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COVID-19: why pressure on emergency departments is taking a toll

Winter pressures and rising COVID-19 cases have put emergency departments at the eye of the storm – and staff are struggling

Winter pressures and rising COVID-19 cases have put emergency departments at the eye of the storm and staff are struggling

  • The inevitable rise in COVID-19 cases in the winter has put pressure on emergency departments as they attempt to manage COVID-19 patients alongside those without the virus
  • Logistical problems include a lack of space to ensure social distancing and effective red and green zoning as well as inadequate staffing levels
  • Emergency nurses are exhausted and need emotional and psychological support

Winter combined with COVID-19 was always set to be the perfect storm for emergency

Winter pressures and rising COVID-19 cases have put emergency departments at the eye of the storm – and staff are struggling

  • The inevitable rise in COVID-19 cases in the winter has put pressure on emergency departments as they attempt to manage COVID-19 patients alongside those without the virus
  • Logistical problems include a lack of space to ensure social distancing and effective ‘red’ and ‘green’ zoning as well as inadequate staffing levels
  • Emergency nurses are exhausted and need emotional and psychological support
A steady stream of patients arriving at the Royal London Hospital in Whitechapel, January 2021
A steady stream of patients arriving at the Royal London Hospital in Whitechapel, January 2021 Picture: Mark Thomas/Alamy Live News

Winter combined with COVID-19 was always set to be the perfect storm for emergency departments (EDs).

And with the current wave of the virus peaking at the busiest time of the year for hospitals, it has proved to be just that.

NHS England figures show that the numbers of patients coming to ED are still much lower than they were before the pandemic. In England, the attendance figures for December 2020 were down by nearly one third – but that does not reflect the complexity on the ground where units are balancing the competing demands of COVID-19 patients and those who do not have the virus.

How are EDs coping and what is the impact on emergency staff?

RCN Emergency Care Association member Justin Walford
Justin Walford

RCN Emergency Care Association member Justin Walford says it is definitely ‘much harder’ than the first stage of the pandemic in the spring of 2020.

‘In the first wave, our non-COVID-19 patients evaporated, but now EDs are seeing lots of people in the green (non-COVID) areas, as well as COVID-19 patients in the red.’

That in itself has proved challenging for some hospitals.

The size and layout of ED units has meant it has proved difficult to establish workable set-ups, with some hospitals having to flip their green and red areas as patient demand changes.

Research published in the Emergency Medicine Journal ahead of winter warned of ‘insufficient space’ in waiting areas to enable social distancing and a lack of cubicles and side rooms for patients who are suspected to have COVID-19.

A hospital waiting area set up for social distancing
A waiting area set up for social distancing Picture: Alamy

The report cited a lack of negative pressure rooms to perform aerosol-generating procedures and a difficulty at some units in providing separate ambulance entrances, with fire exits being repurposed and used at times.

Knock-on effect for non-COVID-19 patients

Mr Walford also said there are signs non-COVID-19 patients are beginning to come into the ED ‘in a more deteriorated state than you would expect’.

‘There are quite high numbers in peri-arrest, in particular. The impact of people not seeking care for all those months is being felt.’

This was something that many feared when attendances plummeted in the first wave. They dropped to half their normal levels and have never fully recovered.

Working on the non-COVID-19 side also comes with other challenges, says Mr Walford.

‘You also have the fallout from having an asymptomatic COVID-19 case in green.

‘It can lead to other patients having to isolate and this is understandably concerning as you can be talking about vulnerable patients.

‘Red shifts are very difficult. Some hospitals do have direct access for COVID-19 patients, meaning they don’t all come through ED, but in many they do.

‘Patients have to be assessed and arrangements made for admission. You are in full personal protective equipment. It is hard work.’

A patient arrives at Glasgow Royal Infirmary’s emergency department
A patient arrives at Glasgow Royal Infirmary’s emergency department Picture: Iain Masterton/Alamy Live News

Exhaustion is affecting nurse staffing levels

Mr Walford adds: ‘I know ED departments try to share the load between green and red shifts.

‘But ED nurses are exhausted – there was already a shortage of nurses before the pandemic hit and on top of that we are having to cope with significant numbers off sick or having to isolate.

‘You keep going because you don’t want to let your team down.’

Investment has been made to support staff emotionally. Nationally, there is a dedicated well-being support line run by the Samaritans and a bereavement service run by Hospice UK.

A suite of different apps covering everything from mental health to exercise have also been made available free to NHS staff.

NHS England and NHS Improvement have provided an extra £15 million to local areas to build on this support ahead of winter. Money has also been supplied by the devolved administrations in Scotland, Wales and Northern Ireland.

This funding has helped EDs, and hospitals more generally, to invest in well-being hubs, offer access to psychological support and counselling services, train mental health first aiders and create wobble rooms for staff to visit when they are feeling anxious or stressed.

But Royal College of Emergency Medicine (RCEM) associate professor Edd Carlton says access is still not universal.

‘Access to well-being and mental health support varies for individuals across the country.

‘In the face of the biggest challenge the NHS has ever faced we need to ensure formalised routes are in place to help colleagues get the support they need.’

Manchester Arena trauma service offers mental health support to front-line staff

The Greater Manchester Resilience Hub was originally set up in response to the 2017 Manchester Arena bombing to provide support to the families affected by the event.

But last year the hub – run by the region’s four mental health providers – opened its doors to front-line healthcare staff in recognition of the stress the COVID-19 pandemic was having.

