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• Consequences of the emergency response to COVID-19
  david ratcliffe
  Published on: 15 April 2021

• Published on: 15 April 2021

  Consequences of the emergency response to COVID-19

  • david ratcliffe, General Practitioner Salford Royal Hospitals Trust, North West Ambulance Service, Greater Manchester Health and Social Care Partnership

  Dear Sir,

  Within their conclusion, Charlton et al recommend further research to understand patient behaviour toward seeking help during the pandemic. In response to this, we would like to highlight the findings of our work which address this. We undertook a mortality review of all deaths in Salford during the peak 7 weeks of the initial pandemic surge (522 deaths), looking at themes which, if addressed could result in reduced mortality in future waves. We reviewed all 111, 999, general practice and hospital contacts for all patients from the 1st March 2020, to ensure all help seeking behaviour and the system response was understood. We have summarised these here.
  We noted 60 cases where patients delayed seeking help. We were also concerned that patients who were advised to call 111 by their GP, and were offered advice, would only call back when seriously ill. “COVID phobia” was evident in a small number of cases, at its extreme, including refusal to attend hospital and subsequent death at home.
  Fewer than half of NHS 111 calls were answered during the review period. Of those that were answered, 46% resulted in advice to contact their GP. Of these, 5 were subsequently admitted to hospital later the same day. Indeed, despite the national directive to telephone 111 as the first point of contact, only 13% actually did. 81% of patients contacted their GP in the period prior to their death.
  However, a lack of early face to face assessments was identi...

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  Dear Sir,

  Within their conclusion, Charlton et al recommend further research to understand patient behaviour toward seeking help during the pandemic. In response to this, we would like to highlight the findings of our work which address this. We undertook a mortality review of all deaths in Salford during the peak 7 weeks of the initial pandemic surge (522 deaths), looking at themes which, if addressed could result in reduced mortality in future waves. We reviewed all 111, 999, general practice and hospital contacts for all patients from the 1st March 2020, to ensure all help seeking behaviour and the system response was understood. We have summarised these here.
  We noted 60 cases where patients delayed seeking help. We were also concerned that patients who were advised to call 111 by their GP, and were offered advice, would only call back when seriously ill. “COVID phobia” was evident in a small number of cases, at its extreme, including refusal to attend hospital and subsequent death at home.
  Fewer than half of NHS 111 calls were answered during the review period. Of those that were answered, 46% resulted in advice to contact their GP. Of these, 5 were subsequently admitted to hospital later the same day. Indeed, despite the national directive to telephone 111 as the first point of contact, only 13% actually did. 81% of patients contacted their GP in the period prior to their death.
  However, a lack of early face to face assessments was identified as a theme of concern. Further to this, patients could then be faced with delays in ambulance attendance, evidenced by 44% of Category 2 ambulance response taking over two hours in March 2020 (These delays were mitigated by changes to the national ambulance protocol in early April).
  Our findings demonstrate that not only was there concerning evidence of patients avoiding healthcare contact, but the Healthcare system response was also inadequate to allow appropriate assessment in many cases. Furthermore, patients vulnerable to health inequality such as older people and those with learning disabilities, appear to have suffered the greatest risk of adverse outcome as a result of these changes in system response.
  Our review led us to make several recommendations which informed the subsequent local response. These included:
  • Clear messages needed about using NHS services when required;
  • “It is vital anyone who thinks they need any kind of medical care comes forward and seeks help “
  • Patients must be encouraged to contact NHS 111 or GP if COVID-19 positive or with symptoms
  • Ask about the health of others in the house, particularly if not tested or vulnerable
  • If the ambulance can not respond quickly, just get to hospital
  • Be clinically curious, don’t just assume it is COVID (diagnostic overshadowing)
  • Establishing virtual ward with easy ‘onboarding’ referral processes.
  • Review ceiling of care decisions in light of new knowledge of the disease
  • Care and Residential Homes may need additional support for end of life care
  • Ensure extra support and reasonable adjustment should be made for patients with learning disabilities, limited English language skills, or other communication difficulty.

  Sincerely,

  Dr J Tankel, Dr D Ratcliffe, Prof D Green , Dr M Smith, Dr P Bennett

  1. Charlton K et al. Incidence of emergency calls and out-of-hospital cardiac arrest deaths during the COVID-19 pandemic: findings from a cross-sectional study in a UK ambulance service. BMJ 2021. doi: http://dx.doi.org/10.1136/emermed-2020-210291
  2. Tankel JW et al. Consequences of the emergency response to COVID-19: a whole health care system review in a single city in the United Kingdom. BMC Emergency Medicine. 2021 doi: https://doi.org/10.21203/rs.3.rs-134729/v1

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  Conflict of Interest:
  None declared.

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