Telehealth is a gateway to how healthcare will be delivered in the future and has enabled the transition to consumer-centric care paradigms. Because of the need to create social distancing in a safe environment and the introduction of reimbursement for virtual visits, telehealth has become an important communication and treatment tool during the COVID-19 pandemic.

Telehealth involves the use of communication systems and networks to enable either a synchronous or asynchronous session between the patient and the provider. A virtual care solution usually involves a much broader scope of clinical and work-flow processes, remote monitoring, and several providers over time. Although there is not a universal agreement, telemedicine generally refers to the remote delivery of medical or clinical services, while telehealth is a larger platform that includes telemedicine along with remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services. Virtual care extends the options to manage the patient well beyond a specific event.

Figure 1 shows the benefits of Telehealth to different stakeholders in the healthcare industry.

Technology has become mainstream with more than 50 per cent of hospitals in the UAE using various IoT-based solutions; approximately 90 per cent of doctors use smartphones and medical apps to provide healthcare. The UAE government supports the establishment of a telematics infrastructure and the advancement of telemedicine applications with the aim of country-wide provision of healthcare services in the long term through various initiatives. The UAE has several companies offering teleconsultations from independent telemedicine companies to health insurers. Global and regional private players offering telehealth services have opted to take the B2B and B2G route.

Access to telehealth has broken a major barrier of adoption with an increase in reimbursement due to COVID-19 outbreak. Mandatory health insurance and rise in penetration of private health insurance players covering telemedicine services are driving the adoption. However, the lack of federal guidelines in the UAE act as a barrier for the telehealth players to expand their services to all the emirates due to different regulatory requirements. Thus, the concentration is seen in major cities of Dubai and Abu Dhabi.

In March 2020, UAE Ministry of Health and Prevention (MOHAP) had collaborated with Du, a telecom company, for setting up the first virtual hospital in the middle east for providing remote care to patients. In July 2020, UAE's Mulk Healthcare launched the first "e-hospital" as a downloadable app for providing global medical services.

In May 2020, UAE's MoHAP upgraded all its hospitals' outpatients' clinics to virtual. Many leading public and private hospitals in the UAE established their virtual clinics such as Aster DM Virtual Outpatient Department (OPD) and TruDoc 24x7's Health & Wellness Virtual Clinic.

Because the UAE boasts of a population which is younger, in fact, 85 per cent of the total population is below the age of 45 years, the use of mobile technology, laptops and tablets have over 90 per cent penetration in the region, which has made it very easy for the UAE to implement telehealth. The utilisation of teleconsultations has increased multi-fold during COVID-19. For example, Al Jalila Children's Speciality Hospital in the UAE did 75 per cent of their consultations through the telehealth service during the first three months of the pandemic.

The UAE’s major telemedicine player Abu Dhabi Telemedicine Centre's services provide access to Medgate trained physicians to approx. 1.2 million Daman Enhanced and Thiqa cardholders in the country. There are many private players providing telehealth services such as Health at Hand, TruDoc 24x7 and InstaPract.

Market size and revenues

The Telehealth market in UAE is forecast to reach over US$536.5 million by 2025, expanding at a CAGR of 25 per cent from 2020 to 2025. The highest growing segment within telehealth will be virtual visit market, which is expected to grow from US$73.5 million in 2020 to US$280.7 million by 2025, representing a CAGR of 30.7 per cent. Virtual visit providers are gaining traction as employer health plans have started offering these services as a member benefit. The health plans generally fund these services on a per-member-per-month basis.

The total UAE mHealth market is forecast to grow from US$86.8 million in 2020 to US$222.4 million by 2025., representing a healthy CAGR of 20.7 per cent. mHealth growth will be stimulated by increased utilisation of smartphones, tablets, wearables, and medical-grade apps. Government initiatives for radical change in healthcare is seeing a shift in focus from treatment to prevention through remote preventive care, virtual hospitals, and other technologies.

The overall remote patient monitoring (RPM) market is forecast to grow from US$15.5 million in 2020 to reach US$37.1 million by 2025, representing a CAGR of 16.7 per cent. The RPM market in UAE remains unexplored due to the higher percentage of young population, and with 90 per cent of the population being expats who settle back to their original countries at retirement age. The demand for RPM devices will see traction due to the upcoming virtual hospital and clinics.

Growth opportunities

Virtual clinics and hospitals to strengthen Telehealth system for efficient remote care

When building a digital front door, too many organisations are simply replacing a patient's analogue experience—like calling to schedule an appointment—with a digital one. But digital replacement is not digital transformation. Patient experience and patient engagement is becoming critical and hence the work in the future will be to create an infrastructure and platforms that allow for seamless and holistic care across different care settings.

Reenita Das

Results of a study by researchers from the Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU) in the UAE show that the diagnostic accuracy of saliva for viral detection of COVID-19 has a similar sensitivity to the currently used nasopharyngeal swab.

The research team from MBRU, who were joined by teams from Dubai Health Authority (DHA); Unilabs; Cleveland Clinic Abu Dhabi; New York University Abu Dhabi (NYUAD); and the National Reference Laboratory, took saliva and nasal swabs from 401 adults present for COVID-19 screening at Al Khawaneej Health Center, 50 per cent of whom were asymptomatic. The samples were tested for detection of SARS-CoV-2 virus at Unilabs Dubai.

The findings of the study showed that the saliva can be used for viral detection with 70 per cent sensitivity and 95 per cent specificity, proving to be just as effective as the nasal swab.

Use of saliva could exponentially widen the testing network for COVID-19, simplify community testing, and reduce the risk to frontline healthcare professionals. The saliva specimen was self-collected into sterile containers by the patients without requiring the presence of a healthcare professional. It did not require the use of preservative transport media while in transit to the laboratory.

