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Evaluating The Implementation of A National COVID-19 Hospital Guideline In
Wales
Rhys Jefferies ( jefferiesrhys@gmail.com )
Public Health Wales NHS Trust: Public Health Wales https://orcid.org/0000-0002-3101-7900
Mark J Ponsford
Cardiff University
Simon Barry
Cardiff and Vale NHS Trust: Cardiff and Vale University Health Board
Research
Keywords: National guideline, COVID-19, implementation framework, implementation methodology, implementation evaluation, timeliness, facilitation
DOI: https://doi.org/10.21203/rs.3.rs-477444/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License
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Abstract
Background
The COVID-19 pandemic created a unique situation where a national clinical guideline would address uncertainty, and provide a trusted source for up-to-date
information and advice. We developed a dynamic online infrastructure together with a dedicated implementation team to deliver this at scale and pace. The
guideline was implemented through a digital implementation framework (SIMPSI framework) deploying facilitators to maximise guideline adoption,
particularly targeting senior clinical decision makers (consultants) involved with the care of COVID-infected patients across six Health Boards (HB) in Wales.
Methods
We evaluated guideline implementation using the Taxonomy of Implementation Outcomes Model.The primary outcome was consultant engagement, with a
target of 193 registrations. We assessed wider impact through analysis of guideline platform activity and a user survey, withadditional sensitivity analysis to
derive penetration ratios, catchment population, clinical staff, acute beds, and COVID-19 admissions.
Results
The guideline platform had 4521 total registrants, with over 170,000 page views during the rst wave. We exceeded the target nearly six-fold (1159 consultant
registrants). This represented 45% of all medical consultants in Wales, and made up the highest proportion of guideline registrants of all professional groups
(23%, 1159/4521). We observed signicant variation in guideline penetration across the six HBs, ranging from 31% to 74% of consultants registered. The HB
with highest penetration had the most active guideline facilitator. The HB with the lowest penetration was the region rst impacted and most affected by
COVID-19 at the time of guideline publication (37% inpatients of peak, versus 10% or less for the other HBs).
Conclusion
Weutilised a digital implementation framework to construct a system that could be rapidly applied throughout all hospitals in Wales. Whilst we exceeded the
intended target demonstrating full implementation, we identied two key factors to account for differences in the penetration rates across the different HBs.
First, an experienced and active facilitator with thecapacity to undertake the role was associated with signicantly better penetration. Second, timeliness of
implementation was crucial as evidenced by lower penetrance is the one HB that was impacted earliest by COVID-19 at the time of guideline dissemination.
Nevertheless, the rapid implementation of the guideline has coincided with Wales demonstratingmore favourable intensive care survival rates and
maintaining one of the lowest mortality rates when compared to the UK as a whole for the rst wave of the COVID-19 pandemic.
Contributions To The Literature
The COVID-19 pandemic created a contextual backdrop to align government, Health Boards and hospital clinicians at a time of profound uncertainty.
The guideline was a trusted source for up-to-date instruction during a period where the evidence base was limited and fast changing.
Readiness was greatest when local alternatives were not routinely being applied, emphasising the value of timeliness in implementing large-scale
programmes.
Active dissemination delivered through local facilitators with good understanding of dissemination and implementation methodology increased guideline
penetration.
An integrated digital implementation framework improved accessibility and reach, facilitating scale and pace.
Background
The emergence of a highly infectious novel coronavirus (SARS-CoV-2) in December 2019 has given rise to the greatest challenge faced by our healthcare
system in the last century. Over 120million infections and almost 3million deaths worldwide to date (1). This has been associated with a rapidly evolving
evidence base surrounding the optimal management of individuals with COVID-19. At the start of the pandemic, we surmised that a lack of clear guidance
would lead to confusion amongst Healthcare Professionals (HCP) and create variation in care and outcomes. We responded to this challenge through the
rapid creation and implementation of a real-world national guideline; underpinned in design and delivery by the principles of implementation science. This can
be dened as the scientic study of methods to promote the systematic uptake and application of research ndings and other evidence-based practices into
routine practice to improve the quality and effectiveness of health services and care (2). At its core is the question:
“How do we get what works to the people
who need it, with greater speed, delity, eciency, quality, and relevant coverage?”
