Policy responses for France - HSRM


Policy responses for France

3.2 Managing cases

The management of cases will remain similar by the end of the lock-down, mainly at home if there is no complication, but confirmed cases will have the possibility to be more stringently isolated in requisitioned hotels to protect their relatives. For the moment, there is no specific measure for strengthening home care services.

Patients infected by Covid-19 in long-term care settings (that is, nursing homes and facilities for disabled people) are treated within these settings.

Starting on January 20, 2021, all people tested positive will receive an at-home visit from a nurse.

So far, there are no legal recognition, specific care modalities or benefit package for people with long-haul Covid-19. This is, however, evolving over time. The health authority (HAS) has issued on February 12, 2021, the first recommendations, focused on patient-centred care and rehabilitation, to help physicians take care of this group of patients. Concurrently, MPs have filed a legal resolution for the official recognition of long-haul Covid-19 as a disease and for planning its care.

Initially, in early stages of the epidemic, all suspected people were referred to hospitals. National recommendations for managing COVID-19 cases were first published in March and regularly updated on the Ministry of Health webpage (https://solidarites-sante.gouv.fr/soins-et-maladies/maladies/maladies-infectieuses/coronavirus/covid-19-informations-aux-professionnels-de-sante/article/covid-19-prise-en-charge-en-ambulatoire). The current (since week 12) national recommendations for people who have symptoms suggestive of COVID-19 are that:
• If there are no signs of severity, patients should contact their regular doctor. Otherwise, they are encouraged to call health centers or use telemedicine (that is, have a consultation online with any physician). In any case, tele-consultation solutions should be favoured, depending on the situation.
• In the event of serious signs (breathing difficulties, etc.), patients are asked to call 15, the paramedics service (SAMU), which organizes transfers to the hospitals. Patients are asked not to go directly to emergency departments to avoid contact with other patients.
For face-to-face consultations, general practitioners are invited to group their consultations with patients suspected of being infected by COVID-19 over the same time slot. The recommendation on the Ministry's website says "It would be good to wear a mask during the consultation, and not to carry out an ear, nose and throat examination". If the patient shows signs of severity during examination, the generalists are asked to call the SAMU center (15).
Testing. Patients with signs of COVID-19 are no longer systematically classified and tested biologically (RT-PCR SARS-CoV-2). Only the following cases should be systematically tested:
- people with severe symptoms and signs of COVID-19
- healthcare professionals with symptoms suggestive of COVID-19
- people who are fragile or at risk with symptoms suggestive of COVID-19
- the first three people with symptoms suggestive of COVID-19 in nursing or older people housing facilities, to take rapid measures to avoid transmission between residents
- hospitalized people with symptoms suggestive of COVID-19
- symptomatic pregnant women, whatever the term of the pregnancy
- organ, tissue or hematopoietic stem cell donors.
For patients in hospital and for those with severe symptoms, these tests will be performed in hospitals. For other patients who meet the screening criteria, it is possible to be tested in ambulatory laboratories, on medical prescription. The first week of April, less than 20% of all tests were conducted out of hospitals.
Care at home: Patients with COVID-19, in the absence of hospitalization criteria, are treated at home and are asked to be strictly isolated. They benefit from sick leave on free medical assessment. In case of strong suspicion of COVID-19, the recommended duration of isolation is 14 days.
Treatment is symptomatic, accompanied by hygiene and monitoring advice. NSAIDs and corticosteroids are prohibited.
The monitoring methods are decided on medical assessment:
- Simple self-monitoring of symptoms, without subsequent consultation.
- A medical follow-up (teleconsultation to be favored) between D6 and D8 for surveillance.
- Reinforced follow-up at home by nurses for patients at risk (usually older people) who cannot assume self-monitoring.
- Hospitalisation at home for older people (> 70 years) with high risk of complication or in difficult psychosocial situation.

If symptoms worsen (breathing difficulty), patients should contact the SAMU Center. The entire household living with a COVID-19 case must also be isolated strictly at home. Asymptomatic members must apply the recommendations for isolation with a patient, take their temperature twice a day and self-monitor their symptoms.

There are few initiatives at the margin for ensuring a regular monitoring of high-risk patients at home and unclog the emergency services. The Assistance Publique – Hôpitaux de Paris (APHP), which is the University hospital trust working in Paris and surrounding areas, has set up  a tele-monitoring platform since March 9, which allows daily and automated monitoring of patients who are positive for the coronavirus, or suspected of having contracted Covid-19, but who do not have severe symptoms. The platform, which had about 30 000 patients by March 31, is maintained by about 200 to 300 volunteers, who benefited from a training and get support from doctors and call between 4,000 and 6,000 people every day depending on the alerts received. Their mission is to prevent patients from going to hospital without really needing but also to convince them to go there quickly if they notice a deterioration in their health.

Patients infected by Covid-19 in long-term care settings (that is, nursing homes and facilities for disabled people) are treated within these settings. 1 500 volunteers and 3 000 auxiliary nurses in training were mobilized to help permanent staff within these settings. It is estimated that 45% of nursing homes have at least one infected case and that 50,000 tests were carried out in such settings.