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Key takeaways Presentation weeks and/or months after ICU discharge Physical and mental tolls of critical illness and care Beware of the possible warning signs, which may include: muscle weakness or problems with balance, problems with thinking and memory, severe anxiety, depression and nightmares The medical community expects to see a high number of PICS cases among COVID-19 survivors due to the increasing number of patients receiving critical care.

Sudre et al. analysed data from 4182 incident cases of COVID-19 who logged their symptoms prospectively in the COVID Symptom Study app. 558 (13.3%) had symptoms lasting >28 days, 189 (4.5%) for >8 weeks and 95 (2.3%) for >12 weeks. Long-COVID was characterised by symptoms of fatigue, headache, dyspnoea and anosmia and was more likely with increasing age, BMI and female sex. Experiencing more than five symptoms during the first week of illness was associated with Long-COVID. This model could be used to identify individuals for clinical trials to reduce long-term symptoms and target education and rehabilitation services. *Note: this article is a preprint and has not been through the peer review process yet.

Key messages There is a widespread perception that people either die, get admitted to hospital or recover after two weeks. It is increasingly clear that for some people there is a distinct pathway of ongoing effects. There is an urgent need to better understand the symptom journey and the clinical risks that underlie that. People, their families and healthcare professionals need realistic expectations about what to expect. A major obstacle is the lack of consensus on diagnostic criteria for ongoing COVID-19. A working diagnosis that is recognised by healthcare services, employers and government agencies would facilitate access to much needed support and provide the basis for planning appropriate services. Whilst it is too early to give a precise definition, guidance on reaching a working diagnosis and a code for clinical datasets is needed. The fluctuating and multisystem symptoms need to be acknowledged. A common theme is that symptoms arise in one physiological system then abate only for symptoms to arise in a different system. There are significant psychological and social impacts that will have long-term consequences for individuals and for society if not well managed. The multisystem nature of ongoing COVID-19 means that it needs to be considered holistically (both in service provision and in research). The varying degrees of dependency mean support in the community should be considered alongside hospital one-stop clinics. Social support needs to be understood together with the financial pressures on previously economically active people. COVID-19 has a disproportionate effect on certain parts of the population, including care home residents. Black and Asian communities have seen high death rates and there are concerns about other minority groups and the socially disadvantaged. These people are already seldom heard in research as well as travellers, the homeless, those in prisons, people with mental health problems or learning difficulties; each having particular and distinct needs in relation to ongoing Covid19 that need to be understood.

Key aims Reassure patients they have not been forgotten during the coronavirus pandemic. Establish the patient's wishes regarding treatment. Good communication with patient and GP. Produce a validated waiting list that allows operating lists to run effectively. All Trusts are required to complete a clinical validation of patients on an admitted patient care pathway by 23 October, and for it to be captured in NHS e-Review. Trusts will be required to identify four user groups for the system; a user to upload patients to the system, an administrator, a super user to upload and download waiting lists and the outcomes from clinical reviews, and a clinical reviewer who is responsible for reviewing a cohort of patients within a specialty. Letter to healthcare providers and bodies Video software overview

