Andrew Tagg. More questions than answers, Don't Forget the Bubbles, 2020. Available at:
Given the rapidly changing climate for all things COVID19 the DFTB wanted more information. We know our strength is in our community so we hosted a series of webinars linking healthcare workers with a special interest in paediatrics. No one person is an expert but we are all in the same situation facing similar challenges. These are some of the questions that came out of the discussions. With the proviso that information is changing on a daily basis and resources in terms of staff, space and stuff is 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.
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 very slim. However, as of the 17th of March 2020 the WHO has recommended against using ibuprofen in patients with symptoms suggestive of COVID19. What does this mean in real terms? We don’t know which children are asymptomatic carriers.
If you look at the source of the message it is even more striking – the French health minister suggested that anti-inflammatory drugs could exacerbate symptoms. He suggested that we should not prescribe NSAID’s or cortisone/steroids to patients with suspected COVID19. 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 to more evidence of harm over benefit. If you want a great, easy read on the matter then check out fullfact.org.
Very little is known on the potential impact of ACE inhibitors on COVID19 in adults, let alone children. The Venn diagram of children with the disease and on perindopril (say) is represented by two separate and distinct circles at the moment. If you are curious as to how there may be an interaction then 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 taking a 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
To claim that there is a cure 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 then dashing your hopes when there is a negative outcome we’ll reserve our judgement at this stage.
Sorting and Streaming
A common challenge mentioned by all sites is just how do we triage? How do we sort patients so that we are not mixing potentially infected with non-infected patients? There cannot be a one size fits all approach as the needs of a single provider clinic are every different from those of a district general hospital and these are very different from a tertiary paediatric centre. Rural and remote populations have different resources to the big, shiny hospitals complete with fish tanks and meerkat enclosures.
A number of hospitals are using a concierge based approach. As a patient approaches the department they are met by a greeter (who is usually a member of the nursing staff), dressed in full PPE. They help determine the first decision point – possible COVID19 or unlikely COVID19. 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 the presence of 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 21sst century solution with carers/patients logging important information on a tablet-style device before their secondary medical triage. This would require the user to clean the interface after use – something that is already tough.
Children with special medical needs
There is insufficient data to make hard and fast rules about the management of children with complex healthcare needs. Adults with multiple comorbidities have increased mortality so it is biologically plausible that the same will hold true 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 little guidelines available on how to do this without just picking up your own mobile phone. This is not an ideal solution but is being offered to many children with diabetes, chronic respiratory conditions or children with 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 COVID19 until proven otherwise.
Once the children have been streamed into a respiratory disease cohort should we assume they all have COVID19 until proven otherwise? Should we treat the patient with clinical bronchiolitis or croup as a potential carrier? And what about those that 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 PICU for the full workup, whether they need intubation or not.
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 that 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 that 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 have no control over at the moment.
Most of us do not have the luxury of working in a tertiary paediatric centre where the 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 the age of 25. That makes sense in a mixed environment but one wonders what happens in centres that do not routinely see any 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 COVID19 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 feel uncomfortable.
At the time of writing this the mortality in children is exceedingly low. This is very reassuring but business will continue as usual. Treatment options may be limited dependent 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, as well as mandating consultant approval of high flow nasal cannula oxygenation. In centre without access to a PICU on-site how are these children being managed? What have 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 starting to consider this and set 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.
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 and, as always, be mindful of your local guidelines if they differ.
Some hospitals are requiring all healthcare providers to undergo mandatory, face-to-face training in donning and doffing PPE prior to deployment. It has been suggested that we should wear the highest standard of PPE for every encounter in order to present nosocomial transmission. Unfortunately, supplies are limited and 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 what an aerosol-generating procedure is. 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, 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.
We are already overstretched – both on the floor and in the back office. Corona conditions are making this even more apparent as we are wondering whether we should stretch our elastic workforce just that little bit more before the wave hits so that we have a rested and well cohort, ready to go. Those of us that 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 who have a lower case burden? Orthopaedic registrars could oversea minor-injuries clinics in a remote location. Dermatology trainees could answer the question of “What on earth is that rash?” in a medical/non-COVID assessment area?
Healthcare workers that 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 too may become patients. None of us is immune to catching the disease. In its mild form, it will be an inconvenience to 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, the pregnant trainee? These are questions that have not yet been answered.
As we are being asked to work longer hours how many hospitals have made provision for routine, everyday tasks? How many have designated areas for staff to catch some 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 is offering free drinks to those with NHS cards but you can only last so long on caffeinated brown water.
The situation with SARS-CoV19-2 is a rapidly evolving one with advice changing on a daily basis. 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, moving departments. Making sure that information trickles down from an operational level to a clinical level can be hard, especially with a workforce that might be relying on bank or agency staff. A lot of departments are trialling WhatsApp groups as a means of sharing the very latest information but it is still possible for a key piece of information to be lost in the stream.
Most hospitals have now cancelled face-to-face education sessions. There are plenty of of resources available to help educators plan sessions remotely. This series from ALiEM is the standout. The DFTB team hope to be adding more resources for you shortly (especially if we get put in isolation).
A number of 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 that they should be doing something and a number of 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.
At the moment we are all nervous anticipation, stepping over wavelets or paddling our boards out ready to catch the big wave. This sense of nervous excitement is palpable in the emergency room. The feeling getting is getting stronger as regular hospital services wind down. How do we maintain our own morale in the face of hard shifts? How do we look after each other when a colleague gets ill? How do we make sure that strangers fro other services are welcome in the safe space we call work?
At this time of great uncertainty, it is important that we remain kind, that we show #PandemicKindness to those we meet. Everyone is working their hardest and to the best of their abilities. Take time to recognise that, whether it is the security officer that has to ask you for your ID to allow you into the building or the cleaners that we rely on. Take your time to thank them for their hard work, offer them a coffee (or a tea if they are in the Northern hemisphere. Remember that the ED is often overstretched so that serum rhubarb may not have been ordered. Be mindful that those of us who are dealing with adults as patients too and recognise that they need our kindness now, more than ever.
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 firstname.lastname@example.org with your ideas and suggestions. And be safe.