(3). Contextualised and rearranged, we asked
– How do we get timely,
relevant information, instruction and advice for the management of COVID-19 to clinical decision-makers, in an easily accessible format to help improve
COVID-19 survival rates across the country?
Guideline design
The guideline was designed so that HCPs could easily access and understand the basic principles of COVID-19 management, with supplemental detail that
could change as new evidence emerged. The xed component of the guideline represented ow through the system (Fig.1). This was compatible with all
hospital structures and therefore suciently exible for local adoption across all HBs in Wales. The dynamic component of the guideline is represented by the
QR codes with web links to new clinical instruction as it emerged. Local experts from a variety of different professional groups provided contextual and
instructional education, a factor that has shown to increase the rate of adherence substantially (11). Updates were delivered in a contemporary format, with
information distilled into brief 3–5 minute videos with summaries, graphs and other visual aids incorporated during the editing process to promote ease of
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information transfer. We hosted these on a single, unique web-based platform to increase reach and accessibility – thereby facilitating a rapid response to the
expected changes in clinical instruction.
Leading experts in respiratory, intensive and palliative care developed the guideline content, with the national respiratory lead for Wales (S.B) acting as the
primary author and guideline coordinator. The oce of the Chief Medical Ocer (CMO) in Welsh Government mandated the use of the guideline in each HB in
Wales. The national lead considered all decisions about what to include as updates for the guideline, then invited experts to deliver an update in a video
format on specic topics. Many of these were practical in nature, for example – how to deliver Continuous Positive Airway Pressure (CPAP) therapy, how to
prone patients, or how to provide palliative support, with others outlining emerging national evidence from clinical trials. Consultation amongst a network of
clinical colleagues enabled consensus decisions around issues with a limited evidence base, such as the target oxygen saturation ranges, or decisions about
thromboprophylaxis.
Guideline Implementation
The guideline was implemented using the SIMPSI framework, a digital framework inuenced by the Active Implementation Framework (4), the Translating
Evidence into Practice Model (5) and the Quality Implementation Framework (6). Broadly, it incorporates a set up phase, and active delivery phase. We
established an implementation organisational structure (Fig.2), facilitating central control through the Implementation Team (ImT). The ImT could then
manage locally positioned facilitators to increase widespread adoption by the target audience – clinical decision makers responsible for managing patients
admitted with COVID-19. This specically included Emergency Department (ED), Respiratory, Intensive Care, and Palliative Care consultants, which we
calculated to be around 193 clinicians across Wales (7). The central guideline management team primarily supported facilitator activity, but could also
respond quickly to any technical issues, user requirements and requests.
Implementation software supported the implementation process, enabling locally selected facilitators to increase reach and regional acceptance. A Guideline
Facilitation Dashboard (GFD) provided engagement and activity tools with feedback. Implementation data was viewed, analysed, and reported, in real-time by
the ImT. The Welsh Government received periodic implementation reports to support strategic decision-making.
Methods
Study aims
Here, we evaluate guideline implementation using the Taxonomy of implementation Outcomes Model (ToIOM) (8). We focus on the evaluation of the
implementation process of the COVID-19 Hospital Guideline, rather than assessing the effectiveness of the clinical recommendations made within it.
Fundamental to this article is distinguishing guideline implementation effectiveness from guideline instruction effectiveness; this is critical for transporting
interventions from controlled settings to real-world clinical practice. When such efforts fail to deliver, it is important to know if the failure occurred because the
intervention [guideline] was ineffective in the new setting – intervention failure – or if a good intervention was deployed incorrectly, leading to –
implementation failure (8). Whilst the guideline was available to everyone, the primary target group were senior decision-makers with clinical responsibility for
patients admitted with COVID-19. We hypothesised that implementation of the guideline would inform local operational practices, subsequently inuencing
clinical behaviour.
