Emma Green: The impact of covid-19 is hitting emergency departments in many ways

Since the covid-19 pandemic started, I have been working additional shifts in the emergency department alongside my role at the Medical Protection Society. I am however starting to see a decrease in the number of available shifts. This seems to be due to an increase in staff testing and staff who were off ill with covid-19, and are now back at work. 

I was humbled to learn on my last shift that a colleague from the hospital where I was working had been admitted to intensive care with covid-19 and was being transferred for ECMO treatment. Despite this, staff spirits were high with nobody minding working in the covid-19 “hot areas.”

In the last week, my emergency medicine colleagues have also lost a well-respected consultant colleague to covid-19. Having taught alongside him on some courses, the impact of this pandemic is hitting home in so many ways.

It is hard to describe how emergency departments have changed with this crisis unless you have been in one and experienced it, either as a patient or with a relative. In recent years “corridor medicine” has become an accepted norm. As patient numbers have exceeded capacity, many patients have to be seen and nursed on trollies. This has raised issues of confidentiality and patient privacy, but has now become an accepted part of emergency care. Just days before the covid-19 crisis, the Royal College of Emergency Medicine launched a campaign to end “corridor care” after data showed more than 100,000 patients waited over 12 hours in A&E departments last winter.

Corridor care is no longer an issue during covid-19 in the hospital where I have been working. Elective surgery has been cancelled, staff have been redeployed, and hospital beds have been redistributed. All of this has led to bed availability. Patients were proactively discharged during crisis planning and many emergency departments increased their capacity by removing short stay wards, removing  “minors and majors” areas, and in some emergency departments, by redirecting paediatric care to other facilities.

Although these major service reconfigurations have undoubtedly had an impact on patient care, it also means that patients attending A&E who need to be admitted can be transferred to a bed in the hospital. They no longer have to wait for hours. Attendances have also reduced by 57% compared to April last year. Emergency department doctors feel (and I quote a consultant colleague from North West England) that with no overflowing or overcrowding or “decision fatigue” there is time to spend with patients and as such more are discharged with management plans which avoid re-admission. There is still capacity to admit those who need to be in hospital, but increasingly fewer patients want to be admitted and there is a shift in patients taking more responsibility for their illness management. It seems likely that some patients don’t want to be admitted as they are nervous they will contract hospital acquired covid-19. It is understandable that they would prefer to self-manage at home. But there is a risk that patients who need care are not presenting to A&E in time. 

Attendances are felt to be so low at present that some NHS Trusts have launched campaigns to remind and encourage people to go to hospital if they are ill. There is a genuine concern among my paediatric colleagues that sick children may be deteriorating at home. 

The reduced attendances have also generated interesting discussions. My optimistic perspective is that maybe some acute attendances have been avoided through change in lifestyle. Maybe some heart attacks and strokes have reduced due to fewer environmental stressors as some people are managing to have a greater work life balance. Could infective exacerbations of illnesses such as COPD be reduced as people have less contact with others who are ill and germs are spreading less virulently. Similarly, alcohol induced injuries from a Friday night on the town may be reduced as pubs are closed and people stay at home. My colleagues however are more pessimistic and postulate that people are just staying at home and choosing not to come to hospital; and the consequences in future will be greater due to illnesses that would have responded to earlier treatment or intervention. There are also the hidden impacts of lockdown such as rises in domestic violence and increased alcohol consumption at home. Social isolation also has a impact on people’s mental health and wellbeing. It will be interesting to see what trends the data show in the future.

So I have spent my shifts re-learning some medicine skills that I hope will come in handy as I continue this work in the future. From relocating dislocated shoulders to discussions on raised lactate levels in otherwise well patients. Every day remains a school day and I am in awe of my colleagues who continue to use remote learning platforms to share resources, learn from covid-19, and continue to train junior doctors.  

But my message to patients and the public is simple. Do not forget that if you, or your friends and family need emergency care, the doors to the hospital remain wide open. Wider in fact than they have been for a long time.

Emma Green is Medicolegal Consultant at the Medical Protection Society (MPS) and doctor in A&E.

Competing interests:  Membership with MPS provides the right to request access to expert advice and support on clinical negligence claims, complaints, GMC investigations, disciplinaries, inquests and criminal charges such as gross negligence manslaughter. Members also have the right to request indemnity for claims arising from professional practice.