key: cord-1000741-7e0ane55 authors: Kursumovic, E.; Cook, T. M.; Vindrola‐Padros, C.; Kane, A. D.; Armstrong, R. A.; Waite, O.; Soar, J. title: The impact of COVID‐19 on anaesthesia and critical care services in the UK: a serial service evaluation date: 2021-05-18 journal: Anaesthesia DOI: 10.1111/anae.15512 sha: 5593ed15bfacd0a15351f73cec63699231616abc doc_id: 1000741 cord_uid: 7e0ane55 Between October 2020 and January 2021, we conducted three national surveys to track anaesthetic, surgical and critical care activity during the second COVID‐19 pandemic wave in the UK. We surveyed all NHS hospitals where surgery is undertaken. Response rates, by round, were 64%, 56% and 51%. Despite important regional variations, the surveys showed increasing systemic pressure on anaesthetic and peri‐operative services due to the need to support critical care pandemic demands. During Rounds 1 and 2, approximately one in eight anaesthetic staff were not available for anaesthetic work. Approximately one in five operating theatres were closed and activity fell in those that were open. Some mitigation was achieved by relocation of surgical activity to other locations. Approximately one‐quarter of all surgical activity was lost, with paediatric and non‐cancer surgery most impacted. During January 2021, the system was largely overwhelmed. Almost one‐third of anaesthesia staff were unavailable, 42% of operating theatres were closed, national surgical activity reduced to less than half, including reduced cancer and emergency surgery. Redeployed anaesthesia staff increased the critical care workforce by 125%. Three‐quarters of critical care units were so expanded that planned surgery could not be safely resumed. At all times, the greatest resource limitation was staff. Due to lower response rates from the most pressed regions and hospitals, these results may underestimate the true impact. These findings have important implications for understanding what has happened during the COVID‐19 pandemic, planning recovery and building a system that will better respond to future waves or new epidemics. During the COVID-19 pandemic, there has been considerable focus on the escalation of critical care capacity, capability and delivery. In many UK hospitals, critical care and anaesthesia departments work together and share staff. The expansion of critical care capability has inevitably led to redeployment of staff, space, equipment and drugs intended for anaesthesia and peri-operative care [1, 2] . In the first wave of the pandemic, most planned surgery was stopped for several months but, after this, there were specific efforts made to restore surgical activity and to maintain this, even in the face of subsequent waves of pandemic activity [3, 4] . The extent of disruption of anaesthetic and peri-operative activity in the second wave has not been clearly documented. The 7th National Audit Project (NAP7) is a national service evaluation, run by the Health Service Research Centre within the Royal College of Anaesthetists (RCoA), examining peri-operative cardiac arrest which had been due to start in May 2020. Early in the first wave, NAP7 was postponed and, as part of assessing when anaesthetic and peri-operative services might have returned to a stable baseline and thus be ready for starting NAP7, we undertook a series of national surveys in order to track activity during the second wave of the pandemic. The Anaesthesia and Critical Care COVID-19 Activity Tracking (ACCC-track) survey did not meet the definition of research as per the UK Policy Framework for Health and Social Care Research [5] , was deemed a service evaluation and therefore did not require research ethics committee approval. The conduct of ACCC-track was approved by the RCoA Clinical Quality and Research Board. During the planning stages of NAP7, a network of 330 local coordinators was established in all NHS hospitals and many independent sector hospitals in the UK. After the postponement of NAP7, as part of planning for restarting, we initially devised the ACCC-track survey to determine the degree of disruption of peri-operative services and readiness to start NAP7. A questionnaire was submitted to all local co-ordinators in July 2020 which showed a majority (75%) supported the concept of the ACCC-track survey. An electronic survey tool (SurveyMonkeyâ) was used to conduct three successive ACCC-track surveys. The survey tracked changes of systemic stress in surgical and critical care during different stages of the COVID-19 pandemic. Rounds 2 and 3 differed from Round 1 (see also Supporting Information Appendix S1) by removal of questions that did not need repetition and addition of new questions as indicated. Drafts of the survey were reviewed and tested by clinicians involved with NAP7 and the RCoA Quality Improvement committee. Rounds 1 and 2 of the survey were sent to all local coordinators. Responses were encouraged by email reminders at regular intervals to local co-ordinators and to