Notes from the Field: Dynamic Triaging Using Quality Improvement (QI) Methodology to Prevent the Admission of Asymptomatic COVID Positive Obstetric Patients in New Delhi, India

Abstract

A single undiagnosed COVID-19 positive patient admitted in the green zone has the potential to infect many Health Care Workers (HCWs) and other patients at any given time with resultant spread of infection and reduction in the available workforce. Despite the existing triaging strategy at the Obstetric unit of a tertiary hospital in New Delhi, where all COVID-19 suspects obstetric patients were tested and admitted in orange zone and non-suspects in green zone, asymptomatic COVID-19 positive patients were found admitted in the green zone. This was the trigger to undertake a quality improvement (QI) initiative to prevent the admission of asymptomatic COVID-19 positive patients in green zones. The QI project aimed at reducing the admission of COVID-19 positive patients in the green zone of the unit from 20% to 10% in 4 weeks’ time starting 13/6/2020 by means of dynamic triaging. A COVID-19 action team was made and after an initial analysis of the problem multiple Plan-Do-Study-Act (PDSA) cycles were run to test the change ideas. The main change ideas were revised testing strategies and creating gray Zones for patients awaiting COVID-19 test results. The admission of unsuspected COVID-19 positive cases in the green zone of the unit reduced from 20% to 0% during the stipulated period. There was a significant reduction in the number of HCWs, posted in the green zone, being quarantined or test positive for COVID-19 infection as well. The authors conclude that Quality Improvement methods have the potential to develop effective strategies to prevent spread of the deadly Corona virus.

Quality improvement initiative: improving obstetric triaging practices in a rural maternal hospital in central India

“…12 Puri et al concluded that QI methods have the potential to develop effective strategies to improve triaging. 13 Kumar et al reported that QI methodology was practical and effective in reducing waiting time to triage in the emergency department of a large hospital in India. 14 Joshi et al succeeded in establishing a paediatric emergency triage system and culture in a small hospital in India through QI methodology using successive PDSA cycles and improving the triage rate from the baseline of 16-20% to 68% and sustaining it.…”

Power of daily huddles in COVID-19 pandemic: a QI initiative

“…The problem was flagged at a daily huddle and a QI project was initiated, which reduced the incidence of COVID-19 positivity in non-suspect zones from 20% to <5% in 7 weeks’ time with subsequent reduction in infection of HCWs. This was achieved by interventions such as universal testing of all obstetric admissions and creation of a grey zone for untested asymptomatic obstetric patients 4. These QI projects were successful only because a daily review of the implementation of the interventions was taken at the morning huddle along with analysis of the data, which led to prompt redressal of problems encountered by front-line HCWs.…”