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Challenges for NHS hospitals during covid-19 epidemic

Rapid Response:
COVID-19 checklist: a tool for hospitals facing the pandemic

Dear Editor,

The unprecedented increase in the workforce and infrastructure of the NHS and other health systems that governments are implementing in response to the covid-19 pandemic is certainly of utmost importance.


However, the processes that patients go through to be assessed, admitted, and treated in hospital will also undergo dramatic change. Bringing in more staff, more beds and more equipment is not enough - the way we work and the protocols we follow also need to adapt.

Hospitals are changing how they function in an attempt to limit the impact of the pandemic. This includes faster triage and assessment, radical redeployment of personnel, and implementation of new management strategies, forcing challenging ethical decisions to be made in a context of increasing scarcity [1]. This can lead to poor outcomes for patients and a high burden of psychological stress for staff.

Checklists are a frequently used tool in aviation, healthcare and other industries to support decision-making and reduce human error. Their use in healthcare has had some notable successes, such as the Safe Surgery Checklist from the WHO (World Health Organisation), which has been found to be effective in reducing post-operative mortality and complication rates [2,3]. However, effective implementation is not easy. As well as the checklist itself needing to be carefully designed and locally relevant, outcomes should ideally be measured and fed back to staff members, and a workplace culture that emphasises good performance should be encouraged [4].

In a large tertiary hospital in Hull, a new one-page checklist for all inpatients suspected of having COVID-19 has been implemented. It aims to:

  1. Clearly state the diagnostic criteria of suspected COVID-19. This will help reduce diagnostic uncertainty in a new, unfamiliar disease, where limited tests are available. It also aims to help staff promptly isolate and test previously admitted patients who develop new symptoms suggestive of COVID-19.
  2. Act as a single point of reference throughout the patient’s admission to facilitate decisions about their care and allow easy calculation of how far they are through the course of their disease.
  3. Help clinicians in a high-pressure environment remember all the key investigations that need to be performed. In addition, a local management guideline based on WHO [5] and Public Health England advice for suspected or confirmed covid-19 patients is on the reverse of the checklist. These features are particularly important for healthcare professionals redeployed to the emergency department or acute medical wards who are working outside of their usual area of clinical practice.
  4. Prompt early senior discussion about the ceiling of treatment, so that in acute deterioration, clear plans can be implemented in the most equitable and caring way possible. The checklist includes Clinical Frailty Score (as suggested in recent NICE guidelines [6]), age and comorbidities to ensure that the information needed to make these discussions is easily available.

Due to the urgency of the situation, this checklist has been implemented rapidly, incorporating feedback gathered from frontline staff during a 24-hour pilot. We hope to evaluate its utility more formally in the near future. The checklist is freely available at www.bit.ly/3asTVFs. We encourage other organisations and researchers to use and adapt the checklist, and collaborate in rethinking the way we can best care for patients during this global crisis.


  1. Macchini D, Parker C, World Economic Forum. ‘Every ventilator becomes like gold’ - doctors give emotional warnings from Italy’s Coronavirus outbreak. 2020.https://www.weforum.org/agenda/2020/03/suddenly-the-er-is-collapsing-a-d... (accessed 29 Mar 2020).
  2. Haugen AS, Søfteland E, Almeland SK, et al. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Ann Surg 2015;261:821–8. doi:10.1097/SLA.0000000000000716
  3. Chaudhary N, Varma V, Kapoor S, et al. Implementation of a Surgical Safety Checklist and Postoperative Outcomes: a Prospective Randomized Controlled Study. J Gastrointest Surg 2015;19:935–42. doi:10.1007/s11605-015-2772-9
  4. Bosk CL, Dixon-Woods M, Goeschel CA, et al. Reality check for checklists. Lancet 2009;374:444–5. doi:10.1016/S0140-6736(09)61440-9
  5. World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. 2020;:12.https://www.who.int/internal-publications-detail/clinical-management-of-...(ncov)-infection-is-suspected%0Ahttp://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1... (accessed 29 Mar 2020).
  6. National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults. NICE Guidel. [NG159]. 2020.https://www.nice.org.uk/guidance/ng159 (accessed 28 Mar 2020).

source: https://www.bmj.com/content/368/bmj.m1117/rr-4