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How Primary Healthcare in Iceland Swiftly Changed Its Strategy in Response to the COVID-19 Pandemic

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How Primary Healthcare in Iceland Swiftly Changed Its Strategy in Response to the COVID-19 Pandemic Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-043151 on 7 December 2020. Downloaded from How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic Emil Larus Sigurdsson ,1,2 Anna Bryndis Blondal,2,3 Jon Steinar Jonsson,1,2 Margret Olafia Tomasdottir,1,2 Hannes Hrafnkelsson,1 Kristjan Linnet ,2 Johann Agust Sigurdsson4 To cite: Sigurdsson EL, ABSTRACT Strengths and limitations of this study Blondal AB, Jonsson JS, et al. Objective To describe how the primary healthcare (PHC) How primary healthcare in in Iceland changed its strategy to handle the COVID-19 ► The data are based on medical records of all con- Iceland swiftly changed its pandemic. strategy in response to the tacts to the primary healthcare centres. Design Descriptive observational study. COVID-19 pandemic. BMJ Open ► The primary healthcare in the research area serve Setting Reykjavik, the capital of Iceland. 2020;10:e043151. doi:10.1136/ the whole capital area which counts two- thirds of Population The Reykjavik area has a total of 233 000 bmjopen-2020-043151 the population of Iceland. inhabitants. ► The contact register information is very reliable and ► Prepublication history for Main outcome measures The number and the mode comprehensive. this paper is available online. of consultations carried out. Drug prescriptions and To view these files, please visit ► Due to the short study period, that is, 2 months, we changes in the 10 most common diagnoses made in the journal online (http:// dx. doi. were not able to depict the long-term changes in PHC. Laboratory tests including COVID-19 tests. Average org/ 10. 1136/ bmjopen- 2020- healthcare services. numbers in March and April 2020 compared with the same 043151). ► The consequences of postponing regular healthcare months in 2018 and 2019. service are not presented. Received 28 July 2020 Results Pragmatic strategies and new tasks were Revised 21 November 2020 rapidly applied to the clinical work to meet the foreseen Accepted 23 November 2020 healthcare needs caused by the pandemic. The number of daytime consultations increased by 35% or from 780 (PHC) is the cornerstone of healthcare and to 1051/1000 inhabitants (p<0.001) during the study the first point of contact.4 In epidemics and period. Telephone and web- based consultations increased a pandemic, as the first line of defence, the http://bmjopen.bmj.com/ by 127% (p<0.001). The same tendency was observed role of PHC in the healthcare system is more in out- of- hours services. The number of consultations important than ever. Whereas the hospitals © Author(s) (or their in maternity and well- child care decreased only by 4% have to concentrate on the disease, people- employer(s)) 2020. Re- use (p=0.003). Changes were seen in the 10 most common permitted under CC BY- NC. No diagnoses. Most noteworthy, apart from a high number centred PHC has to focus on the patients as commercial re- use. See rights of COVID-19 suspected disease, was that immunisation, well as the health of the whole community and permissions. Published by at a population health level. In such situa- BMJ. depression, hypothyroidism and lumbago were not among the top 10 diagnoses during the epidemic period. The tions, triage and gatekeeping play a central 1Department of Family Medicine, number of drug prescriptions increased by 10.3% (from on September 24, 2021 by guest. Protected copyright. Faculty of Medicine, University role. First, the task is to protect the health- of Iceland School of Health 494 to 545 per 1000 inhabitants, p<0.001). The number of care professionals in the first line of defence Sciences, Reykjavik, Iceland prescriptions from telephone and web- based consultations from becoming infected. Other important 2Development Centre for rose by 55.6%. No changes were observed in antibiotics responsibilities include informing the popu- Primary Healthcare in Iceland, prescriptions. lation, identifying and protecting individuals Primary Health Care of the Conclusions As the first point of contact in the COVID-19 and groups of vulnerable people from getting Capital Area, Reykjavik, Iceland pandemic, the PHC in Iceland managed to change its 3 infected, and last but not least, protecting Faculty of Pharmaceutical strategy swiftly while preserving traditional maternity and Sciences, University of Iceland, well- child care, indicating a very solid PHC with substantial the tertiary care level, the hospitals so they Reykjavik, Iceland would not become overwhelmed or out of 4 flexibility in its organisation. Faculty of Medicine, function because of infected staff and too Department of Public Health and Nursing/General Practice many COVID-19 cases. Some guidelines have Research Unit, Norwegian INTRODUCTION been published to assist general practitioners 5 6 University of Science and The COVID-19 pandemic caused by (GPs) on how to act on COVID-19. Technology (NTNU), Trondheim, SARS- COV-2 