The pandemic has presented complex challenges to health care systems around the world. Rising cases and changes to the delivery of health services put significant strains on the capacity of hospitals and providers to deliver vital care.
This created an increased urgency and focus on using limited health care resources wisely.
In response, Choosing Wisely Canada in collaboration with international Choosing Wisely campaigns led the development of a list of recommendations based on the collective experiences and insights from front line clinicians, patients, and campaign leaders. The list reflects the rapid learning and sharing of experiences from across the globe on public health strategies to slow the transmission of COVID-19 and reduce the strain on health care systems.
Physical distancing, along with handwashing, are the most effective ways to reduce the spread of COVID-19. Avoid crowds, unnecessary travel, and social gatherings. Individuals should only go out for groceries, to the pharmacy, or other essential trips. Decreasing the spread of COVID-19 can help alleviate the pressure on the health care system.
For more information:
World Health Organization: Coronavirus Disease (COVID-19) Advice for the Public.
Avoiding these locations lowers personal risk of infection. Clinics, hospitals and facilities are determining what care will continue and what can be delayed or rescheduled. Some routine tests or procedures may not be necessary if an individual has no symptoms or risk factors, while others should not delay. Individuals should speak with their health care provider. Health care professionals are also offering care virtually.
For more information:
Canadian Medical Association: Managing your practice during COVID-19.
Individuals with mild symptoms of COVID-19 should not go to the emergency department for COVID-19 testing. Online self-assessment tools and dedicated screening centres can help people determine how to seek further care if necessary. Avoiding unnecessary calls and trips to the emergency department will help protect vulnerable patients in the emergency department, as well as health professionals caring for them.
For more information:
BMJ: COVID-19: A Remote Assessment in Primary Care.
Centers for Disease Control and Prevention: What To Do if You Are Sick.
There are currently no medications or natural health products that are known to treat or protect against COVID-19. Using non-evidence- based treatments may expose patients to harm and lead to resource shortages. Additionally, antibiotics do not work against viral infections like COVID-19.
For more information:
Public Health Agency of Canada: Coronavirus Disease (COVID-19): Symptoms and Treatment.
World Health Organization: Coronavirus Disease (COVID-19) Advice for the Public: Myth Busters
Virtual care can often meet patients’ needs in a safer way. Further, delaying non-essential care or laboratory testing may free capacity for sicker patients. However, it is imperative to maintain continuity of care for patients with chronic medical conditions.
Sources:
BMJ: Covid-19: A Remote Assessment in Primary Care.
World Health Organization: Operational Guidance for Maintaining Essential Health Services During an Outbreak.
Safety of nursing home facilities, residents and staff can be ensured through adequate infection prevention and control activities. Transfers to hospital can be harmful to frail elderly through increased risk of hospital-acquired infections, medication side effects, lack of sleep, and rapid loss of muscle strength while bedridden. Harms often outweigh benefits. If a transfer is unavoidable, give clear instructions to the hospital of the patient’s advance directives for care.
Sources:
Shepperd S, Iliffe S, Doll HA, et al. Cochrane Systematic Review. Admission Avoidance Hospital at Home.
World Health Organization: Infection Prevention and Control guidance for Long-Term Care Facilities in the Context of COVID-19.
Many Choosing Wisely recommendations indicate that RBC transfusions are overused. In non-bleeding patients, more appropriate approaches include single unit transfusions when the hemoglobin is less than 70-80 g/L (7-8 g/dL) Conserving the blood supply during the COVID-19 pandemic is critical.
Sources:
Baron DM, et al. Anaesthesia. Patient Blood Management During the COVID‐19 Pandemic ‐ a Narrative Review. doi:10.1111/anae.15095.
Choosing Wisely Canada: Why Give Two When One Will Do Transfusion Toolkit.
Pagano M, Hess J, Tsang H, et al. Transfusion. Prepare to Adapt: Blood Supply and Transfusion Support During the First 2 Weeks of the 2019 Novel Coronavirus (COVID-19) Pandemic Affecting Washington State. PMID: 32198754.
In the COVID-19 pandemic, these decisions must be made urgently, hopefully based on prior discussions. Frail elderly patients who are sick enough to require intubation for any reason, including COVID-19, have very poor survival outcomes and poor quality of life. Early conversations with patients and families help to prevent rushed decisions or ones that do not reflect patient wishes.
Sources:
There is no formal consensus between clinician groups regarding treatment of COVID-19 and evidence is evolving. Treating patients outside of clinical trials will limit our collective ability to scientifically assess treatment efficacy and put patients at risk of harm from drugs. Monitored compassionate use approaches may be acceptable in some jurisdictions.
Sources:
Kalil A. JAMA. Treating COVID-19—Off-Label Drug Use, Compassionate Use, and Randomized Clinical Trials During Pandemics.
The recommendations represent what was known about COVID-19 in March – April 2020. For updated resources and guidelines regarding COVID-19, follow guidance from your national or local public health authority.
This list recognized that both clinicians and the public play a critical role in resource stewardship. Public recommendations highlighted key areas of the early response efforts including physical distancing, navigating virtual care visits, and a focus on the importance of trusted sources of health information.
Clinician recommendations acknowledged that with a new virus, the science and evidence on how to treat and prevent COVID-19 was changing at a rapid pace. The list further emphasized the importance of critical thinking and considering how more medical interventions can result in harm to patients and waste limited health care resources.
A Global Movement:
This list represents shared experiences and knowledge of clinicians, patients, and international leaders as the pandemic unfolded in different ways around the world. Since the release of the list, the recommendations were endorsed by Choosing Wisely campaigns in Australia, Brazil, Denmark, France, Italy, Japan, Portugal, Switzerland and the United Kingdom.
As hospitals and providers continue to grapple with capacity issues of COVID-19, the work of Choosing Wisely campaigns has never been more relevant. It is imperative to continue to address the problem of non-essential health care services that consume limited resources during the pandemic and beyond.
