Severe cases of COVID-19 often include gastrointestinal (GI) symptoms, complicating prognoses for gastroenterologists. As a result, according to Dr Prithvi Priyadarshini, Specialist Gastroenterologist and Head of the Gastroenterology Department at Al Zahra Hospital, Sharjah, the pandemic has added a new layer to her work. 

“When we talk about colitis of any cause, patients present with diarrhea, abdominal pain and potential rectal bleeding. The first we’d ask is if this could be cancer,” Dr Priyadarshini said. 

COVID-19 has complicated matters, however. “There are two main issues here. Firstly, COVID-19 has affected patients who have already been diagnosed with IBD and are on treatment. Secondly, it is also an issue for patients who are recently developing IBD symptoms and are hesitating to come to hospital due to the pandemic,” she explained. 

For the first group of patients, their gastroenterologist would have supplied them with a few months’ worth of medication to cut out the need for frequent hospital visits. Even so, some patients may develop acute symptoms like diarrhea or bleeding all of a sudden, even on the same medication. This is where step-up therapy has been crucial, where treatment is individualised and constantly tweaked. “The issue is that patients are hesitating to come to hospital. They don't visit as frequently, and they tend to do self-medication even though IBD patients are well aware that this could be dangerous.”

Telemedicine has made it easier to manage long term patients, Dr Priyadarshini said. “Newly diagnosed patients and the patients who are developing symptoms now are the ones who are lagging behind in proper treatment.”

A mainstay in IBD diagnosis are endoscopy or colonoscopy procedures. Over the last 18 months, Dr Priyadarshini has observed a lot of hesitation from newly diagnosed patients in undergoing these procedures. “This delays the diagnosis and we need to convince the patient saying that these could be the complications, and these are the reasons why you need a colonoscopy.”

When it comes to COVID-19 infected IBD patients, Dr Priyadarshini says it’s a completely different story. A lot of times, gastroenterologists work with physicians and intensivists to treat these patients, because both IBD and COVID-19 are treated separately. “If an IBD patient gets COVID-19 it could be mild, moderate or severe. They can come out of it depending on the severity of COVID-19, not the severity of IBD.”

Ultimately, gut health needs care and attention, starting with good nutrition, stress management and probiotics, which Dr Priyadarshini sees as “wonderful when taken in a proper sequence and in a proper way”.

A lot of her patients have expressed worries over taking the COVID-19 vaccination and whether it will exacerbate IBD. Dr Priyadarshini stresses that there is no link and encourages everyone to get vaccinated. “From January this year, it’s very clear to all of us that the vaccine is safe for IBD patients. Please go ahead and take the vaccine. It's safe.”

Burnout affects physician well being, job satisfaction and patient outcomes. It has always been a major challenge for physicians, but now that the phenomenon has been thrust into the spotlight, there’s hope that institutions can support their staff, said Dr Alain Sabri, chairman and residency director of Otolaryngology at Sheikh Shakhbout Medical City. 

Speaking at the ENT Conference at Arab Health, Dr Sabri explained the causes and impact of burnout on not just individual physicians but the institutions they work for and the communities they serve. 

Burnout affects millions of people today as Covid-19 continues to take a toll on the general public. However, physicians are arguably impacted more acutely, said Dr Sabri. 

The issue is that people don’t recognise burnout and when it happens, they don’t address it. The term is so commonly used that Dr Sabri believes it is underestimated when it does happen. “Burnout isn’t having a bad day at work, not liking your boss, or being frustrated if things don’t go according to plan,” he said. While burnout may be newly recognised, it’s a hot topic in all professions.”

Burnout is a syndrome characterised by physical and emotional exhaustion, cynicism, reduced effectiveness, depersonalisation, and a diminished sense of purpose and personal accomplishment. It is more pronounced in healthcare; 50% of physicians have experienced burnout, and for certain specialisations, it is as high as 70%.

“MDs are 15 times more likely to experience burnout. 45% of doctors report that they would quit if they could afford to,” Dr Sabri said. Why? The long hours and purpose-led nature of the profession could be a reason. 

Physicians have a 20% higher divorce rate than the global average, and Dr Sabri’s research reveals that suicidal ideation, substance abuse and psychological problems abound for health workers facing burnout.

