3. Providing health services effectively
The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.
3.1 Planning services
At the beginning of the outbreak in Israel, all patients were taken to hospitals to limit the spread of the virus. Once the virus had continued to spread, it was no longer possible to hospitalize all patients. As of March 30, severe patients were being taken to hospitals where the most intensive treatment of COVID-19 is provided. Mild cases are sometimes placed in geriatric hospitals or empty hotels that have been converted into internal medicine (IM) wards in order to ensure that they do not infect other household members. Yet, patients with mild cases stayed at home, where they are monitored by HP professionals. However, the current policy is to encourage them not to stay at home (in order to not infect other members of the household) and instead to move to care facilities. Patients do not always comply with this recommendation; apparently this is due in part to fear of not being treated properly and/or fear of leaving the family. Elective procedures have been reduced to a minimum, to enable the medical staffs to focus on the treatment of COVID-19 cases and reduce spread of the virus.
Outpatient health professionals, including those involved in primary care, are mostly treating COVID-19 patients remotely because they do not have proper protective equipment, and the MoH wants to avoid spread of the virus in outpatient facilities (e.g. in the waiting rooms). Primary care physicians were involved when hospitals were already crowded, and they are now helping with initial screening, particularly to rule out individuals with similar symptoms and with monitoring diagnosed cases who stay at home. Another important role of primary care providers is to support patients through designated on-line and telephone centers. These centres provide medical information and mental health assistance as needed.
New and clear definition of COVID-19 illness severity and treatment guidelines
Different hospitals had different definitions of “severely” ill COVID-19 patients, which caused confusion in reporting to the ministry of health, and sometimes variations in treatment paths of patients. In order to harmonize the definition and set standard paths of care, and treatment guidelines, the ministry of health issued on July, 12th, 2020 a circular with clear definitions of “severely” ill COVID-19 patients. The definition is based on COVID-19 severity definitions from the American National Institute of Health (NIH), the WHO and other academic publications. Patients are to be classified as follows:
i) Mild illness – patients with COVID-19 symptoms: fever, cough, weakness, loss of taste and smell
ii) Moderate illness – patients with clinical or X-ray diagnosis of COVID-19 Pneumonia
iii) Severe illness – patients with COVID-19 symptoms and and one of the following:
1. Breathing shortage: faster than 30 breaths per minute
2. a saturation of oxygen (SpO2) ≥93% on room air at sea level.
3. PaO2/FiO2 ratio lower than 300
iv) Critical illness - Patients in need of mechanical breathing assistance (invasive or non-invasive) or Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.
(General Medicine Division MoH, Unified definition of hospitalized COVID-19 patients, 294754420)