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How early preparations have helped one emergency department during the COVID-19 pandemic

Medway NHS Foundation Trust consultant nurse Cliff Evans describes how forward triage using a tent and temporary cabin enables ED nurses to prevent unnecessary admissions and cross contamination 

  • Forward triage proves vital in controlling spread of disease, protecting vulnerable patients
  • Support increased for staff amid awareness they may be vulnerable to post-traumatic stress
  • Fears patients are staying away until they are so unwell they need significant treatment
Picture shows nursing staff starting a shift in the resuscitation room at Medway Maritime Hospital wearing personal protective equipment.
Starting a shift in the resuscitation room at Medway Maritime Hospital (left to right): resuscitation practitioner and charge nurse Antonio Sobrido, associate practitioner Charlotte Hill and lead nurse manager and resuscitation room lead Michelle Leach 

In the weeks since the start of the COVID-19 pandemic our early preparations at Kent’s busiest hospital, Medway Maritime Hospital in Gillingham, where I’m a consultant nurse, have stood up well.

Our local population has a high level of chronic respiratory problems and lung disease, and the three main reasons for admission are pneumonia, chronic obstructive pulmonary disease (COPD) and heart failure.

We have been developing our response continually. One example is that we have adapted our initial nurse practitioner triage area to include treatment facilities, which is proving very effective. But ultimately the vulnerability of our patients will be reflected in mortality figures.

Identify and isolate: a strategy for coping

My experience serving with the military and 30 years in the NHS is that when confronted with any outbreak of infectious disease, whether unknown pathogens, diarrhoea and vomiting, or differing strains of influenza, you try immediately to identify and isolate those affected, especially in the early stages when you don’t know how contagious the infection may be. 

One of our fantastic service managers at Medway Maritime Hospital in Gillingham, Kent, sourced, erected and equipped a tent outside the emergency department (ED) in one day, facilitating risk stratification of all new patients before they entered the ED separated into hot and cold zones.

Forward triage assesses both worried well and symptomatic patients

This forward triage position allowed nurse practitioners to assess both worried well and symptomatic patients on arrival. These patients did not come into contact with other ED staff, and most were safely discharged home to self-isolate with verbal and written advice on self-managing their condition and what to do if symptoms worsened. We also devised a way to remotely book in patients.

Many high-risk patients with conditions such as asthma or chronic obstructive pulmonary disease, and even those on chemotherapy, presented with similar symptoms to patients with COVID-19 but, given the infection risk, admitting them may not have been in their best interests.

So we worked with our estates department to construct a temporary cabin next to the tent where nurse practitioners could assess and initiate treatment for patients with moderate exacerbations of their long-term conditions and possible COVID-19 infection, preventing unnecessary admission and cross-contamination. 

‘Freeing hospital beds for patients requiring higher levels of care is key to reducing the overall mortality rate’

Our evidence shows this has been highly effective: nearly 300 patients have been discharged home by our nurse practitioners, assisted by nursing associates and associate practitioners. 

Many of those patients would otherwise have been admitted to a COVID-19 ward due to their symptoms mimicking those of the virus. Freeing hospital beds for patients requiring higher levels of care is key to reducing the overall mortality rate, and this initiative has played its part.

 

Traditional approaches to managing respiratory failure are being challenged

Coronavirus is challenging many traditional approaches to managing respiratory failure. Modern treatment options such as high-flow nasal oxygen were not advocated for COVID-19 patients based on lack of efficacy, oxygen consumption and the potential to spread infection to the healthcare team.

The use of invasive mechanical ventilation is indicated in some patients but can have many complications, and evidence is emerging that it may not be the most effective treatment for stabilising some patients with type 1 respiratory failure who are infected with COVID-19.

Picture of Tracey Croft, lead practitioner and practice development nurse at Medway Maritime Hospital in Gillingham.
Tracey Croft

Continuous positive airway pressure, known as CPAP, is the preferred form of non-invasive ventilation support in the management of hypoxaemic patients with COVID-19.

Many newer members of our nursing team were unfamiliar with the use of CPAP, as we train them mainly in the use of bilevel positive airway pressure (BiPAP). So we deliver training sessions in the clinical area to ensure they understand the latest machines and protocols.

We simulate the use of these machines in different emergency department (ED) areas, which we would use if patient presentations overwhelmed our initial resources.

Our lead practitioner and practice development nurse Tracey Croft has played a crucial role. She has worked day and night to ensure that our huge workforce – more than 150 nurses, plus doctors and other front-line staff – are all proficient with personal protective equipment (PPE). 

Nursing handover allows the team to discuss tactical changes as well as concerns or issues

We’re mindful of the possible psychological impact of the pandemic on our teams. Some staff are shielding due to high-risk conditions, others are isolating because members of their family are affected. Several have received treatment for the virus. It’s inevitable that people feel ‘it could be me next’.

