St Paul’s and COVID-19 – one specialty’s response to the pandemic

Despite talks of reducing the lockdown, the NHS will continue to experience challenges as a result of COVID-19 for a very long time.

For St Paul’s, most routine clinical and surgical activity has stopped, with the exception of emergency surgery, such as vitreo-retinal and trauma, and intravitreal injections for macular degeneration. The remaining clinics have been reduced in order to fit with social distancing guidance and to safely continue to see those with a sight-threatening disease, where there is a serious risk of permanent sight loss. Other groups of patients are being called at home to assess their symptoms.

 

Cometh the hour, cometh the man or woman

The speed at which standard operating procedures had to change to tackle COVID-19 required plenty of teamwork, leadership, flexibility and courage.

Many of our doctors are from countries where COVID-19 had taken hold and there was genuine concern, and rightly so. Despite their concerns, staff were ready and willing to be redeployed to other areas of the Trust to help the huge effort of looking after patients. One nurse in outpatients complained that she wasn’t allowed to be redeployed because she was “too old!” It was a testament to the dedication of staff to their professions.

 

Thinking creatively

When we think of dentists, we think of them wearing masks. However, when we think of ophthalmic staff we never think of them wearing masks, and yet when a patient is on a slit-lamp, the patient is less than 20cm away. It was quickly decided that a makeshift breath Makeshift breath guard barrier on equipmentguard barrier was needed and the idea of using laminated plastic sheets on slit-lamps and other imagining equipment was forged. Within two hours of asking, our colleagues in the University of Liverpool's Department of Eye and Vision Science had provided A3 lamination wallets and a laminator. Not long after, the University’s Department of Engineering started producing visors on their 3D printers for the Trust staff, and soon companies, schools and members of the public were rallying support too. It was this show of support, amongst the many, many other offers of support that will never be forgotten and will always be appreciated. Thank you!

Colleagues in the Clinical Eye Research Centre managed to maintain near to capacity as possible with regards to the research being undertaken there, despite implementing new working practices to maintain social distancing and reduce the risk of cross contamination. As with all clinics in St Paul’s, patients often expressed their gratitude to the staff for the lengths they went to protect themselves and patients.

Our orthoptic, optometrist and ophthalmic imaging colleagues have had similar challenges to overcome, due to the proximity in which they also work with patients.

Colleagues in the ocular oncology department have their own challenges when it comes to emotional support. As Sister Gill Hebbar explained, "Our patients usually come to clinic with relatives or friends but with COVID-19 social distancing, we have had to ask the patient to only bring one person for support. As you can imagine, a cancer diagnosis is such devastating news and brings with it a mixture of emotions for the patient, but throw COVID-19 into the mix and having to socially distance, holding hands or a hug of support is not allowed. As oncology nurses, this has been one of the most difficult situations to deal with as we are ‘huggy’ people, instead, we have had to hug virtually."

There is so much that we can learn from this period in time and which may well be integrated into future standard procedures. At the time of writing this blog, steps are being considered to slowly but safely increase patient numbers.

 

Patient flow

Prior to elective procedures being cancelled, the department’s compliance of “Referral To Treatment” (RTT), which is the maximum waiting time a patient should wait before accessing our service, was 95%. At the time of writing it is 77% and likely to decrease further until we start to slowly bring patients back for less urgent procedures. St Paul’s is the largest department within the Trust seeing around 1/3rd of all cases, and cataract operations are the commonest surgical procedure in the NHS.

St Paul’s faces new challenges as staff start to deal with the backlog caused by cancelled appointments. Many patients, even those with sight-threatening conditions are understandably reluctant to attend appointments, and we are already seeing those whose condition was previously well controlled, but who have been reluctant to attend, coming urgently with severe disease. Virtual appointments, ie telephone calls, have played an important part in assessing patients considered low to medium risk, and reduce footfall in clinics and likelihood of infection.  

There is likely to be a sudden surge of people needing to be seen and a possible “perfect storm” as new and urgent cases start to present themselves again, at the same time as those with serious but less urgent conditions need to have their appointments rescheduled. Patients with less urgent conditions, but which also have a huge impact on their quality of life and/or ability to work, will also need to be seen. All of this will need to occur at the same time as continuing social distancing in the foreseeable future. Those who have been to St Paul’s willMain outpatient clinic with many of the chairs removed know how busy the clinics get, often full to capacity – compare that to the picture of the clinic shown here with many chairs removed and those remaining spread as wide apart as possible. The clinic was closed at the time of the picture being taken, but demonstrates the current capacity with only a handful of patients in attendance at any one time.

Given the nature of work, we also have to be mindful of our patients with visual impairment and social distancing, an issue flagged up by our Eye Clinic Liaison Officer, who is registered blind. How can we help patients with either lack of depth perception, or no central vision and in her case no peripheral vision to maintain distance?

In the background are teams of clinical and clerical staff, who need to check through thousands of patient records and assess the urgency of their condition in order to minimise preventable permanent sight loss.

We have only been bringing medium and high risk patients into clinic, but we are working with multidisciplinary teams, both internal and external to Liverpool University Hospitals NHS Trust to formulate plans to address low risk patients whilst abiding with social distancing.

We still have many challenges to overcome in the weeks and months to come. We are extremely fortunate to attract some of the best people in their field from all over the world to work here and ensure our patients get the very best treatment, care and support they need and deserve. The NHS is a truly wonderful organisation because of the people that work within it, but it would not be the same if it didn’t have the support of the public. As mentioned earlier in this blog, when it mattered the public supported and played their part to protect the NHS and then did a whole lot more.

We must also pay tribute to our patients that have been so understanding and supportive during these very difficult times for us all.

Thank you from all of us here in St Paul’s.

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