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:
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.