Clinical Management of Nonrespiratory Diseases in the COVID-19 Pandemic: What Have We Done and What Needs to Be Done? (Re: Telemed J E Health [Epub ahead of print]; DOI: 10.1089/tmj.2020.0106)
Recently, Omboni1 reiterated how the unexpected arrival of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19),2 has taught us that we no longer have to linger long in a transition to a model of care which considers the full integration of telemedicine services in the armamentarium of health services.
In Italy, the number of cases continues to rise; up to April 28, 2020 there had been 199,470 confirmed SARS-CoV-2 infections and 25,215 deaths.3
Public health efforts in Italy have been geared toward preventing and controlling the disease spread by implementing at the end of February 2020, social distancing, telecommuting, and reducing unnecessary travel. Hospitals dramatically reshaped their structure and capacity to adapt to the increased number of patients with pneumonia and acute respiratory distress syndrome presenting to the emergency room (ER) requiring advanced life support.4,5 Separated triage programs in the ER to avoid contact between positive and negative patients have been implemented, self-presentation to the ER has been discouraged, and finally dedicated COVID-19 wards, often managed by multidisciplinary teams of specialists,6 have been introduced. Outpatients clinics have been remodeled to follow recommendations by experts and scientific societies for patients with coexisting chronic diseases. These recommendations are mostly based on the implementation of telemedicine services and telephone triage systems with the postponement of nonurgent ambulatory visits.7
These measures have allowed Italian hospitals to be able to manage the wave of COVID-19 patients, but have led to reduced delivery of care for patients with coexisting chronic conditions or nonrespiratory acute diseases. Indeed, by cumulatively analyzing two large university hospitals in Milano (Humanitas IRCCS Research Hospital and San Giuseppe Hospital MultiMedica), we noticed that from March 1 to April 15, 2020 the mean number of patients for month admitted to the ER dropped from 7,130 (during December 2019, January and February 2020) to 3,268 (−54%) (Fig. 1). These figures were consistent within the two hospitals (−53% Humanitas IRCCS and −56% San Giuseppe MultiMedica IRCCS) and were largely caused by a drop in neurological, gastrointestinal/liver, and heart diseases. Similarly, the reduction in the outpatient clinical activity led to a 58% reduction in the mean number of visits per month from March 1 to April 15, 2020 (12,986) than those performed in December 2019, January and February 2020 (30,693), with sharp declines among all medical specialties, including neurology, GI/liver, cardiology, and oncology (Fig. 1). Altogether, these findings suggest that thousands of patients with acute and chronic nonrespiratory conditions have not accessed specialist care in the past 2 months in Lombardy. This finding is likely to have two major outcomes in the near future: first an increase in morbidity and mortality rates for nonrespiratory diseases and second the need to increase the capacity of our hospitals once restriction measures are softened or removed. The first point is supported by a recent study in Italy showing that mortality from acute heart attack has almost tripled for late clinical presentation caused by patients avoiding hospitals for fear of SARS-CoV-2 infection.8
Fig. 1. Mean variations in the ER admittances and outpatients visits from March 1 to April 15, 2020 compared with December 2019 and January/February 2020. ER, emergency room; GI, gastrointestinal.
The second point is where we think that our data may be useful as it could provide guidance in retooling our clinical practice in the next months. Indeed, once lockdown rules and travelling bans are reduced/withheld the increased number of flow of patients to the ER and outpatient clinics will likely overwhelm hospital capacity. This is even truer since several nonrespiratory hospital specialists will likely be still involved in managing the remaining COVID-19 wards for several months. Prioritizing outpatient visits based on disease severity in patients with chronic diseases already in regular follow-up could be done through semiautomated artificial intelligence systems to avoid further worsening of the underlying diseases. Patients with mild conditions could, in contrast, be managed outside the hospital by implementing telemedicine and creating networks of general practitioners who can consult with in hospital specialists. To date, the use of telemedicine in Italy is almost limited to a remote exchange of data between patients and health care professionals as part of patients’ management. Examples include the monitoring of blood pressure, peripheral oxygen saturation, and glucose in patients with cardiovascular disease, chronic obstructive pulmonary disease or diabetes, respectively, or for monitoring with heart rate telemetry in home-controlled patients with heart failure.
Telemedicine could be used in the current context to rapidly check on chronic patients to make sure their conditions have not deteriorated in these months of lockdown thus allowing to prioritize visits for some patients. Also given the need for social distancing that will reduce the hospital capacity in the next several months/years, the implementation of telehealth may help patients with chronic diseases in better understanding their health conditions through self-monitoring and motivational tools. Similarly the creation of dedicated in hospital specialized outpatient clinics accessible 7 days a week to manage clinical conditions that have been under-represented in the ER and outpatient activity in March/April 2020 could provide the ER with some needed help in containing the wave of patients and allow patients to rapidly access a specialist.
In conclusion, we think that it is time to concentrate our efforts also on non-COVID-19 patients by analyzing the flow of patients in the ER and outpatients clinic in the past months and designing innovative measures to deliver care for these patients. Telemedicine will be a valid approach to reorganize health care for all our patients.
REFERENCES
- 1. Telemedicine during the COVID-19 in Italy: A missed opportunity? Telemed J E Health 2020; [Epub ahead of print]; DOI:
10.1089/tmj.2020.0106 . Link, Google Scholar - 2. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497–506. Crossref, Medline, Google Scholar
- 3.
Istituto Superiore di Sanità. “COVID-19 epidemic. 2 April 2020 national update” Appendix to the bulletin with a regional breakdown. Available at https://www.epicentro.iss.it/coronavirus/bollettino/Bolletino-sorveglianza-integrataCOVID19_28-aprile-2020_appendix.pdf (last accessedApril 07, 2020 ). Google Scholar - 4. . The response of Milan’s Emergency Medical System to the COVID-19 outbreak in Italy. Lancet 2020;395:e49–e50. Crossref, Medline, Google Scholar
- 5. . Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: Early experience and forecast during an emergency response. JAMA 2020; [Epub ahead of print]; DOI:
10.1001/jama.2020.4031 . Crossref, Google Scholar - 6. Let’s not forget our COVID-19-free cirrhotic patients! Liver Int 2020; [Epub ahead of print]; DOI:
10.1111/liv.14460 . Google Scholar - 7. . Supporting the health care workforce during the COVID-19 global epidemic. JAMA 2020;323:1439–1440. Crossref, Google Scholar
- 8. An in-hospital pathway for acute coronary syndrome patients during the COVID-19 outbreak: Initial experience under real-world suboptimal conditions. Can J Cardiol 2020; [Epub ahead of print]; DOI:
10.1016/j.cjca.2020.04.011 . Crossref, Medline, Google Scholar