Dr Abiola Senok, Lead Investigator of the study and Professor of Microbiology and Infectious Diseases, College of Medicine, MBRU, said: “The scientific community is working hard conducting research on ways to facilitate making COVID-19 testing easier and more readily accessible. Using saliva is a step towards making it easier as samples can be self-collected by patients.

“We can envisage a future where samples can be self-collected even in the patients’ homes and sent to the laboratory. However, for patients to do the test at home themselves, further research and development for point-of-care testing kits using saliva are needed.”

The study and its findings will be published in the peer-reviewed journal Infection and Drug Resistance.

The following article is available in full, including figures and data, on Cleveland Clinic Journal of Medicine June 2020 as part of its COVID-19 Curbside Consults.

Hospital-to-hospital transportation of patients in the COVID-19 era presents unique challenges to ensuring the safety of both patients and health care providers. Crucial factors to address include having adequate supplies of protective equipment and ensuring their appropriate use, defining patient care procedures during transport, and decontamination post-transport. Transport vehicles need to have adequate physical space, an isolated driver compartment, NS HEPA filtration of air. Having a standardized intake process can help identify patients who would benefit from transport to another facility.

Introduction

Transport of critically ill patients with COVID-19 presents a unique challenge given the risk of transmission for the disease. Most often, patients are transferred from one hospital to another for specialized services or a higher level of care.

Communication and preplanning are key elements to ensure safe transport of these patients and to minimize risk of disease transmission to the transport personnel. Items to consider at intake include necessity of transport, ideal destination facility and unit type, and duration of transport or out-of-hospital time. Subsequent planning includes appropriate use and type of protective equipment, patient care procedures during transport, and decontamination post-transport.

Cleveland Clinic Transport Plan

The Cleveland Clinic critical care transport team (CCT) partnered with the Cleveland Clinic Health System, our vehicle vendors, and the Ohio Department of Health to develop a comprehensive transport management plan for the transport of patients with confirmed or suspected COVID-19 infection. It was finished in about mid-March 2020.

Crucial factors in the plan for the safety of patients and transport personnel include maintaining adequate types and volumes of personal protective equipment (PPE) as well as ensuring that all staff have the appropriate training in regards to PPE management, including donning and doffing. Also needed are patient barriers and device adjuncts based on the patient’s clinical situation. Examples include face masks for nonintubated patients, adding HEPA filters at the ventilator exhalation valve or expiratory port of manual resuscitation devices (such as bag-valve-mask devices), and avoiding any disconnects of the ventilator circuit.

Policies and training modules were implemented to address PPE management and PPE recommendations based on risk in transport. For example, when transporting any patients with suspected or confirmed COVID-19, team members are required to wear a gown, gloves, goggles, and surgical mask. For patients at high risk for aerosolization of infectious material (eg, intubated patients), an N95 mask is required.

Patient transport factors to consider

The environment of the transport vehicle is also an important consideration. This includes having adequate physical space, isolating the driver (or pilot) compartment, providing HEPA filtration of recycled air, ensuring proper PPE, adequate cleaning of the space, and training of all transport personnel.4 Additionally, contingency plans should be in place for patient deterioration or medical emergencies during transport, including having additional PPE available for all transport personnel. Efforts should be made to ensure patient stability prior to transport, with particular emphasis on securing the airway. Having controlled intubation in a closed room will result in less aerosolization and, thus, less risk to caregivers versus intubation in a transport vehicle.

Collaboration between the Cleveland Clinic CCT and Cleveland Clinic Institutes and vehicle vendor partners has been crucial to ensuring seamless and safe transport of patients during the COVID-19 pandemic. The CCT provides care in a variety of environments ranging from the emergency department and intensive care unit transfers to prehospital requests with outside emergency management service (EMS) agencies.

Establishing a process for transfers

To standardize the intake process and ensure protection of all health care providers involved with a patient transfer, the CCT clinical coordinator routinely screens all transfer patients with a short COVID-19 screening questionnaire at the time of transfer request. As it is often not possible to obtain substantial patient-specific details for EMS or other out-of-hospital transfers prior to on-scene arrival, and due to the urgent and unpredictable environment while on scene, all of these patients are treated as potential COVID-19 cases and managed appropriately.

Additional modifications to the hospital transfer and CCT inter-facility transport request process have been implemented due to the risks of COVID-19 transmission. Cleveland Clinic has an external hospital transfer workflow protocol for patients with COVID-19 to help identify which patients may benefit from treatment or therapy otherwise unavailable at the referring facility (including referring capacity issues).

Read the full article.

The following article is available in full, including figures and data, on Cleveland Clinic Journal of Medicine June 2020 as part of its COVID-19 Curbside Consults.

The operating room environment is very dynamic with many unique challenges for anesthesia teams caring for patients with confirmed or suspected COVID-19. Specific recommendations by national organizations and institution specific step-by-step guidelines and education materials are required to maintain safety for both patients and caregivers perioperatively, with transport, and medication management.

Introduction

Anesthesiology caregivers face new challenges in perioperative areas and the operating room (OR) in caring for patients with COVID-19 and patients under investigation (PUI) for COVID-19.

In addition to recommendations issued by national organizations such as the Centers for Disease Control and Prevention, the Anesthesia Patient Safety Foundation and the American Society of Anesthesiology, the Anesthesiology Institute at Cleveland Clinic has created step-by-step guidelines for patients with COVID-19 and PUI for COVID-19 requiring surgery or procedures with anesthesia. Key considerations are shared below.

Preoperative

Before the patient arrives in the OR, the entire OR team should perform a huddle to discuss the logistics of the patient transportation, procedure, and disposition.

Monitored anesthesia care or regional anesthesia should be avoided and general anesthesia should be considered for patients with confirmed or suspected COVID-19.

