Dr Richard Biram is a Consultant Geriatrician in Cambridge. He is a full-time NHS clinician providing cover for a geriatric medicine ward with a sub-speciality interest in peri-operative medicine. He is currently Chair of the BGS England Council.
At a recent meeting of the BGS England Council, we spoke about the latest growing wave of COVID-19 admissions we were starting to see around the country.
Unlike seasonal flu, COVID-19 outbreaks seem to have been a persistent year-round issue ever since the start of the pandemic. Various regions described outbreaks closing wards and leading to considerable morbidity and mortality throughout the year.
Concerningly, over the past couple of years, since the initial major waves of COVID-19 passed, there seems to be some variation in how different areas are approaching infection control measures for respiratory viruses. This led us to a discussion about a recent lack of availability of screening tests, slower recognition of infectious patients, and worryingly in some areas, a difficulty finding appropriate personal protective equipment (PPE).
Obviously times have changed since the first months of the pandemic. Most of us have been vaccinated or have experienced a COVID-19 infection over the past few years. As a consequence of this, and due to the extreme difficulties imposed by isolation measures, there has been a major move towards trying to ‘get back to normal’ as far as possible.
This is reflected in the current UKHSA guidance for healthcare professionals with symptoms of a respiratory infection or a positive COVID-19 result. Staff are no longer asked to test for COVID-19 and most staff are no longer required to have 2 negative lateral flow tests before returning to work (this does not apply to people working with severely immunocompromised patients for whom separate guidance applies).
In geriatric medicine, we are caring for vulnerable patients living with frailty or with multiple co-morbidities in what are often crowded, poorly-ventilated in-patient areas. Under these circumstances, our experience has shown us over the past four years that an incautious approach to infection control can lead to the development of outbreaks which can have serious consequences such as unnecessarily long hospital stays, closure of wards, major morbidity and an increased risk of death.
After the England Council meeting, I returned to work and received a call from our Departmental Lead. My general geriatric medicine ward had been identified as being the ward which would become the Trust COVID-19 escalation ward. This was no surprise. Our ward has a configuration suited to managing groups of patients with different respiratory viruses and I had run the COVID-19 unit there last January. COVID-19 cases had been rising over the previous fortnight and a couple of wards had experienced large numbers of cases the week before.
This served to highlight the need for persistent vigilance in relation to communicable diseases, and the difficulties inherent in trying to act as though COVID-19 is no longer of clinical concern.
On opening the unit, I was pleased to find our Trust proactive in terms of testing and cohorting of patients. We have some extremely good extended respiratory virus swabs locally (which can identify all manner of common respiratory viruses) which aids greatly with management. I was also pleased to find support for urgent mask fit-testing for new staff members, and good availability of appropriate PPE. I am aware that this may not be the experience of other units around the country and I feel very fortunate that our Trust is responsive in this regard.
In running the ward, we have found the current COVID-19 management guidelines to be reasonably clear, albeit a bit complicated. NICE guidance currently recognises that patients over 85, or patients over 70 from care homes or who are already in hospital, are in a high risk group for progression to severe COVID-19 infection. This means that a significant proportion of our in-patients may qualify for some form of antiviral therapy.
On reflection, we are not yet able to act as though COVID-19 has gone – certainly not where our group of patients are concerned. The effect of an active infection in a geriatric medicine ward where strict isolation procedures are not taken will be evident to anyone who has experienced it. Nearly five years since the first COVID-19 cases, we are still seeing this infection leading to closed wards, prolonged admissions and poor clinical outcomes.
Whilst writing this, the COVID-19 enquiry is ongoing. It is shocking listening to some of the testimony, remembering how things were back in the early days of the pandemic. Thankfully the situation has improved since then, due to vaccination, a better understanding of respiratory viral transmission and with new therapeutic approaches available. However, it does not seem we are yet at a point where we can be complacent. COVID-19 still has the capacity to cause significant harm to older adults living with frailty and to the overall workings of a general hospital.
Above all, we must ensure we do not forget all the lessons we have learned during the nearly five years since the start of the pandemic in such areas as respiratory protection and vaccination for staff and improved ventilation and cohorting of patients on the wards. Despite everything we now know, it seems that we will need to remain vigilant to the potential risks towards both vulnerable patients and staff for the time being at least.
