The impact of COVID-19 on anaesthesia and critical care services in the UK: a serial service evaluation*

Between October 2020 and January 2021, we conducted three national surveys to track anaesthetic, surgical and critical care activity during the second COVID-19 pandemic wave in the UK. We surveyed all NHS hospitals where surgery is undertaken. Response rates, by round, were 64%, 56% and 51%. Despite important regional variations, the surveys showed increasing systemic pressure on anaesthetic and peri-operative services due to the need to support critical care pandemic demands. During Rounds 1 and 2, approximately one in eight anaesthetic staff were not available for anaesthetic work. Approximately one in five operating theatres were closed and activity fell in those that were open. Some mitigation was achieved by relocation of surgical activity to other locations. Approximately one-quarter of all surgical activity was lost, with paediatric and non-cancer surgery most impacted. During January 2021, the system was largely overwhelmed. Almost one-third of anaesthesia staff were unavailable, 42% of operating theatres were closed, national surgical activity reduced to less than half, including reduced cancer and emergency surgery. Redeployed anaesthesia staff increased the critical care workforce by 125%. Three-quarters of critical care units were so expanded that planned surgery could not be safely resumed. At all times, the greatest resource limitation was staff. Due to lower response rates from the most pressed regions and hospitals, these results may underestimate the true impact. These findings have important implications for understanding what has happened during the COVID-19 pandemic, planning recovery and building a system that will better respond to future waves or new epidemics.     

COVID-19: legal implications for critical care

The COVID-19 pandemic has caused an unprecedented challenge for the provision of critical care. Anticipating an unsustainable burden on the health service, the UK Government introduced numerous legislative measures culminating in the Coronavirus Act, which interfere with existing legislation and rights. However, the existing standards and legal frameworks relevant to critical care clinicians are not extinguished, but anticipated to adapt to a new context. This new context influences the standard of care that can be reasonably provided and yields many human rights considerations, for example, in the use of restraints, or the restrictions placed on patients and visitors under the Infection Prevention and Control guidance. The changing landscape has also highlighted previously unrecognised legal dilemmas. The perceived difficulties in the provision of personal protective equipment for employees pose a legal risk for Trusts and a regulatory risk for clinicians. The spectre of rationing critical care poses a number of legal issues. Notably, the flux between clinical decisions based on best interests towards decisions explicitly based on resource considerations should be underpinned by an authoritative public policy decision to preserve legitimacy and lawfulness. Such a policy should be medically coherent, legally robust and ethically justified. The current crisis poses numerous challenges for clinicians aspiring to remain faithful to medicolegal and human rights principles developed over many decades, especially when such principles could easily be dismissed. However, it is exactly at such times that these principles are needed the most and clinicians play a disproportionate role in safeguarding them for the most vulnerable.     

Factors associated with mortality in patients with COVID-19 admitted to intensive care: a systematic review and meta-analysis

Identification of high-risk patients admitted to intensive care with COVID-19 may inform management strategies. The objective of this meta-analysis was to determine factors associated with mortality among adults with COVID-19 admitted to intensive care by searching databases for studies published between 1 January 2020 and 6 December 2020. Observational studies of COVID-19 adults admitted to critical care were included. Studies of mixed cohorts and intensive care cohorts restricted to a specific patient sub-group were excluded. Dichotomous variables were reported with pooled OR and 95%CI, and continuous variables with pooled standardised mean difference (SMD) and 95%CI. Fifty-eight studies (44,305 patients) were included in the review. Increasing age (SMD 0.65, 95%CI 0.53–0.77); smoking (OR 1.40, 95%CI 1.03–1.90); hypertension (OR 1.54, 95%CI 1.29–1.85); diabetes (OR 1.41, 95%CI 1.22–1.63); cardiovascular disease (OR 1.91, 95%CI 1.52–2.38); respiratory disease (OR 1.75, 95%CI 1.33–2.31); renal disease (OR 2.39, 95%CI 1.68–3.40); and malignancy (OR 1.81, 95%CI 1.30–2.52) were associated with mortality. A higher sequential organ failure assessment score (SMD 0.86, 95%CI 0.63–1.10) and acute physiology and chronic health evaluation-2 score (SMD 0.89, 95%CI 0.65–1.13); a lower PaO₂:F_IO₂ (SMD −0.44, 95%CI −0.62 to −0.26) and the need for mechanical ventilation at admission (OR 2.53, 95%CI 1.90–3.37) were associated with mortality. Higher white cell counts (SMD 0.37, 95%CI 0.22–0.51); neutrophils (SMD 0.42, 95%CI 0.19–0.64); D-dimers (SMD 0.56, 95%CI 0.43–0.69); ferritin (SMD 0.32, 95%CI 0.19–0.45); lower platelet (SMD −0.22, 95%CI −0.35 to −0.10); and lymphocyte counts (SMD −0.37, 95%CI −0.54 to −0.19) were all associated with mortality. In conclusion, increasing age, pre-existing comorbidities, severity of illness based on validated scoring systems, and the host response to the disease were associated with mortality; while male sex and increasing BMI were not. These factors have prognostic relevance for patients admitted to intensive care with COVID-19.     

