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Nursing

A&E Covid 19 Story Week 10

Covid-19 and BAME Inequality.

Previously, I have talked about the gender inequalities that wearing scrubs has exposed within the healthcare system. This weeks post there will be a wider focus on Covid-19 and BAME inequality. 

Recently, the murder of George Floyd, a 47 year old Black man, has been brought to the attention of the public eye. Footage has been shared of the (now charged) police officer kneeling on George’s neck. This happened for 9 minutes, whilst he begged for his life and can be heard saying “I can’t breathe”. This event lead to the murder of the 47 year old. This tragic death is an unforgivable casualty of police brutality and systematic racism.

A Subject People Find Difficult to Address

Firstly, it is undoubtably a difficult subject to address. It is extremely important to talk about, regardless of how uncomfortable it may be. Secondly, its important to address the leading voices on the matter Alicia Garza, Patrisse Cullors and Opal Tometi (Founders of the Black Lives Matter movement). Finally, I can only speak from my own expertise and experiences. Therefore, I wanted to make this next post about something I am very familiar with. Concluding this, this post will be (as you might have guessed) about Covid 19!

Covid-19 and BAME Britons

This week I would like to talk about how BAME Britons have a disproportionate mortality rate from this virus. This is twice the risk of death according to the ONS. This is a health inequality that needs addressing.

Whilst we are in the middle of the pandemic with a virus that has many victims (including young and usually health people) many people seem to think its unimportant to focus on specifics such as who is more affected. However, as the affects of the virus have unrolled across the UK, it has become ever more pressingly apparent that people from ethnic minority backgrounds are disproportionately dying from the Corona Virus. Out of the 200 health workers who have died in the UK from Covid 19, 60% of the people were BAME.

It has never been more important to collect, study and distribute the findings from a health crisis. To look into who is disproportionately affected by it and what we can do to minimise this public health inequality. In summary It is not ok to place unequal value on the lives that have been lost during this pandemic and its time we addressed it. 

On the 10th May there were calls for a public enquiry into this issue. 70 public figures (including London Mayor Sadiq Khan) signed a letter to the Prime Minister demanding transparency into this matter. Public Inquiry’s are important for safety, education and can lay foundations for future policy makers and research. An inquiry could help employers make appropriate allocation decisions based upon risk assessments increased safety for staff.

Risk assessment for BAME NHS staff

Gal-dem.com outlines excellently why there is a need for an independent public inquiry into this.

Moving on from the public inquiry, here are other recent and relevant pieces of news.

Firstly the first news story I will mention is, The tragic death of Belly Mujinga. A woman who lost her life 2 weeks after being spat on by a man claiming he had the Corona Virus whilst working her essential role at London Victoria station. 

Additionally, The tragic death of Trevor Belle a 61 year old taxi driver who died 3 weeks after being spat at by one of his passengers.

What you can do

Firstly, for people living in London who want to support communities in the capital.

Similarly, for people who want to volunteer:

Moreover, if you can donate money to support memorial services for BAME families, bereaved because of Covid-19

Additionally, if you can sign a petition supporting a public inquiry into BAME loss of life to Covid:

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Nursing

Post Covid Complications: A&E Covid 19 story Week 9

This week I will be addressing post Covid complications. I think I looked after the first (known) patient at my hospital with post viral delirium due to Covid. It was a rather scary experience as the patient, who will remain anonymous, was usually healthy/non-elderly. Delirium is a dangerous condition in which a persons mental state is altered. This means people can be confused, disorientated, aggressive, restless, incoherent and/or unengaged. Delirium can be due to infection, sepsis and pain. It can also be from other reasons like hypoxia, recent extubation etc. Despite the cause, it is most likely always a sign someone is unwell.

In this particular situation, the patient was experiencing delirium as a viral complication due to a previous infection of the Corona Virus. Delirium is very serious and it can lead to an increase in the chance of mortality. It can also mean patients hurt themselves and do not tolerate treatment interventions they desperately need, such as cannulas, IV fluids, IV antibiotics and oxygen that they may need to reverse the delirium! My patient was being violent, throwing things around the room, trying to turn on the defibrillator in the room and spitting at staff. They needed to be sedated in best interest i.e. for cooperation in care so they were not a danger to themselves and would tolerate the treatment.

