Providing 24/7 healthcare for all during the COVID-19 pandemic
Novel Coronavirus 2019 (COVID-19) is a respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is responsible for sparking a global pandemic that has infected over 5 million people and killed over 350,000 to date.(1) Amid the COVID-19 pandemic, Canadian physicians have been advised to provide virtual care wherever possible.(2) Telemedicine presents its own unique challenges and has been met with some resistance in the past. However, virtual options can provide rapid, safe and high quality care and increase access to care in circumstances such as the COVID-19 pandemic.(3)
The County of Renfrew, located on the west bank of the Ottawa River (ON, Canada) has a population of approximately 107 000, spread over 7400 square kilometres.(4) It has some of the highest provincial rates of chronic physical and mental illness, above average rates of provincial unemployment and overall low socio-economic status.(5) When combined with its vast rural geography, these factors pose increased challenges to healthcare delivery at any time, especially so in the face of this current pandemic. These geographic and socio-demographic difficulties are exacerbated by the shortfall of Family Physicians and significant number of residents without consistent access to a Family Physician. In response to the COVID-19 pandemic, priorities included ensuring that Emergency Departments and 911 paramedics were available to deal with genuine emergencies, whilst providing alternative 24/7 access to healthcare for all residents of Renfrew County. There was also a need to quickly establish supply management of personal protective equipment (PPE) for healthcare workers.
Throughout Ontario, physical assessment centres were established to test patients for COVID-19 in the out-of-hospital setting.(6) Given the geographical makeup of Renfrew County, health-care providers recognized that a single assessment site would have been unsuitable and that an alternative solution, specific to local needs, was required.
A collaboration of unprecedented scale and speed between Family Physicians and other primary care providers, the County of Renfrew Paramedic Service and five local hospitals resulted in the conception, development and implementation of the Renfrew County Virtual Triage and Assessment Centre (VTAC) in just 12 days.
Renfrew County VTAC is a novel, centralized, 24/7 health-care service, available to all residents of Renfrew County. It provides initial virtual assessments by Family Physicians and Nurse Practitioners, home assessments, treatment and remote monitoring capability by Community Paramedics and escalation of care to a Community Acute Care physician or a Palliative Care physician as required. Renfrew County VTAC provides multiple layers of care designed to reduce attendance at, and transfer to local Emergency Departments. Any Renfrew County resident can contact Renfrew County VTAC for initial assessment. Additionally, patients may be referred directly by their Family Physician or Nurse Practitioner to any of the Renfrew County VTAC branches.
The program was promoted through multiple communication platforms including newsprint, social media, radio, television, community pharmacies, local hospitals, primary care providers and Public Health. Patients are encouraged to call a toll-free phone number to speak with a medical receptionist who schedules a telephone assessment with a Family Physician or Nurse Practitioner. The telephone visit can be quickly escalated to a video assessment if required. All providers share a common electronic medical record which is used to order any necessary diagnostic testing, print prescriptions and refer patients to the Community Paramedic Response Unit (CPRU), Public Health and other specialists as required. Point of care testing, including COVID-19 swabs and blood work, can be conducted in the patient’s home by Community Paramedics with results relayed directly to the Renfrew County VTAC provider. Drive-thru sites for COVID-19 swabs of multiple patients have been established. Additional assessment and support can be requested from the CPRU or Community Acute Care branch of Renfrew County VTAC. The Community Acute Care branch is staffed by acute care physicians who provide management support to patients with more significant or deteriorating symptoms, including symptoms related to COVID-19.
It has been suggested that successful implementation and deployment of in-home monitoring devices linked to telehealth, can reduce the burden on healthcare systems throughout this evolving situation. Shifting patient care from hospital to home can lead to improved clinical outcomes through early and timely intervention by identifying deterioration and exacerbation.(7) Additionally, physical contact between medical staff and patients can be minimized by remote monitoring and care. The Renfrew County VTAC Community Paramedics can establish in-home monitoring, allowing vital sign parameters to be set and overseen in real time. Home monitoring is particularly beneficial for patients who do not require immediate hospitalization. This local approach allows care to be maintained in the patient’s home wherever possible, whilst allowing for rapid intervention in patients requiring escalation of care to a hospital setting. Given the poor prognosis of COVID-19 infections in the elderly and co-morbid populations(8), the ability to provide palliative and end-of-life care is an indispensable component of community care in the face of a pandemic. Renfrew County VTAC integrates with existing community palliative care resources allowing for 24/7 access to an on-call palliative care physician and in-home support from Community Paramedics.
