Figure 1 User interface composed of the tip camera video (a) and the device configuration feedback (b), and anatomical features detection (c to e). The square indicates the successful recognition of the laryngeal inlet. The white dot represents the detected entrance of the glottis, while the white cross aims into the direction the tip is pointing. This difference triggers the proposal to ‘move the device to the left’, which appears in the left upper corner of the screen. The entire larynx (double line square), the corniculate cartilages (dotted small square), glottis (full line square) and subglottic trachea (segmented square). On the video screen (a), these squares are colour coded for better differentiation.
Airway protection with reduced risk of pulmonary aspiration of gastric contents (most patients do not present fasted).
Slower door‐to‐groin puncture time and thus may delay vessel recanalisation.
Less patient movement which is desirable from the perspective of the interventional radiologist and may reduce procedural time and complications.
Potential for a greater degree of iatrogenic hypotension
Lower potential for patient discomfort.
Unable to monitor neurological status intra‐operatively.
Ensures direct anaesthetic involvement in the procedure which may secondary benefits such as: dedicated intra‐operative clinical monitoring; assessment and correction of volaemic status; and assistance with postoperative care destination (e.g. critical care admission).
Risk of postoperative hangover effect with potential for POCD/POD.
Table 1 Advantages and disadvantages of general anaesthesia (including tracheal intubation) for mechanical thrombectomy.
I moved halfway across Canada to start a new position in a dynamic academic department shortly before SARS-CoV-2 moved to Canada. An understatement, as we Canadians are known for, is that COVID-19 has fundamentally changed the way we practice medicine. My first night of call, I asked a maintenance worker to point me to the trauma room. As I walked away, he said “Thank you for your service”. I was first humbled by this statement, then somewhat unsettled. Isn’t that what we say to members of the military? Don’t members of the military consciously sign-up for the potential of personal harm?
Some may perceive resistance to these safety initiatives as signs of arrogance or hubris, but we disagree. Medical training and evaluation build and test recalled facts assembled into knowledge used at appropriate times. A ‘good’ physician can recall enormous amounts of information and is definitive in their decision-making. Does that mean a physician seeking the help of others and using written checklists is not? Knowledge retrieval, contextual awareness and communication are all severely tested when our own health is at stake. The COVID-19 pandemic has leveled the playing field between healthcare providers, aircrew or nuclear power plant operators; now our lives are at risk too.
There has been a paradigm shift in civilian healthcare; our workplace may now be a hostile environment where we may be at risk of illness and or death, whether or not a patient appears unwell. Our medical training has left us ill-equipped to deal with this dynamic. Understandably, this has caused great anxiety in many health care providers. As more is known about how COVID-19 spreads, or as supplies of PPE diminish or are substituted, guidelines and checklists will change. Constant change when one’s own health is threatened can also be a nidus of anxiety of what can be perceived as an opaque or confusing healthcare system, a system we once knew so well. Anaesthetists are very familiar with making do despite unavailable or backordered medications and supplies, being presented substitutes without consultation or discussion, or simply ‘MacGyvering’ equipment where there is a perceived need. Anaesthetists are also very used to being asked to do more with less and making their own individual decisions about the management of each patient. Safe anaesthesia care now requires we have a team-based approach where our patient management is predictable and more protocolised. We required more support and more time for procedures while acknowledging, in the short term if not longer, less patient throughput. This calls for a fundamental cultural shift of measuring productivity not simply by patient throughput, but by maintenance of healthcare provider safety and avoidance of harm.
Are there lessons to be learned from aviation or the military where the simple act of going to work, can put our lives at risk? How do pilots and soldiers face these risks and maintain their mental health? There may be a perception that it is simply an acceptance of the risk inherent in these career choices. This is not the only difference. Pilots and soldiers simulate emergencies. It is a mandatory part of training and maintenance of competence. Until recently we’ve only been simulating emergencies where the patient’s life is at risk. We may have intubated thousands of times, but now we’re being told to do it differently, in different environments and wearing PPE that is uncomfortable and inhibits our performance. We became novices again. Recall how anxious you were the first time you performed tracheal intubation on a well patient. Next, recall how anxious you were performing tracheal intubation a very sick and unstable patient. We are almost back to that level of ‘competence’ because we are essentially performing a new procedure. We need to now perform a familiar procedure in accordance to an unfamiliar protocol, in unfamiliar uncomfortable PPE, oftentimes in an unfamiliar environment with healthcare professionals we may be working with for the first time. We must adhere to protocol or risk our own health and the health of those around us. What will help alleviate this stress and speed up our progress to competency? Simulation. Practising over and over again what is required for safety and competency while maintaining the skills of an experienced airway manager. Change as little as possible with how you perform a tracheal intubation in a patient with COVID-19 disease. Be open to changes that make airway management a predictable safe team effort. If you almost never use a bougie, now is not the time to start. Additionally, we need practice. Lots of practise. We need to embrace drills, protocols, checklists and one another’s corrections and suggestions.
A second issue is kit, and PPE is particularly emotive. I’ve heard the cries “COVID-19 is a war. We’d never send our soldiers out without proper weapons and PPE!“. This is not as black and white as civilians would think. There are many examples even from the most recent conflicts of lack of contingency planning, unintended consequences and unanticipated needs. We plan based on past experience, both in medicine and in the military. COVID-19 a novel disease, consequently we have very little evidence what level of PPE is actually required for different procedures; therefore, protocols are a changeable montage. Are protocols changing because we have more evidence, or are they changing in an attempt to preserve PPE stores? Health care providers are understandably skeptical and are assuming the latter.
