More questions than answers

Given the rapidly changing climate for all things COVID-19, the DFTB wanted more information. We know our strength lies in our community, so we hosted a series of webinars that linked healthcare workers with a special interest in paediatrics. No one is an expert, but we are all in the same situation and facing similar challenges. These are some of the questions that came out of the discussions. With the proviso that information is changing daily and resources regarding staff, space, and stuff are different, let’s dive in.

This data is correct as of 19th March 2020. Please let us know in the comments if you spot anything new.

Science

NSAIDs

There has been a suggestion that non-steroidal agents are unsafe for use in SARS-CoV2-19 patients. As we have already seen, the evidence for anything in the paediatric realm is slim. However, as of March 17, 2020, the WHO has recommended against using ibuprofen in patients with symptoms suggestive of COVID-19. What does this mean in real terms? We don’t know which children are asymptomatic carriers.

If you look at the message’s source, it is even more striking – the French health minister suggested that anti-inflammatory drugs could exacerbate symptoms. He suggested that we should not prescribe NSAIDs or cortisone/steroids to patients with suspected COVID-19. Given that one of the few drugs that work in one of our more prevalent respiratory diseases, croup, is a steroid, then I think we need to look for more evidence of harm over benefit. If you want a great, easy read on the matter, check out fullfact.org.

ACE-I

Very little is known about the potential impact of ACE inhibitors on COVID-19 in adults, let alone children. Currently, the Venn diagram of children with the disease and on perindopril (say) is represented by two separate and distinct circles. If you are curious about how there may be an interaction, read this great Tweetorial from Jonny Wilkinson.

ACE inhibitors as a potential risk factor for fatal Covid-19 / Don’t confuse ACE-I and ARB’s when treating #COVID19 patients…they have quite the opposite potential effects. One exaggerating mortality, the other reducing? ‍♂️ #FOAMed #FOAMcc https://t.co/aElIliuPXP

— Jonny Wilkinson (@Wilkinsonjonny) March 12, 2020

It is also worth looking at this letter in the Lancet to better understand the theory.

Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? The Lancet Respiratory Medicine. 2020 Mar 11.

Vaccines and various treatments

Claiming that a cure is just around the corner or that a certain combination of vitamins and herbs will keep the virus away is pure quackery. Rather than tell you what research is going on and then dashing your hopes when there is a negative outcome, we’ll reserve our judgment at this stage.

Sorting and Streaming

A common challenge mentioned by all sites is how we triage. How do we sort patients so we do not mix potentially infected patients with non-infected patients? There cannot be a one-size-fits-all approach, as the needs of a single-provider clinic are very different from those of a district general hospital and those of a tertiary paediatric centre. Rural and remote populations have different resources, from big, shiny hospitals with fish tanks and meerkat enclosures.

Triage

Several hospitals use a concierge-based approach. As patients approach the department, they are met by a greeter (usually a nursing staff member) dressed in full PPE. They help determine the first decision point – possible COVID-19 or unlikely COVID-19. The latter group is pretty easy to spot. Determining what patient sub-types fall into the former is more of a challenge.

In the initial phase of the disease, most hospitals have looked for respiratory symptoms PLUS a fever. If you look at the published and pre-print paediatric data, around 2/3 of children with the disease have a fever, and a large proportion appear to be asymptomatic. A number of patients also present with predominantly GI symptoms. Should they be treated as potential carriers? (And who should change their nappies, given they can shed SARS-CoV2-19 for up to 40 days?)

An alternative triage approach utilizes a more 21st-century solution: caregivers/patients log important information on a tablet-style device before their secondary medical triage. This would require the user to clean the interface after use, which is already tough.

Children with special medical needs

There is insufficient data to make hard and fast rules about managing children with complex healthcare needs. Adults with multiple comorbidities have increased mortality, so it is biologically plausible that the same will hold in the paediatric population. Pre-notification of attendance can help as these kids are brought in via a different entrance.

Many places are trying to replace standard outpatient visits with telehealth options on an ad hoc basis, with few guidelines available on how to do this without picking up your own mobile phone. This is not an ideal solution, but it is being offered to many children with diabetes, chronic respiratory conditions, or rheumatological conditions requiring immunosuppressive agents.

The RCPCH recommends that children who have an exacerbation of their chronic respiratory illness and require admission should be considered to have COVID-19 until proven otherwise.

Internal streaming

Once the children have been streamed into a respiratory disease cohort, should we assume they all have COVID-19 until proven otherwise? Should we treat the patient with clinical bronchiolitis or croup as a potential carrier? And what about those who are wheezy but don’t have a fever? Just what do we do then?

The number of critically ill children presenting to the ED is likely to be small, but it has been suggested that these are rapidly assessed and transported to a negative pressure room in the PICU for the full workup, whether they need intubation or not.

Testing

Children do not come into the hospital on their own. They often bring carers, parents, grandparents, aunts, and uncles. Adjusting the policy on attendant carers is a tough sell to those who are looking after the potentially infected child. Most mixed EDs seem to be keeping the family unit together for testing. It would be interesting to know if any tertiary paediatric centres are testing the grown-ups who come with the children.

Just how accurate is the PCR test? And just how long does it take a result to come back? We are looking into the former question and can sense the frustration around the latter. Cohorting patients in negative pressure rooms just waiting five days for a swab result is not helping us clear the decks. We should be mindful, though, that there are things we can control and things we cannot. This is one of those things we currently have no control over.

