Challenges for NHS hospitals during covid-19 epidemic
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1117 (Published 20 March 2020) Cite this as: BMJ 2020;368:m1117Read our latest coverage of the coronavirus outbreak
All rapid responses
Dear Editor,
The unprecedented increase in the workforce and infrastructure of the NHS and other health systems that governments are implementing in response to the covid-19 pandemic is certainly of utmost importance. However, the processes that patients go through to be assessed, admitted, and treated in hospital will also undergo dramatic change. Bringing in more staff, more beds and more equipment is not enough - the way we work and the protocols we follow also need to adapt.
Hospitals are changing how they function in an attempt to limit the impact of the pandemic. This includes faster triage and assessment, radical redeployment of personnel, and implementation of new management strategies, forcing challenging ethical decisions to be made in a context of increasing scarcity [1]. This can lead to poor outcomes for patients and a high burden of psychological stress for staff.
Checklists are a frequently used tool in aviation, healthcare and other industries to support decision-making and reduce human error. Their use in healthcare has had some notable successes, such as the Safe Surgery Checklist from the WHO (World Health Organisation), which has been found to be effective in reducing post-operative mortality and complication rates [2,3]. However, effective implementation is not easy. As well as the checklist itself needing to be carefully designed and locally relevant, outcomes should ideally be measured and fed back to staff members, and a workplace culture that emphasises good performance should be encouraged [4].
In a large tertiary hospital in Hull, a new one-page checklist for all inpatients suspected of having COVID-19 has been implemented. It aims to:
1. Clearly state the diagnostic criteria of suspected COVID-19. This will help reduce diagnostic uncertainty in a new, unfamiliar disease, where limited tests are available. It also aims to help staff promptly isolate and test previously admitted patients who develop new symptoms suggestive of COVID-19.
2. Act as a single point of reference throughout the patient’s admission to facilitate decisions about their care and allow easy calculation of how far they are through the course of their disease.
3. Help clinicians in a high-pressure environment remember all the key investigations that need to be performed. In addition, a local management guideline based on WHO [5] and Public Health England advice for suspected or confirmed covid-19 patients is on the reverse of the checklist. These features are particularly important for healthcare professionals redeployed to the emergency department or acute medical wards who are working outside of their usual area of clinical practice.
4. Prompt early senior discussion about the ceiling of treatment, so that in acute deterioration, clear plans can be implemented in the most equitable and caring way possible. The checklist includes Clinical Frailty Score (as suggested in recent NICE guidelines [6]), age and comorbidities to ensure that the information needed to make these discussions is easily available.
Due to the urgency of the situation, this checklist has been implemented rapidly, incorporating feedback gathered from frontline staff during a 24-hour pilot. We hope to evaluate its utility more formally in the near future. The checklist is freely available at www.bit.ly/3asTVFs. We encourage other organisations and researchers to use and adapt the checklist, and collaborate in rethinking the way we can best care for patients during this global crisis.
References
1 Macchini D, Parker C, World Economic Forum. ‘Every ventilator becomes like gold’ - doctors give emotional warnings from Italy’s Coronavirus outbreak. 2020.https://www.weforum.org/agenda/2020/03/suddenly-the-er-is-collapsing-a-d... (accessed 29 Mar 2020).
2 Haugen AS, Søfteland E, Almeland SK, et al. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Ann Surg 2015;261:821–8. doi:10.1097/SLA.0000000000000716
3 Chaudhary N, Varma V, Kapoor S, et al. Implementation of a Surgical Safety Checklist and Postoperative Outcomes: a Prospective Randomized Controlled Study. J Gastrointest Surg 2015;19:935–42. doi:10.1007/s11605-015-2772-9
4 Bosk CL, Dixon-Woods M, Goeschel CA, et al. Reality check for checklists. Lancet 2009;374:444–5. doi:10.1016/S0140-6736(09)61440-9
5 World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. 2020;:12.https://www.who.int/internal-publications-detail/clinical-management-of-...(ncov)-infection-is-suspected%0Ahttp://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1... (accessed 29 Mar 2020).
