Timely Identification of deteriorating Patients from acute respiratory infections at the primary care level in the COVID-19 Era: quality improvement collaborative

Background Primary care has been essential in ensuring the continuity of health services for patients with COVID-19 and other conditions. We aimed to increase the adoption of evidence-based interventions to identify clinical deterioration in adult patients with confirmed or suspected respiratory COVID-19 at the primary care level.

We implemented specific interventions in nine Primary Health Care Centers (PHCC) through a Quality Improvement Collaborative (QIC) with an interrupted time-series design. Interventions included triage for acute respiratory symptoms, the NEWS2 scale, portable oximeters for selected patients, and the provincial telehealth system. Additional components involved leadership commitment, teamwork tools, reminders, audits, feedback, and direct observation. A mixed-method evaluation was conducted, with two learning sessions and three action periods to test and implement selected change ideas.

Six PHHCs completed the study. Over 48 weeks, data from 877 patients were gathered, 356 in the baseline period (BP) and 477 in the implementation period (IP). Eight hundred sixty-two medical consultations were reported, 367 for BP and 495 for IP. More COVID-19-confirmed diagnoses were observed in the IP group (1.9% vs 15%, p<0.001). The bundle was implemented in 0% and 28.4% of patients in the BP and IP groups, respectively. Upon evaluating the individual components of the bundle, we discovered enhancements in the utilisation of triage, application of NEWS2, and utilisation of oximeters when appropriate. A decrease in the number of follow-up calls was observed at the end of the implementation. Patients rated the quality of care as positive in 66% of the cases in the BP and 76% in the IP group (p=0.023).

We successfully implemented a triage algorithm based on the NEWS2 score to identify respiratory deterioration in adult patients in primary care through a QIC. This intervention was perceived as an improvement in the quality of care by the patients. What is already known on this topic There is an urgent need to develop new methods to support patients with SARS-CoV-2 or other respiratory infections at risk of developing severe disease, implement new remote care models to facilitate risk stratification, decompress hospitals and emergency rooms, and preserve the availability of personal protective equipment. What this study adds Through a Quality Improvement Collaborative (QIC), we implemented a triage algorithm based on the NEWS2 score to identify respiratory deterioration in adult patients in primary care. This intervention improved the patient’s perceptions of their quality of care. How this study might affect research, practice or policy The utilisation of the triage algorithm founded on NEWS2 in primary care settings has garnered extensive approval, thereby enabling the expansion of interventions to additional locations within the region. Competing Interest Statement The authors have declared no competing interest. Funding Statement PFIZER COMPETITIVE GRANT PROGRAM ID: 74261789 Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The institutional review board approved the study protocol and the informative consent for interviews with users and healthcare workers (Institutional Review Board, Mendoza Government, Ministry of Health, Social Development and Sport, Directorate of Research Science and Technology, Mendoza, Argentina - Disposition number 121/2022 – November 1st 2022) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Footnotes PFIZER COMPETITIVE GRANT PROGRAM ID: 74261789 Data Availability All data produced in the present study are available upon reasonable request to the authors https://osf.io/dnpsq/?view_only=9b336ab2a9f9496f99c9ccccc2c0aeb6