ANNALS OF IBADAN POSTGRADUATE MEDICINE
The Annals of Ibadan Postgraduate Medicine (Journal of the Association of Resident Doctors, U.C.H. Chapter) is published bi-annually.
T. Ilori1,2, T.O. Salam2 , and O.E. Olalemi2
Coronavirus Disease (COVID-19) is the largest outbreak of severe acute respiratory syndrome (SARS). It was declared a pandemic by the World Health Organization (WHO) on 11 March 2019, and it has since disrupted many health systems and a threat to the fragile, unprepared health care services in LMICs. Many patients avoided the health facilities despite battling with chronic non-communicable diseases which needed medical attention. Hence, the healthcare providers had to devise means of ensuring the running of essential medical services amidst the pandemic. Scheduled patients’ appointments and medical consultations through telemedicine were adopted. A scrutiny of the adjustment in the routine medical consultations in a limited resource country like Nigeria will help to identify the strength and limitations in sustaining safe consultations even after COVID-19 pandemic.
Keywords: COVID-19, Medical consultations, Telemedicine, Outpatients clinics.
Dr. T. Ilori
Department of Family Medicine,
University College Hospital,
In December 2019, the emergence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV2) popularly called COVID-19 was reported in the province of Hubei (China). 1 The novel human coronavirus disease; COVID-19 was declared a pandemic on 11 March 2020 by World Health Organization (WHO). The highly contagious, rapidly evolving SARS-CoV-2 is a zoonotic infection linked to a seafood market in Wuhan city, China.1 Over 100 million infections in 219 countries and almost two million deaths globally has been reported since the start of the pandemic. Hence, this posed a global challenge to public health systems.
These challenges include the need to maintain routine health services and the increasing demand for care of people with the COVID-19 infection. It suffices to know that essential health services must continue to reduce both the direct mortality from the outbreak and the indirect mortality from non-communicable diseases and other treatable conditions amidst this pandemic. The World Health Organization (WHO) in its survey on the impact of COVID-19 on noncommunicable diseases (NCDs) reported a widespread disruption of health services in many countries.3 Many of the countries surveyed have partially or entirely disrupted services for the treatment of hypertension, diabetes, cancer and cardiovascular emergencies.3 Rehabilitation, a necessary adjunct treatment following recovery after a severe illness from COVID-19 services, and other chronic diseases were reported to have been disrupted in two-thirds of countries.3 In mitigating this impact and safely meeting the populace essential health needs and controlling infection risk in health facilities, different health care centres have developed protocols for prioritisation and adaptation of services. This is done by adopting the essential requirement for infection prevention and control (IPC), which are measures put in place according to guidelines of the Centre for Disease Control (CDC).4 These measures include physical distancing, hand hygiene, use of personal protective equipment, surface and environmental cleaning and regular disinfection of the health centres, particularly the frontline care sites such as the Outpatient Clinics and the Emergency Units.
The full extent of the impact of disruptions on healthcare delivery during the COVID-19 pandemic is not fully documented, however different countries have adopted innovative ways to ensure that essential services continue. The COVID-19 pandemic has influenced how patients are attended to in outpatients’ clinics, especially in resource-limited settings. At the onset of the pandemic, many healthcare providers deferred preventive visits such as routine medical screenings and elective procedures. Many patients also avoided visits to health care facilities because of the risk of exposure. However, a rebound has been noticed in recent times in patients visits to health facilities as the government in different countries ease lockdowns. Most healthcare facilities have restricted patients visits to telemedicine care visits,with routine outpatients physical consultations reduced to the barest minimum.5 There is, however, a doubling of the average daily virtual consultations.5
Telemedicine is the use of electronic and telecommunication technologies to provide medical services to patients at a distance. The pandemic has improved telemedicine, which has been reported to improve home management of some medical conditions, access to care, and reduce patients’ waiting time and stress of remote physical consultation.5 In a trauma and orthopaedic outpatient clinic in the United Kingdom, it was reported that a decision is taken to either undertake telephone consultation or physical consultations depending on the clinical needs for each patient that visits the outpatient.6 African countries were also not spared of the effect of the pandemic as WHO reported an increasing number of health workers in Africa contracting COVID-19 infection7 which is similar to what was reported by the Nigeria Centre for Disease Control (NCDC). 8
Community transmission of COVID-19 infection has been reported to be high in Southwestern Nigeria, especially Lagos, Ogun and Oyo States.8 As such, medical consultations have been tailored to mitigate infection transmission in health care facilities. Therefore, many public and private health care facilities have restricted physical consultations to only patients whose symptoms require a physical examination. Teleconsultation has been adopted as an essential means of attending to outpatients, given that the clinical history provides the most significant part of the information that leads to a diagnosis.9A study in a General Practice reported that remote consultations were not associated with any statistically significant change in visits to the emergency department or any difference in admission rates or quality of patients’ satisfaction.10 In many Clinics, screening healthcare providers for COVID19 infection before the commencement of work daily has been instituted, and workers with a high screening score are flagged and classified as a suspected case and asked to self-quarantine after undergoing a COVID-19 test. Also, all healthcare providers are encouraged to adhere to COVD-19 preventive measures.
The need for patients triaging to priorities care became apparent since the onset of COVID-19 pandemic. The most senior health personnel provide leadership as the team leader, and health care workers are stratified into teams for effective coordination and to limit exposure to infections. Different teams perform tasks such as triaging patients, physical consultations with or without physical examination, attending to priority cases, and teleconsultations. The triaging point is usually located outside the outpatient clinics in the open air, under a tent or tree shade. At the triaging point, patients are asked to wash hands and sit at a distance of one metre away from each other, wearing face masks. All patients are then screened for COVID-19 infection with the aid of a screening tool. This tool contains questions on COVID-19 symptoms, travel history, and contacts with a COVID-19 positive patient. The temperature check using an infrared thermometer is also recorded. The patients are given health talks on COVID-19, other infections and the need for self-care. Information leaflets are written in English, and the local languages and distributed to patients after the health talks. After the triaging, patients that need personal consultation are seen by clinicians in individual cubicles as soon as possible with social distancing maintained. Patients whose symptoms required physical examination and had been screened (according to the national guideline at the time) were allowed into the clinics for targetedphysical examination. Following the consultation and examination, a treatment plan is drawn up and treatment instituted. Investigations are kept to a safe minimum to reduce patients’ exposure, investigations, and interpretations communicated virtually. Self-care tips are emphasised, and patients are given helplines to call for counselling, clarifications and follow-ups. An extended appointment is given for physical interactions as most follow up visits are done via telephone consultations as much as it is medically permitted. Patients come for drugs refill, and drugs pick up with minimal physical interactions with the health personnel.