A good military officer can make their soldiers feel that despite putting them risk (no risk in combat is impossible), that they’ve done everything possible to mitigate unnecessary risks. Additionally, good officers will spend at least some time with the troupes. Decision-makers, from government officials to hospital administrators, are also facing duties the likes they have not seen before. Connecting with one another ‘on the front line’ may benefit both healthcare providers and decision-makers by adding clarity to the physical and emotional issues at hand. There is no substitute for seeing with one’s own eyes what’s going on on the battlefield. Captain Crozier, commanding officer on the USS Theodore Roosevelt, experienced this first-hand. He was faced with a growing number of sailors suffering from COVID-19 disease in crowded conditions. Despite being commanded not to disembark the majority of the 4,865 sailors on board, he sounded a very public alarm in a way he knew would be career ending. He viewed the lives and safety of his crew as more important and placed them before his own career. Healthcare workers need to feel that our leaders would do the same for us.
Finally, what motivates solders to risk their lives is not patriotism, or a good leader, it’s the band of brothers – the women and men in the trenches with them every day. The comradery coming out of Milan, London, New York etc. are similar – the shared experience that has formed bonds between healthcare providers that last a lifetime. We trust and understand one another. In fact, this bond and shared experience is what may help some health care providers weather their psychological trauma storms. We have only recently recognised post-traumatic stress as a formal diagnosis in soldiers. We have known for some time that soldiers facing extreme psychologic distress sometimes needed a break from the horror of the battlefield, but that keeping them away from the front and their buddies for too long would almost guarantee that that soldier would never be able to return to battle. Simply being amongst a group that knew what horrors you’ve lived through somehow helps you weather them. This will no doubt also be the case in healthcare workers who’ve been on the front lines of this pandemic, however we need to be vigilant of the workers who came from away (either other departments or even other cities) as they will lose this close support once they return to their home units. Additionally, we need to be mindful that for many, even with the support of a group, they may need extra resources to overcome their moral injury.
It is an accepted truism that war leads to advances in medicine. This war against Covid-19 is no exception. What I find the most heartening is how silos are being broken down, and not only people from many different specialties are joining the fight, but people from around the world are sharing information too. Opinions and ideas from groups that are diverse (people from different countries, specialties, ethnic backgrounds, gender, etc.) perform better, make better decisions, and are more innovative. This is the battle of our generation; we need to ensure we mobilise all of our resources by building and fostering diverse teams.
We can combine all three things: healthcare providers confident in their new skills because they have drilled them; feel supported by a leadership that has their safety and best interests in mind; and who feel a common bond with the other healthcare providers they’ve worked with. We believe we would not simply feel safer, we would actually be safer, both physically and psychologically as we connect more with those around us.
Figure 1 The predicted, observed probability and diagnostic ability in each risk group by ‘eFONA’ score. The predicted and observed probability grouped by sum of the risk score are shown in each cohort. The observed probability is the proportion of actual eFONA procedures performed. The predictions are well‐calibrated with the observations. Error bars, 95%CI.
Figure 2 The total Quality of Recovery (QoR)‐15 scores per time‐point. The data are presented as mean with SD error bars. The percentage and absolute decrease between pre‐operative QoR‐15 and postoperative 1 were different (p = 0.019 and p = 0.013) between the intervention and control groups. There were no significant differences between absolute values between the groups. A score of 118 (dashed line) is defined as acceptable symptom state.
Rightly or wrongly, Impact Factor remains the most widely used performance metric against which scientific journals are judged. According to this new analysis from McHugh and Yentis, we published 115 original articles, 22 reviews, 56 editorials and 186 letters in 2016. In the following two years, these 379 articles were cited in 1506 articles. Of these, 476 (32%) were from Anaesthesia and 1030 (68%) were from elsewhere. Some might argue 32% is too high, but there is currently no consensus on what an ‘optimal’ self-citation rate should be. Too low, and the relevance or appropriateness of the journal comes into question. Too high, and there might be a suggestion of Impact Factor gaming. One possible solution is transparency, and it is the policy for all Anaesthesia editors and reviewers not to ask authors to add or remove specific references/citations to any journal, including Anaesthesia, in their final revisions.
Figure 3 Results of booking to the mean. The actual list duration is plotted against the intended list duration (from y‐axis in Fig. 1). Had booking to the mean been accurate, most points would lie on or close to the line of identity, but the majority lie above it. Hollow circles are lists that suffered a patient cancellation (for these times, the mean time of the cancelled cases is included in the actual list time).
“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.”
Florence Nightingale, Notes on Nursing: What It Is, and What It Is Not.
The coronavirus disease 2019 (COVID-19) continues to define 2020. Across the world it is causing medical, financial and social distress. It is destructive both physically and psychologically. Many countries have been grappling with national lockdown and wholescale reorganisation of their healthcare systems to cope with the expected epidemic surge (or wave) of cases – the purpose of social distancing (perhaps better referred to as aiming for people to be physically distanced and socially connected) and latterly lockdown, has been to flatten the wave from a tsunami to something smaller, and the purpose of the healthcare reorganisation has been to scale up services to deal with that wave.