anaesthetic department clinical leads once per round. Respondents were asked to provide information for the main hospital site they represented, which was identified by region and name of hospital. Response rates from the independent sector were limited and for Round 3 only the 273 local co-ordinators representing the 420 NHS hospitals were asked to respond [6] . This analysis only includes data from NHS hospitals. Duplicate responses and those which did not record a hospital site and/or region were excluded. Since some local co-ordinators represented more than one hospital across multiple sites, the hospital response rate was calculated using the 420 NHS hospitals with anaesthesia provision as the denominator. This denominator was cross-referenced using NHS digital [7] and NAP7 lists of hospital sites [6] . Data collection periods were as follows: Round 1 (R1) for the month of October 2020; Round 2 (R2) for 2 weeks between 1 and 18 December 2020; Round 3 (R3) for 2 weeks between 18 and 31 January 2021. Surveys could be submitted for 4-5 weeks after distribution. These three rounds corresponded to different stages of the second wave, as recorded on the UK government's COVID-19 data website [8] : Round 1 from the start of the second wave and before the second lockdown in England; Round 2 shortly after the end of this lockdown, during a period of slowly increasing hospital activity, and Round 3 during the third lockdown and shortly after the peak of the secondary surge caused by the SARS-CoV-2 Kent B117 variant [9] . The relationship between the timing of the surveys and UK hospital admissions due to COVID-19 is shown in Figure 1 . Each 'red' rating describes a system "not ready for a return", 'amber' a system "close to being ready for a return" and 'green' a system "ready for a return" to undertaking planned surgery (see also Supporting Information Appendix S1) Statistics [11] were used as the denominator for the number of current anaesthesia (13,119) and critical care (2404) staff in England and this was scaled up to UK levels by multiplying by 1.187 [12] . Responses were received from 176 (64%) NHS local coordinators in R1, 154 (56%) in R2 and 140 (51%) in R3. These local co-ordinators represented 65% of NHS hospitals in R1, 54% in R2 and 51% in R3. Response rate varied by region Figure 1 Timing of the surveys and number of hospital admissions due to COVID-19 in the UK. Grey areas represent the timeline for October 2020 (R1), December 2020 (R2) and January 2021 (R3). Data adapted from [9] . (see also Supporting Information Appendix S1). In R1, this ranged from 80% from the East and West Midlands to 46% from Wales, in R2 80% from Yorkshire and Humber region to 35% from Wales and in R3 from 68% from the South-West to 32% from the East Midlands. Response rate fell most between R2 and R3, with half the regions having a <50% response rate in R3. A summary of key results is presented here, with a more detailed analysis of theatre processes and personal protective equipment and detailed results by region presented in the Supporting Information Appendix S1. Staff and space were the resources most frequently affected ( Fig. 2) . Nationally, between R1 and R3, green ratings for staff reduced from 58.3% to 16.5% and for space from 61.1% to 20.3%. Stuff (equipment) and systems were less impacted; green ratings for both fell to approximately 50% in R3. In R1 and R2, 54% and 68% of departments, respectively, had at least one red or amber domain and therefore self-declared as not ready for a return to planned surgery. In R3 this rose to 90%. In R3, no region reported being above 50% green for space or staff with most above 80% amber/red, of which most were red. In R2, 45% reported ICU expansion beyond baseline capacity (staged resurgence plan 3-5) and in 15% there was an imminent or actual need for mutual aid to transfer critically ill COVID-19 patients to other hospitals (staged resurgence plan 4-5) (see also Supporting Information Appendix S1). In R3, 74% of ICUs were expanded above capacity, with 39% likely or actually needing mutual aid. In in R3 (see also Supporting Information Appendix S1). Regionally, the steepest rises in operating theatre closures were in London, and the East and South-East of England, which all had among the lowest rates of closure until R3. In R3, five regions (42%) had more than 50% of their normal operating theatre capacity closed, eight (67%) more than 40%, and 10 (83%) more than 30%. The overall use of external sites to maintain surgical activity decreased from R1 (10%) to R3 (8%) (see also Supporting Information Appendix S1). While some regions were able to maintain external surgical capacity between R1 and R3 (London and South-East England both maintained > 10%), this reduced in many (e.g. North-West England 10% to 8% and Yorkshire and the Humber 12% to 7%) and Information Appendix S1). Between R1 and R3, near-normal productivity (75-100%) fell from 48% to 32% and operating at < 50% productivity increased