Beating the odds with systematic individualized care: Nationwide prospective follow-up of all patients with COVID-19 in Iceland
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Letter to the Editor
doi: 10.1111/joim.13135
Beating the odds with systematic individualized care:
Nationwide prospective follow-up of all patients with
COVID-19 in Iceland
General approach The COVID-19 Clinic
The current pandemic of a novel coronavirus As the epidemic grew, a systematic approach to
disease 2019 (COVID-19) began in December monitoring patients was developed and an outpa-
2019 in Wuhan, China, and has since spread tient clinic was formally established. The primary
worldwide [1]. Pandemic preparedness has been an goals of the clinic included close monitoring of
ongoing project in Iceland since the severe acute patients to provide them with instant access to
respiratory syndrome (SARS) epidemic in 2003– appropriate care, aiming to decrease the risk of
2004. In mid-January 2020, the Directorate of unexpected hospitalization, reduce morbidity and
Health (DOH) and the Department of Civil Protec- increase quality of life.
tion and Emergency Management (DCPEM) revised
the current pandemic preparedness response plan. The COVID-19 Clinic was divided into two units: a
The DOH and DCPEM, in close collaboration with telehealth centre and a specialized urgent care
the Department of Clinical Microbiology and Inter- clinic.
nal Medicine Services at Landspitali–The National
University Hospital (LUH) and deCODE genetics,
The COVID-19 Telehealth Centre
initiated a nationwide surveillance program for
COVID-19, including diagnostic testing which All SARS-CoV-2-positive patients were captured
began on 31 January. A report describing the and entered into a database in the electronic
extensive screening efforts in Iceland has recently medical record system at LUH. The list of patients
been published [2]. was automatically updated in real time when new
patients tested positive at the Department of Clin-
The first case of COVID-19 in Iceland was diag- ical Microbiology or deCODE genetics.
nosed on 28 February. Immediately, a plan was
activated to contact all SARS-CoV-2-positive All patients were enrolled into a telehealth moni-
patients upon diagnosis, trace contacts and initiate toring program through an interview with a physi-
isolation and quarantine to minimize spread in the cian, who systematically documented past medical
community. The principal objectives were to gain history, medication use, social history, lifestyle
control, prevent unexpected visits to the Emer- factors and allergies. A standardized checklist
gency Department and to facilitate appropriate containing 19 symptoms was filled out for each
care early in the course of illness. In the beginning, phone call.
an infectious disease specialist contacted all diag-
nosed patients daily to monitor their symptoms. As Patients were stratified into three risk categories
the outbreak progressed, additional physicians according to age and underlying conditions, which
and nurses were allocated to this service, estab- included cardiovascular disease, hypertension,
lishing a comprehensive telehealth program. diabetes, chronic lung disease, chronic kidney
disease, cancer and systemic inflammatory dis-
In the first two weeks, statistical models projected eases. The risk categories were as follows: (i) low
a dramatic rise in the overall number of COVID-19 (age
Letter to the Editor Figure 1 Projections of hospital admissions during the COVID-19 pandemic and actual outcome in Iceland [3]. improving symptoms); yellow (mild dyspnoea, By 7 May, 1762 patients had been enrolled into cough or fever for
Letter to the Editor
weeks of the outbreak, patients were evaluated in was initially projected. Ongoing studies analysing
the LUH Emergency Department and through our efforts will be reported in the scientific
house calls carried out by primary care physicians. literature.
In order to minimize the risk of viral spread within
the hospital and to meet the rising demand for
Conflict of Interest
care, a specialized urgent care clinic was opened on
24 March in a separate facility on the hospital The authors have no conflicts of interest to declare.
campus. It took only several days to refurbish the
facility with appropriate isolation rooms. Patients
Author Contribution
were assessed in a standardized manner which
included full physical examination, laboratory Dadi Helgason: Conceptualization (equal); Data
testing, 2-minute walk test with pulse oximetry curation (supporting); Formal analysis (support-
and imaging as needed. Front line medical staff ing); Methodology (equal); Writing-original draft
consisted of doctors in postgraduate training and (equal). Elias S Eythorsson: Conceptualization
nurses, who all wore full personal protective equip- (equal); Data curation (lead); Formal analysis
ment, whilst a supervising consultant physician (lead); Methodology (equal); Writing-original draft
participated in the patient interviews through a (equal). Lovisa B Olafsdottir: Conceptualization
video call. Based on this evaluation, a decision (supporting); Methodology (supporting); Writing-
whether to admit patients to the hospital was review & editing (supporting). Tomas Agustsson:
made. No staff member was infected whilst working Conceptualization (supporting); Methodology (sup-
at the COVID-19 Clinic. porting); Writing-review & editing (supporting).
