MEASURES INTRODUCED IN 2020
Patients who have flu symptoms are advised not to seek care in primary health care settings, or hospital emergency units, but instead to call either their family physician or 112. Hospitals are advised to create a triage section at the entrance to screen all patients, to identify possible cases and to limit the spread of the infection in the hospital.
The National Centre for the Surveillance and Control of Communicable Diseases has published a set of recommendations for health premises and health workers with regards to patients’ admission, management of suspected or confirmed cases, protection of health workers, and communication with COVID-19 suspected or confirmed patients. These recommendations are based on WHO guidelines.
Diagnostic procedures have been established in accordance with the methodology and testing algorithm of the National Centre for the Surveillance and Control of Communicable Diseases. While waiting for the test results, patients are isolated in individual rooms in buffer zones in order to prevent the spread of the infection. Patients who do not test positive for COVID-19 will be referred to non-COVID hospitals. Patients who tested negative but having symptoms and a COVID-19 characteristic CT feature will be kept in isolation and will repeat the test in 48 hours. Patients testing positive will be referred to a phase I or phase II hospital (see Section 3.1), where they will be clinically evaluated and further referred to an appropriate medical unit, in accordance with the severity of the disease. Asymptomatic patients without underlying risk factors will be referred to specific isolation and treatment facilities for 48 hours, then they will be isolated at home for the remaining 12 days. Asymptomatic patients with risk factors and patients with mild symptoms will be referred to phase II hospitals or support hospitals. They will be discharged after at least 10 days if they do not have fever and their symptoms have ameliorated within the last 72 hours. A control test is done in the 8th day after admission. Patients testing positive despite ameliorated symptoms will be kept in isolation at home 4 more days after discharge. Patients isolating at home will be monitored by the family physician or by the district health authority if he/she is not enrolled with a family physician. Asymptomatic patients under dialysis will be discharged after 14 days. Patients with more severe symptoms will be admitted to hospitals that have IC units. Specific criteria have been established for transferring patients from one medical unit to another when there are changes in their symptoms. Patients discharged with persistent dyspnoea are referred to respiratory monitoring and rehabilitation services.
Patients tested outside of hospitals (dialysis centres, nursing homes, ambulatory settings, etc) will be isolated at home, separated by family members, while waiting for the test results.
Dedicated procedures have also been developed for the maternities and maternity wards and the dialysis centres included in the support hospital network (see Section 3.1). These procedures concern patient flows (including patients discharge, transport and transfer), tasks and responsibilities for each member of medical staff involved in providing care, preventive measures, and rules for mothers.
In the case of COVID-19 infection suspicion, the physician reports the case to the district public health authority. Testing is not possible without a physician referral. For the confirmed cases the district public health authority initiates the epidemiological investigation within two hours from reporting. The epidemiological investigation is supposed to reveal preliminary results within 24 hours, in order to identify close contacts.
Only confirmed cases are admitted to the hospital. Currently, all COVID-19 patients are admitted for hospital treatment. As the number of cases increased and the capacity of COVID-19 hospitals was reaching its limit, a specific order was issued on the 21st of June by the National Committee for Special Emergency Situations introducing measures for quick reporting of cases and bed occupancy in the COVID-19 hospitals and long-term social and medical facilities. These measures are aimed at supporting the management of cases and minimising the risk of new outbreaks.
The national treatment protocol is periodically updated and recommends differential treatment for outpatients as well as mild, moderate and severe in-patient cases. It has been developed based on WHO and ECDC recommendations, clinical guidelines in China, Italy and Belgium, and other research evidence.
In April 2020, the Ministry of Health accepted the donation of three devices for convalescent plasma extraction and is investigating this therapy in three hospitals. This work is based on research protocols developed by the National Agency for Drugs and Medical Device, following similar investigational treatments applied in other EU countries, USA and China. By June 2020 another 15 devices had been donated. The number of persons who donated plasma was low (490 by August 2020) - this has been ascribed to complex methodology and weak awareness rising campaign. To increase the number of donors the Ministry of Health has simplified the methodology for convalescent plasma donation so that any person who was previously infected could become a donor, and not only persons were admitted to hospital. Further, prospective donors no longer need to bring proofs of two RT-PCT negative tests and the list of required documents has been shortened.
