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
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Dear Editor
In the COVID-19 epidemic era, one of the most important challenges is being able to keep all patients and operators safe from the risk of infection. 1 In neurorehabilitation hospitals, as well as post Intensive Care Unit (ICU) department, there are normally a large number of frail inpatient or outpatients who come, that are at risk subject to develop a SARS-COV pneumonia. Although it is possible to divide COVID patients from non-COVID patients with rigorous hospital path, with dedicated and well equipped staff, actually there are no indications with subjects who has had a COVID-19 infection and is now negativeized (after two negative oropharygeal swab).
This emerging and urgent problem was recently highlited by the evidence of a possible fecal-oral transmission and by the presence of viral shedding weeks after the resolution of the COVID-19 infection.2 Addressing this point with a specific protection and risk management plan (for example contact protection, different rehabilitation areas, specific indications for biological fluid management) will be fundamental for national health systems to reduce the risk of infection from a mode that has been ignored today.
Finally, more and more subjects after COVID (many of these with negative oropharygeal swab) will need a rehabilitation program to improve respiratory and mobility function post SARS-COV pneumonia after ICU stay and/or after specific neurological sequels linked to COVID-19 infections as stroke or guillain barre sybdrome,3 and how this subjects could be considered non-infectious is a challenge.
1. Willan J, King AJ, Jeffery K, Bienz N. Challenges for NHS hospitals during covid-19 epidemic. BMJ. 2020 Mar 20;368:m1117.
2. Ding S, Liang TJ. Is SARS-CoV-2 Also an Enteric Pathogen with Potential Fecal-Oral Transmission: A COVID-19 Virological and Clinical Review. Gastroenterology. 2020 Apr 27. pii: S0016-5085(20)30571-0
3. Helms J, Kremer S, Merdji H, et al. Neurologic Features in Severe SARS-CoV-2 Infection. N Engl J Med. 2020 Apr 15.
Competing interests: No competing interests
In 2017, during the Ebola crisis, the New England Journal of Medicine published a stimulating editorial raising the need to develop an international framework for a rapid and effective response to epidemics (1). Unfortunately, this appeal was not heeded. As a consequence, the health care systems of many countries have been found unprepared for the outbreak of COVID-19.
In the UK, the challenges for the NHS hospitals have been thoughtfully discussed by Willan and co-workers in their editorial recently (2). The authors describe a complex reorganization of the workforce and infrastructures aimed to face the COVID-19 outbreak while protecting the health of professionals working in clinical and non-clinical settings.
We think that the NHS has to face also some additional challenges related to peculiar aspects of SARS CoV-2 diffusion and strategies adopted to tackle it.
It is indisputable that, in the absence of any preventive treatment, isolation, interpersonal distancing, identification and quarantine of infected subjects, represent draconian interventions with a substantial impact on the coronavirus spread (3). In the UK, the delay in applying these strict measures (3) more timely adopted by other countries (https://www.covid19healthsystem.org/searchandcompare.aspx), will possibly translate into a high number of positive cases and deaths before the suppression of COVID-19 will be effective (4).
According to recent estimates, only 4.4 to 15% (2, 5) of infected subjects are expected to be admitted to hospitals, whereas the rest will stand on the shoulders of primary care and community health workers. In fact, based on the guide of the NHS London Clinical Networks (6) only consenting subjects with one or more specific symptoms (drowsiness, unconsciousness, new-onset confusion, dizziness, inability to make sentences due to shortness of breath, cardiac chest pain) and alarming clinical features (O2 saturation ≤93%, heart rate>110 b/min, signs of sepsis or other emergency signs) should be transferred to hospital. It is therefore left to primary care and community health workers, managing the majority of infected subjects and go through the complex triage pathway proposed by the London Clinical Networks (6). It should also be considered that the number of positive cases by SARS CoV-2 with minor symptoms is definitely higher than the number of those with the infection confirmed by a swab (and reported in official daily bulletins) (3).
Are the NHS and the community health workers ready to face this medical and humanitarian crisis? Also, are there adequate measures to protect the health of these workers and avoid that a large number of them will be away from work due to SARS CoV-2 infection?
Despite the practical guide for GPs and primary care workers (7), the answers to these questions are not reassuring, given the concerns expressed by these professionals (8) and the experiences of other countries which are some weeks ahead in the fight against COVID-19. In Italy, the country with over 100,000 people infected and more than 13,000 deaths, the inadequacy of the community services was a major bottle-neck in facing the increased demand for care. It has been reported that over 10,000 health workers have been infected and more than 100 died. This is picture is even more meaningful if we consider that in Italy the criteria for admission to hospital were less stringent, with approximately 40% of patients hospitalized.
Thus, we think that the upcoming challenge for the primary and community health care should be carefully taken into consideration, also to avoid an excessive pressure on hospitals and intensive care units.
Another challenge for the NHS is worthwhile to be mentioned.
