key: cord-1028664-ubhvzh5x authors: Cernei, Cristina; Shrivastava, Manu K.; Colquhoun‐Flannery, William; Winter, Stuart C. title: Timing and volume of information produced for the Otolaryngologist during the COVID‐19 pandemic in the UK: A review of the volume of online literature date: 2020-12-06 journal: Clin Otolaryngol DOI: 10.1111/coa.13669 sha: 6d966eea7eea5433ecabd25654fdec0ed74b5700 doc_id: 1028664 cord_uid: ubhvzh5x BACKGROUND: The SARS‐CoV‐2 was first reported in December 2019 in Wuhan, China and has been declared a pandemic in March 2020. COVID‐19 has caused unprecedented and lasting biopsychosocial effects worldwide. All healthcare professionals have faced life‐threatening risks by attending their daily jobs. The daily emergence of advice and guidelines was necessary to ensure the safety of patients and staff. To this effect, all elective services came to a halt to preserve hospitals’ capacity for dealing with the sickest. This retrospective, descriptive review aims to assess the volume and timing of the advice released specifically relevant to UK ENT specialists. METHODS: Two separate searches were performed. One involved online advice published in English by international, national and ENT‐specific organisations between January 1 and May 31. The date, title, source, type of advice and link to the advice were recorded in Excel. The resources were analysed per week of publication. A second separate search for peer‐reviewed publications was conducted using PubMed Central and Cochrane databases. FINDINGS: COVID‐19‐related guidance was considered, of which 175 were identified. 52/175 (29.7%) articles were published by international organisations. 56/175 (32%) were produced by national organisations, and 67/175 (38.28%) were produced by ENT specific organisations. The peak guidance production took place in the third and fourth week of March (16/03/2020‐29/03/2020) with 72/175 publications. Of these, 27/70 came from the international category, 17/70 from national bodies and 26/70 from ENT‐specific organisations. 13 863 total publications relating to COVID‐19 were found using PubMed and Cochrane search strategies; 76% were relevant to ENT. CONCLUSION: The challenges faced by ENT relate to the unprecedented, sudden and daily changes to clinical practice. Multiple bodies interpreted the guidance, giving an opportunity for confusion and delay in treatments for patients. Implementing a system with clear lines of communication and dissemination of information will improve our response to future pandemic events whilst maintaining a commercial awareness to better use the human and financial resources of an already financially restricted NHS. The COVID-19 pandemic caused by the SARS-CoV-2 coronavirus infection has challenged the world's healthcare systems in an unprecedented way. 1, 2 In the UK and wider world, there has been a lot of discussion about how to change the shape of the SARS-CoV-2 incidence and associated mortality curve. The aim of this study is to look at the shape and timing of the information curve, in particular with reference to otolaryngology in the UK. Although the broad principles may apply to other specialities and in other countries. The result of the pandemic has led to a significant reduction in GP cancer referrals, elective otolaryngology and cancer surgery. [3] [4] [5] This reduction is due to a number of factors, including access to healthcare and re-purposing theatre suites, ventilators and staff. Additionally, evidence suggests an unacceptably high morbidity and mortality if patients contract COVID-19 in the perioperative period. [6] [7] [8] [9] Furthermore, there has been significant concern as to the risks to the surgical team. 10 Early evidence emerged that surgeons, in particular otolaryngologists, as well as other professionals operating on the aerodigestive tract, were at particularly high risk. This is due to the high level of aerosol-generating procedures involved in the speciality. A number of fatalities among otolaryngologists and other similar practitioners have been reported. 4, 11 During the pandemic, there have been a significant number of guidelines produced by international sources, UK governmental organisations as well as specialist bodies such as the Royal Colleges and specialist organisations. These guidelines deal with a number of issues, including personal protective equipment, prioritisation of treatment and recovery, and, specific to ENT, cancer, clinics, tracheostomy, rhinology, otology and paediatrics. [4] [5] [6] [12] [13] [14] [15] [16] [17] The volume and quantity of guidelines resulted in significant challenges for otolaryngologists to stay up to date and to incorporate the advice into safe practice, both for the patient and the clinician. In addition to published advice, otolaryngologists have been required to assimilate guidance produced by local hospitals, as well as considering government briefings, web-based discussion, the press and social media. This study aims to document the volume and timing of advice targeted at ENT practice. The value of this study is to highlight the need for a pathway and establish a framework prior to any future overwhelming medical emergency leading to agreed pathways to disseminate information from high-level organisations (such as NHS England/WHO) down to area-specific advice (such as ENT-UK, BAHNO). This would ensure there are no disparities in the information and a clear message can be communicated. There should be an agreed checking point of the quality of advice and clear guidance on how promptly it should be evaluated in light of emerging information and developments. With the possibility of "second" waves, it