On The Up

23rd June 2021

UK COVID Deaths – Daily 19 / 7-Day average 14

Total UK COVID Deaths within 28 days – 128,027

Total UK Deaths with COVID-19 on the death certificate – 152,490 (up to 11 Jun)

All COVID cases within South Tees Hospitals Trust – 14

James Cook Critical Care

COVID cases – 4 (3 ventilated)

Non-COVID cases – 50 (29 ventilated)

Last week the UK had the highest rate of new coronavirus cases in Europe despite its vaccination success. I’m not sure how accurate this statistic really is, as different nations test and record COVID cases in different ways. However, it does serve to highlight what a dramatic effect the Delta variant has had since its arrival on our shores in April. The threat posed by the arrival of further variants is very real and explains why nations may be reluctant to relax foreign travel restrictions for a while longer.

We now know that the Delta variant is 60% more infectious than the previous dominant Alpha variant. This explains how it has elbowed every other variant out of the way and now accounts for over 90% of all new cases in the UK. The incidence in European countries remains significantly lower but the EU Centre for Disease Prevention and Control (ECDC) estimates that a similar prevalence of 90% will have been reached across Europe by the end of August.

The good news is that the rate of increase of these new cases has slowed over the past fortnight. Cases are currently doubling every 17 days with the biggest increases seen in younger age groups. The Delta variant appears to be associated with roughly double the risk of being admitted to hospital and so it’s a relief to find that, whilst hospital admissions are rising, they are not rising like they did at the beginning of the second wave. The rise in the number of COVID deaths is also much slower than we saw back then.

It is mass vaccination that we have to thank for this. Whilst we know that vaccines are not as effective against the Delta variant, we now know that one dose of either the Pfizer or the AstraZeneca vaccine appears to reduce your chance of becoming infected and hospitalised with COVID-19 by 75%. This risk is reduced by more than 92% if you have had two doses. Back in January when the Alpha variant was dominant, about 10% of all those infected with COVID-19 required admission to hospital. Currently, about 4% of all infections are requiring hospitalisation. At the peak of the second wave, about 25% of all patients admitted to hospital died but that figure is now about 10%. Patients in hospital this time around are younger and they are recovering quicker. Thankfully, far fewer of them are dying.

Of course, if case numbers continue to climb there is still the potential for a significant number of hospital admissions. On Teesside the incidence of cases is steadily increasing and our hospital is now beginning to admit COVID patients again. We currently have four such patients on ICU in our isolation cubicles.

One of these is a young patient who has been admitted following an assault. He was found to be coincidentally COVID positive. He is requiring Intensive Care as a result of his injuries rather than as a result of COVID-19. Another patient is in their 30’s and has not been vaccinated. They deteriorated shortly after admission to the ICU and ultimately required intubation and ventilation. They are displaying all the hallmark features of severe COVID pneumonitis.

Our other two COVID patients are older and have both been vaccinated twice. However, both have reasons for their apparent vaccination failure. One is receiving immunosuppressive treatment following a kidney transplant and the other has recently spent a long time in hospital recovering from septicaemia. Both of them seem to have perhaps been spared the severest COVID pneumonitis but have presented with what appear to be secondary bacterial pneumonias. This is obviously still worrying as both of them have become ill enough to require ventilation. Perhaps the vaccination has resulted in a milder COVID-19 infection than they otherwise might expect but their COVID infection has caused them to develop a subsequent pneumonia? This is what tends to happen with influenza infections in vulnerable people and I wonder whether we might see more of this type of presentation in vaccinated individuals over the forthcoming months.

Now, four COVID patients isn’t a lot when compared to what we have dealt with before but we know that more will be coming our way. The trouble is that we are still full of non-COVID patients and the last two weeks have been pretty busy. We have had more admissions than we would normally expect at this time of year and have many more sicker, ventilated patients. This places a greater demand on our nursing staff and means that our admitting capacity becomes uncomfortably tight at times.

The rest of the hospital has also been busy. The last two weekends have resulted in a record number of A&E attendances. The number of people who are unable to return home on a night without falling over, being hit by cars, being assaulted or becoming unconscious is quite impressive. The workload seems to be increasing everywhere. In fact, the only illnesses we have been seeing less of have been non-COVID respiratory tract infections. These appear to have been knocked on the head as a result of social-distancing.

Of course, if necessary, we could always reopen our Surge ICU but this has inevitable knock-on effects on the operational capacity of the rest of the hospital and requires us to rummage around for extra nurses. Taking non-ICU nurses from another part of the hospital to help out ends up robbing Peter to pay Paul. Fewer nurses elsewhere will affect the hospital’s ability to play catch-up with all the non-COVID work that hasn’t happened over the past 15 months.

Opening the surge unit would also be rather depressing for everybody. We really had hoped that we might avoid having to do this for a few more months. It is easy to forget what a big step this is for us. Prior to the pandemic we had never entertained the idea of a temporary ICU. Sure, there were many occasions when we ran out of beds and had to ventilate people in A&E or Theatre Recovery for long periods of time, but open a temporary ICU? It had been unthinkable. The pandemic has changed all that and highlighted just how short of ICU beds we now are.

However, rather than end this post on a bit of a downer, I will share some cheerier news. We have received further data regarding our performance during the second wave in the form of a local report from the Intensive Care National Audit & Research Centre (ICNARC). ICNARC collects data from Intensive Care Units across the country and provides detailed information about those COVID patients that are sick enough to require Critical Care.

We had previously received a local report that covered the first part of the second wave. This was the period from 1st September through until 31st December last year. We were delighted when we discovered that 71% of our COVID patients were leaving Intensive Care alive compared with a national average of 58%. However, we had been all too aware that this figure did not include those patients seen at the peak of the second wave. The first months of 2021 were the time when we were struggling with large numbers of very sick COVID patients. During this time we were opening surge unit after surge unit in order to accommodate everyone and all of us were worried that standards might have slipped.

This latest report is reassuring in that regard. It looks at the whole of the second wave, the period from 1st September 2020 to 31st March 2021. As before, our mix of patients was similar to those seen in other hospitals. We did admit a slightly higher proportion of women and we saw more severely obese patients than other hospitals. We had more patients whose ethnicity was classified as white but we had many more patients who were in the ‘most deprived’ social deprivation category.

Overall, nearly 69% of our patients survived to leave ICU, compared with a national average of nearly 61%. Whilst not quite as good as the result from the ‘first half’, this is still a great result and one that we are very proud of. We are also aware of the fact that, unlike a lot of other hospitals, we managed a lot of our less sick COVID patients on the ward. These patients were less complicated and often younger and fitter than those we admitted to the ICUs. They received CPAP on the ward rather than in ICU and had a lower mortality than our ventilated patients. Had we been able to include them in our ICNARC data we are confident that our survival rate would be better still.

Having gained all this useful COVID experience, we’d like nothing better than to not have to use it again. Of course this is not a realistic expectation but we were hoping that things might be calmer right now. Summer is the time that those working in ICU traditionally catch their breath but it looks like the summer of 2021 is not going to be a quiet one.