key: cord-0804835-zb36w1aj
authors: Johnson, Douglas F.; Steinfort, Daniel P.; Cowie, Benjamin
title: Navigating shifting waters: rapid response to change in the era of COVID‐19
date: 2020-07-12
journal: Intern Med J
DOI: 10.1111/imj.14921
sha: 58c8415bd759e81a2e52729de336137dff6a2384
doc_id: 804835
cord_uid: zb36w1aj

nan

Navigating shifting waters: rapid response to change in the era of COVID-19

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan, China in December 2019 has resulted in a global COVID-19 pandemic and a consequent rapid transformation of medical practice in 2020. Overseas, distressing reports of overwhelmed health systems, 1 healthcare workers losing their lives 2 and shortages of personal protective equipment (PPE) 1,3-5 have created significant anxiety and catalysed rapid action across Australia and New Zealand. Enormous effort has been invested in developing screening clinics; redesigning general practice, hospital inpatient wards and emergency departments (and the models of care used within them) and expanding intensive care capacity. Public and private pathology services have rapidly expanded their capacity to meet the testing demand. As of 6 May, 664 756 tests for SARS-CoV-2 have been performed in Australia, representing 2611 tests per 100 000 people. 6 Fundamental changes to general practice have also occurred rapidly; across five Australian Primary Health Networks, weekly face-to-face consultations dropped from around 300 000 to 200 000 per week from February to April 2020; in the same period, telephone/telehealth consultations in general practice rose from 0 to 120 000 per week, now representing 40% of consultations overall. 7 Modelling-derived estimates of infection in our populations are constantly changing, as is our understanding of how to best care for patients infected with SARS-CoV-2. In both Australia and New Zealand, mathematical modelling efforts 8, 9 have been vital sources of strategic information to inform the public health and social policy decisionsincluding requirements to stay at home; restrictions on educational, recreational and social gatherings and travel, isolation and quarantine directions that have made daily life in our countries almost unrecognisable when compared with a few weeks ago. Elements of these pandemic countermeasures are likely to continue for months to come. To date, the heroes of Australia and New Zealand's effective response to COVID-19 are the epidemiologists and public health physicians who have enacted these community interventions (and the politicians who have heeded their advice). We are now well placed to respond to COVID-19, and our public health leaders, politicians and the general community must be commended for slowing the spread of SARS-CoV-2.

The result of sacrifices made is that we have been spared the enormous morbidity and mortality experienced by most countries. As of 17 April 2020, cumulative COVID-19 related deaths reported to the World Health Organisation (WHO) from New Zealand and Australia were around 0.25 per 100 000 population (similar to those reported by Singapore, Japan, South Korea and Chinaall <1 per 100 000). In contrast, the cumulative reported mortality in Germany (4.6 per 100k), the United States (8.5), the United Kingdom (20.2) and Italy (36.7) ranges from 18 to 145 times that reported from Australasia. 10 However, even these stark figures are almost certainly underestimates of total deaths attributable to COVID-19 based on analysis of excess mortality in the most affected populations. 11 The other result is that we now have time, time to ensure the health system preparations we have put in place are ready to be activated at an unknown point in our future; time to determine whether locally acquired infection has truly been suppressed below the critical R0 value of 1that is, that each infected individual infects (on average) less than one other person, thereby breaking the chain of transmission and time to scale further up access to diagnostic testing and use the rapidly expanded public health workforce available to health departments to design and implement rapid response mechanisms to swing into action whenever and wherever local clusters of infections are detected. This will be essential to prevent our communities from again being set along the trajectory of a substantial epidemic curvethe 'second wave'or from being forced once more to endure profound restrictions on individual freedoms and to our way of life.

Evidence of high asymptomatic proportions continues to mount when universal testing irrespective of symptoms is implementedfor example, recent accounts from the United States, including a naval vessel (600/4500 sailors infected, 60% asymptomatic), 12 a New York maternity service (33/215 women infected, 88% asymptomatic) 13 and a Boston homeless shelter (146/397 clients infected, 100% asymptomatic). 14 General population testing in Iceland identified 87 positive individuals out of 10 797, with 41% of these reporting no symptoms at the time of testing. 15 While many of these individuals may have been in pre-symptomatic or convalescent phases of infection, it appears clear that asymptomatic infections still represent a profound public health challenge. It also suggests why early adopters of whole-of-population social-distancing measuressuch as New Zealand and Australiamay have averted the crisis seen overseas. If adhered to, these measures reduce the potential for transmission of infection from all infected individuals, symptomatic or not. This contrasts with traditional clinically focussed approaches, such as testing those with symptoms and isolating them until cleared; if a substantial proportion of infected people have no symptoms, these measures alone will be doomed to fail. While Australia's COVIDSafe App can speed up contacting of people exposed to a diagnosed case of COVID-19, it cannot replace broader social distancing and other public health measures should we face a second, more substantial wave of infections in coming months. To develop an early warning capacity ahead of a substantial increase in presentations to hospital, other innovative surveillance mechanisms must be considered, including real-time data from presentations to general practice 7 and surveillance for SARS-CoV-2 detection in sewerage. 16 Pleasingly, with the success of social/physical distancing measures, it seems our countries will be spared the prospect of clinicians being forced to practise outside their knowledge/skillset, as has been required in many other countries. 17 Even so, clinicians whose purview would ordinarily include severe respiratory infective illnesses face the prospect of clinical decision-making in the absence of established evidence supporting specific interventions.

