The benefits of AI in healthcare will only be realised if we consider the whole clinical context and the AI’s role in it. The current, standard model of AI-supported decision-making in healthcare risks reducing the clinician's role to a mere ‘sense check’ on the AI, whilst at the same time leaving them to be held legally accountable for decisions made using AI. This model means that clinicians risk becoming “liability sinks”, unfairly absorbing liability for the consequences of an AI’s recommendation without having sufficient understanding or practical control over how those recommendations were reached. Furthermore, this could have an impact on the “second victim” experience of clinicians.It also means that clinicians are less able to do what they are best at, specifically exercising sensitivity to patient preferences in a shared clinician-patient decision-making process.There are alternatives to this model that can have a more positive impact on clinicians and patients alike.

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Managing women who are pregnant with severe COVID-19 is complex. This paper focuses on the debate surrounding steroid use in this group. Unfortunately, despite international efforts to identify treatments for COVID-19, there is very little research which has focussed specifically on pregnant women. Therefore current guidance is based on consensus and expert opinion, with variation in these guidelines worldwide, and reports that 73% of pregnant women do not receive steroids at all. There is an assumption of a steroid class-effect implicit within the UK guidelines for the mother with COVID-19 which is at odds with established within-class differences for effects on the foetus. This now warrants further discussion given the increasing numbers of pregnant women being admitted to hospital with COVID-19.  

The recently published “Deaths in children and young people in England after SARS-CoV-2 infection during the first pandemic year”1 attempts to unpick the issue of paediatric deaths “with” versus “from” COVID-19, additionally reporting on pre-existing comorbidities of the children and young people (CYP) who died after a COVID-19 diagnosis. Linking data from the National Child Mortality Database (NCMD), hospital data from the Secondary Uses Service (SUS), and PICU audit data, the authors have re-examined deaths in CYP after a COVID-19 diagnosis using these datasets. However, whilst data on any pre-existing conditions may be useful to identify the children at highest risk from COVID-19, we have some concerns around the methodology and presentation of the first part of this study.

IntroductionHospital-acquired infection with COVID-19 (HAI) has reduced from 14.3% to 4.2% over the last year, but substantial differences still exist between English NHS trusts.MethodsWe assessed rates of HAI, comparing trusts using airborne respiratory protection (RPE, eg FFP3 masks) for all staff, as a marker of measures to reduce airborne spread, against those using mostly droplet precautions (eg surgical masks).Results/DiscussionRPE use was associated with a 33% reduction in HAI odds in the Delta wave, and 21% in the Alpha wave (p<0.00001). We recommend all hospitals make airborne mitigations a priority.

