Response of a tertiary dermatology department to COVID‐19

Dear Editor

A novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) was reported in December 2019 causing the disease known as COVID‐19. As of March 24th, 2020 there have been 195 countries affected with 387 354 cases and 16 758 deaths. In Australia every state has been affected and as of March 24th there were 2136 cases with 8 deaths. ¹ A significant rise in case numbers is expected in the coming weeks.

China’s lockdown measures are considered the main factor in a decline in transmission from a median daily reproduction rate of 2.35 to 1.05 within a week. ² The Dermatology department of West China Hospital implemented several changes. Clinics were reduced to emergency cases, teledermatology was implemented, only one support person was allowed to accompany patients, upon entry to the department patients had their temperatures measured as well as wearing masks and having travel histories recorded. Doctors were mandated to wear full PPE. ³

Due to the unprecedented nature of this pandemic there has been uncertainty regarding what changes should be implemented to Australian dermatology services.

Given the reported efficacy of China’s response in reducing COVID‐19 transmission, we are employing similar protocols (Table 1). At the Department of Dermatology, Liverpool Hospital, we have deferred non‐urgent cases from surgical and medical clinics. We have defined urgent surgical cases as melanoma, and squamous cell carcinoma and other cutaneous tumours in high‐risk areas or immunosuppressed patients. Medical cases are reviewed on an individual basis. With the Government implementation of teledermatology, we are utilising this where possible. ⁴ We are staggering patient appointment times to minimise the number in our waiting rooms, limiting patients to bringing one support person, and spacing seating by 1.5 m. For inpatient consultations we have limited the number of doctors seeing a patient to two. Patients are being proactively contacted to discuss the need for continuation of immunosupressive therapy. The British Association of Dermatologists have released a statement suggesting there is insufficient evidence to advocate stopping biologic therapy at this time. ⁵

Table 1.

Changes to clinical practice resulting from COVID‐19 in the Dermatology Department, Liverpool Hospital

Area	What is being done
Departmental Communication	Ongoing liaising with hospital managers to ensure consistency Frequent e‐mails are sent to staff (approximately every 2–3 days) with updated changes and requesting feedback
Clinics	Deferring non‐urgent cases (registrars are reviewing each clinic) Calling the non‐urgent cases and providing a phone consult service employing teledermatology where possible
Waiting Rooms	Written signage at the front door warning those with cold like symptoms or travel history in the last 14 days not to enter and guiding them to appropriate services Staggering of patient times Patient chairs spaced 1.5 m from each other Limiting support persons to one
Phototherapy	Most phototherapy clinics are going ahead as normal
Surgery	Limiting clinics to urgent/semi‐urgent cases defined as suspected melanoma, SCC on high‐risk areas and in keratinocytic tumours in the immunocompromised
Personal protective equipment	Supplies are being numbered and recorded to identify missing units PPE is being rationed to allow for the best protective practices while also preventing a complete shortage. This is a dynamic process dependent on supply.
Biologics/immunosuppressants	Proactively contacting all patients on immunosuppressants Individualised treatment weighing up risks and benefits, suspending a select group of patients
Ward Consultations	Greater utilisation of teledermatology for consults Only 1‐2 doctors to see patients during rounding

Given the nationwide shortage of PPE, supplies are being numbered to identify missing units. The use of masks and other PPE has been dynamic, directed by hospital guidelines. Should a complete community lockdown be initiated, we plan to continue to work via telehealth with physical attendance only for the most acute presentations.

We hope that our experience serves as a nidus to stimulate discussion among departments. An avenue for this may be teleconference between departmental heads with the aim of providing a wider consensus. This being said, we recognise that many of the changes to clinical services are made beyond the departmental level. Hopefully, it can guide those in private practice also, recognising the differences in caseloads between the settings.

While COVID‐19’s impact on the Australian health‐care system and economy is uncertain, our departments and hospitals to which they belong play an important role in mitigating the burden by implementing initiatives to reduce the spread and severity of disease.