6 National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults. NICE Guidel. [NG159]. 2020.https://www.nice.org.uk/guidance/ng159 (accessed 28 Mar 2020).
Competing interests: No competing interests
Dear Editor
I read with interest your article. Considering the current COVID-19 outbreak, looking at investigation results in a small cohort of patients with suspected COVID-19 infection, the author observed that 10 out of 13 patients (77%) had a reduced eosinophil count of 0.0.
It is a known fact that eosinophils are potential targets of virus attacks and more importantly that eosinophils can reduce virus infectivity (1). It has been shown that both isolated human eosinophils and the major eosinophil ribonuclease, EDN (Eosinophil-derived neurotoxin) are effective against viruses (2).
This leads us to two simple hypotheses:
(1) In patients presenting with or without symptoms of temperature, cough or breathlessness, currently considered to be COVID-19 symptoms (3), a simple blood test in the form of a Full Blood Count to check the eosinophil count might be a quick enough test for medical staff be able to take adequate precautionary measures and initiate early management.
(2) Perhaps our research into finding a cure for the COVID-19 infection should concentrate on eosinophils and their derivatives if not already being done.
References
(1) Rosenberg, H.F., Dyer, K.D. & Domachowske, J.B. Eosinophils and their interactions with respiratory virus pathogens. Immunol Res 43, 128–137 (2009). https://doi.org/10.1007/s12026-008-8058-5
(2) Joseph B. Domachowske, Kimberly D. Dyer, Cynthia A. Bonville, Helene F. Rosenberg, Recombinant Human Eosinophil-Derived Neurotoxin/RNase 2 Functions as an Effective Antiviral Agent against Respiratory Syncytial Virus, The Journal of Infectious Diseases, Volume 177, Issue 6, June 1998, Pages 1458–1464, https://doi.org/10.1086/515322
(3) World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report-51. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situatio... Updated 2020. Accessed March 26, 2020.
Competing interests: No competing interests
Dear Editor,
While our focus unsurprisingly is on the covid-19 impact in hospitals and in the community from a medical and economic perspective, we must think of it from another dimension – mental health.
This will, by no doubt, result in a mental health spike superimposed on the coronavirus pandemic and existing mental health problems in the population. The closure of businesses, schools, shops, recreation centres etc. The separation of friends and families. The isolation of our vulnerable communities. These mitigation strategies are, indeed, vital in successfully overcoming the pandemic. However, these measures leave room for financial, social and psychological burden to individuals.
We must think of our patients suffering through depression and anxiety and how they will struggle during the next few months. What about the psychotic patients managed in the community, will we be able to help them efficiently through isolation measures? The wellbeing of children at home may come to compromise as schools close. The impact on lifestyle, food and exercise may hit harder for those who struggle with eating disorders and body image. And will our homeless population be left to their own devices?
Mentioned are just a handful of concerns among a wide spectrum of mental health related issues ranging from learning disabilities to domestic abuse. We must prepare to address and tackle these problems as the situation evolves.
Competing interests: No competing interests
Dear Editor
The exponential curve continues upwards with little sign of flattening. Nearly all modelling experts seem to agree [1-3] that NHS critical care capacity will soon be overwhelmed, so a radical change in attitudes is needed. We cannot keep deluding ourselves that we can muddle through somehow by producing more ventilators and virus testing kits. Apart from measures to slow the spread of the epidemic, the most urgent action is needed in 3 main areas:
1. Policy for allocation of ICU beds
There will soon be 2, 4, 8, 16… deserving candidates for each ventilator, ECMO unit etc. In this situation the old attitude of “do everything we can for everyone who needs it” is not just unsustainable but actively harmful.
We need HONEST reports of fatality rates and lengths of stay among ICU patients, stratified by age group, etc. So far, precise figures are hard to find, other than a series of 52 cases, treated on ICUs in Wuhan (out of 201 with confirmed SARS-CoV-2 pneumonia) early in the outbreak [4].
