Primary Sources

New routine in primary care: Experiences from an Austrian PHC center during the COVID-19 crisis

At the European Forum for Primary Care (EFPC), we are pleased to join this collaboration on Primary Sources with Wonca, AfroPHC, and PHCPI to promote stories from the frontlines of PHC during the COVID-19 pandemic. EFPC was initiated in early 2005 to improve the health of the population in Europe by promoting strong primary care through generating data and evidence on primary care and by exchanging information between its members.
We believe that strong Primary Care produces better health outcomes against lower costs, supported by available scientific evidence. Strong Primary Care does not emerge spontaneously, however - it requires appropriate conditions at the health care system level to capacitate and encourage primary care providers to take responsibility for the health of the population under their care. 
There is a strong need to collect and share information about what structures and strategies matter. From the start of the COVID-19 crisis, the EFPC was interested to collect stories and experiences on how to deal at the primary care level with this unprecedented situation, resulting in a statement on COVID-19 from the European Forum for Primary Care: “Reducing the Impacts to Vulnerable Groups”.
At EFPC, we are proud to offer this first European contribution to Primary Sources from Austria, St Pölten. As another first for Primary Sources, we also offer a short video bringing you inside the St Pölten clinic to bring a new view of what is going on at practice level during this crisis. We hope these continue to expand our global understanding of how PHC is critical to countering the widespread damage from this pandemic.
Kind regards from the Primary Health Care Center St. Pölten’s team on duty and the Austrian Forum for Primary Care. The Austrian Forum for Primary Care began in 2016 as a bottom-up initiative to act as advocates for primary care professionals and expedite the national PHC reform. Our PHC center in St. Pölten in lower Austria launched as one of the pioneer projects in January 2019.
After one year in practice at the beginning of this year (2020) so much is changing so quickly. We have seen that firsthand in Austria. On the 25th of February, our country recorded the first confirmed case, leading to a dramatic shutdown of public life on 13th of March. Additionally, as health workers we were confronted with the disruption of the regular operation of hospitals and primary care, now limited to acute cases and emergencies.
COVID-19 related structures in Primary Care
A national hotline was created for triage and registration of suspected cases, and also helped to organize testing. We also adjusted and intensified our internal hygiene standards at the clinic. During one weekend, we were forced to buy protective material ourselves from private providers at overcharged prices to ensure the safety of the patients and the PHC center’s operational procedures. We separated areas with patient contact and the back office through a double door system. After entering the treatment area, contact with patients was only allowed when equipped with the full protection equipment consisting of a FFP 3 mask (filters 99% of all viral particles), safety glasses, single-use gown and gloves. Every two hours, all staff team members’ had their temperature checked and documented. Only a maximum of 3 people were allowed to use the staff room and kitchen at the same time, so a joint lunch was only possible on the parking lot while keeping a minimum distance of 2 meters and of course only in good weather! To ensure availability even in case of a quarantine, the team had to be divided into two separate groups, which we called the “elk” and “unicorn” groups. This led to a whole new experience in our service handovers. For our colleagues with kids, we organized home office jobs as well as day care directly in the PHC center.
Our daily routine during the lock-down
The daily routine during our 12 hour shift stayed the same, but our daily routines changed fundamentally. We watch every press conference and are constantly updating and optimizing our telephone triage. We acted as quickly as we could and even installed a double-door system within a day so registered patients could only enter one by one. As a result of the great number of incoming calls, we found our mobile phone batteries taxed and running out each day. Therefore we installed five additional telephone lines as well as online services, altered our rosters and rewrote extra notices for patients.  
Triage and patient management
Practice assistants conducted a rough triage of patients on seven telephone lines in acute and non-acute cases. Each phone call was returned by a GP who further clarified by phone or summoned to the PHC center.  Without notification in advance - doesn’t matter if via phone, e-mail or the online service center and following a medical triage – patients would no longer be allowed to enter our medical practice. In order to minimalize the contact time with and between our patients, we optimized the appointment system, only personally met patients in cases of absolutely need and defined measures in advance (ECG, blood-draw etc.).
Patient contact and demands during the pandemic
We diagnosed our patients using telemedicine and electronically sent their prescriptions to the pharmacies by a rapidly established national e-prescription system. During the peak-phase of the pandemic our GP’s made 80-100 phone calls per day to treat ordinary demands like cuts and infections as well as providing advice on COVID-19 related issues for anxious and positive-tested patients. Our GPs used video-calls if necessary to visually assess injuries and skin rashes. For our patients at risk, we even established a medication delivery service in cooperation with the local ambulance service. This led to a decline in overall contacts of 20% and face-to-face contacts of 80% - something we felt in our daily practice.
Since we noticed an increase of mental stress, our psychotherapists and social workers conducted support and consultations by phone from home office. Also our physiotherapist proactively created video tutorials for instance for neck and back disorders and provided the links directing to our homepage.
Changes in our resources
During the first phase, we noticed the jump in injuries and emergencies in the PHC center ranging from strokes and heart attacks to advanced infections. Under normal circumstances, they would initially be treated in the hospital but now could not. These patients required an increased amount of time and consequently an increase in staff as well, highlighting the importance of local primary care. Maintaining good care of complex and urgent cases reduced the stress on the health care system.
Our “new daily practice”
Since the 15th of April after the flattening of the infection curve, we were permitted to restart the routine operation of primary health care under new conditions. The government deemed this re-opening to be critical for the protection of the population and prevention of collateral damage due to non-utilization of important routine health care services. Routine examinations, medical check-ups for adults and children as well as protective vaccinations are now being carried out again and the number of patients is constantly rising. To protect our staff and maintain health care services, all health professionals continue using personal protective equipment.  Because this equipment makes the visits more difficult, physiotherapy sessions were shortened from 50 to 30 minutes in duration. Ordinary consultations like discussion of test results are still carried out by phone. Experiences showed that the rapid implementation of the electronic prescription system is an enrichment for our daily practice.
The crisis may help with “lessons learned” for our patients. We hope in the future patients will continue to be better able to assess the acuity level of their health problems and contact our multiprofessional team at the PHC center for most of their demands instead of presenting directly to emergency care units in hospitals. As of the 7th of June, there were 437 confirmed infections in Austria, and 69 hospitalized patients of which 17 were treated in intensive care with 645 fatalities from the coronavirus.
Challenges and experiences
The challenges we faced due to the pandemic in our PHC center were fundamentally different from our known routine. The experiences of our team led us to restructure our care processes in a way that called for patients to take more responsibility for their own health. We are quite happy to treat our patients personally again. Nevertheless, we hope that our patients will benefit from their experience during this crisis and play a more active role in their own health care.
Thank you and keep up your amazing work!
Thanks to good self-organization of decentralized primary health care providers in the region, quality patient care was ensured, and hospital capacity protected. We – the Austrian Forum Primary Care and the whole team of the Primary Health Care Center St. Pölten in Lower Austria – hope we could give you some insights in our new day-to-day life. We wish our friends, families and all our colleagues a lot of strength in this difficult situation. Please stay healthy and keep up your amazing work. Together we will get through this crisis!

By Rafael Pichler, MD12 Cindy Frühwald1, Sarah Burgmann BSc MA23 , Diederik Aarendonk3

1. PHC Center St. Pölten, Austria
2. Austrian Forum for Primary Care
3. European Forum for Primary Care