Coronavirus disease 2019 (COVID-19) is a challenging health crisis and has strained medical capacities worldwide. The clustering of cases in families is a characteristic trait of COVID-19. Many patients are admitted with family members also infected with the causative virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Here, we describe companion of family members with COVID-19 and its potential benefit for the treatment of the disease.
This retrospective observational study was approved by the Ethics Committee of Peking University Third Hospital (No. IRB00006761-M2020060), including adult patients from one ward of the Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. Patients admitted between February 9 and 29, 2020, were included if they were diagnosed with COVID-19 according to the Chinese COVID-19 clinical guideline. Patients with other comorbid critical diseases and those who survived with extracorporeal membrane oxygenation support were excluded. Patients from a single family, defined as the family companion (FC) group, were housed in the same room after obtaining verbal consent from themselves and their roommates. Patients admitted without family members were housed according to sex as per routine practice and comprised the no family companion (nFC) group. All patients were isolated within their room, where cellphones and routine psychological support were available. All patients were treated according to the same therapeutic path.
Data were extracted from electronic medical records. Disease severity was classified according to the Chinese COVID-19 guideline. Survival rate refers to patient survival at 28 days after admission. Continuous and categorical variables were expressed as median (interquartile range [IQR]) (the normality of distribution was check by Kolmogorov-Smirnov test) and number and percentage (n [%]), respectively. The Mann-Whitney U test or one-sided Fisher exact test were used to compare variables between the groups. Statistical analyses were performed using SPSS version 20.0 (IBM Corporation, Armonk, NY, USA); differences with P < 0.05 were considered to be statistically significant. Due to the outbreak of COVID-19 and the pilot design of this study, no formal hypotheses were implemented to drive a sample size calculation; as such, the maximum number of patients as possible was included. Therefore, a statistical comparison of survival rates between the groups was not performed.
Of 66 patients who were admitted during the study period, 53 were included in the final analysis [Supplementary Figure 1, http://links.lww.com/CM9/A338]. Ten (18.9%) patients, admitted together with their family member(s), comprised the FC group (four couples, and a father with his daughter), while 43 patients (81.1%) comprised the nFC group. Clinical characteristics of patients in both groups on admission and treatment during hospitalization are summarized in Supplementary Table 1, http://links.lww.com/CM9/A338. Patients in the FC group were 9 years older than those in the nFC group (median age, 73 years vs. 64 years, Z = 2.789, P = 0.005). More patients in FC group had comorbid hypertension than patients in nFC group (90% vs. 39.5%, P = 0.005). There were no significant differences between the two groups in terms of other demographic and clinical characteristics and treatment (all P > 0.05).
Details of patients in the FC group are summarized in Supplementary Table 2, http://links.lww.com/CM9/A338. Chest computed tomography images of two critical patients in the FC group are shown in Supplementary Figure 2, http://links.lww.com/CM9/A338. Patients in the FC group with relatively mild disease assisted nurses with taking care of their family members in terms of feeding, cleaning, and toileting. Some patients provided linguistic support to medical staff by translating the local dialect and/or comprehending body language and writings of their family members who required an oxygen mask or non-invasive ventilation (NIV). The four couples accompanied each other throughout hospitalization, all of whom, including four with severe and one with critical COVID-19, survived. Regarding the father-daughter family, the father was stabilized with medication and NIV. However, his daughter recovered and decided to discharge earlier. Subsequently, however, the father became depressed and developed delirium with poor adherence to oxygen support. His condition changed dramatically with onset of acute cardiac injury after excluding myocardial infarction and deterioration of respiratory failure. He died 6 days after his daughter's discharge.
Patients’ overall survival rate at 28 days after admission was 81.1% (43/53) [Table 1]. This was numerically higher in FC patients than in nFC patients for the entire group, and the severe and critical subgroups. Considering the severe and critical subgroups together, the survival rate of the FC and nFC groups was 83.3% (5/6) and 57.1% (12/21), respectively.