Since October 2020, as the number of cases increased, RT-PCR tests administered in the hospital emergency rooms have been combined with rapid antigen testing for symptomatic cases. Patients with positive rapid test results will be immediately isolated in COVID-19 departments, while patients with negative rapid test results will be sent to the buffer zones if the symptoms require admission or will be isolated at home until the RT-PCR test result is found if the symptoms are mild. Patients tested outside of hospitals (in dialysis centres, nursing homes, ambulatory settings, etc.) will be isolated at home, in separation from family members, while waiting for the test results.
Physician are required to report suspected COVID-19 infections to the district public health authority. At the beginning of the pandemic, testing was not possible without a physician referral, but later, as testing capacity increased, tests could also be performed without a referral for those who could pay for them out of pocket. If COVID-19 infection is confirmed, the district public health authority initiates the epidemiological investigation within two hours from reporting of test results. Preliminary results of the epidemiological investigation should be available within 24 hours, in order to identify close contacts.
From the end of October 2020, asymptomatic patients without risk factors and patients with mild symptoms have to isolate at home for 14 days and are monitored by family physicians. Only confirmed cases are admitted to hospitals. While the early response plans foresaw hospital admission for all COVID-19 patients, with an increased number of cases, only severe cases are now admitted to hospitals and mild and moderate cases are treated in outpatient settings.
By the end of October an electronic information system was set up to improve communication among patients, laboratories, district public health authorities (DPHAs) and family physicians. Thus, it is expected that all tests will be processed within 24 hours and the results will be automatically sent by e-mail and SMS to the tested person, the family physician or the DPHA if the patient is not enrolled with a family physician. The DPHAs will send isolation orders to patients who tested positive and to their family physicians. In absence of other events, the patient’s file will be closed automatically after 14 days and marked as “healed”. If the patient was admitted to the hospital, the hospital will mark the patient’s status (“healed”, “transferred”, “isolated at home”) at discharge.
Retesting within 90 days after recovery can only be done for severely immunosuppressed patients and for those with suggestive symptoms of infection.
MEASURES INTRODUCED IN 2021
WHAT ARE THE GREATEST CHALLENGES IN MANAGING COVID CASES AT THIS STAGE IN THE PANDEMIC AND WHAT IS BEING DONE TO ADDRESS THEM?
One of the greatest challenges in managing COVID-19 cases is the lack of adequate resources, including modern hospital infrastructure. This was acutely manifested in the fire outbreaks that occurred recently in two hospitals treating COVID-19 patients (in November 2020 and in January 2021). The majority of public hospitals are old (most of them built over 50 years ago) and do not allow for proper implementation of fire preparedness and prevention measures. A recent report has found that power systems in older hospital facilities are not suited to support high numbers of patients and electrical devices and do not have a proper technical division for maintenance, safety checks and necessary updates and development. Following these events, the Minister of Health announced implementation of the following four measures:
• Improving hospitals prevention and preparedness;
• Allocation of EUR 50 million for urgent hospitals investments;
• Improving communication between COVID-19 patients admitted to hospitals and their relatives;
• Change in the vaccination priority: for one month Stage 2 vaccination was available only to high risk groups, while vaccination of other groups was postponed. This measure was aimed at reducing the burden for hospitals.
HOW HAS THE ROLE OF PRIMARY CARE AND GPs IN MANAGING CASES CHANGED DURING THE FALL AND WINTER 2020/2021?
Family physicians were initially neither involved nor supported in treating COVID-19 patients. Their key contribution at the beginning of the pandemic was to provide remote consultations and advise patients who tested positive to call the ambulance. From the end of October 2020, with the increasing number of cases, family physicians have taken charge of remote monitoring of asymptomatic COVID-19 patients without risk factors and of patients with mild symptoms who had to self-isolate at home for 14 days. They have been paid 105 RON (approx. 21 Euros) for every monitored patient.
Since the vaccinations started, family physicians have been expected to advise patients on vaccinations (to that end they were supplied with information materials) and to help them make online vaccination appointments. There are plans to further involve family physicians in the vaccination of the general population (Stage 3 of vaccination campaign) with vaccines that do not require special conditions (such as extremely low storage temperatures).