Although the numbers were small the pattern was clear: 74% of patients aged 60 or over (90% of those 70 or over) died within 28 days of ICU admission, compared with 25% of those aged under 50.
Even if our figures are better, using ICU for over 60s is bound to deny lifesaving treatment to younger people - and this knowledge must make the experience of dying on ICU with a highly contagious illness even more horrendous, both for patients and families.
For the minority who get ICU care, participation in well organised multicentre research studies should be automatic.
2. Palliative care for those who would normally be considered for, but are denied an ICU bed
Patients sick enough to need hospital admission should be prepared for the possibility that ventilatory support may not be available, and allowed to express their preferences for palliative care. As an over-60 year-old, I have signed a declaration that, in the unlikely event of severe Covid-19 complications, I would choose palliative over ICU care, until the WHO declares the pandemic to be over. I would encourage others to do the same.
3. Support for the less severely ill, mainly focused on keeping them isolated and out of hospital
The vast majority of Covid-19 cases should stay at home, but this is bound to include large numbers of people with associated chronic health issues, both physical and mental. The main focus of the NHS should be on providing practical advice and emotional support for these people. As hospitals fill up, this change will happen inevitably, but it is essential to plan now for all possible situations. Communication is key and steps should be taken to ensure that every vulnerable person living alone has access to an adequate (smart) phone or computer and a designated health advisor. As well as primary care teams, this could include retired doctors, nurses and other professionals. Again, possible arrangements for palliative care should be considered.
It is understandable that images of heroic but exhausted health care staff, battling against increasing odds, are promoted in all media, and public gestures of support such as #clapforourcarers are a welcome boost for morale, but for many of us the realities are likely to be less glamorous and much grimmer.
1. Ferguson NM, Laydon D, Nedjati-Gilani G, et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand.
https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-... Accessed: 22nd March 2020.
2. Jombart T, Nightingale ES, Jit M, et al. Forecasting critical care bed requirements for COVID-19 patients in England.
https://cmmid.github.io/topics/covid19/current-patterns-transmission/ICU...
3. Deasy J, Rocheteau E, Kohler K, et al. Forecasting Ultra-early Intensive Care Strain from COVID-19 in England. Preprint uploaded to medRxiv MEDRXIV/2020/039057 (awaiting checks and update, v1.1.0)
4. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med, Published Online February 21, 2020. https://doi.org/10.1016/S2213-2600(20)30079-5
Competing interests: No competing interests
Dear Editor,
One of the unforeseen challenges would be ensuring the safety of patients who would normally be residing within the hospital at this time of year. A large proportion of these patients would be individuals over the age of 60. This makes the current population "sitting ducks" for acquiring COVID-19 should a COVID-positive individual be placed within the immediate area. Our department is generally populated with a mixed-age group of patients with numerous multiple co-morbidities which places them in a very risky situation. Immediate departmental recommendations have been put in place to safeguard these patients including; limitation of number of visitors, higher thresholds for home visits and ward leave, limitations on social dining , and therapy sessions limited to the immediate bed space until sufficient isolation experienced by new admissions. The national shortage of PPE is disappointing and will, undoubtedly, have significant consequences. Therapists are at risk of contracting COVID on the basis of contact time. These issues indicate the need for an urgent national guideline on how to ensure continued access to rehabilitation could be achieved within a high risk group at a time when the NHS could do with the improved bed flow.
Competing interests: No competing interests
Dear Editor,
Having been sent away from the wards and told there will be no requirement to complete the remaining two months of our training, many final year medical students are waiting in the wings. Whilst your editorial suggests that we will be registered and working earlier than August, both the GMC and BMA have sent out guidance suggesting this will not be the case. Many students have already completed both final examinations and the Prescribing Safety Assessment and feel ready to start work as junior doctors. I would suggest that there is little difference between an April and an August start date, and that our training may be considered more up-to-date than doctors who have been in retirement. It should also be noted that doctors who have retired may be in the ‘higher risk’ age bracket as determined by the government, compared to mostly younger medical students. In such unprecedented times of international need, it seems that bringing forward our start date is necessary and good common sense. However it must be done sooner rather than later.
