Primary and secondary care join forces to manage COVID-19 in North West London

Wednesday, September 23, 2020

North West London took an integrated approach to the management of COVID-19 patients, with specialists supporting general practice. We asked Dr Sarah Elkin & Dr Kuldhir Johal about how close collaboration between Primary and Secondary care made this possible. 

Our approach revolves around empowering and supporting primary care practitioners in managing patients affected by the virus, keeping hospital admission for the most serious cases and therefore reducing patient flow in secondary care.

We first started to think how we could deal with a possible pandemic just before March, after seeing what other European countries were experiencing and right as we started to see the number of cases in the UK rise. At that point, the national guidance for both primary and secondary care on how to identify and deal with the virus was in its infancy. We were seeing patients with symptoms of COVID-19 in primary care practices, but had little knowledge of risk factors and co-morbidities at that point. Most of the severe cases were being seen in the hospitals which is where the initial learning took place.

It became apparent very quickly that the disease was mostly respiratory in nature, even if that knowledge later evolved into defining COVID-19 as a multi-system disease, and it was at this time that we began to work more closely together to better understand the guidance that was being released and to adapt it to primary care settings. A support line was set up by the hospital respiratory specialists to support the GP hot sites and this was further augmented by weekly webinars to share learning and emerging guidelines. 

One of the big concerns everyone had was how would it be possible to support patients in case of rapid deterioration, and how can these patients be spotted as soon as this begins to happen?

Help came from NHS Digital, who was already present in the STP working on a separate project, focussing on diabetes. NHSX offered their expertise, and quickly became involved in our growing multidisciplinary team, and helped us develop one of the apps they were working with, and tailor it to the monitoring of COVID-19 patients.
Thanks to this technological solution, we were then able to monitor more patients remotely and more regularly, with oximetry, pulse, temperature and dyspnoea scores. A dashboard was developed to highlight those requiring earlier review. This helped identify early when a patient was in need of hospital admission. This remote monitoring initially ran as a pilot service in two of the COVID-19 hot-hubs in NW London, supported by secondary care consultants and registrars. It has since expanded into six hot hubs.

How does it work in practice

Once someone calls 111 reporting COVID-19 symptoms, they are triaged and either sent to self care at home, referred to a GP consultation or referred to hospital admission. Patients with suspected or proven COVID-19, but not requiring urgent hospital admission, are called by their local primary care team, and are assessed and stratified based on a risk assessment. The less severe cases are given advice and allowed to return home, those with a higher risk of deteriorations are advised to visit one of the COVID hot-hubs for a clinical assessment or reviewed at home.

If their assessment supports the diagnosis, patients are then given information about the virtual ward, how it works and asked whether they would like to be enrolled. If they consent, they receive a download link for the monitoring app and a pulse oximeter, and later, an onboarding call to run them through the monitoring routine, how to upload their readings and given advice on what to do if they feel their condition is worsening.

While on the virtual ward, on top of sending their readings regularly throughout the day, the primary care team checks on them three times a day, whether by phone or via video call. Most virtual ward models only use two calls, but given the rapid deterioration that can be seen in COVID-19 patients, we felt safer with three.
All data collected by the patient is fed into a dashboard that is monitored by both GPs and consultants to ensure a 24 hour cover, which has a built in system that gives early warnings of deterioration, and that alerts the healthcare team if a reading is delayed, triggering an automated text alert, followed by a call by a member of the team. Since mid-April, when we rolled out the programme, over 800 patients were referred to the hot-hub for assessment, and 180 patients have been enrolled on the virtual ward.

This approach was very much a two way collaboration between the primary and secondary care in the STP. Secondary care’s contribution was focussed on education and support. Consultants were involved in the drawing of the triage rules and the guidelines for risk assessment, and offered a direct advice phone line for primary care practitioners, staffed 24/7 to provide specialist advice, support in evaluating cases, deciding whether people needed to come in to hospital, and in discussing care pathways. Each week, the topics discussed on the helpline were addressed in a webinar open to all 400 North West London practices. The ability to access the webinars at any time, also meant that more people have been able to attend them and be constantly up to date with new findings.

Primary care practitioners were essential in the refinement and evolution of guidelines. Because of their close observation of patients, and the concerns they raised, we were able to pick up trends and patterns in pre-existing conditions, lifestyle habits or BMI and severity of the disease and likelihood of deteriorations, which all informed successive revisions of the COVID-19 guidance alongside respiratory specialists. 

The helpline and webinar sessions have led to fewer queries over time, and they really contributed to improve the relationships and respect between primary and secondary care colleagues, and greater awareness of the work done in Primary Care in managing risk in community.

Lesson learnt and future directions

Importantly, the remote monitoring project has proved to be a sustainable system, with the potential to be used beyond COVID by both primary and secondary care. There are obvious candidates like the management of long term respiratory conditions such as COPD and ILD. This set-up would allow both continual monitoring throughout the year, providing data for more detailed annual reviews and more intense monitoring during exacerbations. The latter may well become important this coming winter to relieve bed pressures.

Something else that came out of the pilot is that we have all upskilled our knowledge and use of virtual platforms such as MS teams, which are allowing to make MDT meetings more accessible to GPs, for example.

We have also learnt how important it is to link advice and guidance queries to education activities. We plan to use this approach in the future with webinars and integrated MDTs. It makes much more sense to offer training for GPs based on the questions being asked and actual needs, rather than making assumptions on what the content should be.

Finally we have recognised a gap in support for the COVID recovery period and have developed a COVID recovery page on the care information exchange website, (patient knows best that will be offered to all patients on discharge from hospital and from the hot sites. This links into useful information and local social prescribing.