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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.