Covid-19: UK government is urged to publish daily care home deaths as it promises more testing
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1504 (Published 15 April 2020) Cite this as: BMJ 2020;369:m1504
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Dear Editor
COVID-19 represents a challenge for modern Health Care Systems, due to the mismatch between the number of patients and hospitals' capabilities. Waves of hundreds of patients, day after day, for a prolonged period of time, easily overwhelm any mass casualty protocol. Ferguson estimated that the total number of infected within European countries could amount to anywhere between 1,5% - 15% of the total population, translating to 6 million infected people in Italy, and 7 million in Spain. To put these numbers into context, data published estimates that 10% of COVID-19 positive patients will require admission to an intensive care unit (ICU).
Furthermore, it is important not only to consider the total number of patients requiring ICU capabilities, but also their condition and clinical history. Our experience in Northern Italy has been that many present to the hospital after spending 10-15 days at home, with fever and cough, without any medical therapy. The COVID-19 interstitial pneumonia is characterized by terminal alveolar damage, that results in a discrepancy between histopathologic findings, the clinical signs and patient’s subjective feeling. Many symptomatic COVID-19 positive people do not comprehend the seriousness of their condition, even when they are clearly in respiratory distress. The fear of in-hospital contagion further explains the delay in seeking medical attention.
At the time of presentation to the Emergency Department, this patient population arrives in a state of dehydration, often suffering from thrombosis of the vessels and a bilateral interstitial pneumonia. Patients in this condition are strictly dependent on oxygen and some are even positive end-expiratory pressure dependent.
In lieu of the growing numbers of patients presenting to the hospitals in serious condition (after delaying care until they deteriorate), it was obvious that intensive care therapy could be the solution. An earlier intervention was needed to try and reduce the burden on the over-extended intensive care capabilities. We must not only concentrate on delivering the best medical care, but on understanding the right timing.
In this context, the military deployed medical system provides a perfect perspective: organized in a system of echelons, with front line buddy aid and battalion aid stations, through forward resuscitation and surgical teams, all the way back to the field hospitals. Proving “front line” care allows for an opportunity to be more effective and increases the chances of saving more lives. In a way, this is the equivalent of an earlier “Damage Control” management protocol or the Golden Hour concept, familiar from the field of trauma care.
The COVID-19 therapy paradigm has to change from a hospital-based to a house-based framework. Patients must be treated sooner rather than later, to avoid hospitalization at a late stage of their illness. For COVID-19 patients, the right timing could be as beneficial as the right therapy to stop the inflammatory ascending climax.
Medical systems perform best when not overwhelmed or in distress. We believe that a pre-hospital protocol could substantially reduce the hospitalization rate, avoid war-like triage situations, the shortage of ICU beds and thus save many lives.
Competing interests: No competing interests
Re: Covid-19: UK government is urged to publish daily care home deaths as it promises more testing
Dear Editor,
It is right that coronavirus testing is provided for care home residents and staff, however, it is important that an increased COVID -19 mortality rate within care homes is not automatically equated with a failure of community healthcare systems. For many older people, with significant frailty, the decision to go to hospital will be based on whether the admission will improve the likelihood of a return to their pre-morbid function. With increased testing capacity, quantifying the reversibility and benefit of hospital admission in people with confirmed or suspected COVID -19 infection is likely to become a frequent challenge in the community setting.
At present, there is a lack of prognostic evidence or data indicating the characteristics of those patients with COVID-19 who survive a hospital admission. What is clear, is that the morbidity and mortality of COVID-19 significantly exceeds other commonly occurring viral and bacterial lower respiratory tract infections. Western Sussex Hospitals NHS Foundation Trust is an acute hospital trust that has had 200 in-patients return a positive COVID -19 test since the 2nd of March. Over a third of patients were 80 years or older (n=72). Of those with a completed outcome (i.e. excluding those still in hospital) 61% died, compared to 28% for those <80 years. The median length of stay for the remaining 27 in-patients over 80 years is 11 days. To date, only one patient over 80 years has been admitted to critical care. We recognise the limitations of stratifying outcome based only on age and work is underway to incorporate additional markers of frailty when considering outcome predictors in patients with COVID-19.
It is crucial when making the decision to admit to secondary care that the wishes of the person and their kin are considered alongside the specific clinical context and likely efficacy of more advanced treatment. Our preliminary data indicates the potentially limited benefit of hospital admission for a cohort of elderly patients with COVID-19, a disease that currently has no curative treatment, with management in hospital purely supportive. The hospital environment, particularly for older, frail people is not without a significant risk of associated harm (1) and decisions to admit and escalate care are often a delicate balance of risk and benefit.
Our health and social care system must ensure adequate resources, including palliative, are available to holistically and compassionately manage people, for whom hospital admission is deemed inappropriate. Finally, it is imperative to share and review outcome data across primary and secondary care to enable accurate prognostication to help inform individualised decision-making for our population.
1. Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: Systematic review and meta-analysis. BMJ. 2019;366:l4185.
Competing interests: No competing interests