Reverse triage in COVID surge planning: a case study of an allied health supported clinical care pathway in an acute hospital setting.

ObjectiveThis case study describes the development and outcomes of a new integrated and multidisciplinary care pathway. Spearheaded by allied health, the 'COVID community navigator team', applied established principles of reverse triage to create additional surge capacity.MethodsA retrospective cohort study examined workflow patterns using electronic medical records of patients who received navigator input at the Royal Melbourne Hospital between 20 September 2021 and 20 December 2021.ResultsThere were 437 eligible patient encounters identified. On average patients stayed 4.15 h in the emergency departments (ED) (s.d. = 4.31) and 9.5 h (s.d. = 10.9) in the short stay unit. Most patients were discharged into a 'low risk pathway' with community general practitioner follow up. Of discharged patients, only 38 re-presented to the ED with symptoms related to their initial COVID-19 diagnosis (34.9% of total re-admissions). Of these re-admissions, more than half did not require admission to a ward.ConclusionThe findings presented here provide support for the clinical utility of a multidisciplinary reverse triage approach in surge planning for anticipated presentation peaks.

Mental health symptoms in Australian general practitioners during the COVID-19 pandemic.

BACKGROUND: General practitioners (GPs) play a central role during the COVID-19 pandemic, and yet awareness of their mental health is limited. METHODS: A nationwide online survey of self-identified frontline healthcare workers was conducted between 27 August and 23 October 2020. Participants were recruited through health and professional organisations, colleges, universities, government contacts, and media. A subset of the findings on GPs and hospital medical staff (HMS) was used for this study. RESULTS: Of 9518 responses, there were 389 (4%) GPs and 1966 (21%) HMS. Compared with HMS, GPs received significantly less training on personal protective equipment usage or care for COVID-19 patients, and less support or communication within their workplace. GPs were significantly more concerned about household income, disease transmission to family and being blamed by colleagues if they became infected, all of which were associated with worse psychological outcomes. Significantly more GPs reported burnout, and experienced moderate-to-severe emotional exhaustion than HMS. Both groups used similar coping strategies, except fewer GPs than HMS used digital health applications or increased alcohol consumption. Less than 25% of either group sought professional help. CONCLUSIONS: GPs are vital in our healthcare systems, yet face unique workplace challenges and mental health stressors during the pandemic. Targeted workplace and psychological support is essential to protect wellbeing among the primary care workforce.

Remote COVID-19 patient monitoring system: a qualitative evaluation.

BACKGROUND: Many COVID-19 patients are discharged home from hospital with instructions to self-isolate. This reduces the burden on potentially overwhelmed hospitals. The Royal Melbourne Hospital (RMH) Home Monitoring Programme (HMP) is a model of care for COVID-19 patients which chiefly tracks pulse oximetry and body temperature readings. OBJECTIVE: To evaluate the feasibility and acceptability of the HMP from a patient perspective. DESIGN, SETTINGS AND PARTICIPANTS: Of 46 COVID-19 patients who used the HMP through RMH during April to August 2020, 16 were invited to participate in this qualitative evaluation study; all accepted, including 6 healthcare workers. Attempts were made to recruit a gender-balanced sample across a range of COVID-19 severities and comorbidities. Participants completed a brief semistructured phone interview discussing their experience of using the HMP. OUTCOME MEASURES AND ANALYSIS: A thematic analysis of interview data was conducted. Feasibility was defined as the HMP's reported ease of use. Acceptability was considered holistically by reviewing themes in the interview data. RESULTS: The HMP allowed clinical deterioration to be recognised as it occurred enabling prompt intervention. All participants reported a positive opinion of the HMP, stating it was highly acceptable and easy to use. Almost all participants said they found using it reassuring. Patients frequently mentioned the importance of the monitoring clinicians as an information conduit. The most suggested improvement was to monitor a broader set of symptoms. CONCLUSIONS: The HMP is highly feasible and acceptable to patients. This model of care could potentially be implemented on a mass-scale to reduce the burden of COVID-19 on hospitals. A key benefit of the HMP is the ability to reassure patients they will receive suitable intervention should they deteriorate while isolating outside of hospital settings.

Utility of SARS-CoV-2 rapid antigen testing for patient triage in the emergency department: A clinical implementation study in Melbourne, Australia.