Guideline setting
The guideline was implemented across six of the seven HBs in Wales (Aneurin Bevan UHB, Cardiff and Vale UHB, Hywel Dda UHB, Swansea Bay UHB, Betsi
Cadwalladr UHB and Cwm Taf Morgannwg UHB, randomised in no particular order in the results section). The remaining HB, Powys was not included since it
did not have any DGH within its boundaries. We collected data from all DGHs, but not from smaller rehabilitation or community hospitals, which did not have
facilities for acute medical care, and were not sites for admitting patients with acute COVID-pneumonitis.
Implementation Evaluation
We assessed guideline engagement through analysis of guideline platform activity and a user survey. Implementation was evaluated using ToIOM (8) which
best reected the aims of this project, and the methodology applied. Other common implementation evaluation tools considered were the PRECEDE-PROCEED
framework (9) and the RE-AIM framework (10). However, the ToIOM best reected the aims of this project, and the implementation methodology applied.
Guideline activity was analysed for the period comprising the rst wave of the COVID-19 pandemic (21/3/20 to 15/8/20). The entire guideline registrant
database of 4521 HCPs based within NHS Wales was analysed, thereby representing registrations for the rst wave of the COVID-19 pandemic. We used
Survey Monkey to conduct an anonymised registrant survey from 8/6/20, for a period of two weeks. The survey was emailed to all participants with a further
two reminders within the two week period to increase participation (Appendices 1). This comprised 11 multiple-choice questions, 3 open questions, a star
rating for overall quality, and sliding scales to determine ease of use and by how much the guideline had inuenced their practice. Penetration ratios were
calculated by dividing the total number of registrations within a HB by relevant metrics to standardise for variation in HB size, capacity, and burden of COVID-
19 admissions for the implementation period, derived from publically available hospital data sources (7)(11). Data curated in Microsoft Excel. Chi-squared
testing performed using GraphPad Prism (version 6.06).
Results
Scale and pace
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From March 21st to March 28th, 18 DGHs in Wales received several hundred hardcopy guideline posters, subsequently distributed in areas where relevant
HCPs could easily access them, such as COVID-19 wards, medical assessment units and emergency departments. Figure3 highlights the publication of the
guideline coincided when total conrmed COVID-19 inpatients and COVID-19 deaths were low. Registration rates increased substantially around 28th March in
response to a range of alignment and facilitation activity, including email campaigns, formal guideline on-boarding, and discussions promoting adoption with
executive teams. New registration rate slowed commensurate with a reduction in the rate of patients admitted to hospital and dying from COVID-19 (Fig.3).
Total registrants reached 4521 during the rst wave (Fig.4).
Penetration of the target
The primary target audience, consultants, accounted for the greatest proportion of professionals registered with the guideline platform (23%). We observed
uptake across allied health professionals (including physiotherapists, pharmacists, dieticians and occupational therapists) accounted for 21.4%, and nurses
20.6%. We next evaluated uptake for consultants predicted to manage patients admitted with COVID-19, estimated as the sum of all ED, Respiratory, intensive
care, and palliative care consultants across Wales (Supplemental Table A). We next compared this to all consultants. From a possible 2505 consultants
employed in Wales (7), 1131 (45%) registered with the guideline. As the total number employed within each HB was known, we used this to normalise uptake
between HB and derive a penetration ratio (Fig.5). HB6 showed the greatest penetration, with 73.7% (325 of a possible total 440) of all consultants registered,
followed by 51.9% (111 of 214) within HB5. Uptake was lowest in HB1 at 30.5% (131 of 429 consultants) but still superseding the original target (x3.6). This
variation in consultant uptake between HBs was highly signicant (Chi-squared testing, p < 0.0001).
Given the potential impact of sickness and staff transfers on this estimate of guideline uptake, we conducted additional sensitivity analysis to derive
penetration ratios, using publicly available gures for total HB catchment population, total number of clinical staff, number of acute beds, and COVID-19
admissions (Supplementary Table B). This conrmed the observed trend in guideline registration between HBs. Remarkably; we observed a ratio of four HCPs
registering within HB6 for every COVID-19 admission. Within HB1 (with the lowest penetration), this fell to approximately one HCP for every two COVID-19
admissions.
