key: cord-0931088-ibjo28eg
authors: Sgalla, Giacomo; Iovene, Bruno; Bruni, Teresa; Flore, Maria Chiara; Porro, Lucia Maria; Lalvani, Ajit
title: Telemedicine-enabled, Hotel-based Management of Patients with COVID-19: A Single-Center Feasibility Study
date: 2021-03-30
journal: Annals of the American Thoracic Society
DOI: 10.1513/annalsats.202101-018rl
sha: 887290aabcbaa59a259de8318c52efde63511949
doc_id: 931088
cord_uid: ibjo28eg

nan

To the Editor:

The dramatic spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in the first half of 2020 demanded a significant readjustment of healthcare organization to deal with the massive wave of patients with coronavirus disease (COVID-19) (1, 2) . Healthcare resources were exploited not only by patients who were severely ill but also by those who were still contagious after clinical recovery and could not be discharged at home. As such, it became pivotal to develop innovative management strategies to unload hospitals while reducing the risk of SARS-CoV-2 transmission among family members of infected patients who could not ensure effective domiciliary isolation.

Between April and May 2020, a novel framework consisting in a telemedicine-enabled hotel facility was implemented by the Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome, Italy. The scope was to provide adequate isolation for clinically stable patients with COVID-19 while ensuring clinical safety (3) . We assessed the feasibility and safety of this management approach.

Consecutive patients with COVID-19 discharged from the emergencycareortheCOVID-19unitsofourhospitalwerereferredtothe hospital facility if they were unable to comply with self-isolation measures at home. Eligibility criteria for study participation included a COVID-19 diagnosis (requiring a positive real-time reverse transcriptase-polymerase chain reaction [RT-PCR] nasopharyngeal swab test), self-sufficiency, ability to use a smartphone (as reported by the patient), and persistence of SARS-CoV-2 infection via RT-PCR at the time of hospital discharge. Clinical stability at the time of hospital discharge was also required, as defined by arterial oxygen tension/pressure >60 mm Hg in room air, absence of fever, and no need for intravenous therapies. Institutional Definition of abbreviations: CRP = C-reactive protein; HFNC = high-flow nasal cannula; ICU = intensive care unit; IL-6 = interleukin-6; SD = standard deviation. review board approval for the study was obtained from the local ethics committee (protocol number 0020504/20); written informed consent was obtained from all participants. A sanitized telemonitoring kit (Doctor Plus by Vree Health Italia S.r.l.) consisting of a digital pulse oximeter, an electronic thermometer, and a smartphone with a preinstalled interface for connection and data entry was provided in each hotel room upon the arrival of a new participant. A help desk instructed patients via phone on the use of the kit. During the hotel stay, patients were asked to provide measurements of vital signs two times daily (at 9 A.M. and 6 P.M.), with the possibility to provide extra measurements. Recorded parameters included oxygen saturation and heart rate as provided by the pulse oximeter, respiratory rate (self-measured, tutorial provided upon arrival), and body temperature. Data were transmitted to a web-based telemonitoring platform and checked daily by trained medical staff on site. Different alert codes were set off by missing or predefined out-of-range measurements, triggering different types of responses as described in Table 1 . "Red" code alerts were deployed when more vital parameters were out of range or at least one parameter was out of safety ranges, potentially indicating clinical deterioration and therefore requiring immediate patient contact by the medical staff. The failed provision of measurements for three consecutive times deployed a "gray" code alarm that was directly managed by the help desk, which verified potential technical issues. The end of the isolation period was determined by two consecutive, 24-hour-apart RT-PCR nasopharyngeal swab tests negative for SARS-CoV-2. In case of positive testing, further swabs were performed every 48-72 hours. Analysis of accrued data was performed using SPSS (version 24; IBM). A t test for independent samples and the x 2 test (or alternatively the Fischer exact test) were used to compare collected data between groups. Statistical significance was set at P , 0.05.

