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“AAt the moment we feel that we are on the razor’s edge, ”says Professor Tim Orchard. The head of one of the NHS’s largest trusts, a consultant gastroenterologist, refers to apprehension among his 14,000 employees about the second rise in Covid-19.
You are not the only one feeling anxious. The recent ominous rise in infections and hospital admissions due to the disease, and the likelihood that the death toll will soon follow suit, has put the entire NHS on alert.
The first wave of spring, when Covid-19 was claiming several hundred lives a day, is fresh on Orchard’s mind. Orchard, the executive director of the Imperial College Healthcare NHS Trust, which runs five hospitals in London, recalls the “terrible problems we had in terms of the number of sick patients.”
Just before Easter, 346 of the trust’s 1,000-odd beds were filled with people seriously ill with coronavirus.
In the rush to reorganize the way its hospitals provided treatment, on an unprecedented scale, the trust acquired more ventilators, doubled its stock of intensive care beds, and repurposed hundreds of staff to take on new roles, in a desperate effort to save as many lives as possible. They could.
He suspended most of his normal care – diagnostic tests, screening, outpatient appointments, and surgery – to free up beds and staff, just like hospitals around the world. Then came Orchard’s own battle when he contracted the virus. “It wasn’t great. I was lucky in that it wasn’t particularly good for my lungs. ”Although he was very ill, he convinced the doctors that he could manage at home.
“While I was sick, I monitored my oxygen saturation levels all the time because I knew the danger point was between day 7 and day 10 when hypoxia [oxygen starvation] it can take effect. I lost about a stone and a little bit in two weeks. “
Early October hauntingly reminds mid-March. The trust is once again reorganizing its services and staff, in anticipation of the likely return of massive Covid-19 victims. However, this time he is doing it after analyzing what he got at the time and what could have gone better. That reassessment has dragged on for months, in contrast to the hasty leap into the unknown in March when he tackled a terrifying new disease for the first time.
“The NHS has decided to do things very differently this time and we will do things very differently,” Orchard explains. In a major shift in focus, NHS England has told hospitals to continue to provide as many non-Covid services for as long as possible, especially operations, while also facing the intense demands that the second wave will bring. To do that, some hospitals will treat Covid-19 patients while others will remain “Covid-free” and perform other care: outpatient appointments, CT and MRI scans, endoscopies, screenings, and operations.
That rethinking comes after doctors, health charities and heads of hospitals expressed growing concern about the millions of patients who were unable to access normal care, or faced long delays, due to the focus on the pandemic. The consequences have been profound, with cancers being overlooked and patients struggling with pain with an unreplaced arthritic hip or knee. Before the coronavirus, there was a backlog of people who needed care; that queue is now longer than ever.
So while Imperial didn’t end up overrun in the first wave, a price was paid.
“For the second time we have tried to learn the lessons of the first wave of Covid-19,” Orchard explains. “The key for us as a service is to realize that we cannot just stop everything that we are doing (normal non-Covid care) to treat Covid-19. We did a good job in the first wave to keep services, like cancer surgery, going.
“But we stopped a lot of things.”
As a result, Imperial’s five hospitals will have a role to play in preventing what the NHS Confederation calls the “triple blow” of winter. Doctors will have to deal with the second wave of Covid-19, provide normal care and tackle waiting lists, simultaneously. To do this, Hammersmith hospital will be “covid-free”, focusing on planned operations such as hernia repairs and joint replacements. Charing Cross Hospital and St Mary’s Hospital, the trust’s flagship, will care for Covid-19 patients in their wards and intensive care units, and will also treat non-Covid cases.
“This time it will be different because we are better prepared,” says Professor Julian Redhead, Imperial’s chief medical officer. The offer of intensive care beds for patients with high dependency or intensive care has increased. Before the pandemic he was 68, and in the struggle to cope with the first wave, this was temporarily increased to 143. This time, the baseline is 104 and may go up to 191 under his “surge plan.”
The success of the NHS ambition to provide much more normal care this time will also depend on having enough staff and being able to prevent the disease from entering “clean” areas containing vulnerable patients.
