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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

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 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!

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Nursing

A&E Covid 19 Story Week 1

Week 1

A&E Covid 19 Story: Cancelled training sessions, E learning and apprehension

To begin the A&E Covid 19 story I start at week 1.This is mostly training. The first day I sit in a training classroom of about 30 people. We are given advice on hand washing and vague advice about isolating/not attending if you have Covid 19 symptoms. No one else on the induction is about to start in the Emergency Department (ED). Everyone looks slightly concerned when I tell them where I will be working. We are made to take part in teamwork activities with no respect shown to social distancing advice and we are given lunch. There’s plenty of hand sanitiser to go around and a lot of people are covering their phones with it too.

My online timetable shows the activities for the day but have gaps for the next day with no explanation of what they require me to do on these days. I emailed my line manager and received no reply so walked to the emergency department to suss out the situation about what they had planned for me for the week.

Covid-19!

There are banners everywhere, COVID-19. No visitors! Most importantly, there is a sense of alarm and panic once inside the department however it seems unusually quiet as there are no visitors. I meet with my manager who apologises for a chaotic induction week due to the circumstances and explains the clinical educators are both currently off work. 

The nurse asks me to go home and work on e-learning for the week. This is due to the cancellation of all of my training classes, apart form basic life support and IT system training.

I prep for the next week which is where I start working in ED. Click on the links below to read more on A&E Covid 19 Story.

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