Policy responses for Spain - HSRM


Policy responses for Spain

3.2 Managing cases

On May 9, the Ministry of Health published new guidelines for managing COVID-19 cases during the transition period (https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov-China/documentos/COVID19_Estrategia_vigilancia_y_control_e_indicadores.pdf).

Cases not requiring a hospital admission will be isolated at home and monitored by primary care services until medical discharge. If isolation of mild cases cannot be guaranteed at home, patients will be allocated at hotels or other premises set up for this specific purpose. In case of those cases requiring hospital admission, they will be isolated and treated according to hospital nosocomial infection guidelines. If patients are discharged while being PCR positive, isolation will continue at home.

In nursing homes or assisted living homes, confirmed cases will be isolated for at least 14 days and closely monitored by a physician. Only one case will support a declaration of an institutional outbreak and all close contacts will be quarantined, monitored and PCR tested in case they show compatible symptoms.

In prisons and other closed institutions, confirmed cases not requiring hospital admission will be isolated for at least 14 days and treated by the healthcare services in the institution.

Lastly, confirmed cases among health and social care personnel will be treated as the general population although, in addition to symptoms’ recovery, a negative PCR test will be required to go back to work.

On March 4, the Public Health Commission approved a document describing the adoption of the measures in nursing homes and social care centres in the context of vaccination. Residents, workers and relatives should be informed that, despite the decrease in the risk of COVID-19 infection after vaccination, this fact does not guarantee a total protection of the vaccinated people. In that sense hygienic and prevention rules, such as mask wearing, hand washing and physical distance must keep being observed.
New residents will be vaccinated prior their admission and in case of urgent admission, preventive measures will be taken until the patient is vaccinated. In the same way, new workers will be vaccinated before their incorporation to the centre.

Screening residents or performing serological tests to verify effectiveness of the vaccine is not recommended. Screening workers is not recommended either, but regions can consider this option in light of their epidemiological situation. In this case, testing is recommended after holidays or long absences. In case of a suspected case among the vaccinated residents or workers, they will be isolated until the tests results. If tested positive, measures to be taken will be those already described here (https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov/documentos/COVID19_Estrategia_vigilancia_y_control_e_indicadores.pdf). In any case, those residents not vaccinated will be especially protected, placing them in individual rooms when possible.

Nevertheless, rules for visits and permission for residents to leave the nursing home temporarily will be relaxed after a personalised assessment of each resident and centre (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5257).

The first contact point measures have changed with the evolution of the outbreak and are somewhat different across Spain’s regions (Autonomous Communities). 

At the very beginning of the crisis, the usual pathways of care, that is, primary care centres and hospital emergency departments, were the reception point for cases. Shortly afterwards, mild cases were advised to stay at home and call the regular 24/7 emergency call centres from which they could obtain advice and/or the activation of a mobile unit to their home. Currently, most Autonomous Communities have a dedicated phone helpline that is different from the regular 24/7 call centre number, keeping the latter for emergencies not related to COVID-19. Some Autonomous Communities have also developed an on-line self-administered survey to help citizens figure out how likely it is for them to be infected. 

The dramatic increase of cases within a short period of time has strained the response capacity of the health system in specific areas of the country.  In particular, emergency departments, hospital beds and ICU beds and devices, especially in the city of Madrid, are experiencing long queues of patients, with delays in the triage of patients and subsequent care. No rationing measures have been proposed to solve the situation but field hospitals have been set up to either unlock regular hospital beds or to provide triage and first emergency care to patients with mild symptoms. On the other hand, patients who are close to being discharged, can also be transferred to hotels that have adapted rooms for this purpose.

Although there are no reports on care rationing for COVID-19 patients, the working group on bioethics of the Spanish Society of Intensive Care Medicine, Critical Care and Coronary Units (SEMICYUC) has published a document with ethical recommendations meant to guide clinical decisions in intensive care units (ICU) within COVID-19 epidemics. These recommendations include guidance on: a) decisions on patients’ admission in the eventual case of a shortage, based on the principle of distributive justice; b) decisions on ICU patient referral to other ICUs or other intermediate resources, within the same hospital, a different hospital, and a different region; and c) decisions aimed at the protection of healthcare workers (RECOMENDACIONES ÉTICAS PARA LA TOMA DE DECISIONES EN LA SITUACIÓN EXCEPCIONAL DE CRISIS POR PANDEMIA COVID-19 EN LAS UNIDADES, https://semicyuc.org/wp-content/uploads/2020/03/%C3%89tica_SEMICYUC-COVID-19.pdf)

In addition, the Ministry of Health has compiled best practice and recommendations on how to cope with the outbreak, prevention and control of the infection, guidance on case management in hospitals and ICUs, and management of vulnerable groups. These documents are being continuously updated as evidence progresses (Consumo y Bienestar Social - Profesionales - Documentos técnicos para profesionales - Coronavirus, https://www.mscbs.gob.es/en/profesionales/saludPublica/ccayes/alertasActual/nCov-China/documentos.htm).