Uncertainty as the new normal: what we have learned from the COVID-19 pandemic so far - webcast

Sofie Smulders 15-11-2020

The COVID-19 crisis didn’t change our healthcare system, but the system has definitely been shaken. How do we cope with the uncertainty that the pandemic has brought into our lives? That was the main question for the panelists of webcast ‘High Value Care and Corona: Uncertainty as the New Normal'.

The webcast was chaired by Fenna Heyning, board member of the Linnean Initiative and co-hosted by Arie Franx, president of Linnean. Along with sharing personal experiences and bringing some comforting take home messages, panelists Richard Bohmer, Marcel Persad, Marian Verkerk, Hans Bart, Nienke Huijbregts, Hester Lingsma and Hans Bart tried to answer the question about uncertainty together.

Richard Bohmer: structure in order to deal with uncertainty

Keynote speaker of the webcast was Richard Bohmer, who currently works as a director of clinical leadership resources in London. Earlier this year, he helped to set up the Florence Nightingale ICU (also in London), which provided thousands of extra care beds in these difficult times within short notice. Bohmer shared which huge uncertainties, both operational and clinical, accompanied the challenge of setting up the Nightingale ICU. Recognizing this, Bohmer and his colleagues built a learning system to reduce the uncertainties as fast they could (from minute 04:29). The mechanisms within this closed learning system (fig. 1) used data, both from the bedside and external, for creating insight and responding to changes that had been detected at the bedside, as well as implementing proposed redesigns back to the bedside. Bohmer explained how this structure helped develop a daily rhythm for detecting things and making meaning of insights derived at the bedside and to rethink the approach clinically and operationally.

The learning system components and structure were created to
facilitate rapid analysis of internal and external experience of treating
Covid-19 and the implementation and assessment of changes. From start to finish,
discrete problems could be identified and addressed on a 24-hour
cycle.

(fig. 1. The Learning System at NHS Nightingale Hospital London. Bohmer, R., Shand, J., Allwood, D., Wragg, A., & Mountford, J. (2020). Learning Systems: Managing Uncertainty in the New Normal of Covid-19. Nejm Catalyst Innovations in Care Delivery, 10.1056/CAT.20.0318. https://doi.org/10.1056/CAT.20.0318)

From minute 12:18 Bohmer elaborates on how the Nightingale Hospital dealt with data: there were nine different data streams, both qualitative and quantitative, a bedside learning coordinator collected experiences from colleagues, information that was captured in a database. Next to that, they shared daily data and incident data with hospitals in England. “You've got to deliberately work to connect qualitative and quantitative data [...] and find patterns in those data. For that you need people to do that on a daily basis. The key insight is the integration of multiple data sources.” 

In addition, Bohmer answered the following questions from the online audience:

  • What have you learned on the implementation of new insights on the disease or the treatment and how can we use this to improve implementations in normality? (from minute 29:35);
  • Panelist Hester Lingsma asked: To what extent were the data reliable? (from minute 32:17);
  • How did you combine the local experiences and learnings with the output of that scientific team and how did you integrate that into one new policy? (from minute 33:27).

Marcel Persad: uncertainty from the patient perspective

To help us gain insight from the patient perspective, Marcel Persad shared his story. He has been a kidney patient for over 15 years. In March 2020 he tested positive for COVID-19, was hospitalized and admitted to the ICU for a week. Persad’s kidney transplantation, originally planned for late March, was postponed twice. The operation finally took place on 1 October. Persad is doing well now, but how has he been dealing with this extra uncertainty in his life? (from minute 35:00) You can find the full interview with Marcel Persad here, for a short version click here.

Marian Verkerk: loss of ontological security

Marian Verkerk, full professor of care ethics at University of Groningen, shared her thoughts on uncertainty in the exceptional situation that we are now in: “Maybe we should do something else with this uncertainty and insecurity, and that is trying to accept that life is uncertain. Not only at this moment, but it has always been uncertain. What we do in Western society is thinking that we can be in control, that society at the end of the day is a ‘Socially Engineered Society. With the crisis that we’re facing, we are losing what Anthony Giddens calls our ‘sense of ontological security’ [...] We have order, so we can predict our life.” (from minute 40:23)

Nienke Huijbregts: act today, but think about the near future  

Nienke Huijbregts, manager Trauma Centre South-West of the Netherlands, started off her story by addressing the importance of a pre-crisis built network. The trust between members of an already existing network is extremely powerful in crisis situations. Huijbregts is ultimately responsible for the staff office, and currently they’re working on 15 projects on chain alignment. During the crisis Huijbregts arranged the consultations on COVID healthcare, such as administrative consultations, ROAZ's (The Health Care Coalition for Acute Care) executive board and consultation with all hospital directors. In addition, team members consult with the tactical layer of all chain partners in the different sub-regions. They discuss how to deliver COVID care and to ensure that this does not come at the expense of regular care. Huijbregts has learned a lot from the military way of working. “It’s important to act for today, but also think about the near future. What’s the problem for two or three weeks? What can we do to keep ahead in this crisis?” (from minute 53:48)

Hester Lingsma: transparency about uncertainty

Hester Lingsma is head of the medical decision making group at Erasmus University. Her team developed a decision model to help prioritise surgeries. It estimates the amount of health loss that is caused by the delay of surgery. “As we deal tonight with uncertainty, working on this specific model and also the COVID-19 crisis in general, reminded me of that for many things we do in healthcare, there is little evidence that it improves patient outcomes. Doctors and patients make uncertain decisions all the time. The best thing that we can do is be transparent about that uncertainty.” (from minute 01:01:26)

Hans Bart: the role of the patient

Hans Bart, programme leader in outcome-based healthcare at Netherlands Patients Federation (PFN), discussed communication from the government and the much raised questions about leadership during this pandemic. Where does the patient come into the equation? During the first wave Bart noticed that it wasn’t at all obvious for the patient to be part of the process. The patient federation had to work hard and knock on doors to be taken into account in all the guidelines, black books, triage models etc. The situation in nursing homes is a good example: there was hardly any discussion with the residents about what they thought was important. Even today in the second wave, it’s very difficult to talk with residents and their relatives. Bart stresses that in the future, shared decision making must be more embedded in the care we provide with each other (from minute 01:11:44)

Should we advocate uncertainty as a value? Not all panelists agree with that final conclusion. We should embrace uncertainty, and at the same time work hard on reducing those parts of uncertainty that we can reduce. 

The full webcast is available on demand.

Value-based triage in relation to the OR

During the webcast, we received a question about the decision-aid model that was presented by Hester Lingsma. Please find a preliminary version of the tool here and the pre-print can be found at MedRXiV.

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