Facing a new reality – challenges for acute care of older people

Dr Mark Roberts FRCP MPH is a Consultant in Medicine for Older People and Chair of BGS Northern Ireland. He tweets @markvignesha

To the two infamous certainties in life, we can now add the fact that Coronavirus (COVID-19) is going to stretch us all psychologically and physically and also as a broader society. Worse, for some the stretch will be too much, leading to their untimely death. The scale of the situation facing us is almost too much to digest fully. The human mind is not well geared to understanding and preparing for the exponential growth of a threat that can harm human life. Yet here we are, and health and social care workers and the wider public alike are rapidly having to adjust to this new reality, unthinkable even weeks ago.

How does our country best address the needs of the 'frail older' individual with the needs of the wider healthcare system and society? The truth is: I don't know how we as a country will cope. I don’t envy any government in the world the task of reassuring its citizens and trying to provide certainties in a very uncertain world. But I do know how I intend to approach this, as a Physician working in Medicine for Older People, but also from the perspective of a role that seeks to promote the quality and safety agenda within our region, in both normal times and exceptional ones. I hope that it gives qualified reason for optimism in the value of what we can do collectively.

Older people and the effects of COVID-19

It is worth remembering that the majority of people across all age groups make an uneventful recovery. However, there are lots of frightening statistics, predominantly aimed at the older age group and those with significant medical conditions. Age-related patterns are clearly evident, with the proportion of people dying with the disease in the over-80-year age category in Italy being 1 in 5, around 20%, which is broadly similar to a severe pneumonia. The headline issues at present are crystallising around intensive care bed availability, and for good reason, given the experience of the Italians. Intensive Care is the setting where machinery and finely-tuned expertise temporarily assist the vital functions of the body like breathing, and can be the bridge between catastrophe and recovery.

The continuum of care

Acutely ill older people presenting to hospital teams in normal times broadly fit into two groups: those for whom the ceiling of treatment is Intensive Care and those for whom the ceiling of treatment will be inpatient, ward care. For some people, their physical reserves and robustness are insufficient to cope with the demands that Intensive Care places on the body.

Inpatient ward level care delivered by a skilled multi-professional team, whilst utilising fewer machines and analysers to track a body’s physical response to illness and treatment, can be usefully compared to secondary school. Secondary school isn’t University, and University isn’t secondary school. They are part of a continuum of educational opportunities, and it also follows that not all students should or need to proceed to University if it is not the right fit. In the same way inpatient ward care and the Intensive Care Unit are part of a continuum of care options: not all patients should or need to proceed onto Intensive Care. That’s how it works in ‘normal’ times.

COVID-19 and the provision of Intensive Care

In these exceptional times that we are facing, a significant proportion of inpatient, ward level patients, who are fit enough candidates, will not graduate from ward level care to the Intensive Care Unit if the pressures on Intensive Care are as predicted by the experience emerging from other countries.

This reality is both sobering and tragic. We all hope the worst-case scenarios do not materialise. However, whilst Intensive Care bed capacity is vital, we must take a broader systems view of what older people being hospitalised will need in these challenging times. A chain is only as strong as its weakest part. For example, if no social care packages to facilitate discharges are available, our hospital system will gridlock, leading to congestion and poorer outcomes for older patients that no bountiful supply of Intensive Care capacity can help. As teams working in older people’s medicine, we will need to be well- calibrated to identify early who might be a candidate for escalation beyond ward level measures and who won’t be, and explain this compassionately and truthfully to patients and their families. What we must all strive to do is ensure that the access to Intensive Care beds remains on the basis of who has the greatest chance of crossing the short-term bridge that it offers, and that age alone is not the deciding factor.

Other illnesses will continue despite the COVID-19 onslaught

Patients will continue to come into hospital with acute conditions unrelated to COVID-19, or a condition where in fact COVID-19 is a coincidental finding in an unrelated illness. This is because we know a proportion of patients, in all age groups, can be either asymptomatic or have minor ill effects. For all these patients but also those critically ill with COVID-19, compassionate care, maintaining comfort and dignity and focusing on treatable conditions must be the bedrock of what we provide and we must not be side-tracked from what we know we can do well.

Looking after the clinical and support team

My sense is staff in hospital and community teams have good insight that the challenge from COVID-19 will be a marathon, not a sprint. Looking out for each other, sharing useful information, releasing tension through humour (the blackest versions shared in only the smallest circles), being agile in how we cross-cover: these are the approaches we will need more than ever. Already, despite the main wave not hitting us yet, the psychological burden of preparing for what is coming is clearly seen amongst capable, solid multi-professional teams of doctors, nurses, therapists, pharmacists, social workers and administrative staff working in older people’s medicine.

Keeping the individual ‘match fit’

I have not come across a single colleague who is not expressing a willingness to go the extra mile, over a prolonged period, to help us get through the challenges ahead in the best shape possible. These sentiments are admirable and indeed vital but we need to make sure staff working in health and social care pace themselves, get sufficient opportunity to pause, reflect, remain healthy and refresh. Otherwise the sustainability of such efforts is in jeopardy. In particular, we know empathy – the ability to share and understand the feelings of another – is eroded in the context of chronic fatigue. This in turn has a detrimental effect on compassion – the ability to act with empathy. Older people’s medicine, indeed all clinical care, without compassion is like springtime without a warming sun.

Planning for after the storm

The silver lining to the COVID-19 threat and the major disruption it brings appears to be a willingness to work more flexibly and across professional, organisational and geographical boundaries. How do we best continue the most valuable and sustainable components of these new approaches, that have been produced quickly with focus and determination? A switch to remote and virtual working, renewing contacts between primary and secondary care to support where patients are best placed are trends we should try to build on after the storm with renewed vigour. It has taken a simple but effective infectious agent to remind us all of the interconnectedness of our work and its interdependency.

Moreover, are there unique opportunities to consider a fundamental shift away from silos and specialist interests towards a greater weight on systems leadership focusing on both population and individual need? We need a smaller part of the health and social care system to step back from the acute, noisy arena that is making the ‘Breaking News’ media slots and build space to plan more maturely what the components of a truly continuously improving system are. A system that is also less hesitant to consider the role of digital technology for convening and connecting people. A system that seeks to better tackle duplication in health service settings and the unintended waste it creates, whilst also moving towards a truer integration of health and social care - not just in structure but also in spirit.

We know COVID-19 is going to bring pain and major disruption, not just to those connected to the health service as patients, families and staff, but also to the economy and wider society. How we best emerge from this in six or twelve months’ time depends in part on how well we adopt the best innovations and changes to working practices and how we embrace our interconnectedness and interdependency to build a better health service, fit for the 21st century.