All equipment and medication need to be prepared in advance, so patients can be brought directly to the OR and induced (if not intubated) without delay. Patients who are in the intensive care unit (ICU), but not intubated should preferably be intubated in the ICU by the anesthesia team before transport to the OR.

In preparation for intubation, anesthesia team members should properly don personal protective equipment (PPE) using the buddy system. There are specific considerations for use of PPE based on American Society of Anesthesiology recommendations such as double gloving for intubation.

The member of the anesthesia team with the most experience intubating patients should perform the intubation and the number of caregivers near the patient should be minimized. Measures to decrease the chance of aerosolization and contamination should be implemented (ie, barrier device over the patient’s head, no bag-mask ventilation, rapid sequence induction, use of video-laryngoscopy).

Proceeding with rapid sequence induction is recommended, try to avoid Fentanyl, to prevent coughing consider the use of Esmolol or Lidocaine or both. Once the patient is unconscious, the patient should be covered with a plastic transparent drape/barrier device, while maintaining intubating equipment and suction visible underneath it. Bag-mask ventilation of the patient should be avoided. However if, manual ventilation is needed, small tidal volumes with two-handed mask ventilation to ensure good mask seal should be utilized.

Video laryngoscope for intubation is preferred. Once the patient is intubated, the endotracheal tube cuff needs to be inflated. Connect to heat and moisture exchanger filter and anesthesia circuit, initiate ventilation. Check for presence of end-tidal carbon dioxide (ETCO2) and bilateral chest rise. With all the PPE in place, auscultating the patient may not be the best way to confirm proper position of the endotracheal tube. Checking for endotracheal tube depth, chest rise, and ETCO2 is a better choice.

Once intubation is successful, the patient should be adequately sedated (with sedatives and muscle relaxant) and stable for transport. Providers who participated in intubation should change below-the-neck PPE using the buddy system.

Intraoperative

Patients either from the ICU or other locations should be brought directly into the OR and universal protocol for safety check should be followed.

If the patient is on supplemental oxygen, oxygen flow should be maintained at minimum necessary to decrease the potential for aerosol generation. They should keep their protective isolation mask on right up to the induction of anesthesia, and only uncover for the anesthesia team’s airway exam. Perform a meticulous airway assessment as this may be your first opportunity to assess the patient’s uncovered airway.

OR preparedness is fundamental. Make sure to have a video laryngoscope with transparent plastic cover, empty biohazard plastic bags available to dispose of used blades when contaminated, styletted endotracheal tubes, precut tape straps or tube strap to secure the endotracheal tube once in place. Additionally, have available airway backup devices like a laryngeal mask airway, a disposable laryngoscope, a bougie, oral and nasopharyngeal airways.

It is fundamental that the heat and moisture exchanger filter is in place at the distal end of the anesthesia circuit Y-piece, with an ETCO2 monitor in the protected side of the circuit, this will help filter the patient’s exhaled breaths.

Postoperative

As you are getting ready for induction, place all medications on a designated table including emergency medications. Personnel nonessential to induction should leave the room.

Before you proceed with induction, make sure you put on a second pair of gloves. If inducing a nonintubated patient in the OR, you should follow above mentioned induction procedures. Resheath the laryngoscope immediately postintubation. Seal all used airway equipment in a double zip-locked plastic bag. Once settled, remove your gloves, perform hand hygiene, and put on a single new pair of gloves.

Remember to place the ventilator on standby whenever a circuit disconnection is required, such as tube repositioning, and to restart mechanical ventilation only after the circuit has been reconnected.

Any contact with outside personnel for supplies, blood products, and samples should be minimized. It is advised to have at least 1 dedicated runner to assist the anesthesia team.

Read the full article.

Allergies are on the rise worldwide, especially in children. Since allergic reactions to food can in some cases induce severe or even fatal reactions, it is imperative to identify the exact triggers of the allergy symptoms. Specific IgE (sIgE) multiparameter tests are particularly beneficial in allergy diagnostics, as they yield detailed sensitisation profiles for minimal effort and from only a small blood sample. Molecular allergy diagnostics based on defined components of allergen sources such as milk, egg or peanut provide precise identification of the allergy-causing proteins, which facilitates risk assessment and dietary planning, thus improving patient management. In cases of reactions to peanut, molecular allergy diagnostics enable the critical differentiation between true peanut allergy and pollen-associated cross-reactions.

Paediatric food allergies

Food allergies in children cause a variety of symptoms affecting different organ systems, such as the skin, gastrointestinal tract and cardiovascular system. They are, moreover, the most common cause of anaphylaxis. Up to 20 per cent of children are suspected to have a food allergy, but only 4 per cent of cases are actually confirmed by means of an oral provocation test. The most common triggers of food allergy are cow’s milk, chicken egg, peanut, nuts, soy, wheat, fish and shellfish.

The diagnostic procedure in suspected paediatric food allergies is based on anamnesis, followed by in vitro determination of specific IgE. Subsequently, a monitored oral provocation test is performed to confirm the agreement between the laboratory results and the clinical symptoms. Skin prick tests are no longer performed in children.

Component-based diagnostics

Specific IgE against different foods can be determined using test systems based on food extracts or defined components thereof. Extract-based tests are useful for broad screening for allergies against many different foods. Component-based tests provide in-depth analysis of the allergy-causing proteins and allow differentiation of reactions against high-risk components and low-risk components. This enables a more precise evaluation of the risk of severe reactions and the potential outcome of a provocation test, as well as the likelihood of tolerance development. It also aids dietary counselling. For example, patients who react to heat-labile components may tolerate cooked or processed forms of the food. The structural similarity of the allergy-triggering components within protein families can also give an indication of possible cross-reactions to other foods and/or tree or grass pollens.

