Safety of emergency, elective and day case operating during the winter period at East Suffolk and North Essex NHS Foundation Trust: lessons from the outcomes of 4,254 surgical patients from the first COVID-19 wave.

BACKGROUND: There is limited evidence on perioperative outcomes of surgical patients during the COVID-19 pandemic to inform continued operating into the winter period. METHODS: We retrospectively analysed the rate of 30-day COVID-19 transmission and mortality of all surgical patients in the three hospitals in our trust in the East of England during the first lockdown in March 2020. All patients who underwent a swab were swabbed on or 24 hours prior to admission. RESULTS: There were 4,254 patients and an overall 30-day mortality of 0.99%. The excess surgical mortality in our region was 0.29%. There were 39 patients who were COVID-19 positive within 30 days of admission, 12 of whom died. All 12 were emergency admissions with a length of stay longer than 24 hours. There were three deaths among those who underwent day case surgery, one of whom was COVID-19 negative, and the other two were not swabbed but not suspected to have COVID-19. There were two COVID-19 positive elective cases and none in day case elective or emergency surgery. There were no COVID-19 positive deaths in elective or day case surgery. CONCLUSIONS: There was a low rate of COVID-19 transmission and mortality in elective and day case operations. Our data have allowed us to guide patients in the consent process and provided the evidence base to restart elective and day case operating with precautions and regular review. A number of regions will be similarly affected and should perform a review of their data for the winter period and beyond.

Modelling the impact of changes to abdominal aortic aneurysm screening and treatment services in England during the COVID-19 pandemic.

BACKGROUND: The National Health Service (NHS) abdominal aortic aneurysm (AAA) screening programme (NAAASP) in England screens 65-year-old men. The programme monitors those with an aneurysm, and early intervention for large aneurysms reduces ruptures and AAA-related mortality. AAA screening services have been disrupted following COVID-19 but it is not known how this may impact AAA-related mortality, or where efforts should be focussed as services resume. METHODS: We repurposed a previously validated discrete event simulation model to investigate the impact of COVID-19-related service disruption on key outcomes. This model was used to explore the impact of delayed invitation and reduced attendance in men invited to screening. Additionally, we investigated the impact of temporarily suspending scans, increasing the threshold for elective surgery to 7cm and increasing drop-out in the AAA cohort under surveillance, using data from NAAASP to inform the population. FINDINGS: Delaying invitation to primary screening up to two years had little impact on key outcomes whereas a 10% reduction in attendance could lead to a 2% lifetime increase in AAA-related deaths. In surveillance patients, a 1-year suspension of surveillance or increase in the elective threshold resulted in a 0.4% increase in excess AAA-related deaths (8% in those 5-5.4cm at the start). Longer suspensions or a doubling of drop-out from surveillance would have a pronounced impact on outcomes. INTERPRETATION: Efforts should be directed towards encouraging men to attend AAA screening service appointments post-COVID-19. Those with AAAs on surveillance should be prioritised as the screening programme resumes, as changes to these services beyond one year are likely to have a larger impact on surgical burden and AAA-related mortality.

Substantial decline in hospital admissions for heart failure accompanied by increased community mortality during COVID-19 pandemic.

AIMS: We hypothesized that a decline in admissions with heart failure during COVID-19 pandemic would lead to a reciprocal rise in mortality for patients with heart failure in the community. METHODS AND RESULTS: We used National Heart Failure Audit data to identify 36 974 adults who had a hospital admission with a primary diagnosis of heart failure between February and May in either 2018, 2019, or 2020. Hospital admissions for heart failure in 2018/19 averaged 160/day but were much lower in 2020, reaching a nadir of 64/day on 27 March 2020 [incidence rate ratio (IRR): 0.40, 95% confidence interval (CI): 0.38-0.42]. The proportion discharged on guideline-recommended pharmacotherapies was similar in 2018/19 compared to the same period in 2020. Between 1 February-2020 and 31 May 2020, there was a 29% decrease in hospital deaths related to heart failure (IRR: 0.71, 95% CI: 0.67-0.75; estimated decline of 448 deaths), a 31% increase in heart failure deaths at home (IRR: 1.31, 95% CI: 1.24-1.39; estimated excess 539), and a 28% increase in heart failure deaths in care homes and hospices (IRR: 1.28, 95% CI: 1.18-1.40; estimated excess 189). All-cause, inpatient death was similar in the COVID-19 and pre-COVID-19 periods [odds ratio (OR): 1.02, 95% CI: 0.94-1.10]. After hospital discharge, 30-day mortality was higher in 2020 compared to 2018/19 (OR: 1.57, 95% CI: 1.38-1.78). CONCLUSION: Compared with the rolling daily average in 2018/19, there was a substantial decline in admissions for heart failure but an increase in deaths from heart failure in the community. Despite similar rates of prescription of guideline-recommended therapy, mortality 30 days from discharge was higher during the COVID-19 pandemic period.

Securing a sustainable and fit-for-purpose UK health and care workforce.

