We are waging a battle against an invisible enemy. COVID-19 is changing our world in ways we could never have previously imagined—not just in terms of social distancing, closing of non-essential shops and services, and our subsequent social isolation. We are learning of this virus’ impact on our world through various sources – including television, radio, social media platforms and even chatting to our neighbours over the fence. This pandemic has probably changed our world forever.
At the time of publication, Johns Hopkins Hospital Corona Virus Resource Centre (2020) cited mortality rates at the lowest end at 4.1% (Germany) and 15.7% at the highest (Belgium), with the UK an uncomfortably close second at 15.6%. Despite such depressing statistics, we should also remember that, for most people, this appears to be a minor self-limiting illness from which the majority of patients recover. The continuous and apparently unrelenting news of rising virus-related deaths and infection rates leaves us feeling rather depressed. Observing the leadership skills—or lack thereof—of the world’s politicians further compounds our feelings of helplessness and frustration.
Much of the news agenda is using war metaphors—talk of ‘battle-lines’, the virus being an ‘enemy’ and our subsequent ‘fight’ against it. In such unprecedented times, we perhaps need greater clarity; this is not a ‘war’ in the usual narrative of armed conflict, battalions of armed soldiers and its related bloody consequences. Our battle is perhaps far more subtle, invisible and global.
While our universal capacity to connect via air travel is largely halted, as a society we are discovering increasingly innovative ways of staying in contact. As many countries implement social isolation policies and the majority of non-key personnel work from home, the subsequent use of home-based technology has escalated. British Telecom (BT) (2020a) has reported an ‘explosion’ in data use, with a 35-60% increase in daytime data traffic. While some data use is associated with voice and video calls, such as teleconferencing and videoconferencing, online gaming has shown a large percentage rise in usage (BT, 2020b)—probably related to school closures or some adult downtime during the workday!
Against a background of a rising uptake of healthcare technology, the use of technology-enabled care is being implemented at an unprecedented rate, with a growing range of technologies available to assess and treat patients. Within the ambulance service, paramedic and other prehospital practitioners, in roles such as primary and critical care, we are witnessing the emergence of new treatment pathways. For example, avoiding emergency department (ED) admissions for patients who can be managed safely at home is becoming increasingly essential as the COVID-19 pandemic progresses.
Commonly referred to as telemedicine—essentially medicine at a distance—videoconferencing is emerging as the key tool for linking remote clinicians to their patients, but the pace of the pandemic has resulted in some non-healthcare applications being adopted. One example, WhatsApp, is commonly used for text and video chat and regarded as a ‘back door’ implementation, graduating from a social to a professional clinical setting. De Benedictis et al (2019) recommended further overview and governance for these applications as there is a temptation to use a range of untested and unsupported software in the current climate.
However, we need to keep in mind potential security issues. While WhatsApp has recently been endorsed for use in healthcare (Downey, 2020), other video applications have not. Information governance and security should remain key considerations in spite of the need to rapidly transform static clinical services to a remote, mobile support network on whichever system appears to be the most easily accessible.
Within my own clinical and managerial experience, we have been using videoconferencing telemedicine technology to bring expert, remote healthcare to patients since 2010 across the east of England. Our Partnership of seven hospitals is supported by 12 stroke telemedicine consultants, providing an out-of-hours service for potentially thrombolysable stroke patients.
This collegiate partnership makes best use of limited stroke resources, reduces the burden on the ambulance service and, most importantly, ensures that acute stroke patients are assessed rapidly at their local hospital without either patient or clinician needing to travel. We essentially reverse the traditional medical model—we have the clinician come to the patient.
This unprecedented growth in technology is at odds with the current clinical situation. Anecdotally, staff report a 30-40% reduction in the number of stroke patients and the British Heart Foundation reports a 50% drop in myocardial infarction (MI) patients presenting to healthcare (Bakker, 2020). Although unknown, the underlying rationale may be a result of patients’ fear of adding unnecessary pressure to the ambulance and hospital services. Undoubtedly, as with many aspects of this pandemic, this will be explored and understood in the fullness of time. What is clear, however, is that many patients are still having strokes and Mis—many doctors fearing that these patients will present later with significant disability and associated healthcare issues.