To better understand the potential inuencers for guideline registrations we assessed facilitator activity. We calculated the number of unique interactions
(number of logged in page visits) with the GFD. There were 972 interactions in total. Of these, HB6 had the highest-most interactions (642, 67%) (Fig.6). The
HB with least interactions was HB1, with nine interactions (0.9%). This is a similar gure to HB5 (1.4%) suggesting penetration accounted to more than
facilitator activity alone.
To explore further reasons for the low penetration in HB1 we investigated the burden of COVID-19 within each HB at the time of guideline publication. This
estimated the degree of organisational readiness across each HB. At the time of guideline launch, HB1 had the greatest number of COVID-19 inpatients when
compared to the other HBs. This equates to a greater percentage of the peak number of inpatients (37.4%) when compared to other HBs (4.9%, 10.4%, 6.3%,
5.7%, and 5.9%, respectively) (Table1). This suggests HB1 had low organisational readiness at the time of guideline release.
Table 1
– Table of gures representing inpatient numbers at time of guideline launch against its peak for each HB.
Health
Board COVID-19 inpatients around the time of the
guideline launch (data from 22nd March) Maximum COVID-19 inpatient
count during the rst wave COVID-19 inpatients around the time of the
guideline launch as percentage of peak
HB1 107 286 37.4%
HB2 12 243 4.9%
HB3 26 250 10.4%
HB4 13 208 6.3%
HB5 5 88 5.7%
HB6 12 202 5.9%
Survey Responses
In total, 178 healthcare professionals responded to the survey representing 3.9% of the total number of registrants at the time. Of all responses 33.9% of these
were consultants, with 23.1% nurses and 26% reported as ‘other’. The average rating of the guideline platform was 4.01 out of a maximum of ve stars. Of all
respondents from the survey, 68% had encouraged others to use the guideline platform, 28% had not. The majority of respondents reported using the guideline
weekly (26.6%), 23.2% using it 2–3 times per week and a further 22.6% used it daily. The majority of respondents accessed the guideline most often whilst on
duty at work (53.2%), whilst 26.3% accessed it most often from home, whilst not on duty, and a further 19.3% during work, whilst off duty. The majority of
respondents accessed the guideline using a hospital computer (57.3%), 24.0% accessed using mobile phones, 20.5% using their personal computer, and 7.0%
using a tablet device. A commonly reported complaint to the central guideline management team however, was accessibility issues using hospital computers,
where local rewalls blocked access to the guideline website and/or video play function. The mean sliding scale score for the extent to which the guideline
informed their practice was 63 out of 100 indicating the majority of reported the guideline informed their clinical practice. Eighty one per cent of respondents
indicated that they would like the update emails to continue.
Volume of content available
At the time of writing, 7 national pathways and approximately 260 information pages are freely available to HCPs online (www.covid-
19hospitalguideline.wales.nhs.uk). More than 180 pre-recorded video tutorials featuring 45 clinical specialists are freely available to registrants, which have
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resulted in 31,000 video plays. During the rst wave alone, there were nearly 170,000 page views from those signed in. Google analytics show approximately
40,000 sessions, consisting on average of 4.2 page views per session and average session duration of over 5 minutes. The guideline continues to provide
weekly updates throughout the second wave. There were 101 email campaigns (mail-out clinical updates and video synopses, to registrants). In total, 207
registrants unsubscribed to the emails (4.6% of total registrants). This equates to 2.5% unsubscribes per email campaign, or 0.04% of all users per email
campaign. Of the un-subscribers who entered their job title (n = 189, 91% of un-subscribers), the highest proportion came from Medical Students – 21% (n =
40), followed by ‘Other Healthcare Professional’ – 17% (n = 33) and Registrars – 16% (n = 31).
Discussion
The fundamental principle underpinning implementation science is to reduce the gap between knowing and doing, which, for ease of expression can be
termed the ‘know-do gap’ (12). We were aware that standard approaches to disseminating guidelines would not be effective in such a rapidly changing
scenario, such as that presented by the COVID-19 pandemic. We sought to maximize the effectiveness of a national COVID-19 guideline by adopting
implementation science principles, which have proven to improve outcomes for patients by increasing rates of adoption of evidence-based practice (13).