Approximately 13% of the total UK workforce is employed in the health and care sector. Despite substantial workforce planning efforts, the effectiveness of this planning has been criticised. Education, training, and workforce plans have typically considered each health-care profession in isolation and have not adequately responded to changing health and care needs. The results are persistent vacancies, poor morale, and low retention. Areas of particular concern highlighted in this Health Policy paper include primary care, mental health, nursing, clinical and non-clinical support, and social care. Responses to workforce shortfalls have included a high reliance on foreign and temporary staff, small-scale changes in skill mix, and enhanced recruitment drives. Impending challenges for the UK health and care workforce include growing multimorbidity, an increasing shortfall in the supply of unpaid carers, and the relative decline of the attractiveness of the National Health Service (NHS) as an employer internationally. We argue that to secure a sustainable and fit-for-purpose health and care workforce, integrated workforce approaches need to be developed alongside reforms to education and training that reflect changes in roles and skill mix, as well as the trend towards multidisciplinary working. Enhancing career development opportunities, promoting staff wellbeing, and tackling discrimination in the NHS are all needed to improve recruitment, retention, and morale of staff. An urgent priority is to offer sufficient aftercare and support to staff who have been exposed to high-risk situations and traumatic experiences during the COVID-19 pandemic. In response to growing calls to recognise and reward health and care staff, growth in pay must at least keep pace with projected rises in average earnings, which in turn will require linking future NHS funding allocations to rises in pay. Through illustrative projections, we show that, to sustain annual growth in the workforce at approximately 2·4%, increases in NHS expenditure of 4% annually in real terms will be required. Above all, a radical long-term strategic vision is needed to ensure that the future NHS workforce is fit for purpose.

Shaping the future of healthcare: building back better.

The Covid-19 pandemic has not only highlighted societal inequalities but also shown how a resilient health service is essential for protecting citizens. The NHS was founded in 1948 to provide universal healthcare but has been under sustained attack for the past thirty years. As a seven-year-old patient with osteomyelitis, the NHS almost certainly saved my life. Seventy years later I reflect on the humanising and civilising aspects of the NHS, the need for doctors to be advocates and custodians, as well as clinicians working in the best interests of their individual patients; and the requirement for the medical profession to understand the social determinants of ill health and how these can be ameliorated. The reward for engaging in this struggle: a healthier world in the widest sense and greater satisfaction for all those working in the prevention and treatment of ill health.

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ENT trainees' experience of redeployment during the coronavirus disease 2019 pandemic: a qualitative study.

BACKGROUND: As a response to the acute strain placed on the National Health Service during the first wave of coronavirus disease 2019 in the UK, a number of junior doctors including ENT trainees were redeployed to other clinical specialties. This presented these trainees with novel challenges and opportunities. METHODS: A qualitative study was performed to explore these experiences, undertaking semi-structured interviews with ENT trainees between 17th and 30th July. Participants were recruited through purposeful sampling. Interview transcripts underwent thematic analysis using Dedoose software. RESULTS: Seven ENT trainees were interviewed, ranging from specialty trainee years four to eight ('ST4' to 'ST8') in grade. Six core themes were identified: organisation of redeployment, utilisation of skill set, emotional impact of redeployment, redeployed team dynamics, concerns about safety and impact on training. CONCLUSION: The ENT trainees' experiences of redeployment described highlight some important lessons and considerations for future redeployments.

New geographic model of care to manage the post-COVID-19 elective surgery aftershock in England: a retrospective observational study.

OBJECTIVES: The suspension of elective surgery during the COVID-19 pandemic is unprecedented and has resulted in record volumes of patients waiting for operations. Novel approaches that maximise capacity and efficiency of surgical care are urgently required. This study applies Markov multiscale community detection (MMCD), an unsupervised graph-based clustering framework, to identify new surgical care models based on pooled waiting-lists delivered across an expanded network of surgical providers. DESIGN: Retrospective observational study using Hospital Episode Statistics. SETTING: Public and private hospitals providing surgical care to National Health Service (NHS) patients in England. PARTICIPANTS: All adult patients resident in England undergoing NHS-funded planned surgical procedures between 1 April 2017 and 31 March 2018. MAIN OUTCOME MEASURES: The identification of the most common planned surgical procedures in England (high-volume procedures (HVP)) and proportion of low, medium and high-risk patients undergoing each HVP. The mapping of hospitals providing surgical care onto optimised groupings based on patient usage data. RESULTS: A total of 7 811 891 planned operations were identified in 4 284 925 adults during the 1-year period of our study. The 28 most common surgical procedures accounted for a combined 3 907 474 operations (50.0% of the total). 2 412 613 (61.7%) of these most common procedures involved 'low risk' patients. Patients travelled an average of 11.3 km for these procedures. Based on the data, MMCD partitioned England into 45, 16 and 7 mutually exclusive and collectively exhaustive natural surgical communities of increasing coarseness. The coarser partitions into 16 and seven surgical communities were shown to be associated with balanced supply and demand for surgical care within communities. CONCLUSIONS: Pooled waiting-lists for low-risk elective procedures and patients across integrated, expanded natural surgical community networks have the potential to increase efficiency by innovatively flexing existing supply to better match demand.

