The UK’s main initial preparations for the first COVID wave involved reconfiguring urgent and emergency care systems, increasing ICU and bed capacity, and enhanced infection control measures in healthcare. Concerns about sustainability in the long term are discussed
In late 2020, less than a year after reports of a new virus first emerged from China, we are only just beginning to appreciate the potential impact of the COVID pandemic on healthcare in general, and on emergency care in particular. This view offers one perspective on our journey so far.
As information started flowing about the potential impact of COVID on emergency care, our initial preparations focused on:
- Reconfiguring prehospital care and Emergency Departments (EDs)
- Increasing and reconfiguring ICU capacity
- Increasing general hospital bed capacity, and developing separate streams for COVID patients
- Reconfiguring the wider system.
Initial thinking centred on what seemed likely to be an overwhelming surge of patients requiring hospitalisation, intensive care and/or ventilation.
For EDs, the focus was on protecting staff and patients and generating additional capacity, while maintaining core business. This primarily involved the adoption of more stringent IPC measures, and separation of flows so that patients deemed at higher risk of COVID were managed in cohorted areas or were treated in rooms deemed more suitable for aerosol-generating procedures (cubicles). In many departments, there was rapid adaptation of existing facilities, or co-located areas were subsumed into the ED footprint to help generate floorspace. In some departments, minor injuries and illness were moved off-site. Additionally, there was widespread development of ambulatory treatment or ‘streaming’ pathways designed to avoid admission. There was improved access to specialist teams, whose availability was in turn enhanced as a result of service reconfiguration and changes to working patterns.
There was considerable attention to generation of ICU capacity within hospitals, with early models suggesting the need for substantially increased numbers of ventilated beds. Additionally, much elective surgery was cancelled nationally to free up inpatient beds, and there was extensive redeployment of clinical teams to acute areas. These included the ED, ICU and inpatient medical floors. Arrangements to improve discharge of ‘medically fit’ patients from hospitals were introduced, designed to reduced ‘delayed transfers of care.’ In England seven ‘Nightingale’ Hospitals were developed, mostly in convention centres, with an additional three hospitals in each of Wales, Scotland and Northern Ireland. These were intended to provide additional critical care capacity.
Underpinning the creation of additional capacity was a massive effort to increase the available workforce. This not only included redeployment, but also the early awarding of medical qualifications to final year medical students, deployment of nursing students to wards, and a call for volunteers from retired staff. There was extensive reorganisation of rotas with cancellation or postponement of what was deemed non-essential work. Regulators produced guidance designed to offer regulatory and legal protection for staff working outside of their normal scope. Planned rotations of medical trainees to different specialities, due in April for the final four months of the training year (August to August) were postponed so that staff were working in areas already familiar to them. Lockdown also resulted in the cancellation of most educational events and exams. This will of course require some unpicking down the line and regulators are working together with training bodies to do this.
Within the wider system there was attention to demand management strategies. Existing prehospital telephone services were developed as a source of enhanced remote clinical advice, with additional clinical support brought on-line. There was also a drive to introduce improved access to alternatives to hospital admission, such as ambulatory care (known as Same Day Emergency Care). Ambulance services focused heavily on prioritisation and the need for conveyance. Many specialties changed the way they delivered care to their most vulnerable patients, again through the use of virtual consultations. The increase in the use of telemedicine extended to many sectors in acute care, including fracture clinics, primary care and mental health services. There was also careful consideration around the value of hospital admissions and end-of-life care for some patients. Many of these changes were welcome, perhaps overdue, but they were implemented at pace and the normal safeguards to ensure they worked as intended may have been missing. In these cases, it is important to consider the changes carefully and adapt them where necessary.
When COVID did start appearing in hospitals, it was doing so contemporaneously with efforts to ramp up capacity. There was an early initial focus on ensuring that staff working in higher risk areas had access to adequate higher-level PPE, and that the risk to patients from cross infection was reduced. The basic pathways adopted in most organisations involved separation of patients more likely to have COVID. These patients were managed through higher risk areas until their COVID status was known, and those who were COVID-positive were then treated in cohorted areas. There was also a need to ensure that access for patients needing the services of EDs and hospitals was maintained. These pathways have subsequently been improved and embedded, such that they are now part of routine NHS practice.