Epidemiologic characteristics and pre-hospital care of traumatic injuries during the COVID-19 pandemic in an emerging and developing country: A single tertiary centre experience

BackgroundPre-hospital care has been shown to reduce the mortality in trauma patients. The present study is an attempt to identify the status of pre-hospital orthopaedic trauma care in developing countries during COVID-19 pandemic.MethodsThis was a prospective observational study carried out in a tertiary care setup from March 25th^, 2020 to January 31st^, 2021. All the data pertaining to the traumatic injuries including demographic details and epidemiologic characteristics were recorded in an electronic database.ResultsA total of 1044 patients were included in the study for evaluation. The mean age was 35.24 ± 19.84 years. There were 873 males and 171 females. A total of 748 presented from nearby states, with 401 being the referrals and 347 cases coming directly to hospital. A total of 141 open fractures presented directly and 269 were referred from nearby states. Out of 269 cases of open fractures, only 67 and 139 were given intravenous antibiotics and had wound dressing done respectively at the periphery site. A total of 125, 112, 92 and 84 patients were received without traction/splintage, intravenous fluids, dose of analgesics and recording of vitals respectively. Delay from injury to presentation in emergency/administration of antibiotic (Hours) was 7.06. Road side accidents were main cause comprising of 52.58% cases. Gustilo Anderson classification grade-2 comprised of majority of the open fractures (51.63%). Lower limb fractures comprised of majority of the injuries (70.59%). Majority were adults and conservative management was the most common mode of treatment. A total of 197 and 265 patients had associated head injuries and blunt trauma chest/blunt trauma abdomen respectively.ConclusionEmphasizing on pre-hospital care measures, with special focus on co-ordination between primary, secondary and tertiary health care facilities is the need of the hour and can prevent additional morbidities, avoiding overburden of the already compromised healthcare centres.     

COVID-19 infection and maternal morbidity in critical care units in Scotland: a national cohort study

BackgroundPrevious research has shown that, in comparison with non-pregnant women of reproductive age, pregnant women with COVID-19 are more likely to be admitted to critical care, receive invasive ventilation, and die. At present there are limited data in relation to outcomes and healthcare utilisation following hospital discharge of pregnant and recently pregnant women admitted to critical care.MethodsA national cohort study of pregnant and recently pregnant women who were admitted to critical care in Scotland with confirmed or suspected COVID-19. We examined hospital outcomes as well as hospital re-admission rates.ResultsBetween March 2020 and March 2022, 75 pregnant or recently pregnant women with laboratory-confirmed COVID-19 were admitted to 24 Intensive Care Units across Scotland. Almost two thirds (n=49, 65%) were from the most deprived socio-economic areas. Complete 90-day acute hospital re-admission data were available for 74 (99%) patients. Nine (12%) women required an emergency non-obstetric hospital re-admission within 90 days. Less than 5% of the cohort had received any form of vaccination.ConclusionsThis national cohort study has demonstrated that pregnant or recently pregnant women admitted to critical care with COVID-19 were more likely to reside in areas of socio-economic deprivation, and fewer than 5% of the cohort had received any form of vaccination. More targeted public health campaigning across the socio-economic gradient is urgently required.     

