Background: World Health Organization recommends two ways to reduce COVID-19 cases, one is increasing the testing of suspected cases & isolation, and second way is to implement mass vaccination. Systematic checks should be implemented in these activities to validate its effectiveness. Primary Health Care Corporation (PHCC) is using the clinical audit as a tool to measure the quality of its services. The evaluation of PHCC’s COVID-19 pathway, which encompasses screening and management of suspected cases, and the audit also measured the effectiveness of pre and post COVID-19 vaccination assessment. Methods: A representative sample of 420 records from all health centers was taken to perform this audit. The sample consist of two data sets. First comprise of 48% of sample (200/420) records from dedicated COVID centers and the second set of data comprise of 52% of sample (220/420) from non-covid health centers. In addition, to measure the pre and post COVID 19 vaccination assessment practice of the health centers in line with National COVID-19 vaccine guidelines, a sample of 382 randomly selected electronic medical records of vaccination encounters was taken for the review. Results: COVID-19 pathway findings showed 99% compliance with the appropriate triaging and suspecting the patients using clinical case definition and triage screening tool. Out of suspected cases swabbed only 30% were found to be positive. Out of the positive cases, 43% were asymptomatic and 57% positive cases had milt symptoms. 81% of the total positive cases received good care coordination and safety netting. 98% of those referred to next level of care were seen by the physician and had received appropriate management. COVID-19 vaccination assessment results demonstrate optimal level of compliance (100%) in following the age specific criteria of vaccines. Assessing vaccination pre-assessment and documents showed 77% of compliance to vital signs assessment and documentation. The COVID-19 vaccine protocol recommends 2nd dose of vaccine should be administered at 28th day for Moderna vaccine and at 21st day for Pfizer vaccine. The records showed that 77% among Moderna vaccine receivers and 76% of Pfizer vaccine receivers received second dose of vaccine in recommended intervals. The post vaccination assessment documented only in 10% of the records. Conclusion: COVID-19 pathway helped PHCC health centers to effectively manage the COVID cases. Similarly, COVID-19 vaccination electronic assessment created for vaccination assessment helped to adhere with age wise criteria of vaccines, cater provision to capture risks and contradictory factors to COVID-19 vaccination.
Keywords: COVID-19 pathway; COVID-19 vaccination; Screening Triage Questionnaire; Primary healthcare
An outbreak of unknown pneumonia reported in Wuhan, China in 2019 changed the world’s normalcy and led to a complete havoc and chaos. This pandemic caused the world to pay a high toll in terms of human life lost, economic crisis and poverty . On January 2020, WHO declared the COVID-19 outbreak has a Public Health Emergency of International Concern, and it’s sweeping continues as of today 27/06/2022, 540,923,532, active positive cases and 6,325,785 (WHO COVID-19 dashboard) deaths were reported all around the world.
In Qatar, the first case reported on 29 February 2020 following to this reporting, the country promptly implemented aggressive public health measures such as restrict travel, implement strict national public health measures, increasing existing hospital capacity, developing temporary quarantine with 12,500 beds and isolation facilities with 37,000 beds etc. to flatten the curve and implemented virtual consultation to ensure the continuity of patient care with chronic conditions. As of today 27/06/2022, a total of 380530 active cases and total 679 deaths have been reported in Qatar . This is far less than any other developed countries in the world .
The ministry of public health in Qatar has steered the healthcare system by harmonizing the capabilities of primary and secondary healthcare facilities with the corporation of its public of the relatively young and healthy expat population has perhaps contributed to the lower mortality rates as compared to the global average . This strategy helped in effective coordination of disaster management across the country .
In many countries primary healthcare centers faced difficulty in operating during the early critical stage of this pandemic, however, further streamlined and played a predominant role in screening, isolation, and total care at large. Qatar with strong primary care settings with 29 health centers scatter across the country in 3 different regions (central, north, and south region) has been playing a crucial role in controlling the number of cases and has been providing care to infected population. The PHCC, Qatar adopted COVID-19 pathway, across its health centers including 4 COVID-19 dedicated health centers.
