Predicting endoscopic activity recovery in England after COVID-19: a national analysis.

BACKGROUND: The COVID-19 pandemic has led to a substantial reduction in gastrointestinal endoscopies, creating a backlog of procedures. We aimed to quantify this backlog nationally for England and assess how various interventions might mitigate the backlog. METHODS: We did a national analysis of data for colonoscopies, flexible sigmoidoscopies, and gastroscopies from National Health Service (NHS) trusts in NHS England's Monthly Diagnostic Waiting Times and Activity dataset. Trusts were excluded if monthly data were incomplete. To estimate the potential backlog, we used linear logistic regression to project the cumulative deficit between actual procedures performed and expected procedures, based on historical pre-pandemic trends. We then made further estimations of the change to the backlog under three scenarios: recovery to a set level of capacity, ranging from 90% to 130%; further disruption to activity (eg, second pandemic wave); or introduction of faecal immunochemical testing (FIT) triaging. FINDINGS: We included data from Jan 1, 2018, to Oct 31, 2020, from 125 NHS trusts. 10 476 endoscopy procedures were done in April, 2020, representing 9·5% of those done in April, 2019 (n=110 584), before recovering to 105 716 by October, 2020 (84·5% of those done in October, 2019 [n=125 072]). Recovering to 100% capacity on the current trajectory would lead to a projected backlog of 162 735 (95% CI 143 775-181 695) colonoscopies, 119 025 (107 398-130 651) flexible sigmoidoscopies, and 194 087 (172 564-215 611) gastroscopies in January, 2021, attributable to the pandemic. Increasing capacity to 130% would still take up to June, 2022, to eliminate the backlog. A further 2-month interruption would add an extra 15·4%, a 4-month interruption would add an extra 43·8%, and a 6-month interruption would add an extra 82·5% to the potential backlog. FIT triaging of cases that are found to have greater than 10 µg haemoglobin per g would reduce colonoscopy referrals to around 75% of usual levels, with the backlog cleared in early 2022. INTERPRETATION: Our work highlights the impact of the pandemic on endoscopy services nationally. Even with mitigation measures, it could take much longer than a year to eliminate the pandemic-related backlog. Urgent action is required by key stakeholders (ie, individual NHS trusts, Clinical Commissioning Groups, British Society of Gastroenterology, and NHS England) to tackle the backlog and prevent delays to patient management. FUNDING: Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) at University College London, National Institute for Health Research University College London Hospitals Biomedical Research Centre, and DATA-CAN, Health Data Research UK.

Rapid quality improvement in a preterm birth clinic care pathway during the COVID-19 pandemic.

BACKGROUND: Preterm birth (PTB) occurs in 8% of births in the UK. At Imperial College Healthcare NHS Trust, our PTB prevention clinic manages the care of approximately 1000 women/year. Women referred to the clinic are seen from 12 weeks of pregnancy with subsequent appointments every 2-4 weeks to measure cervical length (CL) using transvaginal ultrasound (TVUS). Women with a history of cervical weakness or short cervix on TVUS are offered a cervical cerclage. LOCAL PROBLEM: During the COVID-19 outbreak, pregnant women were strongly advised to avoid social mixing and public transport. The National Health Service had to rapidly adopt remote consultation and redesign clinical pathways in order to reduce transmission, exposure and spread among women at high risk of PTB. METHODS: We focused on Specific, Measurable, Achievable, Realistic and Timebound aims and used a driver diagram to visualise our changes. We used a series of Plan Do Study Act cycles to evaluate and adapt change ideas through the UK's national lockdown during the COVID-19 pandemic between 23 March and 29 May 2020. RESULTS: We reduced the number of face-to-face appointments by 54%. This was achieved by increasing remote telephone consultations from 0% to 64%, and by reducing the intensity of surveillance. The rate of regional anaesthetic was increased from 53% to 95% for cerclage placement in order to minimise the number of aerosol-generating procedures. Patient and staff satisfaction responses to these changes were used to tailor practices. No women tested positive for COVID-19 during the study period. CONCLUSIONS: By using quality improvement methodology, we were able to safely and rapidly implement a new care pathway for women at high risk of PTB which was acceptable to patients and staff, and effective in reducing exposure of COVID-19.

