Written evidence submitted by Mr Theo Chiles, Policy Research Manager and the Royal College of Emergency Medicine  (DEL0288)

COVID-19 has brought significant disruption to the way medical care is delivered across all areas of clinical practice. As we move from a pandemic to an endemic state, delivery of care must adapt to ensure this – and similar diseases – can be managed safely within our Emergency Departments. This submission makes recommendations about how care in Emergency Departments in the UK needs to be transformed.

The recommendations support these five fundamental aims:

  1. Emergency Departments must not become crowded ever again
  2. Hospitals must not become crowded again
  3. Emergency Departments must not become reservoirs of nosocomial infection for patients
  4. Emergency care must be designed to look after vulnerable patients safely
  5. Emergency Departments must be safe workplaces for staff.

These five fundamental aims and associated recommendations are designed so that we can minimise the harms of nosocomial infection and continue to provide the best possible care for patients in our Emergency Departments.

If we do not do this, people will die of avoidable nosocomial infections.

 

The Emergency Medicine response to COVID-19: much done, more to do.

The coronavirus pandemic has brought suffering and damage to many lives across the world and will continue to challenge national health systems for years to come. The NHS response has been phenomenal; demonstrating an ability to optimise the delivery of patient care that puts patient safety first.  As we move from a pandemic to an endemic state, delivery of care must also change to ensure this – and similar diseases – can be managed safely, alongside regular Emergency Care, within our Emergency Departments and wider healthcare systems.

Past disruptions to healthcare delivery have put increased pressure on Emergency Departments as they are perceived to be ‘safe places’ by the public and other parts of the system, and therefore the default option for all healthcare needs. This has contributed to unsustainable overcrowding and corridor care in Emergency Departments.

The SARS-CoV-2 virus causing COVID-19 is not unique in its method of spread, and this pandemic has highlighted the critical importance of high-quality infection prevention and control. We must learn from this response and make changes to our future operations. As we progress beyond the peak of this outbreak, we must take action now to ensure patient safety is never jeopardised again through poor infection control, design, physical crowding, inadequate staff protection, and corridor care. We cannot treat ill and injured people in an environment that does not allow adequate social distancing.

Attendances at Emergency Departments fell during the first two months of the pandemic. Possible reasons for this include changes in disease patterns or behaviour, patients being treated by alternative pathways, or anxiety over presenting to hospitals.

This is not fully understood yet but there appears little or no evidence of patients being able to access ‘alternative pathways’. The extent to which patient behaviour was influenced by each of these is uncertain, but we know that most of the decline has been in lower acuity groups and the rate of presentation of seriously ill patients has fallen by a lesser amount. It is important to consolidate alternative routes of access for lower acuity patients, whilst maintaining access for those who need the services of Emergency Departments and hospitals. This would both ensure the best possible outcomes and lower nosocomial infection risk for patients and staff.

The response of the public in complying with the social isolation imposed by lockdown has been impressive and effective. The pandemic has driven use of NHS 111 and other advice lines in a way that had previously not been realised.

Ambulance services have focused heavily on prioritisation and need for conveyance. Primary care and other services have undergone a paradigm shift in how consultations are conducted, and community work is undertaken. There has been a transformation in the way that many specialties have delivered care to their most vulnerable patients to minimise their risk of nosocomial infection, by increasing the use of telemedicine and remote consultations. This needs to continue. Major changes have been made to the way patients are cared for throughout the system to effectively respond to the pandemic. Some of these changes are welcome – many are overdue – such as increased use of virtual fracture clinics, telemedicine, and careful consideration around the value of hospital admissions and end of life care. Many such changes have been implemented at pace and the normal safeguards to ensure they work as intended may be missing. In these cases, it is important to consider the changes carefully and adapt where necessary. It is also important that the public, who pay for and use these services, are meaningfully consulted as to how Emergency Departments need to change.

Emergency Departments have been extensively reconfigured into streams to separate patients more likely to have COVID-19 from those less likely; in many cases this has involved changed or increased footprints. Many departments have also operated different rotas and introduced new processes, and traditional inpatient team involvement at the “front door” has increased, with improved access to face-to-face specialist opinions and radiology.

