GP partner Dr David Coleman explains how his practice has used car park assessment bays to assess the severity of suspected COVID-19 patients in a reduced risk environment
Hot hubs are a new innovation recommended by NHS England to support primary care’s response to the pandemic. They are centralised clinics within a designated GP practice or medical centre, dedicated to the assessment of patients with suspected COVID-19. In my CCG, Doncaster, a town centre hot hub has been developed and continues to evolve, facilitated by two-way communication between the CCG and the local GP community.
However, some concerns have been raised about these models. For example, staff – whether only working exclusively at a hot hub or doing shifts on a rota basis – will be seeing high numbers of patients with suspected COVID-19, and (particularly if there are issues with PPE or limitations affecting donning/doffing/hygiene) may be more vulnerable to infection. Consequently, there is the potential risk of health care workers becoming vectors of the disease, especially if rotating between hot and cold sites regularly.
Patient continuity is also compromised. This may not be an issue if the decision is over whether to admit or not, but any discussions regarding ceilings of treatment would benefit from the context of an established doctor-patient relationship.
Ultimately, the key principle should be to see as few patients face-to-face as is necessary, for the shortest time possible, with the best PPE available, and to minimise the contact time these patients have with other staff and patients. As the recently published NICE guidance succinctly puts it – ‘minimise face-to-face contact’. But this shouldn’t mean taking dangerous shortcuts.
We are hearing about (and have started to see) cases of ‘silent’ hypoxaemia, where oxygen saturations are often significantly reduced without particularly prominent symptoms of breathlessness. A binary model – fully remote or face-to-face assessment – runs the risk of missing a proportion of these; this led us to conclude that a hybrid model, featuring remote assessment enhanced with physiological data (pulse, oxygen saturations) would add value.
Our practice (suburban, 11,500 patients) is situated 5km from our designated hot hub. Public transport is not an option for suspected cases. Many, but not all, patients own a car. We also have many patients who are housebound, and a high care home population.
We determined that, if uncertain after telephone/video consultation, assessment with a pulse oximeter would be sufficient for decision making based on the following considerations:
We are encouraging a degree of caution and a low threshold for pulse oximetry in those with persistent symptoms beyond seven days, as this seems to coincide with the period of deterioration.
We are fortunate to be blessed with a large car park and having seen ‘drive-through’ models for testing, looked at how we could use the space to create an assessment area that patients and staff could use safely. The CCG was made aware of the arrangement, as was the PCN.
Staff segregated off an area at the back of the practice and signposted it as our COVID-19 Assessment Zone. This area consists of five parking bays, around 10 metres by 4 metres. At the moment we are only using one bay and operating 20-minute appointment slots. There is scope to increase this to two bays. We bought some generic traffic barriers online and used these to prevent other patients accessing it.
We set up a handwashing station in a foyer inside the service entrance of our building, with a table, alcohol gel, a clinical waste bin, a kidney bowl with tap water (to be discarded and replaced between assessments) plus a clearly marked PPE donning/doffing area. An alternative for the handwashing station could be a table under a gazebo.
We obtain consent from the patient in advance to carry out tests while they sit in the car – our patients have been very understanding and nobody has declined.
One of our key mantras is ownership of these cases from start to finish. The clinician triaging the case follows it through to its conclusion. If there is a feeling that face-to-face assessment may be required, the triaging clinician will discuss the case with the on-call GP (or another GP if they are not available). At this point if face-to-face assessment is deemed necessary, we ask the patient if they are able to drive up to the practice for a car park assessment.
Patients invited so far are typically those with persistent or worsening symptoms beyond seven days, or those with borderline respiratory rate and symptoms of exertional breathlessness.
Patients are asked to come alone, or with a household contact only, and instructed to bring a mobile phone if they have one. They are instructed to drive to the bay and turn off their engine, not to leave the vehicle or enter the premises.
On arrival the patient’s identity is confirmed over the telephone and a pulse oximeter is deposited either outside of their car, or through the passenger window. The person handing this over wears a fluid resistant surgical mask, gloves, apron and eye protection.
The patient follows instructions over the telephone to measure their oxygen saturation and pulse, relaying the results back to the clinician. They then deposit the monitor into a clinical waste bag via the window, to be collected again by the clinician wearing PPE who will then clean the device thoroughly and doff their PPE, handwashing thoroughly.
If saturations are satisfactory on rest but there is concern about breathlessness on minimal exertion, a short 20-step walk followed by pulse oximetry is performed. The clinician must maintain an adequate distance (minimum 2 metres) from the patient throughout.
Oxygen saturation and pulse readings combined with clinical history determine the next step, which may be rest at home with safety netting or monitoring (if saturation is 92% and above) or admission via ambulance (if levels 91% or below, or other concerning features).
If further clinical examination is necessary then this could be done in a dedicated isolation room in the practice, or at the designated hot hub depending on local arrangements or urgency. We haven’t reached a point where this was necessary thus far.
For patients who don’t have a car, or are otherwise housebound (including care home patients), we have modified the procedure for home use. This accounts for around one in four of our suspected COVID-19 assessments.
A clinician – who doesn’t have to be a doctor – visits the patient, dons PPE and delivers a pulse oximeter, either by placing it on the doorstep or passing it through the letterbox. Again, telephone can be used to explain the procedure. A carer can facilitate this in a care home setting.
Doffing PPE and hand hygiene is trickier, but we have devised a portable solution involving bottled water, a kidney bowl and soap for washing; alcohol gel would be another alternative. Discarded PPE should be bagged in a clinical waste bag; the pulse oximeter goes in another waste bag, to be cleaned once back at the surgery.
This model is clearly not a panacea. Like so much about this pandemic, if you take a step back it does seem bizarre that we should assess people in their cars. Of course, you can’t diagnose endocarditis or aortic dissection through a car window. But with an extensive history and some vital physiological data, you can most likely determine if someone requires admission or not. And critically, you can significantly reduce the need for more prolonged face-to-face assessments, as some CCGs who have developed scaled up versions, such as this one in Shrewsbury, are learning.
We may still refer some patients to the main hot hub, but my hope is that we can reduce those numbers dramatically, protecting the service for other practices who may not have the staffing or infrastructure to employ a model like ours. Crucially, it will allow us – GPs who have dedicated our careers to the local community – to be there for our most vulnerable patients at the time when they need us most.
Dr David Coleman is a GP partner and trainer in Conisbrough, South Yorkshire
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