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Covid at Home
Charles Liang, DO discusses the purpose of the Covid at Home program. He walks us through how Carle identifies patient selection for this program and the goals of the program.
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Learn more about Charles Liang, DO
Charles Liang, DO
Charles Liang, DO is the Health Alliance Medical Director.Learn more about Charles Liang, DO
Transcription:
Melanie: Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole, and I invite you to listen as we discuss the COVID-At-Home Program at the Carle Foundation Hospital. Joining me is Dr. Charles Liang. He's the lead physician in Transitional Care at the Carle Foundation Hospital.
Dr. Liang, it's a pleasure to have you join us again today. Tell us what is the COVID-At-Home program. What's that all about?
Dr. Charles Liang: It's a program that Carle's come up with to help monitor patients at home, so that they feel more comfortable about their condition and it helps to alleviate a lot of their anxiety that they have. What we've seen with COVID that we haven't seen with, for example, pneumonia is the amount of anxiety that patients are having over their condition. And this is no doubt fueled by what they see on television, sees ICU being overfilled and patients passing.
So one of our ER doctors, Dr. Ben Davis, started something on his own with one of his coworkers who had COVID and who was very anxious about the condition. So Dr. Davis called them daily and walked them through the process and they found that this was so helpful that Carle decided to try to implement this for all of our COVID patients who have been seen already by a provider, have had a chest x-ray.
And what we ended up doing is giving them a little COVID kit with a pulse oximeter and a thermometer and some instructions and literature. Then the next piece of it, which is really the most important part is where a provider, usually a physician, but sometimes an APP, will call that patient daily. And we try to set up calls so it's the same provider calling for at least four or five days in a row. So that way, you develop a rapport with the patient and you also build a level of trust. And you can also tell if they're getting better, getting worse or staying the same.
Melanie: Wow, what an amazing program and what a great idea. So how do you identify the ideal patient selection for the COVID-At-Home Program? And as you mentioned, Dr. Liang, it can be nerve-wracking. In some sense, it's like more reassuring to be in the hospital, if you needed oxygen, if you spike a fever, but if you're at home, it can be a little bit frightening, really. So how do you identify that ideal patient for COVID-At-Home?
Dr. Charles Liang: We depend on the emergency department a lot, because initially our referrals are all coming from the emergency department. When the emergency department finds a patient or sees a patient that their pulse ox is a little bit below normal, but otherwise they're fine, they may even have a little COVID pneumonia on chest x-ray, but they really don't meet admission criteria.
So it's good for the ER, it's good for the patient to know that they're going to be followed every day. And that makes a patient so much more comfortable and makes the docs more comfortable to know that, "Yeah, I know I'm not going to be admitted today, but what about tomorrow?" "We're going to have someone call you tomorrow and they're going to call you every day until you stabilize, until you get to the point where we feel like you're doing okay. And you know what? You get to keep the pulse oximeter. So that's yours now."
Melanie: Take home prizes. Is this a televisit or is it on the telephone?
Dr. Charles Liang: This is a telephone visit. We've tried to use televisits a bit and we've had mixed success with it. Some patients don't have the bandwidth for it. Some others don't have the tech savvy. They're using the phone or they have to download an app. It was a barrier. So we've gone with phone calls and, even though it's low tech, it's surprising how much information you can get from a phone call when you're talking to the same person over time.
And another piece that's developed is patients that have family at home with them, that helps a lot. Especially with an older patient, speaking to a daughter or a son, it's great to be able to ask them, "Hey, does your dad look better than yesterday or the same? Or does he look better than two days ago or the same?" That also gives us more clinical information.
Melanie: That certainly does. And I imagine it's quite reassuring. So what's the next step. Suppose somebody's pulse ox drops below, what are we looking at? Ninety? Eighty-five?
Dr. Charles Liang: We're using 93. If they go below 93% at rest, then we have the option of starting them on oxygen. We can send and order home oxygen for them. They'll get there within four hours. So that's a huge plus. Through Carle Medical Supply, we're able to do that.
Melanie: That's incredible!
Dr. Charles Liang: Yeah, it's not just the number though. It's also where they are in the illness. It's multifactorial. Obviously, if someone's pulse ox has dropped down to 85 or 80, then you know, you need to go in and something's wrong. But for those patients that are on the border, we look at what day is it in their illness, because per the CDC and I agree with this from our clinical experiences, days eight through 12 tend to be the days that patients are going to get in trouble, if they're going to get in trouble. Or I should say, if they're going to get in trouble, days 8 through 12 are the days that it usually occurs in.