Resilience strategies to manage psychological distress among healthcare workers during the COVID-19 pandemic: a narrative review

The COVID-19 pandemic marks an extraordinary global public health crisis unseen in the last century, with its rapid spread worldwide and associated mortality burden. The longevity of the crisis and disruption to normality is unknown. With COVID-19 set to be a chronic health crisis, clinicians will be required to maintain a state of high alert for an extended period. The support received before and during an incident is likely to influence whether clinicians experience psychological growth or injury. An abundance of information is emerging on disease epidemiology, pathogenesis and infection control prevention. However, literature on interventions for supporting the psychological well-being of healthcare workers during disease outbreaks is limited. This article summarises the available management strategies to increase resilience in healthcare workers during the COVID-19 pandemic and beyond. It focuses on self-care and organisational justice. It highlights various individual as well as organisational strategies. With the success of slowing disease spread in many countries to date, and reduced work-load due to limitations on elective surgery in many institutions, there is more time and opportunity to be pro-active in implementing measures to mitigate or minimise potential adverse psychological effects and improve, restore and preserve the well-being of the workforce now and for years to come. The purpose of this review is to review available literature on strategies for minimising the psychological impact of the COVID-19 pandemic on clinicians and to identify pro-active holistic approaches which may be beneficial for healthcare workers both for the current crisis and into the future.     

Considerations and strategies in the organisation of obstetric anaesthesia care during the 2019 COVID-19 outbreak in Singapore

The provision of safe obstetric anaesthesia services is essential during the COVID-19 global outbreak. The identification of the ‘high-infection risk’ parturient can be challenging especially with the rapidly changing risk criteria for COVID-19 ‘cases’. A multidisciplinary taskforce is required to review the infection control protocols and workflows for managing the parturient for labour analgesia and for caesarean section in order to minimize infection risk to healthcare staff and other parturients. A constant review of such processes is needed to enhance efficiency and to optimise use of finite resources. Good communication between health officials, institutional leadership and ground staff is essential for the dissemination of information.     

Long-term outcomes in COVID-19 patients admitted to intensive care in Denmark: A nationwide observational study

Background

Among ICU patients with COVID-19, it is largely unknown how the overall outcome and resource use have changed with time, different genetic variants, and vaccination status.

Methods

For all Danish ICU patients with COVID-19 from March 10, 2020 to March 31, 2022, we manually retrieved data on demographics, comorbidities, vaccination status, use of life support, length of stay, and vital status from medical records. We compared patients based on the period of admittance and vaccination status and described changes in epidemiology related to the Omicron variant.

Results

Among all 2167 ICU patients with COVID-19, 327 were admitted during the first (March 10–19, 2020), 1053 during the second (May 20, 2020 to June 30, 2021) and 787 during the third wave (July 1, 2021 to March 31, 2022). We observed changes over the three waves in age (median 72 vs. 68 vs. 65 years), use of invasive mechanical ventilation (81% vs. 58% vs. 51%), renal replacement therapy (26% vs. 13% vs. 12%), extracorporeal membrane oxygenation (7% vs. 3% vs. 2%), duration of invasive mechanical ventilation (median 13 vs. 13 vs. 9 days) and ICU length of stay (median 13 vs. 10 vs. 7 days). Despite these changes, 90-day mortality remained constant (36% vs. 35% vs. 33%). Vaccination rates among ICU patients were 42% as compared to 80% in society. Unvaccinated versus vaccinated patients were younger (median 57 vs. 73 years), had less comorbidity (50% vs. 78%), and had lower 90-day mortality (29% vs. 51%). Patient characteristics changed significantly after the Omicron variant became dominant including a decrease in the use of COVID-specific pharmacological agents from 95% to 69%.

Conclusions

In Danish ICUs, the use of life support declined, while mortality seemed unchanged throughout the three waves of COVID-19. Vaccination rates were lower among ICU patients than in society, but the selected group of vaccinated patients admitted to the ICU still had very severe disease courses. When the Omicron variant became dominant a lower fraction of SARS-CoV-2 positive patients received COVID treatment indicating other causes for ICU admission.     

Risks to healthcare workers following tracheal intubation of patients with COVID-19: a prospective international multicentre cohort study

Healthcare workers involved in aerosol-generating procedures, such as tracheal intubation, may be at elevated risk of acquiring COVID-19. However, the magnitude of this risk is unknown. We conducted a prospective international multicentre cohort study recruiting healthcare workers participating in tracheal intubation of patients with suspected or confirmed COVID-19. Information on tracheal intubation episodes, personal protective equipment use and subsequent provider health status was collected via self-reporting. The primary endpoint was the incidence of laboratory-confirmed COVID-19 diagnosis or new symptoms requiring self-isolation or hospitalisation after a tracheal intubation episode. Cox regression analysis examined associations between the primary endpoint and healthcare worker characteristics, procedure-related factors and personal protective equipment use. Between 23 March and 2 June 2020, 1718 healthcare workers from 503 hospitals in 17 countries reported 5148 tracheal intubation episodes. The overall incidence of the primary endpoint was 10.7% over a median (IQR [range]) follow-up of 32 (18–48 [0–116]) days. The cumulative incidence within 7, 14 and 21 days of the first tracheal intubation episode was 3.6%, 6.1% and 8.5%, respectively. The risk of the primary endpoint varied by country and was higher in women, but was not associated with other factors. Around 1 in 10 healthcare workers involved in tracheal intubation of patients with suspected or confirmed COVID-19 subsequently reported a COVID-19 outcome. This has human resource implications for institutional capacity to deliver essential healthcare services, and wider societal implications for COVID-19 transmission.     

