key: cord-354160-sca9bgeq
authors: Al-Tawfiq, Jaffar A.; Al-Yami, Saeed S.; Rigamonti, Daniele
title: Changes in Healthcare managing COVID and non-COVID-19 patients during the pandemic: Striking the balance
date: 2020-08-13
journal: Diagnostic Microbiology and Infectious Disease
DOI: 10.1016/j.diagmicrobio.2020.115147
sha: 
doc_id: 354160
cord_uid: sca9bgeq

Abstract Following the emergence of the COVID-19 pandemic, Healthcare organizations began concentrating on the preparation for and management of the surge of COVID-19 cases, while trying to protect the healthcare workers and other patients from getting COVID-19. Changing the way people work requires innovative approaches and questioning some long-held medical practices. There are multiple factors contributing to the apparent reduced utilization of healthcare services by to non-COVID-19 patients. We discuss ways to deal with preexisting chronic and COVID-19 patients at the time of the pandemic.

Healthcare organizations began concentrating on the preparation for and management of the surge of COVID-19 cases, while trying to protect the healthcare workers and other patients from getting COVID-19 [1, 2] . This latter task is critically important as patients are the most vulnerable victims of COVID-19, because they are usually older adults, with chronic medical conditions, frequently multiple, or immunocompromised. The rapid adoption of alternative ways to deal with those patients was unprecedented across the globe. The risk of aerosolization and thus the risk of dissemination of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) seems higher in certain surgical and aerosol generating procedures [4, 5] . For those procedures, appropriate personal protective equipment are needed during these procedures and N-95 use for aerosol generating procedures, in addition alternative none surgical managements strategies should be sought [6] .

Changing the way people work requires innovative approaches and questioning some longheld medical practices. Medical therapy such as in the case of acute coronary syndrome catheterization is presently undergoing re-evaluation, where non-surgical interventions such as the use of thrombolysis therapies are being considered [7] . In one study of urologic services, 19

of 53 (35.8%) consultations were performed via Telemedicine [8] . Adopting virtual visits through telephone calls and video calls is another avenue of great potential. This is particularly J o u r n a l P r e -p r o o f Journal Pre-proof helpful for patients who do not require invasive procedure and do not require in-hospital care.

These visits will allow the healthcare worker to assess the progress of the patients, response to therapy, and adjust or refill medications. Clearly each country's laws and regulation need to be supporting the legality of virtual visits. In combination with virtual visits, home delivery or delivery at satellite pharmacy locations is becoming more popular. Our own organization has implemented in selected cases both virtual visits and home delivery of medications. categories: care needed in 0-6 hours, 6-48 hours, 48 hours to 14 days, and >14 days [6] . That organization functioned on the presumption that all patients and staff could be positive asymptomatic cases requiring social distancing of staff and residents during case discussions, rounds, and classes, in addition to the use of personal protective equipment and universal masking [6, 9] .

The concern about possible transmission of COVID-19 in hospital setting has also moved the practice from more invasive to more conservative procedures. Evidence-based medicine articles looked at various medications, such as aspirin, B-blocks, angiotensin-converting enzyme inhibitors, and statin therapy that could reduce non-COVID-19 hospital admission [10] . symptoms and checking the temperature were adopted, directing those identified as possible COVID-19 patients to the appropriate testing facilities and disposition [11] . Furthermore, in order to properly care for non-COVID-19 patients, it had been suggested that there should be separate hospitals for those with COVID-19 and those without COVID- 19 [7] introducing the concept of segregation at the level of the hospital rather than the level of a unit or ward in a specific hospital.