All of us are working additional hours and some also care for older and vulnerable relatives after their shifts, which must be a huge worry. 

We have a nursing handover each morning to discuss tactical changes and allow the team to discuss concerns or issues. When you break down fear and anxiety into blocks – in this case, individual questions – they become more manageable. The questions cover many areas, such as PPE, how treatment has changed and what might come next.

Picture shows a forward triage position at Medway Maritime Hospital.
A forward triage position at Medway Maritime Hospital (left to right): trainee advanced clinical practitioner John Ferguson, lead emergency response practitioner Terrianne Noonan and trainee nursing associate Chloe Newson

Post-traumatic stress likely for many emergency department staff

We have also changed the way we work, introducing different break systems as staff were at risk of dehydration from working in contaminated areas and being unable to access fluids easily. Six hours in resus in a hazmat suit is enough for anyone.

Although we’re supporting staff now we’re aware we will be picking up the psychological impact for months and possibly years, with post-traumatic stress likely.

ED nurses are used to change, but this virus has led to almost constant change. We’re trying to minimise disruption and, with advance notice, deliver key changes while keeping disruption and uncertainty to a minimum.

We’ve changed our means of communicating. WhatsApp messaging has proved a great way to ensure immediate communication between our nursing workforce and wider teams. All phones are kept in plastic bags, as accessing computers can be an infection risk.

An ongoing challenge is the constant need to increase the size of the ED to meet growing patient acuity and demands – on one day we saw 113 emergency ambulances. The senior team evaluates the data and emerging clinical evidence at a tactical meeting every other day to plan the next steps.

We will shortly move our co-located children’s ED to another part of the hospital, but we have also developed contingency plans for our minor injury unit to become a high dependency unit if necessary.

Many people may be staying at home until they are really unwell

There has been a change in non-COVID-19 presentations to our ED. Sadly, almost as soon as the government advised people to stay at home, our paediatric ED lead sister Nicky Keane was reporting a dramatic increase in violence and abuse against children. We’re seeing increased violence between cohabiting adults and, more recently, significant presentations related to mental health.

The overall number of attendances has fallen from around 450 a day to 190. We’re concerned that many people may be staying at home until they are really unwell and may need more significant treatment as a result. 

We are already considering our population’s future care needs. We have never seen a coronavirus that has caused such significant damage to the lungs and other organs such as the heart, liver and kidneys. Going forward, we may have a significant number of people affected by long-term lung disease.

When the pandemic is over, as well as inquiries into the lockdown process, PPE availability and testing policies, there will be much to learn about making future health services more robust.

For example, when hospitals started putting plans in place, there was no unified approach to how you would change the front door. Some two-site trusts made one hospital a ‘hot’ site and one ‘cold’ to try to manage infection, but for many this failed dramatically. Some were overwhelmed within a week. 

And it is clear how much the front-line NHS has depended on the care sector in managing this pandemic. I’m so inspired by the care homes, their nurses and care assistants, who have worked so hard to keep residents out of hospital.

Picture shows entrance to the emergency department at Medway Maritime Hospital in Gillingham with a cabin used for forward triage.
The entrance to the emergency department at Medway Maritime Hospital with a cabin used for forward triage

Through Clap for Carers it has been fantastic to know how much the country is supporting the NHS

When I teach emergency nurses, I talk about how dangerous triage is, because you don’t know what will come through the door next, including contagion from anywhere in the world. Yet care assistants in care homes are facing these dangers without that training and still going to work every day.

Public support continues to be overwhelming. I can’t tell you how much we have all appreciated the gestures of kindness. Our community has also raised funds to buy visors and coveralls – truly unbelievable.

Through Clap for Carers it has been fantastic to hear and to know how much the country is supporting the NHS. For many, this is a sudden realisation of just how important it is to have a highly trained, well-equipped and resilient healthcare workforce. 

Admiration and affection for our health services has not been reflected in its funding, but this tragic event could be the catalyst for fundamental reform and the start of investment similar to that of other high-income countries. 

I’m sure there will be calls for nurses to receive a significant pay rise – and waiving the tax they pay on any additional shifts worked to ensure patient safety would be welcome. But the basic starting point post-coronavirus will be implementation of mandatory staffing standards and working conditions to support nurses to deliver dignified care. 

The World Health Organization designated 2020 the International Year of the Nurse and Midwife, and we have been demonstrating the complex, critical role we play in modern healthcare delivery. I hope this will inspire a new generation to join our profession as society sees what it is to be a nurse.

View our COVID-19 resource centre


Picture of Cliff Evans, consultant nurse and educationalist, emergency medicine, Medway NHS Foundation Trust, and a member of the Emergency Nurse editorial advisory boardCliff Evans is consultant nurse and educationalist, emergency medicine, Medway NHS Foundation Trust, and a member of the Emergency Nurse editorial advisory board

 

 

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