A mixed methods protocol to evaluate the effectiveness and acceptability of COVID-19 Community Assessment Hubs

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has created substantial demands on the Irish healthcare system. Irish hospitals operate at near full capacity on a regular basis (Keegan et al., 2019), and the COVID-19 pandemic has raised concerns whether all COVID-19 patients can receive the care they need. The low ratio of ICU beds to population size compared to other countries is of concern (Keegan et al., 2019; Rhodes et al., 2012), given late presentation to hospital and subsequent rapid deterioration, resulting in more patients requiring admission to the intensive care unit (ICU). High levels of COVID-19 amongst healthcare staff adds to the existing staff shortages and demand on the system (Kennelly et al., 2020). Ireland’s low GP to population ratio (Teljeur et al., 2010) has meant that primary care is experiencing challenges managing the surges in COVID-19 positive or suspected positive patients. The healthcare system in Ireland is not well-equipped to manage an escalating number of people presenting with COVID-19 symptoms, mild or severe.

We now have evidence that the majority of COVID-19 patients suffer with mild to moderate symptoms and can be cared for remotely in self-isolation (Greenhalgh et al., 2020), however, severe cases must receive timely care. The ability to detect deterioration in suspected and COVID-19 positive patients early and direct them to the appropriate care setting would have a substantial impact on efficient resource utilisation and patient outcomes. Well planned triage strategies in emergency situations can enable more efficient resource utilisation and improve decision-making, particularly important for critical care allocation (Christian, 2019). Triage can ensure that the most appropriate care is provided in the most appropriate setting.

The World Health Organisation (WHO) recommended expanding screening and referral pathways in community settings to ensure preparedness for the COVID-19 pandemic and provide primary care surge capacity (World Health Organisation, 2020). Such examples include fever clinics or influenza assessment centres. Assessment centres were set up globally to protect health systems from over-stretching capacity during the COVID-19 pandemic (Huston et al., 2020). These centres provide specialist services to test, assess, triage, and treat COVID-19 positive or suspected COVID-19 patients in the community rather than in hospitals, but vary in the range of services provided depending on place. Patients receive care plans tailored to their needs and it allows fast-track of severe cases to hospital for more advanced care. Although limited, emerging evidence does suggest that these centres can contribute to reducing the burden on overwhelmed hospitals and acute services (Hall et al., 2013; John et al., 2020; Wang et al., 2020; Yen et al., 2014), allowing other primary care services to run as normal whilst mitigating the risk of infection.

Evidence from the H1N1 influenza epidemic in 2009 suggests that these centres successfully reduced Emergency Department (ED) volumes and avoided overwhelming hospitals in Canada and Taiwan (Hall et al., 2013; Yen et al., 2014). In Taiwan, assessment centres, along with other infection control procedures, were suspected to delay the peak of H1N1 pandemic while vaccines were under development (Yen et al., 2014). Similarly early evidence has shown that fever clinics in China, initially established during the SARS outbreak, were repurposed for the COVID-19 pandemic and reduced infection spread and ED visits (Wang et al., 2020). In Massachusetts, USA, a community COVID-19 management model was set up, which included telehealth, assessments for testing and advice for self-isolation, and respiratory centre for in-person visits (John et al., 2020). This community model of care for COVID-19 patients enabled 92% of patients to be managed at home, and resulted in fewer ED visits compared to the national average (John et al., 2020). However, in England the COVID-19 primary care hubs lacked central guidance and many hubs have closed after evidence showed that utilisation of hubs was low, with responsibility reverting back to GP practices (Majeed et al., 2020).

