Pathway for patients needing post-hospital discharge monitoring in Ontario

For patients with COVID who are still on O2 but can safely leave hospital and continue to recover at home with care and monitoring by primary care providers. The same HFAM primary care COVID monitoring and management pathway and system is used with a few additional pieces.

  1. Monitor patients as for the Current COVID High Risk category with the same attention to change in symptoms, change in vitals including O2 saturation, and hydration concerns.
  2. In addition current oxygen flow requirements should be noted at each check-in to monitor deterioration (i.e., increasing oxygen requirements to maintain O2 saturations in target range of 92 to 96%).
  3. Ensure all patients have received information with safety net instructions. See the Management tab below for detailed information and a pdf that can be emailed to patients.

EMR templates for monitoring can be found here.

See information on Monitoring and Follow-up and Management below.

  1. Confirm date of first symptoms (if symptomatic) as well as date of positive test (for end of isolation calculation).
  2. Check whether has had public health contact. If not discuss self isolation and contacting contacts ASAP: see script for this. Instructions for Individuals who Test Positive for COVID-19 provided by Dr. Doug Sider, Hamilton Public Health.
  3. Patient can be directed to hfam guides for self isolating under patient resources tab.
  4. Check equipment patient has available. Check whether patient has or can borrow pulse oximeter. (patients can be directed to instruction YouTube video on using pulse oximeter on hfam.ca patient resources tab: found under “Self Isolation” heading).

Monitor post-hospital discharge patients daily

  1. Assess current symptoms and change (better / worse). See symptoms / atypical symptoms in history section above.
  2. Vitals – patient to record until symptoms resolve
    • once daily T, BP (if patient has access to a cuff)
    • twice daily HR, RR, +/- SPO2
    • note oxygen flow to maintain O2 saturation and especially note INCREASING O2 NEED (a red flag for considering referral to hospital)
  3. Assess level of dyspnoea (see Examination/Remote Examination on this page for tips on assessing dyspnoea virtually)
  4. Check urine output and fluid intake
  5. Check for respiratory and other red flag symptoms (See When to Refer to ED and Who to Call for Acute Care Advice sections below)
    • RESPIRATORY
      • Severe shortness of breath at rest
      • Difficulty in breathing
      • Increasing significant fatigue (reported in some patients as a marker for hypoxemia without dyspnea)
      • Blue lips or face
      • Hemoptysis
    • OTHER
      • Cold, clammy, or pale and mottled skin
      • Reduced level of consciousness or new confusion
      • Little / no urine output
      • Pain or pressure in the chest
      • Syncope
  6. Note underlying chronic disease that indicates increased risk. For patients with diabetes increase to daily monitoring.
  7. Assess need for regular medication changes or advice (see “management” tab below).
  8. Check mental health, access to food, support or carer, financial or housing stress.
  9. Assess whether this patient can still be managed at home (see When to Refer to ED and Who to Call for Acute Care Advice below consider whether goals of care conversation is appropriate).
  10. Give detailed management advice (see management tab below)
  11. Set up time for next follow-up – If follow-up falls on weekend make plan for this.

You can download EMR templates of this COVID monitoring pathway, with embedded links to hfam, from the EMR tools section of HFAM.

Here also is an example of a monitoring template you could use all or parts of to track all your clinic patients. Download or save a copy of this template.

Billing codes are COVID Codes (effective March 14, 2020)             

  • K080A: minor assessment of a patient by telephone or video, <10 minutes $23.75
  • K081A: intermediate assessment of a patient by telephone or video ≥ 10 minutes $36.85
  • (And if applicable K082A: primary mental health care, psychotherapy or psychiatric interview conducted by telephone or video $67.75)
  • These codes are in basket.
  • They are eligible to be billed with Q012A (after hours premium and on weekend) if calling patient after hours or weekend/holiday.
  • Other billing codes can be found here.

Here is a summary sheet that can be used as a guide for a potential COVID care daily “rounds” for monitoring.

Here is an example of a completed COVID-19 Ward Monitoring Sheet.

Here also is an example of a monitoring template you could use all or parts of to track all your clinic patients.  Download or save a copy of this template

EMR Tools are available to assist with monitoring too.

The Ministry of Health has now procured a stockpile of oxygen saturation monitors for monitoring COVID-19 positive patients through primary care. They will deliver these to your practice wherever you are, for you to lend to patients during monitoring.

Here is the information from them on how to access an oximeter, and a resource toolkit.

Patient instructions on using the pulse oximeter:

The instructions below are on the HFAM site, and will be included with the unit. These can also be printed and shared with patients as needed.

Pulse Oximeter Patient Instructions (ProResp)

Translated Pulse Oximeter Patient Instructions are available in Arabic, Bengali, Chinese (simplified), Dari, French, Hindi, Portuguese, Russian, and Spanish.

Download a PDF of this information on accessing pulse oximetersDownload

Cleaning

Public Health Guidance: Pulse oximeters should be cleaned with approved alcohol wipes and then ordered by return date in storage. Public Health advice suggests this cleaning plus a 24-hour “rest period” before re-allocating to protect those handling devices for the patient.

