"When all else fails you have to come to the emergency department": Overarching lessons about emergency care resilience from frontline clinicians in Pacific Island countries and territories during the COVID-19 pandemic.

The COVID-19 pandemic continues to test health systems resilience worldwide. Low- and middle-income country (LMIC) health care systems have considerable experience in disasters and disease outbreaks. Lessons from the preparedness and responses to COVID-19 in LMICs may be valuable to other countries.This policy paper synthesises findings from a multiphase qualitative research project, conducted during the pandemic to document experiences of Pacific Island Country and Territory (PICT) frontline clinicians and emergency care (EC) stakeholders. Thematic analysis and synthesis of enablers related to each of the Pacific EC systems building blocks identified key factors contributing to strengthened EC systems.Effective health system responses to the COVID-19 pandemic occurred when frontline clinicians and 'decision makers' collaborated with respect and open communication, overcoming healthcare workers' fear and discontent. PICT EC clinicians demonstrated natural leadership and strengthened local EC systems, supporting essential healthcare. Despite resource limitations, PICT cultural strengths of relational connection and innovation ensured health system resilience. COVID-19 significantly disrupted services, with long-tail impacts on non-communicable disease and other health burdens.Lessons learned in responding to COVID-19 can be applied to ongoing health system strengthening initiatives. Optimal systems improvement and sustainability requires EC leaders' involvement in current decision-making as well as future planning. Search strategy and selection criteria: Search strategy and selection criteria We searched PubMed, Google Scholar, Ovid, WHO resources, Pacific and grey literature using search terms 'emergency care', 'acute/critical care', 'health care workers', 'emergency care systems/health systems', 'health system building blocks', 'COVID-19', 'pandemic/surge event/disease outbreaks' 'Low- and Middle-Income Countries', 'Pacific Islands/region' and related terms. Only English-language articles were included. Funding: Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Copyright of the original work on which this publication is based belongs to WHO. The authors have been given permission to publish this manuscript. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of WHO. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant. RM is supported by a National Health and Medical Research Council (NHMRC) Postgraduate Scholarship and a Monash Graduate Excellence Scholarship. GOR is supported by a NHMRC Early Career Research Fellowship. CEB is supported by a University of Queensland Development Research Fellowship. None of these funders played any role in study design, results analysis or manuscript preparation.

Lessons from the frontline: Leadership and governance experiences in the COVID-19 pandemic response across the Pacific region.

Background: Universal access to safe, effective emergency care (EC) during the COVID-19 pandemic has illustrated its centrality to healthcare systems. The 'Leadership and Governance' building block provides policy, accountability and stewardship to health systems, and is essential to determining effectiveness of pandemic response. This study aimed to explore the experience of leadership and governance during the COVID-19 pandemic from frontline clinicians and stakeholders across the Pacific region. Methods: Australian and Pacific researchers collaborated to conduct this large, qualitative research project in three phases between March 2020 and July 2021. Data was gathered from 116 Pacific regional participants through online support forums, in-depth interviews and focus groups. A phenomenological approach shaped inductive and deductive data analysis, within a previously identified Pacific EC systems building block framework. Findings: Politics profoundly influenced pandemic response effectiveness, even at the clinical coalface. Experienced clinicians spoke authoritatively to decision-makers; focusing on safety, quality and service duty. Rapid adaptability, past surge event experience, team-focus and systems-thinking enabled EC leadership. Transparent communication, collaboration, mutual respect and trust created unity between frontline clinicians and 'top-level' administrators. Pacific cultural assets of relationship-building and community cohesion strengthened responses. Interpretation: Effective governance occurs when political, administrative and clinical actors work collaboratively in relationships characterised by trust, transparency, altruism and evidence. Trained, supported EC leadership will enhance frontline service provision, health security preparedness and future Universal Health Coverage goals. Funding: Epidemic Ethics/World Health Organization (WHO), Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Lessons from the frontline: Documenting the experiences of Pacific emergency care clinicians responding to the COVID-19 pandemic.

