COMMENTARY

COVID-19 in Emergency Departments: Buckle Up!

Dr Dan O'Carroll

Disclosures

September 08, 2021

'Freedom Day' has been and gone and the Government's gamble to rush the return to normal has gone ahead despite the ongoing daily tragedies brought by COVID-19.

In the last week, numbers of positive new cases have continued to rise (nearly 250 000), and the number of deaths has also risen, with nearly 800 deaths.

We seem to have become desensitised to these numbers and there are even some suggestions that the media should "stop scaring people' and stop reporting the current COVID statistics , but to put the number of deaths into context it's almost the  equivalent of two full standard Boeing 747s crashing every week.

I wonder if the airline industry renowned for its approach to safety would be doing more to mitigate this.

The numbers of cases have remained stubbornly high and will surely increase further with the start of the new school year.

Mercifully, unlike previous waves, the high rate of infection is not translating to the same number of patients requiring hospital admissions, or deaths, and in that respect there can be no doubt about the success of the roll out of the vaccination programme. The 6566 hospital admissions, including those requiring intensive care is undoubtedly going to hamper the attempted recovery in the huge elective case backlog that was exacerbated, but not solely caused, by the pandemic.

Unfortunately, the vast majority of younger patients that we are seeing in emergency departments (ED) currently with COVID have not taken up the offer of vaccination, and it is frustrating that the widespread disinformation regarding vaccines is resulting in unnecessary hospital admissions and preventable deaths.

Summer Pressures

In previous years, summer months were quieter and gave the staff the opportunity to recover from the usual winter pressures. This has not been the case for several years now, and the current workload is stretching an already exhausted work force to its limits. Discussions amongst consultant colleagues tell similar terrible work pressures and all of us are very clear that retirement as soon as possible is very much on the agenda. Some colleagues are so worried about the perilous state that the NHS is in that they have taken out private health insurance for themselves and their families because they no longer have faith that the NHS would be able to deal with any problems should they arise

This ongoing situation is putting even more pressure on massively overburdened EDs. June 2021 saw the highest number of attendances to type 1 EDs on record. The number of attendances and admissions are largely not down to COVID-19 infections. As ambulance services are overwhelmed patients are increasingly being held outside of the already overcrowded EDs further worsening their response times, with anecdotal stories of patients who have been left for several hours on the floor whilst waiting for assistance as the ambulance staff are having to prioritise more critical patients and inevitably delays in reaching these calls can result in tragic outcomes.

Why Are EDs So Overstretched at Present?

There are several contributing factors to the current poor position we find ourselves in, but it seems that the increased attendances are not translating to increased admissions suggesting that the acuity of the extra patients is low and possibly could be better treated elsewhere

One of the main problems is the public's perceived difficulty in accessing their GP. Certainly, patients are presenting to EDs with problems that don't require specialist emergency medicine consultations, and often they are claiming it is because they haven't been able to see their GP. Sometimes this will be true, but often the trusted 'brand' of ED is the first port of call. GP colleagues have given me examples where they have triaged patients and advised them that they don't need an appointment, eg, a short-lived history of earache or sore throat and the patient subsequently attending an ED as they 'couldn't see a GP'.

The pandemic forced many GP practices to offer virtual consultations. This ease of access for some patients may have increased the demand. There's no question that our primary care colleagues are providing more consultations than ever before, but this is not keeping up with patient demand.

In an attempt to manage the patient flow and reduce overcrowding NHS 111 were able to offer appointments to be seen in the ED. The pilot of NHS 111 First is ongoing but many of us feel that this has increased low acuity attendances rather than reducing the ED workload. NHS 111 deals with a huge number of calls and currently streams 12.4% of them to emergency services. This has increased significantly over the last 12 months and translates into an extra 100,000 attendances. Certainly, from my experience most of these patients did not need to attend an ED.

There is no question that the number of patients suffering with mental health problems has increased since the first lockdown. The pandemic has taken its toll on many people's mental health. Many mental health services moved to virtual appointments and many patients suffered from the lack of face-to-face consultations.

Over the summer months most EDs have seen a huge upsurge in paediatric patients presenting with respiratory illnesses, and this does not bode well for the normal seasonal illnesses as we approach autumn. It seems this need, in particular, has suffered due to the reduced face-to-face consultations from GPs and parents are seeking physical ED assessments for reassurance rather than alternative providers.

National Insurance

The Government has announced an increase in National Insurance, to bring the rate up by 1.25%. Most of this money, up to £12 billion, is said to be earmarked for the NHS to try to bring down waiting times, and to tackle the social care crisis. 

This money is to be welcomed, of course, and will make up for some of the chronic underfunding but I am unsure as to whether this will result in a quick fix. The number of staff vacancies across the NHS is alarming, and I'd suggest that recruitment and retention of staff will be one of the main ways to improve the backlog but obviously this has a lead time of many years due to training requirements. I don't believe that there is a huge appetite for staff to take on extra work. I have never known the workforce to be so demoralised and exhausted. Consultants and other high earners may find themselves falling foul of the punitive pensions taxes if they take on extra work. This, coupled with a sub-inflation pay offer as well as increased National Insurance contributions, may bring forward retirement plans for many.

The announcement seems to me to have been a missed opportunity. There is a genuine need to transform social care with many carer's jobs being paid at the minimum wage. But the measures announced seem to concentrate on protecting the wealthiest in society rather than addressing the chronic shortage of carers with a fair level of pay, whilst private providers continue to make profits.

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