NI COVID - TRANSPLANT STORY
NI COVID-Transplant story
At the end of 2019, we heard of a viral infection in an unknown province of China. But very few had any idea just how this particular coronavirus was going to change the world, change our worlds, in 2020.
By March the health service in NI was preparing for treating the huge numbers that were anticipated would be infected. The transplant team recognised that continuing the kidney transplant programme was going to be impossible for two reasons. Firstly facilities such as theatres, wards, intensive care etc. would be recruited along with the associated staff to look after those with COVID-19 infection. Secondly since the risks of any infection are magnified by the obligatory transplant anti-rejection drugs (which suppress the immune system) it seemed foolish to consider transplanting in this setting. The final transplant took place on 18 March.
Across the UK organ donation and transplantation dramatically reduced; almost every kidney transplant unit closed though some heart, lung, and liver transplants (when the alternative for the patient was certain death) did take place. For this reason a young man in one of the local hospitals, who sadly was dying, was able to fulfil his wish and that of his family to become a donor, and give life to two patients also dying but of heart and liver disease. But there was no hospital in a position to transplant his kidneys. The Belfast team wondered…was there any possibility of being able to transform the lives of two patients in NI by transplanting these two kidneys?
By this stage the Belfast City Hospital (BCH) had been requisitioned as the Nightingale Hospital for NI, so the theatre suite was closed. No operation could take place there. Could we operate somewhere else? Emergency theatre provision was essential for non-COVID related disease, and for Belfast this was maintained in the Royal Victoria Hospital (RVH). This might be an option. However the transplant ward and staff were all in the BCH hospital (albeit relocated to a different level, with many of the nursing staff deployed elsewhere and fewer beds – since the transplant programme was closed!). So where and how could we look after these patients, even if we could do the operation? And if we could do the operation, and find somewhere to care for the patients, how could we ensure they could be safely followed-up? All out-patient facilities had closed, and what if they needed to have a second operation?
It seemed improbable that these issues could be resolved, or at the very least resolved in the tiny time-window of opportunity before these two kidneys would be buried. Improbable? Yes. Impossible? No.
In mid-April two kidney transplants were performed simultaneously in the RVH. Two patients received life-saving surgery with life-transforming impact for them and their families. This was the start of the new Royal Victoria Hospital Transplant Unit, which over the next 7.5 weeks became the busiest kidney transplant unit in the UK – carrying out a third of all the kidney transplants in the UK.
To achieve this number of transplants, 63 in this period, would have been incredible even in ‘normal’ circumstances. To do this in a hospital where there had never previously been a kidney transplant and in the midst of the exacting restrictions imposed by COIVD-19 precautions was herculean. One transplant was even undertaken in the Ulster Independent Clinic, with the staff willingly going out of their way to facilitate this when there was no capacity in the RVH. On 8 June the programme returned to the BCH hospital, with the surgeons then operating exclusively at night or weekends. A brutal regimen, but one that each embraced as the alternative was to deny a patient a transplant.
On a practical level, the success of this ‘story’ depended on a massive number of staff (medical, surgical, nursing, laboratory, clerical, managerial) being willing to think innovatively, work differently, take on new roles, and most importantly work collaboratively together. The anaesthetic, theatre and recovery teams readily adopted a whole new service. The current and retired transplant theatre nursing sisters in BCH were key in ensuring the relocation was successful. The Burns Unit in the RVH were willing, at short notice, to provide the immediate pre- and post-operative care for all the transplant patients, even though none had any experience of this previously. The BCH transplant nurses went willingly to work in RVH to support them and ensure the necessary expertise was available.
The staff in the transplant laboratory (H&I or ‘tissue typing’ lab) had adapted and taken on much of the COIVD testing for NI – since the transplant programme had been suspended. Then NI embarked on the busiest period ever in its history! They worked night and day for several weeks to serve our patients.
The post-operative and outpatient care also had to be adapted to the ‘new normal’. Rapid discharge planning (essential to minimise time in hospital) put much pressure on the ward staff, pharmacists, and outpatient teams. The pharmacists quickly modified their work so that there was always one of the specialist renal team working on Saturday and Sunday, and developed innovative approaches of educating supporting relatives too since none were allowed to visit. The out-patient staff also showed immense agility in changing practice – normal processes had to change to ensure social distancing (particularly crucial for this cohort of patients), typical numbers that could be seen were dramatically reduced, and all at a time when the volume of patients needing seen twice a week was increased 8-fold. For 3 months there was a weekend clinic which was essential to successful post-transplant care.
It is important to note that patients with COVID-19 disease are precluded from donating, so no organs are offered for transplantation from such patients. The temporary increase in availability of kidneys for NI patients, simply reflected the closure of other UK units to transplant because of the pandemic restrictions. It was anticipated that by opening in mid-April Belfast might have a 2-3 weeks head start. It turned out to be a 2-3 month period. Other units reopened one by one and by the final week in July when all were transplanting again, we had performed 101 deceased donor transplants in 101 days. Ordinarily we would expect 14 in that time period.
This was an unprecedented period for renal failure patients in NI. An extraordinary golden-transplant-COVID-cloud-lining. The transplant team, in its very broadest sense, were inspirational in its willingness and enthusiasm to adapt, innovate, and work exceptionally hard. In so doing it has serviced its people and fulfilled its purpose.