Clinical Advisory Panel
Thursday 19th November 2020
The first wave of COVID-19 placed huge pressure on our health service, with elective surgeries suspended, and treatment capacity reduced significantly. We spoke to Consultant Cardiologist Dr Michael Mullen from Barts, London to understand how his centre responded to the crisis, how the pathway has changed and what they did to maximise treatment capacity.
"Initially, there was a lot of concern about the impact COVID would have on our ability to maintain the service, and there was a couple of weeks where treatment virtually stopped." Dr Mullen said. "However, we recognized, even at this stage, that there was a need to maintain some percutaneous activity, as in some patients the risk from their aortic stenosis posed a greater risk than COVID."
Despite the pressures exerted by COVID on Barts, the team were able to quickly establish pathways that allowed them to treat urgent patients safely, which allowed them to move quite early on to high-risk electives and then into general waiting lists.
- Clinical team triage patients to understand symptoms and risk categorise them
- Identify patients most in need of treatment.
- Pre-op assessment of exposure and symptoms and when available COVID test
- Patient self isolates before admission
- Admission into COVID free area. Tested again on admission
- Treated and discharged in 2-3 days
"The first thing we needed to do was get an understanding of patients' symptoms and how they were doing to identify who needed treating most. Dr Mullen said. "Then we needed to ensure an efficient journey through the hospital to keep footfall as short as possible, to reduce the risk of catching COVID in hospital and to reduce the burden on bed capacity which had been reduced during the peak of the pandemic. Now we've treated several hundred patients through this pathway, and during that time, we had zero positive COVID tests on that pathway."
Since the first wave of COVID-19 access to testing has improved significantly, and patients are now posted tests prior to admission and then admitted in to 'COVID Free' wards to be treated safely and efficiently.”
By redesigning pathways and working with patients to ensure they were COVID free, Barts were able to give hundreds of people the life-saving treatment they needed timely and safely.
However, despite these pathways, valve disease treatments across the UK were not able to recover to the same levels as last year.
Dr Mullen said "With our pathway now, we're running at 80% capacity of a year ago, so activity has mostly recovered. There are still some bed limitations, and we do four cases a day rather than 5, but we also are looking to expand the lists to ensure we can treat as many patients as possible."
Despite this, Dr Mullen sees a continued reduction in referrals as a critical issue. "There is a problem building up in the system due to a lack of referrals, which are at about 50% of last year. This fall is likely due to patients not presenting at GP's due to fear of COVID, which we have certainly experienced in the hospital, or a lack of access to diagnostics at the primary care level. My concern is that it could translate into late presentations and an increase in emergency admissions which will further increase the pressure on the health service and we know is associated with worse outcomes."
As we move forward with our response to the second wave of COVID, Dr Mullen believes our understanding and management of the virus has improved significantly, which will change the impact it has on heart valve disease treatment. "From our perspective, it's important we maintain the service. Pathways are in place, and we hope to be more resilient this time so we can preserve the programme. Arguably, having these treatments available is more efficient than surgery, and the availability of percutaneous therapies allows for shorter hospital stays and limits the strain on ITU bed capacity."
Heart Valve Voice CEO Wil Woan said "Thank you to Dr Mullen for taking the time talk to us about his experiences at Barts. The treatment pathway they have been able to develop highlights how centres were able to adapt their practices to ensure they retained treatment capacity despite the pressures of COVID. This spotlight highlights the importance of Heart Valve Voice's Three-Point Plan for heart valve disease care during the second wave of COVID. Patients must go to the doctor if they experience symptoms of heart valve disease or worsening of their current symptoms, primary care must have the confidence to refer timely, and secondary centres must reassess treatment options to maximise treatment capacity."