In the UK we have been luckier than some. In Wuhan, China the healthcare system was rapidly overwhelmed by an epidemic surge it could not have prepared for. One well-highlighted response was to build several new hospitals – at breakneck speed and to use other communal areas for stepdown-care and oxygen delivery. Outside of the hospitals the country was put into a rigorous lockdown and this reduced R0 to < 1 and controlled the epidemic in the rest of the country – at least for now. When Lombardy, Italy became the epicentre of the emerging pandemic, its healthcare system was also overrun with Northern Italy and then the whole country entering a strongly policed lockdown.
The ‘fortune’ we have had in much of the UK is both time and information to make preparations. To get our health service in the most suitable state to deal with the pandemic effects of COVID-19, major changes to all aspects of care have been implemented. All but the most urgent surgery has been stopped. Non-urgent outpatients ceased. Hospitals have been emptied in preparation. Staff have been given crash courses in use of PPE and skills that may aid the respiratory and critical care services. ‘Cross-skilling’ has entered the medical lexicon.
Despite the time for preparation and the enormous efforts on all levels to be ready, the UK NHS has, in some parts, struggled. Hospitals have been overwhelmed by the scale of admissions, leading one to put out a desperate call for volunteer assistance to transfer critically ill patients to other hospitals when the scale of its influx was too high. In another incident, hospital oxygen supplies failed, again requiring urgent transfer of critically ill patients to other hospitals. Behind these front-page stories there are likely many more hospitals operating at or beyond their limits – even after increasing their capacity as much as they can.
So why the title of this blog? At first glance the topics seem unrelated; but some thought reveals that triage and the new Nightingale hospitals, rapidly commissioned and brought into service across the UK, are two sides of the same coin – or perhaps two solutions to the same problem.
The models have predicted that, despite best preparations within and outside hospitals, the service will be stretched or overwhelmed in most parts of the country for a sustained period of time. That the surge of patients needing admission, oxygen and ICU care may all be several-fold too high for even the maximum capacity. There are, broadly speaking, two potential solutions: triage and Nightingales.
Triage is a term borrowed from the battlefields of war and usually involves attempting to select, in a mass casualty situation, those patients who are most in need of immediate medical care in order to survive. The walking wounded and those unlikely to be saved are not prioritised. In the pandemic situation the process may be turned on its head (so called reverse triage) and, in the setting of inadequate resource, selection seeks to identify those patients unlikely to survive. These patients are then not offered advanced treatment but must be cared for differently, treating them symptomatically and compassionately in anticipation of their death.
A central tenet of any medical care is that it should provide benefit and be consistent with what the patient would want. It should only be for those who can survive and only for those for whom it offers a future with a quality of life they would want. The treatment itself should not cause suffering that the patient would find intolerable. Where possible, the question of benefit is grounded in clear knowledge of what will happen to that patient, but in truth clinicians are not great predictors of outcome and so we often err on the side of caution and offer trials of treatment, including ICU care in the hope it will work. In normal circumstances the ethics of patient care is straightforward, even if predictions of outcomes and decisions are not. The ethical framework of medical care – beneficence, non-maleficence, justice and autonomy – means that the basics of decision-making around critical care (both starting and stopping it) are entirely focused on the individual. In some countries, ‘community’ is also considered a part of the ethical framework – what is right for society.
For COVID-19 in particular, we lack clear predictors of good or poor outcome, relying instead on univariate predictors of mortality such as age, high blood pressure and cardiac disease which may in reality all co-exist. We also may not have the luxury of offering trials of intensive care treatment. For it must be remembered that when COVID-19 causes critical illness, it kills most patients. Studies of those requiring ICU care, and particularly ventilation, from China, Italy and the US have all reported mortality rates of half to two thirds of patients. In the UK outcomes are the same, suggesting this illness is twice as deadly as other viral pneumonias. The myth that those dying are old and dependent is slowly being dismantled as we realise what a truly awful disease this is. Perhaps the cruellest element of the illness is that patients admitted to ICU will receive no visitors, and although who die there will not die alone, they will be surrounded only by caring staff, rather than family.
If the number of COVID-19 cases is such that capacity is overwhelmed the prospect of triage is a real one. And this is a completely new ethical arena. It may be necessary to choose for instance between two or more patients needing one ICU bed or one ventilator, or to decide whether to stop ventilating one patient in order to offer it to a patient who is more likely to survive. These are extraordinary concepts for extraordinary times. The ethics of decision-making changes to what some describe as societal or public health decisions. Those who have argued that ‘doctors make these decisions all the time’ are wrong. Although we wrestle with decisions every day about what is right for our patient, balancing burden against benefit, this decision is about an individual. But when triage occurs the decisions are about what is in the ‘greater good’, ‘doing the best for the most’ and ‘the best for society’. This is not normal decision making but something quite alien, and which even the GMC states in normal times must not happen.
In this setting doctors need help because the wider ethical environment must be considered, and the choice is—put simply—too important to be made just by doctors. Decisions about how we choose between members of society require a discussion about what society wants and will accept. A framework is needed (not a checklist) which will enable doctors to step away from the bedside, pause, consider and reach a decision which 100 days ago none of us would ever have considered. Numerous documents have been published in the last months that consider these issues – some in journals and some by learned bodies. Several are vague and opaque and some wise and helpful, particularly that from the BMA. Some of the ethical factors are shown below. It is worth pausing and contemplating these. But these frameworks need operationalising – turning conceptual and discursive documents into SOPs that real clinicians use make real decisions for real patents.
Figure 1. Some key ethical considerations for COVID-19. *Examples include healthcare workers, vaccinologists, farmers or politicians.
