Home COVID-19 care surged as Japan's hospitals filled up, but treatment options were limited

In the dim light of a small Tokyo apartment, Ryoichi Ichihashi kneels in blue protective gear to prepare a blood test for a bedridden mother infected with COVID-19.

Above the doctor, a plastic bag containing nourishing fluid dangles from a clothing hanger hooked to a curtain. Through an open doorway to the kitchen, the patient’s husband and one of her three sons watch anxiously as the doctor goes about his business and a nurse waits outside for him to finish.

The family shares a one-bedroom apartment where the middle-aged mother has it the worst, with symptoms including a steady fever, shortness of breath and dehydration as she waits for a hospital willing and able to take her in.

For this family of five — all infected but only one son vaccinated — there’s only so much a doctor can do.

“Upon arrival we check the patient’s oxygen concentration, blood sugar and hydration levels — and we do it quickly,” Ichihashi explained as his driver weaved through traffic on the way to the next patient on an early September day. “We do our best to make them comfortable and reassured but, beyond that, we basically act as gatekeepers for patients who need or want to be hospitalized.”

Thankfully, he was notified hours later that the mother had been admitted.

Ichihashi — a seasoned doctor as well as a fellow of the Japanese Academy of Home Care Physicians and the founding director of the General Home Care Clinic in Gifu Prefecture — was called to Tokyo in August during the height of the fifth wave to provide ground support for the Yushoukai Medical Corp., an in-home medical care company.

Each day during his brief but hectic stay in the capital, Ichihashi visited a handful of COVID-19 patients of all backgrounds and severity of illness: A diabetic young man in his early twenties who was suffering from a fever and struggling to breathe, an older man with low oxygen levels whose wife was trying to convince him to go to a hospital, a middle-aged mother who had likely been infected by one of her three sons and was no longer able to rise from her bed or consume fluids on her own.

Immobile, older or terminally ill patients unable to leave home have always relied on doctors, nurses and other medical personnel to provide treatment until they can be hospitalized.

But providing at-home treatment for a patient infected with a virus — particularly one that spreads quickly, especially in closed spaces — presents an entirely different dilemma.

On his way to each patient, Ichihashi calls ahead to check their condition and asks them to prepare for his arrival. Once there, he dons multiple layers of protective gear at the front door before entering.

Nurses and doctors have to put on, and later remove, personal protective equipment (PPE) at each residence in a quick but seamless process to ensure they themselves don’t become a vector.

Once inside, their options are limited.

If the patient’s oxygen concentration is low, a plug-in oxygen machine is brought to their house and left there until they recover. If they’re dehydrated, and a sore throat or nausea prevents them from taking in fluids, the patient is often hooked up to an IV bag.

After the doctor or nurse leaves, the patient or someone living with them needs to make sure the intake fan of the oxygen machine isn’t blocked and monitor the drip speed of the IV bag.

Unlike in a hospital, where most patients are admitted willingly and are more compliant, COVID-19 patients at home can deny blood tests even when they’re strongly advised to do so. They can also refuse hospitalization.

“Frankly, there isn’t all that much we can do if a patient is infected,” said Koji Maruyama, a staff member of Call Doctor, an at-home treatment company based in Tokyo’s Shibuya Ward. “We do what we can, as quickly but thoroughly as we can, but the most we can do is guide them toward a safe recovery or make sure they don’t die before getting hospitalized.”

Though new cases are declining in most parts of the country, the fifth wave of the pandemic brought with it a record-breaking surge of infected patients that temporarily inundated the country’s health care system.

While past waves in the capital put the health care system on the brink of collapse, this one turned that fear into an unmistakable reality.

In August, nearly a quarter of the more than 125,000 people infected with COVID-19 in Tokyo contracted the virus at home.

The number of COVID-19 patients who died somewhere other than at a hospital — including their own home — reached 250 nationwide in August, according to the National Police Agency, far surpassing the previous record of 132 set in January.

Transmission is thought to occur between spouses or parents and their children, most often after somebody became infected at work, school or elsewhere and unwittingly brought the virus home.

