'Pleural triage' facilitates effective Management of a pleural service in the covid-19 era

ABSTRACT

Aims The COVID-19 pandemic has created new challenges for management of pleural diseases. Pleural patients can be highly vulnerable to infection and often have conditions for which treatment cannot be safely delayed. We reviewed our pleural service to implement changes that allowed maintenance of a service whilst maximising patient and staff safety. Method Establishment of a Pleural Triage MDT meeting 48 hrs prior to pleural clinic to review all referrals and stream patients to i) telephone consultation only, ii) remote CXR (24 hrs pre-clinic) plus telephone consultation iii) face-to-face (F2F) review or iv) direct to a procedure. We reviewed case numbers post lockdown for March-August 2020 and compared to 2019. Results During the COVID pandemic outpatient pleural management was implemented where possible, including adaptation of our ambulatory pneumothorax pathway to comply with COVID-19 recommendations. March-August 2019 there were 293 F2F pleural consultations. March-August 2020 there were 408 consultations [103 telephone only, 168 remote CXR + telephone consult (11 declined) and 123 F2F (3 declined)]. The 14 declines had telephone consults only. Previously all these patients would have been F2F. COVID-19 symptom screening occurred if attending for CXR/F2F. F2F consults were held in designated outpatient areas with access to CXR and procedure rooms, with timings to maintain social distancing. Where required, definitive pleural intervention was undertaken on the same visit. Direct-to-procedure pathways for thoracoscopy or IPC were implemented with COVID-testing 48 hrs prior. Patients with malignant effusions were counselled on management options and uptake of day-case IPC increased [March-August 2020 vs 2019 IPC = 44 vs 35] compared to elective admission for drain and talc pleurodesis. During the April 2020 COVID peak there were 12 admissions for chest drain vs 50 in April 2019. The pleural/cancer themed ward was designated a COVID-negative area for inpatients. Conclusion In the ever-changing situation of a global pandemic it is possible to successfully implement changes to maintain and enhance the safety and efficiency of pleural services, with selected changes likely to remain post-pandemic. Further evaluation of these changes over time could help to shape the future of pleural medicine.