National lockdown was introduced in the face of rising infections. The impact of lockdown on demand for emergency care was profound, with significant reductions in attendances, although patients with more severe illness did continue to present. Possible reasons for this include changes in disease patterns or behaviour, patients being treated by alternative pathways, or anxiety over presenting to hospitals. The balance of each possibility is not fully understood, nor is the harm that may have arisen from delayed presentation for either emergency or less acute care. The impact of COVID itself was more variable, with some parts of the country much harder hit than others. The NHS as a whole was never completely overwhelmed, although some urban hospitals did reach full general and ICU capacity. Nightingale facilities were, in most cases, not required.
During the initial phase of the pandemic crowding disappeared from EDs. This is an observed phenomenon internationally and prompted emergency medicine leaders to call for improvement in the emergency care system to be made so that it did not return. In the UK, the Royal College of Emergency Medicine published ‘COVID-19, Resetting Emergency Care’ with this in mind.
Many organisations reported an improved sense of cohesion, and better collaboration between specialists and the ED. In addition, there was a reduction in bureaucracy and perceived barriers to innovation, with clinicians feeling more in-control. One might observe that the scope to leverage the organisational capacity of the NHS was demonstrated, with the entire national health service across four nations reorientated towards a single problem, whilst at the same time continuing to provide ongoing care for the population as a whole.
Information sharing, along with sharing of experience, was crucial. Within emergency medicine the introduction of video conferencing involving clinical leaders from across the nation has proved extremely valuable and is likely to continue into the future. International networking has also been improved in a similar fashion.
Lockdown eventually suppressed the first COVID peak and has gradually been easing, although at the time of writing there is concern about rising cases. Demand for emergency care has steadily risen from its nadir and is returning to normal. There is concern that the phenomenon of ED and hospital crowding is threatening to return. There are considerable challenges ahead for the emergency care system, particularly as we enter winter with a predicted increase in respiratory illness. Primary care services are still adjusting to the current situation and calibrating what can be safely achieved through virtual consultation, and with the demands of face-to-face assessment of potentially higher risk patients. Similar challenges exist for mental health services. EDs and hospitals now have systems to deal with symptomatic patients, although developments in more rapid testing may help decision making. Acute hospital capacity is believed to be significantly reduced as the result of attempts to distance patients (for instance, by reducing the numbers of patients in shared bays), while elective services have restarted with a need to start reducing backlogs. There is also an imperative to ensure that patients leaving hospital to care and residential facilities are discharged safely with regard to potential contagion.
In the immediate future, the NHS is investing more in forward-facing facilities, with a view to increasing capacity. There is a drive towards improved triage and direction of patients seeking urgent and emergency care to reduce ED attendances and help patients find the best avenue to secure the help they need. There is also a focus on the use of ambulatory care and early specialist involvement in care to avoid admission. The biggest challenge remains around overall acute capacity and workforce, along with the ongoing need to make improvements in hospitals around acute flow, since the main driver of ED crowding in the UK remains exit block. ED crowding in the face of a highly communicable endemic disease, which is so dangerous for many of the patients likely to be in our departments, is even more unacceptable than it was before the pandemic.
COVID 19 has proved an immense challenge to the emergency care system in the UK. The speciality of emergency medicine has demonstrated its ability to adapt to change and work to continue providing care to its patients, whilst the acute care system on the whole has changed profoundly in the face of this threat. The effects will be long lasting, with some of the adaptations likely to become permanent. Although there is a tendency to focus on the technological innovations, it is how we use existing technology that is new. However, it is the changes in culture, resource, and process in our systems that will have the greatest long-term impact, and our ability to learn from mistakes, and embed the positive lessons, which will be the greatest measure of our determination to change.
Ian Higginson BM MSc FACEM FRCEM
Emergency Physician; Vice President of The Royal College of Emergency Medicine, UK