ABSTRACT
Background University Hospitals of Morecambe Bay NHS Trust, witnessed an early peak of COVID-19 with related hospital admissions in early 2020, this created a need for a coordinated approach to post COVID-19 rehabilitation needs across the area. Objectives A three-armed COVID-19 rehabilitation pathway was devised in March 2020 with Arm 1 aiming to assess and address the immediate rehabilitation needs of those leaving hospital following an admission for respiratory complications of COVID-19. Methods Existing Pulmonary Rehabilitation teams were repurposed by integrated care network (MBRN) to be a new 'Virtual' rehabilitation service. A register of patients discharged from hospital sites was remotely screened for pathway suitability. Then, using a multi-professional template a holistic assessment needs was conducted using telephone and/or home visit consultations. Clinical assessment tools were built into the assessment process. Weekly 'acute-community' virtual in-service training sessions and multi-disciplinary case discussions supported the clinicians. Results To date 207 patients have entered the service for virtual triage, 138 patients were deemed suitable for further assessment and interventions. 427 direct clinician consultations were delivered to these 138 patients [122 initial telephone assessments;53 initial home visit assessments;168 follow-up telephone consultations;84 follow-up home visits]. Two of the 138 patients assessed died, both were expected deaths. No clinical incidents occurred and no staff contracted COVID-19 during this period. Feedback from the services' staff survey was very positive highlighting the supportive value of virtual training and MDT and the enjoyment of being part of creating and delivering this new service to patients recovering from COVID-19. Conclusions Utilising the skills of pulmonary rehabilitation staff to deliver a holistic rehabilitation and treatment service to those discharged from hospital after suffering respiratory complications of COVID-19 was feasible, safe and well tolerated by staff and patients. This service is now being used to address the needs of post-COVID-19 patients presenting with respiratory needs in the community. We aim also to assess clinical outcome.
ABSTRACT
INTRODUCTION: Infection control measures introduced during the COVID-19 pandemic present myriad challenges to end-of-life (EOL) care beyond restricted hospital visiting hours. The objective of this analysis was to understand the effect of infection control measures on bedside care for dying patients in a study embedded in an evaluation of the 3 Wishes Project. We hypothesized diverse effects from clinicians' perspectives. METHODS: Using a mixed-methods design, we enrolled patients with a ≥95% probability of dying in hospital, or plans were to withdraw life support on 3 hospital wards. Clinicians who cared for these patients were purposively sampled 2-10 weeks postmortem for an audio-recorded interview;data were analyzed by conventional content analysis. RESULTS: In total, 45 patients were enrolled in the ICU (n=34);COVID-19 ward (n=7), or medical step-down unit (n=4) from March 16-July 1, 2020. Of 236 terminal wishes elicited, 99% were implemented. During their hospital stay, 32 (71%) patients had ≥1 family member visit in the patient's room, outside the room, or at the outdoor window. At the time of death, 20 (44%) patients had family members at the bedside (none had COVID-19). Perspectives from 45 clinicians (16 nurses, 10 physicians, 8 residents, and others) highlighted several changes to physical aspects of EOL care during the pandemic. Patients with COVID-19 are cohort and/or isolated. Care for patients with and without COVID-19 is clustered to preserve personal protective equipment (PPE), thereby modifying the number and nature of bedside conversations, and physical aspects of care by some healthcare professionals. PPE, including gowns, masks, face shields, and gloves hinder visual and tactile aspects of care, precluding lip reading, covering facial expressions, interfering with natural tactile manifestations of concern. Many wishes were targeted at reducing patient isolation. Beyond task-oriented aspects of care, infection control strategies affect both verbal and non-verbal communication, including expressing and detecting emotion. CONCLUSIONS: Care for patients with and without COVID-19 is affected by infection control measures necessary during the pandemic, which modify many aspects of end-of-life care.
ABSTRACT
INTRODUCTION: Restricted visiting hours during the COVID-19 pandemic are common. We hypothesized that clinicians would be distressed caring for patients at the end of life (EOL) related to visiting restrictions, as assessed in our pandemic-specific study to evaluate whether the 3 Wishes Project is feasible and valuable for dying patients. METHODS: In an embedded mixed-methods study from March16-July 1, 2020, we enrolled patients with a ≥95% probability of death or plans to withdraw life support. Clinicians and families elicited and implemented ≥3 final wishes/patient. We recorded patient characteristics and clinician demographics. We purposively sampled clinicians who cared for these patients for interviews 2-10 weeks postmortem;transcripts were analyzed using a qualitative descriptive approach. RESULTS: For 45 enrolled patients, 236 wishes were elicited. Overall, 5.2 (2.1) [mean (SD)] wishes/patient were implemented;50 (21%) by families. Most patients (32, 71%) had family visits during their hospital stay (in the patient's room, outside the room, or at the outdoor window). At the time of death, a family member was present with 20 (44%) patients. We interviewed 45 diverse clinicians with 13.7 (11.5) years of experience. Clinicians discussed operationally challenging dimensions of visiting restrictions related to the timing, duration, number, and purpose of visitors;different policies across units;variable implementation of the same policy;and policies shifting during the pandemic. Clinicians experienced moral distress caused by limited family companionship for patients. Emotions evoked included heartbreak, concern, devastation, frustration, and helplessness. This prompted professional coping strategies such as peer support;story-telling;informal debriefing;family advocacy;initiating research on this issue;and more intentional acts of compassion by creating meaningful wishes to personalize EOL care without family presence. CONCLUSIONS: Clinicians experienced both first-hand and vicarious distress when caring for dying patients during the pandemic related to visiting restrictions. The 3 Wishes Project provided a framework for empowering clinicians to provide humanistic EOL care for patients who were separated from their families.
ABSTRACT
P35 Figure 1ConclusionsUtilising the skills of pulmonary rehabilitation staff to deliver a holistic rehabilitation and treatment service to those discharged from hospital after suffering respiratory complications of COVID-19 was feasible, safe and well tolerated by staff and patients. This service is now being used to address the needs of post-COVID-19 patients presenting with respiratory needs in the community. We aim also to assess clinical outcome.