CUH has avoided the planned-for surge in Covid-19 cases, for now at least, but doctors’ concern for non-Covid patients has never diminished, writes
With the daily slew of statistics around the level of coronavirus infection almost relentlessly grim, some cheering news is emerging from Cork University Hospital (CUH) where just 33 staff have tested positive for Covid-19.
The number of confirmed cases among in-patients is stable at around 30, and the number in intensive care on any given day is staying constant at five or six. The hospital had planned for upwards of 100 in the ICU.
A number of outpatient clinics are resuming off-site this week, albeit on a reduced scale, among them Care of the Elderly, Rheumatology, Gastroenterology, and Respiratory Medicine.
Cancer surgery and cancer treatment is continuing, although some patients due to undergo chemotherapy are unable to do so because it weakens the immune system, which puts them at risk of Covid-19.
There are also concerns that patients who suffer minor strokes are not coming to hospital — the number of stroke attendances halved in the first few weeks of the pandemic, but these figures have now begun to improve.
Mary Horgan, consultant physician in infectious disease at CUH and president of The Royal College of Physicians of Ireland (RCPI), says good planning and fantastic public compliance with Government restrictions designed to limit the spread of the virus have fed into the hospital’s success.
“I’ve been on the last two weekends and it was so nice to see the number of positive tests markedly reduced for those people coming into the hospital.
At the weekend, there was just one positive case of someone who presented to the hospital, and in actual fact, they were known positive, so we were just re-swabbing them to see if they had cleared it.
Dr Horgan, who has more than 30 years experience in acute medicine and infectious disease, says she has “never seen anything like Covid-19”.
“I suppose why it is different is it doesn’t affect children, yet it affects everybody else.
“And while most people have no symptoms, or mild symptoms, others will get a lot sicker.
“If I looked at two [ostensibly healthy] 50-year-olds, I wouldn’t be able to say: ‘You are going to do really well and you are not going to do so well’.”
Dr Horgan doesn’t like what she has seen: “I’m doing this for 30 years and I can tell you after looking after patients - I would not like to get this infection.”
CUH has devised two separate patient pathways for Covid and non-Covid patients.
If there’s an index of suspicion, they go into the Covid pathway, where they are swabbed and isolated, and staff put on their PPE (no shortages at the moment).
Oxygen levels are monitored and once the test is back, they are treated accordingly.
Dr Horgan says most of those who are admitted require some level of breathing assistance. They usually have viral pneumonia.
“It’s a lack of oxygen that results from the viral pneumonia that gets a patient into trouble. The virus is gone down into their lungs.”
Some patients have ended up on ventilators, including some in their 30s. Some people recover quickly, others don’t.
As of the end of March, about one-third of those admitted had been discharged, Dr Horgan says.
"About 50% of those admitted are under the age of 60 “and otherwise healthy”.
The big question now, she said, was what the impact on the hospital system will be as restrictions are gradually lifted.
I think what we are going to be looking at in the health system is cranking up non-Covid activity again, so that we are giving care in the way we always have, as well as having a parallel life of Covid care delivery.
“We have to start planning for us to increase outpatient numbers, to ensure people come into hospitals when they are getting sick,” Dr Horgan says.
Her sentiments are echoed by CUH clinical lead for stroke services, Liam Healy and clinical lead for cancer services, Richard Bambury.
Dr Bambury, a consultant medical oncologist, says as of last weekend, there were 146 empty beds in the hospital.
Pre-Covid CUH was pretty much running “at max capacity”, “so in a way this [empty beds] is welcome, but this is an unusual situation”.
CUH has not made much use of private hospitals in the region — some acute medical patients have been transferred to the Mater Private, but no-one so far to the Bon Secours. Dr Bambury says there are “ongoing discussions”.
At CUH, they have worked to make the hospital as safe as possible for cancer patients, creating a separate entrance and triage area, swabbing any suspected cases, and if they test positive “we don’t recommend chemotherapy”.
This is because chemotherapy suppresses the immune system, which heightens the risk to cancer patients in the event of Covid-19.
“The risk:benefit ratio in some situations has changed. For some, the risk might outweigh the benefits so if alternative therapy is available we are looking at that.
"It’s a case-by-case decision.”
Alternative treatments include the use of hormone therapy in treating prostate cancer.
Postponing treatment where it is safe to do so is another. For those on annual check-ups or who are in remission, their appointments can be postponed for a month or two until the Covid situation stabilises, Dr Bambury says.
There’s been “some decrease in non-urgent activity to reduce the footfall and help with social distancing”, Dr Bambury says — but in saying that, in the past six weeks they have 200 new patients on radiotherapy and 50 on chemotherapy.
Rapid assessment clinics for anyone with a high suspicion of cancer are continuing.
On Ward 3B, Dr Healy, consultant geriatrician, is happy to see they are “nearly back to the normal cohort” of around 25-30 stroke patients, after seeing figures halve, dropping back to 10 or 15, in the early days of the pandemic.
I suppose the general message has been one should not come to hospital unless one absolutely needs to - but there are some conditions, like stroke, whereby if someone’s having symptoms, the only right thing to do is come in as quickly as you possibly can.
There’s a worry, he says, that people with a minor stroke may have stayed away, “but there’s plenty we can do for them in terms of optimising their treatment, or seeing if it’s something we can reverse," Dr Healy says.
They’ve had no Covid-19 staffing issues on his ward and very few patients affected by Covid-19, even though some of the early indications in this outbreak were that a higher percentage of people with the virus would have strokes.
“There’s not a case that I can think of whereby we’ve had a stroke patient who’s been disenfranchised by it or has had any kind of problems because of Covid-19,” he says.
Consultant geriatrician at CUH, Paul Gallagher, is playing a role in the care of Covid patients in residential care facilities.
They have set up four teams to cover Cork and Kerry, each with senior nurses, and led by a geriatrician.
They are taking calls from care homes in the community - of which there are c100 in the region - and giving expert advice and guidance.
In some cases there are site visits to assist with care on the ground, for example at Clonakilty Community Hospital where there has been an outbreak and, tragically, a number of deaths.
Dr Gallagher says some elderly people have typical Covid symptoms, but others have atypical symptoms, “such as a tummy upset, as well as fever and shortness of breath”.
Within CUH itself, the number of Covid patients he sees remains stable, “which has allowed us to manage it in a more planned way”.
“We had planned for upwards of 100 in ICU, that hasn’t happened at all.”
Dr Gallagher resumed his outpatient clinic for Care of the Elderly this week, albeit a scaled-down version.
The clinic is being run off-site on Model Farm Road.
“At the moment, we are seeing urgent new referrals.
"Hopefully it will ramp up, but we have to be very cautious. Appointments will be staggered and time allowed between appointments to clean the rooms, for protection of patients and staff”.
As CUH looks to returning to a more “normal” service, the medics do have certain concerns.
As Dr Gallagher points out, the fear now is of “a non-Covid surge”.
“If people who need it don’t seek treatment now, the risk is that we will be overwhelmed down the line.”
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