Collateral damage of COVID-19 pandemic: Delayed medical care

During the COVID-19 pandemic, emergency room visits have drastically decreased for non-COVID conditions such as appendicitis, heart attack, and stroke. Patients may be avoiding seeking medical attention for fear of catching the deadly condition or as an unintended consequence of stay-at-home orders. This delay in seeking care can lead to increased morbidity and mortality, which has not been figured in the assessment of the extent of damage caused by this pandemic. This case illustrates an example of “collateral damage” caused by the COVID-19 pandemic. What would have been a standard ST-elevation myocardial infarction treated with timely and successful stenting of a dominant right coronary artery occlusion, became a much more dangerous postinfarction ventricular septal defect; all because of a 2-day delay in seeking medical attention by an unsuspecting patient.     

Hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Italy

The first person-to-person transmission of the 2019 novel coronavirus in Italy on 21 February 2020 led to an infection chain that represents one of the largest known COVID-19 outbreaks outside Asia. In northern Italy in particular, we rapidly experienced a critical care crisis due to a shortage of intensive care beds, as we expected according to data reported in China. Based on our experience of managing this surge, we produced this review to support other healthcare services in preparedness and training of hospitals during the current coronavirus outbreak. We had a dedicated task force that identified a response plan, which included: (1) establishment of dedicated, cohorted intensive care units for COVID-19–positive patients; (2) design of appropriate procedures for pre-triage, diagnosis and isolation of suspected and confirmed cases; and (3) training of all staff to work in the dedicated intensive care unit, in personal protective equipment usage and patient management. Hospital multidisciplinary and departmental collaboration was needed to work on all principles of surge capacity, including: space definition; supplies provision; staff recruitment; and ad hoc training. Dedicated protocols were applied where full isolation of spaces, staff and patients was implemented. Opening the unit and the whole hospital emergency process required the multidisciplinary, multi-level involvement of healthcare providers and hospital managers all working towards a common goal: patient care and hospital safety. Hospitals should be prepared to face severe disruptions to their routine and it is very likely that protocols and procedures might require re-discussion and updating on a daily basis.     

Effect of COVID-19 on management of type 1 diabetes: Pushing the boundaries of telemedical healthcare

The new coronavirus disease 2019 (COVID-19) pandemic posed a great burden on health care systems worldwide and is an enormous and real obstacle in providing needed health care to patients with chronic diseases such as diabetes. Parallel to COVID-19, there have been great advances in technology used for management of type 1 diabetes, primarily insulin pumps, sensors, integrated and closed loop systems, ambulatory glucose profile software, and smart phone apps providing necessary essentials for telemedicine implementation right at the beginning of the COVID-19 pandemic. The results of these remote interventions are reassuring in terms of glycemic management and hemoglobin A1c reductions. However, data on long-term outcomes and cost reductions are missing as well as proper technical infrastructure and government health policy support.     

Obesity in women: anaesthetic implications for peri-operative and peripartum management

The prevalence, healthcare and socio-economic impact of obesity (defined as having a body mass index of ≥ 30 kg.m^-2) are disproportionately higher in women than men. A combination of biological and social factors, including the adaptation of energy homeostasis to the increased demands of pregnancy and lactation and poor access to healthy foods or exercise facilities, contribute to the increasing prevalence of obesity in women. Obesity-related physiological changes stem from mass loading and increased metabolism of adipose tissue, as well as secretion of bioactive substances from adipocytes leading to chronic low-grade inflammation. As a result, obesity is associated with increased risks of: infertility; malignancy; sleep-disordered breathing; cardiovascular disease; diabetes; and thromboembolism. Hence, obese women are at markedly increased risk of peri-operative morbidity and mortality and require comprehensive evaluation and targeted comorbidity optimisation by a multidisciplinary team. In addition to routine obstetric challenges, pregnancy in women with obesity further exacerbates the above risks, making multidisciplinary management starting at pre-conception even more important. Weight loss, lifestyle management and optimisation of comorbidity are the cornerstone of reducing obesity-related risks. The anaesthetist plays a vital role within the multidisciplinary team by emphasising weight loss as part of pre-operative comorbidity optimisation, formulation of individualised peri-operative management plans, supervising postoperative care in the high dependency or intensive care settings and providing safe labour analgesia and careful peripartum management for obese parturients.     