  1. Set expectations – similar to influenza this is most often a longer recovery than “A.Virus.” Explain that the typical symptoms are cough, fever and fatigue but they may also have breathlessness, muscle aches, sore throat, headache and loss of sense of smell / taste.
    Here is a pdf of instructions that can be provided to a patient (Georgian Bay Family Health Team) This is also included in the emailable pdf at the bottom of this section.

  1. REST – fatigue is often a marker for hypoxia, and experience with more unwell patients tells us increased mechanical work of breathing may lead to increased lung damage, so it makes sense NOT to do anything that triggers dyspnea / tachycardia. It patients have pulse oximeters they can measure after different activities and this is a way to reinforce this message.

  1. Change position to aid breathing (prone lying is used for inpatients, there is no evidence for outpatients either way but it makes sense to change positions including prone to move secretions and change mechanical work of breathing).
    Here is a pdf of instructions that can be provided to a patient (Georgian Bay Family Health Team) This is also included in the emailable pdf at the bottom of this section .

  1. Give clear guidance on who to contact if symptoms (such as breathlessness) get worse*
    For example, give patient a self-monitoring checklist with a plan for deterioration, as well as details about the contact process:
    1. Call 911 if:
      • You have severe trouble breathing or severe chest pain.
      • You are very confused or not thinking clearly.
      • You pass out (lose consciousness).
    2. Call clinic if:
      • You have new or worse trouble breathing.
      • Your symptoms are getting worse.
      • You start getting better and then get worse.
      • You have severe dehydration such as:
        • having a very dry mouth
        • passing only a little urine
        • feeling very light-headed
        • For patient with pulse oximeters: as outlined in the instructions for use, your care team will advise you what pulse oximetry levels are acceptable for you. Generally, an oxygen level of 93% or greater is acceptable. Call the clinic if your reading is below this level after rechecking or if your oxygen level changes by 3%.

  1. Give advice to ensure adequate hydration

  1. Direct to latest information on self-isolation / caring for someone with COVID

7. Direct patient and carers to information on mental health social supports etc. as appropriate (patient resources tab on HFAM)

*A pdf of advice including red flags that can be emailed to patients is available here. Long form instructions for patients also include pulse oximeter information.

Translated Patient information documents for people being monitored at home are available in Arabic, Bengali, Chinese (simplified), Dari, French, Hindi, Portuguese, Russian, and Spanish.

  • Comfort: Acetaminophen is safer than NSAIDS (not specific to COVID but NSAIDs increase the cardiovascular risk in any viral illness). Read more here.
  • Existing
    • ACEs and ARBs seem safe. Read more here.
    • Medications for COPD and Asthma should be continued. Read more here.
    • If the patient is at risk of dehydration (e.g. diarrhoea) think of acute kidney injury risk (SADMAN) if they are on an ACE / ARB plus diuretic plus aspirin these may need pausing to avoid AKI which is a significant feature of more severe COVID illness.
    • If the patient is on immunosuppressant medications consult with the relevant specialist – they may need pausing.
  • No specific investigations are necessary for monitoring mild – mod COVID in the community setting, except as guided by comorbidities
  • CXR may be indicated to assess for bacterial pneumonia

Aim is to keep O2 saturation between 92% but not above 96% for best outcomes for COVID-19. 

You can obtain a pulse oximeter for patients who do not have one here.

Evidence for Oxygenation targets

Current NIH guidelines for oxygenation targets in COVID-19 are congruent with local GIM advisers recommendations and state:

“The optimal oxygen saturation (SpO2) in adults with COVID-19 is uncertain. However, a target SpO2 of 92% to 96% seems logical considering that indirect evidence from experience in patients without COVID-19 suggests that an SpO2 <92% or >96% may be harmful.”

In one trial of ventilated patients with COVID-19 and ARDS, those randomised to a lower target range (88-92%) had poorer outcomes and a higher mortality rate. However this trial has been assessed by the McMaster Evidence Review group as high risk of bias so the evidence remains uncertain.

Regarding the potential harm of maintaining an SpO2 >96%, the NIH guidance refers to a meta-analysis of 25 randomized trials involving patients without COVID-19 found that a higher SpO2 was associated with an increased risk of in-hospital mortality compared to a lower SpO2 comparator (relative risk 1.21; 95% CI, 1.03–1.43).

