Cardiac surgery cannot wait

Dr Shelley Rahman Haley
By Dr Shelley Rahman Haley     26/03/2021

Despite the global pandemic, we have still been performing heart surgery at Royal Brompton and Harefield hospitals over the past year, as it is vital that cardiac patients, especially urgent cases, get the treatment that they need.

People haven’t stopped having heart attacks and people are still living with serious heart conditions that require urgent attention to prevent permanent damage. So how have we made sure, in the midst of a pandemic, that the right treatment gets to the right patients at the right time?

One year ago, during the first wave of Covid-19, we set up the cardiac hub multi-disciplinary team meeting – where clinicians from hospitals across London and the South East came together via a virtual platform, such as Zoom or Microsoft Teams, to review patients and decide who most needs urgent treatment. At the start of January 2021, we reopened the cardiac hub during the second surge of Covid-19 so that as many patients as possible could be treated – not only emergency cases. If someone needs cardiac surgery, it can’t wait!

Prioritising the sickest patients

The first step in the cardiac hub is a daily virtual multi-disciplinary team meeting of surgeons, consultants and radiologists, where individual patients from a number of hospitals are discussed and we collectively decide the clinical priority for each one. I chair the meeting with Mr Mario Petrou, cross-site co-lead cardiac surgeon. Having so many experienced clinicians in one ‘room’ can inevitably give rise to differences of opinion, but as I’m not a surgeon, I am able to be a neutral voice when weighing up the clinical details in order to decide who needs surgery in the next few days, and who can wait longer. Of course, I am guided predominantly by the opinion of the surgical team who know the patient well. 

Time is an important currency for patients with critical conditions, and the cardiac hub process helps to clarify who needs treatment and when. We have to juggle those who need surgery in the coming days and weeks, with those patients that need to be seen within the next three months. As many of our intensive care beds have been dedicated to caring for Covid patients, we have been able to operate on far fewer patients daily than would normally be the case – after heart surgery, many patients need to stay in hospital and be cared for and monitored by specialist intensive care staff for a few days or sometimes weeks, if there are no intensive care beds available then their surgery can’t take place. However, since Christmas we have already carried out over 150 cardiac procedures.

Those patients who are most at risk are scheduled to have surgery within the next 14 days. But how do we ensure their surgery is ‘Covid secure’? Well, when patients arrive the first thing we do is test them for Covid-19 and then we make sure they are kept apart from other patients in their own room, for their safety and ours. If they are Covid negative they can enter something called the amber pathway, meaning we try to limit the amount of people with whom they come into contact. They can have their surgery as soon as 24 or 48 hours later. If, unfortunately, patients are positive at this stage, they enter the red pathway and wait two weeks, away from other patients, or until they have had two negative tests, before their surgery can go ahead. Of course, none of this would be possible without people like our patient pathway manager, Debbie Martin, and our wonderful fitness for surgery nursing team.

Heart surgery during a pandemic is risky, but sometimes the risk to patients of doing nothing is worse, and we must make difficult choices. This way of working, where surgeons work with and take on work from other surgeons in a real collegiate manner, showcases the best of the NHS. It’s a fantastic initiative to have come out of such awful circumstances.

Practising medicine in a virtual world

Covid-19 has not only transformed how we interact with our colleagues across hospitals; it has changed how we interact with our patients too. For example, we are using an app – Medopad – to encourage patients to report their symptoms to us from home, in real time, through their phone. It is a simple but brilliant piece of technology that allows clinical teams to keep track of how patients are doing – who is OK and who is deteriorating. I urge every patient and hospital to use it. We also have a fitness for surgery team responsible for checking in on patients to see how they are and if their symptoms have changed or worsened.          

Of course, it can be hard getting people to come to hospital and report their symptoms in the first place – in part I fear because they do not want to ‘overwhelm’ the NHS, which they believe is already stretched due to Covid-19 – so by the time they do seek medical help their symptoms and condition are much worse. I’ve seen some unbelievable things during this pandemic, complications from heart attacks that should have been treated within an hour of chest pain starting but have been left three or four days because people just aren’t calling 999. Holes in the heart that develop after a heart attack should be rare, but we’re seeing them on an unprecedented scale because of these delays.

All doctors advocate for their patients and right now the way we are doing that is through the daily team meetings of the cardiac hub, where we figure out who to operate on next.  But the best advice I can give to you is to tell you that if you experience chest pain; don’t ignore it. By asking us for help, you will not be “overwhelming the NHS” – you will be ensuring that you get treated before irreversible damage is done to your heart!