is critical that this is implemented. Two separate searches were conducted. The first considered online advice published in English by official sources between 1 January and 31 May relevant to hospital-based practitioners involved in aerosol-generating procedures ( Table S2a ). The sources were broadly grouped in international, national and ENT-specific • The timing of these publications, as the mortality from COVID-19 was also rising, represents a challenge to incorporate all the advice into safe clinical practice. • As the number of COVID-19-related cases begins to rise for a second time, we should endeavour to flatten the infection and mortality rates curve and shift the information curve to the left, allowing our healthcare system to prepare and implement changes into practice in a timely manner. and hyperlink for each day since January 1. The results were subsequently grouped per week; thus, each Monday of the month since January 1 reflects all results from the previous week. The type of advice referred to areas of concern during the pandemic-PPE, service prioritisation, general (advice on treatment and/or investigations), cancer, tracheostomy, otology, rhinology, paediatric ENT and service recovery. The volume of advice published weekly in each of the three main categories aforementioned was reviewed. The number of SARS-CoV-2-related deaths recorded during the above period was extracted from the government website. 19 This was used to analyse the trajectory of COVID-19 related deaths and the volume of advice published between 1 January 2020 and 31 May 2020. The second search included the electronic databases PubMed Central and Cochrane library which were considered separately using the same strategy from the 30 December 2019 to 31 May 2020 (Tables S1,S2b). Initially, all publications related to COVID-19 were identified, the duplicates were filtered and number of publications by week was calculated. Next, a subset of these COVID-19 papers relating to ENT were identified. These papers were categorised according to those describing subspecialties within ENT, common ENT symptoms, anatomical areas relevant to ENT, and research relating to personal protective equipment, service prioritisation and recovery following the COVID-19 pandemic. The official UK government website was again used to map daily laboratory-confirmed cases in England and UK deaths across the same time period. 19 Ethical approval was not required as this study was a review, and all data were extracted from published articles. Most guidance targeted at otology, rhinology and paediatric ENT was produced during the peak period, constituting 10%, 7.1% and 7.1%, respectively. During the subsequent four weeks, between one and two pieces of advice were produced per week before the number of publications tailed off. The WHO considered SARS-cov-2 infection to be a global pandemic on 11 March 2020. 20 This study documents the advice that ENT allied specialties in the UK would need to read and assimilate to prioritise, protect and triage patients as well as staff during this period. As we emerge from the first wave of this unprecedented worldwide pandemic, we must learn lessons. Since the start of this century, there have been a number of epidemics; all have arisen outside the UK, including Ebola, severe acute respiratory syndrome (SARS), (MERS) and H5N1. 21 The COVID-19 pandemic represents an opportunity to analyse retrospectively the UK's response in terms of the volume and timing in which information was produced. The virus, first noticed in Wuhan, spread throughout the world. Whilst the infection was recognised as a pandemic on 11 March, UK incidence numbers did not start to significantly rise until later in March, with a probable peak in mid-April 2020. By the time, the infection was recognised as a global risk, there had been a significant number of cases reported worldwide. Otolaryngologists and other medical practitioners performing aerosol-generating procedures (AGPs) were identified early on as being at a high risk. 4, 10 While this study is specific to this subset of medical practitioners, the volume of advice and the time it was produced is likely to be applicable to other specialties. This study has identified 175 guidance-related publications issued from a number of international, governmental and specialist groups relevant to ENT as per Figure 1 . The subject of that advice covered a number of topics included in Table 1 . It is likely that this is an underestimate of the total guidance produced. During this period, medical services have been required to rapidly redevelop to allow for appropriate provision of care for COVID-19 patients. There has also been a need to limit hospital visits, rationalise procedures and limit surgical operations. 16, 22 The latter reflects the risks to patients contracting COVID-19 in the perioperative period and the high rate of pulmonary complications and mortality. In addition to protecting patients, there has been considerable guidance on how best to protect medical staff. As a consequence, a large number of clinical pathways have been changed. The long-term impact of such changes remains to be assessed. 7, 23 The peak time for guidance production in the UK was between Stuart Winter involved in overall supervision, discussion and editing. This work did not require any patient sensitive data and did not focus on any patient intervention, therefore, ethical approval was not necessary. The data that support the findings of this study are available in the Supporting Information of this article. https://orcid.org/0000-0002-0888-2525 Stuart C. 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