These 4 Covid-19 dedicated centers were equipped with laboratory facilities, short quarantine and stay beds, and onsite radiology facilities with a structured referral arrangements with secondary care hospitals as COVID hospitals for admissions and further management of covid-19 positive patients with symptoms .
On parallel, the COVID-19 mass vaccination project got kicked off through all PHCC health centers and other public facilities convention centers, drive through venues etc.
Primary Health Care Corporation (PHCC) is using the clinical audit as a tool to measure the quality of its services. To this end we had conducted two clinical audits:
- The evaluation of PHCC’s COVID-19 pathway in screening suspected cases, confirming diagnosis, providing appropriate treatment including referrals to secondary care, and isolation/ quarantine.
- The effectiveness of pre and post COVID-19 vaccination assessment and appropriateness of documentation in the clinical information system.
To standardize the COVID-19 screening and further management, an evidence-based care pathway was adapted in line with the national (CDC) protocols. The COVID-19 care pathway was implemented in all the primary health centers across the state of Qatar. This audit was performed to evaluate compliance to the COVID-19 care pathway.
In addition to the COVID-19 care pathway, the scope of the audit also included the pre and post covid-19 vaccination assessment practice of the health centers in line with National COVID-19 vaccine guidelines.
COVID-19 Pathway: To provide safe, efficient, and timely care to its patients Primary Health Care Corporation (PHCC) classified its health centers into COVID health centers and non-COVID health centers. According to the COVID-19 care pathway, all PHCC centers are required to screen all patients for COVID-19 presenting at all health centers. All COVID-19 positive patients at non-COVID centers should escalate the level of care to the COVID centers. At the COVID center, the positive patients should be seen by the physician and routed either to the quarantine facility or to the hospital as clinically appropriate. The COVID health centers were provided additional resources to provide the care under the revised scope of services. A COVID-19 screening triage questionnaire was used to triage all scheduled and walk-in patients. A representative sample of 420 records from all health centers was taken to perform this audit. The sample consist of two data sets. First comprise of 48% of sample (200/420) records from dedicated COVID centers and the second set of data comprise of 52% of sample (220/420) from non-covid health centers.
Pre and post COVID-19 vaccination assessment
The MOPH has approved mass vaccination against COVID-19 soon after the vaccine became available (Pfizer & BioNTech, and Moderna) Qatar was one of the few countries started COVID-19-vaccination campaigns for vulnerable population (above 50 years age) and for healthcare professionals. PHCC was one of the leading providers to provide the vaccination through all its health centers and other venues approved by the government. To make sure the safety of vaccination, screening and post vaccination monitoring which includes screening of clients for contraindications and precautions before a vaccine is administered helps prevent adverse reactions. A clinical audit was conducted to measure the appropriateness of pre and post vaccination assessment and related documentation practices. A sample of 382 randomly selected electronic medical records of vaccination encounters was taken for the review.
COVID-19 pathway tool: This pathway was developed by the PHCC clinical practices guidelines committee through a rigorous consultative and peer review process. The clinical practices guidelines review committee used WHO (World Health Organization COVID-19 clinical care pathway) and MOPH COVID-19 guideline  to develop the pathway. The pathway consists of two parts. The first part is screening tool known as COVID-19 screening triage questionnaire and second part is care flowchart to route the care at appropriate levels. The visual triage tool served as first screening opportunity at the Primary Health Centers across the country.
- COVID-19 pathway: All patients (planned & walk-in) who showed up at the health centers went through the mandatory COVID-19 screening using COVID-19 screening triage questionnaire in the pathway. The screening triage questions were grouped in three parts, i.e., 1) clinical signs & symptoms, 2) risk exposure and 3) etiology. The suspected patient would then be swabbed for the confirmation. Positive cases are appropriately managed in the COVID-19 health centers which includes laboratory investigation, and treatment plan according to the severity of symptoms and referral to critical care in case of urgency. Less severe cases sent for home quarantine with appropriate clinical justification.