Milk components 

Allergy to milk from cows (Bos domesticus) is the most frequent food allergy in infants and toddlers, occurring with a prevalence of 2 per cent. Symptoms include atopic dermatitis, urticaria, gastrointestinal complaints, asthma and anaphylaxis. Spontaneous tolerance develops in around 80 per cent of cases between the ages of two and five years. The main allergenic proteins in milk are casein (Bos d 8), alpha-lactalbumin (Bos d 4), beta-lactoglobulin (Bos d 5), lactoferrin (Bos d LTF) and serum albumin (Bos d 6).

Casein is a major allergen and is heat-stable. Therefore, patients who react to casein must avoid all forms of milk and dairy products, both raw and cooked. High titers of specific IgE against casein indicate a persisting sensitisation. Cross-reactions with goat’s and sheep’s milk are possible in these cases.

The other four components are heat-labile. Thus, patients who react to these proteins may tolerate some forms of cow’s milk, for example in cooked or baked foods. Reactions to alpha-lactalbumin indicate possible tolerance development. Serum albumin is present in beef and is also used in some cell-based immunotherapies, so reactions against these sources are also possible in sensitised individuals.

Egg components

Sensitisation to eggs from chicken (Gallus domesticus) is the second most common food allergy in infants and toddlers, occurring with a prevalence of 1.5 to 2 per cent. Symptoms are similar to those of milk allergy and there is a 70 per cent likelihood of spontaneous tolerance development between the ages of two and five. The most relevant allergen components are contained in the egg white, but avoidance of the complete egg is recommended due to the risk of cross-contamination between the white and the yolk. Allergenic proteins include ovomucoid (Gal d 1), ovalbumin (Gal d 2), conalbumin (Gal d 3) and lysozyme (Gal d 4).

Ovomucoid has a high allergenic potential and is heat-stable. Patients reacting to this protein must avoid all products containing raw or cooked eggs. High titers of specific IgE against ovomucoid indicate a persisting sensitisation.

The other three components are heat-labile. Patients with reactions against these proteins may, therefore, tolerate sufficiently heated egg. Ovalbumin is a component of certain vaccines, and lysozyme is contained in some pharmaceutical products as a preservative agent, so sensitised persons may also react to these medications.

Peanut components

Allergy to peanut (Arachis hypogea) is the most frequent cause of food-mediated anaphylaxis and occurs with a prevalence of 1 to 3 per cent. The clinical symptoms depend on the sensitisation pattern to the different peanut proteins. In most cases peanut allergy persists lifelong.

Reactions to the storage proteins Ara h 1, Ara h 2, Ara h 3, Ara h 6 and Ara h 7 indicate a primary peanut allergy. These proteins are heat-stable and resistant to digestion. Patients who react to these components have a high risk of severe reactions and must strictly avoid even minimal amounts of peanut. Moreover, reactions to multiple components are associated with more severe allergies.

Specific IgE against the 2S albumins Ara h 2 and Ara h 6 is most predictive for clinical peanut allergy. A further 2S albumin, Ara h 7 (isoform Ara h 7.0201), represents a newly characterised major allergen containing unique IgE epitopes as well as epitopes that are shared with Ara h 2 and Ara h 6. Although co-sensitisations to Ara h 2, h 6 and h 7 are most common, monosensitisations have also been observed in some individuals. Therefore, analysis of reactions to all three 2S albumins is recommended to avoid missing patients.

The lipid transfer protein (Ara h 9) is also heat-stable. Reactions to this protein range from mild to severe. Allergies against this protein are common in Southern Europe.

Reactions to the PR 10 protein (Ara h 8), which is homologous to Bet v 1 from birch pollen, indicate a secondary peanut allergy. This is associated with milder symptoms (oral allergy syndrome), and strict avoidance of peanut is not necessary. Similarly, reactions to the panallergen profilin (Ara h 5) are also associated with mild symptoms.

Multiparameter specific IgE detection

In suspected cases of food allergies in young children a parallel analysis of the most important allergens is recommended to obtain comprehensive results in the shortest time.

Multiparameter tests, moreover, require only small amounts of serum (100 µl for 14 allergen components) compared to single-parameter testing, which is an advantage, especially in paediatric diagnostics.

Specific IgE in the most common childhood allergies can be detected in parallel using EUROLINE DPA-Dx (defined partial allergen diagnostics) profiles (Figure 1). The EUROLINE DPA-Dx Pediatrics 1 and 2 profiles combine components from milk, egg and peanut in one test. The milk components comprise nBos d 4, d 5, d 6, d 8 and d LTF and the egg components nGal d 1, d 2, d 3 and d 4. For analysis of reactions to peanut, the EUROLINE DPA-Dx Pediatrics 1 profile provides the components rAra h 1, h 2, h 3, h 9, which represent the most frequent sensitisation parameters.

The EUROLINE DPA-Dx Pediatrics 2 profile includes seven peanut components, namely rAra h 1, h 2, h 3, h 5, h 6, h 7 and h 9, thus enabling a more refined analysis encompassing both common and rare parameters. Individual profiles for characterising peanut or milk allergies are also available.

The EUROLINE DPA-Dx assays are easy to perform, delivering results in less than three hours. The test strips can be processed manually or automatically on instruments such as the EUROBlotOne. Results are evaluated fully automatically according to the EAST (enzyme allergosorbent test) class system using the EUROLineScan software.

Figure 1

 

Conclusions

Component-resolved test systems represent the state-of-the-art in allergy diagnostics. The in-depth sensitisation profiles aid risk assessment and dietary counselling, as well as decision making on the necessity of carrying an emergency kit.

Paediatric patients benefit in particular from multiparameter analyses, which require only very small amounts of serum and deliver results quickly. As further components of allergenic foods become better characterised, the spectrum and relevance of molecular allergy tests will increase further. 