Harnessing Digital Health Technologies During and After the COVID-19 Pandemic: Context Matters.

A common development observed during the COVID-19 pandemic is the renewed reliance on digital health technologies. Prior to the pandemic, the uptake of digital health technologies to directly strengthen public health systems had been unsatisfactory; however, a relentless acceleration took place within health care systems during the COVID-19 pandemic. Therefore, digital health technologies could not be prescinded from the organizational and institutional merits of the systems in which they were introduced. The Italian National Health Service is strongly decentralized, with the national government exercising general stewardship and regions responsible for the delivery of health care services. Together with the substantial lack of digital efforts previously, these institutional characteristics resulted in delays in the uptake of appropriate solutions, territorial differences, and issues in engaging the appropriate health care professionals during the pandemic. An in-depth analysis of the organizational context is instrumental in fully interpreting the contribution of digital health during the pandemic and providing the foundation for the digital reconstruction of what is to come after.

COVID-19 confessions: a qualitative exploration of healthcare workers experiences of working with COVID-19.

OBJECTIVES: To gain insight into the experiences and concerns of front-line National Health Service (NHS) workers while caring for patients with COVID-19. DESIGN: Qualitative analysis of data collected through an anonymous website (www.covidconfidential) provided a repository of uncensored COVID-19 experiences of front-line NHS workers, accessed via a link advertised on the Twitter feed of two high profile medical tweeters and their retweets. SETTING: Community of NHS workers who accessed this social media. PARTICIPANTS: 54 healthcare workers, including doctors, nurses and physiotherapists, accessed the website and left a 'story'. RESULTS: Stories ranged from 1 word to 10 min in length. Thematic analysis identified common themes, with a central aspect being the experience and psychological consequence of trauma. Specific themes were: (1) the shock of the virus, (2) staff sacrifice and dedication, (3) collateral damage ranging from personal health concerns to the long-term impact on, and care of, discharged patients and (4) a hierarchy of power and inequality within the healthcare system. CONCLUSIONS: COVID-19 confidential gave an outlet for unprompted and uncensored stories of healthcare workers in the context of COVID-19. In addition to personal experiences of trauma, there were perceptions that many operational difficulties stemmed from inequalities of power between management and front-line workers. Learning from these experiences will reduce staff distress and improve patient care in the face of further waves of the pandemic.

Investigating the challenges and opportunities for medicines management in an NHS field hospital during the COVID-19 pandemic.

INTRODUCTION: Hospital admissions from COVID-19 initially increased rapidly within the UK. National Health Service (NHS) field hospitals are part of a capacity building response built at great scale and speed to respond to the anticipated increased demand the NHS faces during this time. NHS Nightingale Hospital Birmingham (NHB) is modelled to treat mild to moderate (non-critical care) COVID-19 disease, to provide step-down capacity for patients in recovery, or for palliating patients in the dying phase of their disease in the Midlands. Opportunities and challenges presented for optimal medicines management (MM) during the development of the NHB are investigated, and a framework developed to support future NHS field hospitals of this model. METHODS: A team, comprised of an associate medical director, trust chief pharmacist and senior pharmacists iteratively developed a framework to convert the large non-hospital setting into a functioning NHS field hospital with standardised MM processes adjusted appropriately to cope with operational constraints in the pandemic situation. NHB has, because of its repurposing, both challenges and advantages affecting MM that influence development of the framework. Throughout implementation, a 7-week period between announcement and opening, there was continuous evaluation, external stakeholder validation and peer review. RESULTS: The PESTLE model, a mechanism of analysis to identify elements of a project environment (Political, Environmental, Social, Technological, Legal and Economic), was applied to identify influencing factors and support detailed project planning. Compliance with medicines legislation was at the forefront of all MM process development for the NHB field hospital. Internal factors were identified by the core MM team, resulting in a workforce, education & training and clinical pharmacy MM plan. DISCUSSION: MM processes are extensive and integral to NHS field hospitals. The presented framework of influencing factors may support future NHS field hospital development. It is pertinent to have a broad team working approach to any large-scale project such as outlined here, and suggest the identified factors be used as a core framework for development of any future MM processes in NHS field hospitals.