It is difficult to discern signal from noise among the deluge of published studies on COVID-19 (over 5500 studies recorded in PubMed since 1 April 2020). 18 Unsurprisingly, for an illness undocumented less than 4 months ago, no treatments, beyond supportive care, have been established to be effective, highlighting the need for well designed and coordinated clinical trials. Guideline development is tricky when even basic questions are unknownis hydroxychloroquine effective 19 or toxic; 20 is use of high-flow nasal prongs an aerosolgenerating procedure 21 or not; 22 should anti-coagulation be at prophylactic or therapeutic dose; 23 in isolated hypoxic respiratory failure, is there a role for conscious proning of hypoxic patients 24 or is mechanical ventilation the only acceptable management pathway?

As COVID-19 has forced innovation at a health service level, it is also accelerating a transition in scientific publishing. The results of the hundreds of therapeutic studies currently underway are likely to be unavailable for some time. 25 Much of the knowledge regarding clinical presentation of COVID-19 or management strategies are gained from unconventional sources, for example, early findings regarding the efficacy of resdemivir have been published in conventional literature, 26 but presentation of nonpeer-reviewed data in a White House media conference gained vastly more publicity. 27 Pre-print publications have gained prominence in their ability to provide data quickly (veracity of these studies will remain an ongoing challenge for the medical community), 28 and the spike in such studies is proportionally significantly greater than seen in traditional peer-reviewed literature. 29, 30 Even more nimble social media tools have proven incredibly effective at dissemination and have the advantage of being obtained from a trusted source (or at least a source where trust can largely be established). Their ability to disseminate rapidly experience from the frontline has proven invaluable in allowing clinicians to compose a picture of what COVID 'looks like' and what impact might be anticipated for their institutions. One tweet, chosen somewhat randomly from those we have received, has garnered a level of engagement (10 300 retweets, 30 400 'likes') 31 that would make a Nobel Laureate blush. This does not even include the innumerable occasions where this tweet was communicated between colleagues through email, text or WhatsApp.

One curious side-phenomenon is that previously esoteric and little-known studies have provided a significant basis for guideline development. Two studies regarding aerosol generation during non-invasive ventilation from Hui et al. 21, 32 had garnered a total of 18 citations prior to January 2020 but, in the 3 months since, have been cited 57 times, 33, 34 including within WHO guidance 35 and other consensus/position papers. 36 The constantly changing landscape has provided challenges but highlights the ability of our healthcare systems to adapt and develop new models of care. An opportunity exists to transform many aspects of healthcare for the longer term once the pandemic phase of COVID-19 has passed, acknowledging that the threat of focal outbreaks seeding an epidemic second wave in almost completely susceptible populations means that a time when the pandemic phase is truly past for New Zealand and Australia is an unknown point in the future.

At the patient level, we rely heavily on seeing patients face to face. The response to COVID-19 has demonstrated that telehealth appointments, remote monitoring and visiting patients (in their place of residence) are feasible and often preferable for many patients. 5 There are marked efficiencies for both healthcare workers and patients minimising travel and waiting times at hospital clinics, as well as the ability to remain at work or at home. Evaluating the uptake of telehealth and other ambulatory services will be influential in the design of a post-pandemic health service.

This pandemic response has highlighted critical issues to address, including the ability to expand rapidly inpatient capacity, access to PPE and stockpiles and challenges beyond the health system, including viable and scalable local manufacturing and the ability to be selfsufficient in an era of globalisation. Governments and health officials must also plan for future pandemics and learn from countries that have responded well. In doing so, we have the opportunity to expand our public health support networks, hospital infrastructure and training.

Coronaviruses with pandemic potential have emerged three times in the past 18 years -SARS (2002 18 years -SARS ( -2003 , Middle East Respiratory Syndrome (MERS) (2012) and now COVID-19. 37 Following the initial SARS outbreak in 2003, both Singapore and Taiwan developed national command frameworks to respond to future pandemics. 38, 39 As a result, Singapore's initial response to COVID-19 was rapid, successful and widely praised. However, subsequently, significant outbreaks in the migrant worker population in Singapore provide a cautionary tale for Australia and New Zealand. 40 Despite our initial success in controlling the spread SARS-CoV-2, we must identify, screen and care for vulnerable and marginalised populations that do not traditionally seek medical care. This includes the homeless, people who inject drugs, international students and migrant workers.

