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. 2023 Feb 9:10547738231155298. doi: 10.1177/10547738231155298

Hospital Days Reduced for Moderate and Severe COVID-19 Patients Through a Home Monitoring Program With Oxygen

Jessica A Martinez 1,2,✉, Ariana Ehsan 3, Mary Mellady 4, Lisa Goldberg 4, Ryan A Martinez 1,4
PMCID: PMC9975290  PMID: 36760006

Abstract

While the COVID-19 pandemic continues to strain the healthcare system, it has also expanded telemedicine. There is a subset of hospitalized moderate to severe COVID-19 patients requiring oxygen but no other intervention. This is a retrospective study of patients ≥18 years with moderate to severe COVID-19 that participated in a home monitoring program with supplemental oxygen (HMP-O2) (N = 25). For study outcomes, HMP-O2 participants were compared to patients meeting the same inclusion criteria but did not participate in the program (N = 60). On average, the HMP-O2 patients spent 5.8 days (±5.5 days) in the hospital compared to 8.12 days (±5.5 days) for non-program patients. This resulted in 19% cost-savings for HMP-O2 patients. Lessons learned from this program can be applied to future HMPs for either COVID-19 or other conditions that would benefit from telecare.

Keywords: home monitoring program; COVID-19; telemedicine; telecare, home oxygen

Introduction

The COVID-19 pandemic introduced incredible strain on the healthcare system and challenged the traditional delivery of care (Fauci et al., 2020; Ranney et al., 2020). In efforts to alleviate hospitals, barriers to insurance reimbursement for telemedicine were removed (Kichloo et al., 2020). Subsequent implementation of home monitoring programs (HMPs) for patients with mild to moderate COVID-19 was successful in terms of positive outcomes, high patient satisfaction, and low hospital readmission rates (Annis et al., 2020; Gordon et al., 2020; Kodama et al., 2021; Martinez-Garcia et al., 2020; Pimlott et al., 2020; Ryan et al., 2020; Shah et al., 2020). However, thus far there are no reports of HMPs that exclusively used telemedicine to monitor patients that required supplemental oxygen.

As part of President Trump’s declaration of a State of Emergency for COVID-19 on March 30, 2020, the qualifying requirements for at-home oxygen for patients were relaxed in the United States. Thus, many hospitals were able to send patients home on supplemental oxygen with instructions to follow-up with their primary care provider. However, in the experience of the investigators, many patients either had a delay in follow-up or did not follow-up at all. In addition, these patients were not educated on the use of at-home oxygen, or what to do if their condition worsened. In response to this problem, we report the results of a completely remote pilot HMP with supplemental oxygen (HMP-O2) for moderate to severe COVID-19 patients. To our knowledge, there are no other publications reporting the safety and efficacy of virtual only HMPs with at-home oxygen even though home oxygen was part of regular practice for many hospitals at the height of the pandemic.

The primary objective for this retrospective analysis of a pilot program was to determine whether early discharge of moderate or severe COVID-19 patients from the emergency department (ED) and/or inpatient units with supplemental oxygen and close monitoring via phone calls for at least 5 days was feasible. Secondarily, we sought to determine whether the program reduced total number of days in the hospital for these patients and whether this resulted in cost-savings for patients in the HMP-O2.

Methods

Study Design and Setting

This is a retrospective study of patients with moderate to severe COVID-19 that participated in an HMP with supplemental oxygen (HMP-O2). HMP-O2 participants were compared to patients meeting the same inclusion criteria but did not participate in the program.