To be prepared for a potential surge in the need for intensive care beds for COVID-19 patients, major logistical efforts become necessary. Logistics of and preparedness of healthcare organization to accommodate non-COVID-19 patients such as the availability of ICU beds for both non-COVID and COVID-19 patients rely on other community activities for the control of COVID-19, such as self-isolation, quarantine facilities, and curfew. In one study, the need for ICU beds was estimated to be 569 ICU bed days per 10,000 population in case of no selfisolation of infected patients [12] . This number is reduced by 23.5% and 53.6% assuming 20% and 40% of cases practiced self-isolation, respectively [12] . The true need of hospital, and in particular ICU, beds actually seems dependent on several factors. A very important (and controllable) factor is the policy regarding management of confirmed positive asymptomatic cases. The option, sanctioned by the local government, to (successfully) quarantine such patients at home or in designated quarantine facilities would dramatically "decompress" healthcare organizations that would then focus on symptomatic patients, only. Another important (but noncontrollable) factor determining the need of hospital beds is the average age of the population.

As it became apparent in Europe, nations with a high percentage of elderly individuals cared for in nursing and retirement homes have experienced an overwhelming surge of severely symptomatic elderly individuals with an associated mortality one order of magnitude higher than nations with a lower average age [13] . The US CDC had proposed for nursing home residents who are asymptomatic to have increasing monitoring from daily to every shift to more rapidly detect any resident with new symptoms [14] . However, how those asymptomatic COVID-19 positive patients in nursing homes or other long-term care facilities be managed is not clear.

However, it is not clear how to protect patients and healthcare workers from those so called "non-COVID-19" who might be asymptomatically infected with SARS-CoV-2. Would routine nasopharyngeal swabs and PCR testing be screening of high enough sensitivity that a negative test would indicate that those patients are not infected? What about those who might be incubating or are in the pre-symptomatic stage? Data suggest that the nasopharyngeal swab had about 75% positivity from a single swab and three swabs are needed to reach more than 95% [15] . The utility of antibody use in the diagnosis of COVID-19 had not been recommended at this time. Currently the evidence for the use of serologic testing of SARS-CoV-2 is not optimal.

Serologic tests have variable sensitivity and specificity, with different timing of the appearance of these antibodies, and it is not clear if these antibodies confirm protection [16] .

All the measures mentioned above had dramatic effects on the utilization of healthcare resources. One study reported a decrease by up to 75% of referrals for suspected cancer [6] .

Another study showed a reduction in trauma-related cases in emergency department and hospital admissions [17] . In an additional study, the emergency room visits of non-COVID-19 patients had significantly decreased overtime in Italy due to the COVID-19 pandemic [18] . In a study of 2537 dental visits, dental urgency visits decreased by 38% and non-urgent case visits decreased J o u r n a l P r e -p r o o f Journal Pre-proof to 30% [19] . A recent report pointed out a decreased number of admissions for emergencies such as coronary artery disease and cerebrovascular accidents [20] . Similarly, there was a reduction of 39.4% of patients admitted with acute coronary syndrome (ACS) [21] .

There are multiple factors contributing to the apparent reduced utilization of healthcare services by to non-COVID-19 patients. Firstly, there is a fear to visit clinics as they might be a place carrying a higher risk of getting infected with SARS-CoV-2 [1] . There are other factors contributing to low patients' volume of non-COVID-19 in the healthcare system (figure 1) besides the fear of patient of becoming infected, as mentioned previously. The greatly curtailed ability to move at times of curfew or lockdown is creating a new challenge. Additional factors include the reduced offering of non-urgent and routine clinic visits or their outright cancellation.

The underlying causes for such administrative decisions include the desire to decrease the crowding and its associated increased risk of spread and decreased availability of healthcare workers, often reassigned to meet the increasing demand to care for COVID.

It is becoming evident, however, that we need to develop new solutions on how healthcare organizations should provide care of non-COVID-19 patients, especially those with chronic diseases. While insisting on keeping patients outside the hospital as much as possible to enhance physical distancing, it is important to bolster social support, as patients might need to come to clinic and not be able to visit the clinics, independently. It is the duty of healthcare professionals to reach out to those patients as they feel they are invisible [7]. J o u r n a l P r e -p r o o f 

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