Rising through the pandemic: a scoping review of quality improvement in public health during the COVID-19 pandemic

Improving the quality of COVID-19 care in Sierra Leone: A modified Delphi process and serial nationwide assessments of quality of COVID-19 care in Sierra Leone

INTRODUCTION

Improving the quality of care that patients receive is paramount to improving patient outcomes and engendering trust during infectious disease outbreaks. Whilst Quality Improvement (QI) is well established to drive improvement in routine care and in health systems, there are fewer reports of its use during infectious disease outbreaks.

METHODS

A modified Delphi process was undertaken to create a standardized assessment tool for the quality of COVID-19 care in Sierra Leone. Four rounds of assessment were undertaken between July 2020 and July 2021. To assess change across the four assessment periods compared to baseline we used a mixed effects model and report coefficients and p values.

RESULTS

During the Delphi process, 12/14 participants selected the domains to be assessed within the tool. The final 50 questions included 13 outcome questions, 17 process questions and 20 input questions. A total of 94 assessments were undertaken over four assessment periods at 27 facilities. An increase of 8.75 (p = <0.01) in total score was seen in round 2, 10.67 (p = <0.01) in round 3 and 2.17 (p = 0.43) in round 4 compared to baseline. Mean cumulative scores for COVID-19 Treatment Centres were higher than Hospital Isolation Units (p<0.02) at all four timepoints. Significant improvements were reported in coordination, diagnostics, staffing, infection prevention and control (IPC), nutrition, and vulnerable populations domains, but not in the oxygen, care processes, infrastructure and drugs domains.

CONCLUSION

We demonstrate the feasibility of creating a quality of care assessment tool and conducting sequential nationwide assessments during an infectious disease outbreak. We report significant improvements in quality-of-care scores in round 2 and round 3 compared to baseline, however, these improvements were not sustained. We recommend the use of QI and the creation of standardised assessment tools to improve quality of care during outbreak responses.

Emergent themes from a quality improvement programme for CLABSI/CAUTI prevention in ICUs amid the COVID-19 pandemic

Objectives

Healthcare-associated infection (HAI) prevention has been difficult for healthcare providers to maintain during the COVID-19 pandemic. This study summarises themes for maintaining infection prevention activities learnt from the implementation of a quality improvement (QI) programme during the pandemic.

Methods

We conducted qualitative analysis of participants’ semistructured exit interviews, self-assessments on HAI prevention activities, participant-created action plans, chat-box discussions during webinars and informal correspondence.

Setting

Intensive care units (ICUs) with elevated rates of central line-associated bloodstream infections (CLABSI) and/or catheter-associated urinary tract infections (CAUTI) participating in the Agency for Healthcare Research and Quality Safety Programme for ICUs: Preventing CLABSI and CAUTI.

Results

Forty-nine ICU teams who participated in the programme between December 2019 and April 2021 found ways to maintain activities such as daily huddles, multidisciplinary rounds, and central line and indwelling urinary catheter monitoring despite barriers, including staff turnover, a lack of time, staff fatigue and pandemic-related guidelines limiting providers’ time around patients. We use four themes to summarise the ICU teams’ adaptations that allowed them to sustain infection prevention activities: (1) Units had CLABSI and CAUTI prevention teams, policies and practices established prior to the pandemic; (2) Units were flexible in their implementation of those policies and practices; (3) Units maintained consistent buy-in for and engagement in HAI prevention activities among both leadership and care teams throughout the pandemic and (4) Units looked to learn from other units in their facility and beyond.

Conclusions

Future shocks such as the pandemic must be anticipated, and the healthcare system must be resilient to the resulting disruptions to HAI prevention activities. This study encountered four themes for successful maintenance of infection prevention activities during the current pandemic: the value of a pre-existing infection prevention infrastructure; a flexibility in approach; broad buy-in for maintaining QI programmes and the facilitation of idea-sharing.