COVID-19 testing in English care homes and implications for staff and residents.

INTRODUCTION: Care home residents are at high risk of dying from coronavirus disease 2019 (COVID-19). Regular testing, producing rapid and reliable results is important in this population because infections spread quickly, and presentations are often atypical or asymptomatic. This study evaluated current testing pathways in care homes to explore the role of point-of-care tests (POCTs). METHODS: A total of 10 staff from eight care homes, purposively sampled to reflect care organisational attributes that influence outbreak severity, underwent a semi-structured remote videoconference interview. Transcripts were analysed using process mapping tools and framework analysis focussing on perceptions about, gaps within and needs arising from current pathways. RESULTS: Four main steps were identified in testing: infection prevention, preparatory steps, swabbing procedure and management of residents. Infection prevention was particularly challenging for mobile residents with cognitive impairment. Swabbing and preparatory steps were resource-intensive, requiring additional staff resource. Swabbing required flexibility and staff who were familiar to the resident. Frequent approaches to residents were needed to ensure they would participate at a suitable time. After-test management varied between sites. Several homes reported deviating from government guidance to take more cautious approaches, which they perceived to be more robust. CONCLUSION: Swab-based testing is organisationally complex and resource-intensive in care homes. It needs to be flexible to meet the needs of residents and provide care homes with rapid information to support care decisions. POCT could help address gaps but the complexity of the setting means that each technology must be evaluated in context before widespread adoption in care homes.

Enhanced lateral flow testing strategies in care homes are associated with poor adherence and were insufficient to prevent COVID-19 outbreaks: results from a mixed methods implementation study.

INTRODUCTION: Care homes have been severely affected by the SARS-CoV-2 pandemic. Rapid antigen testing could identify most SARS-CoV-2 infected staff and visitors before they enter homes. We explored implementation of staff and visitor testing protocols using lateral flow devices (LFDs). METHODS: An evaluation of a SARS-CoV-2 LFD-based testing protocol in 11 care homes in Liverpool, UK, including staff and visitor testing, plus a qualitative exploratory study in nine of these homes. The proportion of pilot homes with outbreaks, and outbreak size, were compared to non-pilot homes in Liverpool. Adherence to testing protocols was evaluated. Fifteen staff were interviewed, and transcript data were thematically coded using an iterative analysis to identify and categorize factors influencing testing implementation. RESULTS: In total, 1,638 LFD rapid tests were performed on 407 staff. Protocol adherence was poor with 8.6% of staff achieving >75% protocol adherence, and 25.3% achieving $\ge$50%. Six care homes had outbreaks during the study. Compared to non-pilot care homes, there was no evidence of significant difference in the proportion of homes with outbreaks, or the size of outbreaks. Qualitative data showed difficulty implementing testing strategies due to excessive work burden. Factors influencing adherence related to test integration and procedural factors, socio-economic factors, cognitive overload and the emotional value of testing. CONCLUSION: Implementation of staff and visitor care home LFD testing protocols was poorly adhered to and consequently did not reduce the number or scale of COVID-19 outbreaks. More focus is needed on the contextual and behavioural factors that influence protocol adherence.

COVID-19 point-of-care testing in care homes: what are the lessons for policy and practice?

COVID-19 has devastated care homes. Point-of-care tests (POCTs), mainly using lateral flow devices (LFDs), have been deployed hurriedly without much consideration of their usability or impact on care workflow. Even after the pandemic, POCTs, particularly multiplex tests, may be an important control against spread of SARS-CoV-2 and other respiratory infections in care homes by enabling identification of cases. They should not, however, replace other infection control measures such as barrier methods and quarantine. Adherence to LFDs as implemented among care home staff is suboptimal. Other tests-such as point-of-care polymerase chain reaction and automated antigen tests-would also need to be accommodated into care home workflows to improve adherence. The up-front costs of POCTs are straightforward but additional costs, including staffing preparation and reporting processes and the impacts of false positive and negative tests on absence rates and infection days, are more complex and as yet unquantified. A detailed appraisal is needed as the future of testing in care homes is considered.

Implementing lateral flow devices in long-term care facilities: experiences from the Liverpool COVID-19 community testing pilot in care homes- a qualitative study.