Over the coming months, we will have easing of restrictions across Australia and New Zealand, and it is likely we will see the emergence of localised outbreaks of COVID-19, necessitating extensive testing and potential reintroduction of restrictions. We must be vigilant to prevent a 'second wave' of the pandemic in our largely non-immune population.

We have plenty to learn as we navigate these shifting waters. We are also fortunate now to have time to develop constructive and permanent reforms in our health system to improve the health of our populations well after the threat of COVID-19 has ebbed. As we embrace these opportunities for domestic reform, we must also engage with our colleagues around the world to ensure that the next emergent virus with pandemic potential is met by a connected and prepared clinical and public health community. Support of key global networks and agencies, such as the WHO, remains critical as we mobilise against a shared threat. The national responses of New Zealand and Australia have emphasised the importance of decisive coordinated action and working in partnership to face major threats. We should strengthen our resolve, contribute more resources (financial and human) to international partners involved in the fight against COVID-19 and set an example as good global citizens in the face of shared threats. Once the pandemic phase of COVID-19 is passed, lessons learned and opportunities missed should rightly be examined and challenged. Now is not that time.

Critical supply shortages -the need for ventilators and personal protective equipment during the Covid-19 pandemic

Rapidly converting to "virtual practices": outpatient care in the era of Covid-19

COVID-19 and Australian General Practice -Insights Paper No. 3: a preliminary analysis of changes due to telehealth use: Outcome Health

Modelling the impact of COVID-19 in Australia to inform transmission reducing measures and health system preparedness. Melbourne: The Peter Doherty Institute for Infection and Immunity

Potential Health Impacts from the COVID-19 Pandemic for New Zealand if Eradication Fails: Report to the NZ Ministry of Health

COVID-19) Situation Report -88. Geneva: World Health Organization

Tracking COVID-19 excess deaths across countries

Coronavirus clue? Most cases aboard U.S. aircraft carrier are symptom-free

Universal screening for SARS-CoV-2 in women admitted for delivery

CDC reviewing 'stunning' universal testing results from Boston homeless shelter

Spread of SARS-CoV-2 in the Icelandic population

A Presence of SARS-Coronavirus-2 in sewage

Covid-19 message from Milan: be ahead of the curve. You cannot wait. NEJM Catal

COVID-19 OR COVID OR SARS-CoV-2

Clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow up: a pilot observational study

Heart risk concerns mount around use of chloroquine and hydroxychloroquine for Covid-19 treatment

Exhaled air dispersion during high-flow nasal cannula therapy versus CPAP via different masks

Comparison of high-flow nasal cannula versus oxygen face mask for environmental bacterial contamination in critically ill pneumonia patients: a randomized controlled crossover trial

COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up

ICS Guidance for Prone Positioning of the Conscious COVID Patient

Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial

Fauci says remdesivir reduces recovery time for coronavirus patients

Coronavirus tests science's need for speed limits

Preprint archive search: covid

MedRxiv preprint server

Exhaled air dispersion during noninvasive ventilation via helmets and a total facemask

Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease is Suspected: Interim Guidance

Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19)

Covid-19 -navigating the uncharted

From SARS to COVID-19: the Singapore journey

Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing

Singapore was a Coronavirus success story -until an outbreak showed how vulnerable workers can fall through the cracks

Australia Key words deteriorating patient, rapid response system, observation and response chart

We sought the role of the hospital inpatient observation and response chart (ORC) in reducing adverse outcomes. We sourced articles written in English and published in PubMed. Track, trigger and response systems can be tiered and use single parameter or aggregate scoring systems, the latter being more prone to error. The documentation and detection of abnormal vital signs can be affected by choice of trigger and response and by ORC design. There is considerable variation in the design of ORC and of rapid response systems (RRS) in general, and this impairs assessment of their efficacy. A high rate of modification of pre-determined triggers and poor sensitivity of measured outcomes further compromise systematic review. The best-designed ORC and RRS should optimise the frequency of response team activation to minimise adverse patient outcomes without excess resource utilisation. The role and the risks of electronic data recording are underexplored. Detecting and responding to deteriorating patients relies on accurate and clear documentation of vital signs. ORC design and staff education on ORC implementation and usage are integral to minimising ALF and optimising patient outcomes. Standardisation of the design of both the ORC and the hospital RRS are overdue. Preventable in-hospital adverse outcomes include cardiac arrest, death and unanticipated intensive care unit (ICU) admission. All are often preceded by acute clinical deterioration, which itself may go unrecognised, undiagnosed and untreated without escalation of care. 1 Adverse outcomes can be mitigated or prevented by timely detection and intervention. 2,3The taking and recording of inpatient vital signs is a long-standing and ubiquitous ward activity. A system that facilitates the monitoring and documentation of patients' vital signs ('track'), the recognition of vital signs indicative of patients at risk of adverse outcomes ('trigger'), and timely escalation of care in response to triggers ('response') may mitigate adverse outcomes. Such a system, often referred to as rapid response systems (RRS), requires monitoring of vital signs indicative