Following the WHO guidance, the Irish health service announced that COVID-19 Community Assessment Hubs (CAHs) would be established to provide timely specialised services for COVID-19 positive or suspected patients in need of care (Nolan & Ní Bhriain, 2020). Suspected or positive COVID-19 patients can contact their GP for CAH referral if their symptoms are getting worse, they have concerns about breathing or other health conditions or cannot manage symptoms at home (Health Service Executive, 2020). These hubs were staffed voluntarily by GPs, but registrars and primary care staff were also redeployed to CAHs (Bury et al., 2020). Staff deemed high risk of severe COVID-19 (over 60 years, have pre-existing health condition, pregnant) were not asked to work at these hubs. The hubs consists of a multi-disciplinary team of GPs, nurses, physiotherapists, and administrative staff. The aim of the hubs is to prevent patients from overburdening the hospital system by providing timely community based care to COVID-19 positive or suspected positive patients, avoid unnecessary attendance to acute hospital, and maximise the number of patients who can self-isolate at home (Nolan & Ní Bhriain, 2020). GPs can refer deteriorating patients (i.e. . patients who can not manage symptoms at home) to these hubs for assessment where a decision to either refer to ED, refer to a self-isolation unit or self-isolate at home is made (see Figure 1 for CAH pathway). Patients are triaged at two stages; firstly, when the referring GP discusses the case with the CAH, and secondly when CAH assessment is complete. The benefits of this approach include reducing infection risks associated with in-person GP attendances and allowing GP services to operate normally, reduction in ED attendance and hospital bed occupancy, and reassurance for the patient and the GP after clear care plans are provided by CAHs. Without this triage strategy, Ireland’s GP and acute care services may have been less capable of managing patients and infection spread, potentially resulting in the health system being unable to manage the volume of COVID-19 patients. The service aimed to take referrals and provide appointments within 2–4 hours. CAHs were staffed for 12 hours a day, 7 days a week. To our knowledge, there has been one study to investigate CAHs in Ireland that focused on the infection control training that staff received and voluntary uptake to work shifts in these hubs (Bury et al., 2020). This study found that compliance with infection control procedures was high, and staff had positive experiences working in the hubs (Bury et al., 2020).

Figure 1. Community Assessment Hub Pathway.

Patient referral and assessment pathway. Adapted from (Nolan & Ní Bhriain, 2020)]

To date, there is a dearth of research evaluating these centres. In addition, there is very little published on patient experiences of this type of care (Fitzgerald, 2020). We hope to address this gap by exploring the impact of CAHs on service delivery in one region in Ireland. The aim is to assess the effectiveness and acceptability of CAHs during the initial COVID-19 peak and identify how the service might be improved or adapted for future waves of COVID-19 and public health emergencies. This will be achieved by: assessing patient predictors of CAH acceptability; exploring patient experience of CAHs; exploring staff experiences of the acceptability and challenges of CAHs; investigating the predictors for CAH outcomes using CAH patient data. Patient and staff perspectives will be gathered using online surveys and interviews from CAHs in one region in Ireland that were operational during the first wave of the COVID-19 pandemic. Patient outcomes will be analysed using clinical patient data from CAHs in one region in Ireland. Our mixed-methods approach will provide comprehensive findings to inform whether CAHs were acceptable and effective during the pandemic.

Methods

Discussion

The overarching aim to evaluate CAHs in Ireland and determine their effectiveness will be achieved using a mixed-methods approach. Quantitative and qualitative data on patient and staff experience will provide a dual lens to holistically capture CAHs in operation. This will also provide insight on patients preferred care pathways and staff’s perceptions of the benefits and challenges of delivering care in this way. We will be able to assess how well the multi-disciplinary teams at the hubs worked together and understand where there is room for improvement at these unusual settings. Clinical data will ensure comprehensive analysis of the effects of CAHs on patient outcomes. We will be able to determine whether CAHs achieved their goal of providing timely community-based care to patients, optimise patient outcomes and minimise unnecessary use of acute hospital capacity by maximising the number of patients self-isolating at home. These findings will provide valuable information on the benefits, limitations, and areas of improvement of CAHs. This will be beneficial to all stakeholders and inform decision-making on the implementation and operation of these or similar hubs in the future. These findings may also aid potential repurposing or integration of other COVID-19 services, e.g., rehabilitation and testing, with CAHs to provide improved care of COVID-19 patients.

The findings from this research will have international relevance as it will contribute to improvement of assessment services during the COVID-19 pandemic, and for future public health emergencies, where assessment centres in the community may need to be set up to address need and mitigate hospital visits. Rapid release of findings is intended for this work to aid service improvement of primary care triaging for COVID-19 patients in a time-sensitive manner. It is essential that health systems adapt to the rapidly changing situation caused by the pandemic, as such, this research should inform service development.

There are several hurdles to overcome to conduct research during a pandemic. One challenge to implementing co-design principles is co-ordinating with busy healthcare collaborators, this will be addressed via flexible remote meeting arrangements and sustained open dialogue across sites. Another challenge is recruitment of participants to our study, this will be mitigated through the use of brief surveys and interviews to reduce burden on participants.

Data availability