The magnitude of IV medication error even under ‘normal’ conditions is large. Smart Pumps with Dose Error Reduction Systems (DERS) reduce this risk with the application of hard limits for dose/rate, concentration, and duration of continuous and intermittent medications. The COVID-disease pandemic’s requirement for strict isolation of large numbers of patients has made maintaining the Rights of IV medication administration: patient, medication, dose, route, timing, and documentation, increasingly difficult.

There is also the Right Maintenance of continuous critical short half-life infusions (CSHLI) such as noradrenaline or glyceryl trinitrate. Of course, with critically ill COVID-disease patients in the ICU, any prolonged interruption of CSHLI infusion delivery could be fatal. Monitoring of these infusions is vital for isolated ICU patients, as nursing staff must respond promptly to any infusion alarm, and certainly within the plasma half-life of these medications if serious cardiovascular events are to be avoided. Some typical half-lives of CSHLI are given in Table 1.

A three-year retrospective study in The University Hospital of Antwerp, Belgium identified that centralised monitoring of isolated neonates in a NICU with 60 single rooms reduced nurse reaction times to CSHLI alarms by 31 per cent and reduced the total number of alarms that nurses are exposed to by 56.25 per cent. We, therefore, recommend central monitoring of all infusions delivered to isolated patients. This has an extension beyond the pandemic to immunocompromised critical patients who require protective isolation. The use of wireless pumps in single rooms that can transmit their infusion data and any alarms to a centrally based monitor is extremely valuable in this respect.

To reduce the nursing time for IV bag changes and intermittent IV medication administration spent inside rooms of SARS-CoV-2 virus-infected patients, some facilities have adopted the use of long extension lines that allow the patient’s pumps to remain outside of the isolation room. This practice does have some issues that must be considered to maintain safety, infusion continuity and accuracy. This includes considerations on how to run the IV line to the patient. Running the IV line under the door and across the room’s floor and taping and padding it to prevent tripping or dislodgment, is not ideal but does provide protection of the line and a visual warning of its presence. However, the technique may cause issues of pressure gradient changes affecting occlusion alarms, accumulation of air in the line due to the low level of the line in relation to the pump and the patient, and of rate accuracy.

Smart pumps are accurate, but long lines can, in theory, increase siphonage in the case of large-bore lines and increase downstream pressure when microbore lines are used. It is important to maintain the recommended height of the infusion bag above a large volume pump (this is usually 50 centimetres) and any unnecessary resistance in the downstream line should be reduced by keeping the extension set additions as limited as possible to achieve a safe working distance, and infusing through as large an IV catheter as possible. Priming of long extension lines can be undertaken by gravity, but it is often easier to control the prime by using the pump.

Protecting staff and other patients requires isolation of COvid-19 patients. Smart pumps with long lines can reduce trips into the patient’s room. Barcode scanning of patient ID and medication scanning for confirmation of Medication Rights reduces the number of staff potentially exposed during administration.  

Another consideration with long lines is that downstream occlusion pressure limits may need to be increased to avoid nuisance alarms, particularly at higher rates, due to higher volumes being forced through long narrow tubing. This can be done by the user at the bedside, but when we have wireless-connected smart pumps in a facility that changes to default pressure alarms, configurations can be made centrally and distributed rapidly via the network to all pumps. Smart pumps should also have an option of occlusion pressure limits that are dynamic, meaning that the flow rate automatically determines and alters the downstream occlusion pressure alarm. In this case, with long extension lines, this mode can be considered at rates above 30 ml/hr. Of course, critically ill COVID-disease patients are likely to be receiving multiple infusions through one IV access line, and if the disease causes Systemic Inflammatory Response Syndrome or there is secondary systemic sepsis, there may be an emergent need for rapid delivery of IV fluids. In this situation, a dynamic occlusion alarm is of real value, as it will reduce the number of nuisance occlusion alarms and assist with infusion continuity. Pumps with auto-pressure features which, on activation, set a margin of 30 mmHg above the patient-line pressure also allow for a rapid user response to occlusions alarms.

Independent studies on the cleaning of long-lines and their materials suggest that wiping a PVC extension set 2-3 times daily with 70 per cent isopropyl alcohol solution has minimal impact on the line’s function and performance (i.e. there will be no weakening leading to excess kinking or excessive compliance on the line). The risk of isopropyl alcohol entering the fluid pathway is negligible. It is, therefore, expected that the PVC IV extension sets would still deliver their critical function with minimal risk to clinician or patient. With repeated disinfection of PVC extension sets clinicians may note visual defects on the line’s surface and that it feels ‘tacky’. This has no impact on the line’s performance and is limited to the exterior of the line.

Administration of intermittent infusions with long lines requires that we know the priming volume for the entire length of the tubing when programming infusion rates and flush volumes. Nurses should consider priming the set with the medication rather than with normal saline or dextrose, to facilitate prompt delivery. Post-medication flushes should be given at the same rate as the medication. This is best achieved with well-constructed DERS libraries with pre-set durations of delivery for each medication and smart pumps with a ‘restore’ function for ensuring accurate rate/volume delivery of the flush.

The COVID-19 Virus Pandemic has seen ‘pop-up’ hospitals and ICUs being built rapidly. Wireless connected smart pumps are ideal for instant deployment of medication safety libraries, and for updating libraries as complex IV medication therapies change.

A large capacity DERS library with multiple profiles can allow for a specific library for critically ill COVID-disease patients, giving rapid and easy access to specific medications used to care for these patients along with specialist concentrations and higher dilution medications to be used with long-lines. The COVID-disease pandemic has also caused supply shortages in key medications, such as Fentanyl, the ability to rapidly update alternate medications in the DERS library, such as substituting Propofol 2 per cent for 1 per cent, and to deploy the new library remotely via wireless allows facilities to respond and adjust rapidly to supply challenges, and to emergent changes in treatment protocols such as the new protocol for Dexamethasone use in COVID-disease.