Risk of death among people with rare autoimmune diseases compared with the general population in England during the 2020 COVID-19 pandemic.

OBJECTIVES: To quantify the risk of death among people with rare autoimmune rheumatic diseases (RAIRD) during the UK 2020 COVID-19 pandemic compared with the general population, and compared with their pre-COVID risk. METHODS: We conducted a cohort study in Hospital Episode Statistics for England from 2003 onwards, and linked data from the NHS Personal Demographics Service. We used ONS published data for general population mortality rates. RESULTS: We included 168 691 people with a recorded diagnosis of RAIRD alive on 1 March 2020. Their median age was 61.7 (IQR 41.5-75.4) years, and 118 379 (70.2%) were female. Our case ascertainment methods had a positive predictive value of 85%. A total of 1815 (1.1%) participants died during March and April 2020. The age-standardized mortality rate (ASMR) among people with RAIRD (3669.3; 95% CI: 3500.4, 3838.1 per 100 000 person-years) was 1.44 (95% CI: 1.42, 1.45) times higher than the average ASMR during the same months of the previous 5 years, whereas in the general population of England it was 1.38 times higher. Age-specific mortality rates in people with RAIRD compared with the pre-COVID rates were higher from the age of 35 upwards, whereas in the general population the increased risk began from age 55 upwards. Women had a greater increase in mortality rates during COVID-19 compared with men. CONCLUSION: The risk of all-cause death is more prominently raised during COVID-19 among people with RAIRD than among the general population. We urgently need to quantify how much risk is due to COVID-19 infection and how much is due to disruption to health-care services.

The Factors That Influenced Medical Students' Decision to Work Within the NHS During the COVID-19 Pandemic-A National, Cross-sectional Study.

PURPOSE: Medical students across the United Kingdom helped the National Health Service (NHS) with the increased workload caused by the COVID-19 pandemic. This study was conducted to better understand the implications of COVID-19 on the intricate relationship between the psychological wellbeing of students and working within the NHS. METHOD: This was a cross-sectional, national UK study analyzing the self-reported pandemic anxiety scale (PAS) of participants during the pandemic, using an online questionnaire. RESULTS: 25.2% of participants worked within the NHS. Working significantly reduced anxiety levels of participants. Concerns around the training and information provided on personal protective equipment (PPE) (odds ratio [OR] 2.57, 95% confidence interval [CI] OR: 1.93, 3.43) (P < 0.001) and Ethnicity (OR 2.15, 95% CI OR: 1.54, 2.99) (P < 0.001) were the most significant covariates affecting the likelihood of working. CONCLUSION: Working during the pandemic was influenced by age, ethnicity, and information surrounding PPE. On average those who worked experienced less anxiety and were more cheerful and energetic.

COVID-19: it happens to nurses too-a case study.

The COVID-19 pandemic will have long-term ramifications for many patients, including those who work in the NHS and have been victims of the disease. This short case study describes the journey of an emergency department (ED) charge nurse who contracted COVID-19 and was hospitalised in the intensive care unit (ICU). Post-discharge, he experienced a multitude of physical and mental health complications, which ultimately impacted on each other. Therefore, a bio-psycho-pharmaco-social approach to care is recommended from admission through ICU, discharge and beyond. From this and other narratives, it appears that COVID-19 patients are not adequately followed up after ICU discharge, something that must be considered going forward.

Considering care in context.

Sam Foster, Chief Nurse, Oxford University Hospitals, reflects on the need for regulators to take into account the care context, particularly with some trusts under more pressure than others from a second wave of COVID-19.

General practice's early response to the COVID-19 pandemic.

The COVID-19 pandemic has resulted in multiple changes in the delivery of general practice services. In response to the threat of the pandemic and in order to keep their businesses safe and viable, general practices have rapidly moved to new models of care, embraced Medicare-funded telehealth and responded to uncertain availability of personal protective equipment with innovation. These changes have shown the adaptability of general practice, helped keep patients and practice staff safe, and undoubtedly reduced community transmission and mortality. The pandemic, and the response to it, has emphasised the potential dangers of existing fragmentation within the Australian health system, and is affecting the viability of general practice. These impacts on primary care highlight the need for improved integration of health services, should inform future pandemic planning, and guide the development of Australia's long-term national health plan.

Nosocomial COVID-19: experience from a large acute NHS Trust in South-West London.

Transmission of coronavirus disease 2019 (COVID-19) in healthcare settings has significant implications for patients and healthcare workers, may amplify local outbreaks, and may place additional burden on already stretched resources. Risk of missed or late diagnosis of COVID-19 was high during the UK's initial 'containment phase', because of strict criteria for testing. The risk remains due to asymptomatic/pre-symptomatic transmission, complicated by challenges faced with laboratory testing. We present a case study of potential nosocomial transmission associated with the first case of COVID-19 at a large acute NHS Trust in South-West London, and we describe the prevailing burden of nosocomial infections.