This month, we are beginning to see what many think may be the second surge of COVID-19 across Europe and elsewhere. Although some of the papers in this month’s issue were written and published during the first surge, they are now arguably more important than ever. First, Cook and Harrop-Griffiths discuss the many challenges of planned surgery, which includes time-critical and wholly elective procedures, in the context of the many issues affecting hospitals and the services they offer. We need to: manage the increased ICU activity associated with COVID-19; make hospitals safe places for staff, patients and relatives; ensure all patients are treated fairly; and look after our most important resource, our staff. Again, the challenges back in May are the same as those we face now and there are no easy answers. Professor Pandit suggests modelling might play a role when efforts are made to match demand and capacity (Fig. 1). Key questions include: how to set capacity; how to fund increased capacity; how to manage COVID-19 pathways; and how to manage demand. The current situation has forced us to increase capacity in the NHS and encouraged us to ask difficult questions about how we manage demand. As anaesthetists, we are well placed to influence the national agenda, which is what is needed to help us to learn to live with COVID-19.
Figure 1 Demand (which can be measured variously; horizontal black line) is constant over time so optimal capacity (red line 1) is easy to estimate. For varying demands shown, although mean demand is identical to the horizontal black line, the optimal capacities required to meet all the demand all the time increase (from dotted red line 2 to solid red line 3) as variation increases. However, this results in wasted capacity when demand falls to less than the peak.
Figure 3 The relationship between prior knowledge, clinical evidence and posterior knowledge from Bayes’ theorem are shown, for an example where the trial result (clinical evidence) shifts our final belief (posterior) towards accepting the intervention. Note that the precision (reflected in the width of the bell curves) of the posterior knowledge is tighter than prior knowledge and clinical evidence. The trial result (clinical evidence) may indicate a high probability of success of intervention, but our final belief will be tempered in a Bayesian framework: we do not accept this blindly. The distance between the distributions, their position and their precision arguably tell us more about the probability of success of an intervention than simply setting out to prove that something is true or false.
Earlier this year, the law in England changed to an ‘opt-out’ system for organ donation. This means that if you are not in an excluded group and have not confirmed whether you want to be an organ donor, it will be considered that you agree to donate your organs when you die. This month’s issue provides several brand new clinically-relevant updates in the field of solid organ transplantation from experts from around the world.
Figure 1 Schematic overview of the process of deceased organ donation.
Figure 2 Number of UK DCD cases and contribution as a percent of total deceased donations over time. Columns – number of DCD cases; Line – percent contribution of DCD (compared with total DBD and DCD).
Figure 3 Last recorded TOF values in 13,562 cases. A TOF value of 100 depicts the scenario where no fade is seen and the ratio is 1.0. The vertical line represents the median at 97, while the mean (SD) is 97.4 (24).
The COVID-19 pandemic has affected all aspects of life in many different ways, and one clear theme is the saturation of our inboxes, newspapers, televisions and medical journals with COVID-19-related content. As a journal, we handled and made decisions on a record number of submissions over recent months, and we have: carefully selected 74 COVID-19 papers for publication, which are free to access forever; registered over 1,000,000 full text downloads; and reached over 2 million users on Twitter. However, the sheer volume of information may have, at times, resulted in cognitive overload, more so at times of escalated clinical activity. Kearsley and Duffy discuss all this and more and ask, have we managed the information surge? There are many lessons we can and must learn for the future.
Figure 2 Microlaryngoscopy view showing a 10‐French oxygen catheter in‐situ.
Figure 3 The underlying principles of per‐oxygenation, which includes pre‐oxygenation and apnoeic oxygenation and ventilation. Pre‐oxygenation ends when apnoea starts due to induction of anaesthesia and administration of neuromuscular blocking drugs. Thereafter, apnoeic oxygenation and ventilation and, in the setting of high‐flow nasal oxygen, transnasal humidified, rapid‐insufflation ventilatory exchange. This may continue until desaturation commences. Efficacy describes the time during which pre‐oxygenation achieves a pre‐determined end‐tidal oxygen concentration before apnoea commences. The apnoea time is the time between commencement of apnoea and arterial oxygen desaturation. Efficiency is the combination of pre‐oxygenation with apnoeic oxygenation and ventilation.
