To cope with a growing number of hospitalisations for covid-19, we need to once again stretch our staff, writes Shondipon Laha
I have been working in intensive care for over 20 years, including a decade as a consultant, and facing winter pressures has always been the norm. However, the past 18 months have been something else.
During the winter peak of the covid-19 pandemic in the UK, intensive care units (ICUs) in many regions were managing double the number of beds compared to their normal baseline. To do this safely, the intensive care community massively increased their working hours by reducing leave, staying late, and working on rest days. This was supported by uplifts in the acute medical specialties whose contribution has been invaluable. This was not enough, and hospital trusts were forced to delay non-elective work so that non-ICU staff could be redeployed to provide support. This still was not enough, so available beds in alternative and occasionally distant hospital trusts were used flexibly with the introduction of mutual aid and regional transfer services. The whole country also ground to a halt, reducing the transmission of covid-19 and the number of hospitalisations.
With the effect of the lockdown and the parallel rapid upscale in vaccination, we started to see numbers fall. Staff in ICUs heaved a collective sigh of relief, hospital departments opened up, and the push to ensure that delayed operations were completed began, although many challenges remained.
One of the biggest struggles has been dealing with continued restrictions on patients receiving visits and their inability to have face to face conversations with their loved ones. Balancing the backlog of elective procedures and ensuring staff had time to recover both psychologically and physically, while having to anticipate the impact from the Delta variant, has also been difficult. Covid positive, negative, and potential areas also need to be segregated, leading to increased staffing demands.
Over the past four weeks, many regions have seen increasing hospital admissions for covid-19. However, the concurrent nationwide commitment to ensure the backlog of planned surgery is completed and a simultaneous rise in non-covid related acute admissions is already producing an increasingly exhausted workforce.
The disease is presenting differently this time. Many more of our patients are younger and fit. Most are unvaccinated or have had one dose. The older patients we’re seeing predominantly have either refused the vaccine or have comorbidities that reduce its effectiveness. We are seeing a disproportionate number of pregnant patients, many of whom require invasive ventilation. The number of patients needing respiratory support through non-invasive ventilation is also on the rise.
Many of our patients stay in ICU for about three weeks and require prolonged stays in hospital to recover. The rehabilitation demand for a relatively young cohort will be a challenge for years to come. This is why the Intensive Care Society launched their Rehab Collaborative to encourage initiatives to support our ICU colleagues to deliver essential rehab.
Conversations with patients and families have also changed, placing a greater strain upon healthcare staff. Some of the families and patients are in denial that they even have covid and many ask for unproven therapies to be used. Often, the last recollection that family members have of their loved one was of them being breathless but looking well. Their inability to witness their deterioration in person exacerbates the difficulty of helping them understand the severity of their loved one’s condition. Many treatments we provide have their own significant side effects, like barotrauma from ventilation, haemorrhages from anticoagulation medicine, and infections from the immunosuppressants they receive. These can often be difficult to communicate to an increasingly sceptical family.
The number of staffed beds that the NHS has baseline funding for in intensive care continues to be below that of equivalent economies in Europe. Covid-19, like many other diseases, predominates in lower socioeconomic areas, yet bed numbers and their distribution have historically never reflected this. To increase these historically low and finite numbers to cope with hospitalisations, we need to once again stretch our staff. In many smaller units, this is an incredibly difficult task. Redeploying non-ICU staff is now a challenge as they are needed elsewhere. Among the intensive care community, there are higher levels of psychological trauma and sickness affecting staffing levels.
Many units are also compromised from the increasing number of their staff in isolation. The measures being introduced that waive the need for NHS staff to isolate may help, however, due to the nature of ICU care, many of our patients are vulnerable, making it more difficult for this guidance to apply to our staff. The Intensive Care Society and local trusts have been providing access to wellbeing support, however, this can’t solve the national, historical underlying pressures created by a lack of the right resources in the right places.
NHS England, hospital trusts, and regional networks have all been modelling the predicted increases in the number of covid cases. Several units are planning to expand into “surge” capacity again, with the training of non-ICU staff having continued throughout. The use of other departments, such as respiratory medicine, to help provide essential care has shown good results and continues to be developed. Communication between trusts and regions has improved greatly, with daily planned surgery management, mutual aid, and regional transfer services providing some safeguards.
We all know that we won’t see the true impact of lifting restrictions for another two weeks, and infection rates are already high. And while vaccination has reduced the link between disease and hospitalisation, it has not broken it. To quote a colleague, “A smaller percentage of a big number is still a big number.” In addition, the potential for cases of other viral infections to climb over the coming months, including seasonal influenza and respiratory syncytial virus, increases the risk of overwhelming both adult and paediatric ICUs. All this points to a very challenging autumn and winter. This will not be restricted to ICUs and will inflict a greater burden on our emergency and acute medicine colleagues.
The key to managing all of this depends on two things. Firstly, reduce the transmission of covid cases. This is up to all of us as individuals. We all have a responsibility to socially distance and wear masks when appropriate and to be vaccinated if possible. The second is to improve the functioning baseline of our ICUs, investing resources in the right places to avoid stretching services for years to come.
I would like to thank the public and my multiprofessional colleagues both in the wider hospital and community for their continued support and resilience throughout the pandemic, but I’d also ask for their patience. We are not out of the woods yet.
Shondipon Laha is an intensive care consultant and honorary secretary and chair of the Professional Affairs Division, Intensive Care Society. Twitter @shond3
Competing interests: none declared.