IV medication administration commonly requires a two-nurse check. With highly infectious isolation patients this can potentially expose two nurses to the risk of infection during patient identification. In highly developed IV infusion medication safety systems, the second nurse can be replaced by barcode medication administration (BCMA) during which the smart pump, via a bidirectional wireless communication with the patient’s electronic medication administration record (EMAR), undertakes the bedside checks of the right patient, right medication, and the right timing, and automatically documents administration in the patient’s EMAR.

Appropriate cleaning and decontamination of pumps between patients, and on a regular basis, is both a vital component of pandemic planning, as well as being central to any ‘standard’ infection control plan. Selection of infusion pumps is a factor here. There should be no difficulty to access areas that can harbour contaminant and that cannot be exposed to disinfectant material. This includes plunger grips on syringe pumps and line or cartridge loading spaces on large volume pumps. Furthermore, the pump’s body must be not be degraded by cleaning products that can fight the SARS-CoV-2 virus. New polymers released in the last few years for pump manufacture have considerably broadened the cleaning products that can be used without fear of damage to the device. If there is any doubt over the use of a cleaning product, the manufacturer’s local agent should be contacted. We have found that a review of the Material Safety Data Sheet of combination cleaning products has allowed us to reassure customers over the continued use of their chosen cleaning product. 

The care of patients in isolation stretches a facility’s physical resources but demands on resources do not stop at devices and equipment, there is also a high demand for Critical Care clinicians as ‘pop-up’ pandemic critical units are opened. Facilities have had to quickly cross-train existing staff and recruit new staff to ease the burden. Clinical facilitators are tasked with upskilling nurses who usually work non-critical care areas to care for critically ill patients. The training and education of staff is essential to maintaining patient safety. Facilities benefit from partnerships with device vendors, providing educational resources and clinical training to ensure best practices. Infusion therapy during a pandemic is multi-faceted and challenging, but patient safety does not have to be compromised even under the strictest of isolation procedures. Engaging with your infusion device vendor to seek expert advice, the application of technology and creative strategies that build on, or adapt, existing safeguarding processes and strategies are the keys to keeping both critically ill patients, and the staff caring for them, safe.

References available on request.

As we continue conversations about how individual stakeholders, organisations and policymakers can address the COVID-19 crisis, we must understand the interconnected and essential challenges it poses. Below we take a look at social trends in healthcare during the era of COVID-19.

Healthcare is a basic human need

Equal access to healthcare is a basic promise of democracy. Healthcare is part of the social fabric that binds us all as a society. It is an essential service and not discretionary like retail goods such as clothing and dining. Unfortunately, COVID-19 will acutely exasperate prior challenges to our universal needs.

The opioid and substance use disorder problems will get worse

With the economic and social damage occurring across the U.S., it will take some time to recover. This will lead to increased opioid and substance use disorder for many.

“Rising unemployment and reduced opportunities caused by the pandemic are also likely to disproportionately affect the poorest, making them more vulnerable to drug use and also to drug trafficking and cultivation in order to earn money,” according to a report published by the United Nations Office on Drugs and Crime. We clearly have seen this in prior economic downturns, including the Great Recession in 2008.

Moreover, the circumstances of the pandemic itself are not causing just increased use but increased overdosing. Monthly overdoses are up as much as 42 per cent compared to the same time last year. Disrupted supply chains have caused people to turn to new substances they are unfamiliar with, leading to a higher risk of fatal overdose.

In addition, the isolation of lockdown means other people are not around to make lifesaving interventions. These interventions are not only important during this phase, but more so during the aftermath of an economic crisis. As the economy improves, there is a chance that many people will be left out of it, making the situation worse.

Behavioural health needs are soaring

The impacts of mental health during the pandemic include, but are not limited to, negative effects of social distancing, the psychological toll of a humanitarian crisis, the fear surrounding a healthcare crisis (particularly for those who already have obsessive-compulsive disorder or other forms of anxiety), the well-documented link between economic downturn and mental health, and the multi-directional causal link between substance use disorder and mental health.

Domestic abuse issues are on the rise as well

Domestic abuse also has a documented relationship with economic downturns. Workforce gender composition shifts, which are going to be at play in the U.S., have been known to cause an uptick in domestic violence as the role of “breadwinner” is transitioned from the male to the female.

In particular, during this crisis, social distancing is, quite literally, locking victims in with their abusers and isolating them from their support system. Technology can help here, but it also poses risks of its own.

This could be the demise of the skilled nursing facility model

The U.S. has hundreds of independent retirement homes and skilled nursing facilities. These care models have been mostly one-size-fits-all with little individualisation. Even before the COVID-19 pandemic, 82 per cent of all skilled nursing facilities had infection prevention and control deficiencies cited in one or more years from 2013-2017, according to the Government Accountability Office, and 48 per cent had such a deficiency in multiple years.

With the advancement in remote patient monitoring, it is becoming increasingly possible to realistically take care of more patients in their homes, or even in much smaller groups of four to eight people who live in home-like facilities with full-time caregivers. A smaller number of people living together lessen the chance of the next pandemic ravaging skilled nursing facilities where hundreds of residents reside.

Healthcare disparities are widening

COVID-19 will, unfortunately, make housing, food, transportation, job and healthcare insecurities much worse. Minority and immigrant communities will be disproportionately affected. Without equitable healthcare to all, there will be no upward economic mobility.

As conversations around racial equity remain at the forefront of the collective consciousness right now, we must take healthcare and health outcomes into account.

Many will be affected by the stigma of COVID-19 and guilt of having had the disease

Unfortunately, as we have seen, some ethnic groups are unfairly targeted as having COVID-19 and even implicated in being complicit to it. This is intolerable and completely unacceptable. As a society, we must categorically reject the stigmatisation of anyone with COVID-19. This virus knows no boundaries.

