Staff experiences of working on a new Critical Care Unit during the COVID 19 pandemic

Introduction: Intensive Care Unit (ICU) design impacts staff well-being1 with relocation to a different ICU layout causing staff stress.2,3 During the COVID-19 pandemic our new critical care centre was opened expediently allowing increased patient capacity and providing a purpose-built environment for ICU patients. The new single-bed room layout differed to other open plan multi-bed ICUs in the hospital. New design features included large floor-to-ceiling windows with park views, modernised equipment such as computer screens on movable pendants and noise reduction features. The pandemic accelerated the opening of the new unit and practice was adapted to address surge conditions (e.g., there were two patients in each 'single' room, and PPE could only be worn in specific areas of the unit, restricting movement). Objectives: We sought to understand the impact of the ICU design on staff experiences during pandemic conditions. Methods: Following ethical approval, staff who had worked on the new unit were invited to participate in a semi-structured interview. The interview guide was based on the Theoretical Domains Framework (TDF),4 a framework to identify the determinants of behaviour change. Interviews were audio recorded, anonymised and transcribed verbatim. We used line-by-line coding and analysed data informed by the TDF. Results: 21 participants captured experiences of a wide range of multi-disciplinary staff members. The most common domain identified within the data was 'Environmental context and resources', including data pertaining to barriers and facilitators of the new unit to effective working: Having large bed spaces is perfect for getting people out [of bed]. They are soundproofed as well, so patients were sleeping really well at night. Also, 'social/professional role and identity' (including group identity, leadership), 'skills' (including competence, skills development), and 'beliefs about consequences' (perception of the effects of the new units) were frequently identified in positive and negative ways: .because of where it [the patient's room] is located you do not get to see people often. I got forgotten for rolls.It was a constant struggle Medical staff and allied health professionals described advantages over the old unit design including improved team-working, oversight of patients, and mood from the design features. Participants perceived patient benefits from improved lighting and views and stimulation due to access to social media. Conversely, nurse participants perceived less support, less team-working and increased levels of anxiety due to the single rooms. Nurse experiences improved as patient numbers reduced. However, changes in how nurse teams worked was an ongoing challenge: staffing breaks and things is quite tricky. You need a permanent floater that is never allocated to patients, to try and help people, because they cannot leave their bays. Conclusions: Our findings support previous research2 demonstrating increased nurses stress when transitioning to a single-bed room ICU layout. Providing systems to alleviate nurse isolation, promote teamworking and reduce stress in future relocations may significantly improve staff well-being (e.g., video-calling and messaging between patient rooms). A multidisciplinary awareness of the impact on nurses is vital to support strategies to ameliorate the impact of changes during relocation.

Nurse-led PoCUS in the Management of the Critically Ill COVID-19 Patient

Introduction: Point-of-Care Ultrasound (PoCUS) can rapidly diagnose presence and severity of COVID-19 disease and associated pathologies.1 PoCUS identifies life-threatening complications at the bedside, with the potential to reduce the need for out-of-department transfers for imaging, alongside associated radiation exposure and spread of infection.2 Use of PoCUS by doctors in the intensive care unit (ICU) is becoming increasingly widespread. However, uptake by ICU nurses is poor despite evidence to suggest comparable accuracy in acquiring and reporting PoCUS scans, and the potential benefit to patients as a result of an increased workforce of competent PoCUS clinicians.3-5 Objective: To report findings in critically ill COVID-19 patients identified through nurse-led cardiac and 6-point lung PoCUS. Method: This case series was part of the national service evaluation led by the Intensive Care Society, SAM, FUSIC, and FAMUS. Conduct was approved by the departmental lead for critical care ultrasound. An ICU nurse trained in Focused Intensive Care Echocardiography (FICE) and Focused Ultrasound in Intensive Care (FUSIC) performed cardiac and 6-point lung PoCUS scans on ICU patients with confirmed COVID-19 disease during the recovery phase. Severity of disease was scored between 0-3 (Table 1) in each lung region (upper anterior;mid-anterior;posterolateral) and a total score calculated (0-18). PoCUS scans were only performed on patients identified by the treating ICU consultant. Correlations between PoCUS findings and patient demographics, key clinical data, physiological parameters, and 30-day outcome were analysed using Pearson's coefficient. Descriptive statistics analysis (mean;standard deviation/ mode;interquartile range) were used to describe data. Results: A cardiac and 6-point lung PoCUS scan was performed on 15 patients. Fourteen (93%) scans were performed to answer lung-specific clinical questions including assessment of ventilation strategy (ventilation mode;PEEP level) in 5 (33%) patients, extravascular lung water assessment in 9 (60%), and lung assessment prior to tracheostomy decannulation in 1 (7%). Moderate to severe COVID-19 was apparent in all lung fields with severity scores from 6 to 14 (Figure 1). Left ventricular (LV) function was normal in 13 (87%) patients, 2 (13%) demonstrated signs of a dilated right ventricle (RV), and 1 (6%) had impaired LV and RV function (Figure 2). Ten scans identified pathologies that contributed to a change in clinical management immediately following the scan (Figure 3). Interventions included: (1) change in fluid management (increased fluid removal on renal filtration, new furosemide prescription) 4 (27%) patients) and a level 2 echo assessment due to identification of new cardiac pathologies (3 (20%) patients). Five patients had no change in care. We identified a moderate positive correlation between lung severity score and APACHE II (Pearson's coefficient: 0.69;p value <0.01). Weak correlation was found between lung severity score and white cell count, SOFA score, and PaO2/ FiO2. There was no difference in 30-day outcome in patients with a higher lung severity score or abnormal cardiac scan. Conclusion: Cardiac and lung PoCUS is a vital tool in the assessment of COVID-19 disease. The addition of ICU nurses to the growing workforce of PoCUS competent clinicians increases availability of real-time imaging.