Appropriateness of the Emergency Referrals Made by Primary Care Clinicians: A cross-sectional review of referral notes.

Objectives: This study aimed to evaluate the appropriateness of the emergency referrals made by primary care clinicians and determine the factors contributing to inappropriate referrals. Methods: This cross-sectional study utilises referral notes review between October 2019 and March 2020. Patients referred to Khawla Hospital's emergency department by a primary care clinician in Muscat Governorate were randomly selected; their referral notes were reviewed by five family physicians. The appropriateness of the referrals was evaluated according to the primary care referral protocol. Any referral that deviated from the protocol was classified as inappropriate. The prevalence and characteristics of inappropriate referrals were identified, and the factors contributing to inappropriate referral were determined using multivariable logistic regression. Results: In total, 591 referrals were reviewed; 354 (59.9%) of them were classified as inappropriate due to inadequate medical notes (291, 82.2%), lack of provisional diagnosis (176, 49.7%), misdirected to a non-concerned emergency (30, 8.4%) or misclassification of urgency (107 [30.2%] were classified as urgent and 45 [12.7%] as routine). After adjusting for multiple variables, insufficient clinical notes, unavailability of referral guidelines and lack of expertise were found to be strong determinants of inappropriate referral, with an odds ratio of 62.52 (95% confidence interval [CI]: 32.04-121.96), 2.88 (95% CI: 1.40-5.92) and 9.37 (95% CI: 4.09-21.43), respectively. Conclusion: While most of the referrals required emergency management, the majority were inappropriate, mainly due to insufficient clinical documentation. Inadequate clinical notes and lack of national guidelines and expertise were found to be strong predictors of inappropriate emergency referrals.

Characteristics of the First 102 Severe COVID-19 Cases Treated With Convalescent Plasma or Tocilizumab or Both in Al-Nahdha Hospital, Oman.

BACKGROUND: In the absence of an effective vaccine, the coronavirus disease (COVID-19) continues to cause more deaths. Evidence on the effectiveness of various COVID-19 management plans is inconclusive. This paper describes the characteristics of the first 102 severe COVID-19 in-patients treated with Convalescent Plasma (CP) therapy or Tocilizumab or both at Al-Nahdha hospital in Muscat, Oman. Additionally, differences in requiring critical care were explored across the treatment groups. METHODS: Data of all the positive cases in Al-Nahdha hospital were retrieved from the electronic health information system retrospectively from April 1st to July 31st 2020. The required information was recorded in a bespoke sheet and exported to SPSS for further analysis. The primary outcome was defined as improved (discharged home) vs worsening (requiring critical care). RESULTS: Out of the 102 severe cases of COVID-19 admissions, 20.6%, 59.8% and 20.6% received CP, Tocilizumab and both respectively. In average, CP was introduced at day 3.7(4.8) whereas Tocilizumab at day 7.8(5.1) from admission. The between-group differences in the proportion of patient who improved vs worsened were not significant (P = 0.7). However, the within-group difference in the proportion of patient who improved vs worsened was significant in the Tocilizumab treatment group (P = 0.03). All socio-demographics were not significantly different across the treatment groups. Most improvements in the studies parameters [CBC (total WBC, Lymph and neutrophil counts), oxygen and immune response "cytokine storm" parameters] post-treatment was attributed to the use of Tocilizumab. There was a statistically significant difference in the mean hospital stay between the improved and worsened cases across all treatment categories [at the population level: 8.2(5.0) improved vs 4.7(3.7) worsened-P < 0.001]. CONCLUSIONS: Results from this study provided baseline information about the characteristics of confirmed COVID-19 cases in Al-Nahdha hospital who received CP, Tocilizumab or both. Results obtained seems to be promising in preventing critical care, especially for Tocilizumab. However, further randomized studies are needed.

The Use of Telephone Consultation in Primary Health Care During COVID-19 Pandemic, Oman: Perceptions from Physicians.

INTRODUCTION: To enforce physical distancing measures during COVID-19, Telephone Consultation (TC), a form of telemedicine, was initiated as an alternative technology to face to face consultation in primary health care (PHC) in Muscat, Oman. This study aims to explore the perceptions of physicians about the use of TC with respect to process of implementation; challenges and limitations; lessons learned and the way forward. METHOD: This was a qualitative study using interpretive phenomenological analysis. Physicians who were actively conducting TC in PHC were purposively selected and individually interviewed until no new responses were obtained. All interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis. RESULTS: Twenty-two participants were interviewed. Participants were predominantly females (98%) and qualified family physicians (77.3%). Overall, all participants accepted this initiative as a possible method to continue health services during COVID-19. Perceptions about the process of implementing TC in PHC were themed to; inconsistent implementation of the guideline, variability in roles and responsibilities, and Semi-supportive infrastructure. Five themes were identified as challenges and limitations: limited staff training on TC, suboptimal patient-physician interaction, insufficient technical support, ensuring privacy, and confidentiality of the communication, and different ways to document the TC. Physicians expressed that TC worked better in following COVID-19 cases, chronic conditions, and, in general, simple cases. They also expressed a reduction in the crowdedness in PHC facilities and the risk of acquiring COVID-19 and other types of infections. Tailoring the existing structural clinical setting, capacity building activities on the use of TC, and improving the quality of the TC are viewed as essential steps for the future sustainability of TC in PHC. CONCLUSION: Given the exceptional situation of COVID-19, the current evidence suggests that the use of TC in PHC, especially in chronic cases, is promising. However, measures including training of staff, improving the structural setting, and selecting suitable cases for TC are the main elements for high quality and sustainable TC services in PHC from physician's perspective.