- Pre Covid-19 vaccination assessment: An electronic COVID-19 vaccination assessment form was generated on key variables such as:
- Age details, name of the vaccine, vital signs, COVID-19 vaccination assessment questions, physician referral.
- Administration of the Vaccine; Verification of vaccine expiry date, and lot number, site of administration, dose (1st, 2nd, or booster).
Post vaccination assessment following the administration of the vaccine, the assessment is being done after 15 minutes and via telephone by nurses after 3 days to collect details especially on the side effects and provide special instructions, if needed.
COVID-19 pathway: The findings showed 99% compliance with the appropriate triaging and suspecting the patients using clinical case definition and triage screening tool. Out of suspected cases swabbed only 30% were found to be positive. Out of the positive cases 43% were asymptomatic and 57% positive cases had mild symptoms. 81% of the total positive cases received good care coordination and safety netting. Similarly, 100% compliance in evaluating the patients who need for further investigation for G6PD, CXR & ECG. 98% of those referred to next level of care were seen by the physician and had received appropriate management. 9% of those seen by the physician were referred to the hospital for further management and 89% seen by the physician were sent to the quarantine facility and 2% sent to the home quarantine as they refuse to move to the quarantine facility.
COVID-19 vaccination assessment: The results demonstrate optimal level of compliance (100%) in following the age specific criteria of vaccines (Pfizer for individuals aged 16 and above, Moderna for individuals aged 18 years and over). Assessing vaccination pre-assessment and documents showed 77% of compliance to vital signs assessment and documentation. Adherence to vaccination pre-assessment questions also shown 100% (382/382) so is the referral to physicians which is 100% (2/2) whenever required. Similarly, documentation of date of vaccine administration shown 100% compliance, whereas documentation of expiry date, lot number of vaccines, and site of vaccine administration was only 29%, 22% and 39% respectively. The COVID-19 vaccine protocol recommends 2nd dose of vaccine should be administered at 28th day for Moderna vaccine and at 21st day for Pfizer vaccine. The records showed that 77% among Moderna vaccine receivers and 76% of Pfizer vaccine receivers received second dose of vaccine in recommended intervals. The post vaccination assessment documented only in 10% of the records.
Table 1. Compliance to overall triaging practice for suspected patients (n=420).
Not suspected but swabbed
Other pre-determined indications
Suspecting using physician judgement & Screening triage questionnaire
Table 1 indicates out of 420 cases, 4 cases were randomly swabbed without any symptoms, 18 cases undergone swabbing due to COVID-19 related symptoms and 398 cases identified for swabbing with the help of screening triage questionnaire.
Figure 1. COVID -PCR Results.
Figure 1 shows all 420 patients in the sample were swabbed. 124/420(30%) were found to be positive.
Figure 2. COVID -PCR Results by severity of symptoms of positive patients.
Figure 2 shows that 53/124 (43%) positive patients were Asymptomatic whereas 71/124(57%) positive patients had mild symptoms.
Figure 3. Patient Referred to the COVID Center.
Figure 3 shows that 81% (101/124) out of the total positive patients were referred the COVID centers for further management.
Figure 4. Referred patient attended by Physician.
Figure 4 shows that 98% (99/101) of those referred were seen by the physician.
Figure 5. Investigation Ordered & Management of COVID-19 positive Cases.
Figure 5 shows that 100% compliance in evaluating the patients need for further investigation G6PD, CXR & ECG etc. 88/99 (89%) were sent to the quarantine facility, 9/99(9%) were sent to the secondary hospital and 2/99(2%) refused to be moved to the quarantine facility sent to the home quarantine.