INTRODUCTION: Antigen-based lateral flow devices (LFDs) offer the potential of widespread rapid testing. The scientific literature has primarily focused on mathematical modelling of their use and test performance characteristics. For these tests to be implemented successfully, an understanding of the real-world contextual factors that allow them to be integrated into the workplace is vital. To address this gap in knowledge, we aimed to explore staff's experiences of integrating LFDs into routine practice for visitors and staff testing with a view to understand implementation facilitators and barriers. METHODS: Semi-structured interviews and thematic analysis. RESULTS: We identified two main themes and five subthemes. The main themes included: visitor-related testing factors and staff-related testing factors. Subthemes included: restoring a sense of normality, visitor-related testing challenges, staff-related testing challenges, and pre-pilot antecedent factors. CONCLUSION: Our study demonstrates that the real-world implementation of LFDs to test visitors and staff faces significant challenges as a result of several contextual factors negatively affecting the work practice and environment. More comprehensive studies are needed to identify and inform effective implementation strategies to ensure that LFDs can be adopted in an agile way that better supports an already exhausted and morally depleted workforce.

Care pathway and prioritization of rapid testing for COVID-19 in UK hospitals: a qualitative evaluation.

OBJECTIVES: The second wave of the coronavirus pandemic is now established, occurring at a time of winter pressure on acute care in the NHS. This is likely to be more challenging then the first wave for the diagnosis of COVID-19 because of the similar symptomology with other respiratory conditions highly prevalent in winter. This study sought to understand the care pathways in place in UK NHS hospitals during the first wave (March-July 2020) for identification of patients with COVID-19 and to learn lessons to inform optimal testing strategies within the COVID-19 National Diagnostic Research and Evaluation Platform (CONDOR). DESIGN, SETTING & PARTICIPANTS: Sixteen hospital-based clinicians from 12 UK NHS Trusts covering 10 different specialties were interviewed following a semi-structured topic guide. Data were coded soon after the interviews and analysed thematically. RESULTS: We developed a diagrammatic, high-level visualisation of the care pathway describing the main clinical decisions associated with the diagnosis and management of patients with suspected COVID-19. COVID-19 testing influenced infection control considerations more so than treatment decisions. Two main features of service provision influenced the patient management significantly: access to rapid laboratory testing and the number of single occupancy rooms. If time to return of result was greater than 24 h, patients with a presumptive diagnosis would often be cohorted based on clinical suspicion alone. Undetected COVID-19 during this time could therefore lead to an increased risk of viral transmission. CONCLUSIONS: During the winter months, priority for provision of rapid testing at admission should be given to hospitals with limited access to laboratory services and single room availability. Access to rapid testing is essential for urgent decisions related to emergency surgery, maternity services and organ transplant. The pathway and prioritization of need will inform the economic modelling, clinical evaluations, and implementation of new clinical tests in UK.

Mechanisms of decision-making in preoperative assessment for older adult prostate cancer patients-A qualitative study.

BACKGROUND AND OBJECTIVE: Little research exists which investigates the contextual factors and hidden influences that inform surgeons and surgical teams decision-making in preoperative assessment when deciding whether to or not to operate on older adult prostate cancer patients living with aging-associated functional declines and illnesses. The aim of this study is to identify and examine the underlying mechanisms that uniquely shape preoperative surgical decision-making strategies concerning older adult prostate cancer patients. METHODS: Qualitative methodologies were used that paired ethnographic field observations with semistructured interviews for data collection. An inductive thematic analysis approach was used to identify, analyze, and describe patterns in the data. RESULTS: Factors underlining surgical decision-making originated from the context of two categories: (1) clinical and surgery-specific factors; and (2) non-patient factors. Thematic subcategories included personal experiences, methods of assessment during medical encounters, anticipation of outcomes, perceptions of preoperative assessment instruments for frailty and multimorbidity, routines and workflow patterns, microcultures, and indirect observation and second-hand knowledge. CONCLUSION: Surgeon's personal experiences has a significant impact on the decision-making processes during preoperative assessments. However, non-patient factors such as institutional microcultures passively and actively influence decision-making process during preoperative assessment.

Interoperability after deployment: persistent challenges and regional strategies in Denmark.

QUALITY PROBLEM OR ISSUE: The European Union has identified Denmark as one of the countries who have the potential to provide leadership and inspiration for other countries in eHealth implementation and adoption. However, Denmark has historically struggled to facilitate data exchange between their public hospitals' electronic health records (EHRs). Furthermore, state-led projects failed to adequately address the challenges of interoperability after deployment. CHOICE OF SOLUTION: Changes in the organizational setup and division of responsibilities concerning the future of eHealth implementations in hospitals took place, which granted the Danish regions the full responsibility for all hospital systems, specifically the consolidation of EHRs to one system per region. IMPLEMENTATION: The regions reduced the number of different EHRs to six systems by 2014. Additionally, the first version of the National Health Record was launched to provide health care practitioners with an overview of a patient's data stored in all EHRs across the regions and within the various health sectors. EVALUATION: The governance of national eHealth implementation plays a crucial role in the development and diffusion of interoperable technologies. Changes in the organizational setup and redistribution of responsibilities between the Danish regions and the state play a pivotal role in producing viable and coherent solutions in a timely manner. LESSONS LEARNED: Interoperability initiatives are best managed on a regional level or by the authorities responsible for the provision of local health care services. Cross-regional communication is essential during the initial phases of planning in order to set a common goal for countrywide harmonization, coherence and collaboration.

