"working in the dark but expected to be an expert": Reflecting on critical care preparations for COVID-19

Introduction: Before spring 2020, many healthcare organisations did not possess detailed plans for the expansion and delivery of critical care during a pandemic. Furthermore, there was little directly-relevant individual or institutional experience to draw upon. Local, national and international guidance was drawn up rapidly and subject to frequent revision.1 Reflecting on these challenges, we designed a study to explore critical care and anaesthetic doctors' experiences of preparation for the provision of critical care services in the first wave of COVID-19. Objective(s): 1. To establish what factors facilitated and hindered the expansion and delivery of critical care services. 2. To identify important learning points for the provision of critical care during future pandemics. Method(s): We conducted semi-structured interviews with medical staff from the anaesthesia and critical care departments of our hospital, a tertiary centre with general and cardiothoracic intensive care units, including an ECMO service. We classified participants into two groups;1. Decision makers - individuals instrumental in shaping the critical care response, e.g., clinical directors and college tutors. 2. Staff members - clinicians working within the departments, including consultants and trainees. Thirteen interviews were conducted with 15 participants: eight decision makers and seven staff members. The interviews were recorded, transcribed and anonymised. We manually coded transcripts, and carried out an inductive thematic analysis.2 Results: Eight themes were generated from our analysis: * Problem solving with simulation: simulation exercises allowed experienced clinicians to troubleshoot practical issues and helped staff to prepare for unfamiliar tasks. * A sense of togetherness: staff reported that the "all hands-on deck" ethos was protective against fatigue, although this was short-lived. * Delayed and changing guidance: frequent guideline changes created confusion and anxiety. * Leading from the front: leaders with a clinical role were perceived more positively than those operating at a distance from the "shop-floor". * Coordination, collaboration and compromise: departments that accommodated each other's needs fostered productive inter-departmental relationships. * Insecure supply chains: staff took their own measures to ensure PPE availability, including acquisition of items outside NHS supply chains. * Constant communication: rapid methods of personal communication, e.g., WhatsApp were effective, although "WhatsApp fatigue" was endemic. * Balancing skill mix and fatigue: flux in workload required dynamic staff allocation. Underutilised staff groups created frustration and low morale in overworked colleagues. Conclusion(s): The threat to health and society from pandemic events is expected to increase over time.3 We should take this opportunity to gather experiences from those involved in the COVID-19 pandemic to guide future preparations. In early 2020, decision makes in local hospitals were operating with unclear guidance from external agencies. Our data, obtained in the summer of 2021 demonstrates that individual and departmental reflections had already resulted in processes being refined in later waves of COVID-19. Whilst the exact nature of future pandemics will vary, some elements of preparation will remain consistent. We recommend that plans for pandemic management should aim to reduce workload and target the most effective interventions, including by addressing the themes outlined above.

Embedding new technology into clinical ultrasound practice: Is role extension for sonographers the key to improving patient pathways?

Introduction: MicroUS is a new imaging technique that may have potential to reliably monitor prostate disease and therefore release capacity in MRI departments. Firstly, however, it is essential to identify which healthcare staff may be suitable to learn to use this modality. Based on previous evidence, UK sonographers may be well placed to harness this resource. Topic: Currently, there is sparse evidence on the performance of MicroUS for monitoring prostate disease but early findings are encouraging. Although its uptake is increasing, it is believed that only two sites in the UK have MicroUS systems and only one of those uses just sonographers to undertake and interpret this new imaging technique. Discussion: UK sonographers have a history of role extension dating back several decades and have proven repeatedly that they are reliable and accurate when measured against a gold standard. We explore the background of UK sonographer role extension and postulate that sonographers are best placed to adopt and embed new imaging techniques and technology into routine clinical practice. This is of particular importance given the dearth of ultrasound focussed radiologists in the UK. To effectively introduce challenging new work streams, multi-professional collaboration in imaging, alongside sonographer role extension, will ensure precious resources are maximised thus ensuring optimum patient care. Conclusion: UK sonographers have repeatedly demonstrated reliability in many areas of role extension in various clinical settings. Early data indicate that the adoption of MicroUS for use in prostate disease surveillance may be another role suited to sonographers.