Competing interests: No competing interests
Re: Challenges for NHS hospitals during covid-19 epidemic
Dear Editor
We read with interest your comprehensive description of the reorganization process involving the NHS during Coronavirus Disease 2019 (COVID-19) epidemic.
Reducing the burden on the NHS and preserving the health of professionals working in hospitals are crucial to face the “tsunami” which is hitting the UK.
In China and in Italy, more than 3000 health care workers have been infected and some of them have died. In the absence of vaccines and a tailored treatment, interpersonal distancing in hospital settings, Personal Protective Equipment (PPE) and testing represent some key tools to tackle COVID-19.
Despite the established evidence that coronavirus transmission occurs mostly via symptomatic individuals, there are reports of asymptomatic individuals who have transmitted the disease to their family members (1). These reports raise the concern that pauci- or asymptomatic doctors and nurses may act as carriers of coronavirus in hospital, and highlight the need to avoid cross-infection.
Social distancing is recognized as one of the most effective strategies to decrease the coronavirus diffusion indoors and out. In light of other countries’ experiences, medical staff should be encouraged to take interpersonal distance during training sessions and meetings and limit socializing moments for the unforeseeable future. Videoconferences and webinars are more than ever excellent tools to maintain the multidisciplinary approach to patients.
Since coronavirus is transmitted mainly through droplets, the use of surgical masks with patients who do not have COVID-19 could help to limit the virus diffusion and the burden on the NHS. Someone has suggested that it would be reasonable to ask vulnerable inpatients to wear a mask when sent for radiological exams and other investigations.
In a study of outpatient health care professionals, medical masks applied to both patient and caregiver provided similar protection as N95 masks in the incidence of influenza among caregivers who were routinely exposed to patients with respiratory viruses (2).
At present, Public Health England (PHE) recommends that health care workers should wear a surgical mask in cohorted areas and a FFP3 mask when performing aerosol producing procedures in possible or confirmed COVID-19. To ensure that this war is going to be won, sufficient resources and equipment should be guaranteed to all staff working with COVID-19 patients throughout the pandemic. Given the risk of shortage of supply, hospitals and research are already trying to identify strategies allowing an extend use and/or safe reuse of face masks.
Limiting the unavoidable shortage of healthcare workers constitutes another aspect to work on. A large number of NHS professionals will get infected and will have to stay away from work for at least 7 days. Ruling out COVID-19 among those doctors and nurses who experience flu-like symptoms due to other respiratory viruses will prevent unnecessary prolonged quarantine. PHE is planning to use polymerase chain reaction (PCR) testing to determine which NHS workers currently have COVID-19. The question is whether an adequate supply of these tests will be available in the short and long term.
Finally the NHS could have had substantial support from the population, but this did not happen. After people failed to follow the advice of avoiding mass gathering, on the 23rd of March 2020, the Prime Minister took draconian action by imposing the national lockdown which is likely to last for a few months.
Someone could argue that this kind of action is a violation of individual rights. Indeed we are going to trade a bit of our freedom for the health of the public and the survival of the NHS, which risks being overwhelmed. These are unprecedented times and should be faced with unprecedented resilience, sensibility and maturity. We all are called to keep calm and do something exceptional.
Competing interests: No competing interests.
Giuseppe Maltese, Consultant Physician in Diabetes, Endocrinology and Geriatric Medicine, Epsom and St Helier University Hospitals, London, United Kingdom.
Sergio Bonini, Professor of Medicine, Institute of Translational Pharmacology, Italian National Research Council, Rome, Italy.
References
1. Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA. 2020.
2. Radonovich LJ, Jr., Simberkoff MS, Bessesen MT, Brown AC, Cummings DAT, Gaydos CA, et al. N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial. JAMA. 2019;322(9):824-33.
Competing interests: No competing interests