In order to cope with the outbreak, the medical workforce in UK will shortly include newly graduated medical students, academics, researchers and retired doctors who have been encouraged to return to medical practice by the GMC (2). Their support certainly appears valuable and reassuring, but may not guarantee those up to date clinical skills required to manage patients needing intensive or sub-intensive care.
On the contrary, we believe that academics and scientists should play a different and more appropriate role in the fight against COVID-19 pandemic, more in line with their professional experience.
Biologists have described the biology and the structure of SARS Cov-2 (9) and have partially elucidated the mechanisms of cell infection (10.11). This biological background represents the substrate for the development of target-specific drugs.
Epidemiologists have provided insights into modes of transmission, incubation period, incidence and lethality of Coronavirus.
Clinical researchers should be asked to design and launch well-designed clinical trials. So far, while waiting for a vaccine, the attempts of identifying an effective treatment for COVID-19 have been disappointing. Only 446 papers of those indexed on PubMed explore potential treatments, and to our knowledge only one reports the (negative) findings of a randomized controlled trial (12). We recognize that it is extremely difficult to ensure high quality research during an outbreak, as the investigators have often to prioritize patients care in environments which are particularly overwhelmed. However, conducting randomized clinical trials, particularly the ones with an adaptive design, is the only way to identify effective and safe therapies for COVID-19.
Finally but not least, scientists should make special efforts to improve tests for SARS CoV-2 detection and validate the immunoassays detecting the antibodies (13).
We think that academics and researchers should be encouraged to give a contribution in their field of expertise rather than being redeployed and allocated to a general medicine ward.
At this stage, it is arduous to predict whether Brexit will influence the COVID-19 war and/or vice versa. What is certain is that Covexit will not remain confined to the hospital setting. We should expect a long and exhausting fight that will involve all health care workers, citizens’ compliance and international collaboration.
Sergio Bonini 1, Giuseppe Maltese 2
1 Institute of Translational Pharmacology, Italian National Research Council, Rome, Italy; 2 Epsom and St Helier University Hospitals, Surrey, United Kingdom.
References
1. Baden LR, Rubin EJ, Morrissey S, Farrar JJ, Drazen JM. We Can Do Better - Improving Outcomes in the Midst of an Emergency. N Engl J Med. 2017;377(15):1482-4.
2. Willan J, King AJ, Jeffery K, Bienz N. Challenges for NHS hospitals during COVID-19 epidemic. BMJ. 2020;368:m1117.
3. Ferguson NM LD, Nedjati-Gilani G, Imai N et al. Imperial College COVID-19 Response Team. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID- 19 mortality and healthcare demand. 2020.
4. Flaxman S MS, Gandy A, Unwin HJT et al. Imperial College COVID-19 Response Team. Estimating the number of infections and the impact of non- pharmaceutical interventions on COVID-19 in 11 European countries.
5. Mahase E. Covid-19: outbreak could last until spring 2021 and see 7.9 million hospitalized in the UK. BMJ. 2020;368:m1071.
6. Primary Care and Community Respiratory Resource pack for use during COVID-19. NHS London Clinical Networks; 2020.
7. Razai MS, Doerholt K, Ladhani S, Oakeshott P. Coronavirus diseases 2019 (COVID-19): a guide for UK GPs.Br med J 2020;368 DOI: 10.1136/bmj.m800
8. Horton R. Offline: COVID-19 and the NHS-"a national scandal". Lancet. 2020;395(10229):1022.
9. Gorbalenya AE BS, Baric RS, de Groot RJ et al. Severe acute respiratory syndrome-related coronavirus: The species and its viruses – a statement of the Coronavirus Study Group. Nat Microbiol 2020.
10. Yan R, Zhang Y, Li Y, Xia L, Guo Y, Zhou Q. Structural basis for the recognition of SARS-CoV-2 by full-length human ACE2. Science. 2020;367(6485):1444-8.
11. Lan J, Ge J, Yu J et al. Structure of the SARS-CoV-2 spike receptor-binding domain bound to the ACE2 receptor. Nature. 2020.
12. Cao B, Wang Y, Wen D et al. A Trial of Lopinavir-Ritonavir in Adults Hospitalized with Severe Covid-19. N Engl J Med. 2020.
13. C S. Fast, portable tests come online to curb coronavirus pandemic. Nature Biotechnol. 2020.
Competing interests: No competing interests
Dear Editor,
The authors’ acknowledgement of the challenges posed by this pandemic to the wellbeing of healthcare staff is welcomed. If the NHS workforce does indeed represent our most valuable asset, then efforts to protect such a precious resource must go further than skin-deep. Much has been written about the inconsistent and limited access to PPE for medical staff across the United Kingdom. However, attention must also be drawn to addressing the mental health needs of an NHS workforce who are tasked with working within a healthcare climate which seems more alien, uncertain and unpredictable each day. To realistically ensure that these needs are met, it is likely that we will need to take matters into our own hands. We must work together to find tangible, systematic and creative ways of responding to these inner challenges. And, as workforce of those who devote their lives to caring for others, we must be willing to invest time in caring for ourselves.