So if a patient is day 15 or 16, and they're telling me their pulse ox is dropping a little bit, I'm more inclined to just watch them. If their pulse ox is dropping on day six and they're coming up on days 8 through 12, I'll start them on oxygen a little bit earlier because I know that if it's gonna get worse, those are the days that it'll happen. And then that will also depends on what their family members are saying.
And I'm happy to say that no one that we've ever sent in to the hospital has had to be intubated. So what that tells me is that we're not waiting until, "Oh, no. They're really bad. Let's send them in now." We're sending them in before they get too bad. So they've gotten by just on the Optiflow high flow oxygen and they've all been discharged.
Melanie: And it's certainly more comfortable to do COVID-At-Home, as you say. So before we wrap up, what would you like other providers to know about this incredible program that helps people to feel safe and taken care of while also being a little bit more comfortable and less fearful that they are in the hospital? What would you like other providers to take away from this episode about COVID-At-Home and what you're doing at the Carle Foundation Hospital?
Dr. Charles Liang: I think it's a great option for those patients that you're sending home from ED. It provides additional monitoring. It alleviates bounce-back visits because of anxiety and it also catches happy hypoxemia, which we're seeing with COVID especially, where their pulse ox is dropping, but they feel normal.
So when they come in, they're really low because this has been happening gradually. It's creating the impression that COVID happens fast. I don't know if it happens as fast as we think. It's probably more in combination, but this happy hypoxemia has a big role in it. And being able to give COVID patients a pulse oximeter and checking on them makes a big difference because we're going to catch that drop sooner rather than later.
And then some people may say, "Let's just give a pulse oximeter to every patient with COVID." What we find is that unless you're calling every day, sometimes patients just don't do it. Even though it's there, even though it was free, they don't do it. When I call them, then they go, "Oh, wait. I haven't done that yet. Let me get my meter," and then they'll do it. And then the next day, they're doing it, because they know someone's going to be holding them accountable. Someone's going to be calling tomorrow.
And we got a lot of good feedback from patients saying how much they appreciate the call and how comforting it is to know that they're not alone. Some patients feel like, "My doctor doesn't want to see me because I have COVID. They tell me to quarantine, don't come into the office. Who's going to take care of me? Who knows that I'm here?" So this is a way to stay in touch with them and let them know that they're not alone.
Melanie: What a great program, Dr. Liang. Thank you so much for coming on and sharing that with us. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle-sponsored educational activities, please visit our website at CarleConnect.com for more information and to get connected with one of our providers.
We hope the information gained will be applicable to your work and life. And if you found this podcast informative, please share on your social channels and be sure to check out all the other interesting podcasts in the Carle Foundation Hospital library. I'm Melanie Cole.
Melanie: Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole, and I invite you to listen as we discuss the COVID-At-Home Program at the Carle Foundation Hospital. Joining me is Dr. Charles Liang. He's the lead physician in Transitional Care at the Carle Foundation Hospital.
Dr. Liang, it's a pleasure to have you join us again today. Tell us what is the COVID-At-Home program. What's that all about?
Dr. Charles Liang: It's a program that Carle's come up with to help monitor patients at home, so that they feel more comfortable about their condition and it helps to alleviate a lot of their anxiety that they have. What we've seen with COVID that we haven't seen with, for example, pneumonia is the amount of anxiety that patients are having over their condition. And this is no doubt fueled by what they see on television, sees ICU being overfilled and patients passing.
So one of our ER doctors, Dr. Ben Davis, started something on his own with one of his coworkers who had COVID and who was very anxious about the condition. So Dr. Davis called them daily and walked them through the process and they found that this was so helpful that Carle decided to try to implement this for all of our COVID patients who have been seen already by a provider, have had a chest x-ray.
And what we ended up doing is giving them a little COVID kit with a pulse oximeter and a thermometer and some instructions and literature. Then the next piece of it, which is really the most important part is where a provider, usually a physician, but sometimes an APP, will call that patient daily. And we try to set up calls so it's the same provider calling for at least four or five days in a row. So that way, you develop a rapport with the patient and you also build a level of trust. And you can also tell if they're getting better, getting worse or staying the same.
Melanie: Wow, what an amazing program and what a great idea. So how do you identify the ideal patient selection for the COVID-At-Home Program? And as you mentioned, Dr. Liang, it can be nerve-wracking. In some sense, it's like more reassuring to be in the hospital, if you needed oxygen, if you spike a fever, but if you're at home, it can be a little bit frightening, really. So how do you identify that ideal patient for COVID-At-Home?
Dr. Charles Liang: We depend on the emergency department a lot, because initially our referrals are all coming from the emergency department. When the emergency department finds a patient or sees a patient that their pulse ox is a little bit below normal, but otherwise they're fine, they may even have a little COVID pneumonia on chest x-ray, but they really don't meet admission criteria.