from 10% to 27%. Surgical activity, compared with 12 months previously, reduced in all rounds of the survey, but most markedly in R3 ( Fig. 4) . At all times, the greatest impacts were (in descending order): paediatric; non-cancer elective; cancer; and emergency surgery. In R3, paediatric and non-cancer elective surgery activity were at less than a third of the previous year's activity and cancer surgery was reduced by more than a third. Regional variation in impact was noted, particularly among paediatric and non-cancer surgical activity (see also Supporting Information Appendix S1). Measured over a 24 h period, in R1 and R2 overall surgical activity was reduced by a little over one-quarter compared with 12 months previously (Fig. 5) . This equates to approximately 5000 operations not performed each day [14] . When this accumulated surgical activity is added to pre-existing waiting lists, cumulative waiting lists now are estimated to be between 4.5 million (Dobbs T et al., preprint, https://www.medrxiv.org/content/10.1101/2021. 02.27.21252593v1) and 7.5 million [14] . Optimistically, control of COVID-19 in the UK will be achieved by a combination of prolonged lockdown and extensive vaccination [15] . Resumption of surgical activity and peri-operative services will need to go hand in hand with decompression and step-down of expanded critical care provision [1, 10] . Our data illustrate very clearly that anaesthetists (and in all probability other healthcare providers working in operating theatres) have been central in the critical care response to the pandemic, and that they will have been similarly impacted. It is acknowledged that as a consequence of increased amount and intensity of workload, decreased leave, psychological burden and moral injury, the physical and psychological needs of the workforce must be considered in planning recovery of non-COVID healthcare services [16] . There is a marked regional variation in most of the for mutual aid [18] (compared with 54, one year previously) [19] . Our respondents reported 50% more mutual aid admissions to their hospitals than transfers out, and as each mutual aid transfer must have a decompressing and receiving unit, this provides some support for the idea that we preferentially sampled from less systemically stressed sites. There are some limitations to our surveys. We have had decreasing response rates, falling to 50% in Round 3. In normal circumstances, some will consider response rates of above 60% to be necessary to be judged representative of the population sampled. Others regard 40% as sufficient [20] . Our surveys specifically targeted departments during a pandemic, including when capability pressures were increasing or saturated and survey responses were required rapidly. It is plausible, and perhaps likely that, within regions, the more systemically stressed hospitals were less likely to respond, and the data support this. It is therefore also plausible that the results of the survey underestimate the true extent of the 'system stress' due to failure to capture data from the most stressed part of the system. This is likely to be most marked when overall clinical pressure was highest, in R3. The surveys required respondents to compare activity at the time of the survey to activity a year previously and also to measure activity over 24 h. In some cases, the responses were estimated but sub-analysis of only those reported as accurate did not change the overall results. Finally, for some regions, only a small number of hospitals replied so that these regional results may be less reliable. In conclusion, we have documented the systemic stress on anaesthetic and peri-operative services during the second wave of the COVID-19 pandemic in the UK. This shows growing pressures between October and December 2020 because of critical care demands, predominantly on staff and space. Falls in surgical activity due to having to close operating theatres and reduce activity was mitigated by use of resources in other locations. In January 2021, shortly after the peak of the second surge, there is evidence that systemic resilience was overwhelmed; almost a third of anaesthesia staff were unavailable and surgical activity reduced to less than half, impacting all surgery, including cancer surgery and emergencies. 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Table appendix Critical Care Bed Capacity and Urgent Operations Cancelled Survey research We thank the NAP7 local co-ordinators and other clinicians who have completed any round of the ACCC-track surveys. Additional supporting information may be found online via the journal website.Appendix S1. Information including red-amber-green rating: minimum requirements for restarting elective surgery and procedures, ICU staged resurgence plans and ACCC-track results (Tables S1-S4 and Figures S1-S37) .Appendix S2. List of contributors including the NAP7 steering panel and the NAP7 local co-ordinators and associated clinicians.