ABSTRACT
BackgroundTelemedicine is increasingly used internationally to provide clinical services when patient and clinician are not in the same room. In anticipation of limited physical capacity to meet patient activity within our Paediatric Emergency Department (PED) during the Covid-19 pandemic, we developed a video-consultation urgent care model. We describe the process developed, results and lessons learned from a proof of concept trial.ObjectivesAs an innovative model for the UK we sought to test feasibility, safety and acceptability for clinicians, patients and carers at a type 1 PED.MethodsOur model was developed by our clinical, IM&T and Innovation teams following workshops with colleagues delivering similar models internationally. The trial was conducted over 4 weeks on non-consecutive days based on the availability of trial clinicians who were senior PEM-trained clinicians. Patients who did not require immediate resuscitation based on our usual nurse eyeball assessment were invited to participate in a video-consultation trial. Carers who volunteered were registered on the hospital Patient Administration System (PAS) and received an automated text message link to join a video-consultation on NHS Attend Anywhere using their own device. The clinician was based remotely on a video-equipped laptop or desktop. The patient did not have any triage or physiological observations measured prior to video-consult. A range of outcomes was available to clinician and carer as described in the Results. Clinicians documented directly into the PAS.Clinician and patient-carer feedback was solicited at the end of consultations.Results31 patients were seen. Age range 1 month – 15 years;12 female: 19 male.Presenting complaints included rash, headache – both new and chronic, cough, sore throat, difficulty breathing, diarrhoea or vomiting, eye conditions, allergy, suspected UTI, musculoskeletal complaints and injuries.25% (8 patients) were brought to ED for further action: 4 patients for x-ray or physical examination;2 for urine dipstick and 2 to issue a prescription.1 patient (3.2%) returned within 7 days with same problem with overnight admission for observation only. This is comparable to our usual re-attender rate. Clinical assessment and advice during video consult was reviewed and deemed appropriate.There were no other unplanned returns in the 2 weeks following initial attendance.Feedback suggests video-consultation is acceptable to carers, especially when waiting times are long.Conclusions75% of patients were safely managed with verbal advice only. Of those that needed to attend the PED for investigation or prescription, local options could be implemented to reduce need to travel.Virtual urgent care is feasible, safe and acceptable for clinicians and carers of infants, children and young people. Based on the range of presenting complaints seen during the trial, a significant proportion of attendances to our type 1 PED could be effectively managed through this model.
ABSTRACT
A subset of patients with COVID-19 become critically ill, suffering from severe respiratory problems and also increased rates of thrombosis. The causes of thrombosis in severely ill COVID-19 patients are still emerging, but the coincidence of critical illness with the timing of the onset of adaptive immunity could implicate an excessive immune response. We hypothesised that platelets might be susceptible to activation by anti-SARS-CoV-2 antibodies and contribute to thrombosis. We found that immune complexes containing recombinant SARS-CoV-2 spike protein and anti-spike IgG enhanced platelet-mediated thrombosis on von Willebrand Factor in vitro, but only when the glycosylation state of the Fc domain was modified to correspond with the aberrant glycosylation previously identified in patients with severe COVID-19. Furthermore, we found that activation was dependent on FcyRIIA and we provide in vitro evidence that this pathogenic platelet activation can be counteracted by therapeutic small molecules R406 (fostamatinib) and ibrutinib that inhibit tyrosine kinases syk and btk respectively or by the P2Y12 antagonist cangrelor.