More Post Covid Complications

Other post covid complications I have noticed is many patients attending the emergency department with chest pain. When this happens the patient has blood tests, ECGs and chest Xrays (the appropriate investigations). If diagnostic test results show the persons life isn’t in danger from things like an MI (heart attack) or a PE (blood clot in the lungs) or severe sepsis/pneumonia/covid etc affecting the body; and the persons observations are stable i.e. oxygen saturation levels adequate without supplementary oxygen, then the person will be discharged. The doctors inform these people, who experienced Covid a few weeks/months ago that they are experiencing pain from the effects Covid has had on their lungs and it could take weeks to months to resolve. 

I have also encountered many patients who are experiencing Covid 19 symptoms saying ‘do you get many people with Covid in this hospital?’, and are worried about catching it in hospital when it is most likely they already have it. Many patients are also wearing gloves, touching their phone, using public transport and touching their face with the same gloves. Thus causing much cross contamination. The importance of following guidelines such as hand-hygiene is important to note here for infection prevention and control.

Innovation within the NHS

Covid has necessitated a lot of innovation within the NHS. Rapid Covid test swabs are one of the newest pieces of innovation I was excited to see rolled out. A limited number of these are now available in some A&Es for testing for patients who fit a tight criteria. For example, for patients who are at risk of becoming particularly unwell from the Corona Virus and need to be ‘shielded’ from Covid in hospital. This includes people who are immunocompromised, have diabetes or may be on chemotherapy.

Ideally, these patients need to be in a ‘non covid area’. The difficulty lies when these people need to be admitted to wards. However, they have presented with symptoms in which Covid cannot be ruled out as the cause of their illness. They also could have post covid complications. Therefore these people cannot go to wards where they could potentially pass Covid 19 onto other people. There is also a limited number of side rooms available in the hospitals as most of them are already occupied by similar patients.

Testing

The Rapid Covid swab machine technology is helpful here. As it results in 1 hour, it can dictate if patients are suitable to go to a Covid/Non-Covid area. This saves from breaches in A&E. (Find out what a breach is here)

There has also been the opportunity to have asymptomatic testing for all patient facing staff in the trust. Thus, allowing data collection on Covid 19 prevalence among healthcare staff without symptoms. This means preventing staff working with high risk patients such as on chemotherapy/cancer wards unknowingly spreading Covid to vulnerable patients. If any of the asymptomatic staff test positive for Covid they are to follow self isolation protocols as usual. There is also the opportunity for me to take part in a vaccine trial if I wanted to! I am not taking part in this trial however I am excited to hear more about it. Especially since it is beginning to look like social distancing will continue until a vaccine is found. So I am very much hoping there will be scientific advancements regarding vaccines quickly!

Antibody Testing

Antibody tests are another thing I am eager to try. I had Covid symptoms in early February. However this was before it was prevalent in the UK and I really want to know if I have had the Corona Virus or not as knowing this would make me feel less worried about catching Covid at work.

In conclusion, as we approach the 10th weekly #ClapforCarers this Thursday I think it is important to reflect on what the NHS has achieved during these times. I have seen an incredible amount of innovation and change in the past few months and I am incredibly in awe of everyone who made it happen and adapted to it so well.

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Nursing

Scrubs and Inequality: A&E Covid 19 Story Week 8

Week 8: Scrubs and the Inequality Beneath

Today I am going to address something that has come to light due to Covid 19 which I believe deserves addressing, scrubs and inequality.

If you ask people who work in healthcare if they enjoy wearing scrubs, the majority of nurses (myself included) would say they prefer scrubs to the usual uniform as they are far comfier. Historically people adopted scrubs as they began to realise the importance of a clean surgical environment. Since then, in England it is my understanding that most nurses wear a uniform. The exception to this would be surgical/recovery nurses and nurses in some emergency departments. However, due to the Covid 19 pandemic most staff members who work in hospitals are now wearing scrubs. This is for infection prevention and control reasons – to prevent staff members bringing the harmful virus particles home and on public transport on their clothes. 

Pre-Covid-19

In a time before Covid, nurses, physios, health care assistants, domestics and porters wore a uniform whilst doctors seemed to be the exception to this rule. It seems doctors had the choice between wearing their own (smart) clothes or scrubs. This means doctors wear suits/dresses or ‘professional’ clothes whilst working on a ward, despite having contact with bodily fluids.

Whilst there is the argument there to say that doctors are involved in less direct patient contact than the nurses; it does not explain why it is suitable for a doctor to do a rectal exam in a suit with a thin plastic apron on whilst the nurses who hold clinics or research studies are still required to wear a uniform.

