Preparing for a step-down care surge

Over the past few months a tremendous amount of effort has been expended by the government, public and private sectors on meeting the immediate critical care needs caused by COVID-19. Sourcing PPE, creating more critical care space, boosting staff numbers and sourcing ventilators have understandably been high on the priority list.

The purpose of imposing strict social distancing measures was – in the words of Prime Minister Boris Johnson – to “flatten the sombrero” and ensure that the capacity of the NHS was not exceeded. However, in a democracy a lockdown clearly cannot be imposed indefinitely and an effective treatment or vaccine could be many months away.

Now that the first peak of infections has passed in the UK, thoughts are increasingly turning to how best to support those recovering from the virus and how to start providing ‘normal’ NHS services once again. Naturally as restrictions are reduced and people start to fall back into their previous lives infections will start to spread – at a yet unknown rate – through the population.

At the moment, 9 out 10 of those who have COVID-19 referenced on their death certificates have been aged over 65 and 90% of those who have died have suffered from an underlying health condition.(i)

The situation and evidence base are rapidly evolving as we learn more about COVID-19, its mortality rates and the proportion of the public that are asymptomatic. One of the best sources of up-to-date information is The Centre for Evidence-Based Medicine at the University of Oxford. They have estimated the Infection Fatality Rate (ii) as being between 0.1% and 0.4% for COVID-19 using historical experience, trends in the data, increased number of infections in the population at large and the potential impact of misclassification of deaths. Meaning that between 99.6% and 99.9% of people who contract the virus will survive.

However, according to the Imperial College COVID-19 Response Team (iii) a significant proportion of symptomatic cases in older people will require hospitalisation and critical care support (Table 1).

Table 1

Symptomatic hospitalisation and critical care rates for those over 60 years old

Due to the high levels of sedation required for those in critical care on ventilator support, ordinary muscle wastage and muscle being broken down while patients are critically ill a significant proportion of those who go into critical care and survive will need a period of step-down care and rehabilitation.

Various studies have also shown that around 1 in 10 of people who require intensive care support will go on to suffer from post-traumatic stress disorder, (iv,v) (PTSD) which can take around five years to fully recover from.

Using data from Imperial College and demographic data from the UK’s Office for National Statistics we have created an indicative model to look at the different potential demands for step-down care and rehabilitation across the country.

Our modelling suggests that somewhere between 170,000 and 600,000 patients may be in need of step-down care lasting for between 2-26 weeks in length.(vi) As you might expect, there are significant variations in relative impact across the 191 Clinical Commissioning Groups (CCGs) across England, the top 10 potentially worst impacted from any widespread contraction of Coronavirus is shown in Table 2.

Table 2

Relative impact of COVID-19 on step-down care and rehabilitation demands 

There are three main reasons behind the variation in relative impact.

Firstly, data from a number of countries is now clearly showing that - for yet to be determined reasons - twice as many men are becoming critically ill from COVID-19 than women.

Secondly, the top 10 most impacted CCGs (in relative terms) for COVID-19 step-down care all have significantly higher rates than average for chronic disease indicators, including rates of those suffering from breathing conditions such as COPD.

And finally, the age demographics of different areas varies wildly. For example Norfolk has 210,000 people over the age of 65 compared to Tower Hamlets which has just over 17,000.

Solution focused approach

Developing a strategy to ensure enhanced step-down care arrangements are developed without impacting on ‘business as usual’ services.

2. Exploring the potential for re-purposing of your vacant or under-utilised estate.

3. Approaching private sector businesses such as local hotel operators who may have properties that can be temporarily be re-purposed to support step down care.

4. Identifying land from your existing portfolio to site temporary/ semi-permanent modular structures (factory assembled).

5. Assessment of existing mental health provision, identifying gaps against increased need due to COVID-19 (such as PTSD) and developing revised strategies.

6. Undertaking a review of current commissioning models analysing against current and foreseeable need i.e. current spot purchase arrangement as opposed to targeted potential block booking.

References

i. UK Office for National Statistics, Deaths involving COVID-19, England and Wales
ii. The Centre for Evidence-Based Medicine, University of Oxford https://www.cebm.net/covid-19/global-covid-19-case-fatality-
rates/
iii. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID- 19 mortality and healthcare demand, 16 March 2020,
Imperial College COVID-19 Response Team
iv. Post-traumatic stress in the intensive care unit, Talha Khan Burki, The Lancet
https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(19)30203-6/fulltext
v. ICU Delirium and ICU-related PTSD, Annachiara Marra et al, US National Library of Medicine https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC5747308/
vi. Approximating COVID-19 step-down care may be analogous to the needs for severe pneumonia in both lungs,https://www.blf.org.uk/search/site/double%20pneumonia