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| INVITED COMMENTARY |
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| Year : 2021 | Volume
: 5
| Issue : 1 | Page : 11-13 |
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After COVID - where now?
Andrew Bush
Centre for Paediatrics and Child Health, and National Heart and Lung Institute, Imperial College, London, UK
| Date of Submission | 15-Jul-2021 |
| Date of Acceptance | 18-Jul-2021 |
| Date of Web Publication | 13-Jan-2022 |
Correspondence Address:
Andrew Bush
Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, Sydney Street, London SW3 6NP, AB is an Emeritus NIHR Senior Investigator
UK
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/prcm.prcm_14_21
How to cite this article:
Bush A. After COVID - where now?. Pediatr Respirol Crit Care Med 2021;5:11-3 |
CoVID-19 has shattered our complacent assumptions about the best ways to practice medicine, and it is clear that there is no going back to 2019, whether or not there is a another surge of CoVID or a new viral pandemic.[1] Here we look back to the way we were and consider the changes mandated by CoVID. Finally, we propose a road map for the future, critically considering which of the rapid, non-evidence-based changes worked, and what needs to be refined for the future. Illustrations are taken from respiratory medicine, but the principles are likely applicable to many other specialities.
2019: The way we were. Outpatient practice had not changed in living memory. A child and carer would make sometimes a very long journey; join an unruly scrum in the clinic waiting areas; be summoned to a (usually brief) consultation with an often quite junior doctor, who may never have seen the child before and may never see them again, before departing on the long return journey; the whole sterile process being repeated a few weeks or months later. A new referral would be seen at the hospital, but often investigations would have to be scheduled for a second visit. An emergency admission was usually prefaced by a prolonged wait in a crowded emergency department.
2020: In the throes of CoVID. The imperatives were to reduce travel to the minimum, and reduce face-to-face contacts, to minimize the risk of infection. The default was that the child should stay at home unless it was absolutely essential. The hospitals were flooded with severely ill adults, and children’s services severely cut back. Children frequently presented late with serious illnesses, partly through bad advice and partly through parental reluctance to go to hospitals which were perceived as hotbeds of infection.[2],[3] Outpatient clinics were initially mainly conducted over the telephone and then by video link. Equipment such as spirometry was increasingly provided at home.
2021: Going forward. We are going to continue with the default that the child only comes to hospital if it is absolutely necessary, for example, for a sophisticated test requiring expensive equipment. Much can be done in the local primary care center if we can connect up care for children. The obvious example is measurement of height and weight, which should be plotted on an electronic growth chart with access by the family and all carers.
The first area to consider is referral for a specialist opinion. Hitherto, a referral from primary to secondary care in many cases leads to all responsibilities being devolved away from the community, but this should change. Logically, the first specialist consultation should be by video link, and part of the process would be to plan the next steps. If, as is often the case, sophisticated investigation is determined to be needed, then a hospital visit is required during which a physical examination is performed and all necessary tests are carried out, because they have been pre-planned and booked, preferably as a day case. Also during this visit, the child should be provided with any necessary monitoring equipment and its use demonstrated. In the case of a child with asthma, this could include an APP allowing the mobile phone to be used as an electronic stethoscope; a portable spirometer; and an exhaled nitric oxide meter. A cheaper alternative might be to install these in primary care unless infection control is a major issue, as for example, in cystic fibrosis. Electronic monitoring devices (e.g. SmartinhalerTM) would be attached to the relevant inhalers to monitor adherence[4]; hopefully, future devices would monitor inhalation as well as activation.[5] Directly observed therapy by mobile phone video link is well established in a research context,[6] but there is no reason why it should not also be utilized in clinical settings. All data would be stored on the carer’s mobile phone and be accessible remotely in primary and secondary care.
Follow-up will also be transformed. Remote video supervision of treatment such as airway clearance and monitoring techniques such as spirometry are readily feasible. Intermittent video consultations are also eminently feasible. The advantages to the family of these approaches are obvious: minimal time off work and school, travel costs minimized, and far greater objective monitoring than previously. Pre-CoVID there was increasing emphasis on home visits by specialist hospital teams, but travel time was a problem; much can be done remotely.
Acute care provides different challenges. Video triaging in a virtual emergency room is one obvious way to improve on telephone consultations. There is potential to arrange direct admission from the home, bypassing the emergency department. Parental education in the recognition of a sick child is also essential, to avoid the twin pitfalls of missing serious problems and over-reacting to trivialities.
