Jonathon Dean, Critical Care Hub doctor from Barts Health NHS Trust, is a member of the North East London Critical Care Hub, a group created in response to COVID. Here, he explains how using real-time data is facilitating the crisis management of this new disease.
When an era-defining paradigm shift takes place, real-world data supplants established understanding; with the arrival of COVID, much of what we had considered reliable knowledge became outdated overnight.
When the pandemic hit in 2020, long-standing norms in nearly every sector toppled, leaving behind a void of normalcy: industry, healthcare, supply chains, hospitality, travel, education – even how we as human beings interact with each other.
As we seemingly now enter a third wave of infection while we also prepare for an almost inevitable surge in cases over the winter, I wanted to look back and examine how real-world data in healthcare came to the forefront with the arrival of a wholly new disease.
Overwhelming doses of fresh evidence
The rapidity of data collection and sharing was a major component of the response to COVID. Open access, pre-print papers published prior to peer review were a double-edged sword; cutting edge research and observational studies at the beginning of 2020 helped inform healthcare systems around the world, but also gave a megaphone to conspiracy theories and unproven therapeutics.
With the deluge of information surrounding the pandemic came the need for a single source of truth, and there were no previous pathways or predictions available for this entirely new disease. Ancillary and tangential pathways dealing with everything from diagnostics, elective surgeries, patient flow and medicines, to hospital visitors, staffing, telemedicine and discharge were upended as they did not yet account for the pervasive impediments imposed by this virus.
For affected patients, early clinical strategies leaned heavily on existing archetypes, from early intubation to hypoxia intolerance. We now know that these were misguided. The pathological Semmelweis reflex (a tendency to reject new evidence or knowledge because it contradicts established norms) found ingrained in some political and healthcare systems could only be treated with overwhelming doses of fresh evidence.
Comprehensive snapshots of critical care capacity
We created the North East London Critical Care Hub to integrate care between trusts within the region and facilitate surge planning, decompression (supporting teams to reduce pressure in the system), redeployment and capacity management.
As part of its role, the hub collects a daily snapshot of the capacity and burden of intensive care units across the sector and uses it to plan mutual aid and decompression services. We receive information about the number of patients, the breakdown of their acuities and COVID statuses and the impact of any high occupancy levels. For example, we may be informed that a site is planning on canceling elective surgeries or requesting an ambulance divert as a result of its current intensive care pressures.
Designing the North East London Critical Care Transfer and Retrieval service
As a result of this real-world-data, it was possible to also make a case for a critical care transfer and retrieval service for the region to aid in decompressing overwhelmed sites, based on the network plan of using the Royal London Hospital as a surge facility.
We used it to develop NECCTAR, the North East London Critical Care Transfer And Retrieval service, in under 80 days from concept to launch. This included designing the framework, governance, working group, standard operating procedures, mandate, funding, clinical supervision, training, and the logistical and IT infrastructure. This was breakneck speed in NHS time and a dedicated core of project officers donated their valuable time to launching this essential service in conjunction with an NHS England paper on acute workforce models that highlights the role of critical care transfer services.
At the height of the second wave, we collected daily real-time data and we are currently collating it three times a week. This allows us to predict demand for COVID critical care versus non-COVID beds for those on an elective pathway.
We are now in an excellent position to scale up the service in any future capacity crisis, maintaining the skills we and the transfer teams need.
The importance of data analysis
The Health Economics Unit (HEU) helped us to develop heat maps and risk analysis scores for how likely patients were to survive transfer and any deterioration after transfer, comparing outcomes data where possible, which had not been done at scale before.
The team also helped ensure our databases captured all the fields needed early on. Having an analyst support us from the start meant that we were able to collect the right data, quickly and accurately, enabling us to calculate what the trends look like and even anticipate our needs for COVID specialty stocks and manage our procurement dates.
We saw the value of formalising transfers very quickly, with a reduction in related critical incidents, and it would be impossible for us to go back to that way of working, which involved calling randomly on the doctors and nurses who were available and pulling ambulances out of the operational pool.
Without real-world data, the critical care hub would be working in a highly reactive manner, attempting to catch up to the latest developments rather than proactively moving to decompress a situation before it becomes unsafe. Instead, we now receive a regular flow of information about the sickest patients in the region and this information is processed, analysed, and discussed locally to agree patient movements, load-balancing and safety.
Moving forwards
NECCTAR continues to move patients on a daily basis and decisions on who to move and where to move them to are based on real-world data.
The service is becoming increasingly embedded as part of sector resources as we move forwards, with procedures and pathways in place for us to be more proactive. We also have the opportunity to implement learning before we face another crisis.
We are currently working on the governance for the service to support not just decompression around COVID but also complex patients such as those with head injuries or burns, as other teams become more aware of our capabilities.
NECCTAR is a truly integrated service working across three acute hospitals plus the London Ambulance Service NHS Trust, NHS England and NHS Improvement London and training bodies for doctors. It is jointly funded and accountable to the sector rather than an individual trust.
We’re working with HEU on a business case for mainstream commissioning of the service into the future and we very much hope our experience using real-world data to make a real difference to critical care within the NHS will lead others to learn from our experience and follow our example.
For more information, follow the NECCTAR team on Twitter.