Mapping telemedicine efforts: surveying regional initiatives in Denmark.

OBJECTIVES: The aim of this study is to survey telemedicine services currently in operation across Denmark. The study specifically seeks to answer the following questions: What initiatives are deployed within the different regions? What are the motivations behind the projects? What technologies are being utilized? What medical disciplines are being supported using telemedicine systems? MATERIALS AND METHODS: All data were surveyed from the Telemedicinsk Landkort, a newly created database designed to provide a comprehensive and systematic overview of all telemedicine technologies in Denmark. RESULTS: The results of this study suggest that a growing numbers of telemedicine initiatives are currently in operation across Denmark but that considerable variations exist in terms of regional efforts as the number of operational telemedicine projects varied from region to region. CONCLUSIONS: The results of this study provide a timely picture of the factors that are shaping the telemedicine landscape of Denmark and suggest potential strategies to help policymakers increase and improve national telemedicine deployment.

eHealth in Denmark: a case study.

Denmark is widely regarded as a leading country in terms of eHealth integration and healthcare delivery services. The push for eHealth adoption over that past 20 years in the Danish health sector has led to the deployment of multiple eHealth technologies. However, in reality the Danish healthcare suffers from eHealth system fragmentation which has led to eHealth's inability to reach full potential in delivering quality healthcare service. This paper will presents a case study of the current state of eHealth in the Danish healthcare system and discuss the current challenges the country is facing today.

Determinants of physician networks: an ethnographic study examining the processes that inform patterns of collaboration and referral decision-making among physicians.

OBJECTIVE: Most scholarly attention to studying collaborative ties in physician networks has been devoted to quantitatively analysing large, complex datasets. While valuable, such studies can reduce the dynamic and contextual complexities of physician collaborations to numerical values. Qualitative research strategies can contribute to our understanding by addressing the gaps left by more quantitative approaches. This study seeks to contribute to the literature that applies network science approaches to the context of healthcare delivery. We use qualitative, observational and interview, methods to pursue an in-depth, micro-level approach to the deeply social and discursive processes that influence patterns of collaboration and referral decision-making in physician networks. DESIGN: Qualitative methodologies that paired ethnographic field observations, semistructured interviews and document analysis were used. An inductive thematic analysis approach was used to analyse, identify and describe patterns in those data. SETTING: This study took place in a high-volume cardiovascular department at a major academic medical centre (AMC) located in the Midwest region of the USA. PARTICIPANTS: Purposive and snowballing sampling were used to recruit study participants for both the observational and face-to-face in-depth interview portions of the study. In total, 25 clinicians and 43 patients participated in this study. RESULTS: Two primary thematic categories were identified: (1) circumstances for external engagement; and (2) clinical conditions for engagement. Thematic subcategories included community engagement, scientific engagement, reputational value, experiential information, professional identity, self-awareness of competence, multidisciplinary programmes and situational factors. CONCLUSION: This study adds new contextual knowledge about the mechanisms that characterise referral decision-making processes and how these impact the meaning of physician relationships, organisation of healthcare delivery and the knowledge and beliefs that physicians have about their colleagues. This study highlights the nuances that influence how new collaborative networks are formed and maintained by detailing how relationships among physicians develop and evolve over time.

Rapid point-of-care testing for COVID-19: quality of supportive information for lateral flow serology assays.

