The Action Plan for the Reorganization of the Clinical Center of Montenegro during the COVID-19 pandemic was fully implemented before the first COVID-19 patient was confirmed in Montenegro.
The national recommendations for the treatment of COVID-19 issued by the Clinic for Infectious Diseases at the Clinical Center of Montenegro outlines the stratification of patients by severity, as well as the guidelines for treatment and supportive measures. These recommendations contain the use of investigational therapeutic agents (chloroquine, hydroxychloroquine, lopinavir/ritonavir, remdesivir and tocilizumab), as well as other drugs previously included in the treatment of respiratory disease (vitamin C, antibiotics, antifungal drugs, corticosteroids, oxygen therapy etc.).
The guidelines by the Institute of Public Health classify patients by severity in relation to the need for hospital treatment.
Patients who suspect to have COVID-19 should contact the primary healthcare center or emergency medical service (depending on the degree of emergency), preferably through telecommunication (phone). Asymptomatic cases have the possibility to contact the call center at the Institute of Public Health. The primary care center, emergency medical service or the staff manning the call center at the Institute of Public health assess the patients’ symptoms and epidemiological history against the case definition for COVID-19. The mild cases are advised to stay at home. Suspected cases with moderate or severe symptoms will be hospitalized by the primary health centers or the emergency medical service (depending on the severity of the clinical condition) at a designated healthcare facility.
Patients can be discharged from the hospital when the clinical symptoms disappeared and laboratory parameters (hemograms, CRP, ALT, AST, urea, creatinine, lung X ray) stabilized. In March through July, the criterion for recovery from COVID-19 was a double negative PCR test result, together with the aforementioned clinical recovery. In July 2020, the Institute of Public Health issued a new Protocol for managing COVID-19 cases and their contacts; with regards to the self-isolation and testing rules. Furthermore, the Protocol defined that the symptomatic COVID-19 cases should have at least three days without fever and a significant decrease in the clinical symptoms – as well as 1 negative PCR test after such three days – in order to be confirmed as ‘recovered from COVID-19’.
If the patient, despite the absence of clinical and laboratory signs of an active infectious process, receives a positive or uncertain result from the PCR method, the patient may be discharged to go home for self-isolation under supervision of a primary care physician or be isolated in the institutional isolation facility (if the patient is not able to conduct proper self-isolation at home), as mentioned in Section 3.1.
The first point of contact for COVID-suspected patients are the primary healthcare physicians, the emergency medical services, as well as the epidemiologists in the Institute of Public Health.
The Institute of Public Health has set up a call center helpline for COVID-19-suspected symptoms or contacts (see Section 2.2 on the “Health workforce”). Based on the assessment made by the epidemiologists in the call center, citizens can be tested for SARS-CoV-2 (the initiative starting from the Institute of Public Health which organizes the local epidemiology service in the area where the caller is located). In addition, testing is performed in the healthcare institutions in the triage centers. Every healthcare institution has a designated triage center (which can be a temporary structure or a separate pre-existing building).
The recommendations issued by the Institute of Public Health regarding disease severity and indications for hospital treatment are followed nationally, supported by orders given by the Healthcare Crisis Response Team. All mild cases are advised to stay at home (and are checked up regularly by the GP in their area), and every healthcare institution accepts moderate and severe cases. The general advice was that all older people (over 65 years of age) testing positive for SARS-CoV-2 should be hospitalized and monitored closely (even if they have only mild to moderate symptoms). When a COVID-suspected person contacts the primary or emergency healthcare, a medical examination is made together with SARS-CoV-2 testing in order to complete a health assessment. If the first contact is made with an epidemiologist, the Institute of Public Health transfers the required information to the primary care level in order to organize the medical examination, as well as the testing.
The capacities of the Montenegrin healthcare system were sufficient for the number of patients treated by 20 May 2020. The field hospitals were designated for a large number of patients exhibiting mild to moderate symptoms, in order to allow for health monitoring and to isolate them from their surroundings in order to stop the virus spreading.
However, the number of infected people in Montenegro was not sufficient to start the activities of field hospitals. SARS-CoV-2 positive cases from the entire country who did not have any symptoms and did not have the conditions for self-isolation (living in crowded houses or testing positive while being in quarantine etc.) were isolated in a specific institution in Podgorica, Montenegro. This way, the risk of spreading the disease in homes and in quarantine was reduced.
For further explanation of the increase of COVID hospital capacities in June 2020, see Section 3.1.
The treatment protocol used in Montenegro was based on the protocols provided to Montenegro by the Lombardy section of the Italian Society of Infectious and Tropical Diseases and the National Health Commission and State Administration of Traditional Chinese Medicine, with regular updates based on scientific literature published online. Furthermore, a telemedicine conference was organized with colleagues from the First Affiliated Hospital of Zhejiang University, China, which provided valuable inputs for Montenegrin doctors. At the regional level, consultations with colleagues from Belgrade (Serbia) and Zagreb (Croatia) were undertaken, as well as a telemedicine conference with colleagues from Poland.
Montenegro has initiated the procedure to join the SOLIDARITY Trial.
Capacities for case management were strengthened further through educational video material provided by the staff of the Clinical Center of Montenegro (see Section 2.2), including weekly updates through webinars.
There were no unlicensed treatments tested in Montenegro, nor was there care rationing for COVID-19 patients.