Staff are entitled to screening and can access webinars, peer support groups where they can reflect on their experiences and one-to-one therapy. Outreach support is also provided to the families of front-line workers.

Hub strategic clinical lead Alan Barrett said the move was made in recognition that the pandemic had effectively become a ‘mass casualty’ event, with staff experiencing trauma as a result.

Those working in critical care and the urgent and emergency services were originally prioritised for help, but it has since been expanded to others.

Professor Barrett says staff are facing a very ‘difficult time’. ‘Unlike other work scenarios, COVID-19 has had a significant effect on their personal lives in addition to their professional lives.’

He says the situation has been made even more difficult because the usual self-help strategies, such as socialising or going to the gym, are not available: ‘We cannot take the mental health of those on the front line for granted.’

Front-line staff are experiencing psychological distress

In January, the RCEM published a study based on a survey of 5,400 of its members on the mental health impact of providing care on the front line during the pandemic.

Nearly half reported psychological distress.

Shortly afterwards another poll by Unison of 14,000 staff which included nurses, healthcare assistants and porters, including some who worked in EDs, showed nearly half had struggled to cope.

The problems reported included suicidal thoughts, symptoms of post-traumatic stress disorder and panic attacks.

So what more can be done to tackle the scale of trauma?

One technique known to be effective in stressful situations is the use of ‘debriefs’.

It is an approach borrowed from the military to help review information and performance after traumatic events. The idea is to identify points of excellence as well as potential errors made.

Debriefs can help staff deal with traumatic events

A study published in BMJ Open in September looked at their use in Ireland and found a ‘hot debrief’ – one that is carried out immediately after a cardiac arrest – led to valuable changes to equipment and procedures.

Moreover, 90% of staff reported they have benefitted from them psychologically.

The UK Resuscitation Council recommends debriefs after every cardiac arrest, but this is unlikely to be happening because of time pressures and workload exacerbated by the COVID-19 pandemic.

Emergency department senior sister Nicola Davies
Nicola Davies

ED senior sister Nicola Davies, who works at a major trauma unit, says debriefs are still only being reserved for cardiac arrests and code reds and blacks.

‘We have a well-established debriefing system which involves an immediate “hot debrief” that follows the TAKE STOCK hot debrief tool and then moves onto a “cold debrief” facilitated by an independent person a couple of weeks after the event.

‘These are well attended and feedback has shown it to be useful.’

She agrees the latest COVID-19 wave has been ‘more challenging’ because of the non-COVID-19 presentations, including significant traumatic injuries, which is taking a toll on staff.

But she says on a day-to-day level the support of managers and colleagues – and the camaraderie of the team – is vital.

Good teamwork has been essential for morale

‘The department and staff have worked tirelessly to adapt and change to meet the needs of our patients, often halfway through a shift.

‘We have been exceptionally well supported by our matrons, clinical lead and high management groups,’ says Ms Davies.

‘Our matrons have spent a large amount of time working clinically with the whole team to ensure the department is adequately staffed and supported.

‘This has been instrumental in improving team morale and enthusiasm for work.’

She says one of the things that has had the biggest effect on mental well-being was an informal running challenge.

Staff were set the task of running or walking 50km in a month, logging progress on an app.

She says it created a ‘fun, friendly competition’ and adds: ‘It probably had the biggest positive impact on mental well-being.

‘Understandably there have been days when staff have struggled to come into work, from exhaustion – both physically and mentally.’

An exhausted emergency department nurse in mask
Picture: Alamy

As pressure continues, nurses’ long-term mental health is at risk

And with little sign of let up in the demands being placed on EDs, some are worried just how long front-line staff can keep going.

University of Bath psychologist Jo Daniels has been carrying out research on the mental health impact on staff in urgent and emergency care.

She believes the workforce is at ‘breaking point’ after a long, hard eleven months, adding EDs along with intensive care have become so ‘high pressure, high risk’ that it threatens to have dire consequences.

‘What is at stake not only affects the long-term mental health of this vital workforce, but also their ability to function and deliver the services we depend on.’

The pandemic has made a bad situation in emergency departments worse

Hannah Swift, pictured, left her job as an ED staff nurse in Northern Ireland in October although she has continued to do bank shifts while also working as a mental health nurse.

Emergency department nurse Hannah Swift
Hannah Swift

‘The pandemic has made a bad situation worse. It has made caring for patients in ED more difficult and further highlighted issues I had been worried about for some time. In fact, if anything, I stayed longer because of the pandemic. It felt important to be there and help in any way I could.

‘But it got to the point where it was affecting my health and well-being. I gave my all every day, but it was never going to be enough to meet the ever-increasing demand.

‘It was demoralising. You have to get on with it and say you are fine when you are not. What else can you do? The show must go on, but I got to the point where I knew I couldn’t.

‘Staff are under so much pressure we cannot do our jobs properly. I would finish a shift and be so upset because I had not been able to provide the care that my patients deserve.

‘There are simply not enough beds or staff in the hospital. Our senior and lead nurses are doing all they can to support us, but what can they do when the system is broken. It’s so hard for them too.’

She misses the bond she had with her ED team. ‘Your colleagues are like your family, the whole team are incredible. If you need a laugh or cry, the sluice is the place to go.’

But she is afraid of what is happening to them. ‘There are so many more COVID-19 patients coming in this wave as well as others returning with post COVID-19 complications. There is much more to come that we don’t even know about yet and it’s scary.

‘I worry for my colleagues. They need time to rest and recover, but that is something they are never likely to get. They’re in the eye of the storm.’


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