Successful implementation is dependent on the relationship between three key factors – the nature of the evidence, the quality of the context, and facilitation
(14). We propose adding a fourth – timeliness. Timeliness is the optimal window of organisational readiness to adopt a new intervention. Our results indicate
that when the window of readiness is missed this has a detrimental impact on guideline penetration. During the rst wave of the COVID-19 pandemic, the
evidence-base was initially weak, and subsequently subject to rapid changes. Therefore, a decisive and adaptive communication system was necessary to
render the guideline usable, accessible, effective, and sustainable (15).
A Useable Intervention
Acceptability is the perception among implementation stakeholders that an intervention is agreeable, palatable, or satisfactory. Lack of acceptability has long
been noted as a challenge to implementation (16). Typically, a paucity of evidence makes guideline design and clinical acceptance a signicant barrier to
wider adoption (7), but this was not the case with this guideline. We have demonstrated a rapid uptake of new registrants across the whole of Wales, mirroring
the rise in new hospital cases and deaths. We surpassed our consultant registration target six-fold, with almost half of all consultants in Wales registering.
Although limited in size, user responses within our survey gave excellent feedback, with an overall guideline rating was 4.1 out of a total rating score of ve
with over 80% of respondents requesting on-going email updates and nearly 70% of respondents endorsing the guideline by recommending it to others. Finally,
analysis of website trac demonstrated sustained and signicant engagement with the online resources, consistent with the role of this tool in informing
clinical practice.
Of interest, nurse registrants remained a substantially lower proportion of the total nursing workforce (4.6%) when compared to consultants (45%). They were
not the primary target group and subsequently there was less alignment within the nursing hierarchy to support usage and adoption of the guideline. A
consequence of this was more barriers for nurses accessing the guideline. Registration rate and platform activity was greater mid-week than the weekend,
consistent with the results from the user survey where 53% accessed the guideline most often whilst at work, when on duty, with 57% choosing to use a
hospital computer. Barriers to nurses (and other allied HCP) in accessing the guidelines included the following: rst, nurses rarely use NHS emails so would
not get notications of updates, second, it was impractical for ward-based nurses to access the guideline via QR links as they are prohibited from using
personal mobile devices whilst on duty. Third, some hospital rewalls blocked the video play function from generically logged on ward-based computers. This
latter problem happened despite involving national IT specialists in the planning phase. Therefore, dissemination activity was greatest in those with greater
access to NHS emails or personal mobile devices. This observation emphasises the importance of considering technical practicalities in real world settings as
potential barriers affecting user engagement and satisfaction (17).
Creating Readiness
The implementation phase was initiated in only three weeks from date of commissioning the guideline. The speed of delivery was vital to ensure it kept pace
as the pandemic unfolded. It is therefore of interest that we have demonstrated that the HB with the lowest penetrance (HB1) was the region with the rst
surge of cases. COVID-19 affected different HBs asymmetrically and that early exposure to large numbers of cases before launch of the guideline reduced its
effective uptake. At the time of publication of the guideline, HB1 already had 107 inpatients with conrmed COVID-19, representing 37.4% of their maximum
number of inpatients at the peak of the rst wave and a much higher proportion than for the other HBs. Thus, even a short delay meant that the guideline lost
traction since the window of readiness closed – that is, the extent to which organisational members are psychologically and behaviourally prepared to adopt
an intervention (18). Readiness was low as the national guideline competed with local solutions already established to address the crisis. HCPs were more
likely to view the guideline as undesirable, subsequently avoiding, or resisting its use (18). A corollory to this argument is that as the case load and death rate
from COVID-19 reduced, the rate of new registrants reduced signicantly. Overall, the clear conclusion was that one of the main drivers for guideline adoption
was organisational readiness, a factor inuenced by the timeliness of guideline implementaiton.
