Digital Health Technology and Telemedicine-Based Hospital and Home Programs in Pulmonary Medicine During the COVID-19 Pandemic.

BACKGROUND: The current coronavirus disease 2019 (COVID-19) pandemic has caused a significant strain on medical resources throughout the world. A major shift to telemedicine and mobile health technologies has now taken on an immediate urgency. Newly developed devices designed for home use have facilitated remote monitoring of various physiologic parameters relevant to pulmonary diseases. These devices have also enabled home-based pulmonary rehabilitation programs. In addition, telemedicine and home care services have been leveraged to rapidly develop acute care hospital-at-home programs for the treatment of mild-to-moderate COVID-19 illness. AREAS OF UNCERTAINTY: The benefit of remote monitoring technologies on patient outcomes has not been established in robust trials. Furthermore, the use of these devices, which can increase the burden of care, has not been integrated into current clinical workflows and electronic medical records. Finally, reimbursement for these telemedicine and remote monitoring services is variable. DATA SOURCES: Literature review. THERAPEUTIC ADVANCES: Advances in digital technology have improved remote monitoring of physiologic parameters relevant to pulmonary medicine. In addition, telemedicine services for the provision of pulmonary rehabilitation and novel hospital-at-home programs have been developed. These new home-based programs have been adapted for COVID-19 and may also be relevant for the management of acute and chronic pulmonary diseases after the pandemic. CONCLUSION: Digital remote monitoring of physiologic parameters relevant to pulmonary medicine and novel hospital-at-home programs are feasible and may improve care for patients with acute and chronic respiratory-related disorders.

Intensive Home Care for COVID-19 to Reduce Admissions.

Hospitalization for COVID-19 has placed a significant financial and logistical burden on hospitals and health care systems. Limitations on visitation and isolation precautions have made hospitalization more isolating for patients in the time of COVID-19. Increasing the provision of healthcare delivered at home has the potential to decrease healthcare costs by providing care at home which may be preferred for many patients. We describe a series of 39 patients who were treated with intravenous remdesivir at home in addition to oxygen, dexamethasone, and anticoagulants. These patients were at high risk for decompensation due to COVID-19 and met accepted criteria for admission-need for supplemental oxygen and intravenous remdesivir. All patients had home lab monitoring and frequent telehealth visits. Over the study period 13 (33%) of patients were admitted for worsening COVID-19 and 5 (13%) died. Twenty-six patients avoided admission, and none experienced a severe adverse effect from in-home treatment. The expanded use of telehealth services due to the COVID-19 pandemic has the potential to increase the frequency of patient monitoring by physicians and the provision of care and monitoring usually restricted to hospitalized patients.

The management of suspected heparin-induced thrombocytopenia in US hospitals.

Guidelines for the diagnosis and management of heparin-induced thrombocytopenia (HIT) vary between hospitals. Recent guidelines recommend initiating alternative anticoagulant therapy in patients with suspected HIT while awaiting laboratory test results confirming the presence of heparin-PF-4 antibodies (PF-4). This retrospective chart review was designed to assess the current state of management of patients with thrombocytopenia suspected to be due to HIT at 26 US hospitals. Most hospitals (25 of 26; 96.2%) had guidelines in place for the management of suspected HIT, with 7 (26.9%) having a "halt heparin, test, and await results" (ie, "test and wait") policy. One-third of hospitals had a wait time for obtaining PF-4 antibodies of 3 days or more. Hospital guidelines for the management of HIT may actually discourage the use of optimal HIT management strategies.

The impact of do-not-resuscitate order on triage decisions to a medical intensive care unit.

PURPOSE: To determine whether the presence of a do-not-resuscitate (DNR) order impacts on triage decisions to a medical intensive care unit (MICU) of an academic medical center. METHODS: Data were collected on 179 patients in whom MICU consultation was sought and included demographic, clinical information, diagnoses, ICU admission decision, Acute Physiological and Chronic Health Evaluation II (APACHE II) score, and the presence of DNR order. Functional status was determined retrospectively using the Modified Rankin Score. RESULTS: The only factor that influenced MICU admission was the presence of DNR order at the time of MICU consultation (odds ratio, 0.25; 95% confidence interval, 0.09-0.71, P < .006). There was no difference between the age, APACHE II scores, or functional status between admitted or refused. Medical intensive care unit admission was associated with increased length of stay without difference in mortality. CONCLUSION: The presence of a DNR order at the time of MICU consultation was significantly associated with the decision to refuse a patient to the MICU.