“While I hate to put a cost on something so tragic and important, it is very costly for institutions, communities and governments,” Dr Sabri said. Burnout ultimately leads to increased staff turnover, and physicians are particularly expensive and hard to replace. 

Physician burnout costs the US healthcare system $3.4 billion annually. Within the Department of Medicine at Mayo Clinic alone, where Dr Sabri used to work, it is estimated to cost at least $1.5 to $2.5 million a year in decreased productivity.

“The problem is multifactorial, but truthfully, we are very hard on ourselves and our colleagues,” he added. “There’s a terrible adage in medicine, ‘heal thyself’, but we’re not very good patients. We don’t know when to stop and when to take care of ourselves.”

Dr Sabri concluded with some key advice: “burnout is contagious so surround yourself with positive, supportive people. As physicians we need to reinvent ourselves personally and professionally and sometimes that starts with learning how to say no to demands beyond our capacity.”

The COVID-19 crisis presented health systems around the world with an unprecedented situation. Many clinicians found themselves working in an unfamiliar setting, treating an unknown disease. With relatively little known about COVID-19, and evidence changing daily, there was a lack of authoritative information to support these decisions. 

In this fluid and uncertain picture, the role of clinical decision support (CDS) technology came to the fore. The Wolters Kluwer clinical decision support (CDS) tool UpToDate®, with over 2 million users worldwide, is the leader in this fast-growing field. 

Mobilisation of information 

One of the key attractions of UpToDate during the pandemic was its ability to facilitate the faster mobilisation of information. As the most global CDS tool, with content curated by over 7,000 specialist authors and editors from around the world, UpToDate was uniquely positioned to keep up with the latest COVID-19 intelligence.

Few other organisations have the reach and expertise to sift through the ever-growing volume of COVID-19 information. This work is extremely important as it provides clinicians with the most authoritative and recent guidance and evidence, immediately available at the point of care anywhere in the world.

Even before the pandemic, doctors faced an uphill struggle staying on top of the latest medical literature. COVID-19 compounded the situation, creating an information race as the medical community strived to close the knowledge gap on the disease. 

Decision making in a fast-changing environment

To understand what it is like for a doctor in this age of information overload, Dr Steve Jackson, Consultant Physician, Diabetes and Endocrinology and Chief Medical Information Officer at University Hospitals of Leicester NHS Trust says: “There is so much new evidence and research coming out every day that doctors can’t possibly keep on top everything. The more experienced you get, the more you become comfortable with that. You realise there are inevitably going to be things you don’t know, and where the wisest course of action is to seek support, whether that’s from a CDS tool like UpToDate or the advice of specialist colleagues.” 

Dr Amad Khan, Neurosurgical Registrar, University Hospital Southampton NHS Foundation Trust says colleagues found it reassuring that the information in UpToDate was peer-reviewed and evidence-based.

“It’s good to know you’re not taking decisions in isolation, and that the information is underpinned by a vast and sound base of expertise. The app’s COVID-19 topics have been viewed more than 13 million times since the start of the crisis. This proves that other doctors in the same situation in thousands of hospitals across the world are receiving the same guidance. In a crisis, this can provide some peace of mind at time when you may be second-guessing yourself.” 

According to Dr Fatima Alsayyah, Endocrine Specialist, Dubai Hospital, Dubai Health Authority (DHA), clinical decision support was invaluable in the management of high-risk patients with long-term conditions during the height of the pandemic.

“UpToDate made a big difference during the COVID-19 pandemic especially for in-patient management. It has helped us to provide continuous education to patients who have uncontrolled diabetes and highlight to them the risk of severe infection, longer hospital stays and ICU admission. UpToDate changed our practice in relation to the management of COVID-19 and diabetes. It has kept us informed about the treatment changes and helped us to answer patient questions.”  

Untapped potential of CDS – future predictions

Just as the pandemic has highlighted the value of clinical decision support in treating COVID-19, it has also shown its potential for predicting future outbreaks – of this virus and others that might follow. 

Because UpToDate has 51 million topic views per month the app can provide a detailed picture of what doctors are searching for at any given time. As doctors commonly use UpToDate when faced with unusual symptoms or to double check guidance on a particular condition, it’s possible to see peaks in search activity around specific topics.