Increasing Capacity
Whilst the guideline was available to everyone, the primary target group was senior decision-makers with clinical responsibility for patients admitted with
COVID-19. It is an accomplishment therefore, that 1159 consultants registered with the guideline – six-fold our indented target, which equates to 45% of all
consultants appointed in Wales. This is a remarkable number given that many consultants, such as those in surgical specialities, pathology, mental health,
and sub-specialities within medicine were not directly dealing with COVID-19 patients. It is reasonable to conclude that the guideline increased hospital
capacity by preparing staff for their anticipated redeployment to COVID-19 wards. Evidence that consultants continued to nd the guideline of value was that
they are the professional group least likely to unsubscribe from email updates (0.4% of all consultants registered). This contrasts with medical students, who
have the least decision-making responsibility, and were most likely to unsubscribe (15% of all medical students registered).
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Facilitation
Despite endorsement and indeed mandating guideline usage from Welsh Government, we observed variation in penetration between HBs, with over three times
the number of staff registering in HB6 compared to HB1. This appeared consistent across multiple indices of penetration accounting for differences in HB
size. The ImT had little control over selection of local HB facilitators, who demonstrated variable inuence in guideline penetration. It is notable that HB6
employed a facilitator with previous expertise in implementation methodology. They actively engaged in promoting guideline dissemination and utilised the
facilitator dashboard signicantly more frequently than the other facilitators used it. HB6 also mandated that all local HCPs managing COVID-19 patients
register with the guideline and undertake the COVID-19 assessment demonstrating good alignment with policy leads. No other HB offered a similar local
mandate. These observations coincided with better engagement and uptake within HB6, particularly greater consultant penetration (74% of all consultants
employed). Furthermore, HB6 had a signicantly higher proportion of registrants undertaking the guideline assessment – translating to 68.9% of all
assessments passed (627/910), demonstrating greater delity than all other HBs
Guideline Impact
The purpose of the guideline was to improve clinical outcomes by standardising practice and reducing variation. It is of relevance therefore that Wales had
one of the lowest mortality rates in the UK for COVID-19 during the rst wave of the pandemic (75.7 deaths per 100,000 people (condence interval (CI) 72.7–
78.6) versus 90.9 deaths per 100,000 in England (CI 90.1–91.8)) (19). In addition, the Intensive Care National Audit & Research Centre (ICNARC) report showed
that intensive care survival rates for the rst wave were more favourable in Wales when compared to the UK as a whole (61.7% compared to 59.6%,
respectively), albeit not a statistically signicant difference (20). These results are unusual since Wales has a signicantly older population (21) and a higher
proportion of people with co-morbidities than England (22), both known to be important factors for increasing the probability of death from COVID-19 (23)
(24). This data suggests that creating consistency and reducing variation by actively implementing a relevant national guideline improves clinical outcomes.
Conclusion
Dissemination and implementation of a national clinical guideline can happen in a matter of only a few weeks, provided the context and demand allows, and
an effective implementation framework is applied. This is in marked contrast to the 17 years posed by Balas & Boren (25). However, for one HB, even this was
too late, emphasising that the timely publication and dissemination within a window of organisational readiness, is paramount to guideline implementation
success. A key enabler was an active and experienced implementation facilitator, which resulted in three quarters of employed consultants registering with the
guideline in the most engaged HB. The dynamic features of the guideline have undergone 18 iterations highlighting the rapidly changing context. The platform
now contains 30-fold the number of videos from the six proposed in the original specication. This is largely testament to the implementation success and
value proposition offered by the guideline.
We understand that the COVID-19 pandemic has exerted extreme pressures on governments and health systems to react at a scale and pace far beyond the
norms of practice. The building of eld hospitals, PPE procurement and vaccination strategies can only be understood in this context. It is unreasonable to
expect organisations to replicate the speed of implementation of our guideline across other clinical areas, particularly without the urgency imposed from
COVID-19. However, we suggest that the implementation methodology that underpins this COVID-19 guideline remains valid, replicable, and transferable to
other disciplines.