Guidelines

The Department of Health published guidelines known as the ‘bare below the elbow’ guidance. It also outlines the three objectives when it comes to what health care professionals should wear. To summarise these are: Patient safety (ie infection prevention and control), Public confidence (clean/professional workwear) and Staff comfort (I.e., cultural practises). Reviewing this guidance, I cannot see any reason there should be differences between what doctors and nurses should wear whilst at work. 

Now I may be mistaken here, but I believe the contradictions present in these rules date back to a time, pre Florence Nightingale. A time when doctors were the Professional staff members who held a degree and nursing was an uneducated profession. Hippocrates who is widely regarded as the father of western medicine, claimed doctors should be “clean in person [and] well dressed”.

I believe that due to nursing being a ‘pink collar’ job i.e. a profession held mostly by females (89% in the UK) there is a long withstanding lack of respect and recognition for the level of education and professionalism required nowadays in the nursing profession. 

Hierarchy

Sadly, there is a very intense hierarchy present in healthcare. Anyone who doesn’t work in healthcare probably couldn’t grasp just how tangible that hierarchy feels sometimes. I have seen some people disregard people in job positions such as health care assistants, domestics and student nurses. I was actively terrified of doctors when I was a student nurse which I now realise was ridiculous. Obviously, most organised workforces involve a hierarchical structure. However, this is a problem when it means people feel that they are less important than others. I find uniforms to be an important reflection of hierarchy. 

What about now?

Nowadays, an RN requires a Bachelors degree. Additionally, nurses register to a professional body, the NMC. The discipline of nursing also encompasses many advanced roles such as Advanced Nurse Practitioner’s and specialities i.e. Heart Failure Nurse. Many of these professionals take an active roles in the Medical team. They often prescribe, advise and consult – skills attributed historically solely to doctors. Many nurses also take on a senior roles in the hospital and community settings as matrons, managers and coordinators etc. So, yes it did raise a bone of contention when I saw an Advanced Nurse Practitioner wearing a uniform whilst the doctor holding the same clinic in the room next door did not. This prompted me to write this post – scrubs and inequality.

Going back to the present day, everyone, despite their role is wearing scrubs. Whilst this is more confusing and this practice will not last, I think we can all learn a lesson from this. Nurses and Doctors deserve equality in their uniform or non uniform policies. 

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Nursing

A&E Covid 19 Story Week 7

Changes to the NHS

This week I have noticed firsthand some of the changes to the NHS that Covid has brought about. Firstly, for most of the week I have been working with the non covid patients who come into A&E. These are the patients who present to A&E with no Covid/respiratory symptoms or temperatures and signs of infection. These people are triaged straight to the non covid side of the department. 

These patients have been steadily increasing in number over the past few weeks. Whereas when lockdown started, perhaps due to the #stayhome (or now #stayalert) message being promoted to the public, there were very few patients coming in. However the illnesses and accidents requiring emergency care such as heart attacks, strokes and mechanical injuries are still happening. This lead to NHS England’s Medical Director making a public announcement. He encouraged people to attend the emergency department when needed.

During this period, as Covid patient attendances decrease and non covid patients increase in numbers, there is an uncertainty of how A&Es and wards across the country need to change and adapt again. This would be to ensure minimal cross contamination so inpatients aren’t put at risk of catching the Corona Virus.

To adapt to the pandemic hospitals are changing to have Covid and non covid areas. I.e. there may be a ‘Covid ITU’ where the normal Intensive Care Unit is situated and a ‘non covid ITU’ in i.e. a theatre recovery area.

Patient Flow

As the patient numbers are changing week by week it has thrown many things into question. For example, if the designated areas can now fit the size of the population they are treating. It is also a tricky problem to solve. This is because after having people with Covid in, these areas will need to be kept empty long enough to be extensively cleaned. This is so it would be safe for the non covid patients.

The intensive cleaning involves many steps. Firstly, removing and replacing the curtains. Then, wiping down all surfaces and walls with disinfectant and disposing of any items left in the room. This is usually unused ECG stickers, unopened cannula packets and untouched dressings. Additionally, if these areas were switched back too quickly to ‘clean’ spaces, it might mean there wouldn’t be enough spaces to treat the Covid patients if the prevalence of Covid hospital admissions spike again.