The deployment of videoconferencing (VC) technology within the ambulance service is one key method of ensuring that clinicians can access specialist advice for those requiring additional care, while enabling them to deliver the right care. For example, using VC can allow prehospital clinicians to link in real-time with stroke consultants to jointly assess patients presenting with stroke mimics. Stroke mimic patients represent 40-50% of all stroke presentations, the vast majority of whom do not require admission to ED. Early outcomes from our paramedic telemedicine stroke mimic feasibility study in the east of England suggests that 75% of patients assessed presented with migraine and 25% with a transient ischaemic attack (TIA), all of whom were reviewed later that same day in the hospital’s TIA Clinic. Patient feedback has been unanimously positive—specifically the ability to remain at home.
VC can clearly be used in multiple settings, from linking ambulance clinicians to GPs for primary healthcare issues or a virtual consultation with the critical care team on the air ambulance for virtual triage in more seriously unwell patients. We have the technology.
But technology is actually not the most important aspect of telemedicine—it is rather the people and systems that use it. The most advanced App or software is practically useless to clinicians locally if they are unable to effectively deliver the relevant healthcare. For example, in our stroke telemedicine system, without the local stroke teams, specifically the stroke specialist nurses, being able to administer thrombolysis, our system would be ineffective.
In less challenging times, time would be taken to identify a clinical champion to lead implementation and fully train clinicians in new referral pathways. In the current climate, the temptation is to adopt a ‘just get it done’ approach to leadership and use anything that is available and quickly. Looking for existing models and identifying your resources is perhaps more sensible. Such applications can then be deployed at pace with your current clinicians and with exemplars from other areas. In a very recent web meeting on just such an issue, one attendee observed that this pandemic has allowed us to ‘let the genie out of the bottle’ so to speak.
In 2020, perhaps now more than ever before in this strange new world, technology is an indispensable aspect of clinical life. Social acceptance of technology in finance and shopping, booking clinical appointments and ordering repeat prescriptions are among the many reasons for individual technology use. We are now finally witnessing a new emerging pillar in healthcare delivery, another tool in our toolbox of connecting and providing patient care. A new 5G network is being deployed across the UK and this will provide a timely platform for greater flexibility in caring for our patients, specifically in the prehospital setting. This will hopefully be one of the more positive legacies of COVID-19.
In our brave new world, change is inevitable and perhaps lasting. Aldous Huxley stated, ‘Most human beings have an almost infinite capacity for taking things for granted’.
In this pandemic—perhaps if this virus teaches us one thing—it is that we should take nothing for granted.
Bakker J. Lives at risk due to 50% drop in heart attack A&E attendances. 2020. https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2020/april/drop-in-heart-attack-patients-amidst-coronavirus-outbreak (accessed 1 May 2020)
British Telecom. The facts about our network and Coronavirus. 2020a. https://newsroom.bt.com/the-facts-about-our-network-and-coronavirus/ (accessed 1 May 2020)
British Telecom. Our network. 2020b. https://www.btplc.com/coronavirus/Ournetwork/index.htm accessed 1 May 2020)
De Benedictis A, Lettieri E, Masella C et al. WhatsApp in hospital? An empirical investigation of individual and organizational determinants to use. PloS One. 2019. https://doi.org/10.1371/journal.pone.0209873
Downey A. Clinicians told they can use WhatsApp to share data in face of Covid-19. 2020. https://www.digitalhealth.net/2020/03/clinicians-told-they-can-use-whatsapp-to-share-data-in-face-of-covid-19/ (accessed 1 May 2020)
Johns Hopkins University Coronavirus Resource Centre. Mortality Analyses. 2020. https://coronavirus.jhu.edu/data/mortality (accessed 1 May 2020)