2021: Unresolved problems. The first prerequisite is a step change in technology, allowing storage and remote exchange of data in a manner compatible with data protection and personal security. The NHS has a poor record for Information Technology commissioning, and these difficulties cannot be understated. Also a concern is those for whom the modern world of electronic communications is a closed book, in particular the elderly. For these groups, safety nets must be in place, and remote monitoring will be much less feasible. Another vulnerable group is children for whom there are child abuse and safeguarding concerns; remote access may equate to no access for such children, leaving them trapped in an abusive home. This is no trivial issue; in severe asthma at least, safeguarding concerns are common.[7]
There may also be as an as-yet unresolved legal issue; could failure to see a child face to face be seen as negligent? As far as we are aware, this has not been tested in the Courts, so it is only possible to speculate about a ruling. Perhaps, an important principle is that if the family wants a face-to-face consultation, then that should be provided if at all possible. Secondly, if at the end of the remote consultation, the pediatrician is in any doubt of the clinical circumstances, at the very least a follow-up should be organized within a short time. Indeed, families may find a video or even a telephone call to check out progress to be reassuring. As with all consultations, critical is to ensure that the family feels that their concerns have been heard and they are happy with the proposed plan. The Courts should certainly take into account that, compared with a year ago, remote consultations have become a mainstream part of medicine.
There is also a societal challenge. At least in some hospitals, attendance for asthma attacks[8],[9] and other emergencies[10] has dropped dramatically, and this must be driven by behavioral changes which we should support continuing. The exact reasons are unclear, but are likely multifactorial. Lockdown and isolation have probably greatly reduced the transmission of non-CoVID respiratory viruses, a major trigger of asthma attacks. Environmental pollution has dropped dramatically.[11],[12] Perhaps lockdown has reduced exposure to aeroallergens such as pollens, albeit at the price of increasing indoor exposures if parents smoke or vape. Hypothetically, parents may have had more time to supervise their children’s medications and adherence has improved.[13]
Another key societal challenge is obesity, which has been a worse pandemic than CoVID-19 for far longer. Whereas the threats of cardiovascular disease and cancer in obesity have been largely ignored, the realization that obesity is associated with worse CoVID infection outcomes[14],[15] has stung regulators into action. Weight loss is now on the public health agenda, and it needs to stay there.
Funding is another pertinent challenge. In care systems in which reimbursement is on the basis of face-to-face consultations, devolving these to remote care may cause consternation. The cost of the equipment may well be offset by savings in travel costs and loss of income, but these come from different pots of money!
Finally, as with all sweeping changes, there needs to be in place robust means of assessment, including safety and cost-effectiveness. In the rush of the onset of the pandemic, there was little or no time to do this, and we all learned how to cope as we went along. We now can and should go to more measured appraisals, ensuring we preserve the best of what we learned during CoVID and refining and reworking that which worked less well.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Gupta A, Bush A, Nagakumar P Asthma in children during the COVID-19 pandemic: Lessons from lockdown and future directions for management. Lancet Respir Med 2020;8:1070-1.  |
| 2. | Lynn RM, Avis JL, Lenton S, Amin-Chowdhury Z, Ladhan SN Delayed access to care and late presentations in children during the COVID-19 pandemic: A snapshot survey of 4075 paediatricians in the UK and Ireland. Arch Dis Child 2021;106:e8. |
| 3. | Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G Delayed access or provision of care in Italy resulting from fear of COVID-19. Lancet Child Adolesc Health 2020;4:e10-1. |
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| 9. | Krivec U, Kofol Seliger A, Tursic J COVID-19 lockdown dropped the rate of paediatric asthma admissions. Arch Dis Child 2020;105:809-10. |
| 10. | Dann L, Fitzsimons J, Gorman KM, Hourihane J, Okafor I Disappearing act: COVID-19 and paediatric emergency department attendances. Arch Dis Child 2020;105:810-1. |
| 11. | Fattorini D, Regoli F Role of the chronic air pollution levels in the Covid-19 outbreak risk in Italy. Environ Pollut 2020;264: 114732. |
| 12. | Muhammad S, Long X, Salman M COVID-19 pandemic and environmental pollution: A blessing in disguise? Sci Total Environ 2020;728:138820. |
| 13. | Kaye L, Theye B, Smeenk I, Gondalia R, Barrett MA, Stempel DA Changes in medication adherence among patients with asthma and COPD during the COVID-19 pandemic. J Allergy Clin Immunol Pract 2020;8:2384-5. |
| 14. | Yadav R, Aggarwal S, Singh A SARS-CoV-2-host dynamics: Increased risk of adverse outcomes of COVID-19 in obesity. Diabetes Metab Syndr 2020;14:1355-60. |
| 15. | Alkhatib AL, Kreniske J, Zifodya JS, Fonseca V, Tahboub M, Khatib J, et al. BMI is associated with coronavirus disease 2019 intensive care unit admission in African Americans. Obesity (Silver Spring)2020;28:1798-801. |
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