To use an analogy: when approaching a patient’s bedside, we don PPE. We do this to protect the physical health of ourselves and others. In the same way, it is time to appreciate the value of taking active measures each day to protect our wellbeing so that we can most ably meet the challenge that this pandemic presents to our mental health. Doing so will serve to protect our own vitality, and, by helping to sustain our efforts at work, it will protect those we care for in a healthcare setting.
To enable NHS workers to take these daily measures to fortify their wellbeing, we have created the online platform Beat COVID: Get Prepared at www.beatcovid.co.uk. The site is powered by a team of volunteers which includes doctors, medical students, and health and fitness professionals. It provides daily content from expert contributors - offering Mindfulness sessions, home workouts, yoga sequences, sleep advice and nutrition blog posts. All content is freely available and geared toward to the unique challenges that the COVID-19 outbreak presents to healthcare workers.
The response to release has been overwhelming. In its first week, over 3,000 NHS staff used the platform. Hundreds of workers continue to return each day to don their own individual flavour of PPE when it comes to looking after their mind and body. Whether meditating, exercising, cooking or sleeping more soundly, it is heartening that staff are making time to create foundational routines of wellbeing to prepare themselves for the turbulent conditions of current times.
Greater challenges doubtless await us. Life in the NHS and at home remains up in the air. But it is important to realise in coping with this increasingly bizarre scenario, there are so many things that we cannot control. By taking the time each day to look after ourselves, it makes sense to start with something that we can.
Competing interests: No competing interests
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
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
Maintaining Surgical Skills Through Simulation During COVID-19
Dear Editor,
The current COVID-19 crisis has caused significant disruption across all surgical specialties with departments experiencing a drastic change in their operational procedures. The cancellation of all elective surgery is likely to have an unprecedented effect on training. This is further exacerbated by trainee deployment to other clinical areas. An important issue to address during this period is maintenance of surgical skills, not only for less experienced surgeons, but also senior trainees and consultants.
Microsurgery is an area where skill fade can be rapid and areas such as cataract surgery require interval repetition, with intervals being shorter for less experienced the practitioner. A General Medical Council scoping review of this area when reviewing fitness to practice for doctors undergoing career breaks noted that technical skills, in particular fine motor skills, declined fastest with non-use.(1) There is also evidence suggesting that actively practicing these skills in an interval period increases both proficiency and confidence. Scerbo et al found that a single refresher session almost fully reversed any skill fade in technical skills occurring between 1 and 5 months after acquisition. (2) It is likely that disruption to elective surgery secondary to COVID-19 will last longer than this.
Regular simulated surgery sessions during this period may well provide an answer to this important problem for training surgeons. Taking cataract surgery as an example, the UK Royal College of Ophthalmologists has integrated simulation into their trainee curriculum and thus most ophthalmology units in the United Kingdom have access to the EyeSi® simulation system, which has been shown to correlate highly with real-life surgical performance.(3,4) This may prove to be a crucial method of surgical skill maintenance during this period in terms of both technical proficiency and patient safety.
The amount of simulation training required to maintain surgical skill during absence is another interesting area with particular relevance for cataract surgeons. Ho et al describe a ‘minimum volume threshold’ of case numbers to maintain competence for ophthalmic surgeons and suggested a minimum annual number of cataract surgeries of 50, given that there are published complication rates below 0.8% for consultants performing 50–250 cataract procedures annually.(5) This equates to an approximate minimum of 5 simulated cataract surgeries a week for cataract surgeons, for example. This number would likely vary amongst different specialties and procedures but we feel it would be prudent for departments to address this issue during this indeterminate period of uncertainty secondary to COVID-19.
References
1. General Medical Council - Skills fade: a review of the evidence that clinical and professional skills fade during time out of practice, and of how skills fade may be measured or remediated – Dec 2014 https://www.gmc-uk.org – Accessed 18/04/20
2. Scerbo, Mark & Britt, Rebecca & Montano, Michael & Kennedy, Rebecca & Prytz, Erik & Stefanidis, Dimitrios. (2016). Effects of a retention interval and refresher session on intracorporeal suturing and knot tying skill and mental workload. Surgery. 161. 10.1016/j.surg.2016.11.011.
3. https://www.rcophth.ac.uk/wp-content/uploads/2015/06/Surgical-Skills-Sim... Accessed April 2020
4. Thomsen, Ann Sofia & Smith, Phillip & Subhi, Yousif & La Cour, Morten & Tang, Lilian & Saleh, George & Konge, Lars. (2016). High correlation between performance on a virtual-reality simulator and real-life cataract surgery. Acta Ophthalmologica. 95. 10.1111/aos.13275.
5. Ho J, Claoué C. Cataract skills: how do we judge competency? J R Soc Med 2013;106:2–4
Competing interests: No competing interests