AS WE START the month of May and the numbers of patients in our ICUs with Covid-19 are falling, attention is turning to look at the impact of lockdown measures on non-Covid illnesses and elective capacity in our hospitals.
I dislike the term “elective”, a more accurate term would be “essential” care and this care becomes urgent and emergent if not carried out in a timely fashion.
We went into this pandemic in a challenging position: the lowest number of consultants in the EU, the longest waiting lists, and an endemic Emergency Department overcrowding problem.
Indeed the state of the health service was a major issue in the recent election. The impact of the necessary lockdown on waiting lists is that non-urgent care has been postponed.
To avoid additional morbidity and mortality for all patients we must ensure investment in the infrastructure and capacity to provide timely access to care for all patients.
A vision of what’s next
As we start to try to slowly lift restrictions it is very important that everyone realises the impact Covid-19 is going to have on healthcare for the foreseeable future and that every lifting of restrictions is dependent on effective testing, isolation, treatment and tracing of each new cluster as it emerges. I am concerned that we still have a lot of work to do on this front if we are to effectively shut down each new cluster of infection.
We now have a virulent, contagious, non-vaccinatable disease that transmits almost preferentially among the elderly: almost the identical population to the ED trolley population and the outpatient department waiting room.
Three things that are endemic in Irish healthcare: packed outpatient waiting rooms and EDs overflowing with trolleys, and dramatic workforce shortages can now never again be tolerated.
Planning and investment in the capacity to avoid these scenarios is critical to controlling the spread of Covid-19 and to minimising morbidity in non-Covid illnesses.
As we start to try to plan a flexible roadmap for how the months and years of working in the time of Covid-19 until we have either an effective vaccine or treatment, consultants are looking at how we do that, as safely as possible for all our patients.
For both unscheduled care (ED attendances) and scheduled care (outpatients, day-case procedures, elective admissions) we need to plan streams of care that keep Covid and non-Covid separate. This is especially challenging as we will be trying to keep asymptomatic Covid out of the hospital now that we know so much more about the possibility of asymptomatic spread.
Unscheduled care
Unscheduled care: we must never again tolerate the concept that (mainly elderly) patients can lie on trolleys in corridors our EDs now that we have an endemic, virulent contagious, un-vaccinatable, untreatable infection that disproportionately affects the older population.
We must ensure patient and staff safety in our EDs. We cannot have people having to social distance at the supermarket but the ED waiting room and corridor being packed full because there is nowhere else for these patients to go. Social distancing has become a vital infection control measure to stop transmission of the virus, and so it is similarly essential in an ED.
As we plan for Winter and the flu that will come with it in the setting of Covid-19 we must ensure the investment in the infrastructure and staffing needed to ensure that we look back and say 2020 was the year the trolley crisis ended – not that 2020 was the year that our vulnerable elderly population was subjected firstly to coronavirus and then to a combination of the flu and coronavirus.
Outpatient care
The days of packed waiting rooms are over. We must continue the innovation and flexibility seen in the past few weeks and develop new practices for outpatient care. In this challenge, there is an opportunity for us to improve the service and centre it around patient needs and experience. The bottom line is that we need to cut down on physical attendance to minimise the spread of Covid-19.
IT solutions including virtual hubs where patients have an online triage first will help assist in planning whether patients can be seen virtually or need an in-person assessment.
Patients with complex care needs such as diabetes where they may see multiple providers including diabetologists, ophthalmologists, cardiologists, nephrologists and podiatrists (to name but a few) will be better served by a one-stop-shop where their care needs are met in one visit.
There are already attempts at this in the system, but it will need to become embedded and streamlined. Hospitals with good car park facilities will need to look at using the car park as a waiting room to minimise the number of people in waiting rooms.
It is important to recognise that the design of our hospitals is in general not fit for modern infection control: we need to invest in our physical infrastructure – more single rooms, larger waiting rooms, wider corridors.
We will also need to screen patients for symptoms virtually in advance of attendance. All of this means that the capacity; the number of patients seen in our outpatient departments will fall because of the essential infection control and social distancing measures.
We should be looking to extend the working day into the evening and weekends but to do this we need more staff. Starting with the lowest consultant numbers in the EU places a huge burden but these are the very people who have stepped up so capably and committedly in the past few weeks with all our healthcare colleagues to tackle the Covid-19 crisis.
Elective care
We will need to do all we can to keep Covid and non-Covid care streams separate.
We will have to consider asking all elective patients to cocoon for two weeks pre-operatively as well as virtual screening them for Covid-19 symptoms in advance of admission.
We also must consider testing these patients for Covid-19 in advance of admission. As well as laboratory tests we will have to assess if screening with CAT scans is appropriate. Post-operatively these patients will need to be separate from the patients who have been admitted emergently through the ED to minimise the risk of post-operative Covid infection. We will also have to optimise our screening of staff involved in providing this care.
Once again all of this means that the capacity; the number of patients we can safely operate on will fall because of the essential infection control and social distancing measures.
Infection control measures, air exchange, social distancing measures will really impact our ability to perform all cases that require general anaesthetic examination. Again, the older infrastructure in our hospitals including the ventilation systems has a negative impact on capacity.
Technology is key
Paper charts are an infection risk. We need now, finally, to prioritise the IT investment and rapid delivery of a national unique patient identifier, a national electronic health record that integrates primary and secondary care, integration of the laboratory and radiology systems. This is no small ask, but it has never been more essential.
Our status as having the lowest number of specialist consultants in Europe has now become critical. Against the backdrop of the current challenges, we now can rebuild our system so that we address the care needs of all our people in a timely fashion.
I believe no one should wait more than six weeks for care. Despite the current endemic shortage of consultants, many of those same consultants are those who have put their shoulder to the wheel in a big way (and in a similar fashion to other frontline workers have put their own health and the health of their families at risk from this virulent infection).
We need now to move forward together collaboratively, making the best used of all the capacity in the country for the good of all our patients.
Ní neart go cur le chéile.
Dr Gabrielle Colleran is Vice President of the Irish Hospital Consultants Association and Consultant Paediatric Radiologist at the National Maternity Hospital and Children’s Health Ireland (Temple Street).
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