The Royal College of Physicians has conducted the largest study to date of the quality of care given to patients in the UK with COVID-19 to identify learnings from the pandemic.
This study recruited a sample and demographic representative of English hospitals’ experience of the COVID-19 pandemic. The study gathered information about the quality of care delivered from 19 organisations in England which between them accounted for a population of almost 10.5 million people exposed to the COVID-19 virus. These organisations collectively looked after over 26,000 cases of COVID-19 in 2020 with over 6,000 patients dying with the condition in their care. They reviewed 510 patients and their care.
Using a modified version of an established and validated structured judgement review process already used by many clinicians in the retrospective case record analysis of acute hospital deaths, the study concluded that overall care delivered was judged to have been adequate, good or excellent for 96.5% of patients (good or excellent for 77.4%).
Care judged to be poor overall was very uncommon and occurred in only 3.5% of the total sample. When it did occur, it was related to end-of-life care issues, nosocomial infections (those acquired in hospital), delays in assessment and the two linked issues of poor communication and poor documentation.
The study looked at significant variations between hospitals when it came to end of life care experiences, assessment, documentation and communication, senior review, do not attempt resuscitation decisions and discharge planning. This revealed both excellent care and care that could have been improved.
In a report based on its findings, Caring for Hospital Patients with COVID-19: Quality of Care in England Examined by Case Record Review, the RCP recommends that:
- Hospitals and teams that have delivered excellent care during the pandemic should analyse the factors that enabled them to do so and publish key findings to support more consistent quality of care across the NHS.
- Professionals and organisations should strive to reduce variation in care in key areas including:
- End of life care in hospital
- Early assessment
- Documentation and communication
- Senior review and decision making
- Treatment escalation planning, conversations and documentation
- Discharge planning
- For those with learning disabilities
- Particular attention should be paid to quality of care, decision making, communication and documentation required for vulnerable people, including those with learning disabilities.
- Further analysis should be carried out of the variation in the number of deaths from COVID-19 between different parts of the country.
Dr John Dean, the RCP’s clinical director for quality improvement and patient safety, said: “My colleagues in the NHS have been faced with unprecedented challenges during the pandemic but RCP’s study shows how almost all care provided has been of the right standard. We can, however, learn from excellent care, and variations in care, just as we can learn from poor care, and I am sure that this study will prove invaluable as we seek to learn from this extraordinary time.”
Dr Susie Orme, consultant in care of the elderly and associate medical director (mortality) at Barnsley Hospital NHS Foundation Trust, which took part in the study, said:
“At the start of the first wave of COVID-19 before we had the knowledge and the treatments we now have and when at times, the only available treatment was to care, we continued to care well. This report highlights how healthcare organisations maintained the high standards of patient care we would expect in non-pandemic times. The report highlights positive practice and learning which we will continue to implement.”
Dr Emma Redfern, consultant in emergency medicine, University Hospitals Bristol and Weston NHS Foundation Trust (UHBW), which also took part, said:
“UHBW were delighted to participate in this unique study. Our patients were able to benefit from many of the local system changes that had been introduced prior to the COVID-19 pandemic, particularly the standardisation of NEWS2 scoring and ReSPECT advanced care planning processes. We are committed to continual learning and will endeavour to do so in light of the findings of this report.”
The study used a standardised but slightly modified Structured Judgement Methodology (mSJR) format and common data set collection to understand more completely the care delivered to patients with COVID-19 within the NHS during the COVID-19 pandemic, comment on the emerging themes and create robust conclusions and recommendations. The participants were asked to review sets of patient case notes using the SJR methodology and then construct a ‘report’ which identified and described the themes that they observed. The main outcomes of the study reflect the mostly qualitative analysis of the narrative judgements and the amalgamation of the thematic analysis reported by the participating centres using a combination of manual analysis of the themes described and a natural language processing algorithm.