Editor’s Note: Parts I and II can be accessed here and here. They were published in the November/December 2020 and January/February 2021 issues of the Journal.
Anticipating that hospitals would overflow and the ambulance service would be involved and demand management, patient movement pathways had to be coordinated across the health system in the State of Qatar. As Ambulance Service liaison to the System Wide Incident Command Center (SWICC), I received the direction for patient dispositions from the Communicable Disease Center (CDC) directorate based on whether patients were asymptomatic or symptomatic. As the number of patients peaked to overwhelming numbers, the COVID-19 Desk organized buses, taxis, and limousines to transport patients to facilities not only limited to medical centers but dedicated compounds and hotels attended by medical practitioners.
The COVID-19 Desk—a suite of dispatch consoles expanded across several offices dedicated for coordinators, dispatchers, outbound callers, documentation officers, and auditors—was the hub of managing the transportation of all suspected and positive COVID-19 patients. The Healthcare Coordination Service comprising of both the National Command Center (NCC-999) and the Healthcare Coordination Center (HCC-16099) pulled together resources to operationalize the Desk, which at peak times had nearly 3,000 patients under process. This meant those working the Desk arranged transport for patients and contacted 10 times as many people as normal to coordinate their movements, which ranged from several hours to several days based on acuity. The Mobile Health sector of the Ambulance Service alongside the Critical Care Service assisted with follow-up assessment calls and where appropriate, re-triaging patients in response to their changes in clinical condition.
Demand management
The Emerging Infectious Disease Surveillance (EIDS) Tool for identifying patients that call 999 with the potential to present with infectious diseases (coronavirus, MERS, SARS, etc.) had already been implemented in January 2020. Through quality and patient safety processes proving high compliance with Medical Priority Dispatch System™ (MPDS®) and as an Accredited Center of Excellence (ACE) with the International Academy of Emergency Dispatch® (IAED™), I initiated the use of OMEGA protocols during COVID-19 with MPDS Protocol 36: Pandemic /Epidemic/Outbreak. This special procedure was designed by the IAED to “identify the information needed to implement at dispatch, correctly triage, and set up potentially decreasing response levels to possible flu patients during an officially declared flu outbreak/emergency” (IAED CC 36 v13 Special Procedures Briefing). Protocol 36 was used to sort out suspected COVID-19 patients who reported breathing problems, chest pain, headache, fever, or other general sick complaints.
When Level 0 went live in the beginning of March 2020, we had simultaneously been reviewing the response configuration, moving to MPDS 13.2 and AQUA v7. It was expected that approximately 33% of all medical cases received through the NCC-999 would be initially handled using Protocol 36. There was no change in the Ambulance Service response to these cases as this was only a surveillance mode. However, as we actually experienced suspected COVID-19 cases to be 40% under Level 0, activation of Level 1 was accelerated. During Level 1 (which began only ten days after Level 0), the NCC-999 received an astonishing average of 865 requests for ambulances per day (an increase of 25% above normal call volume) of which 367 (average daily) were suspected COVID-19 cases. Sustaining this level of calls through April, at peak in May, NCC-999 processed approximately 500 cases per day using Protocol 36. As the activation of Level 1 provisioned the OMEGA referral pathway, 58% or approximately 212 (average daily) suspected COVID-19 cases were referral eligible to the area health centers. However, we only actually referred approximately 100 daily cases within the Cordon Sanitaire Industrial Area-Zone 57 for which the criteria applied.
With the continued accuracy of the EMD triaging, the next phase of referrals to health centers was expanded nationwide under Level 3 which was operationalized in late May. By July, we were in de-escalation and NCC-999 was processing 776 (average daily) cases, of which 258 (average daily) were suspected COVID-19 cases. Of those, 48 (average daily) were referred to an area health center. With a return to normalcy, these numbers are consistent with the recommended application of OMEGA across all MPDS; 18% of all requests for ambulances to be referred to an alternate care pathway.
Referrals to the health centers was not initially received well, but the guidelines provided to the EMD staff helped manage expectations and the conversations with callers/patients. Our robust customer service review process within our quality improvement framework provisioned this. With everyone engaged in the field, we were not able to facilitate secondary triage with OMEGA. Upon reviewing the MPDS determinant codes against the provisional diagnosis data, we found congruence that suggested minimal risk in referring callers/patients directly to the health centers in their communities. This improved the utilization of ambulance resources as well as reduced unnecessary trips to the hospital emergency departments. The Desk did aid in escalation of any case that could be overridden for immediate dispatch of an Ambulance Service resource. With this success and acceptance from the greater health system, the new normal will be to implement OMEGA protocols.
The efforts of everyone involved was humbling. The Ministry of Public Health (MOPH) gave the best directions they could so that SWICC could implement command instructions for Hamad Medical Corporation and the Ambulance Service. HCC-16099 (as well as NCC-999) contributed tirelessly to the efforts, being very responsible to the ever-changing demands and commands. The word “synergy” took on an entirely different meaning; the best of us, from all of us. We would use these learnings to co-create new policies and procedures that could be implemented in future COVID waves or pandemics, for that matter. Thank you to all the heroes behind the headset around the world and those whom they work with and otherwise support, in the global fight against the pandemic.
Author’s Note: Full disclosure, the events described in this article, which occurred between February 2020 and August 2020, are not all-encompassing. Additionally, the figures are approximate, and the details, while factual, are generalized for reasons of national security. The purpose of this article was to provide my lived experience of being on the front lines of the COVID-19 pandemic response efforts in the State of Qatar.
