As Consultants in Acute Medicine, Intensive Care, Emergency Medicine, and Microbiology working in hospitals where patients with covid-19 have been cared for, we have significant concerns about the approach taken to identify and isolate patients with SARS-CoV-2 infection presenting to secondary care.
Firstly, we know of patients subsequently found to be positive for SARS-CoV-2 who, at presentation, did not meet the epidemiological criterion from the Public Health England (PHE) case definition for possible covid-19. Initially this required, in the 14 days prior to onset of illness, travel to specified regions of the world or contact with a confirmed case of covid-19. That a patient could have apparently no contact with a known case in the period prior to becoming ill themselves, is of great concern. We think this implies that SARS-CoV-2 is circulating in the UK population more extensively than is appreciated at the present time, which would be in keeping with data from China.
Secondly, we know of patients who, at initial presentation, did not meet the PHE clinical criterion for suspected covid-19, which stipulated either severe acute respiratory infection requiring admission to hospital; an acute respiratory infection of any severity accompanied by shortness of breath or cough; or fever with no other symptoms. This is not unexpected, given that a significant minority of patients may instead present with other features including gastrointestinal disturbance, headache, or confusion.
Third, and perhaps most troublingly, a significant challenge exists with respect to the turnaround time for diagnostic testing in patients suspected to have covid-19. Even when guidance allows testing at the discretion of the treating clinician, PCR assay results for SARS-CoV-2 typically take well in excess of 24 hours from the time of sampling to the time of a result becoming available locally. This is due to delays in the pre- and post-analytic pathways, as a consequence of regional consolidation and centralisation of microbiology services, and the limited number of centres currently providing SARS-CoV-2 testing.
As a result of these factors, patients and healthcare workers in our institutions have potentially been exposed to SARS-CoV-2. This has contributed to significant anxiety and required the deployment of a considerable amount of manpower to contact trace and isolate at-risk individuals at both hospitals. A substantial number of frontline NHS staff—who will be crucial to managing the expected exponential increase in admissions with covid-19 in coming days to weeks—have been advised to self-isolate for 14 days. Other staff who have become symptomatic with flu-like symptoms have also been encouraged to self-isolate, with no apparent prioritisation of screening to exclude SARS-CoV-2 infection.
Events such as these have the potential critically to weaken our ability to respond to the pandemic in secondary care. Delays in test turnaround times will create a huge burden on staff required to wear personal protective equipment (PPE) with the obvious effects this will have on morale and the ability to care for non-covid-19 patients. The wearing of PPE for patients suspected to be suffering from COVID-19 who do not in fact have SARS-CoV-2 infection will also accelerate depletion of stocks of PPE, which the WHO has already highlighted as being in short supply globally.
The announcement on 9th March by England’s Chief Medical Officer, Sir Chris Whitty, that “everybody who has a significant enough pneumonia or other respiratory tract infection to get into hospital at all” will be tested for SARS-CoV-2, is welcome, and the PHE definition of a possible case has subsequently been revised. However, we believe that this does not go far enough. In our opinion, any patient presenting to hospital in whom covid-19 enters the differential diagnosis should be tested on arrival. In fact, given the possibility of asymptomatic infection, if we are to mitigate the problems described above then strong consideration must be given to SARS-CoV-2 testing for every patient admitted to hospital irrespective of the nature of their presentation.
For hospitals in the UK to mount the best possible response to this pandemic, not only will further broadening of the definition of a possible case of covid-19 be necessary. Widespread availability of a rapid point-of-care assay for SARS-CoV-2 with high negative predictive value will also be crucial.
Matthew C. Frise, Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital
Timothy McErlane, Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital
Liza Keating, Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital
Nilangi A. Virgincar, Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital
Shabnam Iyer, Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital
Jamie M. Strachan, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes University Hospital
Joy H. Halliday, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes University Hospital
Andrew P. Walden, Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital
Competing Interests: The authors declare no competing interests.
The views expressed are those of the authors and do not necessarily represent those of their respective NHS Trusts.
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