Low- and middle-income countries (LMICs) across the Pacific region have been severely impacted by the COVID-19 pandemic, and emergency care (EC) clinicians have been on the frontline of response efforts. Their responsibilities have extended from triage and clinical management of patients with COVID-19 to health system leadership and coordination. This has exposed EC clinicians to a range of ethical and operational challenges.This paper describes the context and methodology of a rapid, collaborative, qualitative research project that explored the experiences of EC clinicians in Pacific LMICs during the COVID-19 pandemic. The study was conducted in three phases, with data obtained from online regional EC support forums, key informant interviews and focus group discussions. A phenomenological approach was adopted, incorporating a hybrid inductive and deductive thematic analysis. Research findings, reported in other manuscripts in this collection, will inform multi-sectoral efforts to improve health system preparedness for future public health emergencies. Funding: Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z (Phases 1 and 2A) and an Australasian College for Emergency Medicine Foundation International Development Fund Grant.

Lessons from the frontline: Documenting the pandemic emergency care experience from the Pacific region - Infrastructure and equipment.

Background: The COVID-19 pandemic highlighted challenges for all health systems worldwide. This research aimed to explore the impact of COVID-19 across the Pacific especially with regards to emergency care (EC) and clinicians' preparations and responses. Methods: A collaboration of Australia and Pacific researchers conducted prospective qualitative research over 18 months of the pandemic. In this three phase study data were gathered from Emergency Clinicians and stakeholders through online support forums, in-depth interviews and focus groups. A phenomenological methodological approach was employed to explore the lived experience of participants. This paper discusses the findings of the study regarding the EC building block of 'Infrastructure and Equipment.' Findings: Pre-existing infrastructure and equipment were not sufficient to help control the pandemic. Adequate space and correct equipment were essential needs for Pacific Island emergency clinicians, with donations, procurement and local ingenuity required for suitable, sustainable supplies and facilities. Adequate personal protective equipment (PPE) conferred a sense of security and increased Health Care Workers willingness to attend to patients. Interpretation: Investing in adequate infrastructure and appropriate equipment is crucial for an effective response to the COVID-19 pandemic. The sustainability of such investments in the Pacific context is paramount for ongoing EC and preparation for future surge responses and disasters. Funding: Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

Lessons from the frontline: The value of emergency care processes and data to pandemic responses across the Pacific region.

Background: Emergency care (EC) addresses the needs of patients with acute illness and injury, and has fulfilled a critical function during the COVID-19 pandemic. 'Processes' (e.g. triage) and 'data' (e.g. surveillance) have been nominated as essential building blocks for EC systems. This qualitative research sought to explore the impact of the pandemic on EC clinicians across the Pacific region, including the contribution of EC building blocks to effective responses. Methods: The study was conducted in three phases, with data obtained from online support forums, key informant interviews and focus group discussions. There were 116 participants from more than 14 Pacific Island Countries and Territories. A phenomenological approach was adopted, incorporating inductive and deductive methods. The deductive thematic analysis utilised previously identified building blocks for Pacific EC. This paper summarises findings for the building blocks of 'processes' and 'data'. Findings: Establishing triage and screening capacity, aimed at assessing urgency and transmission risk respectively, were priorities for EC clinicians. Enablers included support from senior hospital leaders, previous disaster experience and consistent guidelines. The introduction of efficient patient flow processes, such as streaming, proved valuable to emergency departments, and checklists and simulation were useful implementation strategies. Some response measures impacted negatively on non-COVID patients, and proactive approaches were required to maintain 'business as usual'. The pandemic also highlighted the value of surveillance and performance data. Interpretation: Developing effective processes for triage, screening and streaming, among other areas, was critical to an effective EC response. Beyond the pandemic, strengthening processes and data management capacity will build resilience in EC systems. Funding: Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

Lessons from the frontline: The COVID-19 pandemic emergency care experience from a human resource perspective in the Pacific region.

