The cuckoo bird and the monster Medusa are helpful metaphors when considering how to respond to the wide-ranging challenges that COVID poses to health systems and to those at greatest risk from the coronavirus itself and also through its impact on services.
The article below is by Dr Michelle Ananda-Rajah, an infectious diseases and general physician with 25 years of experience in major public hospitals. She is Labor’s candidate for the Federal electorate of Higgins.
Michelle Ananda-Rajah writes:
The NSW hospital system is predicted to be overwhelmed in October with Victoria’s turn expected a little later. Most people, except for health professionals, would not understand what an overwhelmed hospital system really means.
Major hospitals, the ones that deal with the sickest of patients, are like small cities. In Australia, they may employ 10-15,000 people, which is disproportionate staffing for a relatively modest number of beds (sub-1000). If it takes a village to raise a child, then it takes a city to manage patients.
Critical care nurses and doctors have raised the alarm over moves to stretch the system with untrained staff, the loss of one to one ratios and rationed care. As always, it is not the number of ventilators or beds, but the staff that is the bottleneck.
A study of our ICU surge capacity estimated that for 4,258 ICU beds (not all ventilated) we would need a whopping 46,000 additional staff. Skilled staff do not grow on trees. They take years to cultivate completing undergraduate then post graduate exams in parallel with on the job training. The art is learnt not from textbooks but as an apprenticeship over years, under the wing of senior clinicians.
Healthcare is delivered by teams rather than individuals. People are arranged horizontally and vertically within the team usually comprising medical, nursing and allied health with formal and informal communication pathways.
Parachuting in new staff carries risks-stress from unfamiliar environments, inter-personal dynamics or equipment. The pace is busy to frenetic, cognitive and emotional bandwidth is limited, multi-tasking is the norm with interruptions coming like volleys.
As cases rise, the whole system which is geared to provide individualised care that follows the highest ethical standards tilts towards crisis management. This compromises the foundations of patient safety and quality, and primes staff for a moral injury that can have long lasting effects.
Vaccine mandates, foreshadowed by the Victorian Premier will raise the ire of some but healthcare professionals drew relief because flogging a system indefinitely is unsustainable. The BBC reports that Irish nurses are showing signs of “an inability to keep going”.
The focus on ICUs detracts from also the importance of care provided in non ICU wards and communities.
COVID is like a cuckoo, when it moves in something else gets pushed out.
Trauma, heart attacks, stroke, chemotherapy, fractures, bowel obstructions, sepsis, overdoses, acute mental health crises – the “everyday” misfortunes of life, still have to be managed. The UK is facing a colossal elective surgery backlog of 5.6 million people that will take years to clear.
So, how do we measure success?
Hospitalisations, ICU admissions and deaths have become the metrics du jour.
But going forwards we need to account for the opportunity costs also. Lengthening elective surgery lists; deaths in the community that are related or not to COVID along with adverse events in hospital (such as falls, pressure sores, infections or unexpected deaths) may reflect a failure to provide timely quality care; delays in cancer care from screening to treatment; emergency department wait times; ambulance response and ramping; length of hospital stay; linkage to community care after a positive COVID test are some.
Costs are never evenly spread. People with limited health literacy and/or few social or economic protections will be disproportionately affected, as they have been throughout this pandemic. Reporting should be broken along gender, age and deprivation lines or we will remain blind to the widening gap at our feet.
What will be the legacy of over policing, stigmatisation and top-down leadership? Alienation, a loss of trust, a rise in anti-authoritarianism perhaps? We can ill afford to leave more people behind.
A society riven with inequality is weak, less resilient, less cohesive and more vulnerable to shocks. Eventually our sins converge in the economic sinkholes of the health, welfare or judicial systems. If we are serious about repair, then broaden the net of what we measure before the back slapping begins.
How we scale care for tens of thousands of infections where 90 percent will be managed in the community is a pressing challenge. The failure of successive governments to address fragmentation of the healthcare system across community, general practice and hospitals is about to come home to roost.
Investment in peacetime pays handsome dividends in a crisis. Just look at Israel who has provided actionable data at speed to the benefit of her people and the world thanks to its integrated electronic health record across multiple jurisdictions.
Medical emergencies are outlier events affecting a few people relative to the population but if your number comes up, then you rightly expect the safety net to catch you. We should take heed of a New Zealand ICU doctor after working for a year in the UK who said, “the ability of this disease to completely overwhelm and close down the health system is quite amazing”.
Hard metrics are relatively easy to measure but no less important are qualitative measures. The patient, family or carer experience is a national standard that is captured by survey. This is as important for those who return home as well as for those who do not.
Providing care means ensuring a good death also. The paradox of this pandemic of death is that it has fractured our connection to dying. Families and carers have been robbed, left with snatches of memories through the dehumanising filter of Facetime and PPE.
Death is out of sight and out of mind barricaded behind hospital doors. The bedside vigil has gone and we as a community are poorer for it. The narratives, the stories, the stages of grief hidden from view replaced by a sanitised morning report. Some 13 million people have died according to The Economist yet people riot in the streets against pandemic control measures.
Statistics never changed hearts nor minds. It’s the stories that matter and we haven’t communed at that table with our biscuits, tea and tears. A community shielded from loss is a community disconnected from it. Conspiracy theories run wild, people question the fuss directing their rage at leaders accused of overreach when they want to protect the health system.
We are transitioning to a new normal.
How we measure success accounting for who is affected and where, will determine how well we manage, noting that you can’t improve what you don’t measure. We better get those metrics right or we will be replacing one problem with a Medusa head of others that threaten the whole house.
Dr Michelle Ananda-Rajah is a physician in infectious diseases and general medicine at a major Melbourne hospital. Her research encompasses health services, artificial intelligence and clinical leadership. She is a past recipient of the prestigious MRFF TRIP fellowship (2019-2020), a statistical and methods reviewer for JAMA Network Open and is on the editorial team of BMJ Leader. With our country facing unprecedented social, economic and environmental challenges, Michelle has decided to stand in the federal election as Labor’s candidate for Higgins.
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