The COVID – 19 pandemic has resulted in significant changes in the healthcare system. In the early stages adult services were overwhelmed with sick patients, whereas it seems that there has been an unprecedented (and rather dramatic) decline in pediatric attendances. Lockdown and advice from the government urged people to stay at home to prevent the spread of the virus. In response we, as paediatricians, were forced to consider making changes in our style of delivering care and clinic services to support children and families.
Telemedicine was not new before COVID-19 but it has now become a legitimate means of allowing medical professionals and patients to communicate in a virtual clinic setting. We aim to provide high-quality safe care to every patient but it has taken a global pandemic for us to start at scale to harness modern technology so that we can deliver care closer to home and provide a seamless service for our patients and their families. To make the most from advances in technology we must understand the benefits and problems.
Let’s start with the pros
Telemedicine is a game-changer in paediatric asthma. Take the example of a district general hospital with 3300 paediatric attendances with asthma/ viral-induced wheeze in a year, 780 admissions and sees a cohort of 120 re-attenders in paediatric ED. During the pandemic, there were concerns that children would present late for emergency care, and be sicker as a result of this delayed presentation. To addressing this, virtual asthma clinics were started seven days a week.
Then the unexpected happened.
Paediatric asthma attendances to ED reduced by 90%, the chronic attendees, some who were on a high dose of steroids and who would attend ED up to 10 times in a year, also needing PICU, on occasions were nowhere to be seen.
Several factors such as lockdown, change in air pollution levels and handwashing were probably the main contributors.
Virtual asthma clinics also reported a high level of engagement and increased compliance with medications, especially from repeat attenders and teenagers who previously had shown poor compliance. Parents were reported to be very appreciative of the virtual clinics at a time when they felt that getting GP appointments was not easy.
Clinicians and asthma nurses were able to suggest modifications in medications through the virtual clinics, treat exacerbations at home and liaise with primary care for repeat prescriptions. Compliance improved to an extent that a shortage of preventors was reported in the trust. Change in patient and parent specific behaviour due to fears of contacting COVID-19 was thought to have led to increased compliance with medication and contributed to better management of paediatric asthma.
One frequent ED attender is a four-year old with recurrent wheezy episodes, who normally presents in respiratory distress needing nebulisation and IV medications. After many months, he arrives back to ED in May 2020 and recieves a rapturous welcome from staff. The triage nurse took him straight in, and the doctors and nurses got ready to write up medication. The patient and family were highly gratified with the welcome, but hastened to report that he had come in with a pulled elbow. “So how was the asthma then?”, the ED staff asked all puzzled. “Great”, said the mum, so well controlled, he has not had wheeze for ages, he is taking his preventors every day. The lad made everyone’s day in ED, even the pulled elbow reduced spontaneously.
COVID-19 seemed to be able to address the compliance issue in ways that clinicians and asthma nurses could only dream of.
Similar experiences were reported from the virtual clinics for paediatric diabetes. Paediatric diabetes consultation is focused on data interpretation, behaviour modification and tweaking of the dosage of medication.
All of this can be done remotely.
Furthermore, children, as it turned out, proved to be a dab hand at uploading data from their glucometers and insulin pumps. This in turn led to greater engagement as children showed their parents and doctors the ropes around tech, giving a sense of ownership and empowerment. The did-not-attend rate became minimal and the compliance improved dramatically.
The virtual endocrine clinic is also working well. Children who present for their initial appointment are best seen in a traditional clinic setting. Subsequently, a vast majority can be followed up virtually with an annual physical assessment. This includes children with problems with growth, thyroid and CAH. However, there will always be a small number of patients who need more frequent physical assessment.
The inability to examine patients in a teleconsultation has risks. For example, a child with a longstanding goitre can become neoplastic. Physical examination allows the experienced clinician to construct the differential diagnosis based on palpation of the thyroid gland which guides further investigation. This is not possible in a virtual clinic setting.
This is where good old-fashioned traditional medicine comes up trumps. Every consultation and physical examination give clinicians an unique opportunity to address existing clinical issues whilst providing an insight into additional psychological issues that may be lurking beneath the surface, especially in children with diabetes.
The consultation effectively starts as the child walks in, the gait, the facial expression there is clue in every step. Vital signs, which often provide clues to the diagnosis, cannot be recorded in telemedicine. Language barriers add a third dimension to telemedicine, using a third party to add to the mix. There is the risk that the equipment related to telemedicine can fail resulting in interruption or cancellation of the virtual clinic.
Complaints received in the NHS often relate to the perceived behavioural aspect of clinicians toward patients sometimes even more than medical management. Bedside manner is of importance, body language clues from the clinicians that reinforces that they are actively listening to children and their families thus making the consultation a positive experience. This results in better patient experience and job satisfaction for clinicians. Compassion and empathy are a vital part of the clinician and patient experience, how this would translate in a virtual clinic needs further investigation.
The disparity between equity of access also emerged during the pandemic when virtual clinics became mandatory. Some children only had access to the internet at school and the local library. This caused some logistical difficulty in managing data remotely. A request to social services was made to fund the upgrading of one family’s phone so they could access the digital platform for diabetes education and data transfer. Fortunately, these cases seemed uncommon.
The UK’s General Medical Council (GMC) provides ethical guidance to help clinicians manage patient safety and risks and decide when it’s usually safe to treat patients remotely. Consent and continuity issues are addressed, additionally, choosing the right patient who is suitable for the virtual clinic is addressed. However, the issues of liability and responsibility are not clear. The UK Care Quality Commission and other national regulators do not provide specific telemedicine polices for healthcare providers.
Some clinicians believe that use of teleconsultation threatens the basics of medicine. Excessive reliance on tech goes against the traditional clinician-patient relationship. We enter an unchartered territory were risks and responsibilities are both unclear and unknown.
The bottom line
The pandemic has given a snapshot on how we can change the way we deliver healthcare. Expectations have changed. We need a system that allows flexibility between telemedicine and traditional medicine and is responsive to clinical needs. It is important not to forget the basics – observing the patient, review of nursing observations, clinical examination, reaching a differential which will then guide the necessary investigations. However, for the right patient, telemedicine can be a safe and cost-effective option.
Caroline Ponmani (Barking, Havering, and Redbridge University Hospitals NHS Trust)
Kausik Banerjee(Barking, Havering, and Redbridge University Hospitals NHS Trust)
Tony Hulse (Evelina Children’s Hospital)