OBJECTIVE: There is a lack of evidence addressing several important human factors questions pertaining to the quality of supportive information provided by commercial manufacturers that can affect the adoption and use of lateral flow serology assays in practice. We aimed to: (1) identify and assess the quality of information that commercial manufacturers provided for their point-of-care tests (POCTs) and (2) examine the implications of these findings on real-world settings. DESIGN: We used a content analysis methodology in two stages to systematically, code and analyse textual data from documents of commercial manufacturers. A deductive approach was applied using a coding guide based on the validated Point-of-Care Key Evidence Tool (POCKET) multidimensional checklist. An inductive approach was used to identify new patterns or themes generated from our textual analysis. SETTING: Publicly available supportive information documents by commercial manufacturers for lateral flow serology, were identified and gathered from online searches. PARTICIPANTS: Supportive information documents retrieved from online searches over 3 months (March 2020 to June 2020). RESULTS: A total of 79 POCTs were identified that met the study inclusion criteria. Using the POCKET coding guide, we found that the quality of information varied significantly between the manufacturers and was often lacking in detail. Our inductive approach further examined these topics and found that several statements were vague and that significant variations in the level of details existed between manufacturers. CONCLUSIONS: This study revealed significant concerns surrounding the supportive information reported by manufacturers for lateral flow serology assays. Information transparency was poor and human factor issues were not properly addressed to mitigate the risk of improper device use, although it should be noted that the results of our study are limited by the data that manufactures were prepared to disclose. Overall, commercial manufacturers should improve the quality and value of information presented in their supporting documentation.

Strategies to implement SARS-CoV-2 point-of-care testing into primary care settings: a qualitative secondary analysis guided by the Behaviour Change Wheel.

BACKGROUND: The purpose of this study is to develop a theory-driven understanding of the barriers and facilitators underpinning physicians' attitudes and capabilities to implementing SARS-CoV-2 point-of-care (POC) testing into primary care practices. METHODS: We used a secondary qualitative analysis approach to re-analyse data from a qualitative, interview study of 22 primary care physicians from 21 primary care practices across three regions in England. We followed the three-step method based on the Behaviour Change Wheel to identify the barriers to implementing SARS-CoV-2 POC testing and identified strategies to address these challenges. RESULTS: Several factors underpinned primary care physicians' attitudes and capabilities to implement SARS-CoV-2 POC testing into practice. First, limited knowledge of the SARS-CoV-2 POC testing landscape and a demanding workload affected physicians' willingness to use the tests. Second, there was scepticism about the insufficient evidence pertaining to the clinical efficacy and utility of POC tests, which affected physicians' confidence in the accuracy of tests. Third, physicians would adopt POC tests if they were prescribed and recommended by authorities. Fourth, physicians required professional education and training to increase their confidence in using POC tests but also suggested that healthcare assistants should administer the tests. Fifth, physicians expressed concerns about their limited workload capacity and that extra resources are needed to accommodate any anticipated changes. Sixth, information sharing across practices shaped perceptions of POC tests and the quality of information influenced physician perceptions. Seventh, financial incentives could motivate physicians and were also needed to cover the associated costs of testing. Eighth, physicians were worried that society will view primary care as an alternative to community testing centres, which would change perceptions around their professional identity. Ninth, physicians' perception of assurance/risk influenced their willingness to use POC testing if it could help identify infectious individuals, but they were also concerned about the risk of occupational exposure and potentially losing staff members who would need to self-isolate. CONCLUSIONS: Improving primary care physicians' knowledgebase of SARS-CoV-2 POC tests, introducing policies to embed testing into practice, and providing resources to meet the anticipated demands of testing are critical to implementing testing into practice.

Applications of health information exchange information to public health practice.

Increased information availability, timeliness, and comprehensiveness through health information exchange (HIE) can support public health practice. The potential benefits to disease monitoring, disaster response, and other public health activities served as an important justification for the US' investments in HIE. After several years of HIE implementation and funding, we sought to determine if any of the anticipated benefits of exchange participation were accruing to state and local public health practitioners participating in five different exchanges. Using qualitative interviews and template analyses, we identified public health efforts and activities that were improved by participation in HIE. HIE supported public health activities consistent with expectations in the literature. However, no single department realized all the potential benefits of HIE identified. These findings suggest ways to improve HIE usage in public health.

Information retrieval pathways for health information exchange in multiple care settings.

OBJECTIVES: To determine which health information exchange (HIE) technologies and information retrieval pathways healthcare professionals relied on to meet their information needs in the context of laboratory test results, radiological images and reports, and medication histories. STUDY DESIGN: Primary data was collected over a 2-month period across 3 emergency departments, 7 primary care practices, and 2 public health clinics in New York state. METHODS: Qualitative research methods were used to collect and analyze data from semi-structured interviews and participant observation. RESULTS: The study reveals that healthcare professionals used a complex combination of information retrieval pathways for HIE to obtain clinical information from external organizations. The choice for each approach was setting- and information-specific, but was also highly dynamic across users and their information needs. CONCLUSIONS: Our findings about the complex nature of information sharing in healthcare provide insights for informatics professionals about the usage of information; indicate the need for managerial support within each organization; and suggest approaches to improve systems for organizations and agencies working to expand HIE adoption.