Impact of the COVID-19 pandemic on the management of open fractures in a major trauma centre

IntroductionThe Coronavrius-19 (COVID-19) pandemic has presented the biggest challenge that the National Health Service (NHS) has ever seen. As one of the worst affected regions, Orthopaedic service provision and delivery in London, changed dramatically. Our hypothesis is that these restrictions adversely impacted the care of open fractures in our major trauma unit in London.MethodsThis is a prospective case control study comparing the management of patients presenting pre-COVID, to those presenting during the height of the COVID pandemic in London. The pre-COVID, control cohort presented between the 1st October and the November 30, 2019. The COVID cohort presented between the April 1, 2020 and the May 31, 2020. Data was collected that related to the 11 clinical domains of the British Orthopaedic Association Standards of Trauma (BOAST) 4 guidance, as well as early complications.ResultsOf the 11 domains, 100 % compliance was achieved in 6 components, across both groups where applicable. During pre-COVID times, the timing to initial debridement was within 12 h for High energy trauma in 16/28 (57.1 %), dropping to 7/22 (31.8 %) during COVID, (p = 0.004). Definitive soft tissue closure within 72 h If not achievable at initial debridement dropped from 9/10 (90.0%) to 4/6 (66.7 %), (p = 0.006). There was no significant difference in early complication rates.ConclusionCoronavirus has changed the landscape of healthcare worldwide and impacted open fracture care by increasing time to theatre. This had no effect on early complication rate but longer term effects remain to be seen.     

The impact of COVID-19 and healthcare system changes on the well-being of rheumatic patients

ObjectivesThe COVID-19 pandemic has significantly impacted the healthcare systems. Many Polish outpatient clinics have been implementing telemedical consultations as a tool to ensure the continuity of care for patients with chronic diseases. The aim of the study was to evaluate patients’ satisfaction with telemedical appointments, as well as availability of the various medical services and patients’ well-being during the pandemic.Material and methodsAn online-based questionnaire on the experience with telemedical consultations, availability of medical services and current state of health was conducted among Polish rheumatology patients approximately 6 months after the outbreak of the COVID-19 pandemic.ResultsThe survey was completed by 107 respondents with a mean age of 41.52 ±14.33 years. The overall level of satisfaction from telemedical consultations, evaluated with a VAS 1–10 scale, was assessed as 6.23 ±3.04 for teleconsultations in primary healthcare units and 6.00 ±2.80 for rheumatology outpatient units. 42.99% of the respondents were in favour of maintaining telemedical appointments even after the pandemic. Incidences of reduced access to medical services during the COVID-19 pandemic were reported by 77.57% of the patients. Almost half of the respondents reported reduced accessibility to rheumatological care. An alarming decline in health self-esteem, evaluated with a VAS 1–10 scale, was noted from the average 6.37 ±1.92 before COVID-19 to the current rating of 5.78 ±1.91 (p = 0.0087).ConclusionsPolish rheumatology patients are moderately satisfied with the medical teleconsultations in primary health care units and rheumatology outpatient clinics. A substantial number of patients experienced deterioration of well-being as well as limited access to traditional healthcare services, including rheumatology care.     

Severe acute respiratory syndrome coronavirus 2 infection risk during elective peri-operative care: a narrative review

The protection of healthcare workers from the risk of nosocomial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a paramount concern. SARS-CoV-2 is likely to remain endemic and measures to protect healthcare workers against nosocomial infection will need to be maintained. This review aims to inform the assessment and management of the risk of SARS-CoV-2 transmission to healthcare workers involved in elective peri-operative care. In the absence of data specifically related to the risk of SARS-CoV-2 transmission in the peri-operative setting, we explore the evidence-base that exists regarding modes of viral transmission, historical evidence for the risk associated with aerosol-generating procedures and contemporaneous data from the COVID-19 pandemic. We identify a significant lack of data regarding the risk of transmission in the management of elective surgical patients, highlighting the urgent need for further research.