Service transformation
The NHS has been stretched to provide care for the already aging
population alongside the new cases of infected COVID-19. As such and due
to limited capacity, there have been some attempts at reconfiguration of
services, in some regions, by creating centralized units to provide care
for sub-specialities that are not in direct response to COVID-19. This
service modification entailed the creation of detailed and tailor-made
protocols for planning cardiac surgery whilst optimising the use of
intensive care and ward beds for the treatment of COVID-19 cases. Such
process required nationwide assessment of capacity and capabilities to
accommodate such changes. In the North-West of England, which serves a
population of 7.3 million, cardiac care was channelled through four
major cardiothoracic units: Blackpool, Manchester Royal, Manchester
Wythenshawe and Liverpool Heart and Chest Hospital (LHCH); LHCH was
chosen to be the central unit for cardiac and aortic surgery and led the
development of the North-West Urgent Cardiothoracic Service (NUCS)
Protocol to guide patient treatment pathways (Appendix 1). As NUCS was
set up, government measures took effect, reducing admissions; in reality
few patients were channelled into Liverpool from other cardiac units,
but some throughput continued from our usual catchment area. North-West
regional pathways still exist in preparation for a potential second
spike. Similarly, in London the service was reconfigured to operate in
only two units among the combined 7 NHS centres serving the population
of 8.5 million people, forming the Pan London Emergency Cardiac Surgery
(PLECS) service (14). It is important to emphasize that the base of
developing such centralized services and detailed protocol was to
provide a COVID-19 free environment for patients undergoing cardiac
surgeries. This is a very critical point as COVID-19 seems to have
significant correlation with cardiovascular diseases and outcomes
(15-17).
Maintenance of a COVID-19 free environment with clean patient pathways
was key to maintaining a limited but safe service. There was significant
reduction in the operational activities, as high as 83% in some cardiac
surgical units (4). Our centre observed similar reductions (Figure 4).
Eventually, the establishment of standardised patient pathways (Appendix
2) for perioperative care and management in theatre (Appendix 3) aided
in a gradual increase in the surgical activities. According to regional
pathways (NUCS and PLECS), patients were classified into four major
categories:
- Level 1: Elective patients who have indications for routine cardiac
surgery and would normally be added to an elective waiting list.
- Level 2: Urgent patients at home who are on the existing waiting lists
or in the process of referral but have critical / life threatening
anatomy with worsening symptoms or the need for urgent prognostic
intervention.
- Level 3: Urgent patient undergoing inter-hospital transfers who by
definition are in hospital with prognostic / critical anatomy or
physiology or with unstable symptoms. They require cardiac surgery
within this hospital admission (but not on the same day), and no other
options for treatment are possible such as medical or percutaneous
intervention.
- Level 4: Emergency cases which are most commonly acute aortic
dissections, such patients have life threatening emergency aortic and
cardiac conditions and require surgery within hours.
For NUCS the decision-making process started with the receipt of an
urgent inpatient referrals, after triage at the referring regional
cardiac hospital (Blackpool and Manchester). These were directed to our
local COVID-19 daily multidisciplinary team meeting (MDT) along with our
local urgent referrals. All our 10 weekly MDTs were amalgamated into a
single and virtual COVID-19 MDT with widespread attendance. After review
of the available information, an outcome was communicated to the
referring clinical team and the patient. If intervention was deemed
necessary, then procedural planning took place and the case was
allocated to a consultant and date for surgery identified. Emergency
referrals were processed in the usual way by on-call staff. A number of
patients requiring emergency care were referred to Liverpool on the
basis on the NUCS arrangement.