Between April 1 and May 31, 2020, 126 patients were admitted to the hotel facility and invited to participate; 87 (69%) provided valid written informed consent. The mean duration of the hotel stay was 15.4 days (standard deviation [SD], 10.7 d). All patients complied with the isolation measurements for the required period with no premature dropouts. The average of daily measurements provided for any vital sign (not including extra measurements) per patient was 6.7 (SD, 2.4), corresponding to an adherence of 84%. The alerts deployed during the telemonitoring period, stratified by different codes and parameters, are reported in Figure 1 . Consecutive missing measurements of one or more parameters represented the most frequent alerts, as they accounted for almost half of the total (46%). There were 126 (21.5%) alerts requiring immediate patient contact. All alarms were cleared either directly on the platform or after phone contact with the patient, who was eventually invited to repeat the measurement setting off the alarm. As such, none of the alerts ultimately resulted in a referral to the emergency department unit.

The time of viral persistence, defined as the time from the onset of symptoms to a double-negative real-time RT-PCR nasopharyngeal swab test, was available for 74 patients (85% of the study population). The mean time to a negative test was 41.2 days (SD, 13.1 d). The study population was divided in two groups using the median of viral clearance as the cutoff (39 d) to explore those factors among the baseline characteristics ( Table 2 ) that could influence the time of viral persistence. Treatment with high-flow oxygen during hospital admission was more frequent in the "long persistence" than in the "short persistence" group (nine and one patients, respectively; P = 0.014), possibly suggesting that more severe patients may present a slower virus clearance.

High patient adherence to the telemonitoring protocol supports the feasibility of a telemonitoring system in patients recovering from COVID-19 undergoing isolation in a dedicated facility. On the other hand,thehigh ratesof missingmeasurements, and "false" alerts,deployed by either erroneous measurements by the tool or incorrect patient entries, highlight the importance of continuous medical and technical assistance to discriminate true emergencies and solve technical issues. Our model included 24/7 support provided by both technical staff and a clinical team consisting of three nurses and three medical doctors. These resources can be considered sensibly inferior to those required by a prolonged hospital stay for isolation purposes. Given the shortage of healthcare staff and bed availability in the context of the SARS-CoV-2 pandemic, the use of dedicated isolation facilities integrated with telemedicine systems can facilitate the hospital turnover of infected patients, protect patients' family members, and reduce the risk of infection of healthcare professionals. On the other hand, no adverse events requiring medical intervention emerged during the telemonitoring period, suggesting that the occurrence of clinical deterioration in SARS-CoV-2-positive, clinically stable patients is uncommon. As such, further research in larger cohorts is warranted to validate our findings and determine the real cost-effectiveness of this approach.

In conclusion, we show that a hotel-based, telemedicine-enabled management represents a feasible and safe approach for patients with COVID-19 requiring long-term isolation. The widespread adoption of telemonitoring tools as alternatives to unnecessary or prolonged hospitalization gets particular relevance in the context of the ongoing second or third wave of COVID-19 in many countries.

Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response

What other countries can learn from Italy during the COVID-19 pandemic

Telemedicine-enabled accelerated discharge of patients hospitalized with COVID-19 to isolation in repurposed hotel rooms

Few studies describe the natural history of PH in infants with BPD after neonatal intensive care unit (NICU) discharge. Two retrospective studies found that 24-34% of survivors still had PH at 3 years of age (5, 6), but it has not been observed in school-age children with BPD (7, 8). Given these studies, our first objective was to characterize preterm infants at risk for prolonged resolution of PH after 1 year of age. Published guidelines recommend screening echocardiograms at 36 weeks postmenstrual age (PMA) for infants with moderate or severe BPD

Subjects were classified as having PH if PH was present on any clinically obtained echocardiogram in the screening period (34-38 wk PMA) and/or follow-up period (.38 wk PMA). The diagnosis of PH was based on elevated right ventricular pressures defined by tricuspid regurgitation jet, patent ductus arteriosus (PDA) gradient, or systolic interventricular septal position. Of the 758 subjects, 57 subjects had echocardiograms only in the screening period, 197 only had them in the follow-up period, and 168 had them in both periods. For this study, we arbitrarily examined children who had PH resolve after 1 year of chronological age versus before 1 year of chronological age. Late-onset PH was defined as PH found in the follow-up period that was not observed during the screening period; infants were only included in this analysis if they had echocardiograms during both the Supported in part by a Johns Hopkins All Children's Foundation Institutional Research Grant (Principal investigator: N. A. Goldenberg; Johns Hopkins "iPICS" prospective multicohort and biobanking study of pediatric acute and chronic health conditions