Mixed departments

Most of us do not have the luxury of working in a tertiary paediatric centre where only adults are dressed as clowns or doctors (or doctor-clowns). Some departments are making provisions by moving their paediatric space to allow for adult overflow. The RCPCH has also stated that paediatricians should be prepared to see patients up to 25. That makes sense in a mixed environment but one wonders what happens in centres that do not routinely see adults. With outpatients and elective surgery being cancelled across hospitals, there is a potential surfeit of doctors with markedly reduced day-to-day work.

There is also the question of what happens in adult hospitals when a COVID-19-positive sole parent gets admitted. What happens to their swab-negative child? In some cases, the decision has been to treat them as a boarder, but this can make many staff members uncomfortable.

Sicker children

At the time of writing this, the mortality rate in children is exceedingly low. This is very reassuring, but business will continue as usual.

Treatment options may be limited depending on restrictions with regard to aerosol-generating procedures. There have been mixed messages as to whether nebulization of medication. leads to increased healthcare worker risk. Some places are now controlling the use of nebulized treatment and mandating consultant approval of high-flow nasal cannula oxygenation. In centres without access to a PICU on-site, how are these children being managed? What measures have paediatric retrieval services put in place to deal with the potential increase in referrals?

Intubation teams are already being considered at a number of sites – teams of doctors, similar to a MET team, that are ready to provide critical care at the sound of a bleep in the hope that this will reduce exposure to one of the highest risk aerosol-generating procedures – intubation. In mixed adult/paediatric hospitals, it is also important to consider the implications of intubation in a resource-replete setting. Some hospitals are considering this and setting up ethics committees to set rules early and consider just who should have access to that last ventilator. The decision is not as easy as you think.

Stuff

Personal protective equipment

There have been some mixed messages about what type of PPE should be worn in what scenario. Public Health England has this handy table to guide you. As always, be mindful of your local guidelines if they differ.

Some hospitals require all healthcare providers to undergo mandatory, face-to-face training in donning and doffing PPE before deployment. It has been suggested that we should wear the highest standard of PPE for every encounter to present nosocomial transmission. Unfortunately, supplies are limited so we should use the most appropriate PPE for the task in hand.

Aerosol generating procedures

There seems to be a lot of confusion about aerosol-generating procedures. As always, it is important to follow your local clinical guidelines. But if you disagree with them, then let the evidence guide you and seek to change the guidelines. Concerns have been raised about everything from just examining the throat to using nebulizers (a daily question) and whether we should be using HME filters on the Neopuff. Rest assured, we are looking at this, and a blog post will follow.

Staffing

Rosters

We are already overstretched—both on the floor and in the back office. Corona conditions are making this even more apparent, as we wonder whether we should stretch our elastic workforce just that little bit more before the wave hits so that we have a rested and well-rested cohort ready to go. Those of us who work in mixed EDs know that paediatric workforce planning is furthest from our minds as we read of the Italian situation.

Should (when?) the pandemic stretch on for months, considerations need to be given to staff longevity. Will there be a burnt-out generation of ED physicians who have seen and been exposed to too much? What about those who have had much-needed leave cancelled? Perhaps some of the daily load can be taken up with doctors from those specialities with a lower case burden? Orthopaedic registrars could oversee clinics for minor injuries in remote locations. Dermatology trainees could answer, “What on earth is that rash?” in a medical/non-COVID assessment area.

Healthcare workers who work across sites are already being asked to reduce cross-campus travel.

Though we go to work for our patients, we also need to be mindful that we may become patients. None of us is immune to catching the disease. In its mild form, it will inconvenience us, our loved ones, and our colleagues. But healthcare workers will die. Healthcare workers have already died. How do we mitigate the risks for the more vulnerable? What should we do with the older, more at-risk paediatrician, the immunosuppressed healthcare worker, and the pregnant trainee? These are questions that have not yet been answered.

Everyday life

As we are asked to work longer hours, how many hospitals have made provisions for routine, everyday tasks? How many have designated areas for staff to sleep before driving home? How many are providing scrubs for staff to change into or are helping with the laundry? The last thing most of us feel like when we get home is loading up the washing machine (and then putting it out to dry. But how clean are your everyday clothes? Your stethoscope? Your phone?

How are workplaces supporting that other basic physiological need – food? With supermarkets reducing their opening hours, how are healthcare workers being supported? McDonald’s in the UK offers free drinks to those with NHS cards, but you can only last so long on caffeinated brown water.

Information dissemination

The situation with SARS-CoV19-2 is rapidly evolving, with advice changing daily. Most hospitals have set up incident management teams that meet at an executive level to discuss the changes that may impact our day-to-day – cancelling elective surgery and moving departments. Ensuring that information trickles down from an operational level to a clinical level can be hard, especially with a workforce relying on bank or agency staff. A lot of departments are trialling WhatsApp groups as a means of sharing the latest information, but it is still possible for a key piece of information to be lost in the stream.

Education

Most hospitals have now cancelled face-to-face education sessions. Plenty of resources are available to help educators plan sessions remotely. This series from ALiEM is the standout. The DFTB team hopes to add more resources for you shortly (especially if we get put in isolation).

Students

Several universities have pulled their students from clinical placements or placed restrictions on their interactions with patients, e.g. not to see a respiratory patient. Many feel they should be doing something, and some great initiatives have been suggested. One group has launched a childcare service for healthcare providers. With schools in the UK due to close early for the Easter break, this will come as a welcome relief to many who may usually rely on (at-risk) relatives. It has also been suggested that they would make excellent scribes to speed up the standard clerking process. Let us know what else is going on.

Please feel free to answer any of these questions in the comments section. Share your resources, your experiences, so that we may learn from each other. E-mail us at hello@dontforgetthebubbles.com with your ideas and suggestions. And be safe.