| Akuamoa-Boateng et al. [14] |
German University Hospital radiation oncology clinic |
3 |
Changing workflow designs and patient selection led to reduced first-contact appointments and significantly increased downstream appointment compliance. Observation of pre-Covid clinic flow including barriers and compared them to during COVID clinic flow with increased precautions and looked for areas to optimize. Having an “active flow management” for each patient helped patients stay on treatment and helped physicians not have to delay future patients from treatment planning.
|
Non-treatment-related routine follow-up appointments were deferred in mutual agreement with patients and rescheduled within 2 to 4 months in close consultation with the primary oncology care giver. Alternative active patient flow management procedures were prepared by installing a hermetically sealed infrastructure and exclusively assigned personnel governed by security concepts.
|
| Anderson et al. [15] |
Ambulatory care pharmacy preceptors in the U.S. |
3 |
Physician/pharmacy care team would ultimately communicate all decisions back to the patient, being mindful to limit the number of people in a single care room. Physical examinations or monitoring tests (vital signs or other point-of-care tests) were conducted by the pharmacist or year 2 ambulatory care residents, whereas student clinicians had less-acute conditions to treat to help with process flow.
|
Learner removed from onsite, reducing their ability to treat in-person. Findings concluded that while there are multiple methods of changing the delivery of care, ultimately the methods need to evolve more to continue addressing the challenges COVID-19 has given the healthcare system for patient care. This is even more true with preceptors and students.
|
| Aquilanti et al. [16] |
Dental patients in Italy |
3 |
|
|
| Atchley et al. [17] |
U.S. nurse practitioner outpatient clinics |
3 |
Sick patients were triaged via telephone. Social distancing was maintained by either seeing patients at well-spaced out intervals or in some cases assessing and treating patients in their personal vehicles in the clinic parking lot. Ensuring open communication channels among the various staff to discuss needed changes and feedback from patients can both support the creation of a culture of change and safety within practices and help reduce wait times. Appropriate staff use, good scheduling practices, and maximization of time spent by patients in the clinic, combined with the integration of telehealth care, can improve clinic flow and reduce wait times. By reducing wait times, providers can reduce costs while improving patient outcomes and perceptions of care.
|
Many patients were sheltering in place at home during this time to decrease the possibility of exposure to the COVID-19 virus. State and local governments invoked recommendations restricting nonessential services, including well and routine healthcare visits.
|
| Baughman et al. [18] |
Boston post-acute care facilities and surrounding healthcare organizations |
3 |
Local government and health care leaders collaborated to rapidly establish a 1000-bed field hospital for long-term care patients. COVID positive patients were transferred to a local health care organization for the homeless with 500 respite beds for required isolation. Centralized, large nonprofit multicenter health care system provided financial, operational, and human resources to develop and manage beds for patients with COVID-19 requiring transitional or respite care from hospitals and outpatient settings. Partnership with local government, military, and major health care organizations was essential for logistical and medical resource support.
|
Admissions were limited by patient perception that the field hospital was more of a shelter rather than a post-acute care hospital and other concerns around general comfort, privacy, and the no-visitor policy. Not all beds were utilized, as only 394 patients were admitted to the field hospital.
|
| Beattie et al. [19] |
Inner Hebrides
of Scotland outpatient clinics |
3 |
Enabled video consultations with specialists to take place in the patient’s home. This study reaffirms the view that patients and the public indeed hold unique perspectives about how health services can be designed to fit their communities. The project successfully codesigned the use of Near Me at Home video consulting, through quality improvement methodologies to address a key issue for the community of Skye.
|
|
| Casiraghi et al. [20] |
Spedali Civili Italian hospital trauma department patients |
3 |
Redistribution of human and technological resources to pneumology, infectious disease, and intensive care increased productivity of the trauma unit. Three “hub” hospitals for major trauma were identified in the region for these specific types of patient. All trauma activities that could not be postponed were concentrated in this trauma hub. Adaptive staging based on patient COVID status at the time of treatment was created to help improve workflow processes, while protecting patients and providers.
|
In order to leave the red zone, all healthcare professionals stepped over a puff embedded with chloro-derivate solution. Other stage-related precautionary measures did slow workflow processes. Creation of a COVID-positive and COVID-negative surgical floor resulted in an imbalance patients on either floor at any one time, resulting in redistribution of resources to accommodate workflow needs.
|
| Darr et al. [21] |
NHS tertiary pediatric referral center |
2 |
Use of virtual outpatient clinic encounters for pediatric otolaryngology assessments resulted in 99% initial diagnosis accuracy. Findings demonstrate a positive response to the addition of the telehealth with less cancellations, increased referral back to primary care and a decrease in planned surgical procedures.
