Summary
During the first wave of the coronavirus pandemic, skin issues in health care workers (HCW) wearing Personal Protective Equipment (PPE) were a significant problem. In January it became clear that the second wave would be very large. At the peak, the Barts Health NHS Trust had 835 COVID-positive inpatients and 263 intensive care unit (ICU) beds (one of the largest ICUs in Europe). A package of dermatology care was devised and rolled out to educate, support and treat the HCWs’ skin issues. This included information leaflets, videos and virtual clinics. In addition, central to the whole programme, were pop-up dermatologist clinics to help the HCW during their breaks and between shifts. Over a 10-week period, 796 HCW were seen and treated. Advice, information leaflets, free samples and free prescriptions were provided. The clinics helped keep staff at work at a time of acute staff shortages.
Method
The education of staff with skin issues was the first objective. Patient information leaflets were written on the commonest skin problems triggered by PPE (hand dermatitis, facial eczema, acne and pressure damage from FFP3 masks) and how to prevent and manage them. These were uploaded to the Trust’s intranet and printed as handouts. An amateur video on how to manage the skin problems was made for staff and uploaded to the intranet. Later, this was replaced with a more professional version. The next priority was to ensure quick and easy access to topical dermatological treatments for the staff. Twelve pharmaceutical companies that manufactured over-the-counter treatments for eczema and acne were approached for free samples for the clinic. They responded generously and quickly, providing a wide selection of moisturisers, soap substitutes and acne cleansers. Negotiations with the Trust management and the pharmacy enabled the prescribing of treatments for staff without them having to be registered as hospital patients. Additionally, the prescription fees were waived by the hospital outpatient pharmacy and paid for by the Trust. Sites adjacent to, or in, HCW rest areas were identified for the pop-up clinics. The clinics were advertised on the intranet and via posters inviting staff with skin issues from PPE to attend. For the first three weeks, clinics were held five days a week, from 8.30-9am and 1-2pm, run by two dermatologists. As demand fell, the clinic frequency was reduced to daily for four weeks and then weekly. All of the pop-up clinics were staffed by volunteering dermatology consultants, registrars and nurses on top of their existing workload, without impacting service capacity. One site without dermatologists was covered with a combination of teledermatology assessment via email and fortnightly pop-up clinics at the wellbeing area, conducted by a consultant dermatologist and a trained dermatology nurse. For those unable to attend, an email-based teledermatology service was provided by dermatology specialist registrars. An audit was kept of all those attending the clinic. This recorded demographic details, the nature, site and severity of the skin issues, the Dermatology Life Quality Index (DLQI) and the treatment. An online feedback questionnaire was introduced after the pop-up clinics had been running for six weeks. HCW with severe skin disease who needed extra help were referred to Occupational Health (OH). OH emailed the referrals to a designated member of the dermatology team, who registered them as patients and offered a formal dermatology outpatient appointment within five working days.
Results
The pop-up clinic and education programme were effective. The significant problem with PPE-related skin issues in the Trust was addressed. The information leaflets on the intranet were viewed 6,352 times; the online video was watched 172 times in the four weeks following upload. Attendance in the clinics was high, with a total of 796 HCW seen and treated in 10 weeks. Of these, 401 were seen in the first three weeks alone. The skin issues were distressing and disabling and HCW often had multiple problems. The mean DLQI score was 8.6. Of the 48.9% who had hand eczema, 16% required hospital prescriptions for potent topical steroids. Acne was treated in 44.7% and 6% required oral antibiotics. Referrals to secondary care were made for 2% who had severe skin issues. At least 12 members of staff had been off sick with skin conditions, representing a total of 114 days of work lost. None had been seen by a dermatologist prior to visiting the pop-up clinic. All experienced improvements in their skin conditions. One of them, subsequently diagnosed with allergic contact dermatitis to rubber gloves, was able to return to work promptly following treatment and appropriate advice. HCW found the advice and treatment effective, demonstrated by their feedback and the rapid drop in numbers attending after the initial three-week intensive period of 30 clinics.
Sustainability and Spread
The care and education package will be provided for as long as it is needed. As COIVD-19 admissions and pressure on ITU beds reduce, only a weekly pop-up clinic at the largest site is offered, and reducing demand may mean this stops soon. Teledermatology assessment or formal appointments continue for those who need urgent advice. The trained dermatology nurse is also providing samples of emollients and educational material at one of the remote sites with teledermatology support from a dermatology consultant. The department would be ready to step up the service again if necessary. The educational aspect remains important. The patient information and videos remain on the Trust intranet and can be accessed by all staff. The OH team members have found the educational resources helpful and are better placed to manage staff skin issues. The referral pathway remains open to the department. The experience is being shared nationally. An abstract has been accepted for presentation at the British Association of Dermatologists’ annual meeting, and a paper is in preparation. Other studies have been published, but this is the largest one globally on PPE skin problems in health care workers to date.