These are complex matters and the decisions are high-consequence. In a truly open and honest society, government or the central NHS would be providing national guidance, drawn up by our medical, philosophical and political leaders, and the National Health Service. However, that is not the case and the result is a vacuum which is being filled by necessity. The decision of how to turn principles into actions is delegated to regional networks or individual hospitals. The result is that guidelines may be drawn up by too small a group, of critical care clinicians alone, or a wider pool of doctors perhaps supported by hospital management. These guidelines may not account for the shift of focus from individual to society or factor in ethical challenges, resulting in blunt tools to score them with. With poor guidance, there is cloistered thinking and with it, the potential for moral, ethical and legal jeopardy.
The possibility of having insufficient resources to care for all, and how that is managed has, with a few notable exceptions, not been well-grasped. But when there is inadequate resource those decisions must and will be made. Much work has been done by general practitioners and other outside hospitals to prepare the frail and ill. To advise them that hospital care may not be the right journey for them if severe COVID-19 affects them. To enable family discussions and decisions and to put alternative pathways in place, perhaps to stay at home if illness strikes. There is no doubt that this has saved many from a death alone, perhaps in distress, in hospital. This is something to be welcomed.
An alternative to accepting that we have insufficient resource and planning for triage is to expand the resource to meet the demand. In the first weeks of the epidemic this effort focussed on ICU capacity – and specifically on ventilators (though now kidney machines may in fact be the greater problem). Hospitals were encouraged to expand ICUs internally up to sevenfold. The NHS ventilator challenge was established. But as well as ventilators, critical care requires (amongst many other things) space and staff. Expansion requires somewhere to else work and a bigger workforce. This was acknowledged with the GMC and other bodies writing to all doctors about the need to work in unfamiliar settings and a loosening of regulatory governance as a consequence. NHS workforce planning proposed a major change from normal standards of care (one trained ICU nurse at the bed of every ventilated patient and one intensive care consultant for each group of eight) to something quite different. In the revised guidelines, each ICU-trained nurse might have responsibility for six ventilated patients and each critical care consultant for 60. While tiers of support are layered below, this is provided by nurses and doctors who are either less experienced or whose training is from other areas of practice. It is hard to imagine that this will not have an impact on quality of care delivered – these are truly extreme measures.
The Nightingale hospitals are a proposed solution. Rather than making ICUs out of repurposed wards, operating theatres and recovery units staffed by theatre staff, it is possible to create purpose built (or at least purposefully redesigned) mega-ICUs on a warehouse scale. These are the Nightingale hospitals, first in the Excel conference centre in London and now planned in a host of settings in the UK including Birmingham, Manchester, Harrogate and Bristol. The Excel Nightingale hospital has the capacity for 4000 ventilated beds – this alone is far in excess of all the ICU beds in the UK before the current epidemic – and the other Nightingale hospitals are each designed to care for many hundreds of patients. The vast majority of these hospitals planned to admit only patients needing ventilation. Scale can provide efficiency and workforce planning breaks down the normal bedside delivery of ICU care into an almost bewildering list of teams – one each for airway, lines, nutrition, turning, comfort etc. At first sight this is a perfect solution to the capacity problem – physically expand the system to the extent that the capacity is sufficient, and the problem is solved. Hospitals will have their space back and may be able to start to recommence services they have had to mothball. Perhaps a semblance of normality can return to NHS services.
However, this solution has its own challenges. The Nightingale hospitals solve only one of the main challenges to ICU expansion: space. ‘Stuff’ (equipment) and staff remain constrained. The Nightingale hospitals will necessarily be staffed by the same skilled staff who would otherwise be working in the hospitals they serve. And these staff will no longer be available there. As the Nightingale hospitals are set up on a regional basis this may mean either staff commuting long distances or relocating for a period. These staff will be working in a new environment in new teams and both changes will require training and adaptation. The same is true for equipment – if a ventilator or renal replacement machine is sent to a Nightingale hospital it cannot be used at a local hospital. So, it should be clear the Nightingale hospitals whose scale may be beneficial in providing economies of effort, are using staff and equipment that would otherwise be at the hospitals they serve. They are not so much additional capacity as relocated capacity. In order for patients to be treated at the Nightingale hospitals patents must be transported there – another service requiring significant redeployment of staff and equipment. The Nightingale hospitals are a bold and ambitious attempt to solve an extraordinary problem. Judging if, when and how to use them will be the challenge. The already stretched service will undoubtedly be further stretched by deployment of the Nightingale hospitals.
As always, we finish with a message of hope. If the surge of cases becomes too much for our NHS, either the Nightingale hospitals or triage may provide the necessary solution to the problem. And it is essential that we are prepared. Far better would be that neither are needed. Across the world, the impact of lockdown is being felt psychologically and financially – but it is working. It worked in China, it is working in Italy and Spain. It is starting to work in the UK. There is evidence that the rate of new cases is falling and the epidemic curve is flattening – with correlation between a region’s compliance with lockdown and the local flattening of the curve. Although the death rate is distressingly high there is evidence that the rate of new cases is falling. As deaths lag new cases by several weeks, it will take some time for this change to be seen. In a week or ten days a reduction in new infections will translate into a fall in hospital admissions, then to a reduction in ICU bed requirement and in a few weeks to a fall in deaths. Projections are changing rapidly but the evidence is mounting that the national effort — by the government, the NHS and the whole population— is working. If we are lucky, both triage and the Nightingale hospitals will become important academic projects but neither needed to be put fully into action.
