Quality of care in the COVID-19 era: a global perspective

Abstract

Key Messages • This article traces the progression of the COVID-19 pandemic from inception through to the present. • Even before COVID-19, previous pandemics tested health services and had trouble keeping patients safe and providing quality care especially during the height of the crisis. • There is a strong requirement for health care systems to simultaneously deal with the pandemic and provide safe, high-quality care. • This means being resilient, and supporting the natural capacities health systems have to be adaptable, flexible, and responsive. Starting from first principles, logic tells us that providing quality care and making things safe for patients will be very challenging during any pandemic. History backs this up, recording the inherent danger of widespread infections and concomi-tant burdens on healthcare systems, both before and after the A(H1N1) virus ('the Spanish flu') of 1918-20, which resulted in 50 million deaths. The A(H2N2) 'Asian flu' of 1957-58 (1 million deaths), the A(H3N2) 'Hong Kong flu' of 1968-69 (1 million deaths), and the Ebola virus in seven countries of West Africa over 2014-16 (11 000 deaths) all sorely tested health services. In the case of coronavirus disease 2019 (COVID-19; SARS-CoV-2), the virus came on suddenly and, despite many health systems having workable pre-pandemic plans, took most countries by surprise, to the justifiable frustration of the World Health Organization (WHO), public health practitioners, infectious disease specialists, and community activists. The situation worsened rapidly, and planning often did not keep up. In response to pandemic-induced pressures, policymakers became reactive [1]. Some politicians emphasized politics over good governance. Others contended, in a false dichotomy, that protecting the economy was more important than tackling the pandemic, when it was clear that both were important-and intertwined. Without effectively addressing COVID-19, a country's economy would rapidly deteriorate-or even become non-functional. Meanwhile, the quality of care suffered. Whether prepared or not, the virus stretched some health systems to breaking point. There were reports from many countries of wards and intensive care units being overwhelmed. Available resources were deployed away from usual care to the surge in new cases. Normal quality and safety activities took a back seat in the face of rapidly accelerating disease transmission trends. The downstream consequence of the prioritization of COVID by health systems is that many routine, non-COVID-19 patients have failed to receive appropriate care. Out of fear, lockdown restrictions, or insufficient availability of staff and resources at health facilities, many patients stayed away from emergency departments; others missed their scheduled checkup , screening, test, or procedure. Others could not be admitted or had delayed or rushed care-the individual or population effects of which have yet to play out. In the case of cancer patients, for example, there are legitimate and very real concerns for the lethal outcomes that will result from lack of timely treatment [2]. Some countries, which responded more rapidly and comprehensively , exhibited their resilience [3, 4] under pressure. One pointed question we must raise when thinking about quality of care globally during COVID-19 concerns the differential way the pandemic was tackled. The '40 health systems , COVID-19 study' (40HS, C-19) [5], reporting on data gathered in March and April of 2020 and published in the International Journal for Quality in Health Care (IJQHC), analyzed three dimensions of tackling the pandemic. These were initial preparedness (labelled government 'capacity to respond'); 'stringency measures' put in place such as quarantine , social isolation, mask wearing and the like; and 'testing', either broadly based, across the whole community, or narrowly based, targeting specific groups, mainly frontline staff and the elderly in residential aged care facilities. The study found that broad-based testing was the key to handling the pandemic. Widespread testing means that people throughout a community know, or can find out, their infectious status, and thus, their level of risk. If sufficient people are informed, most will act appropriately and self-isolate or at the very least wear a mask. Transmission will tend to be mitigated.