8 May 2020
Dear Fellows and Members,
I hope that you, your families and colleagues remain safe and well. It is hard to imagine that it is now eight weeks since the Taoiseach made his announcement from Washington outlining the restrictions that have come to shape our lives since. While we can be really pleased that these restrictions have succeeded in slowing the spread of the virus, we know that there are challenging times ahead in dealing with the unmet surgical need which continues to build.
The COVID-19 containment strategies deployed in acute hospitals across the country has meant elective/scheduled surgery has almost stopped since mid-March when the National Public Health Emergency Team (NPHET) advised the pausing of all non-essential health services in response to both capacity concerns and the risks associated with infection to patients and healthcare workers.
There is evidence that these postponements have been accompanied by a fall-off in presentations in GP and acute settings, which initial research indicates is overwhelmingly due to fear of infection. Since then surgery in acute hospitals has been confined to emergency, maternity and urgent cancer activities.
Since this postponement, the pre-COVID surgical waiting lists have been added to significantly and it can be expected that this backlog will have a significant and lasting impact on the overall health of our population and the ability of the health system to cope with demand.
The RCSI National Clinical Programmes in Surgery and Trauma & Orthopaedics have worked with the HSE and the Department of Health on developing guidelines for a phased return to planned surgical services while also developing a recovery plan.
The acute hospitals subgroup of the Expert Advisory Group to NPHET, which Professor Deborah McNamara from the National Clinical Programme in Surgery sits on, has developed protocols for elective surgery pathways which NPHET have approved and will publish in the coming days.
As we return to surgical service, consideration will need to be given to an expanded workforce and the resources to deal with all of these patients. The reality is that illness, fatigue and social issues among healthcare workers all threaten the system’s capacity to manage the increase in surgical activity that is required. In addition, the persistence of coronavirus circulating in the population, and within hospitals, poses a further challenge to patient safety, staff safety and efficient perioperative care processes.
The challenge of providing safe pathways through the hospital system for patients at low or high risk of COVID-19, and of protecting staff and other patients from hospital acquired infection, will demand resources and time. There will be a need for new procedures, protected surgical wards where surgical patients are isolated from COVID-19 patients, and some form of minimum universal PPE for the foreseeable future.
In planning to resume planned surgical services, the RCSI National Clinical Programmes are working to ensure that, at a national level, the needs of surgical patients are considered on an equal footing with those receiving care for COVID-19 and other medical diseases. In the coming NCPS will publish a number of guidelines including:
- overarching RCSI NCPS model for a return to urgent elective surgery;
- consent guidelines;
- perioperative pathway for urgent elective surgery during the pandemic;
- specialty specific models for a return to urgent elective surgery; and
- guidelines for surgical teams.
These will all be published on our COVID-19 guidelines website section.
The National Clinical Programme in Trauma and Orthopaedics has advocated for a carefully structured return to planned orthopaedics care. There continues to be an excess of patients compared to the resources available to manage their conditions. The problems created by the pandemic has exacerbated the omnipresent need to reduce waiting lists.
Communication regarding the principles and prioritisation system for selecting patients is essential. The transparency of the process should be clear to patients, hospitals, staff, surgeons and the public. Standardising the implementation of decision-making is necessary in order to provide assurance, consistency and reliability.
It is expected that surgeons will work with hospitals to prioritise their patients’ needs for surgery, accounting for risk factors and co-morbidities, while having regard also for the safety and availability of health care workers and hospital resources.
Surgeons of all specialities are expert in assessing, prioritising and planning surgical treatment for their patients. Your professional judgement can be relied upon to balance risk and to prioritise patients based on clinical need and, in the current climate, to consider risk factors.
What is required urgently is clear high-level guidance from experts in infection control. This guidance is essential to ensure standardised implementation of infection control protocols. It must come from a national body which has the expertise, time and resources to develop and disseminate such guidance. There must be no room for ambiguity about what is the process in each hospital, ward or operating theatre area. Social distancing will result in much reduced OPD clinics and much slower turnaround time in theatres and we must ensure that what facilities we do have for planned care are used to the maximum effect.
The clinical programmes are also endeavoring to support the specialties on the ground. Working with their ENT colleagues, the National Clinical Programme in Surgery has identified the need to replace older endoscopic equipment in 13 out of 15 ENT units across the country. This out of date equipment presents an increased risk of infection as the equipment means surgeons are much closer to a patient’s airway than is the case with the newer equipment. Unless this replacement occurs, it will not be possible to resume diagnostic ENT activity.
Based on feedback, the National Clinical Programmes for Surgery and Trauma and Orthopaedics will host a stand-alone webinar on the use of Trauma Assessment Clinics (TAC) to virtually enhance care for patients and practitioners. This webinar will take place next Tuesday with contributions from Mr Eoin Sheehan, Consultant Trauma and Orthopaedic Surgeon and Clinical Lead for Trauma Assessment Clinics, Dr Siobhan Maguire, Consultant in Emergency Medicine, Ms Joan Dembo, ANP Emergency Medicine and Dr Carol Blackburn, Consultant in Emergency Medicine Children’s Health Ireland at Crumlin. You can register for the webinar here.
Behind the sciences, RCSI is working on plans for a phased return to work on Campus. The RCSI Business Continuity Planning (BCP) Group are considering the requirements of students, staff and researchers, with essential and COVID-19 related research prioritised for initial phased return. Working with the Office of Research and Innovation, relevant heads of departments, PIs and the lab managers, this phased return will gradually see an increase in essential researchers on Campus.
RCSI’s research community is responding dynamically to COVID-19 and I’m pleased to let you know about a significant study led by RCSI clinician scientists which found that Irish patients admitted to hospital with severe COVID-19 infection are experiencing abnormal blood clotting that increases their risk of mortality. The study, carried out by the Irish Centre for Vascular Biology, RCSI and St James's Hospital, Dublin, is published in current edition of the British Journal of Haematology. The authors found that abnormal blood clotting occurs in Irish patients with severe COVID-19 infection, causing micro-clots within the lungs. They also found that Irish patients with higher levels of blood clotting activity had a significantly worse prognosis and were more likely to require ICU admission.
This week we entered the sixth week of our new COVID-19 webinar series. So far over 900 fellows and members have participated in this new and valuable resource.
This week’s webinar on Perioperative Perspective on the Planned Return to Surgical Service gave us a valuable insight into how our colleagues across the perioperative pathway have had to adapt in the current environment and what their plans are for a phased return. I was particularly interested in the contributions from Ms Michelle Cooke, Clinical Nurse Manager 3 ASAU University Hospital Limerick, who outlined how the ASAU in Limerick has had to adapt and the positive outcome of this for staff and patients.
Next week's webinar will be a discussion around Necessary Changes to Outpatients Clinics in a COVID-19 era with contributions from Professor Colm Bergin, Consultant Physician in Infectious Diseases, Mr Tony Moloney, Consultant Vascular Surgeon and Professor Peter Gillen, Advisor to the National Healthcare Communication Programme. You can register for the webinar, which takes place next Wednesday at 6pm GMT, here.
Please continue to take care.
Mr Kenneth Mealy, President of RCSI