Future work
In June 2020, Welsh Government formally approved a nation-wide data collection tool for all hospitals across Wales. This has collected specic outcome data
for every person admitted to hospital with COVID-19. Using the digital implementation framework, local hospital data collectors record a whole host of data for
every patient in their hospital onto pre-loaded tablets. Data from the rst wave has been submitted for publication from the rst wave (26) and is currently
being collected from the second wave, which will inform further iterations of the hospital guideline. Senior managers and Welsh Government also have access
to data dashboards for each hospital across Wales. Welsh Government has also commissioned a national primary and community care COVID-19 guideline
using the same design and implementation principles, as well as a national COVID Recovery App for patients.
Abbreviations
BTS – British Thoracic Society
CMO – Chief Medical Ocer
CPAP – Continuous Positive Airway Pressure
DGH – District General Hospital
ED – Emergency Department
HB – Health Board
HCP – Healthcare Professional
ICNARC – Intensive Care National Audit & Research Centre
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ICU – Intensive Care Unit
ImT – Implementation Team
NIV – Non-Invasive Ventilation
PPE – Personal Protective Equipment
QR – Quick Response
ToIOM – Taxonomy of Implementation Outcome Model
Declarations
The Respiratory Health Implementation Group (RHIG), NHS Wales, will fund publication charges for this article.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable. Welsh Government have been informed.
Availability of data and materials
The data generated and analysed during the study are available from the corresponding author upon reasonable request.
Competing interests
The authors report no competing interests.
Funding
The Welsh Government funds the Respiratory Health Implementation Group (RHIG) of which SB is the national clinical lead and RJ the programme manager.
RHIG fund the Institute for Clinical Science and Technology (ICST), which create and implement a range of interventions for NHS Wales. MJP is supported by
the Welsh Clinical Academic Training (WCAT) programme and a Career Development Award from the Association of Clinical Pathologists and is a participant
in the NIH Graduate Partnership Program. IH is a Wellcome Trust Senior Research Fellow in Basic Biomedical Sciences. The funders had no role in study
design, data collection and analysis, decision to publish, or preparation of the manuscript.
Authors’ contributions
RJ is the primary author and member of the guideline implementation team. MJP is a secondary author and provided statistical support and advice. SB is a
secondary author and clinical lead and content coordinator of the guideline. All authors have read and approved the nal manuscript.
Acknowledgments
We would like to thank Welsh Government for supporting the implementation of the guideline, local HB facilitators for actively disseminated the guideline, and
all healthcare workers and clinicians for the direct application of the guideline into delivering excellent quality clinical care to patients admitted into hospital
within each of the HBs across Wales. Professor Chris Davies and his team at ICST who partnered with NHS Wales to successfully implement the national
guideline. Dr Daniel Farewell for careful reading and statistical supervision.
Author’s information
Mr. Rhys Jefferies – rhys.jefferies@wales.nhs.uk
RJ is National Programme Manager for the Respiratory Delivery Plan in Wales and is currently undertaking a PhD with Swansea University in the application
of implementation science principles for a range of interventions in healthcare.
Dr. Mark Ponsford – PonsfordM@cardiff.ac.uk
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MJP is supported by the Welsh Clinical Academic Training (WCAT) programme and a Career Development Award from the Association of Clinical Pathologists
and is a participant in the NIH Graduate Partnership Program.
Dr. Simon Barry – simon.barry@wales.nhs.uk
S.B is the National Clinical Lead for Respiratory Medicine across NHS Wales and respiratory consultant in Cardiff and Vale University Health Board.
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Figures
Figure 1
All Wales COVID-19 Secondary Care (Hospital) Guideline – digital version on the guideline platform, colour posters displayed across each hospital across
Wales
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Figure 2
The Implementation Organisational Structure utilised for the dissemination of the national COVID-19 hospital guideline.
Figure 3
Total new guideline registrations, conrmed COVID-19 inpatients and COVID-19 deaths for Wales as 7-day intervals during the rst wave of the COVID-19
pandemic.
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Figure 4
Cumulative number and trend patterns for guideline registrants, conrmed COVID-19 inpatients, and COVID-19 deaths for Wales during the rst wave of the
COVID-19 pandemic.
Figure 5
Consultant grade guideline registrants as a proportion of all consultant staff employed within each HB