Background: Early, rapid detection of SARS-CoV-2 is essential in healthcare settings in order to implement appropriate infection control precautions and rapidly assign patients to care pathways. Rapid testing methods, such as SARS-CoV-2 rapid antigen testing (RAT) may improve patient care, despite a lower sensitivity than real-time PCR (RT-PCR) testing. Methods: Patients presenting to an Emergency Department (ED) in Melbourne, Australia, were risk-stratified for their likelihood of active COVID-19 infection, and a non-randomised cohort of patients were tested by both Abbott Panbio™ COVID-19 Ag test (RAT) and SARS-CoV-2 RT-PCR. Patients with a positive RAT in the 'At or High Risk' COVID-19 group were moved immediately to a COVID-19 ward rather than waiting for a RT-PCR result. Clinical and laboratory data were assessed to determine test performance characteristics; and length of stay in the ED was compared for the different patient cohorts. Findings: Analysis of 1762 paired RAT/RT-PCR samples demonstrated an overall sensitivity of 75.5% (206/273; 95% CI: 69·9-80·4) for the Abbott Panbio™ COVID-12 Ag test, with specificity of 100% (1489/1489; 95% CI: 99·8-100). Sensitivity improved with increasing risk for COVID-19 infection, from 72·4% (95% CI: 52·8-87·3) in the 'No Risk' cohort to 100% (95% CI: 29·2-100) in the 'High Risk' group. Time in the ED for the 'At/High Risk' group decreased from 421 minutes (IQR: 281, 525) for those with a positive RAT result to 274 minutes (IQR:140, 425) for those with a negative RAT result, p = 0.02. Interpretation: The positive predictive value of a positive RAT in this setting was high, allowing more rapid instigation of COVID-19 care pathways and an improvement in patient flow within the ED. Funding: Royal Melbourne Hospital, Melbourne, Australia.

Differential Impacts of the COVID-19 Pandemic on Mental Health Symptoms and Working Conditions for Senior and Junior Doctors in Australian Hospitals.

OBJECTIVE: This study investigated severity, prevalence, and predictors of workplace disruption and mental health symptoms in Australian junior and senior hospital medical staff during the COVID-19 pandemic. METHODS: A cross-sectional survey collected data on demographics, workplace disruption, personal relationships, and mental health. RESULTS: One thousand twenty-one (62.1%) senior and 745 (37.9%) junior medical staff, located primarily in Victoria, completed the survey. Work disruptions were common but varied by seniority, withjunior staff more frequently exposed to COVID- 19 (P < 0.001). Symptoms of anxiety, depression, post-traumatic stress disorder and burnout were common but significantly higher in junior doctors (P  = 0.011 to < 0.001). Common predictors for experiencing mental health symptoms were identified, including prior mental health diagnoses and worsening personal relationships. CONCLUSIONS: COVID-19 has had significant but varied impacts on junior and senior doctors, with junior doctors particularly susceptible to harm to mental health. Interventions to safeguard hospital medical staff and prevent attrition of this important workforce are urgently needed.

Differences in Coping Strategies and Help-Seeking Behaviours among Australian Junior and Senior Doctors during the COVID-19 Pandemic.

BACKGROUND: Throughout the COVID-19 pandemic, hospital medical staff (HMS) have faced significant personal, workplace, and financial disruption. Many have experienced psychosocial burden, exceeding already concerning baseline levels. This study examines the types and predictors of coping strategies and help-seeking behaviours utilised by Australian junior and senior HMS during the first year of the pandemic. METHODS: A cross-sectional online survey of Australian frontline healthcare workers was conducted between 27 August and 23 October 2020. Data collected included demographics, personal and workplace disruptions, self-reported and validated mental health symptoms, coping strategies, and help-seeking. RESULTS: The 9518 participants included 1966 hospital medical staff (62.1% senior, 37.9% junior). Both groups experienced a high burden of anxiety, depression, post-traumatic stress disorder, and burnout. Coping strategies varied by seniority, with maintaining exercise the most common strategy for both groups. Adverse mental health was associated with increased alcohol consumption. Engagement with professional support, although more frequent among junior staff, was uncommon in both groups. CONCLUSIONS: Junior and senior staff utilised different coping and help-seeking behaviours. Despite recognition of symptoms, very few HMS engaged formal support. The varied predictors of coping and help-seeking identified may inform targeted interventions to support these cohorts in current and future crises.