Accident & Emergency

Where I work in A&E, the changes to the NHS are very visible as the entire department has been rearranged. The non Covid majors patients are treated in the small cubicles that under normal circumstances are used for minor injuries. For example, used for people who need stitches, casts, and wounds dressings. These cubicles are not as big as the standard majors cubicles. These are equipped with a cardiac monitor, a trolley and a patient table.

The nurses looking after the Non Covid Majors patients have to work in a small number of cramped clinic rooms that weren’t designed for majors patients. The environment feels overcrowded and chaotic. For example, it makes simple tasks like getting a hospital bed into the room, difficult due to space. Someone may require a hospital bed in A&E due to being in a wheelchair and not being able to transfer to the height of a hospital trolley or requiring a bariatric bed as the A&E trolleys would not fit these patients.

Redeployment

Additionally, another change the NHS has had to adopt is the mass redeployment of staff. Services like childrens ED’s and speciality clinics are getting relocated. I personally know a lot of stroke and paedeatric nurses who have been told at a few days notice that they will now work at a completely different hospital. This is miles away from where they currently work. This has meant lots of staff have had to sort out temporary accomodation. Staff in management roles have had to leave half way through their current projects/workloads for inductions at totally new trusts.

Redeployment is not always as easy as it sounds. For many, it means going through the stress and hassle of learning new IT systems, acquiring new access badges and getting to know a totally new site or even job role. It means teams who know each other well being pulled apart and has left nurses unsure of what they are allowed to do in their new role specification. (The RCN has a useful advice page if you are going through redeployment here). 

Redeployment has meant the relocation of many specialist nurses and doctors. A lot of whom were about to commence/were mid way through training for a speciality role. They have been since asked to move to places such as emergency departments and ITU’s to support the staff with the projected strain on the NHS that Covid was thought to bring. A close family member of mine, who usually runs a podiatry clinic, has been supporting the district nurses. She has been taking some of their visits to change dressings and give medication. Although this has been difficult and a lot to get used to, she also reports it has been a refreshing change from the usual workload!

Teamwork

The feeling of teamwork and the liberation of being able to ‘pull out all the stops’ to support frontline services has been quite incredible to behold. It has been very useful to have extra staff around to help out when needed and I have felt very supported by this.

Sadly though, the cost of this short term relief has been great. Elective theatre lists have been placed on hold which has left patients with cancer waiting for their operations. It has meant, patients with osteoarthritis that stop them walking have been in debilitating pain. These are just two examples of the people that will have their lives affected by the changes to the NHS and the measures necessary to ensure the NHS would be able to cope with the Corona Virus. Post Covid there will need to be changes brought about to control the after affects of this pandemic, such as an increase in theatre capacity to clear the now massive backlog of theatre waiting lists.

Concluding

This post was not intended to be overly negative and cynical, only realistic and reflective. Whilst this has been a time of great tragedy and suffering, which we must not forget, there are also many things to be thankful for this week. For example, passing the peak of the Corona Virus and the relieving of some lockdown measures. I am extremely proud of my colleagues, friends and family members who have all acted and continue to act so bravely. I know my parents, like many around the world, have been so worried about me, themselves and the people they love of course, and they continue acting bravely. 

There have been large amounts of support available at work. A wellness centre to came to visit with socially distanced activities such as yoga and group support sessions. I have also had a therapist visit the department and taken part in a mindfulness session. Myself and other staff found it to be very stress relieving. 

Its easy to feel overwhelmed at the prospect of facing more long term social distancing, increasingly difficult working conditions. Especially as more changes happen to the NHS and there is a rapid crumbling of summer plans. However the mantra of taking it ‘one day at a time’ helps me here! I hope it helps others too. 

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Nursing

Covid 19 FAQs: A&E Covid 19 Story Week 6

Week 6: Covid 19 FAQs and Myth-busting

Due to the amount of questions people ask me on a day to day basis, I have put together some Covid-19 FAQs.

Do you get a lot of people in the Emergency Department with Coronavirus?

This is classic question for Covid 19 FAQs. Yes. A large number of people who come into the emergency department right now may/have the Corona Virus. Everyone who presents with respiratory symptoms i.e. shortness of breath/cough/low oxygen saturations or fever are triaged as “suspected Covid”. These people are moved to isolation in separate cubicles in the ‘Covid’ side of ED.

