COMMENTARY

A&E Perspective: COVID-19 — What Next?

Dr Dan O'Carroll

Disclosures

May 18, 2020

As the UK seems to be coming through the first peak of the COVID-19 pandemic, the population and the NHS are wondering, what happens next?

Dr Dan O'Carroll

I know that I'm not the only emergency medicine worker who has been surprised at how well the emergency departments (ED) across the country have coped with this unprecedented, novel infection, and there are many of us who would, undoubtedly, prefer our current working conditions and (relatively) empty departments compared to pretty much every day that we've faced over the last 10 years. This is borne out by the recently released NHS England figures that show the total of attendances in April 2020 to be only 917,000, a decrease of 56.6% compared to the same month the previous year.

That's more than 1,000,000 fewer attendances in a month and represents the lowest number since the records began! There were 327, 000 emergency admissions, which was 39% lower than April 2019. The number of patients admitted, transferred or discharged within 4 hours is the lowest reported, but the performance reported against the 4-hour target was 90.4%, which is a significant improvement on recent months/years.

Staggering

The change in the number of ED attendances is staggering and really goes to show that a great deal of what we saw normally really didn't need to be seen in the ED. It has shown that the general public have been capable of managing their own minor problems or have sought assistance from other sources eg, NHS 111 or local pharmacies. But many of us are growing increasingly concerned about the serious pathology that seems to have gone missing. Surely the public are still having their major medical emergencies? Whether that be acute coronary syndromes, including heart attacks, or strokes, or acute surgical emergencies, such as bowel perforations. What has happened to these patients? It’s unfeasible to think that all of them have stayed at home and not presented for medical attention at all, as symptoms can often be severe and may be life-threatening. Or are these patients in the same cohort that are attending and requiring admission with suspected or confirmed COVID presentations? Could it be that during lockdown, and with normal life seemingly on-hold, there are fewer of these acute medical emergencies taking place?

There have been attempts by the Royal College of Emergency Medicine (RCEM) and the Academy of Medical Royal Colleges to reassure the public and to encourage them to return to the EDs or other healthcare providers should they be suffering from potentially serious problems. With this in mind it does appear that the number of cardiac diagnoses has returned to pre-COVID levels.

New Normal

And although it is reassuring to some that this genuine ED workload is returning, it is also hugely concerning for many. It seems that this COVID pandemic is not likely to be over any time soon, and it means that EDs are now having to make plans for how to deal with this new normal. We simply cannot go back to the dangerously overcrowded departments and corridor medicine being an almost acceptable norm. If this were to happen there is no doubt that many patients would come to harm, and staff safety would likely be compromised too. The days of long trolley waits in the ED, often resulting in patients being 'doubled-up' in cubicles designed for one trolley or even parked waiting in corridors have got to be consigned to a shameful historical note.

Social distancing, which thankfully appears to have been embraced by the general public in places such as supermarkets and is requirement for workplaces as lockdown measures are being eased, will need to be enforced within our EDs too, many of which were already too small for the number of patients that were treated in the recent past. How are we going to enforce this? Are we going to follow the supermarkets' lead and queue the walk-in and ambulance patients on the forecourt as the department is already full? Perhaps there would be some merit in that, as I know of many people that have abandoned shopping trips due to the length of the visible queue as they approach.

Ticking Time Bomb

Previously we have used many different metrics eg waiting time to be seen or delay from referral to admission, to try to recognise when the EDs are becoming full, to try to make our responses more proactive. But these, although sometimes useful in the past, will not be adequate in the post COVID NHS. Occupancy has got to be the single most important metric going forwards, as the risk of hospital-acquired infection due to overcrowding will be a real threat to staff and patients alike.

The concerning ticking time bomb for the health system as a whole is the huge drop off in cancer referrals that occurred - NHS England stated that they had dropped down to only 10,000 per week by mid-April, as opposed to the 40,000 that were usually made. This has shown some recovery since then and had subsequently doubled. A huge percentage of elective care was also put on hold to improve the bed availability that may have been required for the surge in COVID patients. This has meant many more patients suffering longer waits for surgery, and, like the delays in cancer diagnosis, will inevitably shorten lives in some cases.

Necessity is the mother of invention, and there are many changes that have been made that should be considered a success and continued before returning to the situation that we had before. Many specialties, including primary care, have successfully implemented telephone or video consultations, and should this prove to have been safe when analysed in the future, its expansion should be explored.

The somewhat muddled messages coming out from the Government on the easing of the lockdown measures has caused disquiet amongst many of my colleagues and we await the seemingly inevitable second spike in COVID-19 in the coming months.

I'm afraid the seeming reliance on the Great British public's common sense seems to have completely forgotten the mass hysteria and panic buying of toilet roll at the onset of this crisis.

I hope to be proved wrong.

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