At the A&E front door at St Mary’s, screening questions help staff separate patients believed to have Covid from the rest. Anyone who enters is then examined or isolated in a side room, and each hospitalized patient also takes a nose and mouth swab each week.
London Trust has two advantages over many others. St Mary’s is one of eight hospitals that are testing the 90-minute Covid tests that Health Secretary Matt Hancock hopes will finally make long delays in testing a thing of the past. And it has its own personnel testing service, which means your staff and their families are not at the mercy of the government’s chaotic test-and-trace program.
The black and oblong DnaNudge testing machines are stored in a side room off a corridor in A&E. They usually give a response within 60 minutes.
“We have four of them, so use them for specific pathways where we need a really fast response. [about a patient’s Covid status]”Says Dr. Ali Sanders, the trust’s director of emergency care.
“We use them with patients who are undergoing urgent surgery, such as after major trauma or stroke, or who are going into intensive care.”
After a pandemic that left several hundred NHS workers dead, the devices also reduce fears among St Mary’s staff that they could be treating someone with Covid and contracting the virus themselves. “It gives everyone the security of knowing what they are dealing with, a positive or negative Covid patient. When winter comes, when people come in out of breath and feverish, we’ll have to know from the start. It will be difficult to know whether or not someone’s pneumonia is Covid pneumonia, ”says Sanders.
However, he adds: “If we had 100 machines, we would test all of them. But we have four. “
Social distancing is another challenge, especially in a former hospital like St Mary’s. The trust is using its £ 1.4 million share of the government’s £ 450 million NHS winter funds to expand both the waiting room and treatment areas in its A&E by taking over other clinical areas. However, the work has not yet started and will not finish until January.
Some of Imperial’s doctors are wearing headphones called HoloLens to broadcast what they see and say to small groups of colleagues observing in a side room. The technology means they can meet patients one-on-one and avoid the gangs of doctors around the beds that often involve ward rounds. “Now 80% fewer doctors go to see the patient. Headphones protect patient staff and staff patients, ”says Dr. James Kinross.
Across the street from A&E, in a mauve brick building, Imperial staff and family testing facilities have gotten busier in recent weeks as infections have risen across the country.
Ian Bateman, a general manager who helped set up the facility, explains that children’s coughs and fever since the schools returned are a major factor in increasing demand as they force parents of Imperial staff to do not work and isolate yourself.
But while the NHS feels better prepared on many levels, the decision to maintain normal care amid the second wave of Covid is ambitious and will test its powers of organization and ingenuity, and 1.4 million staff, once plus.
How do staff feel about a second wave of Covid?
“I’ve been through one wave,” says Redhead, “so I wouldn’t say that people aren’t nervous about going to a second one, because they are, because they know the difficulties in managing these patients. But we are up to it and we will rise to that challenge.
“In spring it was very demanding. We were one of the most affected areas. It was incredibly difficult for staff to work in unfamiliar environments and use unfamiliar equipment and provide end-of-life care. That increases their anxiety to return to that environment.
“But they will; they are up for that challenge. We still hope for the best, but we plan for the worst. “
Many doctors fear that this new wave of Covid could be more demanding than the first, because it is arriving when the NHS enters winter, not outside it, as was the case in March.
“That’s the concern,” says Redhead. “That it will not be only Covid that will boost our numbers; It will be the flu, pneumonia, and the other respiratory illnesses that we contract during the winter. If we have the usual winter pressures plus a second wave of Covid and a bad flu season, that would increase the pressure on hospitals and make things much more difficult for our staff. “
Orchard shares the apprehension, but is also cautiously confident that his confidence, and the NHS in general, is far better prepared for what lies ahead.
“I am very concerned that a second wave adding to the seasonal flu and the normal pressures of winter will be a great challenge for the health service. But if you look at Australia, the flu season has not been bad. And it is certainly possible that the second wave is longer but flatter than the first wave. And unlike then, we now have treatments available, such as [the steroid] dexamethasone, ”Orchard says.
“We are preparing to have to live with Covid in our populations for a long time. We are certainly planning to do it until the end of March. This is a marathon, not a sprint. “
