An audit and analysis of the implementation of COVID-19 policy within a tertiary referral hospital, from the perspective of a junior medical officer.

Abstract

INTRODUCTION The COVID-19 pandemic has significantly impacted the health care of patients globally.1,2 Due to multilayered risks to staff and other patients from exposure to SARS-CoV-2, extensive infection control protocols and precautions have been implemented for all patients deemed suspected COVID1 (sCOVID) or COVID-positive. Accurate patient classification is important as delays in emergency surgery may lead to increased morbidity and mortality, and it also provides protection to health care workers and health services.3 The primary aim of this quality assessment project was to examine the operational implementation of health service and state health department COVID-19 policies. Specifically for patients undergoing emergency surgery within a tertiary referral hospital servicing a catchment of approximately 2 million people. Coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS The COVID-19 pandemic has been characterised by periods of intense activity separated by periods of relative quiet. April 2021 represents a period of relatively low activity, with a statewide moving average of less than 2.1 SARS-CoV-2 positive cases per 14-day period. We identified 498 eligible records in April 2021. We screened a sequential sample of 150 patient records to review for eligibility. Inclusion criteria were adult patients presenting to the emergency department and requiring an emergency operative procedure under general anaesthetic (GA) within the operating theatre or radiology suite within 36 hours of presentation. Patients were excluded if they underwent procedures in other areas or more than 36 hours following the patient's presentation. A review of the Electronic Medical Record (EMR) of patients who met inclusion criteria was undertaken. Evidence of the COVID-19 screening process of each patient was reviewed, and the application of this screening process as applied to the patient was critiqued and compared to our institutional COVID-19 protocols. The screening process, including critical decision-making points, was assessed, and a 'patient flow' assessment was conducted. This audit was approved as a Quality Assessment project by the Research Support Services within the institution. RESULTS A sequential review of 150 patients' EMR identified 39 patients meeting the inclusion criteria. Overall, we identified a failure to follow operational guidelines in 38.5% of patients. We identified that 33.3% of eligible patients met defined high-risk criteria but failed to be swabbed. 66.7% of swabbed and 60.6% of nonswabbed patients managed according to guidelines. Limited information regarding a decision-making process was documented overall, with only 7 patients having clear entries in EMR. Of swabbed patients, one-third did not meet the criteria for swabbing, and none returned a positive result. Eleven patients who were not swabbed did not have sufficient documentation to justify this decision. Three of these patients were categorised as sCOVID probable or low risk. Eight of 39 patients did not have any screening criteria documented. DISCUSSION We documented a high failure rate in implementing COVID-19 infection control processes. Documentation deficiencies led to inappropriate decision-making resulting in an unacceptably high risk to the health of other patients and the operational capacity of health services. Highlighting the difficulties of implementing complex infection control practices. Significant investments in education, training and audit support are required in a relatively simple infection control process to improve compliance.4 Simplification and standardisation of COVID-19 infection control protocols with accompanying education, training and audit are required to improve their operationalisation and improve safety for patients, staff and maintain the operational tempo of health services.