A significant backlog of elective surgical cases has built up during the COVID-19 crisis. The freeze on elective surgery has produced a waiting list that may take years to clear. In the US, the CDC has issued guidelines that "facilities should establish a prioritization policy committee consisting of surgery, anesthesia and nursing leadership to develop a prioritization strategy appropriate to the immediate patient needs". According to the CDC, this committee should work around 'objective priority scoring'. The MeNTS (Medically-Necessary, Time-Sensitive Procedures) instrument is a clever attempt to deliver this scoring, responding to availability of resources and the situation around COVID-19. However, the key challenge is that that the list needs to be prioritised in a way that reflects patient needs and ensures their safety. This is not something that MeNTS can deliver. It also is built around COVID-19 related limitations on resources and this will vary in significance depending on the hospital location and where it is in the journey out of lockdown. The risks of mortality and complications for a patient are a complex combination of the severity of the procedure and the physiological variables of the patient. As an example, a 55-year-old undergoing a radical laproscopic prostatectomy has a risk of mortality of 1.6%. However, if the patient has low blood pressure, that risk triples. If the patient also has low sodium then the risk is 10 times higher [C2-Ai insights]. The spectrum of different operations and key physiological variables creates at least 40 million potential combinations and hence risk. This is hard to manage with one patient but trying to prioritse a group of 5, 10, 100, 1,000 or even 10,000 becomes unmanageable. New patients will be joining the list while others leave following their procedures and so triage of the list will not be a one-off event. The list will need to be populated and triaged intelligently and in a consistent way repeatedly at least until there is a return to ‘normality’. There is evidence that some trusts are attempting to build their own systems for prioritisation. This may be possible around matching operative type and resource availability but the efficiency of these systems overall should be a concern. Best intentions are fine but, when reviewed later, the ability to correctly prioritise patients to minimise harm and mortality is likely to be limited if not flawed. C2-Ai’s COMPASS Surgical List Triage system is an example of a system that can support evidence-based triage and individualised risk assessment of patients, while supporting the objectives of the CDC. It supports clinical decision making across all phases from crisis back to steady state. It has been developed by the creator of the POSSUM system and is built around the world’s largest patient data set (140 million records from 46 countries) through the support of NHS Digital. The underlying algorithms are constantly refined against new and existing data sets to ensure relevance and accuracy. The Surgical List Triage tool combines the mortality and complication risks from the different patients to derive the prioritisation. The system carries out bulk assessments using individualised risk assessments for each patient. These reflect the operative type and their physiology to calculate the risk of mortality and complications, as well as providing a detailed breakdown of potential complications with percentage probability with a simple click. This system also suggests patients that should be reviewed for potential optimisation before any procedure. The physician can click on the link to see the detailed risks for the patient to support their decision making. The system can be used regularly to maintain the logic and integrity of the elective surgical list. This is superior to the potentially fragmented approach where parts of the list are manually considered in isolation as this cannot support effective optimisation of the whole list and the absence of any supporting evidence means the triage will vary enormously. COMPASS SLT is an evidence-based approach that supports optimal ordering of the list and clinical decision making that reduces avoidable harm and mortality. This in turn reduces variation, and cost while freeing bed capacity and also allowing the list to be tackled more quickly. When a patient comes in for the operation, an individual risk-assessment can be done using the COMPASS Pre-Operative Risk Assessment app. This provides a final check on whether the patient’s condition would justify optimising their condition before their procedure. However, it also details the most likely post-procedural complications individualised for the patient and their condition. That allows the treatment pathway to be tailored to that patient as well as recruiting the patient into their own recovery. For example, knowing that chest infection is the highest risk for a patient supports a conversation with them to stress the need for them to get up and about on the day of the operation. As an aside, the risk of mortality and complications can also be used as a strong element in showing informed consent has been obtained from the patient. In combination, these tools can provide a platform to support effective and ongoing triage of the list while reducing harm and unnecessary costs. The systems are currently in use in 12 trusts in the NHS. How are you prioritising waiting lists? We'd be interested to hear and share how you and your trust are dealing with the backlog.