Study Population

Male or female patients greater than 18 years of age that were treated for moderate to severe COVID-19 were participated. Patients were eligible to participate if they had resting oxygen saturation ≤91% in room air, could walk 50 ft on ≤3 L/min O2 maintaining ≥90% oxygen saturation, have a stable oxygen saturation on ≤3 L/min nasal cannula (NC), a respiratory rate <20 breaths/min (bpm) and heart rate <110 beats/min, had a stable home environment, stable cognitive function, tolerated per os intake, had access to a telephone, and were a non-smoker returning to a non-smoking home. Patients were not able to participate if they had blue discoloration of skin, renal failure (creatinine >150% from baseline), heart failure (edema, elevated jugular venous pressure, drop in ejection fraction, elevated brain natriuretic peptide in addition to dyspnea, orthopnea, and pulmonary congestion), white blood count (WBC) >12.0 × 109/L, lactic acidosis, systolic blood pressure (SBP) <90 or SBP drop ≥40 mmHg of normal, language or other communication barrier, if discharge orders included home health, or if they did not require oxygen.

Study Protocol

Figure 1 illustrates the HMP-O2 workflow. Patients that would normally be on supplemental O2 in observation or on inpatient units were monitored at home for at least 5 days with supplemental oxygen delivered via NC and instructions for use, a pulse oximeter (JBunn ref# JB02017), a thermometer (Ekler Corp, ref# VDTS-100U), and given a 10-day prescription low-dose dexamethasone (6 mg). Patients then received phone calls twice daily from a nurse practitioner (NP) for 5 days or until they no longer needed oxygen. The NP collected vital signs, COVID symptoms, and O2 needs each day. All medical decisions by the NP were overseen by an MD (RAM) who also reviewed daily reports for each participant. After at least 5 days, the patient completed the program and was weaned from oxygen, or if they needed continued monitoring they followed up with their primary care provider. If at any time the patient experienced a change in mental status, blue discoloration of skin, a drop in O2 saturation below 90% on 4 L O2, respiratory rate >30 bpm or a heart rate ≥130 beats/min, then this indicated a need for more interventional care and the patient was readmitted to the hospital.

Figure 1.

Figure 1.

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COVID-19 HMP-O2 work flow. When a patient in either the ED or on inpatient units met HMP-O2 criteria, the ED doctor or hospitalist (respectively) put in the HMP-O2 order panel into Epic (the electronic medical record). A case manager in the hospital explained the HMP-O2 to the patient and arranged discharge materials. Once home, a NP called the patient twice daily for 5 days and collected vital signs, symptoms, and O2 levels each day. After 5 days, the patient completed the program; if they needed continued monitoring and/or home oxygen, they followed up with their primary care provider while still tracked to capture readmission to the hospital. If at any time the patient needed more interventional care, they returned to the hospital.

ED = emergency department; HMP-O2 = home monitoring program with supplemental oxygen; NP = nurse practitioner.

Data Collection and Analysis

Demographic and clinical data were abstracted from the medical chart. Data included days spent in the hospital, vital signs on admission, COVID-19 symptoms on admission (fever, cough, fatigue, shortness of breath/difficulty breathing, body aches, sore throat, headache, digestive issues, chills, loss of smell or taste, sneezing, runny or stuffy nose, trouble sleeping, chest pain, weakness), and whether or not a patient was readmitted. Vitals signs and oxygen levels were recorded daily in the hospital for the duration of the patient’s stay. Vital signs and oxygen levels were collected daily for 5 days for the HMP-O2. For the control group, participants were searched using Slicer Dicer. Search criteria matched inclusion and exclusion criteria for the HMP-O2 program. Specifically, search parameters were set to exclude participants with altered mental status, any level of smoker or tobacco use, SBP < 90, diagnosis of renal failure syndrome, abnormal WBC, <91% oxygen saturation, lactic acidosis, or heart failure. Inclusion parameters for Slicer Dicer were ≥18 years of age, diagnosis of pneumonia due to coronavirus disease, and positive for COVID-19. Patient data and medical notes were then individually queried. Unpaired t-tests were used to determine differences at baseline between HMP-O2 and control groups as well as to determine differences in days spent in the hospital and the associated costs for patients in the HMP-O2 and the control patients and to determine differences in the cost to care for these groups. A p-value of <.05 was considered statistically significant. Given that this is a pilot trial mainly to determine feasibility with limited sample size, other comparisons are descriptive.

