Time to plan and time to act again — but this time it’s different (Part 1)

The second surge is upon us and we need to act, but as we do it is also worth reflecting on what we have learnt in the last 8 months. It can reassure us that we have done this before, that we know how to respond, to reflect on how much we know now compared to March and how much care for patients with COVID-19 and their outcomes have improved. There is much to celebrate. At the same time we need to be cautious to avoid complacency, to acknowledge the harm done to many by the first surge and to understand how the response and challenges will differ this time. Here we focus on positive reflection, in part two we will consider the challenges.

In March we wrote a blog highlighting the potential impact of the coming SARS-CoV-2 infection and the need to actively prepare for an influx of ill and critically ill patients. What has happened since is, as they say, ‘history’ and will remain so for decades to come.

Casting our minds back to March, it is difficult to remember quite what turmoil we were in. One of us works in a central London teaching hospital, which like many was intensely busy. The other, who was shielded from frontline work for several months, works in a district general hospital in the south west where the pandemic was considerably less severe, yet hospital services were still restructured, stretched and pressurised. In both hospitals critical care units were expanded, staff retrained and redeployed and the NHS came together as one to meet the coming challenge. During this period what both of us remember most clearly is uncertainty and fear. That fear was, in part, borne of the uncertainty – relating to personal, colleague and family safety, the unmanageable estimates of clinical activity, concerns over our ability to cope with the rigours of work and of what would follow. 

It is important to remember and acknowledge those fears. Also, to remember the acute physical and emotional exhaustion most experienced, due to increased duration, moral burden and acuity of work, compounded by information overload as we planned for and learnt daily about the pandemic response. For many, the impact of spring 2020 will be with them forever, through family loss, moral injury or unexpected and unwelcome experiences that have left shadows that will not lift. At home, the lockdown was unfamiliar, unwelcome and inexorable. For the fortunate, the shadows did pass and summer gave some respite: there was a rather brief period of release from lockdowns and overwhelming work, and perhaps some optimism and time to rest.

It is now clear that we are amid a significant second surge. Much of the country is in some form of local lockdown. We can only hope the government will not demur again over the implementation of significant and effective rules to control community viral transmission and regain control, but popular and professional confidence is not high. A tiered system of local lockdown is to be welcomed, but why it has been created seemingly on the hoof in the midst of an exponential rise in cases, admissions and deaths, rather than planned and announced in the summer months is difficult to fathom. Many are concerned these measures will not be enough and tougher ones will soon follow.

Lessons learnt in the first surge

Despite these many concerns, there are also many reasons to be positive.

We are better prepared 

Our preparation in terms of knowledge of the virus and how to respond to it is immeasurably advanced from 8 months ago. Hospital infrastructure is such that separation of COVID-19 and non-COVID-19 pathways should not need to be hastily constructed, oxygen supplies are established and should not be at risk of exhaustion. The stress of shortages of PPE and drugs should not be repeated. The plans for expansion of critical care services are well developed, and skills acquired by many colleagues in the spring will have been retained and can be rapidly redeployed.

We are more agile

In a short time, we have transformed the way we work and communicate. Video conferencing, virtual patient consultations and working from home have transitioned from ‘not possible’, through ‘possible’ to ‘essential’ and now become embedded in everyday medical life. Lines of communication between frontline clinicians and senior management have become necessarily more open and we have learnt the importance and value of direct contact with colleagues in business modelling, estates and housekeeping, to mention only a few. Clinical networks, most particularly for critical care, have been reinvigorated and have become central to planning for and responding to challenges on a regional or national level, rather than as single hospitals. These new, established ways of working provide an opportunity for more inclusive but leaner and more agile communication and decision-making. 

We are treating COVID-19 more effectively

Early strategies of fluid restriction, avoidance of non-invasive ventilation, early tracheal intubation and high levels of PEEP were, in retrospect, not optimal. These have been replaced by fluid restoration to improve ventilation-perfusion mismatch, improve gas exchange and reduce risk of acute kidney injury, pragmatic use of non-invasive ventilation and high-flow nasal oxygen, prone positioning (both awake and once intubated), timely tracheal intubation and enhanced anticoagulation strategies. 

Mortality in our hospitals has reduced and over 3 months ICU mortality  fell from 60% to 42% globally and in the UK from 44% to 34%. We have benefitted from pragmatic, rapidly deployed and extensively adopted research, much of which has centred on the UK including the RECOVERYREMAP-CAP and genomicc studies. We now know that dexamethasone saves lives once patients require oxygen and that remdesivir may shorten illness in milder hospitalised cases but does not save lives. Importantly we also know that the antiviral combination lopinavir with ritonavir has no effect, that hydroxychloroquine is an ineffective treatment and that in combination with azithromycin it is likely harmful. This important knowledge enables clinicians to focus on what does work and to continue with research to determine the role, if any, of treatments such as convalescent plasma, monoclonal antibodies such as tocilizumab, the cocktail produced by Regeneron and other small molecules. The importance of these speedily conducted, high quality, large scale randomised controlled trials cannot be overstated and should not be underestimated. These studies have provided clear and definitive answers to what we should and should not do and have been the only brake to scientific misinformation arising from small, poorly conducted or even occasionally fraudulent research. In the aftermath of the pandemic, one of the key actions must surely be to re-examine how research is undertaken in the UK – to break down the excessive regulatory barriers and re-enable democratic involvement in large scale clinical studies without the current bloated burdens to patients, clinicians and researchers. 

We are better protected

In the early stages of the pandemic, uncertainly regarding the selection of appropriate PPE and concerns over shortages were a major concern. Frequent changes in guidance from public health bodies and poor communication increased anxiety and decreased confidence. At its heart, PPE strategy is simple – provided you know which mode of transmission you wish PPE precautions to protect against, the choice of PPE is rather simple. However, much doubt has arisen because of a lack of clarity over which modes of transmission should be protected against. The mainstream advice was that SARS-CoV-2 transmission in healthcare settings is via droplet and contact transmission, except during the conduct of a select group of interventions –aerosol-generating procedures (AGPs). However, a wealth of data shows that coughing and sneezing, as well as loud talking and singing, create aerosols. Patient-facing healthcare workers have an increased risk of SARS-CoV-2 infection and harm or death. Amongst healthcare workers, there is an association between those who perform tracheal intubation and subsequent COVID-19 symptoms, but amongst anaesthetists and intensivists as a group, there is a relatively reduced risk of infection with SARS-CoV-2 or death from COVID-19. There is emerging evidence that some AGPs may not be aerosol generating, including airway management during tracheal intubation and extubation and use of non-invasive ventilation and high-flow nasal oxygen. Whether the safety of anaesthetists and intensivists (and those they work with) is due to higher level PPE, safer infection control behaviour, diminished viral secretion at the peak of illness or because AGPs are not AGPs remains an open question. 

Overall therefore we can reflect in many ways on progress, work well done throughout the community, hospitals and by researchers. These are, in a year of gloom, reasons to be optimistic.

Tim Cook and Kariem El-Boghdadly

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