Speaking at the NHS Providers conference today Sir Simon Stevens, Chief Executive of the NHS, announced that £10 million will be invested into additional local funding "to help kick start and designate Long Covid clinics in every area across England".[1] Patient safety concerns for Long COVID patients Long Covid patients are people with confirmed or suspected Covid-19 who continue to struggle with prolonged, debilitating and sometimes severe symptoms months later.[2] Many were never admitted to hospital and have instead been trying to manage their symptoms and recovery at home. At Patient Safety Learning we have seen growing evidence that there are many patients suffering from long-lasting symptoms of Covid-19 who are feeling abandoned, confused and without support. We have featured patient insights of this on the hub, our platform for patient safety, such as the experiences of Barbara Melville and Dr Jake Suett.[3] Informed by patients we have also been highlighting the patient safety issues arising from this.[4] In September we heard from many Long Covid patients who have expressed confusion about access post-Covid support clinics. This followed comments from the Health Secretary Matt Hancock MP at the Health and Social Care Select Committee in which he suggested this support was already available.[5] We wrote to Simon Stevens calling on the NHS to publish details of post-Covid support clinics and confirm the timeframe for the implementation of Phase 2 of the ‘Your Covid Recovery’ support portal.[6] Reflections on today’s announcement The NHS announcement today sets out a five-part package of support people living with Long Covid: 1. New guidance commissioned by NHS England from NICE by the end of October on the medical ‘case definition’ of Long Covid. This will include patients who have had Covid who may not have had a hospital admission or a previous positive test. It will be followed by evidence-based NICE clinical guidelines in November on the support that Long Covid patients should receive, enabling NHS doctors, therapists and staff to provide a clear and personalised treatment plan. This will include education materials for GPs and other health professionals to help them refer and signpost patients to the right support. We welcome this measure and plans to update guidance so that it includes patients who may not have had a hospital admission or a previous positive test. We have heard from patients who have expressed their frustrations around the lack of clinical recognition of their illness, exacerbated by receiving a negative test result. This new guidance should enable health care providers in primary and secondary care to properly capture information about patients that have Long Covid. This should help to create a better understanding of how many patients are experiencing this disease and the services they are receiving. It will also be essential to ensure that service providers are appropriately funded to support these patients. 2. The ‘Your Covid Recovery’ – an online rehab service to provide personalised support to patients. Over 100,000 people have used the online hub since it launched in July, which gives people general information and advice on living with long Covid. Phase 2 of the digital platform being developed this Autumn by the University of Leicester will see people able to access a tailored rehabilitation plan. This will enable patients to set goals for their mental and physical health, provide peer to peer support through social community forums, offer an ‘ask the expert’ facility for patients to contact their local rehab service, and allow patients to be monitored by their local rehab teams to ensure that they are on track with their care. This service will be available to anyone suffering symptoms that are likely due to COVID-19, regardless of location or whether they have spent time in hospital. It is most likely that patients will access the service through their GP, but they could also be referred through another healthcare professional following assessment. From our conversations with patients and community support groups, we are aware that concerns remain about the availability of support for those who have been managing their symptoms at home. Patients have highlighted that much of the ‘Your Covid Recovery’ site focuses only on those patients who have been in hospital. It is essential that patients that are living in the community with Long Covid can access advice and guidance specific to their needs. We are concerned that access to information and advice is only accessible through GPs or another healthcare professional following assessment. We need to ensure that this referral route does not become a barrier to Long Covid patients having the information and advice they need. 3. Designated Long Covid clinics, as announced today. This will involve each part of the country designating expert one-stop services in line with an agreed national specification. Post-Covid services will provide joined up care for physical and mental health, with patients having access to: – A physical assessment, which will include diagnostic testing, to identify any potential chronic health issues. – A cognitive assessment, to assess any potential memory, attention, and concentration problems. – A psychological assessment, to see if someone is suffering potentially from depression, anxiety, PTSD, or another mental health condition. Patients could also then be referred from designated clinics into specialist lung disease services, sleep clinics, cardiac services, rehabilitation services, or signposted into IAPT and other mental health services. We welcome this commitment to a one-stop shop approach to support for Long COVID patients. It is important that we recognise that patients may need to access a wide range of services and that patients who are unwell should not have to move between different clinical specialities to get diagnosis and treatment related to their personal needs. The £10m initial investment is to be welcomed as is the national specification; it is important that we do not have a postcode lottery of services. As the infection rate increases, so will the number of patients with Long Covid. The investment in services will need to match patient need, both initial assessment and diagnosis and access to specialist treatment, support services and ongoing rehabilitation. We also note that these appear to be England-only measures and would be keen to clarify what steps are being put in place to support patients in the other three nations of the UK. 4. NIHR-funded research on Long Covid which is working with 10,000 patients to better understand the condition and refine appropriate treatment. This is welcomed and should inform the development of clinical pathways and best practice guidelines. 5. The NHS’s support will be overseen by a new NHS England Long Covid taskforce which will include long Covid patients, medical specialists and researchers. This is a new disease and we do not yet understand how best to support patients with Long Covid. We believe that a multi-disciplinary task force that engages and welcomes patients' insights is essential. What are your thoughts? Further to our initial reflections on this, we would be keen to hear from people living with Long Covid on their thoughts on this announcement. Please share your thoughts with us on the support that is needed on our patient safety platform, the hub. References NHS England and NHS Improvement, NHS To Offer ‘Long Covid’ Sufferers Help at Specialist Centres, 7 October 2020. The symptoms for those with Long COVID vary greatly but many are experiencing rashes, shortness of breath, neurological and gastrointestinal problems, abnormal temperatures, cardiac symptoms, and extreme fatigue. Barbara Melville, Dismissed, unsupported and misdiagnosed: Interview with a COVID-19 ‘long-hauler’, Patient Safety Learning’s the hub, 24 June 2020; Dr Jake Suett, My experience of suspected ‘Long COVID’, Patient Safety Learning’s the hub, 10 July 2020. Patient Safety Learning, Patient safety concerns for Long COVID patients, 6 July 2020. Rt Hon. Matt Hancock MP commented in a select committee that “The NHS set up Long COVID clinics and announced them in July. I am concerned by reports this morning from the Royal College of GPs that not all GPs know how to ensure that people can get into those services. That is something I will take up with the NHS and that I am sure we will be able to resolve”. Health and Social Care Committee, Oral evidence: Social care: funding and workforce, HC 206, 8 September 2020. Patient Safety Learning, Clarity needed on post-COVID clinics: Patient Safety Learning's letter to NHS leader, 11 September 2020.