Policy responses for Germany - HSRM

Germany


Policy responses for Germany

3.2 Managing cases

First contact point for patients with suspected COVID-19 infection

In the early stages of the epidemic, patients (suspected cases with and without symptoms) were asked to call their general physician or the 116117 non-emergency medical on-call service. In case a person had a direct contact to a confirmed case, the public health service should be called. Patients with mild clinical presentation can be managed at home with instructions to follow up if symptoms deteriorate. As of 9 March, patients with mild disease of the upper respiratory tract can have an incapacity certificate issued for a maximum of seven days, after consulting with their physician by phone. This agreement has been expended on March 24, so that physicians can now issue an incapacity certificate for up to 14 days (agreement is in force until May 31). A resolution that doctors can issue patients sick notes via video consultation, which was adopted in mid-July by the German Joint Federal Committee, entered into effect on October 9 and will initially apply until the end of the year. Patients seeking incapacity certificate must be personally known to the practice via previous treatment and the note can be issued by video for a maximum of seven calendar days. After seven days, the patient must visit the practice if they remain unfit to work. Follow-up prescriptions are also possible to obtain via video if the patient has personally been in the practice before due to the same illness. On December 3, the German Federal Joint Committee extended the regulation regarding the issuance of sick notes via video consultation in case of mild disease of the upper respiratory tract until March 31, 2021.

The 116117 non-emergency medical on-call service of the Regional Associations of SHI Physicians one of the main hotlines for people with confirmed and suspected infections and has been increasingly consulted since the beginning of the outbreak. The Regional Associations of SHI Physicians have strengthened the capacities of the hotline with an increase of staff by 25%, to 1,900 staff members.

Recommendations on treatment and testing criteria

The RKI continuously updates the guidance for care providers reflecting the current situation of the pandemic. A flowchart specifies the clinical treatment protocols and pathways health professionals in ambulatory and hospital settings are held to respect when treating a patient suspected of having COVID-19. The clinical criteria for considering testing for COVID-19 are regularly updated and are subject to change as additional information becomes available. Laboratory testing for COVID-19 should be performed for suspected cases according to the following criteria (last update 24 March):
1. Acute respiratory tract infection and having been in close contact with a confirmed or probable COVID-19 case in the last 14 days prior to onset of symptoms.
2. Clinical or radiologic characteristics of viral pneumonia in the context of increased number of pneumonias in care facilities or hospitals.
3. Clinical or radiologic characteristics of viral pneumonia with no indication of any other cause
4. Any acute respiratory tract infection and a) activity in care, medical practice or hospital, b) high-risk patients or c) without any known risk factors (testing for COVID-19 only if sufficient capacity).

The RKI provides a list of recommendations on how to prevent infections within medical facilities, also for the ambulatory setting. For example, physicians are compelled to provide separate consultations (in terms of time and space) for regular patients and suspected cases of COVID-19. This also holds for dentists. Consultations via telephone and provision of medical services via telemedicine should be extended and patients should be referred to the 116117 non-emergency medical on-call service. Physicians and health professionals in the ambulatory settings are also advised to wear appropriate PPE if there is no alternative but to see patients (depending on the type and extent of exposure).

On April 22, the Robert Koch Institute updated the clinical criteria for considering testing for COVID-19. Tests of person with mild respiratory symptoms do not longer depend on available test capacity (see also Section 1.4 Transition measures: Monitoring and surveillance). Laboratory testing for COVID-19 should be performed for suspected cases according to the following criteria (22 April 2020):
1. Acute respiratory tract infection and having been in close contact with a confirmed or probable COVID-19 case in the last 14 days prior to onset of symptoms.
2. Clinical or radiologic characteristics of viral pneumonia in the context of increased number of pneumonias in care facilities or hospitals.
3. Clinical or radiologic characteristics of viral pneumonia with no indication of any other cause, without contact with confirmed COVID-10 case
4. Acute respiratory tract infection and a) activity in care, medical practice or hospital, b) high-risk patients or c) without any known risk factors.

Organisation of outpatient treatment of COVID-19 cases

The Federal Association of SHI Physicians reported that 85% of COVID-19 cases are treated by ambulatory physicians, mainly GPs in early April. In October 2020, even 95% of COVID-19 patients were treated in ambulatory settings. To manage the high numbers of suspected and confirmed COVID-19 cases the Regional Associations of SHI Physicians and the ambulatory physicians have taken several measures to reorganise the provision of care. Medical practices with a focus on treating COVID-19 patients and outpatient clinics for patients with fever have been set up. Further, medical practices established consultation hours for (suspected) COVID-19 patients. These measures are also implemented during the second wave in autumn/winter (see Section 3.1 Transition measures: planning services).

In addition, mobile teams of ambulatory physicians and/or public health offices visit patients at home to perform tests as well as to monitor and treat COVID-19 patients. In Heidelberg so-called ‘corona taxis’ of health professionals and medical students equipped with testing and monitoring material visit patients at home to check blood pressure levels, oxygen levels, take blood samples and perform tests. The objective is to detect cases that need be hospitalized as early as possible.

Until April 27, more than 600 ambulatory physicians in the state of Rhineland-Palatinate have so far heeded the call of the Regional Association of SHI Physicians to set up appropriate measures in place for consultation hours positively tested COVID-19 patients, suspected cases or those with other symptoms. According to the Regional Association, there are currently around 50 corona outpatient clinics located in public buildings such as gymnasiums or community centres throughout the state of Rhineland-Palatinate. More than 100 registered medical practices also now have open corona consultation hours.  For immobile patients, 340 doctors in the state have also registered to do corona house calls. For their transportation, the state has provided cars, starting with four which has since risen up to ten with the ability to expand or reduce based on the current need.

On May 5, the Regional Association of SHI Physicians of Schleswig-Holstein reported that about 2,300 practices are offering infection consultation hours. In these practices, regular patients are separated physically and spatially from those who show symptoms a possible infection. Many practices have made structural changes so that they can care for patients in separate areas. Other practices have changed their organisation so that different patient groups visit their doctor at different times. However, the need for protective equipment remains high.

Since April 21, a new telemedicine tool is available online that supports people to assess symptoms and uncertainties around COVID-19. The COVID-guide (https://covidguide.health/de/ ) was jointly developed by the Central Research Institute of Ambulatory Health Care in Germany (Zi) with international partner companies from Switzerland and Italy. It allows people to get initial assessments of their situations. Users can input their symptoms and the guide will help distinguish between signs of COVID-19, flu and a cold. It also contains important information from the WHO and governmental institutions. The telemedicine tool is also available in other languages (English, French and Italian).

EU patients treated in Germany

Until April 6, Germany has admitted 130 seriously ill patients with COVID-19 from other EU countries for treatment since the outbreak of COVID-19. Most of the patients were from France (130), 44 patients came from Italy and 24 from the Netherlands. Currently there are still commitments for 58 treatment places that have not been taken up.

Sources:
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https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Massnahmen_Verdachtsfall_Infografik_DINA3.pdf?__blob=publicationFile
https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Getrennte_Patientenversorgung.html
https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Hygiene.html
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