While our focus remains on treating the sickest COVID-19 patients in the hospital setting, how will we place equal importance on managing the disease post-hospital discharge. Hospitalizations for COVID-19 have been a key metric of both the coronavirus’s toll and the health care system’s ability to deal with it.
Globally as of 08/25/2020 , there were 23,518,343 confirmed cases of COVID-19, including 810,492 deaths, reported by the World Health Organization (WHO). Coronavirus cases continue to grow in Texas. From cities to rural towns, COVID-19 is spreading and affecting families, commerce, and travel. Texas is the second largest U.S. state by both area and population and has reported 588,761 cases and 11,391 deaths.
The number of hospitalized patients remains high despite recent decline over the past few weeks. What is important to keep in the forefront of our minds is, what happens now to patients who were once mechanically ventilated or required high levels of oxygen therapy during their treatment? For some patients with pre-existing medical conditions, their new reality will be to be sent home with oxygen and perhaps need it for the short term.
Patients that have been discharged from the hospital or those who treated their symptoms in the hospital are now being called “long-haulers”. While it is unclear how many survivors become long-haulers, a recent study from the United Kingdom found 1 in 10 people are sick for a least three weeks. People are starting to experience the effects post recovery. Andre Sofair, MD, MHS, a Yale Medicine internal medicine physician was interviewed and states that an estimated 20 to 50% of patients continue to face health challenges after being discharged from the hospital. Yale Medicine is in the process of opening a post-COVID clinic. The concept is much like existing outpatient clinics that treat specific diseases and the focus will be to help relieve residual symptoms, which are mostly but not exclusively pulmonary.
The Monitor, a local news outlet in McAllen, TX covering Starr and Hidalgo counties, reported that hospitals in the area are experiencing challenges related to COVID-19 and discharging patients on oxygen. “One of the things that we have experienced is oxygen concentrators that are in high demand and short supply,” said Maritza Padilla, Assistant Chief Nursing Officer at DHR Health. While oxygen cylinders are the gold standard for most patients and often is what is readily available at discharge, they may be the only option for home use if the demand continues to grow. When discussing the topic further Dr. Robert Martinez, Chief Medical Officer for DHR Health, stated “I think that has been a big misconception, the inside of the hospital is not short of oxygen. The home — that’s where our challenge has been.”
In a recent July trip to Weslaco, TX, Gov. Greg Abbott told Hidalgo County Judge Richard F. Cortez that the county would be sent oxygen concentrators, additional beds and IV pumps. It remains unclear, though, how many were sent or whether the additional supply was enough to cover the need. A local DME owner told The Monitor that he has never seen a situation where so many patients needing oxygen are being discharged home at the same time. He has been inundated with calls to meet the needs of oxygen patients from San Antonio, TX, and bordering towns in Mexico. He is seeing the effects in his business, experiencing some back order from oxygen concentrator companies.
Case managers and social workers are working tirelessly to ensure that a patient has a safe discharge however it becomes challenging when patients do not have adequate coverage or the means to get oxygen. With COVID-19, the lungs are greatly affected as are other organ systems that rely on the supplemental oxygen that can delivered with an oxygen concentrator. Veronica Silva, Nursing Director of DHR Special Infectious Disease Unit-2 in Edinburg, TX shared that DHR has developed a charity through which they donate needed oxygen to patients and will continue to do so until resources are exhausted.
Other areas of Texas are also experiencing challenges related to COVID-19 and discharge delays due to shortages in oxygen availability. Last month, the Texas Department of State Health Services responded to the call for help that more than 70 hospitals around the state were pleading for.
The Rio Grande Valley area has been overwhelmed with COVID-19 patients and Doctors from Starr County Memorial spoke out. Hospital President, Dr. Jose Vazquez shared in an interview how greatly affected the population has been in the area, most of which are Mexican Americans with high rates of diabetes and obesity. Dr. Vazquez shared his hospital was lacking even the basic medical necessities, oxygen. He said five patients had a delayed discharged and remained admitted to the hospital because they could not get the oxygen they need for their homes.
“You know, when you live in America an oxygen tank or an oxygen concentrator should not be the reason why a patient is not discharged, when you are needing those beds for somebody sicker than you,” Vazquez said. State officials were working on getting oxygen concentrators to the region to free up more beds, however the status of that remains unknown yet.
While the United States of America may not be experiencing an extreme shortage of oxygen in the hospital settings due to more advanced infrastructure, lower-income countries such as Mexico, Peru, Brazil, and India are experiencing such challenges. Shortfalls include extreme measures such as patients and their family members buying overpriced oxygen on the black market for their sick loved ones in Peru. Or as seen in Reynosa, Mexico there is a shortage of oxygen for coronavirus-infected patients who must be treated at home due to the lack of hospital bed availability. Families in Mexico often wait in long lines to have their oxygen tanks filled, waiting for several hours at times, and are paying inflated cost due to demand. A Rental of a tank costing them $400 a month and additionally $200-300 per refill which is needed about every 3 days depending on the level of oxygen needed.
According to information published by the WHO, they are partnering with the United Nations and are working with manufacturers to buy oxygen concentrators for countries that need them most. This has allowed the WHO to buy 14,000 oxygen concentrators, which will be sent to 120 countries. Additionally, it identified 170,000 more that will be available over the next 6 months at a cost of $100 million.
We now know the vital role that oxygen plays in the treatment of COVID-19. Now more than ever it will be imperative to ensure patients that are discharged home post COVID-19 have the appropriate resources, oxygen therapy, available to them and work to meet the growing demand worldwide.