|
The use of aerosol generating procedures (AGPs), particularly flexible nasendoscopy (FNE) was minimized, with recommendations for use only in extenuating circumstances. Postponement of most elective outpatient and inpatient services occurred per local/regional government policy recommendations. A need for a detailed examination was still identified after a virtual visit. Use of instrumentation and further investigations limited the use of virtual visits, necessitating follow-on face-to-face appointments based on the clinical priority level.
|
| Das [22] |
Community-based ambulatory endoscopy center in the U.S. |
3 |
|
Post–COVID-19 recommended workflow changes significantly impacted the operational and productivity metrics and, in turn, adversely affected the financial metrics. With the addition of COVID 19 procedures, increased time and costs for the patient and center occurred. There was a significant increase in total processing times, waiting times with a consequent decrease in productivity, and financial metrics precisely because of a bottleneck at the time of pre-procedure COVID-19 screening and testing while practicing social distancing. Incorporation of recommended post–COVID-19 related workflow modifications adversely impacted the efficiency and utilization of an AEC across a wide array of performance indicators.
|
| De Biase et al. [23] |
Tertiary institution neurology clinic (U.S) |
2 |
|
|
| dos Santos et al. [24] |
Public university service mastology
outpatient clinic in Ceará |
3 |
Identification of scheduled patients, reading of clinical developments in electronic medical records, individual assessment to define whether or not appointment would remain, telephone contact to inform about unscheduling helped improve operations.
|
The number of outpatient users is high, which normally causes crowds in the corridors. Increased COVID-19 cases brought the need to restructure healthcare services. Lack of time to follow up service was a limitation of this study.
|
| Fu et al. [25] |
Lung Cancer patients at a health system clinic in the People’s Republic of China |
2 |
|
|
| George et al. [26] |
Singapore community health pain management clinics |
3 |
Close partnership between pain specialists and community nurses to collaboratively adopt a systematic and comprehensive approach to assessment, treatment compliance and outcome monitoring. Patients with impaired mobility, poor social support and multiple comorbidities, especially older adults, were considered for referral to community teams. Teleconsultation now recognized as a feasible solution, allowing assessment and social interaction and shortening the waiting times to consultations while fulfilling the requirements of social distancing. Community volunteers assisted patients to be digitally connected with their health and social care providers by improve accessibility to mobile devices and information technology literacy. Overall, the integration of community healthcare teams into the holistic, long-term management plans for vulnerable patients with chronic pain increased patient throughput and overall care.
|
Some barriers with patients who were not able to receive treatment for their comorbidities other than pain. Telemedicine has legal and safety limitations in monitoring opioid consumption. Community services such as home personal care and center-based care services were scaled down. Face-to-face visits were limited to 30 min. Older people and the less ‘tech savvy’ among the pain clinic’s patients were not open to the concept of video-consults initially, preferring telephone interviews and face-to-face consultations.
|
| Gharaibeh et al. [27] |
International orthopedic clinics |
3 |
Orthopedic surgery workflow (zones) created for patients having surgery to safely implement COVID protocols. Outpatient clinics established a provider testing system to ensure they do not spread COVID in the outpatient setting. Part of the clinical assessment such as history taking, may be completed using a digital interface to limit the interaction between the patient and the medical staff. An ‘off-duty’ team can use Telehealth to manage remote follow ups to reduce the burden on the active team or health care system.
|
High-risk outpatients follow a scheduling protocol that automatically establishes a 14-day waiting period. Designated, separate operating suites created for COVID and non-COVID patients (pre-established). Intubation/extubation is to be performed in a separate area from the operating room. Surgical/OR patients are to have a reduced surgical team in order to decrease the movement of individuals and prevent spread of the disease, increasing individual workload in the delivery of care.
|
| Hockaday et al. [28] |
Federal Medical Station for COVID patients in Dallas, TX, USA |
3 |
|
When removal of masks in the patient care areas is required, the affected person should immediately mobilize toward the doffing zone exit, maintaining a minimum distance of 6 ft from all staff and patients.
|
| Janig et al. [29] |
Military medical treatment facilities |
3 |
Established military medicine protocol involves ongoing assessment of available resources and transfer the patient to the highest level of care available if the patient’s status permits. MEDEVAC (helicopter) evacuation protocol exists to also remove the COVID positive patient from theater immediately. Initial or re-evaluation of the patient in theater requires an assessment of COVID-related symptoms to be included in the triage and treatment decision algorithm established in the author’s protocol.
