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.