What happens when an ambulance calls through a priority call for a covid patient

The Resus lead selects a ‘Covid Resus’ cubicl for the patient to go into. The ambulance crew communicate the CAD sign over the phone so the ambulance can be seen as a priority at the ambulance bay. This is incase there is a queue (of other ambulances). At least one doctor and one nurse prepare in ‘full’ PPE. This includes: Gloves, a long sleeved surgical/fluid resistant blue gown, (plus a normal plastic apron if the gown is not fluid resistant) a surgical cap, a FPP3 mask, a visor and then another pair of gloves where the opening of the gloves are taped down to the gown. 

What is PPE?

Personal Protective Equipment. PPE embodies masks, gloves, aprons, visors, and long sleeved gowns to protect staff members from contracting dangerous pathogens and virus’ such as the ones responsible for Covid 19, Hepatitis, HIV or TB. PPE also protects staff from harmful or offensive substances i.e. vomit, urine and blood. 

When do you use PPE?

Where I work mask’s are worn at all times when in the department. Gloves, apron and protective eye gear such as goggles/visor are used when interacting/caring for a patient (this could include recording observations or giving medication, taking bloods etc). When engaging in an aerosol generating procedure (AGP) such as swabbing a patient or ventilation we have to wear full PPE which consists of a long sleeved fluid resistant surgical gown, a surgical cap (which is basically a hairnet), two pairs of gloves, a visor and an FPP3 mask.

What is an AGP?

As mentioned above, an AGP is an ‘Aerosol Generating Procedure’. It is an activity that generates droplet particles that could transmit Covid such as CPAP or swabbing a patient with covid, the Resuscitation Council UK have stated they are as yet unsure if CPR is a AGP. The poster I have attached is useful for healthcare professionals who are unsure about resus scenarios regarding covid.

Why do people wear different types of PPE?

People employed in different professions and trusts have different PPE policies that seem to have been developed due to supply and what the professional may come across in their role. For example, many paramedics wear hazmat suits due to the potential exposure to a variety of things during a call. A nurse working in a place like intensive care where AGP’s are happening constantly may have different PPE practises than someone working in a care home. It would be reasonable to expect less AGPs to happen in a care home. Some wards made preparations for the Covid outbreak and could ensure their staff had fitted reusable FPP3 masks.

A Reusable FPP3 Respirator Mask

Do you always have access to it?

Where I work I luckily have access to the correct PPE at all times, however I understand this is not the situation many nurses are in. 

How long does it take to put on and take off?

It can all be put on in the space of a few minutes if you are in practice in doing it and if it is readily available to put on in an emergency. Taking it off involves tearing off the apron from the front by pulling it forcefully, putting in the bin, washing hands, wiping down the reusable visor, stepping out of the room and then changing your mask and rewashing/sanitising hands. 

Do you use fresh PPE for each patient?

Yes, apart from masks which we change regularly throughout the day but not between each and every patient. 

What happens in Intensive care?

In intensive care many patients with Covid are require invasive ventilation. This means they might be producing aerosols that can transmit the virus into the air in the form of droplets. In these areas the patients with Covid are in a cohort and the people working in those areas will have to wear the full PPE for long stretches of time.

What happens in these areas when nurses need breaks?

As wearing the full PPE is heavy, uncomfortable and hot it is important the professionals working in these areas have regular breaks as they are unable to have a drink or go to the toilet whilst wearing this PPE. This is where wards and Intensive Care Units are struggling with having enough staff to cover each others breaks. Every shift, 1 or 2 A&E nurses work on intensive care for the day to support the staff there. Additionally, the trust set up more intensive care units to cope with the increasing demand for ventilators/intensive care beds. These were in places like theatre recovery whilst there was temporary cancellations of elective theatre lists. 

Do you get breaks?

Yes. Where I work, staff nurses get 2 thirty minute breaks each day. We also get additional tea or coffee break in the morning. In A&E we cover each other’s break and if something comes up for one of your patients during your break (e.g., someone needs pain relief) someone is there to help.

I previously worked on an acute medical unit. If something needed doing during my break it was rare anyone would be able to step in to assist. Some of the time the nurse in charge/another nurse or support worker may have been able to help. However most of the times the other nurses were too busy with their own workload. This meant the task would be waiting for when you returned. This definitely wasn’t anyone’s fault. On the ward the ratio of nurses to patients was 1:8 whereas in A&E majors the ratio is 1:4. However in A&E there are different pressures, such as a quick patient turnover more critically unwell patients in need of stabilising. This means it would be difficult to keep track of what was happening to more than 4 patients. 

Social Distancing at work?