|
|
| Küçük et al. [30] |
Health Ministry of Turkey EHR/EMR data from multiple healthcare organizations |
2 |
|
Scheduling problems, no free time slots available for physicians, and physician or hospital-related problems slowed patient flow. The scheduling system had many barriers, such as health policy implications in Turkey, preventing full implementation.
|
| Kyari & Watts [31] |
U.S. outpatient eye clinics |
3 |
Scheduling adaptations to have specific types of eye patients arrive for care at established time periods allows for increased throughput. Encourage patients to not bring family members/others with them to their appointments. Wayfinding/people moving systems (one-way paths) throughout the clinic for patient-flow and physical distancing enable better workflow. Use of clear and interpretable images (chair markings, etc.) assist in physical distancing communications and related messaging in the eye clinic.
|
Fragile health systems will return to the new normal in a less unified/organized manner. Where there have been no established social protection schemes, the response will be slower, and even more difficult for eye clinics without established protocols. An ongoing review of national and local updates (policy) to be implemented will alter clinic productivity.
|
| Lou et al. [32] |
Orthopedic surgery institution in Shanghai, China |
3 |
Professional organizations provided recommendations/guidelines on how best to manage selective operation patients during post-epidemic period. Strict enforcement resulted in better workflow and less spread of COVID across providers. A developed workflow they returned to pre-pandemic levels of orthopedic cases and they were able to handle them safely. Spread of COVID reduced by a stepwise strategy with a sound screening system, a combination of various diagnostic methods and appropriate personal protection to facilitate workflow.
|
Precautions to manage elective surgeries might be considered unnecessarily costly, overly rigid and time-consuming for a region that has cleared its local infected cases for months. Possible false-negative results for RT-PCR tests resulted in a proportion of asymptomatic or pre-symptomatic COVID-19 patients testing negative; these patients could be potential drivers of viral spreading. Further chest x-ray/diagnostics required that slowed workflow. Orthopedic procedures prone to generate aerosol, raising the potential risk of viral transmission in operating theater.
|
| Lynch et al. [33] |
Representatives from adult pain clinics in Canada |
2 |
They found that the added benefit of telehealth was beneficial to patients with chronic pain issues during the pandemic in helping keep care on track. Most telehealth care offered was for follow-up and maintenance of ongoing care for routine patients only.
|
Survey feedback demonstrated that regardless of tele-health (phone, webinar) options offered by pain management clinics, patient throughput still slowed as patients were reported to have to wait longer than normal for their care. Many patients without access to other diagnostic or therapeutic interventional procedures (urgent pain care offered by providers only during the pandemic). Alternative/complementary therapies in conjunction with regular pain management care was halted.
|
| Mason et al. [34] |
Radiotherapy patients at the The Christie at Oldham satellite center in the UK |
3 |
Designated areas for staff for putting on and removal of PPE. Development of a designated COVID-19 proforma to support telephone triage of patients telephoning with possible symptoms. Patients who themselves are asymptomatic but need to self-isolate due to contact with someone who is symptomatic or confirmed COVID-19, are treated at the end of the day. Patients’ relatives or carers are discouraged from attending with the patient for their radiotherapy appointment. Review of patient scheduling so the department treats at the most risk patient groups in the morning on both linear accelerators.
|
|
| Mukerji et al. [35] |
Otolaryngology clinic at a U.S. community pediatric
hospital |
3 |
Rotation schedule for providers and ancillary staff. Guidelines for in-clinic visits and alteration to surgical block and surgical case cadence. Ongoing algorithm workflow revisions were made at each phase of the pandemic related to in-clinic visits, telemedicine visits, and surgical cases for best outcomes/volume. Team A was designated as the “Urgent” team and Team B was the “Home” (telehealth) Team. Social distancing and prevent cross contamination we designated one area as the “urgent” clinical area and assigned one exam room and one procedure room for the urgent provider to see patients and perform clinical procedures. The “clean area” was used to perform telehealth visits with appropriate social distancing.
|
Otolaryngologists and pediatric otolaryngologists are amongst sub-specialties with an increased risk of exposure to COVID-19. Only one caretaker was permitted to enter the hospital with the patient. A “slow ramp” up phase was required, and limiting clinical templates were opened to provide in-clinic patient care. After a physician performed an aerosol generating procedure, the provider placed the laryngoscope in a biohazard bag and the procedure room was then closed for 1 h. Social distancing was optimized by increasing the turn-over time between procedures.
|
| Raidla et al. [36] |
Hospital system in Sweden |
2 |
Creation of a primary care-like facility in close proximity to the hospitals may relieve overcrowding of the hospital’s ED, especially during COVID-19. Having patients triaged appropriately to the Urgent Care Center helped save patients time and money and helped save the health system in time and they saw a reduction of resource overutilization. Provider familiarity with the facility in which they work and the devices they need to use essential.
