As we reach the anniversary of the first national lockdown, thoughts will inevitably turn to the lives lost in the covid-19 pandemic and the immense number of families torn apart by this novel virus—one which had never been seen and importantly, no-one across the globe knew how to treat.

Prior to covid, few people would have truly understood what intensive care entails. But now, thanks to daily and detailed global media attention, this technical and life-saving medical specialty has been thrust into the spotlight and into the lives of ordinary citizens in every country across the globe.

In early 2020 I remember seeing critical care staff in China, and then in Italy dealing with increasing numbers of critically ill patients. Along with my colleagues here in the UK, we all quickly realised that the NHS needed to prepare a national response like no-one had seen since WWII.

What the NHS needed was a massive increase in hospital critical care capacity, a corresponding increase in the availability of specialist equipment and, most importantly, skilled staff to manage the equipment and care for the flood of patients we were expecting. Working together, hospital managers and highly skilled clinical staff from across the multitude of medical specialties, developed and initiated plans to ensure that NHS intensive care wards were able to admit patients who needed our care, where and when they needed it.

In the UK, the NHS does not have a reserve of critical care staff to call upon in these situations. It takes many years of education and training, acquiring all the necessary knowledge and skills to work as part of an intensive care team. Even with this dearth of skilled, experienced, and immediately available critical care staff, the NHS needed to continue delivering safe and compassionate care to the huge numbers of patients we were expecting. Senior critical care staff ably led the work to temporarily increase ICU bed numbers and re-deploy hospital staff to help in the ICU. With the NHS’s agreement for non-urgent elective care to be delivered in independent hospitals, many NHS staff were then free to be re-deployed to the ICU. Re-deploying staff who had never set foot in an ICU setting was the next challenge. This was helped by cross-skilling guidance developed by FICM and the Royal College of Anaesthetists.

Since the start of the pandemic, intensive care staff continued to abide by our ethical and legal framework for decision making. These principles ensure that every patient is treated compassionately, fairly, and equitably. It is important to understand that not every patient responds to the same extent from the same medical treatment. Some patients are admitted to the ICU because they are critically ill. Others, because they are at risk of becoming critically ill and need continuous monitoring. Others are not admitted to the ICU because in expert clinical judgement, there would be no overall positive benefit to the patient. In difficult and challenging circumstances such as these, the focus of care changes. Intensive care is not the default location for end-of-life care, though this does take place when required on ICUs, as well as in other parts of the hospital. What is important is that the decision is made on an individual basis, by a team of skilled, compassionate, and experienced doctors, and always in the best interest of the patient.

Our initial perception of covid was that it was primarily a disease of the lungs. What took us by surprise was just how sick these patients were and how resistant to treatment they became. The multiple organ failures we saw and the higher mortality rate when compared with non-covid pneumonia meant this was a very different disease. It became apparent that the virus also affected the blood’s clotting system. The presence of multiple small clots in vital organs swiftly led to a change in treatment regimens across ICUs. Many patients also developed kidney failure in the early days, which resulted in a shortage of dialysis equipment. Working with our renal colleagues, once we understood how the body was reacting to the virus, the rapid and widespread change in the NHS’ clinical management of patients reduced the incidence of kidney failure from 27% to 7%. [1] 

During the initial phase of the first wave, we had been advised by Italian colleagues to sedate and ventilate patients immediately as delaying would only lead to instability. However, as Italy began to run out of ICU beds, they were forced to manage more patients on a different form of ventilation—Continuous Positive Airway Pressure. They quickly discovered that many patients survived and therefore their oxygen needs could be managed in a less invasive way. This shift put pressure on hospital oxygen delivery systems but, aware of the risks, hospitals were able to assess their supplies and mitigate accordingly.

Being able to alter treatment quickly and safely in response to new information, meant that NHS patients received evidence-based care throughout the pandemic. I am in no doubt that thousands of lives have been saved by the speed at which intensive care staff were able to respond to new and constantly emerging clinical evidence.

As we learned more about the virus’s transmission and its effects on the body, we were able to reduce the amount of PPE worn, unless staff were working in areas where aerosols were generated. Freeing ourselves of non-required PPE improved staff mobility while maintained the adequate level of protection. The COVID Hub developed by the Faculty of Intensive Care Medicine (FICM), the Royal College of Anaesthetists, and other partners was critical in collating and communicating clinically approved guidance and recommendations to ensure that critical care staff and those re-deployed into ICUs, received clear and up-to-date information. Such clinical guidance was critically important to our understanding of the risks ICU staff were exposed to, and how those risks could be managed by the available equipment at that time.

In collaboration with the Royal Colleges of Physicians of the UK, FICM has produced guidance for the development of Enhanced Care in the Acute Hospital Setting. This is to help manage patients who are at risk of becoming critically ill and need increased monitoring; patients at risk would normally be admitted to intensive care. The consequences of being critically ill have been apparent to those of us working in intensive care for many years but covid has highlighted this. FICM will also be publishing guidance on Life after Critical Illness in the summer. This will outline how rehabilitation services for post-ICU patients must also receive appropriate funding and staffing in order to be effective.

In the UK, just as it did across the world, the first covid wave took its toll—not just on patients, but on clinical staff as well. The physical and emotional stress of dealing with wave after wave of critically ill patients coming into the ICU was immense. As was the heart-breaking last video calls we managed between dying patients and their families. These are the things my staff and I will simply never ever forget. Dealing with the mental stress of this pandemic is going to be critical for the Department of Health and Social Care and the NHS to get right to ensure we are supporting and protecting our greatest asset—our staff. I’m therefore pleased the Government has initiated plans to deliver personalised support to NHS staff. I encourage all NHS staff that when offered, to take up the opportunity.

As the first anniversary of lockdown approaches, we are thankfully now seeing infection rates and hospital admissions decline, I know the NHS and the government has learned a huge amount about the virus. We have also seen how effective we are at collectively responding to a pandemic of this magnitude. We must learn from this experience, and we must do so quickly. While we are currently seeing the benefits of the now-loosening lockdowns, we must not be complacent. As the government uses all available data to gradually and carefully release the lockdowns, we must do all we can now to embed change:

• for clinicians, one important thing we need to do is to take a break—I strongly urge you to do so
• for the government, intensive care must be funded to maintain a sustained increase in both ICU capacity and intensive care training posts over the coming years. In many ways, our lives quite literally rely on this.

Covid-19 has tested the NHS and our intensive care structures like never before. We have, with the huge support of our partner specialties, learned an enormous amount since the first lockdown. The imperative now is to take the positive lessons learned and clear needs we have identified and apply these not just to covid-19, but across the full spectrum of critical care services.

Alison Pittard, is a consultant in Anaesthesia and Intensive Care Medicine and Dean of the Faculty of Intensive Care Medicine. 

Competing interests: none declared. 

Reference:

1] ICNARC report on COVID-19 in critical care, 9 October 2020