The global impact of the novel coronavirus 2019 (2019-nCoV) pandemic has been massive. Schools have been closed. Elite and recreational sport has been stopped. Conferences, medical and otherwise have been delayed or cancelled (including a coronavirus conference). Countries have closed their borders. Global economies have all but collapsed. This pandemic has left its mark on China and is now settling in the current epicentre: Europe, though this is likely transient, and it may soon move to America. Today the number of confirmed cases has passed 1 million.
The ever-changing numbers
Epidemiological patterns that have previously been described in China are replicable in many other countries. This follows what is called exponential growth. This means that the number of new cases increases by a given factor every day (Fig. 1). In most countries, the first 100 confirmed cases of corona virus disease 2019 (COVID-19) are often sporadic and take some time to spread to large numbers of individuals. However, once the first 100 cases are confirmed in each country, the subsequent growth is remarkably predictable (Fig. 2). For example, the time it takes a country to get from 100 to 1000 confirmed cases is fairly consistently between 6–9 days. The next 1000 cases occur in the subsequent 3–4 days. By 14 days, most countries can expect to have had their first 6000 patients with COVID-19.
In Italy and Iran, the exponential growth continued, and each reached more than 12,000 cases exactly 17 days after they hit 100. Today, the numbers in Italy and the USA are higher than those reported from China. However, the South Koreans managed to slow their spread much earlier than the Italians for example by implementing aggressive testing and isolation measures, a highly effective public information and social isolation campaign, early treatment of those that require it, and rigorous decontamination policies. This provides an opportunity for other nations to strongly consider some of these effective (albeit obvious) measures to be implemented early. The intermediate and longer-term impact of these policies are unclear.
The attack rate (the proportion of the population that will be affected by the virus), is likely to be anywhere between 30-80% of individuals. Thus, the importance of effective public health measures is less about limiting the total number of affected individuals, but more about spreading that number over a longer period of time to enable the health service to cope with the demands. Put another way, if a restaurant has capacity for 25 people and 100 people turn up for dinner on one night, the restaurant will be unable to accommodate them physically or with food. If those same 100 individuals attend over four days or more, the restaurant may still be busy, but still able to cope.
Variations in mortality
The case fatality rate (number of deaths/number of confirmed cases) continues to rise. Whilst in China, this rate is approximately 3.9%, in Italy it is just above 10%, and this figure will only increase. Mortality is age-sensitive, and the Italian population is on average older than that of China. Latest analyses suggests that the global case fatality rate may be closer to 5.4%, and the infection fatality rate (number of deaths/number of infections) could be as high as 0.9%. The daily increase in deaths per capita is also an important consideration, with both Spain and the UK showing worse trajectories than Italy and the USA (Table 1).
As devastating as these figures might be, they only tell one part of the story.
All of the victims
Beyond the number of individuals who contract COVID-19 and those that succumb to it, there is a population of people who become critically ill with it. It is estimated that 1.5% of all infected patients need to be admitted to the intensive care unit (ICU), which could be somewhere in the hundreds of thousands in the UK.
Accepting that non-clinicians may be reading this: being admitted to the ICU is a traumatic experience. It often involves being anaesthetised and placing a tracheal tube with ventilation delivered by an increasingly scarce resource. Cannulas and catheters are placed into arteries and veins, the nose, and the bladder. Patients are given analgesia, vasopressors, antibiotics, fluids, neuromuscular blocking drugs and various other drugs. They are unable to move for themselves so must be turned regularly, including being nursed in the prone position for much of the time. If there is evidence of renal failure, their blood must be filtered with another limited resource: haemofilters. In their unconscious state they are unable to communicate with their families, but because of the contagious nature of the virus, no visitors are allowed anyway. This resource-intensive treatment is often initiated very quickly, but in patients with COVID-19, generally lasts for approximately 10 days. Some patients, particularly young patients who do not respond to treatment immediately, may remain in ICU for far longer. Around half of patients will survive their stay in ICU. For these the road to recovery is long. Patients will be weak, may have ongoing respiratory problems, and perhaps most importantly, the long-term psychosocial impact could be traumatic.
Even during an epidemic, the patients with COVID-19 are only part of the responsibilities the health service has. Whilst the resources invested in COVID-19 are already, and will continue to be unprecedented, there is no doubt there will be a major impact on other services that each form part of an effective healthcare system: cancer treatment; cardiac surgery; orthopaedic surgery; psychiatric services; and much more. As resources are stretched to breaking point, those patients who would normally have received prompt and effective treatment may have this care delayed to the detriment of their short- or long-term health. The idea of a waiting list is effectively gone, and patients previously waiting for care could see that wait prolonged to the point of being suspended in an uncertain limbo. The health of some of these patients will deteriorate: they may have pain they might otherwise not have had. Some will die earlier than otherwise. The national mortality rate from disease unrelated to COVID-19 will increase for some time to come.
The impact on healthcare workers cannot be underestimated. Frontline staff who place themselves in direct contact with patients with COVID-19 are at a greater risk of acquiring the disease. In Italy, nearly 1 in 10 new diagnoses have been in healthcare workers. Anaesthetists and intensive care physicians in particular are at high risk due to exposure to a high viral load during procedures performed close to the airway: called aerosol-generating procedures. So too are ear, nose and throat and eye surgeons, as well as dentists. The data remain unclear as to whether mortality rates are greater in healthcare workers or not, and studies are being undertaken to determine this, but it is clear that access to appropriate personal protective equipment (PPE) is of the highest priorities but the lack of access is perhaps one of the biggest threats. Moreover, there remains debate about what appropriate PPE is for different settings. Surgeons have suggested that everyone in an operating theatre setting should don full PPE for all patients, while this disagrees with other recommendations suggesting that full PPE should only be used when there is a significant risk of aerosolisation. These areas of contention leave healthcare workers confused and may compound the high levels of anxieties in healthcare workers. Healthcare workers may also be concerned about taking the infection home to their family and some are even making the decision to remain isolated from their families in order to reduce risk.