Japan’s infectious disease laws prevent public officials from imposing strict lockdowns like those seen in other parts of the world. In the absence of compulsory measures, it’s difficult to prevent mass gatherings or stifle foot traffic, much less ask people to avoid contact with family or loved ones in the confines of their own homes.

Infections among people living together have accounted for the largest portion of traceable COVID-19 cases in every part of the country since the early stages of the pandemic.

During the fifth wave, however, hospital overflow quickly spilled into temporary quarantine facilities but a dearth of medical staff forced tens of thousands of patients to isolate at home, where treatment is often provisional, delayed or beyond reach, and family and loved ones are almost always within coughing distance.

Throughout August, chilling reports emerged of COVID-19 patients who died while isolating at home or were forced to find treatment beyond prefectural borders because they couldn’t find a hospital able to take them in.

In an attempt to alleviate the pressure, Prime Minister Yoshihide Suga announced in early August that the central government would, in principle, prioritize the hospitalization of severe or high-risk patients by asking a greater number of mild or moderate patients to isolate at home.

The policy shift was met with swift opposition, with many concerned because people infected with COVID-19 can unexpectedly see their symptoms worsen and telling them to remain at home could delay potentially lifesaving treatment.

“At-home care is inherently inefficient,” said Hiroko Takasuna, vice president of the National Association for Visiting Nurse Service. Takasuna is an award-winning nurse and the operator of a medical station in Yokohama’s Minami Ward. “Each nurse or doctor has to travel from one home to the next, using limited resources to provide treatment tailored to the needs of each specific patient.”

While the outbreak seems to be subsiding, weeks will still pass before the country can begin to lick its wounds and prepare for the next one.

“The country was bound to reach this point,” Takasuna said. “But that isn’t to say it couldn’t have prepared better.”

The emergence of the delta variant earlier this year exacerbated every aspect of the pandemic and medical personnel are urging the country to prepare now for future waves of the virus.

The potential to expand at-home use of an antibody cocktail — which has been proven highly effective when it comes to preventing severe symptoms — offers hope, but it’s not clear to what extent it can be deployed. The cocktail was used Friday on a COVID-19 patient isolating at home in Osaka, the first time that’s been done in Japan.

In August, “oxygen stations” and other temporary facilities — where COVID-19 patients awaiting admission to a hospital could receive treatment — were established in a number of major cities by the central government and local municipalities.

While those facilities did provide a place for patients to stay, critics said the medical personnel that staffed them were simply rerouted from elsewhere and failed to ease the burden on the health care system.

What the country needs in preparation for a possible sixth wave are at-home doctors and nurses dedicated solely to treating COVID-19 patients, and a system to support them, said Kaichi Shimabukuro, the administrator of Medical Liners, a home care nursing company in Tokyo, and a board member of the Toshima Ward Nursing Association.

Even Yushoukai Medical, one of the country’s biggest providers of at-home medical care, started a crowdfunding campaign earlier this month to raise funds so that its doctors and nurses can continue treating COVID-19 patients and strengthen follow-up support for recovering patients.

Yushoukai consists of 18 clinics nationwide, though most are concentrated in the capital and its neighboring prefectures. Within days, the campaign blew past its goal of raising ¥12 million, having gathered more than ¥32 million in contributions as of Sunday.

But not all home care companies are as big as Yushoukai or as capable of attracting so much public attention and support.

Most nursing stations or at-home care clinics are private corporations staffed by no more than a dozen nurses and a handful of doctors, all working on top of their other jobs at various hospitals, clinics or vaccination sites.

The health ministry issued a directive Tuesday calling on regional municipalities to, among other things, bolster support for medical personnel providing at-home care for COVID-19 patients by expediting communication, lifting any bureaucratic red tape that might delay or hinder treatment and pre-emptively delivering specialized equipment to patients as soon as they test positive.

But the memo failed to specify or mandate any concrete changes.

“If the country wants to depend so heavily on at-home care, there needs to be a dedicated team or an operational center,” Shimabukuro said. “The central government has not put forward any guidelines to determine the best way to handle the treatment of infected patients, so we’re effectively on our own.”