An earlier post on COVID19 wondered why we don’t have more consumer products to replicate intensive care units in hospitals. Such products may be owned and operated with ones own home especially when there are close relatives, friends, or neighbors who can do basic checking of the devices. The devices themselves can connect via the Internet for remote monitoring by health care professionals with alerting for paramedic assistance. that people by for their home use, especially now that we can connect the measuring devices to the Internet for remote monitoring. It seems to be that such devices can be mass produced and made more affordable with the expectation that they would be disposable after a relatively short period of a couple weeks to care for just one patient.
Such a technology could be very helpful for managing epidemics in particular by maximizing the time to keep patients at home and out of hospitals. I imagine that the commercial versions would cost comparably to a home appliance. When it is no longer needed, it may be sold back to the vendor for refurbishment, or the device may merely be leased.
If such products existed, there likely would be a market for it even if the costs were not covered by health insurance. Many people would expect that their homes would be more comfortable than being in a hospital, and these people may accept paying what might amount to have a monthly cost of a car lease or apartment rent payment.
Even if such products would only postpone the inevitable admittance to the hospital, that additional time would save the cost on the hospital and reduce the risk of spreading a contagion within the hospital. I speculate that home health care may be more curative especially in comfortable home environments that are quieter and less bustling than hospitals.
In a true epidemic scenario, there would be multiple cases within neighborhoods so there could be a local nurse located nearby for reasonably quick responses to requests perhaps not much difference than in hospitals especially since the nurse can do a lot of work remotely though remote monitoring and two-way video calls.
I wrote much earlier about the modern possibility of treating more of the epidemic cases with home care using technology to make doctor and nurse visits more efficient. I imagined that it may make sense to have two separate health care systems: one for managing contagious diseases with home healthcare appliances and remote medical attention, and another for managing chronic (and generally noninfectious) conditions in hospitals or clinics. The latter is what we use all the time and they have a continuous utilization of available capacity with new cases replacing the closed cases.
Handling contagious outbreaks of epidemics is always a logistical challenge with the need to rapidly ramp up capacity for new patients and the move patients around through the facilities according to their status. If we can build an epidemic response around home health care with affordable yet effective consumer appliances for life support, then we may be better prepared for future epidemics.
With the current COVID19 situation, we have an recent example to reference to consider how such an alternative would work out. An infected person may already have a bed to use and only needs some consumer appliances for monitoring and basic support such as IV drips and breathing assistance.
When I wrote the earlier post about the lack of consumer availability of ventilators (erroneously referred to as respirators) I was thinking about the most invasive form requiring intubation and pure oxygen tanks. Even with such extreme cases, I imagined it might be possible to develop consumer versions perhaps with added robotics to do some of the mechanical tasks. Alternatively, the devices may be designed so that they would require just short visits by medical staff to do the insertion and removal operations. I fully realize that these are very complex with many ways it could cause problems that require emergency actions, but I’m just imagining a future where most of these emergency conditions could have some form of automated robotic type solution.
My main point then was that we could be investing in the research and development of this kind of solution to be available for the next epidemic, making it possible for people to self treat in their own homes for even more extreme complications that currently require hospitalization.
This current COVID19 crisis suggests that this may be more practical in the near term than I had imagined. Initially, we were getting reports of many people checking into hospitals with conditions that merited admissions and treatments. This lead to reports of high utilization of invasive ventilators and the lack of stockpiles were blamed on increased death rates above what was already considered a high rate.
Later, there are reports that the ventilator use may have contributed to many of the deaths. The ventilator use was properly justified with preexisting protocols, but maybe as much as 75% of those getting this type of ventilator never recovered.
There are also reports of people checking into hospitals for conditions unrelated to hospitals that otherwise would have been successfully resolved, but they ended up being redirected to COVID19 treatment because they tested positive for the virus either because they brought it in with themselves or they picked up in the hospital. This could have lead to rapid intubation and ventilation that ultimately led to their deaths.
We heard from the few that did and they credit their survival to the hospitalization benefits. We don’t hear the opinions of those who were not helped.
On the other hand, there were many people who died at home either because they didn’t have time to get admitted to the hospital or they deliberately avoided the hospital. We don’t hear much about the ones who self-treated even with great suffering but ultimately recovered on their own.