Link to published versionUse of airborne precautions for COVID-19 outside “AGPs” in healthcare settingsTom Lawton, Consultant Critical Care, Bradford Teaching Hospitals NHS Foundation TrustMatt Butler, Consultant Geriatrician, Cambridge University Hospitals NHS Foundation TrustChristine Peters, Consultant Microbiologist, NHS Greater Glasgow and ClydeEilir Hughes, General Practitioner, Ty Doctor, Nefyn, GwyneddHuw Waters, Consultant Risk Analytics, FreshAir.WalesDavid Tomlinson, Consultant Cardiologist, University Hospitals Plymouth NHS TrustLindsay Fraser-Moodie, GP Trainee, East of England DeaneryOn behalf of FreshAir NHS28th June 2021Since the early days of the pandemic there has been debate as to whether COVID-19 transmission can be airborne, and whether healthcare workers require routine airborne precautions, or if respiratory PPE can be preserved for a small list of “Aerosol Generating Procedures”.[1] The former question is now largely satisfied - COVID-19 is airborne[2] - but the latter remains and official UK guidance leaves the matter up to individual NHS Trusts to decide.[3]FreshAir NHS is a group of frontline NHS workers who wrote an open letter signed by over 1,600 colleagues to all governments of the UK nations in January 2021 requesting airborne mitigations to prevent infections in healthcare staff and reduce nosocomial infection risk to patients.[4]We therefore welcome pragmatic data from Ferris, Ferris et al showing that a simple substitution of filtering face piece (FFP3) respirators for fluid resistant surgical masks (FRSM) appeared to eliminate 100% of the 47-fold increase in excess risk of COVID-19 infection in healthcare workers (HCWs) caring for patients on COVID-19 “red” wards.[5] Prior to the introduction of FFP3, HCW infection rates on “red” wards were greater than those on “green” wards, and also demonstrated no correlation with community case rates, suggesting infections resulted from direct patient care - in line with genomic evidence that a large proportion of HCW infections are transmitted from patients.[6] Some studies have suggested that staff infection rates merely reflect transmission in the community such that staff rates increase as community rates rise and are therefore inevitable.[7,8] This study highlights that this is only true for non-COVID-19 facing staff, with exposure to infected patients being the driving factor for infections in COVID-19 facing staff.This has important implications for healthcare worker protection as the UK copes with what is hopefully an “exit wave” as well as trying to reduce the massive backlog of other work whilst coping with inevitable staff sickness and isolation. It also touches on our responsibility as a learning healthcare system to ensure preparedness for future epidemics and pandemics.However, if the precautionary principle were the only factor to consider then the UK would have used airborne precautions from the start of the pandemic - so clearly there are other factors to address. PPE was in short supply in early 2020,[9] which may have made rationing more appropriate, but supply chains have largely recovered - and reusable PPE has both environmental and cost savings.[10] Fit-testing staff adds burden to infection control teams, but NHS trusts which have made the switch have demonstrated it is possible, and there is evidence that reusable elastomeric respirators (but not disposable FFP3 masks) may be used safely with a “fit check” alone.[11] It is clear that tighter-fitting masks can be less comfortable - particularly if the fit is not suitable for the user, but surveyed staff appear in general to prefer the higher level of protection.[12] Most healthcare staff are now vaccinated, but the B1.617.2 (delta) variant appears to reduce vaccine effectiveness at a time when staff absences due to sickness and isolation can critically hamper NHS recovery as patients await delayed treatment.[13]The only remaining argument appears to be that we are beholden to the past; that to change guidance now would be to admit that mistakes were made. Whilst this may have a powerful emotional hold on local and national policymakers and leaders; the best pandemic responses have come when we have learned and changed course when necessary: “Progress is impossible without change; and those who cannot change their minds cannot change anything.”[14]Competing interestsTL, MB, CP, EH, DT, LF-M are practising NHS clinicians and subject to UK PPE guidanceReferences[1] Hamilton F, Arnold D, Bzdek BR, Dodd J, White C, Murray J, et al. Aerosol generating procedures: are they of relevance for transmission of SARS-CoV-2? Lancet Respir Med 2021. https://doi.org/10.1016/S2213-2600(21)00216-2. [2] Tang JW, Marr LC, Li Y, Dancer SJ. Covid-19 has redefined airborne transmission. BMJ 2021;373:n913. https://doi.org/10.1136/bmj.n913. [3] COVID-19 infection prevention and control guidance - Version 1.2. London: PHE; 2021. Report No.: GOV-8505.[4] Wise J. Covid-19: Doctors and nurses demand better PPE for wider range of procedures. BMJ 2021;372:n30. https://doi.org/10.1136/bmj.n30. [5] Ferris M, Ferris R, Workman C, O’Connor E, Enoch DA, Goldesgeyme E, et al. FFP3 respirators protect healthcare workers against infection with SARS-CoV-2. Authorea Prepr 2021. https://doi.org/10.22541/au.162454911.17263721/v1. [6] Illingworth C, Hamilton W, Warne B, Routledge M, Popay A, Jackson C, et al. Superspreaders drive the largest outbreaks of hospital onset COVID-19 infection. OSF Prepr 2021. https://doi.org/10.31219/osf.io/wmkn3. [7] Treibel TA, Manisty C, Burton M, McKnight Á, Lambourne J, Augusto JB, et al. COVID-19: PCR screening of asymptomatic health-care workers at London hospital. The Lancet 2020;395:1608–10. https://doi.org/10.1016/S0140-6736(20)31100-4. [8] Brown CS, Clare K, Chand M, Andrews J, Auckland C, Beshir S, et al. Snapshot PCR surveillance for SARS-CoV-2 in hospital staff in England. J Infect 2020;81:427–34. https://doi.org/10.1016/j.jinf.2020.06.069. [9] Hoernke K, Djellouli N, Andrews L, Lewis-Jackson S, Manby L, Martin S, et al. Frontline healthcare workers’ experiences with personal protective equipment during the COVID-19 pandemic in the UK: a rapid qualitative appraisal. BMJ Open 2021;11:e046199. https://doi.org/10.1136/bmjopen-2020-046199. [10] Higgins GC, Ho J, Robertson E, McLean N, Horsley C, Douglas J. Covid-19: Health and social care workers need, want, and deserve reusable FFP3 respirators. BMJ 2021;372:n759. https://doi.org/10.1136/bmj.n759.[11] McMahon K, Jeanmonod D, Check R, Rivard L, Balakrishnan V, Kelly B, et al. The pragmatic use of industrial elastomeric facemasks in health care practice during the COVID-19 pandemic. Am J Emerg Med 2021;48:273–5. https://doi.org/10.1016/j.ajem.2021.05.025.[12] Butler M, Inkster T, Foster C, Lawton T, Hughes E, Waters H, et al. Effect of Implementation of Aerosol Respiratory Protective Equipment, Vaccination and Natural Infection on a Covid-19 Cohort Ward: A Retrospective Observational Cohort Study. OSF Prepr 2021. https://doi.org/10.31219/osf.io/nh5sr.[13] SARS-CoV-2 variants of concern and variants under investigation. London: PHE; 2021. Report No.: GOV-8715.[14] Shaw GB. Everybody’s political what’s what. Constable and Company Limited, London; 1945.