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Discharging patients with Covid 19: A&E Covid 19 Story Week 4

Week 4: The Logistical Issues of Discharging Patients with Covid 19

This week marks the start of finishing my supernumerary time. I start the shift in majors where I get a steady flow of patients. It’s a fairly quiet day in ED. One of the first tasks I’m given is working out how to discharge a homeless patient who is suspected to have Covid. I initially thought  ‘oh thats easy i’ll just follow the usual guidelines on discharging homeless people’ and then realised, as the patient had Covid, I actually had quite a complex logistical problem to deal with. The worst part of discharging patients with Covid being as this is such a novel issue facing the health service, not many people knew what to do either! 

Uncertainty

The hospitals are understandably doing everything they can to avoid unnecessary admissions so I didn’t have the option of admitting the patient overnight until social services could support them in finding somewhere to go. The homeless team weren’t working as it was a bank holiday and the patient didn’t have anywhere safe to go to self isolate for 7 days.

The patient had been in the emergency department for a few hours already and the managers didn’t want them to ‘breach’.

A breach is when a patient stays in A&E longer than the government target of 4 hours. The waiting times count towards the performance of the trust. Hospital trusts face fines if they have long or a large number of breaches. Subsequently, they must always give a reason for a breach. This could be ‘waiting for a ward bed’. Additionally, it could also be a ‘clinical breach’. This would apply if the patients current condition was not stable enough for them to be safely transferred. A breach could also be caused by waiting for ambulance transport to pick them up. Similarly, it could be caused by awaiting a specialist team to review (ie surgical/gynea) for admission or discharge.

Avoiding Breaches

To safely discharge this patient and to avoid a breach, I ended up liaising with a temporary service that had been set up in London. This was to to provide accommodation for homeless people who need to self isolate. 

Another issue that has been increasingly difficult to manage due to Covid is organising transportation home to discharge patients. Many patients who initially present with Covid symptoms, are clinically stable and therefore have no requirements to be in hospital. They then need discharging, to ensure there are free hospital beds for those who need them.

Ambulance Transport

Patients often take public transport or perhaps call an ambulance to come into hospital. Medical and nursing staff then face the logistical issue of discharging patients with covid. If we suspect the patients may have covid it would be socially irresponsible to let them travel home on public transport. This is because this of the risk of transmission to the other people who are using it. Many people in London rely on public transport and may not drive/know someone who owns a car. It then means nurses are involved in many phone calls and time consuming administration involving calling up patients family members and asking if they can collect their relative. Quite often people are very reluctant to do so. However, the hospital gives all patients a mask when entering the department to minimise this risk of spreading Covid 19.

If patients do not have anyone to pick them up the only option left is booking ambulance transport for them. However this isn’t ideal as ambulance services are seeing an increase in calls and are having to factor in diverts.

Diverts

Diverts are put in place when an emergency department has an unmanageable amount of patients and is at full capacity. When this happens, the ambulances divert all patients to a different hospital. Initially this is for an hour but is needs reviewing hourly with the view of stopping as soon as able. Diverts can lead to paramedics driving longer distances with patients. I imagine this can subsequently cause delays in care and longer waits for ambulances/a backlog of patients. With this in mind calling ambulance transport to take someone, who would usually be able to take public transport home, is awkward and difficult. It also means that since the transportation of stable patients is not a priority, there can be long waits to get them home.

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