COMMENTARY

COVID-19 A&E Perspective: Iceberg Ahoy

Dr Dan O'Carroll

Disclosures

October 16, 2020

As we were approaching the first wave of COVID-19 infections in the UK many of us questioned whether the UK had fully utilised the time available to prepare as we watched the infection spread globally and overwhelm other health systems, and many commentators felt that this time could have been used more effectively.

The national lockdown put the brakes on the exponential spread of the virus, and the NHS just about coped. The rapidly constructed Nightingale hospitals remained largely unused, trusts nationally were able to bring many more critical care beds into the system, and it appears that there wasn't the predicted shortage of ventilators. But this huge effort by staff and the public did not come without cost. The economy has plunged into its deepest ever recession. Many businesses have closed and people's jobs have been lost, possibly for good.

Government  Predicament

The draconian measures which placed unprecedented restrictions on personal liberties meant that the spread of the virus was managed, and this huge sacrifice bought us time.  Plans could be put into place to open up the economy and limit the potential second wave of infections. This time should have been used to develop a competent test, track, and trace system.  It appears that millions of pounds have been spent but the current system is thought to have had only a marginal impact on identifying cases early and limiting spread of the disease, with suggestions it's identifying as few as 25% of actual cases.

I have sympathy for the Government's predicament over protecting the economy and people's health, but in my view, it should have been possible to do both. It was entirely predictable that once 'normal life' returned, and workers went back to their places of work, children went back to school, and university students returned to their places of study, that transmission of the virus would increase. The failure of the track and trace system to identify these outbreaks in a timely fashion has led to ever increasing restrictive measures needing to be put into place for local areas, with obvious detrimental effects to local economies. Much like the first wave, it seems that Government action is occurring too late. It seems to me that either another national lockdown or a 'circuit breaker' may be needed to regain control and halt the current exponential spread of the disease.

A&Es Starting to Buckle

This failure of policy is now being felt in the country's emergency departments (ED). The first wave occurred over the spring months, when the usual seasonal illnesses were on the decline and a lot of the normal ED workload stayed away, which meant most departments coped well.

A&E performance figures for England for September show that the system is starting to buckle. Although the figures show a 20% decline in attendances compared to the same month in the previous year, the number of emergency admissions increased by 1.2% in August 2020. The performance against the 4-hour target was also markedly improved compared to the previous year (44,983 Vs 64,924), but worryingly the number of 4-hour breeches in September was up by 40% compared to August, meaning the number of patients seen within 4-hours fell to 87.3% compared to 89.3% in August. Probably the most worrying measurable metric on the decline concerns delays from decision to admit to admission. There were 44,983 compared to 32,150 in August. This is worrying because this contributes hugely to crowding within the department. There have already been incidences this year of departments being crowded well beyond their 'COVID-secure' number and this is against the backdrop of increased prevalence of the disease in the community. This means that keeping staff and patients safe is becoming increasingly problematic.

Certainly, there is first-hand experience of many pre-alerts being received for patients with respiratory illnesses, presenting with shortness of breath that have exceeded the immediately available capacity, meaning that patients are having to be moved to other parts of the department to accommodate new arrivals. This even includes cases where patients are known to be positive for COVID, undoubtedly, a greater risk for nosocomial spread of disease than is ideal. Ambulance staff conveying confirmed cases of COVID are sometimes, temporarily, being prevented from entering crowded EDs whilst safe space can be identified.

Nightingales Mobilised

As multiple areas of the country start to see a surge in cases, the problems seen in Liverpool can be expected to spread. Already their Intensive care services are struggling, and as there appears to be a 2-3 week delay from infection to critical care requirement, it's no surprise that the NHS Nightingale hospitals are being prepared again.

This ramping up of pressure is being felt by a workforce already struggling. Many members of staff have not managed their usual summer rest and recuperation, due to travel restrictions and on-going issues with childcare. The on-going management of outbreaks in school age children means that some members of staff are having to stay at home to look after children that have been in contact with a positive case, but are completely fine in themselves. This problem is not unique to NHS staff.

Staff absenteeism is increasing in many trusts. This may be down to sickness, but in many cases is down to the Government requirement to self-isolate due to close contact with community positive cases of COVID. There have been several examples of almost whole departments having to stay at home, some of this exacerbated by difficulties in obtaining tests or delays in receiving results.

The anticipated perfect storm seems to be upon us. There has been a palpable increase in COVID related attendances in large parts of the country, and these are now being dealt with in crowded departments with long waits. It's no wonder that an NHS provider survey revealed that 99% of trust leaders were concerned about levels of burnout across the workforce. Many colleagues express concerns that the return of crowding is more of a worry than the increase in COVID, due to the difficulties in establishing patient and staff safety. The Royal College of Emergency Medicine welcomed the report and hopes that it will trigger a call to action.

Crowded departments were always unacceptable and potentially harmful. This is even more true now.

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