Results

Patients

A total of 1,350 COVID-19 patients were admitted to a local hospital from November 1, 2020 to January 31, 2021. Of these, 1,254 did not meet HMP-O2 inclusion criteria and were excluded from the analysis (Figure 2). There were 60 patients included as a control group that were admitted the hospital before the program was in place but met the HMP-O2 criteria. There were 36 patients for whom the HMP-O2 program was initiated in Epic, of these 11 dropped out of the study prior to any home monitoring; 6 patients wanted to participate but the program was discontinued, 2 were lost to follow-up due to non-compliance, 1 chose to stay in the hospital, 1 was not discharged from the hospital, and 1 decided they did not want to be monitored. There were 25 patients with at least 1 day of home monitoring. There were eight patients that had to be readmitted due to hypoxemia (2 were after 5 days of monitoring), and one person chose to discontinue home monitoring on Day 2. There were 18 patients that completed at least 5 days of the HMP-O2 program.

Figure 2.

Figure 2.

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Consort diagram.

Baseline Patient Characteristics

Table 1 shows the characteristics of the HMP-O2 participants compared to the non-participants. There were no significant differences in demographic or baseline clinical characteristics. On admission, there were no significant differences between groups in commonly reported COVID-19 symptoms on admission including fever, cough, fatigue, shortness of breath/difficulty breathing, body aches, sore throat, chills, loss of smell, loss of taste, sneezing, runny or stuffy nose, trouble sleeping, chest pain, or weakness. There were significantly more patients in the HMP-O2 group relative to the control that presented with a headache (HMP-O2: n = 11 [26.3%] vs. control: n = 6 [10.0%]; p = .022) and digestive issues (HMP-O2: n = 17 [44.7%] vs. control: n = 10 [16.7%]; p = .003).

Table 1.

Baseline Characteristics of Patients Meeting HMP-O2 Criteria for the Home Monitoring Program with Oxygen (HMP-O2).

HMP-O2 participants, N = 36 Control, N = 60
Age mean (SD) 59.2 (±14.2) 61.7 (±14.5)
Sex
 Male n (%) 22 (59.5%) 28 (46.7%)
Race
 Caucasian n (%) 33 (89.2%) 53 (88.3%)
 Other n (%) 4 (10.5%) 7 (11.6%)
Hispanic n (%) 18 (48.6%) 29 (48.3%)
Body mass index (kg/m2; mean [±SD]) 31.3 (±6.9) 31.8 (±7.5)
Systolic blood pressure (mean [±SD]) 128.9 (±18.4) 130.0 (±17.1)
Diastolic blood pressure (mean [±SD]) 74.5 (±8.8) 76.2 (±11.3)
Heart rate (beats/min; mean [±SD]) 97.3 (±16.7) 92.7 (±17.0)
Oxygen saturation (%; mean [±SD]) 92.9 (±3.8) 92.2 (±3.2)
Emergency department n (%) 34 (91.9%) 59 (98.3%)
Initial symptoms n (%)
 Fever1 9 (23.7%) 10 (16.7%)
 Cough 27 (71.1%) 38 (63.3%)
 Fatigue 12 (30.0%) 10 (16.7%)
 Shortness of breath/difficulty breathing 32 (84.2%) 51 (85.0%)
 Body aches 11 (28.9) 19 (31.7%)
 Sore throat 6 (15.8%) 2 (3.3%)
 Headache2 11 (26.3%) 6 (10.0%)
 Digestive issues2 17 (44.7%) 10 (16.7%)
 Chills 5 (13.2%) 5 (8.3%)
 Loss of smell 1 (2.6%) 3 (5.0%)
 Loss of taste 1 (2.6%) 3 (5.0%)
 Sneezing 0 (0%) 0 (0%)
 Runny or stuffy nose 3 (7.9%) 7 (11.7%)
 Trouble sleeping 0 (0%) 0 (0%)
 Chest pain 4 (10.5%) 6 (10.0%)
 Weakness 5 (13.2%) 11 (18.3%)
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Note. Missing data: BMI: control; n = 2. Fatigue: HMP-O2; n = 4, control; n = 1. Shortness of breath/difficulty breathing: control; n = 1. Body aches: HMP-O2; n = 1, control 1. Sore throat: HMP-O2; n = 1, control; n = 2. Headache: HMP-O2; n = 1, control; n = 2. Digestive issues: control; n = 2. Chills: control; n = 3. Loss of smell: HMP-O2; n = 1, control; n = 5. Loss of taste: HMP-O2; n = 2, control; n = 3. Sneezing: control; n = 2. Runny or stuffy nose: control; n = 2. Trouble sleeping: HMP-O2; n = 7, control; n = 3. Chest pain: HMP-O2; n = 1, control; n = 2. Weakness: HMP-O2; n = 4, control; n = 2.