I presume that the survival rates are higher for those who were admitted to hospitals than those who avoided the hospitals when they needed it. However, I doubt that this difference is very large. In both scenarios, there is a good chance that an individual will end up dying, so it is really a matter of a gamble for the individual. For larger population statistics, the difference may matter more but there is still a cost-benefit analysis of whether the improvement is really worth the expense.
I know the answer about any expense is worth saving a single life. The calculation changes when trying to save thousands of lives when such as large portion will end up dying despite the added efforts. Eventually, we will exhaust our resources and then experience even higher rates because there won’t be any more resources to help the remaining patients.
Lately there has been some hints of information that the invasive ventilators may not have been the right treatment for many COVID19 patients.
Due to fears of aerosols from non-invasive alternatives such as CPAP or BiPAP with oxygen, the protocol dictated earlier use of the invasive approach than would be used for less contagious scenarios. This fear is unique to the hospital setting where the nurses would operate in close proximity to the patients. If the patients were self-treating at home, then CPAP and BiPAP would not carry the same fears.
In certain cases where practitioners accepted the added risks of using CPAP or BiPAP, they were seeing better outcomes leading them to believe that they were saving more lives with this approach than with the invasive approach. This even without considering newer medication treatments that also improved outcomes recently.
There already exists a consumer market of CPAP and BiPAP appliances and supplies, including oxygen concentrators. The market serves those with various chronic breathing conditions. The most expensive of these are priced in the range of high-end kitchen appliances. Certainly many people can not afford them without some type of assistance, but many others could afford them.
It may be true that hospital versions are more capable, but I wonder about the people who had died at home either by choice or by lack of available hospital beds. I suspect many of these home-care people might have survived if they had access to even the presently available home appliance versions of CPAP with oxygen concentrations that are practical to generate at home.
There are other reports of elevated death rates in hospitals despite access to more expensive equipment. The fear of contagion or spreading the contagion may have resulted in reduced care in terms of frequent patient checks or neglecting to resuscitate when needed. In these environments, the added value of the hospitalization is reduced. There are also reports of pressure for patients to sign do-not-resuscitate agreements that further reduce the value of the hospitalization as compared to just staying home.
More troubling is the rumors of people being aggressively convinced into accepting invasive ventilators in order to make the patient easier to manage (and less likely to spread the contagious) because this is a closed system and it involved heavy sedation. Most of those who get such treatment will not recover.
If there was a home-care option with CPAP and BiPAP, these would be more readily used and this may give the patient an overall higher chance of survival. As the quantity of cases increases in certain hospitals such as what happened in New York City, the relative advantage of hospitalization care likely would decrease greatly compared to stay-at-home care with affordable appliances.
Furthermore, the mind-body factor for recovery favors home health care. Due to the contagious nature of the disease, the hospital staff will avoid checking up on the patient and leaving the patient alone for longer periods of time. In addition, family are prevented from visiting patients due to the risk of their spreading the disease when they enter or leave. The loneliness and the lack of comforting companionship to allay the patient’s fears will likely added to the risk factors against making a recovery. Even if the hospital does a good job at what they are supposed to do, the patient may not survive due to the added psychological stress of being in the hospital.
Certainly, I do not know what I am talking about. I am just speculating that it may be beneficial to reevaluate our approaches for treating contagious diseases especially those associated with epidemics. We have technologies we never had before with automation, communications technologies, and with miniaturization and mass production of highly reliable consumer appliances. We could plan for future epidemics around a near total at-home treatment path instead of following the historic practice of collecting patients into hospitals.
Hospitals are very good at handing the conditions they handle normally outside of epidemics. For epidemics, hospitals are at a natural disadvantage due to the limited capacity and with the challenges of managing those resources through the uncertainties that come up.
For extreme epidemics, the hospital system is guaranteed to fail. It cannot possibly scale to handle a large portion of the population especially over extended periods of time where hospitals will face attrition from loss of staff as well as equipment.
There could be a home health care strategy with standby production capability for consumer appliances to extend the amount of care that can be administered at home. In such an approach, there will be deaths that might have been saved if they were hospitalized. From the hints we are getting from the COVID19 example, there are deaths that resulted from going into the hospital but might have been avoided if the patient just stayed at home. From a statistical perspective the two cancel each each out to some extent, especially if we can advantage the home health care with more technology that consumers can own and operate (with remote assistance from professionals).