It is incredibly hard to maintain social distancing at work. Up until a week ago I could still be in a squeeze in a lift when 6 other people decide they would rather get in, than wait for the next one. There are now lift rules – which means there is a long queue in the morning for people needing to use it. Happily, A&E is on the ground floor. In the staff room at break times people don’t have space to suitably socially distance.

Further FAQs?

Thank you to the people who submitted Covid 19 FAQs to assist me in writing this post. If anyone would like to know anything further I would love to help answer your questions. Feel free to comment anymore Covid 19 FAQs. Thanks for reading.

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Nursing

Clap for Heroes: A&E Covid 19 Story Week 5

Week 5: #ClapforHeroes

This week a 99 year old man walked around his garden 100 times and raised £23m for ‘NHS Charities together’. People were participating in clap for heroes on Thursday at 8pm and Westminster Bridge was (ironically) filled with supporters who were turning a blind eye to social distancing rules.

I love the well wishes and support. Seeing tube stations lit up with ‘Thank you NHS’ after work does makes me smile and feels directly like a ‘thank you’ for the shift I just worked. Food is delivered to A&E every day, often we get deliveries twice/three times a day! The NHS is inundated with people and businesses showing their gratitude and for that I am very thankful, it is much appreciated.

I was very happy when I was given 4 easter eggs this easter from work. Thats more easter eggs than I’ve had in the entirety of my adult life. Just yesterday a charity donated a bag of groceries individually packed for everyone in A&E (and I imagine other departments). Inside was a baguette, a packet of pasta, a banana, a protein bar and a carton of 6 eggs. Meanwhile, my friends and family members have been messaging to check in and all have been very kind. I would very much like to say thank you to everyone for the support.

I do not for a second wish to seem ungrateful for the nationwide effort to support the NHS but I do have some doubts about wether thinking of the NHS as a charity is a harmful stereotype to purport. The NHS is a public service that is funded by taxes, the fact that it has been left in a position where people feel the need to donate their hard earned, already taxed earnings does raise some questions.

What will the money be spent on?

It is also unknown what the money will yet be spent on. A guardian report suggests established NHS charities such as Guys and St Thomas’s can apply for grants. This would be to fund wellbeing projects, refreshments and relocation funds for the staff. Apparently the money cannot be spent on core necessities such as paying wages etc. This makes me wonder if the money could even be used to procure/manufacture PPE. Meanwhile, many news articles now suggest hospitals, hospices and care homes are struggling to supply staff with a safe amount.

This raises a topic I wanted to address this week which is the insistence on branding health-care staff as heroes. This is especially apparent in the clap for heroes practice. Before lockdown, my friend told me her dad was visiting pret to grab an NHS free drink. During this, he was approached by a stranger, only to be heralded for being a ‘hero’ and thanked profusely. This made for a rather awkward/borderline uncomfortable exchange as he thanked her whilst also trying to explain that he ran a clinic and was just doing his job.

#Heroes

In my opinion branding NHS workers as #Heroes during clap for heroes, makes the tragic loss of life almost explainable, rather than the atrocity of what it is. If NHS workers are making a ‘heroic sacrifice to save lives’ by turning up to work, it brands us as martyrs, rather than what we are. People. Every nurse, doctor and healthcare worker is a normal person. Yes brave, yes hardworking and yes rather selfless but still just a normal person, who does not want to die. I work as a nurse, I frequently treat covid patients, I still go into work everyday. It doesn’t make me ‘fearless’, because I’m not, I’m still fucking terrified.

Here are some of my favourite tweets from the week which express my point in tweet format.

Next post I will set up an FAQ’s page so feel free to comment any questions you have for me to answer!

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Nursing

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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Nursing

A&E Covid 19 Story Week 3: Covid 19 Emotional Strain

Week 3: Covid 19 Emotional Strain and Covid Resuscitation

Week 3 in A&E addresses Covid 19 Emotional Strain. My third week in the Emergency Department started off with the tragic news. This was of two nurses losing their life to Covid 19. Reading this along with all of the heartfelt online tributes really shook me. It took a few hours of relaxing, including talking to my housemates and having a nice walk around in the sun to start to feel better

News

However, the next day I woke up to the news that another nurse had lost their life. This time a 23 year old. This was the news that affected me the most. 23 is my age. I think that I had rationalised the other deaths by characteristically distancing myself from them. This was in order to try to convince myself that I am not in any danger. This was what showed me there was absolutely nothing stopping the next nurse to die being myself. This terrified me. I ended up in tears on the phone to my parents twice in the same day, telling them I wanted to quit my job . 

