Home Hospitalization Would Alleviate Strain on Israeli Hospitals From COVID Patients

Yoav Yehezkelli
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The coronavirus intensive care department at Sheba Medical Center.
The coronavirus intensive care department at Sheba Medical Center, Tel Hashomer, July 2020.Credit: Emil Salman
Yoav Yehezkelli

Despite the end the second wave of the coronavirus pandemic, the strain on the Israeli health care system is still being strongly felt. It’s apparent not only in the number of COVID-19 patients but also in the increasing incidence of other chronic illnesses, including mental illness, due to the lockdown. These patients are showing up at community clinics and at hospitals.

The main justification for the radical step of imposing the coronavirus lockdown – which has inflicted enormous damage to the economy, to society and to the health of the country’s population – was the prospect that hospitals would collapse as the rate of infection reached its peak. A red line of 800 seriously ill patients in Israel’s hospitals was arbitrarily set, and as is the case with red lines, it was scrapped when the number was exceeded and redrawn without explanation.

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But the truth is that hospitals never faced the risk of collapse. The non-urgent medical care that they were providing – which gave them the option to shift care if necessary to patients whose cases were urgent – was never reduced, not even at the height of the second wave, primarily due to financial considerations and concern over lost revenues.

As with the first lockdown, the second one was unnecessary and harmful, since such a step does not reduce mortality from the virus. Nevertheless, the strain on the system was considerable and the prospect that it could resurface remains as the ongoing pandemic and the expected spread of the flu during the upcoming winter converge.

Addressing these concerns requires thought, advance planning and a different type of preparations for the treatment of moderately and seriously ill coronavirus patients. Adding hospital beds won’t solve the problem because what limits the system’s capacity to provide medical care is the availability of medical personnel, not the number of beds.

State-of-the-art coronavirus departments that were created in the parking garages at major medical centers with great fanfare and media coverage don’t contribute to hospital patient capacity because they are staffed by personnel from the hospitals’ regular departments.

Thousands of ventilators acquired at huge cost stand unused. That’s because there is no staff to operate them, and efforts are now being made to sell them to other countries.

The steps required now to strengthen the health care system don’t involve the purchase of additional “hardware” but instead genuinely addressing the needs of fatigued personnel and a substantial change in work practices. In light of potential future strain on the system, what is needed immediately is a home hospitalization alternative.

In recent years, Israel’s health maintenance organizations have developed home hospitalization capabilities that have to a small extent been rolled out in the community, so that when patients in stable condition need hospitalization, they can be monitored and treated outside of the hospital. The advantages are clear. Patients are treated in their natural surroundings, and they don’t take up valuable hospital beds, which are then reserved for seriously ill patients who are not in stable condition.

The benefits are particularly relevant to the period of the coronavirus pandemic, when patients have to be in isolation. Home-based isolation can be carried out in a way that is safe for both medical personnel and the patient’s family. It also provides superior human contact between patients and their families, something that is lacking in hospitals and contributes to the patients’ recovery.

All the antiviral medications, steroids and anticoagulants prescribed to coronavirus patients in the hospital can be administered at home, as can remote monitoring of their clinical condition, oxygen saturation and lab test and imaging results. Staffing arrangements should combine personnel from community clinics and the hospitals.

Simple monitoring of coronavirus patients at home who are in good condition will free up emergency staff from the community to treat moderately ill COVID-19 patients through home hospitalization. And hospital doctors can supply the additional expertise and be kept in the loop in the event that a patient’s condition deteriorates and has to be hospitalized.

A nurse caring for a pneumonia patient in home hospitalization in Massachusetts, July 2020.Credit: Elise Amendola/אי־פי

Regulatory obstacles

The HMOs and hospitals have long expressed an interest in home hospitalization. The main obstacles to carrying out the approach have been required changes to monetary compensation to the medical service providers and inflexible regulations from the Health Ministry, which has made nearly impossible medical demands in this regard.

The government funding, which in ordinary times has involved the health and finance ministries’ familiar system of shifting their tight rein on funding between the HMOs and the hospitals as they see fit, needs to be changed if the situation is really to be addressed. Just as the coronavirus pandemic forced rapid changes in the delivery of medical care in Israel, such as the major shift to remote contact with patients, primarily through the HMOs, it is now appropriate to fundamentally change the approach to hospitalization.

It is required by the reality at a time when coronavirus infections are declining and the health care system is gearing up for another wave. The Health Ministry should immediately enable, fund and encourage the establishment of this important system as a national plan. It would provide a true expression of flexibility of thought and necessary professionalism in response to the pandemic.

Home hospitalization would serve the health system and the public well for many years to come after the pandemic subsides, and there wouldn’t be a need to build new hospitals. And most importantly, home treatment of coronavirus patients reduces the strain on demand for hospital beds. As Israel’s Iron Dome anti-missile system provides to the country’s defense, home hospitalization would provide an unparalleled measure of freedom to policy makers when it comes to critical decisions without raising the real or imaginary specter of the collapse of the health care system.

Dr. Yoav Yehezkelli is a lecturer in =the emergency and disaster management program at Tel Aviv University.

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