Most interviewees agreed that the initial draft pathway (presented in Fig. 1) which was presented to them was representative of both the peak of the first pandemic wave (April 2020) and the following reduction in prevalence observed in June with either minimal or no changes being required. The interviews resulted in 3 different iterations of the draft pathway in order to capture additional areas or adjust some diagnostic stages, with the final pathway providing a general overview of admissions into secondary care (presented in Fig. 2). The focal point of all the pathways was related to patient management, infection control, and improving diagnostic detection. Discussions around individual therapeutic options at each stage were not investigated.
Figure 1: Initial care pathway developed through a combination of national guidance and expert opinion before being presented to the interviewees. Patient areas are designated as one of three zones: Red, Amber, and Green depending on the clinical suspicion or diagnosis of COVID-19. Early triage of initial symptoms determines whether the patient is isolated prior to additional tests being ordered, or cohorted together in a separate area. Only when a positive SARS-CoV-2 test is returned, or a clinical diagnosis of COVID-19 given following additional tests, e.g. chest X-ray, is the patient transferred to a Red zone. *Indicates areas in which, due to the external prevalence, the zoning criteria may change. In these cases, with a high prevalence the decision to assign a patient to a Red zone may be taken on clinical suspicion alone to improve patient flow. Additionally, with a high prevalence a single negative SARS-CoV-2 result may not be enough to justify admission into a Green zone.
Figure 2: The revised patient pathway constructed following consultation with the clinicians. Additional triage points (Indicated as Triage Point 1, 2, and 3) have been included to show stages within the pathway where testing and clinical observations are routinely performed. Additional stages have been added following Triage Point 2 to highlight the limiting factors of real-estate/isolation capacity and the availability of rapid/POC testing. If these factors are limited, the decision to cohort can be based purely on Clinical Suspicion (Centre diamond in Red/Yellow). An additional surgical pathway (shown on the right) has been added to highlight the assumption of SARS-CoV-2 positivity due to the urgency of the admission.
Whilst there was a small difference in the approach to isolation and cohorting across different trusts, predominantly due to real-estate and staff availability, the approach used by the majority of interviewees was to cohort patients into areas based on the result of a COVID-19 diagnosis. In general, these areas can be split into 3 categories: Green, Yellow, and Red.
Green - Negative COVID-19 diagnosis
Yellow – Pending COVID-19 diagnosis
Red – Positive COVID-19 diagnosis
During the pandemic, a positive COVID-19 diagnosis was determined through a combination of clinical observations, blood tests, imaging, and Real time reverse transcriptase - polymerase chain reaction (RT-PCR) (See Fig. 3.). Therefore, a positive COVID-19 was described as either:
Figure 3: The determining factors in diagnosing COVID-19 based on test results, presenting symptoms, clinical observations and imaging. Each Triage Point denotes a separate time point in which the results of the testing would be determined. Following the results, the patients were cohorted accordingly into Red, Pink, Yellow, Green, or Hyper Green zones. Zones donated as a different colour, i.e. Blue, Yellow/Amber, indicate a difference in cohort terminology across NHS trusts.
The initial stage for most hospital pathways was to determine if the patient needed admitting into secondary care. Any patients not needing a hospital admission after the initial assessment in the Emergency Department (ED), were not routinely tested for SARS-CoV-2, however one clinician did highlight that this could be a failure in the duty of care as:
“At the moment we don't test you if you go home. That's a policy thing. Personally, I think if you come in with respiratory symptoms, I think we should test you. So that then we can do track and trace in the community, from a public health point of view. And so I think what we're doing at the moment is wrong, but that's what we're doing.” P10
Any patients who needed urgent surgical admission, with a threat to life or limb, requiring intensive care unit (ICU) admission were assumed to be SARS-CoV-2 positive in order to protect the staff and ensure the correct infection prevention protocols were followed with regards to personal protective equipment (PPE) and an enhanced cleaning regime. These surgical patients were then cohorted following the result of a swab taken pre-surgery, with positive patients being transferred to a Red ICU and negative patients being transferred to a Green ICU.
Any non-urgent medical/surgical patients were triaged based on the presence of respiratory symptoms (including cough, fever, and anosmia/ageusia). This initial triage often took place in the ED or within the Medical Assessment Unit (MAU), which was deemed as a Yellow zone. Within this zone those presenting with respiratory symptoms were isolated into individual side rooms, where possible, or else cohorted together in a bay with other respiratory patients. Whilst those presenting without respiratory symptoms were cohorted together in another bay or section of the department.
Patients were then held in a Yellow zone until a result from a SARS-CoV-2 test was available. Where the result of the test differed from a high clinical suspicion (severe symptoms, blood results, and X-ray/CT indications) a second test was often ordered due to the high potential for false negatives. Centres differed on their approach to these patients, with some centres transferring them out of the ED/ MAU and into a Yellow back of house ward. This was because the high turnaround time for testing and result reporting (4–12 hours with an in-house lab, 12–24 hours if externally tested) would have otherwise resulted in a bottleneck at the ED/MAU stage.
The main factors in determining the patient route therefore were real estate capacity, testing time to result, the number of patients presenting, and the current prevalence of SARS-CoV-2 in the local population.