To add to this burden, capacity and resource may simply not be enough to match demand. Frontline staff will shoulder a tremendous responsibility for difficult clinical decision-making, and ultimately in some cases for selecting who is given the best chance of survival and who cannot be saved. The NHS is currently commissioning, planning and constructing at great pace a network of Nightingale hospitals in exhibition centres and empty universities. The aim is to provide much needed additional capacity and to provide a safety valve for current hospitals. It is ambitious and to an extent a gamble to spread the resource and staff even further, but one we all hope will succeed. We will soon know.
Despite the devastating numbers of diagnoses and deaths due to COVID-19, the reduction in R0 in China is reassuring, with the number of new cases falling dramatically and locally spread cases being almost zero. In Italy, their daily rate of new cases has plateaued at around 6000, and may have peaked. The world’s largest democracy, India, has locked down with fewer than 500 cases at that time. And the public health measures implemented in Switzerland mean that their rate of increase has also plateaued. All the evidence is that this will pass.
In the UK, individual hospitals have spent the last few weeks preparing for the worst, and at an institutional level, preparation is probably as good as it could be given the circumstances. The availability of PPE and diagnostic testing for frontline staff is increasing. And the public have never been as well-informed about a health crisis as they currently are.
We encourage all readers to heed public health advice, healthcare professionals to continue to train and prepare for the management of patients with COVID-19, and for institutions to continue to be agile and responsive to the rapidly changing demands on healthcare resources.
As the COVID-19 pandemic sees the UK enter lockdown, here we provide you with a summary of all our new COVID-19 material together with a moment’s respite from COVID-related information overload as we introduce the April 2020 issue of Anaesthesia.
The latter controversial link is not, however, a central thread in White and Shelton’s compelling editorial arguing the case against inhalational anaesthetic agents. The considerable damage done to the environment from volatile agents has only recently entered the collective anaesthetic consciousness, with desflurane now eschewed by many institutions owing to its significant carbon footprint. White and Shelton reason that there is no single instance in which inhalational agents are absolutely indicated over total intravenous anaesthesia with or without locoregional anaesthesia, and that the conventional narrative of volatile anaesthesia as ‘standard’ and other methods as ‘alternative’ deserves to be challenged. They go on to outline the professional and governmental interventions that may support such a seismic shift in the future.
We continue to deal with all previously submitted papers, which will undergo all our usual processes. We remain open to submissions on any topic related to peri-operative medicine, critical care, pain medicine and all other associated topics. All original articles, reviews and correspondence in relation to COVID-19 will undergo rapid peer review and if accepted, rapid publication on early view. We have already accepted several papers from the UK and elsewhere and as soon as these are available, they will be freely available and tweeted from the journal account. Finally, continuing professional development remains important at this difficult time and we believe it must continue. We hope to provide you with a range of high-quality educational content on COVID-19 and other topics.
We will keep you updated as the situation evolves. But please rest assured that we are doing everything we can to support our readers and authors through this challenging time. Please look after each other and yourselves.
Australia had its first case of coronavirus on January 25th, and as of today there are 376 confirmed cases with many test results pending. Cases are doubling every three days, with modelling predicting 153,000 cases by Easter. Australian case numbers more closely align with the experience in Europe, rather than the slower case doubling time in Korea and Singapore. I work in Wollongong, a town south of Sydney in New South Wales with a population of 400,000. If conservative models are correct and 20% become infected, with 5% requiring critical care, this equates to 4000 patients, which is in addition to the usual caseload. We have around 20 critical care beds.
Until recently, health care professionals and the general public have been largely indifferent to the disease. This is despite widely reported experiences in China, Korea, Iran and Italy, with exhausted frontline clinicians imploring us to prepare. Many felt that this disease was ‘just a mild cold’ and that although there were many deaths, these were limited to the frail, elderly and those with medical comorbidities. There was full confidence that the Australian medical system could manage the disease, as it has world-class people and resources. Most seemed to think that this would not impact us. Many were still laughing at toilet paper jokes and coronavirus memes. Some still are.
The mood is rapidly changed. There are increasing numbers of clinicians, medical administrators, politicians and members of the community becoming fearful and frantic. Clinicians in particular have been motivated into action following the Italian reports of overwhelming numbers of critically ill patients and deaths. The exponential growth in case numbers and the subsequent social distancing measures introduced by the Australian government yesterday have also increased the impact of the disease. Legislation will enforce the banning of organised mass gatherings of over 500 people, and self-isolation for all travellers from all countries for 14 days, echoing New Zealand’s move to this the day prior. New Zealand has fewer cases yet has been more proactive. Perhaps the recent White Island Volcano tragedy has made them less willing to become overwhelmed again. Awareness was also raised by Hollywood stars Tom Hanks and Rita Wilson, who tested positive and were admitted to Gold Coast University Hospital last week. The government has announced a multi-billion-dollar stimulus package to address the widespread economic devastation the disease will cause.
