How were patients assessed and triaged at a COVID-19 Referral Centre in primary care?

Problem

Our profession had to rapidly adapt to the new threat of COVID-19 which brought unprecedented diagnostic and management challenges, along with new ways of delivering care. COVID-19 referral centres (also known as hot sites or red sites) were urgently set up to manage essential face-to-face consultations, whilst reducing risk of transmission between patients and staff. New protocols and policies were developed with little or no time for testing or validation.

Our study sought to determine how referring GPs made use of the service, and whether the guidelines for hot site GPs on how to manage patients with COVID-19 symptoms were consistent with real-world practice. We also asked whether patients would be willing to travel to an unfamiliar service for assessment.

This is the first study to describe the characteristics of patients referred to a COVID-19 primary care referral centre and how guidance for escalation of care was applied in a rapidly adapting primary care system.

Approach

This was an observational study using routinely collected data from the Birmingham Out-of-Hours Research Database, covering all patients assessed in Birmingham and Solihull COVID Referral Centre (CRC) between 21st April and 24th July 2020. All CRC consultations were examined to extract patient demographics, free text consultations, prescriptions, observation and onward referrals. The NEWS2 score was calculated and the clinical diagnosis of COVID-19 was established. The population was described and univariate logistic regression was used to identify characteristics associated with clinical diagnosis of COVID-19 and referral decisions.

Findings

681 patients were seen at the CRC and 56.3% were identified to have a clinical diagnosis of COVID-19. Patients were willing to travel several miles for face-to-face assessment and geographical distance from the CRC did not appear to be a restrictive factor. 14.0% of all patients were referred to secondary care, but 59% of patients in the most severe category were not referred. Referral was associated with increasing age, shortness of breath, tachycardia, tachypnoea and hypoxia. However, patients with a clinical COVID-19 diagnosis were less likely to be referred to secondary care than those with other diagnoses (OR 0.54, 95% CI 0.30 to 0.97). COVID-19 patients were significantly more likely to receive antibiotics and oral corticosteroids than those who received alternative diagnoses.

Consequences

Just over half of patients seen in the COVID-19 referral centre were clinically diagnosed with COVID-19. Only a minority of patients were referred to secondary care and even when patients had more severe disease, most patients were managed in the community. Guidelines developed in the absence of service delivery data for the management of COVID-19 were inconsistent with community urgent care delivery in the first wave of the COVID-19 pandemic.