Eligible for extended care at home (det. by COVID inpatient team before discharge) ❏ Yes
❏ No 		 
Home O2 set up by hospital  ❏ Yes
❏ No 		 
Home care from ICC team needed ❏ Yes
❏ No

If Yes:
Coordinator contacted?
❏ Yes
❏ No 		 
Antibiotics ❏ Yes
❏ No 		 
Steroids still required? ❏ Yes
❏ No
(usual dose dexamethasone 6mg OD for 7 days)		 Patient supply on Discharge
❏ Yes
❏ No
Instructions confirmed with pt
❏ Yes
❏ No
Patient had Strongyloides risk screening*
❏ Yes
❏ No
*See “Other care” tab for details
Initiate COVID monitoring pathway as for high risk category ❏ Yes
❏ No 		note this includes patient information package provision including safety net instructions
Safety net instructions given ❏ Yes
❏ No 		 
Discharge from primary care monitoring (criteria below)  
Hospital-Step-down-Care-for-COVID-PatientsDownload

Home Oxygen

  • For patients requiring oxygen post-hospitalization, this will be set up by hospital prior to discharge. 
  • Backup in the event this does not occur, if patient requires home oxygen set up after being discharged, complete and send referral for home oxygen directly to the oxygen provider. Oxygen providers have indicated they can rapidly initiate in the home, including weekends:

(*Check O2 suppliers in your local region)

Monitoring

Home Care

*Establish with stakeholders in your region the fastest way to access home care for patients needing it on discharge in order to facilitate more rapid discharge.

If patient was already receiving LHIN home care services:

Contact LHIN Care Coordinator prior to discharge, initiate/increase home monitoring visits.

  1. Steroids: Check whether the patient will need the tail end of the steroid course. Usual dose is dexamethasone 6mg OD for 7 days. This should have been supplied by the hospital. Primary care role is to remind patient to complete the course.
    • Because of the risk of disseminated strongyloides with steroid treatment (mortality up to 85%), check patient has been screened for epidemiological risk of stongyloides and treated if indicated (this should have been done in hospital prior to initiation).
    • Patients with COVID-19 undergoing treatment with dexamethasone and/or tocilizumab who have Strongyloides may be at increased risk of disseminated Strongyloidiasis, which can carry a mortality rate of greater than 85%. Infection is usually asymptomatic so all patients should be screened for epidemiological risk of Strongyloides prior to starting steroids or tocilizumab and treated with Ivermectin.  Epidemiological risk includes patients born in or residing consecutively for more than 6 months in any of the following regions: Southeast Asia, Sub-Saharan Africa, South America, Caribbean, Mediterranean, Middle East, North Africa, Indian Sub-continent, Asia, Oceania (exclude non-aboriginal Australians and New Zealand). These patients should all receive Ivermectin prior to steroids or toculizimab or other immunosuppressant treatment for COVID. Detailed information and dosing here.
  2. Low molecular weight heparin (LMWH): Updated guidance in July 2021 is that post-discharge LMWH is not recommended.
  3. Check whether other meds that were started in hospital need continuing or discontinuing (e/g/ antibiotics, hypnotics).
  4. Check on primary care monitoring / management of other comorbid conditions as usual (particularly diabetes monitoring) .

Consider emergent transfer to ED (unless not congruent with goals of care*) if:

  • HR >110, SPO2 consistently ≤ 92% despite O2, RR >24
  • Severe shortness of breath at rest (e.g. Breathlessness RR >30 despite normal O2 sats)
  • Difficulty in breathing (work of breathing)
  • Increasing O2 supplement requirements
  • New pain or pressure in chest
  • Decreased oral intake or urine output (dehydrated, needing IV fluids)
  • Cold, clammy or pale mottled skin
  • New onset of confusion, becoming difficult to rouse, syncope
  • Blue lips or face
  • Coughing up blood

Other symptoms indicating severe illness, or significant or rapid deterioration.

The patient’s risk factors for more severe illness should be considered in making the decision to refer to ED: age (>65), comorbidities as above, immunocompromised, higher frailty score.

* see Managing Progressive Life Limiting Conditions (COVID and non COVID)

* Make arrangements in local region for communication with acute inpatient physicians in the event of questions regarding post-hospital discharge patient care

  • Patient is discharged when a mutual decision is reached between MRP and respiratory therapist that patient no longer needs monitoring and oxygen. For most patients, that will likely be between 14 to 28 days after hospital discharge.
  • If patient is receiving home care, communicate with home care team about discharge or alternatively ongoing needs.
  • Home care agency will fax the MRP a summary note outlining the course of care for EMR records at that point.
  • As we are evaluating this program, the patient will receive a patient satisfaction survey by email.

Contacts for Home O2 and Home Care

Organization Contact Name Best way to reach After Hours
Vital Aire Laurie Smith, RPN – Clinical Lead Cell: 519-897-3562 laurie.smith@airliquide.com On call after hrs # 1-833-904-2473
Aaron Kendall RRT & Regional Lead Cell: 226-988-7511
ProResp Melissa Hine, RRT Manager, Local RRT Team Cell: 905-971-7921 After hours, call the office at either: 905-529-2166 Toll Free: 1-800-265-3727

Our Answering Service (AnswerPlus) has a full contingency to ensure you get a response.

Miriam’s cell is on 24/7
Joseph Lyle, RRT, Regional Lead Cell: 647-466-0995 jlyle@proresp.com
Miriam Turnbull, RRT, Broad Co.Lead and VP/GM Cell: 416-688-0286 mturnbull@proresp.com  
*Insert other local O2 providers contact details

* Insert local contact for referral for rapid home care supporting discharge.
Download an editable Word document of the table above