|
|
| Rodler et al. [37] |
Patients currently being treated for genitourinary cancers at a single German hospital |
2 |
Findings showed that there was low risk of this patient population to contract COVID-19 if all protocol was followed. However, it did suggest the option of telemedicine for care to maintain patient care. Significant, early precautionary steps (physical distancing and other patient-acuity level protocols) enabled a low infection spread/rate and kept the clinic open. Multidisciplinary tumor boards for treatment decisions were transformed to teleconferences or video conferences. Virtual management and reductions in frequency of visits are feasible and will likely impact the future treatment approach of patients with genitourinary cancers after the crisis.
|
Strict quarantine of specific patient acuity types was part of the protocol, impeding care processes at the clinic level (while using telehealth resources). All clinical trials were paused.
|
| Sacchelli et al. [38] |
Psoriasis patients in ambulatory care clinics in Italy |
2 |
Psoriasis providers recommend making patients more confident in their services and safety provisions, encouraging them to refer/attend appointments In the case of clinical/therapeutic doubts, achieving a better compliance to treatment is recommended by working to ensure patient safety and control of misinformation via patient-provider communications.
|
Misinformation (termed ‘info-demic’) spread rapidly during the pandemic and changed the clinical course of patients with severe psoriasis. Many patients stopped their psoriasis treatment during lock down as a result. Word-of-mouth (often family member) recommendations to stop psoriasis treatment during the pandemic resulted in frequent appointment cancellations.
|
| Segal et al. [39] |
Washington state pharmacy service for multiple ambulatory care clinics |
3 |
An expedited telehealth program was able to be fast tracked due to the relaxation of CMS guidelines of telehealth regulations. Telehealth visits are preferred over phone visits to ensure patient understanding and to help establish the pharmacist and/or care team establish and build rapport with the patient, eliminating unnecessary in-person follow-up appointments. Expansion of telehealth eligibly pharmacy services patients (not just for rural health and other patient categories).
|
The telehealth visits resembled a scheduled in-person appointment format. For telehealth to be successful, both parties must stick to their scheduled appointment time. For pharmacists working off-site, wireless Internet seems less stable and slowed process workflow.
|
| Tam et al. [40] |
Cardiac health system in Ontario that has outpatient clinics |
3 |
A triage system for patients for was enacted to determine appropriate cardiac care during the pandemic and how to properly gauge the use of resources to slowly reopen to a larger capacity. A proper workflow is needed to balance the need for cardiac care during the pandemic and current COVID-19 patient loads.
|
|
| Thorakkattil et al. [41] |
Johns Hopkins Aramco Health Care (JHAH) ambulatory care pharmacy services in Saudi Arabia |
2 |
Staff schedule rotations and allocations were applied to reduce the number of available staff per pharmacy unit to enable appropriate physical distancing and to cater for the expanded staffing needs of the call center and the additional temporary pickup locations. Through the use of home delivery, off site medication pick up and online portal medication requests, the pharmacy was able to maintain quality in the care offered and honored the infection protocols. Encouraging patients to use the remote pickup locations of JHAH pharmacies helped.
|
Considerations had to be made for the consequences of governmental decisions (e.g., curfew, areas in lockdown, and stoppages of transportation services.
|
| Wang et al. [42] |
Outpatient fever clinics located at the Union Medical College Hospital (China) |
3 |
An evaluation of the effect of upgrading the fever clinic system assisted with rates of nosocomial COVID-19 infection and (ED) emergency department patient attendance at Peking Union Medical College Hospital. The workload of the FC increased significantly after the COVID-19 outbreak and new protocols regarding the use of the fever clinic likely helped prevent the spread of COVID-19 within the hospital and reduced further burden on the ED.
|
|
| Waya et al. [43] |
African healthcare organizations |
3 |
Asymptomatic, mild and moderate cases without comorbidities or risk factors are isolated and managed at home, with symptomatic management for mild and moderate cases and close monitoring for any clinical deterioration. African governments and scientists should strengthen national capacities for the generation of local evidence which could guide the development of home-grown case management strategies, protocols and equipment for the management of COVID-19 cases on the continent. Home-grown, community-specific protocols assist with preventing COVID spread to healthcare providers while also avoiding social stigmas.
|
Facility-based isolation of COVID-19 cases extremely limited, given the health infrastructure and health workforce issues in Africa, including the risk of nosocomial transmission. Poor housing, overcrowding, inadequate access to water and sanitation, and stigma related to infectious disease that is prevalent in many African societies was not an option an further slowed organizational processes.
|