Steinunn Ingvarsdottir: Conceptualization (sup-
Patients not requiring hospitalization generally porting); Methodology (supporting); Writing-review
received appropriate supportive treatment. & editing (supporting). Solveig Sverrisdottir: Con-
Hydroxychloroquine or azithromycin was adminis- ceptualization (supporting); Methodology (support-
tered to selected patients based on an treatment ing); Writing-review & editing (supporting). Erla D
protocol developed by the Division of Infectious Ragnarsdottir: Conceptualization (supporting);
Disease. The outpatient clinic served all COVID-19 Methodology (supporting); Writing-review & editing
patients in the Greater Reykjavik area, and there (supporting). Magnus Gottfredsson: Conceptual-
was close collaboration with healthcare providers ization (supporting); Methodology (supporting);
in other regions of Iceland. Writing-review & editing (supporting). Olafur Gud-
laugsson: Conceptualization (supporting);
In total, 101 COVID-19 patients had been admitted Methodology (supporting); Writing-review & editing
to LUH by 7 May. Ten patients died from the (supporting). Runolfur Palsson: Conceptualization
disease. From 24 March to 7 May, 212 patients (equal); Methodology (supporting); Supervision
were seen at the COVID-19 Clinic in 362 visits, 130 (equal); Writing-review & editing (supporting). Rag-
(61.3%) of whom were women. Most patients nar F Ingvarsson: Conceptualization (equal);
attended the clinic once but 83 patients attended Methodology (equal); Supervision (equal); Writing-
more frequently. Out of those 212 patients, 47 were original draft (equal).
admitted to the hospital. All patients who received
care in the COVID-19 Clinic survived.
D. Helgason1 ; E. Eythorsson1; L. B. Olafsdottir1; T. Agustsson1;
S. Ingvarsdottir1; S. Sverrisdottir1; E. D. Ragnarsdottir1;
Conclusions M. Gottfredsson1,2 ; O. Gudlaugsson1; R. Palsson1,2 &
R. F. Ingvarsson1
Although the COVID-19 pandemic is not yet over, From 1The National University Hospital of Iceland,
we believe that our systematic approach to the Reykjavik, Iceland; and 2Faculty of Medicine, University of
combination of community management and Iceland, Reykjavik, Iceland
patient care, including societal interventions,
screening, isolation, meticulous contact tracing,
References
quarantine, telehealth services, and an outpatient
clinic providing urgent care may have resulted in 1 Huang C, Wang Y, Li X et al. Clinical features of patients
favourable outcomes, highlighted by relatively infected with 2019 novel coronavirus in Wuhan, China. Lancet
few hospital admission and lower mortality than 2020; 395: 497–506.
ª 2020 The Association for the Publication of the Journal of Internal Medicine 3
Journal of Internal MedicineLetter to the Editor
2 Gudbjartsson DF, Helgason A, Jonsson H et al. Spread of University of Iceland; 2020; Available from: https://covid.hi.
SARS-CoV-2 in the Icelandic population. N Engl J Med 2020; is/spa-30-april-2020/.
382: 2302–2315. https://doi.org/10.1056/NEJMoa2006100
3 Jonsson BG, Hrafnkelsson B, Aspelund T et al.Sp alıkan fyrir Correspondence: R. F. Ingvarsson, Landspitali–The National
fj€ lag a
olda tilfella og a heilbrigðisj
onustu [A prediction model University Hospital of Iceland, Internal Medicine Services, Office
for the number of COVID-19 cases and the corresponding E-703, Fossvogur, 108 Reykjavik, Iceland.
burden on the health care system]. Reykjavik, Iceland: (e-mail: ragnari@landspitali.is)
4 ª 2020 The Association for the Publication of the Journal of Internal Medicine
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