So it's good for the ER, it's good for the patient to know that they're going to be followed every day. And that makes a patient so much more comfortable and makes the docs more comfortable to know that, "Yeah, I know I'm not going to be admitted today, but what about tomorrow?" "We're going to have someone call you tomorrow and they're going to call you every day until you stabilize, until you get to the point where we feel like you're doing okay. And you know what? You get to keep the pulse oximeter. So that's yours now."
Melanie: Take home prizes. Is this a televisit or is it on the telephone?
Dr. Charles Liang: This is a telephone visit. We've tried to use televisits a bit and we've had mixed success with it. Some patients don't have the bandwidth for it. Some others don't have the tech savvy. They're using the phone or they have to download an app. It was a barrier. So we've gone with phone calls and, even though it's low tech, it's surprising how much information you can get from a phone call when you're talking to the same person over time.
And another piece that's developed is patients that have family at home with them, that helps a lot. Especially with an older patient, speaking to a daughter or a son, it's great to be able to ask them, "Hey, does your dad look better than yesterday or the same? Or does he look better than two days ago or the same?" That also gives us more clinical information.
Melanie: That certainly does. And I imagine it's quite reassuring. So what's the next step. Suppose somebody's pulse ox drops below, what are we looking at? Ninety? Eighty-five?
Dr. Charles Liang: We're using 93. If they go below 93% at rest, then we have the option of starting them on oxygen. We can send and order home oxygen for them. They'll get there within four hours. So that's a huge plus. Through Carle Medical Supply, we're able to do that.
Melanie: That's incredible!
Dr. Charles Liang: Yeah, it's not just the number though. It's also where they are in the illness. It's multifactorial. Obviously, if someone's pulse ox has dropped down to 85 or 80, then you know, you need to go in and something's wrong. But for those patients that are on the border, we look at what day is it in their illness, because per the CDC and I agree with this from our clinical experiences, days eight through 12 tend to be the days that patients are going to get in trouble, if they're going to get in trouble. Or I should say, if they're going to get in trouble, days 8 through 12 are the days that it usually occurs in.
So if a patient is day 15 or 16, and they're telling me their pulse ox is dropping a little bit, I'm more inclined to just watch them. If their pulse ox is dropping on day six and they're coming up on days 8 through 12, I'll start them on oxygen a little bit earlier because I know that if it's gonna get worse, those are the days that it'll happen. And then that will also depends on what their family members are saying.
And I'm happy to say that no one that we've ever sent in to the hospital has had to be intubated. So what that tells me is that we're not waiting until, "Oh, no. They're really bad. Let's send them in now." We're sending them in before they get too bad. So they've gotten by just on the Optiflow high flow oxygen and they've all been discharged.
Melanie: And it's certainly more comfortable to do COVID-At-Home, as you say. So before we wrap up, what would you like other providers to know about this incredible program that helps people to feel safe and taken care of while also being a little bit more comfortable and less fearful that they are in the hospital? What would you like other providers to take away from this episode about COVID-At-Home and what you're doing at the Carle Foundation Hospital?
Dr. Charles Liang: I think it's a great option for those patients that you're sending home from ED. It provides additional monitoring. It alleviates bounce-back visits because of anxiety and it also catches happy hypoxemia, which we're seeing with COVID especially, where their pulse ox is dropping, but they feel normal.
So when they come in, they're really low because this has been happening gradually. It's creating the impression that COVID happens fast. I don't know if it happens as fast as we think. It's probably more in combination, but this happy hypoxemia has a big role in it. And being able to give COVID patients a pulse oximeter and checking on them makes a big difference because we're going to catch that drop sooner rather than later.
And then some people may say, "Let's just give a pulse oximeter to every patient with COVID." What we find is that unless you're calling every day, sometimes patients just don't do it. Even though it's there, even though it was free, they don't do it. When I call them, then they go, "Oh, wait. I haven't done that yet. Let me get my meter," and then they'll do it. And then the next day, they're doing it, because they know someone's going to be holding them accountable. Someone's going to be calling tomorrow.
And we got a lot of good feedback from patients saying how much they appreciate the call and how comforting it is to know that they're not alone. Some patients feel like, "My doctor doesn't want to see me because I have COVID. They tell me to quarantine, don't come into the office. Who's going to take care of me? Who knows that I'm here?" So this is a way to stay in touch with them and let them know that they're not alone.
Melanie: What a great program, Dr. Liang. Thank you so much for coming on and sharing that with us. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle-sponsored educational activities, please visit our website at CarleConnect.com for more information and to get connected with one of our providers.
We hope the information gained will be applicable to your work and life. And if you found this podcast informative, please share on your social channels and be sure to check out all the other interesting podcasts in the Carle Foundation Hospital library. I'm Melanie Cole.