Innovating fast to save critically ill Covid patients

Like many regional hospitals, Warrington and Halton Teaching Hospitals NHS Trust (WHH) was close to being overwhelmed when the Covid-19 pandemic struck the UK. The trust comprises Warrington Hospital and Halton Hospital in Runcorn. A staff of 4,800 work across the two sites, providing access to care for a population of over 500,000 people.

In the Spring of 2020 there was an anticipated national shortage of intensive-therapy ventilators and the hospital had only 12 such machines. These breathing machines are highly intrusive and require the patient to be put under an anaesthetic in order for a breathing pipe to be inserted down the throat. There was little evidence that patients with Covid-19 had increased chances of recovery after ventilation, and in some cases this was as low as 50%. The mechanical ventilators meant a long and arduous journey back to recovery for Covid-19 survivors.

Facing the prospect of insufficient ventilators should the pandemic lead to excessively high numbers of critically ill patients, the WHH team had, in the words of Clinical Director of Medical Care Dr Mark Forrest, “to look and think ‘outside the box’ to do the best we could for our patients.”

 

Going back to ground zero

Realising from their experience and that of other hospitals around the world that the ventilators were not going to be the magic-bullet solution to Covid-19, the team of doctors, nurses and allied health professionals from multiple medical disciplines took the courageous decision, as Dr Forrest put it, “to start from ground zero” in responding to the pandemic.

The team had heard reports that engineering teams from Mercedes Formula One and doctors at University College Hospital in London were attempting to upgrade continuous positive airway pressure (CPAP) devices (known as ‘black boxes’) to treat Covid-19 patients. Also widely used to treat conditions causing significant breathing problems and low oxygen levels, CPAP therapy seemed to offer a less invasive treatment pathway before resorting to mechanical ventilation.

Led by Dr Forrest, Dr Mithun Murthy, (Consultant Respiratory Physician and Respiratory clinical lead) and Dr Saagar Patel (Consultant in Acute Medicine), the team of consultants and their respiratory colleagues realised early on that modified CPAP devices could prove a key tool in dealing with the Covid pandemic.

Unfortunately, as Dr Forrest recalled: “We ran into difficulties trying to source enough black box CPAP devices.” Undeterred, the critical care and respiratory teams looked at what was available and discovered that the Trust had a stock of community CPAP machines. The beauty of these devices was their simplicity, which is necessary because patients need to use them in their homes to treat sleep apnoea. The team therefore decided to modify these existing, basic community CPAP devices for high-flow oxygen use. This was simply done by changing the mask design and adding a filter that allowed the mask to supply oxygen. The team then tested the devices on themselves, using blood gas analysis to confirm the levels of oxygen being delivered into the lungs.

Initial results suggested the procedure was relatively safe; testing on patients in a controlled environment rapidly followed and the team was hugely delighted when the modified CPAP black box brought almost instant relief to Covid-19 patients suffering from extreme breathing difficulties. Most patients found breathing was quickly made much easier and their oxygen levels rose quickly (patients who did not oxygenate adequately after a few hours of treatment were escalated to intensive care for ventilation).

The black boxes were only used in a high-care area with full ICU-level monitoring and other critical-care facilities immediately available. Remarkably, during the first phase of the pandemic, no one had to be intubated through a failure of the machine, and there were no reported adverse events with their use.

Early treatment of Covid-19 patients not only meant lower mortality rates and less need for the more intrusive ventilators that were anyway in very short supply; the greatly improved recovery rate also meant significantly lower demand on hospital resources from treated patients.

Where bottom-up meets top-down

Implementing the innovation required cross-departmental collaboration where teams of doctors, nurses, physiotherapists and allied health professionals from the intensive care unit, the high-care respiratory ward and the cardiorespiratory team worked together for a common goal: overcoming the crisis.

Such was the success of the modified black box that the hospital had the lowest numbers of Covid-19 deaths in the north-west of England in the first wave of the pandemic, attracting international media attention. This included being the subject of a Sky News documentary (Coronavirus on the Front Line – ‘Hospital of Hope’) and winning a London Business School award for ‘Innovation in Adversity’ following a public vote in June 2020.

The innovation was remarkable for three reasons. First, the ‘bottom-up’ nature of the original innovation, which was developed at ultra-high speed by medics and physiotherapists in different areas who came together to create an entirely new pathway for treatment of Covid-19 patients, resulting in far fewer being put on ventilators and leading to significantly improved outcomes.

Second, it was a remarkable instance of ‘top-down’ management innovation on the part of the Trust (something rarely seen in the complex and bureaucratic nature of England’s NHS). This cleared a path through the usual administrative and financial burdens and gave the clinicians on the ground the freedom and ‘air cover’ to do what they knew was right.

Third, the speed with which technical specialists and engineers came together to adapt the CPAP at scale to be used in a different way highlighted innovation at its best. It was a case of an organisation overcoming deeply ingrained behaviours overnight, reconfiguring itself, and reallocating resources to address an impending crisis.

Dr Forrest described the (re)invention of the black box as “just doing our job”. Sometimes, innovation comes from a pure ‘eureka’ moment. At other times, sheer necessity is the mother to invention. A classic example of recombinant innovation – where new applications are invented by combining existing components and systems – the efforts of all involved at WHH also demonstrate that small innovations made locally by people “just doing their job” can make a huge difference to people’s lives. In this case, it saved them.