The looming disaster is slowly dawning on regulators, administrators and community members. Most Australian hospitals have been slow to act and are only now beginning to look seriously at the logistics of the likely tsunami of potential patients.
Practical difficulties in accessing COVID-19 testing for the public and healthcare workers have led to many frustrations. Some wait up to five days to get tested, and streamlined testing clinics are just starting to appear. The public health advice around testing has changed as the data comes to hand, and is currently limited to those with symptoms and a contact or relevant travel history.
Personal protective equipment
From my own Twitter activity, I noticed and wondered why international colleagues were shaving beards. This led me to discover the much more serious approach to PPE adopted in other countries, particularly those who have experienced respiratory outbreaks before such as Canada. Formal fit-testing of N95 masks is not mandated in most of Australia and New Zealand. Very few have ever heard of fit-testing, let alone formally had it done. I suspect that Australian guidelines for PPE when we are post-COVID will reflect the more pro-active approach adopted by countries who have been here before.
There have been concerns around the ability of institutions to supply sufficient PPE. Although state and federal governments have announced funding for PPE, individual hospitals have not completed stocktakes of equipment. Most do not know how many COVID and other emergency patients they can care for. Few have received training, although this is now starting in earnest for some, with others told that there is insufficient gear to rehearse. Although a few units have conducted simulations, they are in the minority. There are a number of different management guidelines and few institutions have agreed on approaches between departments.
The management of patients requiring elective surgery is becoming increasingly topical. Elective surgery targets are highly politically driven and direct activity in hospital, sometimes at the expense of emergency surgery. It has been very difficult to shift this mindset. In fact, the state of Victoria has announced an ‘elective surgery blitz’ prior to the arrival of the COVID-19 peak. This is difficult to understand in view of the lack of preparedness and the anticipated patient numbers with the impending healthcare crisis. The Australian Society of Anaesthetists has recommended postponement of elective surgery in order to allow preparation time, as have the Royal Australian and New Zealand college of Obstetricians and Gynaecologists. The Royal Australian College of Surgeons have called for surgical fellows to ‘follow local hospital requirements’ around elective surgery and ANZCA is yet to comment specifically on the matter.
Over the last week, medical conference organisers have one by one made difficult but necessary decisions to cancel their events, including the largest anaesthesia event of the year, the ANZCA annual scientific meeting in Perth. Smaller hospital meetings continue, although some clinicians have cancelled. The medical viva part of the ANZCA final exam was cancelled last weekend, and there are concerns about education implications of the crisis for fellows and trainees with diversion of work and cancellation of CPD activities.
Many individuals have cancelled overseas trips for the upcoming school holidays and Easter. Some clinicians are now stranded at home in self-isolation requiring the cancellation or rescheduling of clinical work. Panic buying continues with difficulty accessing toilet paper, hand sanitisers, pasta, and meat. A supermarket chain has introduced an early morning quarantine shopping time for the elderly and vulnerable to protect them from the masses.
Although some schools who have had members test positive for the disease have closed briefly, schools have largely remained open. The rationale for this from public health is that it may do more harm than good. School closures may cause children to be cared for by their grandparents, who are vulnerable to the disease, or parents who are healthcare workers and other essential services and may be unable to present for work if children are at home.
Key clinicians have been employing social media channels to advocate for governmental action. There are a number of private groups also which are sharing information and getting organised. It has been difficult to keep up with official advice from state and federal government, the hospitals, professional societies, my children’s schools and co-curricular activity providers, my private and public social media. Information overload has been particularly difficult with the rapidly changing nature of this epidemic and the ever-increasing need for information.
Pleasingly, there has been the rapid production of a number of excellent educational resources from those who have experienced previous epidemics, and those who are currently in the thick of it. Resources have been shared widely and freely on public and private social media sites. This crisis has demonstrated the value of social media where healthcare workers across the world have generously supported each other with information, advice and moral support in real-time.
Coronavirus disease (COVID-19) literally needs no introduction. It arrived in China as an unwelcome New Year’s Eve present and although it may have taken a few weeks for many to become aware of it, it has become an ever-present in our lives since. It is, as we write, creating an epidemic across the world and is now sweeping across Europe. It is impacting everyday life in many ways and this impact is likely to become much more marked in the coming months.
The single-strand RNA virus was named novel coronavirus 2019 (2019-nCoV), but due to its pulmonary consequences has been renamed as severe acute respiratory syndrome corona virus type 2 (SARS-CoV-2). It arises from mutation of a virus an animal reservoir, and origins from laboratory sources has been ruled out. It is related to the common cold virus and that causing severe acute respiratory syndrome (SARS) and middle east respiratory syndrome (MERS). Vaccines against these viruses are complex to develop, as illustrated by the fact we currently have no vaccine against the cold, SARS or MERS. The disease caused by SARs-CoV-2 is termed corona virus disease-19 (COVID-19) because the World Health Organization (WHO) was first notified of the localised surge in cases of pneumonia of unknown cause in Wuhan, China on 31 December 2019.
The world’s understanding of the disease owes much to massive international collaboration between scientists but most to the efforts of the Chinese clinicians and researchers collecting and making available data on the disease right from the start. The fundamental metrics as we currently understand them are shown in Table 1. As usual the numbers need to be well understood to tell the story.
Up to 14 days
Most infective time
Table 1 Current metrics on COVID-19 (up to date as of 08/03/2020).