1≥100.0°F.

2p < .05.

Total Days in Hospital and Cost for the HMP-O2 Participants Compared to Control

To avoid zeroes in the dataset, days in the hospital included the initial presentation to the ER as Day 1. For those 25 patients that completed at least 1 day of home monitoring, average days spent in the hospital (including days for those that were readmitted) were 5.8 days (±5.5 days). For those patients in the control group, the average days spent in the hospital (including days for those that were readmitted) was 8.1 days (±5.5) which was significantly greater than the HMP-O2 participants (p = .039). The average gross charges incurred for a patient in the HMP-O2 was $32,524 (±$34,406), this was significantly less than the average gross charges incurred for the control group [mean (±SD): $40,356 (±$25,100); p < .001].

For those patients that required readmission to the hospital in the HMP-O2 group, the initial length of stay in the hospital was an average of 2.9 days (range :1–12 days). Notably, six of these patients were never admitted to the hospital and were present at the ED less than 1 full day. Total days for those in the HMP-O2 that had to be readmitted was 9.1 days (range: 4–18 days). There were only two patients that needed to be readmitted in the control group; their average initial stay in the hospital was 9.3 days (range: 2–16 days) and their average total days in the hospital were 17.3 days (range: 9–30 days).

Discussion

On average, patients enrolled in the HMP-O2 spent 5.8 days in the hospital compared to 8.1 days for the control group, and had 19% less gross charges. While our sample size was small, this pilot program provides preliminary evidence that it is feasible to use telemedicine to monitor patients with moderate to severe COVID-19 at home, utilizing NPs, that would normally be under observation in the hospital. Lessons learned from this program could provide guidance for future programs not just for COVID-19 but for other conditions requiring home oxygen and/or close supervision.

To our knowledge, this is the first study reporting a completely remote HMP with home oxygen for patients that would otherwise have stayed in the hospital in the context of COVID-19. While readmission rates for the reported HMP-O2 are higher than overall readmissions for COVID-19 patients not involved in an HMP (here, 35% vs. 4–20%; Gavin et al., 2021), they are similar to the 25% readmission rate reported by Llorens et al. for a home health program that directly discharged mild COVID-19 from the ED. Notably, that program reported a 77% cost-savings for these patients (Abbas Zaher et al., 2021), but did not include patients requiring oxygen (Llorens et al., 2021). Other hospitals developed a hybrid model, Atrium Health provided virtual monitoring for mild patients and in-person appointments for moderate to severe patients that would normally be in the hospital (Sitammagari et al., 2020). The NYU Langone Medical Center-Brooklyn developed an early discharge program for patients with continued oxygen needs; patients were eligible for at-home oxygen if they required 3 L/min or less (Bains et al., 2020). While the focus of that program was to expedite the discharge process for patients ready to leave the hospital, they were successful in reducing hospital stays and reported 50 patient-days saved per 30-day period. Other groups have reduced unnecessary hospital visits with home monitoring; for example, Shah et al. (2020) showed that simply at home pulse oximetry monitoring of patients with initially mild disease reduced unnecessary hospital visits by 50%. Thus, this study adds to a growing body of evidence that moderate to severe COVID-19 patients can be safely monitored at home by NPs through telecare, freeing hospital beds for more critical patients.