has challenged the structure, Soon after the information about the Norway organisation and flexibility of healthcare spreading of COVID-19 from Wuhan in China Correspondence to systems worldwide and has in a certain way in late 2019, Iceland, like other countries, 1–3 Dr Emil Larus Sigurdsson; led to rebooting of the general practice. In started to prepare for an epidemic (box 1). emilsig@ hi. is the global health policy, primary healthcare Before COVID-19 was diagnosed in Iceland Sigurdsson EL, et al. BMJ Open 2020;10:e043151. doi:10.1136/bmjopen-2020-043151 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-043151 on 7 December 2020. Downloaded from During this pandemic, the PHC in Iceland has had the Box 1 Preparation and implementation of tasks in role as the first point of contact for people with symptoms primary care during COVID-19 of the respiratory tract including COVID-19 -like symp- Preparation (January 2020) toms. Directions or indications for tests were published ► Educating staff about COVID-19 disease and the use of personal and promoted by the Directorate of Health. Most of protective equipment (PPE). the tests for COVID-19 in clinical situations were taken ► Providing and ordering appropriate materials and supplies. in primary healthcare centres (PHCCs). Patients with ► Educating staff about alternative management plans at work. confirmed COVID-19 infection were taken care of by Testing and treatment a special unit at Landspitali—The National University Hospital of Iceland. People in quarantine were cared ► Patients with symptoms compatible with those of COVID-19 were offered nasopharyngeal and throat testing with specimens collected for by the PHC. The organisation of PHC in Iceland was by doctors and nurses wearing PPE. rapidly and substantively changed in order to meet the ► All primary healthcare centres (PHCCs) had daily testing outside demands posed by the pandemic. their premises, with samples collected while patients were sitting in Thus, when the first case of COVID-19 was diagnosed their cars. At the weekends, the COVID-19 sample collections were in Iceland on 28 February 2020, the PHC sector was centralised at a single place. confronted with an entirely new and unprecedented ► A specially equipped car was used for home visits to those who disease and the PHC preparations and actions taken were too ill to get tested at a drive- through centre. were accelerated (box 1). To face those challenges, our COVID-19- positive patients received follow- up care by an outpa- ► PHCCs had to adapt swiftly on a much larger scale than tient clinic staffed by Landspitali—The National University Hospital of Iceland. ever before, and completely alter their tasks to defeat the enormous and acute encounter ahead. The spread The shift in workload management of COVID-19 in Iceland has already been described.9 To Patient flow systems date, information on the role of PHC in the COVID-19 ► Patients were advised to call in advance before arriving at the pandemic is lacking and only a few reports have been PHCCs. published on that matter.10 Telephone consultations were offered instead of appointments. ► The aim of this paper is to describe the changes in PHC ► The maternity and well- child care consultations were carried out as scheduled. in Iceland during the COVID-19 pandemic, especially in ► Those with symptoms of respiratory tract infections were given the mode of service and in certain measures of outcomes. appointments at the healthcare centre, which did not overlap with maternity and well-child care consultations. ► New PHCC bookings were scheduled through telephone screening METHODS by a nurse or a doctor. Setting PHC preparedness The Icelandic healthcare system, like other Nordic http://bmjopen.bmj.com/ ► The PHC personnel were divided into two groups: those working at welfare systems, is based on solidarity and equitable distri- the PHCC and the others at home carrying out phone consultations bution of services. It is mainly financed through public on the web. funds, even though the patient pays some minor fees at ► The PHCCs were separated into two areas, one for patients with 11 respiratory tract infections and the other one for patients without the time of service. The general tasks of the PHCCs are them. Patients with respiratory symptoms were scheduled for the defined by laws and regulations, and their administration end of the day. is under the auspices of the health authorities. Thus, the ► PHC personnel prioritised work related to COVID-19. Non- urgent management decisions are made locally in accordance appointments were rescheduled, and all group activities cancelled. with government policy. The healthcare offered by the on September 24, 2021 by guest. Protected copyright. ► The access of patients was increased through telephone consul- PHCCs is based on a holistic approach thereby including tations and web chat. For example, school nurses were released general practice, maternity care, well-child care, school from their routine duties so they could conduct telephone COVID-19 healthcare, minor surgery and emergency care.
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