Discussion
The WHO declared the COVID-19 infection as a global pandemic on the 11th
March 2020 18. This study documents the advice that
the UK-based Otolaryngologist would need to read and assimilate to
prioritise, protect and triage patients as well as staff during this
period.
As we emerge from the first wave of this unprecedented world-wide
pandemic, we must learn lessons. Since the start of this century, there
have been a number of epidemics; all have arisen outside the UK,
including Ebola, severe acute respiratory syndrome (SARS), H1N1
influenza pandemic, Middle East Respiratory Syndrome, or MERS, and H5N1
https://www.who.int/csr/disease/ebola/ebola-6-months/myths/en/.
The COVID-19 pandemic represents an opportunity to analyse
retrospectively the UK’s response in terms of the volume and timing in
which information was produced.
The virus initially described in Wuhan has spread throughout the world
and, while the infection was recognised as a pandemic on the 11th March,
however UK incidence numbers did not start to rise significantly until
later in March with a probable peak in mid-April 2020. By the time the
infection was recognised as a global risk, there had been a significant
number of cases reported worldwide.
Otolaryngologists and other medical practitioners performing
aerosol-generating procedures (AGPs) were identified early on as being
at a high risk 4,10. While this study is specific to
this subset of medical practitioners, the volume of advice and the time
it was produced is likely to be applicable to other specialties.
This study has identified 175 guidance publications issued from a number
of international, governmental and specialist groups relevant to the
Otolaryngologist. It is likely that this is an underestimate of the
total guidance produced. Fifty-two documents came from international
groups including the WHO and international ENT groups. Fifty-seven were
produced by national organisations, including NHS Eng, Public Health
England (PHE), royal colleges (RCS England, RCS Edinburgh, RCPath,
RCRadiology, RCP) and various surgical societies and associations.
Specialist bodies including ENT-UK, BAHNO, BOS, BRS also produced 66
pieces of advice.
The subject of that advice covered a number of topics including PPE,
service provision, general provision of care, cancer-specific
management, screening and recovery as well as specific aspects of
Otolaryngology, including tracheostomy, otology, rhinology and
paediatrics.
During this period medical services have been required to rapidly
redevelop to allow for appropriate provision of care for COVID-19
infected patients. There has also been a need to limit hospital visits,
rationalise procedures and limit surgical operations16,19. The latter reflects the risks to patients
contracting COVID-19 in the perioperative period and the high rate of
pulmonary complications and mortality. In addition to protecting
patients, there has been considerable guidance on how best to protect
medical staff. As a consequence, a large number of clinical pathways
have been changed. The long-term impact of such changes remains to be
assessed 7,20.
The peak time for guidance production in the UK was between the
16-29th March 2020. During this time numbers of cases
of COVID-19 in the UK were rising rapidly. Specific advice regarding
clinical aspects of care required an assimilation of publicly available
information, published data and international experience. This review
illustrates that there was a number of rapidly published guidelines
which informed clinical practice. Limitations of timescale mean that
guidelines have not always been evidence-based and have been formulated
by opinion and consensus, often relying on collaborative approaches21-24.
Peer review publications have followed the pandemic, with an estimated
13, 863 COVID-19-related publications of which 76% were relevant to the
Otolaryngologist. It can be seen that there has been an unprecedented
number of publications published during the pandemic. Also during this
time many publications have been published using preprint servers and
promoted on social media before peer review and even after peer review
at least two high profile journals have had to retract
publications25. This reflects the significance of the
event but also challenges in medicine to understand and utilise this
information.
With so much evidence produced in a short time, while infection rates
were climbing was a huge challenge to incorporate into safe clinical
practice. Moreover, translating high-level international guidance into
meaningful advice for a given procedure in a particular setting is
difficult. It is therefore unsurprising that there was some confusion.
This study is illustrative of the challenges faced by the
Otolaryngologist in absorbing, assimilating, and implementing the advice
produced. Much of the advice was produced while the numbers of new cases
were increasing. While this is specific to the Otolaryngologist, it is
likely that this pattern of advice and timing is relevant to other
specialities operating in different regions of the world.
Within the UK much of the discussion has been about flattening the curve
of infections. This study suggests that there is also a need to move the
information curve to the left. Having a system that identified the
impending pandemic would allow for the preparation of clear guidelines
before the number of cases started to increase.
There is also a need to flatten the information curve. National and
international guidance advice needs to be assimilated into advice that
relates to specific procedures considering the physical setting they
will occur in, local practice and availability of equipment. Having
multiple bodies interpreting the guidance is an opportunity for
confusion. Ultimately, this may result in a failure to follow the
guidance, potentially putting medical personnel or patients at risk, or
an over-interpretation of advice resulting in treatment being withheld.
If a pattern of infections arose again like the COVID-19 pandemic then
there are opportunities if mechanisms are in place to generate and
co-ordinate the advice needed by Otolaryngologists as well as other
medical teams so that the advice can be available before numbers of
infections start to rise. Much like the early warning system introduced
after the 2004 Tsunami, there is a need to establish a similar system in
the UK with clear lines of communication and dissemination of
information.