expenses. There are also certain demands and legal concerns that the house call raises. Some families expect the healthcare information leverage if their primary physician and the house call doctor are from the same institution, despite the fact that the information exchange most of the time does not happen due to logistic concerns between the physicians. As with any health consultation, documentation and confidentiality is a must. There are also safety concerns for both the patient and the physician. The physician should ensure that adequate PPE should be worn to avoid acquiring or transmitting COVID-19. The reality of the current situation is that the health care worker also has uncertainties about the COVID-19 status of the older patient. The patient or the family should ensure full disclosure of symptoms prior to the consultation, and if needed, provide documentation of COVID-19 status with an RTPCR result. Aside from the COVID-19 concerns, there are also other safety issues, like safety and security concerns going to and from the patient.
- Service delivery at home comes in several forms and can be provided by other healthcare workers like nurses, laboratory or radiology staff, although the more complicated procedures are still provided by physicians. These services include instrumentation like NGT and foley catheter insertion, PEG and tracheostomy replacement; IV insertion and drug administration, nursing services like wound care or nursing shift work, specimen collection for laboratory tests and radiology procedures like x-ray or ultrasound. All of these are in conjunction with consultations with the primary physician either by house call or telemedicine.
- There are advantages with service delivery at home. Again it is done at the convenience of home with less logistical requirements on the part of the patient. Services that may be considered as hospital-level, like wound care, PEG or tracheostomy replacement, can be done at home and at lower cost. Similar to house calls, this is a premium service with similar nuisances as previously discussed. The demands and legalities are also similar but adds on a layer of complication by doing instrumentation and procedures. The risks for the HCW and client, COVID-19-related or otherwise, are also similar.
- Telemedicine has been pushed into mainstream by the COVID-19 pandemic but has already been practiced by many physicians in their own capacity, particularly by many geriatricians. Basically, a consultation between the physician and the patient and/or family happens digitally, with a spatial separation. The digital platform may vary depending on the depth of the consultation.
- elemedicine can happen using several platforms. Simple concerns like monitoring of blood sugar and blood pressure with minor adjustments in medications, can be facilitated thru SMS consultations. This is usually for long-time patients who are stable with no other symptoms or concerns, and who are in a close fiduciary relationship with their physicians. Typical teleconsultations can happen via direct video calls using videocall applications like Viber or Telegram. This usually happens if the physician has a dedicated phone number for patients, and prefers the convenience of a direct video call for the teleconsultation. For other physicians, the use of teleconferencing applications like Zoom provides the advantages of not giving out any phone number, and hence, all consultations are strictly scheduled. It also enables simultaneous family conferencing or multidisciplinary conferences. Finally for physicians who want the benefits of a virtual clinic complete with the telemedicine app, EMR, and clinic scheduling, there are several platforms available, where physicians can subscribe to the service and the platforms provides for the marketing of the clinic, patient scheduling, the actual teleconference, EMR, billing and payment of the patients. SeriousMD is an example of this platform
- Again, there is obvious convenience and safety for the patient in doing telemedicine, similar to previously discussed. Telemedicine may be adequate for relatively simple, less toxic or visual medical concerns. However, telemedicine is technology dependent, and older patients (and sometimes younger patients) have to be adept in using their gadgets. There may be a need for younger relatives to assist the older person during the telemedicine process. Since there is physical separation between the doctor and the patient, or there may be no one on the patient’s end to do physical examination, the teleconsultation is mostly limited by the lack of auscultatory or tactile examination of the patient. Even visual examination is limited by the 2-dimensional aspect of the video being seen by the physician. There are also lighting issues that may affect the images or videos being seen by the doctor. These limitations may possibly expose the physician to legal concerns after the consultation, aside from the other aspects that we have discussed earlier. Documentation and confidentiality are ever-present concerns. It has been posited that even simple SMS consultations should be documented by either taking the picture of the entire SMS on the phone, printing the images and inserting these in the patient chart. Recording of meetings with consent of all those participating is another method forwarded for proper documentation of these proceedings.
- There are several ways to mitigate or reduce the limitations of telemedicine, especially the limitation of physical examination maneuvers that can be done. Technology has provided some advancements in facilitation examination of the patient and electronically sending these information to the physician on the other end.
