Returning to ‘new normal’ working
As the UK and Ireland move beyond the current peak (or ‘surge’) in the Covid-19 pandemic, national (state) health systems are looking to resume non-emergency and some elective surgery. Clinicians will rightly have concerns about what this means for their patients and for themselves. The ICM and anaesthesia Covid-19 collaborative in the UK has published a document describing when anaesthetic departments can start to move towards planned surgery, based on an assessment of their readiness.
To ensure we do not inadvertently contribute to a second surge, the Association of Anaesthetists has produced a list of those areas we believe need further consideration. We acknowledge that not all these questions can be answered now; some will require national policies to be developed while others will require local solutions, so that our patients, colleagues and their families are not placed at risk.
The Association believes that a return to non-emergency work will require the resumption of normal (pre-Covid) rotas for both out-of-hours cover and daytime work.
Work patterns should include the usual ratio of SPA to DCC time; SPA time is essential for wellbeing, education, quality improvement, appraisal, training and many other activities that underpin clinical work.
Job planning will use the rules and expectations of standard contract T&Cs to manage clinicians during and after the pandemic; we believe that the ability of employers to use extraordinary circumstances as a reason to vary T&Cs does not apply outside surge periods.
It is essential departmental managers ensure equity across work schedules (and also of opportunity) during and after the pandemic
Any move to seven-day working or evening working for non-emergency work should be via negotiation and job planning, and not enforced.
Trainees should return to their normal rotas, work patterns and training.
Training opportunities will have been lost during the pandemic and cannot easily be replaced; there will need to be latitude in how competency-based assessment is applied, while ensuring the training (including the skills, knowledge and experience) of the future workforce is not diluted. (Read more from the Royal College of Anaesthetists and the GMC.)
Schools of Anaesthesia should acknowledge the stressors put upon trainees including the modified ST3 recruitment process, the impact on completion of training, the lost opportunities, and the type of work undertaken during the pandemic.
There may be an increased need for mentoring, counselling and supervision.
Testing of staff for virus by swabbing (and use of antibody serology, when available) should be part of the strategy for safeguarding patient and other staff, as well as families of staff and other contacts.
We expect regular local and national surveys of staff for the impact of fatigue, burn-out, stress, and PTSD.
There should be recognition that a period of stand down may be required for some of the workforce (this can be staggered and will depend on the Covid workload and can’t be planned until the impact of a second wave is known).
Employers will need to recognise the need for increased access to local wellbeing support including occupational health, counsellors and mentors, GPs and psychologists.
Employers and deaneries will need to provide training on how to act as psychological ‘first-aiders’ (for example, how to recognise PTSD).
Annual leave requests should be respected (in line with pre-Covid practice) to reduce fatigue and burn-out, and allow clinicians to ‘re-charge their batteries’.
Departments will need to continue to accommodate those affected by the closure of schools, acting as carers, or deemed high-risk.
Many ICUs will continue to rely on significant numbers of perioperative care/theatre staff, and it will not be possible to resume all elective work.
PPE must be adequate and at the same level of provision wherever there is possible exposure. Joint statement from UK anaesthetic and intensive care bodies in response to updated PPE guidance.
Clinicians should be empowered to ‘speak up’ about inadequate PPE, with clear guidance from employers that they will be supported and not victimised for halting work while suitable PPE is obtained.
Infection Prevention and Control
The application of Infection Prevention and Control policies, including PPE, will inevitably lead to lower throughput (efficiency, theatre utilisation) than before pandemic.
Wearing PPE is tiring and likely to add to fatigue.
The Association believes it is essential that educational opportunities resume as soon as possible to enable sharing of good practice, of lessons learnt during the pandemic, information about quality improvement, and the dissemination of new (post-Covid) pathways of care.
Employers should not assume returnees will wish to continue their work after the pandemic and its surge(s).
The Association is offering returnees complimentary membership to provide access to educational and wellbeing resources.
There should be a national policy on pre-operative testing to protect patients undergoing surgery, and to protect other patients and staff.
The policy should be coherent, evidence-based, and practical.
In a post-Montgomery world, it is essential patients are informed about the risk of acquiring Covid in the perioperative period; a national statement on the impact of both the knowns and unknowns will ensure complete transparency.
There should be continual, live analysis of data about hospital acquired Covid infections.
Quality of care
Patients and the general public will need to be reassured that the quality of care has not diminished; continual data collection (e.g. outcomes, PROMs, registries, local and national audits) should be focused on providing this reassurance.
Pre-Covid pathways should resume as soon as possible, with clear documentation of when and why a derogation is required.
Clinicians should not be expected to work outside their normal range of activities.
There will need to be a reliable supply of the standard anaesthetic pharmacological armamentarium. While alternatives may be available for many classes of agent, the ‘first choice’ agent will have become that for sound clinical reasons.
Adequate provision for planned and un-planned admissions will be essential; ICUs still managing pandemic patients will not be able to accommodate a further increase in demand from the resumption of non-emergency surgery.
Many models will evolve to provide increased ICU capacity; they need to be sustainable and allow a rapid escalation if a second (or further) surge/peak occurs.
The majority of pre-operative assessments could be delivered remotely, either by virtual clinics, or via online assessments.
New NHS care locations (e.g. independent sector facilities) will require robust on-call rotas to provide routine (e.g. acute pain) and emergency care.
Willing clinicians should be job planned to provide such care (as part of their contracted work).
To deliver a new ‘reset’ NHS service there is a need for IT to match aspirations such as increased use of virtual pre-operative assessment, virtual clinics, virtual meetings, webinars and online education.
Independent hospitals and other sites
The case-mix at adopted facilities (such as independent sector hospitals) will differ from usual ‘private practice’ – for example it is likely to include major cancer resections.
Clinicians should avoid solo working at such locations to prevent fatigue and to provide support for emergency situations.
Pathways and standards of care should not differ, and will require rapid development of SOPs to cover case selection, pre-operative assessment, and postoperative care (such as critical care cover, acute pain teams, and transfer protocols).
Planned changes in location will need to ensure adequate provision of critical care, haematological services, ‘out-of hours’ radiology, and other support services such as physiotherapy, so that the quality of care is maintained across all sites.
Clinicians will want to be reassured that the government will continue to provide indemnity (‘crown indemnity’) at all sites undertaking NHS work.
Clinicians (including anaesthetists) should work together to develop and implement local prioritisation lists or schedules.
The surgical Colleges, working with the Federation of Specialty Surgical Associations, have developed a national prioritisation schedule.
The underlying principle of the NHS about equity of access is applicable at all times.
List planning will need to be coordinated between theatre, surgical and anaesthetic staff (as well as considering support services such as critical care) to ensure all parties have realistic expectations.
There is a risk of well-intentioned colleagues trying to catch-up on lost activity too quickly, risking staff burn-out, an impact on the quality of care and, therefore, outcomes, and giving the public false expectations.