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LETTER TO THE EDITOR
Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 257-258

Facing the challenge - Providing liver care at times of pandemic


1 The Center for Liver Diseases, Chaim Sheba Medical Center, Ramat Gan, Israel
2 The Center for Liver Diseases, Chaim Sheba Medical Center, Ramat Gan; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Date of Submission27-Apr-2020
Date of Decision27-Apr-2020
Date of Acceptance07-May-2020
Date of Web Publication22-May-2020

Correspondence Address:
Dr. Ben Yakov Gil
The Center for Liver Diseases, Chaim Sheba Medical Center, Ramat Gan
Israel
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_66_20

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How to cite this article:
Gil BY, Yana D, Maria L, Oranit CE, Smadar SO, Limor P, Keren T, Ziv BA. Facing the challenge - Providing liver care at times of pandemic. Curr Med Issues 2020;18:257-8

How to cite this URL:
Gil BY, Yana D, Maria L, Oranit CE, Smadar SO, Limor P, Keren T, Ziv BA. Facing the challenge - Providing liver care at times of pandemic. Curr Med Issues [serial online] 2020 [cited 2020 Aug 12];18:257-8. Available from: http://www.cmijournal.org/text.asp?2020/18/3/257/284740



COVID 19 outbreak was first identified in Wuhan, Hubei China during December 2019,[1] as the highly infective viral disease caused by a member of the Corona viral strain presenting with a flu-like symptoms that can deteriorate to Acute Respiratory Distress Syndrome (ARDS) in up to 15% of patients and with a mortality rate of 3.2%.[2]

It was declared as a pandemic by the World Health Organization (WHO) on March 11, 2020[3] as it has spread across 200 countries resulting in >280000 deaths worldwide to date.

Due to the high infectivity of the disease, many countries declared different levels of quarantine, which effected the day–to-day routine of billions of civilians in many aspects, including the routine medical follow-up of chronic diseases.

Many of the diseases that affect the liver are of chronic active pattern and are considered immune-compromised therefore require close and timely follow-up by liver specialists.

Israel is one of the countries affected by the COVID 19 pandemic with more than 8000 infected patients. Sheba is the largest medical center in Israel and has one of the largest liver centers in the country that follow liver patients from all the spectrum of liver diseases.

The center for liver disease includes hepatologists and GI residents that see outpatients and provide consults within the hospital, hepatobiliary surgical clinics, day hospital nurses, administration, clinical research coordinators, psychologists, and dieticians. This structure provides in ordinary days a multidisciplinary approach for liver patients. During COVID 19 pandemic, we faced a sharp decline in clinic visits induced by patients fear to be exposed to high-risk environment. This decline raised a concern that chronically ill liver patients will be lost to follow and might experience hepatic deterioration with no medical attention. We evaluated a mode of operation that will allow safe and continuous care while minimizing the chances of medical crew infection – an event that immediately causes the quarantine of the entire medical crew and imposes shutdown on the liver service.

A week from the WHO COVID 19 pandemic declaration, the liver center was geographically divided into five distinct areas:

Day hospital, patient care section A, patient section B, patients reception, and administration.

Day hospital

All the procedures within the day hospital were triaged in advance to keep only the urgent procedures scheduled, mainly liver biopsies, and large volume paracentesis. Every day a team of a nurse and physician from one of the patient care sections was assigned to cover the procedures at the day hospital, while on the next day, the team is of the other patient care section.

Patient care sections

Four physicians and two nurses were divided into sections that were physically separated. Providing care to outpatients and on alternating days covering the day hospital. The visits were triaged routinely on the day before visit; new urgent visits and urgent follow-up visit that needed an actual evaluation was seen by an on-site physician, whereas the rest of the visits were either rescheduled – mainly new patients with non-urgent issues or were scheduled for a telemedicine video visit using a medical remote platform system developed by DATOS-Health® which comply with HIPA safety requirements for personal information. This system provides initiation of medical video visits by the provider to the patient's camera-equipped smartphone. The implementation of this system enables a physician to work from home or office without unnecessary exposure to the hospital's high-risk environment.

On-site staff was provided with personal protection equipment as recommended by the institutional infection control service.

Reception and administration

The front desk and administration were defined as a separate section that kept working during the whole period with the minimal staff needed for scheduling the telemedicine visits and rescheduling of non-urgent visits.

Dietary and psychology services within the liver center were temporarily postponed.

During the time of this model implementation, there was no evidence of health-care provider's COVID 19 exposure requiring quarantine nor COVID 19 infection. There was also no record of the patient's exposure nor infection that could be attributed to the follow-up in the liver clinic.

Providing routine care as well as protecting the medical staff during times of highly infective pandemic is a challenge that must be met. Patients may prefer to avoid follow-up of their health issues due to fear from infection within medical facilities, which can lead to serious complications of previously controlled medical conditions.

We hereby suggest this mode of operation that allowed the center for liver diseases to stay active and providing continuity of care for the benefit of our patients while protecting both the staff and patients from unnecessary risk of viral exposure, we believe it can be implemented in the different ambulatory disciplines of internal medicine with some service-specific adjustments.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown etiology in Wuhan, China: The mystery and the miracle. J Med Virol 2020;92:401-2.  Back to cited text no. 1
    
2.
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20.  Back to cited text no. 2
    
3.
WHO Characterizes COVID-19 as a Pandemic. World Health Organization Website. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen. [Last accessed on 2020 Mar 15].  Back to cited text no. 3
    




 

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