Similar strategies have been adopted during previous pandemics which helped prevent the spread of infections. In both Toronto and Taiwan, affected hospitals limited the number of entryways. Access stations were staffed with personnel to screen for fever, symptoms, or potential SARS exposures

Hospitals with notable recent nosocomial transmission prevented visitors or nonessential staff from entering. Where medically feasible, all admitted patients were instructed to wear surgical masks. Thorough daily and terminal disinfection were carried out, with careful washing and disinfection of the bed, handrails, bedside tables, floor, and equipment with hypochlorite solution.

To reduce nosocomial transmission, investigations and procedures for SARS patients were carried out in areas separated from other patients. Imaging examinations were performed outside the radiology department as often as possible, using portable x-ray units for inpatients as well as in the emergency department. Imaging units such as ultrasound and CT equipment were dedicated to SARS patients when feasible.[1]

Hospital occupancy has fallen due to a combination of fewer “medically fit” patients remaining in hospital, acceptance of different admission and discharge thresholds, improvements in pathways within hospitals, and reductions in elective surgery. This illustrates that delayed transfers of care and the resulting exit block is not an insoluble problem, and can be fixed where there is a political, financial, managerial and clinical will. Patient flow has improved, and many Emergency Departments are less crowded as result of all of these changes.

RCEM welcomes signs of recovery from the first wave of the pandemic but cautions that we are at the beginning of a long period of necessary transformation. Failing to appreciate this risks minimising the significant pre-pandemic problems in urgent and emergency care. There is also a concerning risk that subsequent waves may coincide with a seasonal flu epidemic, creating more pressure.

There is a moral imperative to ensure our Emergency Departments never become crowded again. If we are crowded, we cannot protect patients and staff. During the SARS outbreak in Hong Kong, 22% of the cases of SARS were healthcare workers. In Canada and Singapore, the proportions were higher (43% and 41%, respectively), as they had fewer SARS cases in the community than Hong Kong.[2]

Some areas of the workforce were more at risk than others: “The effect of the outbreak on intensive care and nursing personnel was disproportionately high. This worsened the pressures on other branches, particularly during the recovery phase when normal services had to be resumed.”[3]

Crowding has long been associated with avoidable mortality, and COVID-19 reinforces and multiplies this risk. Last year a study found that there is a strong correlation between time spent on trolleys in Emergency Department and the risk of death.[4] 12-hour waits, a good indicator of crowding, fell during the initial stages of the pandemic, and must not be allowed to increase as patients return to Emergency Departments.

Productivity and resource gains made by a reduction in crowding must, to a certain degree, be weighed against losses incurred as a result of how staff and departments respond to the current circumstances. At St Thomas’ hospital emergency department, for example, one area that normally houses sixteen seated patients can now only be safely occupied by a maximum of six patients. Disinfection of rooms or cubicles, particularly those where high-risk procedures such as intubation take place, is now a significantly lengthier process, as is the regular donning and doffing of PPE, which adds five minutes or more to every consultation; if a department sees 200  patients in a day this adds up to two, eight hour shifts of worker time.

Emergency Departments will need to continue to operate in segregated streams, with an absolute focus on minimising nosocomial infections. There will be a ‘nosocomial dividend’ from implementing these recommendations, with reduced infections to staff and patients and improved safety and quality of care. This will also need to be the case within the whole system, and the challenge that this represents cannot be underestimated. The whole health system must adapt and change.

Emergency Departments should return to their original core purpose: the rapid assessment and emergency stabilisation of seriously ill and injured patients. They can no longer be used to pick up the pieces where community, ‘out of hours’, or specialist care has struggled to cope. This will need leadership and active support at national, regional and local level, together with changes in behaviour from both the public, this will only be possible if patients have 24/7 access to high quality services they can trust.

 

 

May 2020

Recommendations to ensure patient safety and high-quality emergency care

  1. Improved infection control
  1. Reducing crowding and improving safety


Critical illness and injury
 

Non-time critical presentations

  1. Patients already under the care of specialist teams
  1. Physical Emergency Department redesign


  1. Using COVID-19 testing for best care
  1. Metrics to support reduced crowding

 


[1] M. Chan-Yeung, Severe acute respiratory syndrome (SARS) and healthcare workers Int J Occup Environ Health, 10 (4) (2004), pp. 421-427

[2] Ibid.

[3] Ibid.

[4] https://www.theguardian.com/society/2019/dec/10/thousands-of-patients-die-waiting-for-beds-in-hospitals-study

[5] M. Chan-Yeung, Severe acute respiratory syndrome (SARS) and healthcare worker