In the case of COVID-19, researchers were able to draw a clear correlation between search intensity for selected COVID-19 terms for a specific location with subsequent numbers of confirmed cases. 

In the U.S., Dr. Mauricio Santillana, Director of the Machine Intelligence Lab, Boston Children’s Hospital, and an Assistant Professor of Paediatrics and Epidemiology at Harvard Medical School, has taken this further, using UpToDate data to create an algorithm to forecast coronavirus outbreaks. It uses doctors’ search activity on UpToDate, combined with data streams from social media, internet search trends and mobile data from smartphones.

When data from these sources are aggregated, it provides a coronavirus early warning system that its developers say can forecast an outbreak two or three weeks in advance. 

Clinical decision support and virtual healthcare 

Another key medical trend that CDS is enabling is the rise of the virtual consultation – a clear consequence of the COVID-19 pandemic as many doctors switched to video-based appointments. 

Dr Jackson says this has had a big impact on how he works: “The more I do virtual consultations – and they are now the default option – the more I see an opportunity for patients to be engaged with information about their conditions. That’s far easier in a virtual consultation, when I can be looking at my screen to consult information sources and share information with the patient. 

“Working remotely also means my time is not limited in the same way as used to be in the consulting room. This means I can prepare better for each consultation. Now, before I see the patient, I can open the patient’s record, laboratory system, radiology system, and also my previous notes. If I’m not sure about the plan of action, I can use the CDS to support my decision-making.”

The potential for CDS to be used with the patient to engage them in their treatment also facilitates the trend towards remote, home-based care. Research shows that engaged patients have better outcomes and CDS is responding to this with more patient-centric content. Multi-language materials and video adapted from clinician content can reach more of the population with easy to digest and accessible information. 

The right decisions at the right time

One criticism that some may level at the growing use of CDS is that it risks creating a new generation of technology-reliant clinicians, replacing their own knowledge with the search results from an app. 

However, this is to misunderstand the true role of CDS, especially in the post-pandemic world. The key to the successful implementation of CDS is that it needs to be ‘smart’. Information needs to be delivered in a way that is seamlessly embedded into the physician’s workflow, supporting his or her reasoning process. When CDS technology can be embedded into an EMR then it moves from being an information resource to a personalised and dynamic tool. 

A guiding principle for the use of this powerful technology is that it needs to support the decision-making process rather than replace it. In this sense, CDS technology is about giving clinicians the tools that help them make the right decisions at the right time, and helping the patient receive better and safer care while delivering efficiencies and lowering the cost of care. 

Find out more about UpToDate at https://www.wolterskluwer.com/en/solutions/uptodate 

Article sponsored by Wolters Kluwer

Hospitals and health care organisations that adopt a risk-based approach to JCI evaluations can focus their limited resources on outcomes that truly matter. Dr Joel A Roos, Vice President of International Accreditation, Quality Improvement and Safety at the Joint Commission International (JCI) is speaking at the Arab Health Quality Management conference today to raise awareness of the benefits of the JCI SAFER^TM Matrix. 

The SAFER^TM Matrix allows JCI surveyors  to assess  risk and potential areas of vulnerabilities so organisations can prioritise corrective actions. This data-led approach may make or break overstretched hospitals especially during the pandemic, so that CEOs and quality improvement teams can focus their efforts on what is important, Dr. Roos said. “One of the key benefits is that organisations will know where they stand. The SAFER^TM Matrix allows health care staff to focus time, money and effort on the most important issues that affect patient safety. At the end of the day, it provides clarity,” he added. 

“Infection control in organisations is a priority during the pandemic. We certainly have not changed our standards. We have noticed improved quality while evaluating institutions through the accreditation process.”

Dr. Roos noted that it was difficult  to organize in-person assessments as an accrediting body during the pandemic. “The last thing we wanted was to get in the way of patient care during an emergency situation. Hospitals had to delay accreditation and focus on patients ahead of everything else, and rightfully so,” he said. 

JCI adapted its accreditation delivery process to conduct remote surveys during lockdown. “This is where video technology, via cell phones, tablets, or laptops, has been useful. We can conduct a very accurate and comprehensive survey remotely without ever leaving the confines of another country.” 