High levels of psychosocial distress among Australian frontline healthcare workers during the COVID-19 pandemic: a cross-sectional survey.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had a profound and prolonged impact on healthcare services and healthcare workers. AIMS: The Australian COVID-19 Frontline Healthcare Workers Study aimed to investigate the severity and prevalence of mental health issues, as well as the social, workplace and financial disruptions experienced by Australian healthcare workers during the COVID-19 pandemic. METHODS: A nationwide, voluntary, anonymous, single timepoint, online survey was conducted between 27 August and 23 October 2020. Individuals self-identifying as frontline healthcare workers in secondary or primary care were invited to participate. Participants were recruited through health organisations, professional associations or colleges, universities, government contacts and national media. Demographics, home and work situation, health and psychological well-being data were collected. RESULTS: A total of 9518 survey responses were received; of the 9518 participants, 7846 (82.4%) participants reported complete data. With regard to age, 4110 (52.4%) participants were younger than 40 years; 6344 (80.9%) participants were women. Participants were nurses (n=3088, 39.4%), doctors (n=2436, 31.1%), allied health staff (n=1314, 16.7%) or in other roles (n=523, 6.7%). In addition, 1250 (15.9%) participants worked in primary care. Objectively measured mental health symptoms were common: mild to severe anxiety (n=4694, 59.8%), moderate to severe burnout (n=5458, 70.9%) and mild to severe depression (n=4495, 57.3%). Participants were highly resilient (mean (SD)=3.2 (0.66)). Predictors for worse outcomes on all scales included female gender; younger age; pre-existing psychiatric condition; experiencing relationship problems; nursing, allied health or other roles; frontline area; being worried about being blamed by colleagues and working with patients with COVID-19. CONCLUSIONS: The COVID-19 pandemic is associated with significant mental health symptoms in frontline healthcare workers. Crisis preparedness together with policies and practices addressing psychological well-being are needed.

Coping strategies adopted by Australian frontline health workers to address psychological distress during the COVID-19 pandemic.

OBJECTIVES: The Australian COVID-19 Frontline Healthcare Workers Study investigated coping strategies and help-seeking behaviours, and their relationship to mental health symptoms experienced by Australian healthcare workers (HCWs) during the COVID-19 pandemic. METHODS: Australian HCWs were invited to participate a nationwide, voluntary, anonymous, single time-point, online survey between 27th August and 23rd October 2020. Complete responses on demographics, home and work situation, and measures of health and psychological wellbeing were received from 7846 participants. RESULTS: The most commonly reported adaptive coping strategies were maintaining exercise (44.9%) and social connections (31.7%). Over a quarter of HCWs (26.3%) reported increased alcohol use which was associated with a history of poor mental health and worse personal relationships. Few used psychological wellbeing apps or sought professional help; those who did were more likely to be suffering from moderate to severe symptoms of mental illness. People living in Victoria, in regional areas, and those with children at home were significantly less likely to report adaptive coping strategies. CONCLUSIONS: Personal, social, and workplace predictors of coping strategies and help-seeking behaviour during the pandemic were identified. Use of maladaptive coping strategies and low rates of professional help-seeking indicate an urgent need to understand the effectiveness of, and the barriers and enablers of accessing, different coping strategies.

Threat of COVID-19 impacting on a quaternary healthcare service: a retrospective cohort study of administrative data.

