Result
The main outcomes for the study were change in the proportion of assessments of vital signs for patients with suspected COVID-19 in routine care and change in the proportion of non-face-to-face assessments for patients with suspected COVID-19 at the hot hub. At baseline, all patients were being assessed through traditional face-to-face assessment at the hot hub. After PDSA 1 with the introduction of the doorstep assessment, 27% of patients had non face-to-face assessments. This increased to 28% after PDSA cycle 2% and 100% after PDSA cycle 3 (figure 2)
Figure 2Proportion of non-face-to-face assessments.
On the single day when the doorstep assessment service was not available, the proportion of traditional face-to-face assessments reverted back to 100%. At baseline, there was no doorstep assessment service available, and therefore, no extra physical assessment made. After PDSA 1 with the introduction of the doorstep assessment, 27% (20) of patients had non face-to-face assessments. This increased to 28% (23) after PDSA cycle 2 and 100% (43) after PDSA cycle 3 (figure 3).
Figure 3Number of physical assessments over time.
The total number of doorstep assessments carried out over the three 2-week cycles was 61 (PDSA 1=20, PDSA 2=23 and PDSA 3=18) (figure 2). There were five (8%) hospital admissions to hospital from the doorstep assessment service; in one case, an ambulance was called prior to the arrival of the GP assistant. Four of these patients referred from the doorstep assessment went on to have COVID-19 (mean duration of admission 5 days, range 1–12). This compares with seven admissions (5%) from the 138 patients reviewed at the hot hub over the same time period (figure 4). Five of the patient referred from the hot hub patient went on to have a diagnosis of COVID-19 (mean duration of admission 5 days, range 1–13) (figure 4). All remaining assessments 56 (92%) were followed up by the patient’s usual GP. Three patients had a follow-up doorstep assessment. No patient who underwent a door step assessment went on to have an assessment in the hot hub or vice versa. There were no patient deaths within 4 weeks of using the doorstep assessment service. There were no adverse events or significant adverse events associated with the doorstep assessment service. Data from one of the referring GP surgeries (list size 4831 patients) during the period of the project reported 11 cases of suspected COVID-19. Of these, seven were referred for the doorstep assessment service and one to the hot hub. Three patient did not have any further assessment (mean age 34 years). For these three patients, assessment beyond video consultation was not considered necessary by the GP. All three patients made a full recovery. All patients with frailty were reviewed through the doorstep assessment service. There were no clinical staff absences with suspect COVID-19, and no clinicians were hospitalised with COVID-19. The mean age of patients assessed with the doorstep assessment was 56 (range 21–84) years, and 26% were male. The cost of running the service using the GP assistant was £520 per week. The cost of the drop box was £50 for the basic box (oxygen saturation monitor: £25 and blood pressure machine: £25), £100 with a tablet included (Amazon Fire: £60) and £507 with a digital stethoscope (Thinklabs stethoscope: £397).
Figure 4Patient flow through the hot hub and doorstep assessment service.
Lessons and limitations
The project’s aim was to try to increase the proportion of assessments of vital signs for patients with suspected COVID-19 at the same time increase the proportion of non-face-to-face assessments for these patients, which was achieved. Trying to improve the quality of the doorstep assessment service during the COVID-19 pandemic was challenging given the evolving nature of the pandemic, changing public health measures and the emergence and evolution of new evidence and guidelines during the pandemic. Establishing PDSA cycles and regularly communicating back to hub was vital given the changing situation so that the service could adjust and adapt. Given the cooperative nature in which the service was run, there was a relatively high turnover of clinicians running the hot hub service, which made establishing and maintaining expertise within the service challenging in terms of maintaining institutional knowledge and expertise. In contrast, we were fortunate to have a small number of GP assistants (three) running the doorstep assessment service.
Evaluating data from the service within the PDSA cycles was useful in that it allowed us to identify that service was not necessarily being used in patients at the highest risk of death, for example, male, elderly and obese.12 The typical GP surgery in St. Helens has approximately ~38% male population. Coupled with this, the proportion of males contacting their GP with suspected COVID-19 symptoms appears to be lower than in females. There is also a long history of late presentations with other illnesses such a cancer and cardiovascular disease in male population in the region. We hypothesise that male patients are presenting later with more severe symptoms and going directly to secondary care. It also highlights the potential for inequality when introducing such a service and that the inverse care law may be in operation.13
Establishing a baseline during the pandemic was difficult given the changing epidemiology of the disease and the reconfiguration of local services. The baseline measurement period was relatively short due to: (1) patient and practitioner safety concerns along with (2) local and national concerns regarding the availability of effective PPE and (3) increasing patient demand. The target of a 10% increase in the proportion of patients with vital signs assessment and the 10% increase in non-face-to-face assessments was arbitrary and should we conduct the project again would recommend a much higher target of 50%–100% as we found it at least theoretically possible for all assessments to be conducted non-face-to-face. The study was conducted during the first lockdown, and the number of patients presenting to local GPs with suspected COVID-19 symptoms was falling in PDSA cycle 3, and as a result, the number of physical observations remained static. Future research under experimental conditions would help to evaluate the safety and effectiveness of doorstep assessments.
The changes made in PDSA 2 resulted in a marginal improvement in reducing the proportion of traditional face-to-face contacts with PPE. In contrast, the introduction of the digital stethoscope in PDSA 3 resulted in a step change, which eliminated traditional direct face-to-face contact. Training one of the GP assistants to set up the stethoscope for clinicians reduced the anxiety of using a new device. The lack of utilisation of the remote video consultation service was surprising given the attention this has received nationally. Some clinicians felt this was ‘not needed’ and ‘added little to assessment over the phone’. A number of regions have established a hot hub service, but to our knowledge, relatively few have introduced a doorstep assessment service. We anticipate that our findings may be useful should a second wave of COVID-19 or future pandemic occur. We reflected on the scalability of the intervention using the Intervention Scalability Assessment Tool identified workforce provision as a key challenge.14 We achieved this during the project through a high level of cooperation between local GP providers, but we are now looking to make this more sustainable by linking this workforce provision with the roll out of NHS virtual wards. Evaluating the service through a quality improvement project has helped to facilitate local discussions on how urgent care could be better coordinated following the COVID-19 pandemic given that a number of the findings and service changes were felt to be generalisable to the existing and emerging urgent care and chronic disease services; indeed, the doorstep assessment service has recently been adopted locally by the community nursing team to assist with chronic disease management.