JCI also has adopted a hybrid approach that sends one person to a health care organization instead of a team and uses technology to expand its teams in other geographies. “We started using technology and methods to perform the survey process without sacrificing rigor, collaboration and integrity.

The biggest challenge for hospitals has been keeping focus on quality improvement, Dr. Roos said. “Health care workers have been pressed into service to provide care. It has been “all hands-on deck” during the pandemic just to keep operations running.  During a mass casualty event in an emergency department, (health care workers) are focused on getting things done, and may be doing things differently than if they were during normal operations.”

With COVID-19 pushing telemedicine to the forefront, JCI is now working on accrediting these services.  “It is kind of like the Wild Wild West (in telemedicine) as there are so many different organisations incorporating telemedicine in a variety of methods.  Telemedicine is very effective and is not going away, nor should it.

“It has a tremendous role in bringing access to patients in remote areas, for example, but there needs to be quality standards and methodologies established for telemedicine use. Telemedicine standards do not currently exist. JCI is clearly moving in that direction and will focus upon telemedicine and strive to provide a comprehensive solution.”

To learn more about improving your organisation’s quality management, attend JCI’s Dr. Joel A. Roos’ presentation 'Joint Commission International SAFER Matrix: A Tool to Assess Safety Risk', at 12.45 p.m. at the Quality Management conference at The Conrad Hotel.

Virtual speakers during the Quality Management Conference at Arab Health came together on Thursday to offer final thoughts following a day of talks on digital innovation. 

According to Prof Paul Barach, Clinical Professor, Wayne State University School of Medicine, Children’s Hospital of Michigan, while big data is an “incredible way” to understand population health and realise the “Quadruple Aim”, many companies haven’t approached this with the best transparency or engagement with patients and providers. He cautioned that questions remain over how it might work - and whether it might exposure patient privacy or bring hospitals “to their knees” through hacking. This can only be adequately examined through a framework of a public-private partnership, that engages ethicists, scientists, and users in a way that supports their journey of wellness.

Melania Endicott, Senior Director of International Education & Training for AHIMA, stressed the importance of having good quality health information, a need that requires trained staff educated in documentation best practices, how to maintain records and how to ensure the accuracy of data going into records, that is also accessible by the right people at the right time.

Virtual health needs to be viewed as part of the continuum of care, emphasised Katerina Tarasova, Executive Director of International Accreditation at Accreditation Canada, and attention needs to be paid to patient-centric care. Integrated care is an important factor when looking at all the components and how the system is reacting to new developments in virtual health. 

Richard Wyatt-Haines, founder and director of HCI, highlighted how no technology can be deployed without people – and that they need to be clear about goals, set by leadership, with the commitment to making it happen. Only by bringing a group together comprising operation managers, clinicians and patients - to ensure they are engaged - can all components come together to ensure success. 

The coronavirus pandemic will have a lasting impact on our mental health, which is why healthcare systems need to maintain current levels of support even after the immediate threat of the virus reduces. 
 
A panel of mental health professionals stressed the importance of preventing burnout and creating support pathways for healthcare workers, speaking at the Arab Health Family Medicine Conference on Wednesday. 
 
“We’ve had a record number of referrals and have been busier than we’ve ever been. It’s very worrying, but our services have really responded to that. It’s about meeting the demand, and there’s a recognition that this issue will be around for some time and will need sustained attention and investment,” Dr Adrian James, President of the Royal College of Psychiatrists in London said.
 
Both patients and healthcare workers have been forced to find new ways to cope with a massive spike in negative mental health issues due to the pandemic. From immediate effects like fears of contracting the virus to isolation during lockdown, to the impact of long COVID on recovering patients, the pandemic’s consequences on mental health are still being researched and studied. 
 
For healthcare workers, the pandemic has forced a lot of existing mental health pressures to the surface, making them more susceptible to stress, depression and anxiety. Long hours and isolation have also made burnout commonplace among staff. 
 
“A lot of staff have lost colleagues, family members and friends. Certainly in the UK and the UAE, we have a lot of international medical staff, particularly from India. The increase in the incidents of COVID-19 in India has had a huge impact on staff mental health,” Dr Subodh Dave, Dean of the Royal College of Psychiatrists in London said. 
 
Dr Dave spoke from personal experience. “I’m part of that international staff cohort and I haven’t seen my parents in 18 months. For junior colleagues and medical students, it’s even more isolating to be away from family for that long.”
 