Background: This study explores emergency care (EC) and other frontline healthcare worker (HCW) experiences responding to the COVID-19 pandemic in the Pacific region. The crisis has reinforced the crucial role well-trained, resourced, and supported EC providers play in supporting vital health systems and services in all global regions not only during 'business as usual' periods, but in times of tremendous stress and surge. Methods: Qualitative data were collected from EC providers and relevant stakeholders in three research phases in 2020 and 2021. Data on the World Health Organization's (WHO) Human Resources Building Block, adapted for the Pacific EC context, was thematically analysed. Key findings were further analysed to identify enablers and barriers to effective EC pandemic management. Findings: 116 participants from across the Pacific region participated in this study. Five themes emerged: (1) EC providers performed multiple pandemic roles; (2) Importance of authorities' valuing frontline HCWs; (3) HCW mental health and exhaustion; (4) HCW tension managing stigma, personal/professional expectations, and chronic health needs; and (5) Building health and human resource capacity. Interpretation: This study significantly contributes to the limited scientific literature on HCW experiences responding to COVID-19 across the Pacific. Recommendations arising out of this research align with consensus priorities and standards that were identified pre-pandemic by health stakeholders across the Pacific for enhancing EC system development. With limited HCWs available for many Pacific nations, it is imperative the dignity and welfare of local HCWs is genuinely prioritised. Funding: Epidemic Ethics/WHO, Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

RSTNCOVID Burns: A multi-centre service evaluation and stakeholder survey of the impact of COVID-19 on burns care in England, Wales and Northern Ireland.

As the UK entered the first wave of the COVID-19 pandemic, the National Health Service published consensus guidance to the UK burns services advising changes to the acute management of burns to allow the continuation of safe care while protecting limited hospital resources. We aimed to describe the demographics of burns service users, changes to clinical pathways and experiences of the burns team during the first wave of the COVID-19 pandemic. All burns services in the UK were invited to participate in a national collaborative, trainee-led study supported by the Reconstructive Surgery Trials Network. The study consisted of (1) a service evaluation of patients receiving burns treatment during the COVID-19 pandemic; (2) a multidisciplinary team survey. Analyses were descriptive and narrative depending on data types. Collaborators from 18 sites contributed data from burns MDT surveys and 512 patients. Patient demographics were consistent with typical burns patterns in the UK. The delayed presentation occurred in 20% of cases, with 24 patients developing complications. MDT surveys indicated substantial adaptations and challenges as a result of the pandemic. Access to theatres and critical care were limited, yet a comprehensive acute burns service was maintained. Telemedicine was utilised heavily to reduce patient footfall. Adaptations in the provision of burns care, including greater outpatient care and telemedicine, have emerged out of necessity with reported success. The impact of reduced scar therapy and psychological interventions for burns patients during the pandemic requires longer-term follow-up. Lessons from the UK experience can be used to strategise for future pandemics.

Grass-roots junior doctor communication network in response to the COVID-19 pandemic: a service evaluation.

BACKGROUND: COVID-19 was declared a worldwide pandemic on 11 March 2020. Imperial College Healthcare NHS Trust provides 1412 inpatient beds staffed by 1200 junior doctors and faced a large burden of COVID-19 admissions. LOCAL PROBLEM: A survey of doctors revealed only 20% felt confident that they would know to whom they could raise concerns and that most were getting information from a combination of informal work discussions, trust emails, social media and medical literature. METHODS: This quality improvement project was undertaken aligning with Standards for Quality Improvement Reporting Excellence 2.0 guidelines. Through an iterative process, a digital network (Imperial Covid cOmmunications Network; ICON) using existing smartphone technologies was developed. Concerns were collated from the junior body and conveyed to the leadership team (vertical-bottom-up using Google Form) and responses were conveyed from leadership to the junior body (vertical-top-down using WhatsApp and Zoom). Quantitative analysis on engagement with the network (members of the group and number of issues raised) and qualitative assessment (thematic analysis on issues) were undertaken. RESULTS: Membership of the ICON WhatsApp group peaked at 780 on 17 May 2020. 197 concerns were recorded via the Google Form system between 20 March and 14 June 2020. There were five overarching themes: organisational and logistics; clinical strategy concerns; staff safety and well-being; clinical (COVID-19) and patient care; and facilities. 94.4% of members agreed ICON was helpful in receiving updates and 88.9% agreed ICON improved collaboration. CONCLUSIONS: This work demonstrates that a coordinated network using existing smartphone technologies and a novel communications structure can improve collaboration between senior leadership and junior doctors. Such a network could play an important role during times of pressure in a healthcare system.

