Background to COVID-19 and effects on services for Cardiac Surgery in UK
The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) first emerged in the city of Wuhan, China, in December 2019 and it has since spread rapidly across the globe, causing a disease named as COVID-19 in February 2020 and with the World Health Organisation (WHO) declaring a pandemic in March 2020 (1). As of 20th of August 2020, there are more than 22.2 million confirmed cases of COVID-19 and over 795,000 deaths reported globally (Figure 1) with the United Kingdom (UK) being 12th among countries in term of confirmed cases (more than 326,000) and 5th in COVID-19 related deaths (more than 41,000, Figure 2), (2).
Public Health England (PHE) published the very first report on COVID-19 on 22nd January 2020. Just one day later, the Emergency Department at Royal London Hospital swabbed its first potential COVID-19 patient (3). The declaration of this disease as a pandemic put health care systems in the UK on alert and the government introduced national lockdown on 23rd of March 2020 in an attempt to contain the disease and minimize the transmission risk to others. A campaign was launched under the slogan of “Stay home, Protect the NHS (National Health Service) and Save lives”. Although a critical step to combat this highly contagious disease, it created a significant burden on an otherwise a freely accessibly health care system, the NHS. The NHS had to undergo a significant transformation diverting resources to frontline health care services including ambulance services, emergency departments and allocation of intensive care beds in preparation for the potential influx of COVID-19 patients and the requirement for ventilatory support (Figure 3). De novo facilities, the Nightingale Hospitals, were created throughout the nation to increase capacity; private hospital capacity was purchased, industries were tasked with producing ventilators and academia with producing treatments and vaccines. Effectively, all elective care was stopped with services only maintained for emergencies.
Amongst the many specialities affected by the NHS service reconfiguration was cardiac surgery, given its ownership of a large resource of ventilated beds normally required in elective practice. Attempts were made in a number of regions to create centralized cardiac surgical services to continue provision of care to this high-risk cohort and avoid secondary deaths due to untreated cardiovascular diseases (4). The Royal College of Surgeons (RCS), Society of Cardiothoracic Surgery in UK and Ireland (SCTS) and the NHS issued guidelines and regular updates on the practice of cardiac surgery during this pandemic, introducing protocols and pathways to minimize the risk of COVID-19 to patients and staff without affecting the quality of service and care to those needing cardiac surgery (5-11).
The network of centres that perform cardiac surgery in England generally responded to the crisis according to government guidance by reducing or, more frequently, halting elective operating, but with a degree of independence. The exact timeline during which each centre wound down elective and urgent services varied according to local circumstances and pressures. The processes by which each centre managed patient pathways were dependent on local arrangements. In addition, England, Wales, Scotland and Northern Ireland, each with its own devolved government, responded differently. This paper focusses on the experience of Liverpool Heart and Chest Hospital with changes to service provision for cardiac surgery, focussing on aorto-vascular patients.