Dr Nahida Nayaz Ahmed, Consultant Psychiatrist and Chair of Mental Health at SEHA and Department of Health Abu Dhabi quoted a December 2020 UAE study on the mental health impact of COVID. “Our survey shows young, single, female expatriates working in healthcare are the most affected, particularly in nursing,” Dr Ahmed said. SEHA’s mental health helpline provided a rudimentary level of ‘first aid’ for healthcare workers during the pandemic.
 
The direct impact on staff mental health has led to more healthcare workers prioritising their own wellbeing, a trend that Dr Dave hopes will continue long after. “Broadly, I feel that the direct impact is a rise in healthcare staff seeking help. It’s the new cohort that mostly needs support,” he added. 
 
Speaking to colleagues, some of whom have multiple comorbidities, Dr Dave noted that many healthcare workers are living in constant fear of contracting the virus and bringing it home to vulnerable family members. “For younger people, they are facing isolation, missing out on crucial socialisation experiences. I hope health systems around the world sit up and learn lessons. We need to increase resilience within our systems to provide healthcare for all who need it.”

The pandemic has stress-tested the world’s most robust healthcare systems to quickly adapt and process large volumes of patients with varying underlying issues. A key and often ignored demographic acutely affected by the pandemic is that of women and children. 

Dr Haifa Madi, public health advisor at the Ministry of Health and Prevention, Abu Dhabi, believes that if this problem is left unchecked, millions of women and children may be sidelined to suffer through health issues we’ve already tackled in recent times such as infant mortality. “The Arab world scores highly on the gender inequality index and we also have the highest number of displaced people in the world. This means that vulnerable groups are the easiest to overlook at times of crisis,” she said. 

Speaking at the public health conference at Arab Health on Tuesday, Dr Madi explained how the diversion of resources to address Covid-19 has impacted antenatal care and all services for women and children. Due to lockdown, 80 million children under the age of 1 may miss essential vaccinations. “The lockdown also limited the accessibility of women and children to healthcare, leading to an indirect and direct increase in maternal deaths and child mortality.”

Gender based violence has also increased during the pandemic, she noted. 1 in 3 women worldwide are subjected to sexual or physical violence at least once in their lives. In Arab countries, this figure rises to 37%. Forced coexistence, community closure and economic stress has led to increased tensions at home, which have negatively affected female safety.

The problem is not well documented, because of low reporting levels due to the stigma facing women who do want to come forward. “This is a social, economic and health issue that needs more studying,” she added. 

“Nobody knows when this will really end. This virus has tested the ability and preparedness of even the strongest health systems in the world. If we want to see real progress, we need to address inequalities at every level.”

Technology is the cornerstone of modern day medicine but when it comes to public health, we’re still lagging behind. This is according to Professor Najeeb Al-Shorbaji, president of the Middle East and North Africa Association of Health Informatics, speaking at Arab Health 2021's Public Health conference.

“The problem with health tech is that we’re always a little behind other sectors. We borrow technological solutions from different places to apply the best of the best in health care,” he said. 

The Amman based professor lectures across the world on digital health and innovation, and has seen high tech solutions in practice in hospitals just miles away from other hospitals that sadly struggle to meet the most basic of patient needs. “The truth is that there’s a huge discrepancy between what is used with cities, let alone the region as a whole,” he said. “It’s hard to gauge how we are adapting digital solutions in the region because of the gap in adoption.”

Al-Shorbaji notes that technology as a sector of its own evolves much faster than legal, healthcare or even academia because it’s driven by the private sector. “Faster innovation and solution-finding means that other areas need to play catch-up to roll out healthcare applications. We cannot adopt technological solutions without the right legal structures in place. We cannot roll these out without the right training. It’s a challenge, but one that our sector can bridge with time and good leadership.”

This is why convergence is really important. Not every technological solution is suitable for every single country in the region. Neither is it appropriate for every individual. One size doesn’t fit all, he added. “Technology that is available or appropriate in one place may not be relevant elsewhere.” 

Al-Shorbaji went on to discuss the applications of technology such as mHealth, artificial intelligence, drones and robotics, and blockchain in healthcare. He concluded by speculating how the region can adapt these advancements with a patient-first approach.