Development and implementation of a Pacific Island-centred COVID-19 Health Worker Safety Guide.

OBJECTIVE: Healthcare workers in Pacific Island Countries face unique workload and infection control hazards because of limited resources, cultural practices and local disease burden. In the context of COVID-19, concern around healthcare worker safety escalated in the region, triggering the need for a relevant resource. METHODS: We describe a collaborative, participatory action-research approach with a diverse range of local clinicians in Pacific Island Countries to design, develop and implement a practical guideline assisting clinicians to work safely during the pandemic. RESULTS: The resulting Health Worker Safety Guide for COVID-19 is a relevant and usable protocol developed using local knowledge and now available in several Pacific languages. CONCLUSION: We recommend a creative approach to facilitate meaningful communication with this group of clinicians, including low resolution technology and use of social media platforms.

The impact and lessons learnt from the COVID-19 pandemic on a UK Burns Centre.

The COVID-19 pandemic has dramatically impacted healthcare provision in the UK and burns services have had to adapt to ensure the continuity of a safe care. As we return to "normality" we reflect on lessons learnt from our response to this pandemic. A service evaluation was performed from patient notes between March 23rd and May 8th 2020 and an anonymous survey given to patients attending outpatient appointments. 258 patients were referred to our burns service and 148 patients completed the survey. Eleven burns were caused by treatment or prevention of COVID-19. Patients delayed seeking medical attention due to concern of catching COVID-19 (36% adults, 8% children). There was a delay in referral of 17 patients despite them fulfilling the referral criteria. Infection rates were higher following delayed presentation (21% vs 6%). The majority of burns were managed conservatively (237/258). Dressing changes were performed at home by 32% of patients. The outreach team treated 22 patients. During the pandemic telemedicine has improved the efficiency of outpatient burn care and outreach nurses have enabled treatment of vulnerable patients. More must be done to raise public awareness of preventable causes of burn injury and to reassure them to seek help when burns occur.

Clinical Characteristics and Predictors of Mortality in Patients with COVID-19 Infection Outside Intensive Care.

BACKGROUND/INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has affected all aspects of inpatient hospital medicine with patients admitted from level 1 (general medical wards) to level 3 (intensive care). Often, there are subtle physiological differences in these cohorts of patients. In particular, in intensive care, patients tend to be younger and have increased disease severity. Data, to date, has combined outcomes from medical and intensive care cohorts, or looked exclusively at intensive care. We looked solely at the level 1 (medical) cohort to identify their clinical characteristics and predictors of outcome. PATIENTS AND METHODS: This was a retrospective study of adult patients admitted to a central London teaching hospital with a diagnosis of COVID-19 from 23rd March to 7th April 2020 identified from the hospital electronic database. Any patients who required level 2 or 3 care were excluded. RESULTS: A total of 229 patients were included for analysis. Increased age and frailty scores were associated with increased 30-day mortality. Reduced renal function and elevated troponin blood levels are also associated with poor outcome. Baseline observations showed that increased oxygen requirement was predictive for mortality. A trend of increased mortality with lower diastolic blood pressure was noted. Lymphopenia was not shown to be related to mortality. CONCLUSION: Urea and creatinine are the best predictors of mortality in the level 1 cohort. Unlike previous intensive care data, lymphopenia is not predictive of mortality. We suggest that these factors be considered when prognosticating and for resource allocation for the treatment and escalation of care for patients with COVID-19 infection.

COVID-19 and emergency care for adults experiencing homelessness.

Homeless individuals face many barriers to accessing healthcare, and EDs are often their primary entry point to the healthcare system. The COVID-19 pandemic has the potential to exacerbate existing social inequities and health disparities, including barriers to accessing social services and healthcare. Addressing the complex social and chronic health issues associated with homelessness can be challenging within the acute care environment. This perspective reflects upon the delivery of emergency healthcare to patients experiencing homelessness, and highlights strategies for optimising health outcomes during and beyond the pandemic.