Figure 4 Example scenario of a rotational thromboelastometry with a corresponding Visual Clot. The scenario displays a plasmatic factor deficiency, as shown by the prolonged clotting time (CT ) in the (a) rotational thromboelastometry EXTEM and INTEM channel or the missing plasmatic factors in the (b) Visual Clot. This scenario would be answered correctly by selecting ‘plasmatic factors’ as a treatment and nothing else.
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.
Figure 1 Bubble plots for each surgical category showing the difference between the mean or median age of the randomised controlled trial population and the mean age of the equivalent populations in the English hospital registry, according to the middle year of study recruitment. Marker radius is proportional to the number of study participants.
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
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.
Nightingales
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.
Hope
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.
Figure 1
Figure 2
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.
Hope
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.
In the associated editorial, Aziz and Kristensen highlight the novel consultation of patients as part of the guideline’s creation, given the nature of ATI as requiring a well-informed, calm and cooperative patient. Also worthy of mention is the reliance on expert opinion, emphasising its capacity as advisory and not prescriptive, whilst advocating consistency of approach in a bid to promote patient safety. Aziz and Kristensen do not shy away from robust critique of other areas of the document, including its assertion that bleeding should be viewed as a relative contra-indication for ATI; the ‘sTOP’ acronym, which may be open to misinterpretation (appearing to suggest the correct sequence of events to be ‘sedate, topicalise, oxygenate, perform’); and how to proceed in the event of ATI failure.
Figure 3 Odds ratios for peri‐operative red blood cell transfusions for 2012–2016 vs. 2011. Error bars represent 95%CI.
Over the same period, there was no increase in myocardial infarction, stroke or all-cause 30-day mortality, suggesting that fewer transfusions had not unwittingly contributed to an increase in adverse events. Shah, Stanworth and Docherty, in the related editorial, explore the many reasons for this observed reduction, including survivorship bias and improvements in surgical technique. Data on cell salvage – a technique which rose to popularity over the course of the study – was unfortunately unavailable and could have provided valuable insights. Care must be taken not to assume that reduced transfusion is an entirely positive phenomenon – indeed, more liberal transfusion thresholds are appropriate in certain patient populations, such as traumatic brain injury.
Blood transfusion has been variously implicated in the literature in terms of cancer recurrence and reduced survivorship. Tai and colleagues present retrospective data on this association in the context of post-surgical recurrence of liver cancer. Using a technique known as restricted cubic splines, permitting the application of linear regression models to non-linear data, they were able to demonstrate adjusted hazard ratios of 1.3 (95%CI 1.1-1.4) and 1.9 (95%CI 1.6-2.3) for recurrence and mortality, respectively. Moreover, the greater the number of units received, the stronger became the association with adverse outcomes. It is difficult to tease apart myriad confounding factors and assess causality here. In the related editorial, Dickson and Acheson rightly identify that any randomised controlled trial in this area would be ethically fraught – and so Tai and colleagues’ propensity matching is the closest approximation. Transfusion-related immunomodulation (TRIM) has been shown over time to not fully explain the deleterious effects of transfusion, given that we now live in the era of leucodepletion. Other related factors to consider are the role of individualised patient blood management (PBM) and the possible connection between certain anaesthetic and analgesic drugs and cancer recurrence.
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.
Table 1 Incidence of hemidiaphragmatic paralysis in patients randomly allocated to anterior or posterior approach suprascapular nerve block. Values are number (proportion).
Finally, be sure to follow the blog in the upcoming weeks and months as we publish insights from across the globe into the COVID-19 crisis, having begun already with the Australian perspective by Dr Tanya Selak. In the meantime, check the excellent online COVID-19 repository https://icmanaesthesiacovid-19.org/ for regular updates as the situation unfolds.