The R0 describes the number of patients that a single patient will infect, in an uncontrolled setting. In the early stages of the epidemic it is believed that this figure may have been much higher, and R0s tend to reduce during the evolution of an epidemic. Control measures such as isolation and quarantine reduce R0. If these measures are effective, R0 may be reduced to below 1 and if this is sustained the epidemic will eventually wane and stop. As long as the R0 is >1, the epidemic will continue and there will be a geometric rise in cases. The impact of R0 is important. Influenza has an R0 of approximately 1.3: after 10 infective cycles this would lead to 14 infected patients from a single source. For SARS-CoV-2 after 10 infective cycles 59,000 patients would be infected. By comparison Ebola has an R0 of around 2, SARS of approximately 3 and MERS ranged from 1 to 5.7 until finally it reduced to <1.
Combined with this high R0 is a high virulence, so while many cases cause mild disease the mortality rate is many fold higher than that of even pandemic influenza. Various figures for mortality have been quoted, but each is dependent on the numerator and denominator chosen. Of the first 100,000 confirmed cases approximately 3,400 died: thus, the case fatality rate (CFR) is 3.4%. However, it is likely that many cases, mostly because they cause asymptomatic or mild symptoms, are not detected. If this ‘ascertainment rate’ is only 10% this means 90% of cases are missed and the infected mortality risk (IFR) is 0.34%. But these figures only consider those who are infected, and the burden of disease in the population is also dependent on the proportion of the population who are infected (attack rate): many estimates are around 30%, but some as high as 60% or even 80%. If the attack rate is 30% and the IFR 0.34% the overall mortality rate would be close to 0.1% (1 in 1000 of the population). Lead-time bias (the fact that many patients will undergo several weeks of treatment before dying) complicates factors further and currently means that the initial 3.4% CFR is likely to be an underestimate.
Mortality is higher in males and particularly in those aged over 70 and with cardiovascular disease. This is most notably a disease that kills the elderly: patients aged over 70 represented fewer than 1 in 8 of those infected, but more than half of those who died. Deaths in those under 40 years-of-age account for < 3%. Early evidence outside of China is not reassuring and epidemiological patterns and mortality rates seem to be broadly in line with those from China.
The main feature of severe COVID-19 disease is a viral pneumonia. This presents as fever, cough and dyspnoea progressing to hypoxaemia and respiratory failure and ARDS. Importantly it often presents at least a week after symptoms start. Cardiovascular co-morbidity as a risk for mortality and evidence of hypertroponinaemia, myocarditis and sudden cardiovascular death are notable but incompletely characterised. Acute kidney injury affects up to a third of patients.
The UK’s critical care capacity, which is one of the lowest in Europe, may need to be expanded at many-fold during this surge in demand. This will seriously challenge provision of the 4-Ss of surge capacity in critical care: space; staff; systems; and stuff (equipment). Expansion of critical care capacity requires planning on a massive scale. Critical care provision for COVID-19 patients will likely displace all elective surgical work as critical care units are expanded in many hospitals into operating theatres and anaesthetists and theatre staff become the first staff to augment the insufficient numbers of critical care staff. Emergency surgery will still be required as will provision of critical care for non-COVID-19 illnesses.
Central to care of these patients is staff safety. In the early stages, patients will need to be isolated from other patients and as the epidemic progresses, they will need to be cohorted away from non-infected patients. Staff protection will require a system that includes, but is not restricted to, strict use of personal protective equipment (PPE). Donning and doffing PPE, using a buddy system to ensure this is optimised and engaging in low patient contact methods will need to become second nature for all healthcare workers. Anaesthetists and intensivists are highly invested in this topic because airway management, including tracheal intubation, is associated with some of the highest risks of transmission of infection. PPE is likely to be effective, so too are simple methods of decontamination of surfaces, equipment and ourselves with soap and alcohol-based cleaning processes.
PPE is an emotive and important subject. In China, healthcare workers experienced high rates of infection in the early period of the epidemic, when PPE use may not have been optimal. Over time this rate of infection has reduced but it remains significant, and there is soft evidence from both China and Italy that healthcare workers who are infected have a higher rate of severe and critical illness than the normal population, plausibly because of exposure to a higher viral load. There are likely to be limited PPE stocks and appropriate use of it is essential to maintain stocks throughout the epidemic.
What can we do?
If not already done, it is time to plan and time to act. Every hospital needs to plan its response to admission of its first patients with COVID-19 (phase 1 and 2), its first critically ill patient, and cohort of patients (phase 3). There is a pressing need for anaesthetists and intensivists to talk to each other, join forces and work together to organise and test the best response they are able. Collaboration in planning and delivery of critical care services in the predicted epidemic offers the greatest chance of weathering the storm. Given that the UK has half of the critical care beds per 100,000 capita of population than in Italy who have branched into the operating theatres already, there is a clear risk that our current resources will not suffice . There will also be great strain on PPE supplies and medical, nursing and other workforces.
The numbers do however provide some hope. The spread of the disease beyond Hubei province in China is wide geographically but the number of cases and deaths is rapidly diminishing. The considerable efforts made by the Chinese government and people to control the epidemic appear to have worked and R0 is now less than 1. On 8th March there were no new cases reported in China outside Hubei. Drug trials are underway and will be reported soon, there may be therapies that reduce the severity of illness or help manage critically ill patients.
We encourage all readers to take stock at this time, get fit mask tests as a priority, familiarise themselves with their institutional PPE policies, practice and train for the management of COVID-19 patients, and agree robust local procedures for the likely epidemic to come.