“The only certainty in a pandemic is uncertainty”
While there is much that has improved in our understanding and management of COVID-19, there remains a significant concern about how we will deal with and get through this second surge of the pandemic. In some respects, there was more certainty during the first surge than there is in the second. We were certain that all but the most essential healthcare services were to cease. We were certain that all of our time was to be spent addressing the immediate crisis. We were certain about what we were allowed to do, who, how and where we were allowed to meet others, how our income was going to be safeguarded. We were certain that we did not know enough about this disease, but neither did anyone else. We were certain that our resource-capacity for testing, contact tracing, staff protection, PPE, critical care services were going to be stretched to the limit. We were certain that we were all in it together.
Those certainties have all but disappeared, and we have been left in dark territory without a light. Despite all of the lessons we should have learned in the first surge, there remain many we have failed to learn from, and there remain new hurdles for us to overcome. The healthcare-specific challenges are compounded by the fact that this surge will occur during the winter at a time when respiratory illness, hospital workload and mental health stressors are at their greatest.
Uncertainty in non-COVID-19 services
There is a moral and practical need to maintain non-COVID-19 work alongside surge-related activity. While all but genuine emergency work was postponed in the first surge, this is no longer feasible. There is now therefore a massive backlog of elective work the NHS has committed to both maintaining that elective clinical work and ensuring it continues to deliver healthcare services for all needs. This will pose new challenges which may be at least be equal or even greater than the challenges of the first surge. There is no new capacity in the NHS, but we will undoubtedly need to expand ICUs again, this time while protecting peri-operative pathways. The Anaesthesia-ICM hub has published guidance on how this may be achieved and in it emphasises the important of co-ordinated planning and collaboration between anaesthesia, surgery and critical care. There is likely to be a need for increased liaison and mutual aid not only involving critical care but also elective surgery. This may be between hospitals, regionally or nationally. To achieve this, departments of anaesthesia need to engage with their critical care colleagues if they are separate and it is likely that regional anaesthetic networks, similar to existing critical care networks, will need to be established. The Nightingale facilities (they lack the breadth of structures and services to be called hospitals) remain an important part of the response but only if the rest of the NHS is failing. Critically, Nightingale facilities provide space but not staffed space. So, if opened they will need to be staffed by the same staff who currently work in the very hospitals the Nightingales are designed to decompress. Their use will be a sure signal that the normal NHS is overwhelmed and will likely only occur when quality of care is already decreasing. We must hope they lie idle.
Maintenance of hospital safety
There is the challenge of keeping hospitals, their staff and patients safe from COVID-19. During the first surge hospitals were effectively closed except for COVID-19 patients and true emergency care. The country was in lockdown, schools, universities, pubs and restaurants were closed and social mixing was non-existent. The mantra was ‘protect the NHS’. Yet despite this the rate of infection in hospitals was three- of four-fold higher than in their communities – in one hospital almost half of healthcare workers became infected in a 3-week period. Hospitals such as Weston General and Hillingdon Hospitals had to close temporarily because of COVID-19 outbreaks. In the second surge, ‘the NHS is open’, elective care will continue while in the community town centres, schools and pubs are open and social contact is much increased, and adherence to guidelines has dropped as confidence in these has fallen. The number of staff off work due to illness or precautionary self-isolation as family members are in contact with others is already noticeable and impacting on delivery of care. To worsen matters, barriers such as self-isolation for 14 days before elective admission to hospital and use of high level PPE in elective patients have been removed so that patients may be admitted after no more than 3 days self-isolation (which, based on viral dynamics provides little if any barrier) and for these patients transmission-based precautions such as increased levels of PPE or fallow theatre periods are currently not recommended. Ward-based outbreaks can fuel nosocomial infection and currently approximately 10% of patients in hospital with COVID-19 acquired it there, with rates much higher in some locations. These patients are set for a difficult course: almost one in four surgical and medical patients who develop COVID-19 in hospital will die: far higher than if acquired in the community. Hospital outbreaks lead to patient and staff harm and ward closures, but also removal from work of large numbers of staff making it difficult to run services: we must avoid them at all costs. Hospitals need to monitor local and in-hospital infection rates to determine if and when the barriers that have been lowered need once more to be raised. The flux of patient risk pathways, be it red/amber/green; high/medium/low risk; COVID-free/COVID-positive or any other permutation that varies both temporally or spatially, has thrown healthcare workers into a constant state of confusion. Consistent, well-designed pathways for patients should be agreed upon and not be updated reactively, but rather planned proactively. Last but not least, hospital staff need to improve their behaviour to reduce transmission within hospitals. Social distancing, adhering to the designated numbers of people in any room, strict and proper wearing of facemasks and high infection control standards are essential. Despite weariness and the need to relax and decompress, it is not acceptable for the staff coffee room, doctors mess or departmental offices to be transmission hubs for the virus.
Mental health problems have increased across society during the pandemic. Hospital staff are significantly affected and it is likely that major changes in healthcare worker support will be needed to address the psychological harm already caused. The jump from a traumatic first surge, to the non-COVID-19 recovery, followed once again by a COVID-19 surge has left healthcare professionals fatigued and verging on burnout. Data suggest that more than half of all frontline healthcare workers are suffering either anxiety, depression or PTSD. This psychological burden will be carried forward to this second surge, leaving even greater uncertainty about the wellbeing of the very individuals on whom our healthcare service is dependent. Further, shielding of at-risk individuals is no longer required, and so healthcare workers with higher personal risks may have a significant increase in their absolute risk. Those with the power to do so must act, and we need to look after ourselves and our colleagues, actively managing our own mental health and workload, staying alert for signs in others and supporting those who are struggling. The Association of Anaesthetists and Intensive Care Society amongst others have provided excellent resources and these should be used alongside professional support.
The world around us
Our lack of confidence in predicting the world around us has cast a further shadow on this second surge. Social restrictions change day to day, region to region, and country to country. Financial stability, job security, and government support have all become less predictable for many families. Travel restrictions have meant that a large proportion of the healthcare workforce who have settled in the UK are unable to visit family members abroad. Political disquiet, both in the UK and globally, add to the ongoing state of flux. Leadership that provides long-term strategies and vision appear to be in short supply, given the predictability of many of our current challenges. And of course, there remain questions regarding the role of a potential vaccine on our ability to get through the pandemic.
We are headed into the darkness of a long winter in which every aspect our lives will be affected. This winter is predicted to be one of the most challenging we are likely to face. However, the darkness and the surge will pass. We have always found ways of coming together and finding strength in adversity, and the strength of our healthcare workforce, both as individuals and as a community, will overcome the challenges ahead.
The first surge passed and so will this one.
Tim Cook and Kariem El-Boghdadly