- Many consumer healthcare gadgets have been available and constantly becoming more advanced and affordable. The electronic BP monitor has drastically lowered the learning curve in monitoring a patient’s blood pressure. Thermometers have various degrees of complexity and accuracy. The mercurial thermometer has been replaced already by electronic owns. Infrared skin thermometers are also available, although there are issues with its concordance with core body temperature. Tympanic thermometers have been available for measurement of temperature readings that are more correlated with core body temperature. Pulse oximeters have become so much more affordable since around 2002, when it was initially sold for 10,000php; now it can be bought for < 1000 php. There are single channel handheld cardiac monitors that can help in monitoring the cardiac rhythm. It can be as simple as the gadgets sold for around 2000+php and gives you the cardiac rhythm from their screens. There are also small, US FDA Approved ECG sensors paired with the smart phone, Once paire with the smart phone, your cardiac rhythm will be recorded on the phone and given a preliminary rhythm reading. There are also smartwatches that can monitor the BP using the built-in BP cuff in the watch band. Other “smartwatches” can be bought from Lazada or Shoppee that can measure your heart rate, cardiac rhythm and oxygen saturation. Some can even measure the blood pressure by computing it from the pulse transit time, although there are big concerns about BP measurement accuracy. Information from these gadgets can be sent to the doctor either by texting or sending images or videos of the readings
- There are USB and mic port electronic stethoscopes available that can be attached to your laptop or smartphone and directly provide auscultation findings of the lungs or heart to the doctor. The lung or heart sounds can be recorded and saved in the laptop or smartphone or heard directly in real time using the smartphone or videocall app. Cost is a limiting factor at this point, as prices still range between 400-500 USD. The device also as to be tested and calibrated to ensure consistency and reliability in sound recording.
- Electronic stethoscopes from Littman have been available since around the early 2000s, and they have continued to advance these with their latest CORE line, which can be used with or without the biaural tubes. Other wireless stethoscopes are available which can amplify the sounds being auscultated, record said sounds and can be heard in real time either using wired or Bluetooth earphones. Once recorded, the sound files can be sent to the doctor for evaluation. The main concern her is the cost. The Littman CORE models range around the 17,000php range or more. The ThinkLabs One model is around 26,000 php. The Stemoscope is around 4000+php with the PRO version at around 7500++php.
- There are many enthusiasts out there (myself included) who are trying to come up with a cheap and reliable DIY electronic stethoscope. These can be made from readily-available components like simple stethoscopes, headsets or microphones. Some have also opted to make their own stethoscope bells from materials like plastic bottles. There are those who used their DIY stethoscopes with AI-based software that they have developed to help with preliminary interpretation of the sounds auscultated. Some modifications to the basic concept include adding pre-amplifiers to boost the sound coming of the DIY stethoscope. These need to be validated by clinicians for regular patient use.
- Multiparameter telemedicine gadgets are able to do several physical examination maneuvers. The TytoCare Medical Exam kit includes the main device with the camera and thermometer, and otoscope, stethoscope and tongue depressor attachments. This is a US-FDA approved device that costs 300 USD. There are more comprehensive clinical grade telemedicine stations. The RxBox of the UP Telehealth Center is the 3rd image. It was conceptualized to assist the Doctors To The Barrios program by providing a comprehensive device to assist diagnosis and monitoring in far flung areas. It contains an ECG, BP monitor, pulse oximeter, tocometer, all connected to a central computer. There is also the InTouch Vita, a telepresence robot. In addition to letting specialists advise colleagues and engage with patients and doctors and nurses, it can be used to access recorded information via data ports and can be connected to ultrasound imaging machines, digital stethoscopes, and more. Drones have also been utilized as a telemedicine extension, mainly by helping deliver telemedicine gadgets to areas that need them, enabling patients to be seen by telemedicine, then the devices are brought back by the drones to their respective owners.
- In all of these technologies, accuracy, efficacy and reliability is balanced by the cost of buying the gadget, ease of use, availability and maintenance. For purposes of telemedicine in the Philippines, it may be difficult or less practical for many patients to buy the tried and tested devices for telemedicine. If what is focused on is the problem of doing auscultation of the lungs and heart, the most feasible thing is to find a cheap but effective DIY stethoscope for patients to use. But there is a need to validate the DIY stethoscopes, as different DIYs may yield different results. Some families may have a means to procure some of the relatively cheaper options like Stemoscope.
- Although the theme of the convention is mainly navigating the digital world, there are some issues or events that necessitate thinking outside the box and going beyond technological limitations. The concept of alternate care sites have been in place for several decades, and have been activated recently because the COVID-19 pandemic. It basically involves the use of non-traditional environments for the provision of different levels and models of care.
- Several models have been identified as alternative to acute hospital admission. The 1st 2 options may be obviated by house calls. The 3rd option may be an alternative if there is not need for ventilatory support or ICU-level care. The 4th and 5th options are viable options if house calls and service delivery are availed and combined optimally.
- Combining house calls and service delivery to provide hospital-level care at home as a substitute, is already rapidly gaining favor for many families, especially during this pandemic where many hospitals have no vacancies for both COVID and non-COVID admissions. The intent is to try to provide hospital level care at home, but with a reasonable recognition and acceptance of the limitations of this setup also.
- Generally there are benefits of doing Hospital at Home for many older patients. better clinical outcomes: lower rates of mortality, delirium sedative medication use, restraints Cost savings of 19% to 30% Lower average length of stay Fewer lab and diagnostic tests