COVID-19 is a severe infectious disease and tends to cluster in families. Nearly 20% of patients admitted to our isolation ward had family members who were concurrently infected with SARS-CoV-2. We facilitated their in-person FC by allowing them to stay together during isolation in hospital. In this FC group, moderately ill patients helped medical staff with non-medical, more home-like care of their family members because they were more familiar with each other's living habits. This relieved medical staff from routine non-medical nursing and, therefore, effectively increased the supply of medical care professionals without increasing the need for additional human resources, which is valuable during a pandemic, especially in developing and undeveloped countries where a limited number of medical workers are under significant strain in the fight against COVID-19.
It is noteworthy that patients in the FC group were older and had more comorbidities than nFC patients, which suggests a higher risk for in-hospital death from COVID-19. While their survival rate was not lower, or even numerically higher than that of nFC patients, especially in those who were severely and critically ill. In fact, all patients were cared for in accordance with the same guideline. The only difference between the two groups during hospitalization was the support from family members. Unfortunately, we did not perform statistical analysis of survival rate due to the limited number of cases. We cannot definitely conclude that our FC model increased the survival rate. However, with few currently effective treatments, further investigating the potential effectiveness of FC in improving outcomes of COVID-19 patients is warranted.
For severe infectious diseases, such as COVID-19, patients must be isolated and treated in negative-pressure wards where family visits are prohibited. Conventionally, patients are housed according to sex and are discouraged from visiting each other to reduce the risk for cross-infection. The absence of in-person FC during isolation may be associated with increases in psychological difficulties. Fortunately, housing family members in the same room provides some patients with in-person family support during isolation. This could be beneficial through the following mechanisms. First, patients experience anxiety and even panic with a novel disease with few confirmed effective therapies. Difficult times often elevate patient anxiety; as such, company and face-to-face emotional support from family members or social peers are valuable and may facilitate physical recovery. Second, aside from targeted nursing between patients mentioned above, FC also improves treatment adherence. As shown in Supplementary Table 2, http://links.lww.com/CM9/A338, wife 1 and the old father both underwent support with NIV. Their families, together with our nurses, encouraged them to adapt to NIV. Wife 1 was supported by her husband during hospitalization. She adhered to NIV very well, recovered, and survived. In contrast, the father experienced emotional turmoil and exhibited poor adherence to oxygen support after his FC was interrupted, which unfortunately led to his deterioration and, ultimately, his death. The clear contrast between the two patients suggests a positive effect of family support on adherence. Third, keeping family members together provides linguistic support. Family members helped medical staff in understanding the local dialect and comprehending what their families were trying to communicate because they were familiar with their voices and body language. It enables medical staff to better understand the patient's feelings and help to make correct decisions. All of these issues are beneficial in improving outcomes of patients with COVID-19.
Nevertheless, the FC strategy has limitations. First, it can only be applied to the management of acute infectious diseases like COVID-19, and is non-generalizable to non-communicable diseases. Second, as reported in our results, FC depends on patient consent. It is also at the cost of other roommates’ privacy. Therefore, doctors should first seek consent from all patients involved. Third, health workers must consider cultural and religious factors when applying this strategy in other countries and/or areas.
Our study had some limitations. Firstly, it was not a randomized controlled trial, which may have potentially selection bias. In this study, patients with FC might be at a higher risk for death compared with those in the nFC group because they were older. Therefore, baseline bias would not have substantially altered the trend in difference(s) in survival rate between the groups. Second, our sample size was limited; as such, we did not perform statistical analysis of the difference in survival rate. Nevertheless, under the urgent situation(s) during the COVID-19 pandemic, it would have been difficult—and, perhaps unethical—to perform large randomized controlled trials involving FCs, in which families in the control group would be purposely separated. Therefore, more cohort studies are needed to evaluate the efficacy of FC during the COVID-19 crisis.
In conclusion, our observational study suggests that FC between hospitalized COVID-19 patients may be a favorable factor in alleviating the severity of disease. This holistic strategy assists health care in a medical resource-saving manner and may be considered in the fight against COVID-19.
Conflicts of interest
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