[Proposals by the Spanish Society of Quality in Healthcare (SECA) for the recovery of the National Health Service after the COVID-19 pandemic]. / Propuestas de la SECA para la recuperación del Sistema Nacional de Salud tras la pandemia por SARS-CoV-2.

BACKGROUND: The SARS-CoV-2 pandemic has demanded responses for which the National Health System (NHS) was not prepared. The Spanish Society for Quality in Healthcare (SECA) has the mission of promoting quality in healthcare and contributing to its proper functioning. OBJECTIVE: To present SECA recommendations to ensure the quality and safety of patients in the recovery of the NHS following the impact of the SARS-CoV-2 pandemic and the possibility of a resurgence. METHODS: Qualitative study to seek consensus with the participation of 49 representatives of the different stakeholders (patients, managers, professionals, academics and researchers). The areas to be explored were: lessons learned, management of new care demands from COVID-19 patients, recompositing of templates, strengthening the resilience of professionals, new role of patients and contingency plans. RESULTS: Four hundred and twenty-eight proposals were submitted. Once duplicates were deleted and similar proposals were merged, their number was reduced to 120. Of these, 60 proposals were prioritized and grouped into two categories of measures: (1) to recover the Health System (equity, accessibility, effectiveness, efficiency, safety, patient experience and work morale) and (2) to deal with possible outbreaks. CONCLUSION: SECA responds to its commitment to society with recommendations to ensure quality of healthcare and patient safety in the COVID-19 Era.

Rapid implementation of Microsoft Teams in response to COVID-19: one acute healthcare organisation's experience.

Background COVID-19 presented significant challenges to healthcare organisations, which needed to rapidly remodel their services but were unable to allow staff to meet face to face to minimise infection risk. During this communication predicament, National Health Service (NHS) Digital announced the provision of Microsoft Teams, a digital communication and collaboration tool, which was implemented at Royal Free London NHS Foundation Trust within 2 weeks.Method Given the need to deploy at scale, rapidly and with minimal resource, an agile decentralised innovation management approach was used, empowering staff to be local implementors.Results Resulting use cases were highly original and varied, ranging from a COVID-19 Education Programme to coordination of oxygen demand. Analytics showed rapid and persistent adoption, surpassing 500 daily active users within 11 days. Usage continues to increase, consistent with a direct network effect.Conclusion These findings suggest a high demand for this format of communication and high willingness to adopt it. Further qualitative research into staff perceptions would be valuable to confirm this, and to assess the user experience.Overall, this has been a radical approach to digital implementation in healthcare, and has so far proved effective in delivering a cost minimal, rapid communication tool at scale in the midst of a global pandemic.

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.

One country, two crises: what Covid-19 reveals about health inequalities among BAME communities in the United Kingdom and the sustainability of its health system?

There has been mounting evidence of the disproportionate involvement of black, Asian and minority ethnic (BAME) communities by the Covid-19 pandemic. In the UK, this racial disparity was brought to the fore by the fact that the first 11 doctors to die in the UK from Covid-19 were of BAME background. The mortality rate from Covid-19 among people of black African descent in English hospitals has been shown to be 3.5 times higher when compared to rates among white British people. A Public Health England report revealed that Covid-19 was more likely to be diagnosed among black ethnic groups compared to white ethnic groups with the highest mortality occurring among BAME persons and persons living in the more deprived areas. People of BAME background account for 4.5% of the English population and make up 21% of the National Health Service (NHS) workforce. The UK poverty rate among BAME populations is twice as high as for white groups. Also, people of BAME backgrounds are more likely to be engaged in frontline roles. The disproportionate involvement of BAME communities by Covid-19 in the UK illuminates perennial inequalities within the society and reaffirms the strong association between ethnicity, race, socio-economic status and health outcomes. Potential reasons for the observed differences include the overrepresentation of BAME persons in frontline roles, unequal distribution of socio-economic resources, disproportionate risks to BAME staff within the NHS workspace and high ethnic predisposition to certain diseases which have been linked to poorer outcomes with Covid-19. The ethnoracialised differences in health outcomes from Covid-19 in the UK require urgent remedial measures. We provide intersectional approaches to tackle the complex racial disparities which though not entirely new in itself, have been often systematically ignored.