COMMENTARY

COVID-19 in A&E: Conflicting Advice

Dr Dan O'Carroll

Disclosures

February 24, 2020

The Royal College of Emergency Medicine (RCEM) winter flow project has demonstrated marginal improvements in some of the measured parameters, but worryingly showed that for the first time more than 100,000 patients endured trolley waits of over 4 hours, and that 'corridor care' remained a frequent unpleasant experience for both patients and staff.

It really does not require much imagination to see that even a small increase in attendances could seriously threaten the ability of many emergency departments (EDs) to provide safe care.

'Killer Virus'

Reports of the coronavirus (COVID-19) started in early January, and many mainstream media outlets have used dramatic and fear-inducing language, describing it as a 'killer-virus', or 'deadly disease', and talk of ‘super-spreaders’ has increased public anxieties. I’m aware of EDs having to field enquiries from anxious members of the public concerned that they may be at risk of coronavirus due to: the bottled beer ‘Corona’, or opening some newly-imported trainers from China, as well as people of Chinese heritage who were concerned in case the disease was hereditary.

https://twitter.com/ksh_safety/status/1229922315477094400?s=20

Healthcare providers in the UK looked on fearfully as news of this new disease started to emerge from China, and those of us working in the acute setting were worried about how we would cope should this virus evolve in a similar  fashion to the last global pandemic, swine flu (H1N1) just over 10 years ago. Those of us that were working in some of the worst affected EDs during this last pandemic remember daily attendances almost doubling overnight with all of the logistical problems of trying to isolate suspected cases to prevent further transmission and to treat those who were affected more severely. This was carried out in EDs which were far less crowded than those we find ourselves in now. Between April 2009 and March 2010 more than 800,000 people contracted swine flu, of whom 26,000 were hospitalised and 342 died.

As it stands, even as a medical professional, it has been difficult to keep up-to-date with the current situation, with the advice changing on an almost daily basis. The latest guidance for investigation and initial clinical management of possible cases of COVID-19 throws up some interesting logistical problems for our already overstretched EDs.

Image Credit: Dr Dan O'Carroll

COVID-19 in EDs

How are the EDs coping with suspected cases of COVID-19?

Firstly, and this is one of the problematic areas to get across to the public, patients with symptoms suggestive of COVID-19 should not attend the ED. The NHS website advises that the main symptoms of coronavirus are a cough, high temperature and shortness of breath and that anyone with a history of travel to affected areas or direct contact with a confirmed case of coronavirus within the last 14 days should self-isolate and call 111.

Unfortunately, even with this clear advice, the dynamic nature and rapidly changing advice has resulted in some cases of NHS 111 directing asymptomatic patients to the ED for testing, as there is a lag in dissemination and uptake of the new guidelines.

Image Credit: Dr Dan O'Carroll

EDs have developed novel approaches to attempt to isolate self-presenting/walk-in patients who think they may have contracted the virus. Some departments have big signs at the entrance directing these patients to newly installed pods.

Image Credit: Dr Dan O'Carroll

These pods have telephones from which the patient can then call 111, and appropriate travel and contact history can be taken to decide if further tests and swabs are required. Other departments have instructed reception staff to provide the patient with a face mask and direct them to a marked area outside the department where a member of staff will 'eye-ball' the patient (no closer than 2 metres) and decide if any further tests or admission is required.

 

Governance

This does raise some questions regarding governance, as the patients will not have been registered at the ED, and they may be discharged following minimal assessment with no observations being recorded. From my point of view, I can see [potential] problems with discharging 'worried-well' patients following such a minimal assessment, especially with the previously mentioned media reporting.

Interestingly a colleague had suggested that as this is a public health issue, these swabs and brief assessments should be carried out by infection control teams rather than the already over-stretched ED staff, but this was quickly dismissed as the teams were too busy.

Patients that are arriving at EDs via ambulance are being risk assessed and swabbed in the back of the ambulance and returned home, if well enough, so continue self-isolation. It is planned that patients who are unwell and require admission to hospital should be isolated in high consequence infectious disease (HCID) treatment centres.

And it is now rumoured that teams are being set up that may be able to attend patients that have appropriately self-isolated at home, to carry out the necessary testing there.

Globally, it seems that the mortality rate is relatively low and mainly associated with pre-existing medical conditions, but the highly infectious nature of the disease may mean that the impact felt by the NHS and its users may be much more severe than the swine flu pandemic 10 years ago.

It seems, at this point, that this will cause fewer problems and deaths than 'normal' seasonal influenza, which was associated with 26,408 deaths in England in 2017/18, and this is probably the best outcome that we can hope for until the next pandemic. Lessons are being learned and systems being tested to try to ensure that we are as well prepared as we can be for future events, particularly if they are more virulent.

Beards

It seems that having a beard means that you are not eligible to be fitted with appropriate PPE (personal protective equipment) against COVID-19, as the masks lose their effectiveness due to beards preventing successful fitting of said masks. Source: Health and Safety Executive.

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