Covid-19 HSE Clinical Guidance and Evidence

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Plans to manage vulnerable neurology patients in the community during the COVID-19 epidemic

• Objective

• Rationale

• Plan

• Feasibility

• Procurement of Equipment

• Contingencies for additional care in the event of a breakdown in home care services

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Objective

TO PREVENT ADMISSION TO HOSPITAL OF VULNERABLE NEUROLOGICAL PATIENTS TO HOSPITAL DURING THE COVID-19 EPIDEMIC. 

Rationale

Extremely vulnerable neurological patients include those that are currently using non-invasive ventilation, i.e. those with Motor Neurone Disease, Adult Spinal Muscular Atrophy and Adult Muscular Dystrophy  

The use of NIV poses 2 major risks in the current epidemic : (1) Risk of infection   (2) Risk of spread of infection.  As NIV machines are “open” they are not suited for use in a hospital setting where infection control is in operation.    Additionally, those who are using NIV as a symptomatic therapy for their illness will not be suitable for full mechanical ventilation, and thus should not be admitted to a hospital in the event of an intercurrent infection.

A proportion of those with MND will also experience nutritional decline over the coming 3 months and given the current restrictions on admission for elective procedures including gastrostomy insertion alternative approaches will be required to manage nutrition and hydration. 

Given the likely curtailment of community-based services (PHNs, Palliative care home services, etc.), these patients and their families will also require active surveillance and management by a specialist outreach service.    There is  a high risk of breakdown of care provided by family members  and community based services, and early intervention  and transfer to a care facility may be necessary.  Early recognition of risk, and rapid transfer to an  appropriate facility will be essential to prevent a crisis.

Plan

An integrated national service for this cohort of patients has been established.  This service comprises:  2 HSE funded MND Nurses (Beaumont), 3 Consultant Neurologists (Beaumont, Cork),  4 Registrars expert in Neuromuscular Disease  (Beaumont /Trinity College),  a specialist physiotherapist (Beaumont /TCD) with expertise in MND.   An additional 4 expert nurses with hospital and community experience in MND are available through the Irish Motor Neurone Disease Association (IMNDA) for a period of 3 months.

This integrated  team will be available on a 24/7 basis using a dedicated phone line and email contact, and will have facility to travel throughout the country, providing home visits to:

• evaluate those at risk of early respiratory compromise from their illness,
• initiative and manage NIV use at home, obviating hospitalization
• prevent respiratory tract infections  by training families in the use of  specialist equipment (e.g. breath stacking,   insufflation and exsufflation)
• early identification of intercurrent infections and intervention using oral/ IV antibiotics at home,
• manage nutritional decline / dehydration using nasogastric feeding where necessary, 
• Identify those at risk of breakdown in care arrangements, and early intervention by identification of and  transfer to a care facility where indicated.
• Provide symptomatic management of respiratory distress by judicious use of medications (e.g. low dose opiates)
• Manage end of life where necessary (In the absence of a full palliative care service)

The team will also support, where appropriate, those vulnerable neuromuscular patients infected with COVID 19 who are not suitable for hospitalization / invasive ventilation, in collaboration with Palliative Care services within the hospital and community.

Feasibility

The location and clinical status of these vulnerable patients is already known, as  specialist MND and Neuromuscular  clinics are currently in operation in Dublin and Cork respectively, and there is a full national register for MND.

MND patients are also currently supported in an advisory capacity by the IMNDA nurses, who provide home visits.   A transfer to a fully governed HSE supported team, with nursing governance through the Neuroscience Directorate at Beaumont Hospital, will now enable their full utilization across the range of proposed activities.

Procurement of Equipment

Required equipment to enable safe and efficient visits for health care professionals will include the following:

Personal Protective Equipment for at least 200 visits over 3 months, assuming that a proportion of patients will carry a COVID19 risk (family member affected, etc.)

Home Respiratory Assessment (Spirometry devices @€75 per device).  A minimum of 72 devices will be required  (available from Medical International Research Spirobank II Essential Spirometer - MIR Spirometers in the UK)

Giving sets for IV antibiotics and IV fluids.

Contingencies for additional care in the event of a breakdown in home care services

Vulnerable patients will be categorized according to the likelihood of care breaking down:

For these vulnerable patients, the nursing team will provide national cover, with each nurse taking responsibility of a specific region based on population density. An analysis will be performed across each region to determine the most appropriate care facilities in the event of a breakdown of care. 

Contact will be made with each designated care facility to ensure that rapid access for vulnerable patients will be assured.

Intermediate care facilities will also be identified for those patient who may require monitored intervention that is not related to Covid-19 exposure.