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Thu 1 October 2020
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Stephen Colegrave reports on a new paper that explains what COVID-19 intensive care survivors need to regain their physical and mental health.

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The Nightingale Hospital at the Excel Centre in east London is an amazing achievement. To create a 4,000-bed hospital in a couple of weeks is remarkable, a feat which is now being repeated in Birmingham, Manchester, Harrogate Glasgow and elsewhere. If the efforts to acquire and make ventilators come through, acute hospital capacity will be scaled-up to meet the accelerating demand. But, what happens to the surviving patients and what preparations are being made?

Byline Times has had sight of a proposal put together by surgical registrar at Queens Hospital, Romford, Dr Alice Murray, and a physician with a long-standing interest in rehabilitation, Dr Jackie Morris, that seeks to address this. It recommends creating intermediate step-down and respite care by repurposing existing facilities and utilising ex-private sector workforces like gym and sports physiotherapists.

“We need to match the incredible new acute care capability with the same capability,” explained Dr Murray, “to provide essential rehabilitation and intermediate care.”


ICU Survivors Will Need Help

The Nightingale Hospital in Excel will only take patients who are incubated for ventilation from acute hospitals. Nobody seems to know what the survival rates will be.

Byline Times understands that the Nightingale in London is working on a 65% survival rate but current survival rates for patients with intensive care ventilation seems to be nearer 35% for over-70s and nearer 50% for younger patients. Survivors of ventilation will probably need a at least another 21 days in hospital to recover as they are still very ill and vulnerable when they leave the Intensive Care Unit (ICU).

But it is not just the numbers of patients who survive, but the numbers who need respite care or don’t have a safe place to be discharged. They will need step down facilities. For some patients, continuing care will need to include specialist help.


Post-Intensive Care Syndrome

Surviving ICU care can lead to Post-Intensive Care Syndrome (PICS) which leads to cognitive, psychiatric or physical disability after treatment in intensive care, and often all three.

Physical disabilities include muscle weakness and damaged nerves that can seriously affect mobility. Nobody knows how many survivors will require continuing care, and rehabilitation because of PICS. Normally it would be about 4-5% according to the document, but there could a much higher percentage because the patients might be more likely to have existing health conditions.

Those that don’t suffer PICS are still likely to be suffering from underlying health conditions that are likely to be worsened by their illness. Many will not be able to immediately go back to independent living and their carer or spouses might have health problems of their own. COVID-19 survivors are already beginning to block beds and reduce capacity in hospital wards. The only way to ensure the correct continuing and step-down care is to triage all survivors during their hospital stay to make the correct decisions about their care needs.

“Even those hospitals that have good discharge strategies in place are probably finding there it difficult” says Dr Murray. There are an increasing number of patients staying over 21 days”.

Hospitals are trying to do everything they can to speed up discharges as they know that the significant number of COVID-19 survivors are going to put pressure on freeing up beds. They are using all sorts of novel techniques like virtual discharges but sufficient step-down facilities are urgently need and so far the response to this seems very patchy and embryonic.


An Integrated Approach To Step Down Facilities

“Care homes are completely the wrong places for these patients to be discharged to”, stresses Dr Morris. “They are not appropriate for younger people and do not have sufficient medical and nursing staff to meet the needs of COVID-19 survivors and the additional risks of infection.  We have to ensure they are not pressured to take up the slack”

The only way to provide the necessary scale of facilities is a proper integrated and planned approach. Former Chair of The Royal College of General Practitioners, Dr Clare Gerada, peer-reviewed the Morris and Murray paper and agrees that a properly planned approach to intermediate care should be an urgent priority and properly integrated with the acute sector.

 “We need to take this opportunity to think more about integrating systems and co-locating services together” Dr Gerada told Byline Times, “and really making it work on the ground in the community”

This type of community facility has been successful in the past, but many have disappeared after a decade or austerity.

“We need something like the Lambeth Community Care Centre used to be,” Dr Gerada said: “Here everything was made to make you feel like home – but it was a respite facility where you could stay up to two weeks and it has a GP service, physiotherapy, respite care, a community garden, a canteen run by an organisation for people with learning disabilities. Our rule was that we would do any care that wasn’t intravenous or round the clock monitoring. It’s time we brought back something like that.”


A Concerted And Urgent Approach Is Essential

There are some localities that are already thinking about this, however there doesn’t seem to be a concerted effort or plan in London yet.

Cumbria seems to be ahead of the rest of the country in repurposing facilities. In its five biggest towns: Carlisle, Whitehaven, Barrow, Penrith and Barrow- leisure centres are being turned into intermediate care facilities with rehabilitation facilities.

“It’s not just about hotels and gyms”, explains Dr Morris, “it’s about having a workforce that will support the survivors wherever they are”

There is a real opportunity for private companies and their employees, local government and the third sector to participate in an integrated programme to provide intermediate and respite care for COVID-19 survivors who physically, mentally or due to a lack or a safe, secure home cannot immediately return to their communities.


Many Are Well Placed To Help

The good news is that today it has been announced that the Nightingale Hospital in London is co-locating step-down facilities, but there are still many trusts and healthcare localities that are behind on provision for this including across London. Until now, most the focus has quite rightly been on building ICU capacity but now continuing intermediate care and facilities need to catch up or there are going to be many thousands of COVID-19 survivors that are not going to regain their physical and mental wellbeing.

Operators of leisure centres are well placed to help, also private gyms, hotel operators and property developers that have empty properties. This needs to have the same sense of urgency as the planning and building of the Nightingale hospitals and help from the Army and volunteers. There are too many hotels, leisure centres and other facilities lying idle that could be repurposed to make this happen.  But it needs proper planning and integration to ensure proper cover in all areas. There is also the opportunity to start building a more integrated health and care system that would be a real legacy for the future.

“We need to be adventurous innovative and creative, knock walls down and break boundaries,” demands Dr Morris, ” to create something that actually meets the needs of people”

Unless this is done beds are going to be blocked in hospitals, pressure will be put on care homes to take inappropriate patients and people miss out on the rehabilitation that will enable their recovery. What we need is the same will and determination to help get COVID-19 survivors back on the road to proper recovery and not waste the fantastic effort that is being made in the Nightingale and other hospitals to save their lives. We need it now!


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