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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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