After my flatmates comforted me (both of whom have been very supportive in the past few weeks) I messaged colleagues from my previous job to find out if they were going through Covid 19 emotional strain. As I have recently started in A&E I didn’t feel there was anyone I knew well enough yet to talk to about this. Reactions were mixed. Everyone who I contacted said they could relate in some way to the emotional strain. My friend, who works in A&E elsewhere said she, finds the increased amount of patients dying in A&E upsetting.

Additionally, another friend told me she didn’t want to be a nurse anymore. My friends working on wards have told me they have trouble sleeping. A colleague who I spoke to at work told me she misses her family. This is because she is currently living in hospital accommodation (which lacks any cooking facilities/fridge) as she has elderly parents who she wouldn’t want to risk exposing to the virus. 

In A&E

Despite a shaky start to the week, the rest of the shifts went well. I commenced treating a Covid patient on CPAP (Continuous Positive Airway Pressure) and attended to 3 blue light calls. A ‘priority call’ or ‘blue light call’ is an expression in the nursing/medical profession. It is used to describe an ambulance ringing the A&E red phone (usually located in Resus) en route to the hospital with a patient who is particularly unstable/needs prioritising and urgent medical/nursing attention upon arrival. In the A&E that I work in, these patients are now directed into Covid Resus. This is a Majors cubicles with doors, entirely stocked as a Resus bay) or Non Covid/ ‘Clean’ Resus. Previously, all ambulance priority calls would go straight to Resus.

Covid 19 Emergencies

Covid blue light calls now require all attending staff to dress in level 3 PPE. This is a full length waterproof or surgical gown, a surgical cap, FPP3 mask, 2 pairs of gloves and a visor. They require at least one but preferably more ‘Runners’. The runners are dedicated people (in step-down PPE) who are situated outside of the cubicle and are on hand to assist the staff who are inside the cubicle. 

The runners can take, fetch and process anything the people inside the cubicle need them to. This could range from getting the patient something to drink, bringing in specialist machines such as an ultrasound machine for particularly difficult to place cannulas or a bladder scanner to gauge wether the patients bladder is retaining urine, to complex and vital ventilation machines.

Running

Being a runner often involves being handed blood samples and covid testing swabs from inside the room, in a sealed and wiped plastic bag, to then be placed in another plastic bag to send to the lab. The people inside and outside the cubicles ideally communicate through a walkie talkie, however as people are speaking in noisy environments and are wearing masks, it often means the walkie talkies are useless, meaning shouting and over the top hand gestures are commonplace. 

Another important job for the runners is to liaise with people such as specialist doctors i.e. ITU or medical teams, on the outside and communicate and document this to minimise the amount the cubicle door is open, to minimise the spread of harmful Covid-19 droplets.

Resuscitation

Speaking of Resuscitation, I wanted to cover the changes to CPR/Resuscitation guidelines brought in due to recent events. The CPR guidelines may differ depending on independent trusts but Resuscitation Council (UK) guidelines state that it is unknown if CPR is an Aerosol Generating Procedure (AGP) but expert opinions have suggested it may be, and in the interest of protecting health care workers and medical staff it is advisable to treat chest compressions as if they are an AGP and wear appropriate PPE.

2222

In my induction week I am informed of cardiac arrest procedures. Normally a resuscitation/emergency 2222 call to the cardiac arrest/ crash team includes “(adult/Paediatric) cardiac arrest”. However now it is mandatory to state “COVID” amongst this information. This is so the responders can arrive in the correct PPE. I recieve an email later in the week stating level 3 PPE is the minimum requirements for all arrests. Another difference to note in my trust Resucitation guidance (name held) is that ward staff are not to use a bag-valve mask. Additionally, there is to be no use of stethoscopes in arrest situations. These changes, whilst necessary, poses questions about what to do for an ‘Out of Hospital Cardiac Arrest’. This will inevitably delay life saving CPR. I believe this will undoubtably have impacts across the entirety of health care for considerable time.

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Nursing Self Care

Mental Health Support for Healthcare Workers

Mental health support for healthcare workers:

As always, follow the NHS advice on where to find urgent support if you are experiencing a mental health crisis.

If you work for the NHS and are currently, understandably experiencing more stress, struggling and feel like you need support, here is a list of resources for mental health support for healthcare workers I have compiled in an easy-to-access format. This list is by no means exhaustive and can be used by anyone. As health care workers, it is really important to look after yourself first in these challenging times, as I’m sure we’ve all heard the phrase: ‘you won’t be able to look after others if you don’t look after yourself first’. I hope this list helps.