This program had several strengths. There was strong interdepartmental collaboration that included the ED physicians, infectious disease physicians, hospitalists, case management, respiratory therapists, and the NPs that had direct contact with the patients. The program was overseen by a committee that included outpatient clinicians, hospitalists, ED physicians, NPs, and a clinical coordinator. There were clearly defined algorithms for program admission and clearly defined guidelines for patients if they experienced any change in status. At the time of this program, treatment for patients with COVID-19 was not yet standardized; thus, patients were ultimately treated according to InterQual® guidelines for COVID patients with moderate, severe, or critical disease (Interqual, 2021). While not specifically collected as an outcome from patients, patients reported a high level of satisfaction with the program. Notably, there is generally high patient satisfaction for HMPs overall (Rajaiah et al., 2021), underscoring the importance of utilizing telemedicine services.

Challenges in initiating the HMP-O2 included defining specific metrics for program success, provider education, recruitment, and identification of a vendor for home O2 that could support the program and deliver O2 quickly. A centralized process for addressing barriers to discharge as suggested by Bains et al. (2020) would have helped expedite the process. Another challenge for this program was differentiating between HMP care and chronic disease management since patients often had questions for the NPs unrelated to their COVID monitoring. An up-front streamlined process in the electronic health record would have helped coordinate care with the patients’ primary provider. This program would also have benefited from the addition of video monitoring to improve patient assessment. Due to the limited availability of staff, patients involved in this program were also required to have family support at home. The addition of a full-time staff member dedicated to patient navigation would have allowed inclusion of patients without family support.

Despite the challenges, this pilot program offers several insights into the benefits of future home health programs and the greatly expanded role for telemedicine necessitated by the COVID-19 pandemic. Even at the time of this writing, with a greater understanding of COVID-19 and the etiology associated with different variants, many hospitals are still at capacity. A major challenge facing this and similar programs is financial sustainability. For example, Atrium Health’s program was hugely successful but only sustainable because of donor funding (Sitammagari et al., 2020). Bains et al. (2020) also noted a financial loss with their program. The sustainability of programs such as this one will require innovative ways to reduce costs for the hospital while maintaining the benefit for patients such as the bundled payment model proposed by Federman et al. (2018). Once financially sustainable, future programs could consider using HMPs as part of the triage process to reduce wait times in the ED and to provide beds for more critical patients. Patients that are receiving limited or routine care in the hospital but require a higher level of monitoring than traditional home health provides would also greatly benefit from programs similar to this HMP-O2. Despite the challenges, this pilot program offers several insights into the benefits of future home health programs and the greatly expanded role for telemedicine necessitated by the COVID-19 pandemic. While we are limited by our retrospective study design and small sample size, the outcomes presented here provides initial evidence for a specific subgroup of higher acuity patients that can be safely treated at home.

Conclusions

An HMP with oxygen was safe and saved patients an average of 2.3 days in the hospital and 19% in hospital charges. Implementation of similar programs over the long-term might require government assistance or cost-sharing. Similar programs could be used to remotely monitor patients from rural communities, or for patients currently receiving limited or routine care in the hospital but require a higher level of monitoring than traditional home care. Such patient populations are ideal for utilizing the expertise of NPs. Reducing hospital stays and increasing telemedicine use will be critically important as our healthcare model moves toward value-based care and improving patient satisfaction.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics: This study was approved by the University of Arizona Institutional Review Board (IRB# 2106897288).

ORCID iD: Jessica A. Martinez Inline graphichttps://orcid.org/0000-0001-5811-1019

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