ABSTRACT
Study Objectives: The COVID-19 pandemic placed enormous stress on hospital infrastructure, particularly with regard to bed availability. We adopted a novel clinical pathway to discharge mild to moderately ill patients with Telehealth Follow-up and Remote Patient Monitoring (TFRPM). The objective was to describe the impact of a novel clinical pathway for outpatient telehealth follow-up of patients with presumptive or confirmed COVID-19 discharged from the emergency department (ED). Methods: The clinical pathway allowed patients with presumptive or confirmed COVID-19 disease to be discharged home if they had in-home support and consented to early telehealth follow-up with remote patient monitoring. Patients were eligible for TFRPM if they had a RR<22 AND an exertional oxygen saturation (eO2sat) of 90% or above after treatment and observation. Telehealth visits were performed at least once daily for up to seven days. Patients with an eO2sat of between 92% and 95% were discharged with pulse oximeters (PO) and those with eO2sat between 92% and 90% were given PO and oxygen concentrators (OC) (FIO2 up to 3 l/m). All telehealth visits were performed by providers trained to gauge both subjective and objective measures of disease progression (symptoms, O2 sat, HR, RR). Patients were followed until disease resolution or referral to the ED. We performed a retrospective review of data collected for quality assurance purposes. Trained abstractors performed chart review and data collection. The primary outcome measure was ED revisit. Secondary measures included: disease course, hospital LOS, ICU requirements, respiratory support, mortality and loss to follow-up (LTFU). Descriptive statistics were used to analyze the extracted data. 10% of charts were reviewed by an independent reviewer for data quality assurance. We report a sensitivity analysis accounting for those lost to follow-up and projected cost-effectiveness. Results: From March-April of 2020, we discharged 488 presumed or confirmed COVID-19 patients with TFRPM. Of these patients, 155 were discharged with PO, and 86 were discharged with PO+OC for home use. First (12-24 hour) telehealth contact was successful in 81.7%, 90.3% within 3 days and 9.7% were LTFU. There was a total of 1,431 telehealth follow-up visits. Ninety patients (18.4%) returned or were referred to an ED a median of 3 days (IQR: 2.0 to 6.0 days) after index visit;43 (8.8%) were admitted to the hospital’s general medical floor. Two of these patients were transferred to ICU within 24 hours and both died 5 days after admission;5 others were transferred to ICU and intubated more than 24 hours into their hospitalization and 4 expired (1 patient 9 days later, 2 patients 10 days later, and 1 patient 23 days later). The last patient recovered and was discharged after 7 days of ICU care. The mortality rate for this cohort was 1.2%. The telehealth program cumulative costs of were $621,800, including charges attributed to their actual admissions, were substantially less than the projected cumulative mitigated hospitalization charges of $6,718,296 (IQR: $4,767,344;$9,902,496). Conclusion: Implementing a novel discharge and telehealth follow-up protocol for patients with presumed or confirmed COVID-19 was able to decompress our overburdened inpatient units. The addition of remote patient monitoring and oxygen support appears to be a safe alternative in mild-moderate risk discharges and may serve as an alternative to hospital admission during a crisis of pandemic proportion.