OBJECTIVES: The threat of a pandemic, over and above the disease itself, may have significant and broad effects on a healthcare system. We aimed to describe the impact of the SARS-CoV-2 pandemic (during a relatively low transmission period) and associated societal restrictions on presentations, admissions and outpatient visits. DESIGN: We compared hospital activity in 2020 with the preceding 5 years, 2015-2019, using a retrospective cohort study design. SETTING: Quaternary hospital in Melbourne, Australia. PARTICIPANTS: Emergency department presentations, hospital admissions and outpatient visits from 1 January 2015 to 30 June 2020, n=896 934 episodes of care. INTERVENTION: In Australia, the initial peak COVID-19 phase was March-April. PRIMARY AND SECONDARY OUTCOME MEASURES: Separate linear regression models were fitted to estimate the impact of the pandemic on the number, type and severity of emergency presentations, hospital admissions and outpatient visits. RESULTS: During the peak COVID-19 phase (March and April 2020), there were marked reductions in emergency presentations (10 389 observed vs 14 678 expected; 29% reduction; p<0.05) and hospital admissions (5972 observed vs 8368 expected; 28% reduction; p<0.05). Stroke (114 observed vs 177 expected; 35% reduction; p<0.05) and trauma (1336 observed vs 1764 expected; 24% reduction; p<0.05) presentations decreased; acute myocardial infarctions were unchanged. There was an increase in the proportion of hospital admissions requiring intensive care (7.0% observed vs 6.0% expected; p<0.05) or resulting in death (2.2% observed vs 1.5% expected; p<0.05). Outpatient attendances remained similar (30 267 observed vs 31 980 expected; 5% reduction; not significant) but telephone/telehealth consultations increased from 2.5% to 45% (p<0.05) of total consultations. CONCLUSIONS: Although case numbers of COVID-19 were relatively low in Australia during the first 6 months of 2020, the impact on hospital activity was profound.

Multi-site assessment of rapid, point-of-care antigen testing for the diagnosis of SARS-CoV-2 infection in a low-prevalence setting: A validation and implementation study.

BACKGROUND: In Australia, COVID-19 diagnosis relies on RT-PCR testing which is relatively costly and time-consuming. To date, few studies have assessed the performance and implementation of rapid antigen-based SARS-CoV-2 testing in a setting with a low prevalence of COVID-19 infections, such as Australia. METHODS: This study recruited participants presenting for COVID-19 testing at three Melbourne metropolitan hospitals during a period of low COVID-19 prevalence. The Abbott PanBioTM COVID-19 Ag point-of-care test was performed alongside RT-PCR. In addition, participants with COVID-19 notified to the Victorian Government were invited to provide additional swabs to aid validation. Implementation challenges were also documented. FINDINGS: The specificity of the Abbott PanBioTM COVID-19 Ag test was 99.96% (95% CI 99.73 - 100%). Sensitivity amongst participants with RT-PCR-confirmed infection was dependent upon the duration of symptoms reported, ranging from 77.3% (duration 1 to 33 days) to 100% in those within seven days of symptom onset. A range of implementation challenges were identified which may inform future COVID-19 testing strategies in a low prevalence setting. INTERPRETATION: Given the high specificity, antigen-based tests may be most useful in rapidly triaging public health and hospital resources while expediting confirmatory RT-PCR testing. Considering the limitations in test sensitivity and the potential for rapid transmission in susceptible populations, particularly in hospital settings, careful consideration is required for implementation of antigen testing in a low prevalence setting. FUNDING: This work was funded by the Victorian Department of Health and Human Services. The funder was not involved in data analysis or manuscript preparation.

Patients presenting for hospital-based screening for the coronavirus disease 2019: Risk of disease, and healthcare access preferences.

OBJECTIVE: Early during the coronavirus disease 2019 (COVID-19) pandemic, Australian EDs experienced an unprecedented surge in patients seeking screening. Understanding what proportion of these patients require testing and who can be safely screened in community-based models of care is critical for workforce and infrastructure planning across the healthcare system, as well as public messaging campaigns. METHODS: In this cross-sectional survey, we screened patients presenting to a COVID-19 screening clinic in a tertiary ED. We assessed the proportion of patients who met testing criteria; self-reported symptom severity; reasons why they came to the ED for screening and views on community-based care. RESULTS: We include findings from 1846 patients. Most patients (55.3%) did not meet contemporaneous criteria for testing and most (57.6%) had mild or no (13.4%) symptoms. The main reason for coming to the ED was being referred by a telephone health service (31.3%) and 136 (7.4%) said they tried to contact their general practitioner but could not get an appointment. Only 47 (2.6%) said they thought the disease was too specialised for their general practitioner to manage. CONCLUSIONS: While capacity building in acute care facilities is an important part of pandemic planning, it is also important that patients not needing hospital level of care can be assessed and treated elsewhere. We have identified a significant proportion of people at this early stage in the pandemic who have sought healthcare at hospital but who might have been assisted in the community had services been available and public health messaging structured to guide them there.