People who survive the ordeal will most likely be ridden with guilt, especially if they have loved ones pass away. They will need social and emotional support for many years to come. Moreover, others in their community may react to them with fear or distrust.

Dr. Eric Eskioglu

Having been in healthcare for over 21 years, including being on the frontlines as a Neurosurgeon and partaking in roles as a Physician Executive, the discussion here reflects the author’s personal opinions.

A recent report by Boston Consulting Group (BCG) highlighted that current healthcare systems around the globe are struggling to be sustainable, and solutions must be considered and applied by governments to optimise healthcare spending and improve services for citizens. The report, titled ‘Curbing the Cost Curve in Health Care: Plugging the Leakage,’ stressed that, although there will be challenges along the way, the transition to a value-based healthcare system is a necessity for every system in the region.

According to the report, half of the world’s population is without access to healthcare and those fortunate enough to have access are struggling with rising costs. As an example, more than 800 million people spend at least 10 per cent of their household incomes on healthcare, while 100 million people are driven into poverty annually through out-of-pocket spending on healthcare. Rising costs, an unintended consequence of national healthcare systems, can be relentless. The report highlights practical solutions to ensure the sustainability of health systems by plugging the leakage in funding, payment, provision, and consumption of health services to maximise the share that reaches the population.

When asked about what the common leakages are in the healthcare system, Dr. Nikhil Idnani, managing director and partner, BCG, told Omnia Health Magazine: “Healthcare systems are generally built incrementally, with different stakeholders employing their own ideas on policy, technology, and interventions, resulting in a compilation of unique offerings.

“Based on our analysis of several national healthcare systems, there are leakages that are common across countries’ healthcare systems and leakage that is specific to certain countries. A common leakage across countries relates to the moral hazard where the patient consumes healthcare services while another party (the insurer/ employer/ government) pays for those services, leading to over-consumption. Another common leakage is the lack of integration and collaboration among healthcare stakeholders leading to silos that cause fragmentation and duplication of services.”

To ensure the sustainability of GCC health systems, it is essential to plug the leakage in funding, payment, provision, and consumption of health services to maximise the value that reaches the population, explained Idnani.

Dr. Nikhil Idnani

High quality, low-cost care model

A value-based healthcare (VBHC) model’s aim is to improve population health outcomes while maintaining or lowering overall costs. Value-based healthcare delivers higher-quality patient outcomes at the same or lower total cost for a given condition. It works by analysing outcomes data, identifying best-practices, and disseminating those best-practices. Fundamentally, it’s about identifying the practices that lead to the best outcomes and encourage providers to adopt those, weed out practices that do not lead to high outcomes or actually cause harm.

Moreover, it’s about paying for results rather than for activities. It helps patients know which doctors/ hospitals deliver better care at the same or lower cost, as well as which drugs, procedures, and devices would work best for them. It leads to healthcare payers reimbursing based on outcomes and pushing patients toward care delivery with better outcomes. It causes healthcare providers to compete based on achieved medical outcomes, thereby, attracting more patients, referrals, and payer support. Lastly, it makes suppliers take a more holistic approach, strategically selecting where to play and what to offer to improve outcomes.

“In developing solutions for leakages, a VBHC lens should be adopted to direct spending toward areas that add the most value to consumers,” he said. “Whatever the solution, they must be holistic and consider the entire health system rather than its individual parts, as all too often, reforms take place in silos leading to unintended consequences in other parts of the health system. For example, we change the payment model without taking into consideration the behaviour of providers or patients. Only with a holistic approach can patients derive true health value from their healthcare providers.”

Integrating healthcare systems is vital to establishing value-based healthcare systems, he added. Information sharing across facilities ensures oversight and coordination, and access to all data is essential to transparency and not hindering value through unnecessary or duplicate treatments. Governments can help resolve such issues by assuming a prominent role in managing providers, funding efficiency programmes, and offering financial incentives to encourage providers to report outcomes or mandate reporting results as part of national policy.

Business continuity measures

According to Idnani, in light of the COVID-19 pandemic, healthcare providers must safeguard patient and caregiver confidence – ensure staff safety and wellness, handle employees’ expectations, ensure clear and constant communication and mobilise staff to meet increased demand. Following this, sustained surges in demand must be accommodated for – effectively rotating staff to alleviate workforce stress, securing the supply chain for necessary resources, ensuring equipment readiness and maintenance, making sure technology is safe, resilient, and scalable to increase automation; securing liquidity and managing cash carefully and strategically due to reduced revenues and increased expenditure.

“Lastly, and most importantly, it is critical for healthcare providers to also shift mindsets to the future – to the post-COVID-19 era – and begin planning for it today so that they are resilient and sustainable, and come out of the crisis stronger,” he emphasised. “Providers must invest for the future to implement lasting change and learn from the crisis – instilling agility into operations to switch between COVID-19 and normal modes, implementing efficiency programmes to run lean, rolling out new business models such as telemedicine and remote monitoring, and investing in attractive growth opportunities. Practically speaking, the formation of a COVID-19 Response Team (CRT) is recommended for public and private sector healthcare providers in the Middle East to ensure they can navigate the ongoing difficulties and lay the foundations for a sustainable future.”

He concluded that fundamentally, healthcare systems across the world need to continue to be redesigned in light of many of the dynamics highlighted. “These changes can be imposed on a system or can be embraced by the leadership and eased in across the system. Healthcare leaders have to realise that the current model is not sustainable and has to be radically transformed.”

Recently, AstraZeneca and UK medtech start-up Gendius, which specialises in remote disease management, launched the GCC Health Innovation Hub, a culmination of digital innovation efforts to make diagnosis and treatment easier for diabetic patients. As a result of this partnership, HealthGATE – an artificial intelligence (AI)-powered platform and app to support diabetic patient care in the GCC – will be launched later this year.

