Virtual Care expands options and support for Manitoba COVID-19 patients

To say that Manitoba’s health system has been pressured and challenged over the past year would be an understatement. The arrival of COVID-19 in spring 2020 brought about the need for health system leaders to completely re-evaluate all aspects of care and make difficult decisions based on an unknown, not well-understood novel pathogen that was proving fatal throughout the globe.

Planning and preparations began immediately to meet the demands of an anticipated influx of very sick patients and the resulting impact on the capacity of our hospital system. The system response to the pressing demands of COVID-19 included the suspension, scaling back, or transition to virtual care for all non-urgent and emergent outpatient procedures—including bronchoscopy, GI endoscopy, clinic visits, and most elective and non-urgent surgeries. The impact of these service reductions was very great. There was also the added concern that hospitalizing mild to moderately ill COVID-19 patients (as had been done in other jurisdictions) could pose additional risk of iatrogenic (exposure-related) outbreaks of the virus. 

In response, a group of physician specialists from various backgrounds began working on a concept that would eventually become the Virtual COVID-19 Outpatient Program (VCOP). This remote monitoring program would support the recovery of mild to moderately ill patients at home, while staying connected with their healthcare providers.

While Manitoba’s test positivity rate remained low during the early months of the pandemic, the second wave saw a significant surge in cases and outbreaks declared across the health system. In hospitals, multiple patient rooms and aging infrastructure—including minimal airflow/ventilation systems in many areas—contributed to the challenge to protect staff, minimize spread within facilities, and manage an influx of patients. The focus on advancing the launch of the Virtual COVID-19 Outpatient Program intensified with a motivation to protect patients, staff, and overall hospital capacity.

The program was created and led by Drs. Ken Kasper (medical director, VCOP), Yoav Keynan (infectious disease), Dana Moffatt (gastroenterology), Clare Ramsey (respirology), Martha Ainslie (respirology), and Jonathon Laxton (internal medicine), the majority of whom are UM graduates. VCOP officially launched at Health Sciences Centre (HSC) Winnipeg in December 2020 and later expanded to other sites in Winnipeg and southern Manitoba.

Kasper notes: “Initial applications for start-up funding that would cover remote monitoring equipment, including finger probe oximeters, to measure patients’ oxygen, thermometers to assess for fevers, and tablets for patients without their own devices, along with the request for a physical space to function were met with skepticism.”

However, the surge in cases tied to the second wave and dramatic increase in hospitalizations due to COVID-19, the project gained steam with the help of Dr. Shawn Young (Site Medical Lead, HSC) and Rob Grierson (Chief Medical Officer, Emergency Response Services, Shared Health).

Launching VCOP on December 14, 2020 was made possible with the generous support of the HSC Foundation, which donated funds for tablets, oximeters, and thermometers for the initial phase of the project. Phase One was limited to patient intake through the HSC Emergency Department and COVID wards and the Winnipeg Alternate Isolation Accommodation site (where individuals in need of a safe place to isolate could be accommodated) managed by Shared Health.

The initial goal was to decant 50 patients to the VCOP program, with an anticipated savings of more than 200 patient days in hospital. With each day in hospital estimated to cost approximately $650, the team anticipated hitting its breakeven target for the project without much trouble.

The VCOP Plan – To decant stable and mildly ill new COVID-19 patients with respiratory symptoms requiring low-level oxygen (less than 4 Liters per minute by nasal prongs) from inpatient wards, supporting them instead to continue their recovery at home. These patients would be assessed as low risk for decompensating but slow to recover and would be those stabilized enough to go home on oxygen.

Partners – To ensure VCOP patients have ongoing access to care in the event of decompensating or requiring readmission, we partnered with Shared Health Emergency Response Services and the Winnipeg-based community paramedic (EPIC) program to provide in-person assessment and, if required, transport to hospital.

Aside from the obvious health economic benefits and prevention of iatrogenic infections, VCOP has proven to be a very effective pressure release valve for participating hospitals. Following initial success at HSC, the program was expanded to patients at St. Boniface and Grace Hospitals in March 2021, and to Boundary Trails Health Centre, Victoria General, Concordia Hospital, and Seven Oaks most recently.

As of July 5th, 2021, 300 patients have been supported through VCOP, a large portion of whom have required home oxygen, and a staggering 2,000 plus inpatient days have been saved. The team estimates this may have been the most cost-effective program in its history, and it has the added benefit of glowing reviews from patients about their care.

Kasper says: “While we were confident we could achieve significant benefits for the hospital system and patients through the creation of this program, the feedback from patients has also been very positive. Patients have been incredibly receptive to this new service, welcoming the opportunity to return home from hospital or to avoid admission entirely.”

Kasper explains that the service is personal and consistent. Each day, members of the small – but mighty – team (consisting of a single physician, two nurses, two clerks, and one physician assistant) meet with every active VCOP patient. A nurse and a physician use Microsoft Teams to complete vital sign assessments, modified exercise tolerance testing, and overall wellness checks. 

“I was very fortunate to be one of the first few patients to experience the program,” said one patient who provided their comments anonymously. “I can say that I was satisfied with the way the program was handled. During times of uncertainty and anxiety, it helps that someone who knows …the virus can check on you without the need to go to the clinic or hospital.”

Without exception, patients report being happy to be at home, in a comfortable, quiet place, and are reassured with the daily assessment by nursing and physicians. Patients really do feel like they are getting optimal medical attention.

“Our experience was amazing. To have our family member able to come home and recuperate at home meant she got better quicker,” said an unnamed family member of a participating patient. “Having the oxygen at home and all the monitoring gave us all peace of mind. Having the contact with both nurses and doctors was awesome to have any and all questions answered.”

Plans for expanding this program continue, with work underway to extend to other communities outside Winnipeg while COVID-19 continues to require our services. Ultimately, the recent success and learnings will be important to Manitoba’s broader vision, outlined in the Clinical and Preventive Services Plan, supporting virtual care and remote home monitoring for mild and moderately ill patients and those impacted by chronic disease.

Chris Rutkowski