Mental health support for healthcare workers: Resources and Contacts

If you prefer to phone

0300 131 7000 is a confidential staff support line from Samaritans for NHS staff. (Open between 07:00-23:00 everyday).

If you prefer to text

Text FRONTLINE to 85258 for 24/7 text support

If you prefer to read

Similarly, there is a selection of NHS guides to be found here covering useful topics such as an ABC guide to Resilience, Personal Resilience and creating a ten minute pause space (a place to reset and recharge).

Websites

Able Futures is a useful signposting website if you feel anxiety relating to work or think anxiety is affecting your work. It offers free support to employees (in Great Britain) on behalf of the department for work and pensions.

Their free number to call is 0800 321 3137

They also have a number of helpful pages on their website dealing specifically with topics such as Stress, Anxiety, Depression, Mental Wellbeing and Sleep.

Coping Methods

Mental health charity Mind has specific strategies you can follow to help you manage difficult symptoms you might be experiencing.

Mental health support for healthcare workers

Categories
Nursing

A&E Covid 19 Story Week 2

Starting in the Emergency Department: A&E Covid 19 Story

Week 2

Welcome to A&E Covid 19 Story Week 2. When I first started writing, I had high hopes of following the ins and outs of every shift…this probably wont happen. Even though, like everyone else, I (sadly) have no social life to currently speak of. My state mandated hour of exercise, 2m apart queuing for Tesco and performing excessive amounts of laundry really doesn’t leave me with lots of spare time on my days off. In light I will aim for posts to be once a week. 

I start off as a supernumerary nurse. I am shown the staff room and where to change into scrubs. At the start of the safety huddle, one of the matrons asks how we all are. There’s a few seconds of awkward silence. She then thanks everyone for their hard work and says she wishes she could hug every one of us. This makes me nervous. I get a “everyone say hi to our new starter” shoutout and a lot of people laugh at the improbability and impracticality of starting in one of the busiest A&Es, in the capital city, mid pandemic. A lot of people comment things like “picked a good time to start didn’t you” but everyone is welcoming.

Inductions

I meet the nurse educator for an induction walk around. The department is intimidatingly big and I’m unsure how I’ll ever remember my way around it. She tells me A&E is split into the usual sections. This includes: Majors cubicles, Rapid assessment and treatment (RAT), Urgent treatment centre/treatments (UTC) and Resus. However this has changed due to Covid. Instead, there is a confusing switch around throughout the whole department. Meaning Majors is now entirely for Covid patients. UTC is in use for majors patients who aren’t suspected Covid. A select number of majors cubicles are now set up for a ‘covid resus’. Normal resus is now ‘clean resus’ for non covid patients. The Paediatric department is relocating and with it, all paediatric nurses. This including the nurse educator who is co ordinating my induction period.

Despite these changes, everything is going smoothly so far. The educator who is showing me around keeps remarking how quiet the emergency department (ED) is. It’s not unusual for ED to be quiet in the morning. However, the nurse tells me, on a regular evening it’s not uncommon to have 100 patients in the department. The lack of patients makes everyone uneasy. Therefore, people are throwing phrases like ‘the calm before the storm’ and ‘before shit hits the fan’ around. Apparently tourists, workers and students make up a large amount of the patients who come in and as central London is emptier than usual (understatement I know), this A&E department has the luxury of around a week with minimal patients to prepare for what we all know is coming. 

The Week

The week follows in a rush of training sessions and chaotic rearranging of the department. I learn how to use 3 different types of CPAP machines. the trust has just adopted new ones to prepare for the forecasted surge in demand for these, for the treatment of hypoxic Covid patients. There is a change in the PPE guidance daily, one day we are told we need to wear masks, aprons and gloves even whilst not seeing patients, the next day we are only told to wear masks at all times, unless we are seeing patients, in which case we must wear an apron and gloves.

A lot of nurses are moving beds and trolleys around to make more room for an increase in patients and stocking new PPE stations. There’s also a large induction of new doctors to the department. This is because they have been pulled from other areas of the hospital to support the Emergency Department for the upcoming weeks. The rules are switching and changing at an unsettling rate and I know this is only the beginning.

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If you enjoyed A&E Covid 19 Story Week 2, check out week 1 and week 2 by clicking on the links below!