The HealthGATE app will work as a gateway between healthcare professionals and patients, enabling collaboration for personalised care and the use of AI for better disease management.

Ahmed Soliman, Medical Director – GCC, AstraZeneca GCC told Omnia Health Magazine: “The GCC Health Innovation Hub is the ninth Emerging Market Health Innovation Hub set up by AstraZeneca in the International region (Emerging Markets region) to create integrated science ecosystems through local bio-hubs across the world. These Health Innovation Hubs improve local capacity for R&D to address local needs and reinforce the company’s commitment to create and strengthen partnerships across emerging biomedical clusters to accelerate innovation, increase healthcare access and improve outcomes for patients and society.”

He highlighted that one such example is the Argentina Health Innovation Hub. Launched with the signing of a collaborative agreement with the Argentinian Ministry of Science, Technology and Productive Innovation, and later endorsed by an MoU with the National Secretary of Health in August 2019, Argentina’s Health Innovation Hub aspires to develop the country’s healthcare landscape, introducing a paradigm shift in treatment and diagnosis, and elevating the direction of public policy towards precision medicine.

The core objective of the Emerging Market Health Innovation Hubs is the promotion of global cooperation to further the abilities of science and medicine to improve the lives of patients in these markets. The GCC Health Innovation Hub provides a healthcare ecosystem as it supports local government initiatives and national visions through providing both patients and healthcare practitioners (HCPs) with innovative tools to collaborate and better manage diseases, for improved patient outcomes.

“The GCC countries have ambitious but achievable, national strategies and we are pleased to support these however we can – our medicines, ongoing clinical research and support to the medical community give hope to patients across the region. I am left in no doubt that these strategic visions and plans to invest in advanced sciences, combined with our support through the GCC Health Innovation Hub, ensures a robust healthcare ecosystem in the GCC now and in the future,” stressed Soliman.

How does HealthGATE work?

With Intellin, Gendius’ application service, HealthGATE will use AI to actively monitor patients’ diabetes management and uses their clinical history to highlight their risk for developing diabetes-related complications, such as cardiovascular disease, kidney disease, amputation and blindness. Its algorithms analyse users’ health and wellbeing data to provide individually tailored, clinically validated educational content and guidance, to help people with diabetes manage their condition more effectively.

Moreover, Intellin will provide HealthGATE with the facility to enable users to track and manage their diabetes on a daily basis. The platform integrates with over 150 different diabetes monitoring devices and shares this information with HCPs via a secure dashboard. Through Intellin, HealthGATE will additionally enable participating physicians to follow up with their patients on an individual basis, with the facility to remotely monitor their diabetes.

Soliman explained: “Scheduled to go live in Q3 of this year, the HealthGATE app is a comprehensive healthcare tool for patients in GCC countries. It will enable patients to take part in online consultations, obtain e-prescriptions, and access a library of additional resources for the management of personal well-being from their smartphones: educational materials, risk monitoring and drug delivery services are all readily available, supported by provision from partnering pharmaceutical companies.”

HealthGATE builds on the success of AstraZeneca EduGATE. Launched in Saudi Arabia in March 2019, this platform proved to be an instant success with HCPs, with more than 9,500 medical professionals registering within the first few months.

“AZ EduGATE has been very successful in Saudi Arabia, providing HCPs with scientific information in an innovative way, since its launch. From product information through to educational materials, HCPs are able to access a wide range of content via either the website or mobile app, at their convenience.

“In recent months, we have hosted more online meetings and webinars, helping HCPs to network and connect in a much more collaborative way during the COVID-19 pandemic, and have seen a spike in visits to the portal from HCPs in this time.

“By providing an accessible service for sharing patient materials, medical guidelines, live streaming events, online accreditations and more, EduGATE has helped to further our ability to communicate with local physicians, creating not just engagement, but an experience,” shared Soliman.

Embracing innovation

When asked about the impact of innovation in healthcare, Soliman said that AI is constantly transforming the way healthcare is approached, enabling the creation of solutions that may have been considered impossible only a few years ago.

“While HealthGATE is a great example of AI in practice, there is no doubt that there is much more to come as a result of the proper application of AI in healthcare,” he said. “AI and robotics are key elements of National Strategies in the GCC, with the UAE and KSA leading the way in adopting and implementing the latest technologies in patient care. It is this plan and ambition that has spurred us on to launch the GCC Health Innovation Hub, as we know the region is ready to embrace newer and better technologies to continue to improve the patient experience.”

According to Soliman, the use of technology and digital innovation, from AI through to automated systems and processes are driving the healthcare ecosystem forward, with new and innovative models of patient care increasingly being implemented across disease areas.

“There is no doubt that the GCC countries are taking every possible step to ensure a robust healthcare system is in place now and in the future, moving increasingly towards curative to preventative care, with the patient at the heart of all initiatives.

“The national visions of the GCC governments have put the spotlight on healthcare, ensuring that measures are being taken to put the region at the forefront of modern healthcare. Finally, we must acknowledge the power of partnerships in the GCC – both within companies sharing the same vision and values, as well as between the private and public sector, to improve patient experience and outcomes,” he concluded.

Emirates Oncology Society and AstraZeneca announce partnership

The Emirates Oncology Society and AstraZeneca recently announced a collaboration that aims to address and improve cancer management in the UAE. With a focus on lung, ovarian and breast cancers, the initiative supports the Government’s target to reduce cancer mortality by nearly 18 per cent by 2021. Under the banner of “United Against Cancer”, the two organisations have signed an MoU to raise public understanding of the importance of early detection of cancer. They will also explore policy recommendations to increase the number of people who undergo screenings and improve the referral process and support available for those who are positively diagnosed.