In creating a program focussed on connecting patients to a Family Physician or Nurse Practitioner virtually, there is a risk of creating a misconception that the episodic care provided by Renfrew County VTAC is a reasonable alternative to traditional full-spectrum primary care. Renfrew County VTAC was created to support existing primary care, not to replace it. It has made use of existing health-care infrastructure (primary care physicians, paramedics and hospitals in Renfrew County) in order to ensure that all residents have access to acute episodic care during the COVID-19 pandemic.
Renfrew County VTAC follows the Canadian Government’s COVID-19 “Virtual Assessment and Triage” recommendations; 24/7 care, telephone and video-based communication and tracking data from each virtual visit. Renfrew County VTAC is also aligned with the Government’s “acute care” recommendations which encourage the utilization of strategies to decrease hospital crowding and keeping non-COVID-19 hospital wards free.(9)
Since launching on March 27, 2020, Renfrew County VTAC has carried out over 4500 assessments. Approximately half of the assessments are to "unattached patients" with no existing Family Physician. A review by clinicians of a 48 hour sample of assessment notes showed that almost three quarters of the assessments would likely have resulted in the patient attending the Emergency Department if Renfrew County VTAC had not been available.
Renfrew County VTAC has proven its ability to provide acute episodic care, including COVID-19 testing, during the pandemic. It has highlighted an opportunity to modernize the 911 system and improve access to primary care well after the COVID-19 pandemic. Where communities are unable to recruit Family Physicians locally, access to a named Family Physician via virtual means, with support from locally available Allied Health Professionals, may offer a better alternative to the Emergency Department as the only current option for unattached patients to access primary care in the future.
Dr. Jonathan Fitzsimonis the Clinical Coordinator of the Renfrew County Virtual Triage and Assessment Centre. He is a Family Physician and Chief of Medicine at Arnprior Regional Health, Ontario.
Dr. Oliver Gervais is a Resident Physician in Family Medicine (PGY-1) at the University of Ottawa with his primary family medicine practice base in Renfrew, Ontario.
Chelsea Lanosis a Paramedic with the County of Renfrew Paramedic Service in Ontario. She is a Clinical Research Assistant with The Ottawa Hospital Research Institute’s Clinical Epidemiology program and a fellow with the McNally Project for Paramedicine research.
Maureen Sulliavan-Bentz is a Senior Program Manager at the Canadian Patient Safety Institute, where she leads the Education and Capability Building Portfolio. She is a Professor of Nursing at the University of Ottawa and previously served as the Executive Director of a Rural Family Health Team and Rural Residential Hospice.
References
1. World Health Organization. COVID-19 Situation Reports [Internet]. 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200422-sitrep-93-covid-19.pdf?sfvrsn=35cf80d7_4
2. The Royal College of Physicians and Surgeons of Canada. Telemedicine and virtual careguidelines (and other clinical resources for COVID-19) [Internet]. 2020. Available from: www.royalcollege.ca/rcsite/documents/about/covid-19-resources-telemedicine-virtual-care-e%0D
3. Latifi R, Doarn CR. Perspective on COVID-19: Finally, Telemedicine at Center Stage. Telemed e-Health [Internet]. 2020 May 14 [cited 2020 May 24];tmj.2020.0132. Available from: https://www.liebertpub.com/doi/10.1089/tmj.2020.0132
4. Census Profile, 2016 Census - Renfrew, County [Census division], Ontario and Renfrew[Population centre], Ontario [Internet]. [cited 2020 Apr 18]. Available from: https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/details/page.cfm?Lang=E&Geo1=CD&Code1=3547&Geo2=POPC&Code2=0699&Data=Count&SearchText=Renfrew&SearchType=Begins&SearchPR=01&B1=All&TABID=1
5. Champlain LHIN. Population Health Data [Internet]. 2017 [cited 1BC May 21]. Available from: http://www.champlainlhin.on.ca/AboutUs/GeoPopHlthData/PopHealth.aspx
6. Ontario Health Coalition. Ontario COVID-19 Assessment Centres [Internet]. 2020. Available from: https://www.ontariohealthcoalition.ca/wp-content/uploads/April-6-Assessment-Centers-1-1.pdf
7. Ding X-R, Clifton D, Ji N, Lovell NH, Bonato P, Chen W, et al. Wearable Sensing and TelehealthTechnology with Potential Applications in the Coronavirus Pandemic. IEEE Rev Biomed Eng[Internet]. 2020 May 11 [cited 2020 May 24]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/32396101
8. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality ofadult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020 Mar28;395(10229):1054–62.
9. Government of Canada. COVID-19 Pandemic Guidance for the Health Care Sector[Internet].2020 [cited 2020 Apr 18]. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/covid-19-pandemic-guidance-health-care-sector.html#a32