Sustainable Remote Work for Radiation Therapists: Implementation in a Large Urban Radiation Therapy Centre

Purpose: The COVID 19 pandemic created an urgent need to reduce onsite staff at the hospital. Remote work was implemented for Radiation Therapists (RTs) to reduce COVID 19 transmission, conserve personal protective equipment and facilitate physical distancing for staff required onsite. We report our experiences with a rapid pivot to remote work for RTs during the pandemic and the plan for a sustainable remote work strategy. Material(s) and Method(s): On March 16, 2020, our multi-site healthcare network provided emergency guidelines for remote work. The guidelines included the ability to perform full job duties remotely, appropriate space and equipment, no impact on patient care, and operational feasibility. RTs were asked to self-identify to their Supervisor if they met these requirements and wanted to work remotely. Commencing March 23, 2020, rotations were developed for on and offsite schedules balancing operational needs, skill mix, equity between team members, and cohorting to minimize COVID risk. Those performing direct patient facing activities were not able to work from home. Activities that could be performed remotely included radiation therapy planning, process and protocol development, quality assurance checks, project or research activities, and telephone patient education. Organizational implementation of technology solutions supported this rapid pivot to remote work. For example, remote access was required to clinical applications, email, and document management. Microsoft Teams was used for virtual communication and meetings. Result(s): From March 2020 to Dec 2021, 133 (64%) RTs worked remotely for >=1 day. 32% of RTs worked >100 shifts remotely, and 12% worked more than 200 shifts remotely. This resulted in 15,413 remote work shifts (25% of total shifts worked) for an average of 685 remote work shifts per month, peaking to a maximum of 1096 shifts during March 2021. Generally, remote work was well received by RTs. Many RTs reported benefits, including eliminating lengthy commutes, improved flexibility, reduced distractions and a break from PPE. Initially, there were some IT challenges, such as slow connectivity and incompatible home equipment, that made remote work difficult. Some RTs reported a sense of social isolation. There was a perceived lack of fairness between those who could and could not work remotely. There were also some challenges communicating between onsite and offsite teams, shift coverage, and onsite support. Conclusion(s): Overall, we demonstrated that RTs can successfully work remotely over a multi-year timeframe. Generally, this was a positive experience for RTs, who reported improved work-life balance and more flexibility with job duties. However, there were concerns about a lack of fairness for those in patient-facing roles. Despite these concerns, most RTs support continuing with remote work. Our department will continue with a long-term remote work strategy based on best practices for remote work and input from RTs Copyright © 2022 Elsevier Ireland Ltd. This is an open access article under the CC-BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Virtually Transforming healthcare at scale: Implementing improved access to stroke care across regional and rural areas

Aim: The NSW Telestroke project implemented a virtual model of care to improve access to hyperacute stroke treatment across 23 hospitals. To understand and extrapolate the success factors involved in effective project implementation and sustainability. Objective: The successful implementation of large-scale service redesigns with demonstrated improvement in patient outcomes are limited. The implementation at scale to 23 hospitals with varying local contextual features including resourcing, culture, leadership and facility set up has provided insights into the key elements of successful implementation. Undertaking a systematic approach to implementation including formulating a well-developed and attainable proposal for change in practice with clear targets, assessing the performance and mapping potential barriers indicates markers for successful implementation. Lessons learned has provided a gauge of what future endeavours should consider to inform large scale system transformation. Results: The Telestroke project has been implemented across 18 hospitals to date, with a further five sites by June 30, 2022. This is within the expected timeframe despite COVID-19 outbreaks in NSW and subsequent restrictions limiting activity at crucial time periods. Discussion: Through reflective lesson learned discussions at a program, hospital and individual level key drivers for successful implementation and sustainability of the project were highlighted. They include: 1. A clear roadmap, detailing the implementation approach with matching resources and education packages, have allowed expedited delivery of the program at a site level 2. Skilled, dedicated and consistent staffing in program implementation lead roles has enabled stability in coordination and knowledge management. This supports key learnings being adapted and utilised for future go-lives. 3. Leveraging skill mix at each site to fill knowledge/experience gaps to support and embed Telestroke. 4. A supportive executive team and clearly identified key champions in each department to drive the change forward. 5. Adapting training to suit the local environment including resources and COVID-19 restrictions was crucial during implementation.

Introduction of a night time safety brief;improving patient safety in Critical Care at Sheffield Teaching Hospitals

Introduction: Since the onset of the Coronavirus pandemic in March 2020 we have had to change our day to day working practice in a large Critical Care department, with up to 36 patients across two floors. Prior to the pandemic, each floor functioned as an almost separate unit, with level 2 patients in one area and level 3 patients in another. Patients requiring level 3 care are now present on both floors although the staffing for each floor has not changed to reflect this. Therefore, out of hours more complex patients are being cared for by staff who have less experience in caring for these patients. The introduction of safety briefings in clinical care is based on concepts in aviation, where they are designed to make safety-consciousness routine practice. Objectives: The introduction of a nighttime safety brief aimed to improve safety and communication across Critical Care with the key objectives of introducing all medical and senior nursing staff working across critical care, identifying bed pressures and ill patients. Aims included Increasing visibility of the airway registrar, identifying the skill mix of the staff across the units and initiating contact between medical staff and the nurse in charge across each floor. Methods: A preliminary survey of medical and nursing staffing was undertaken to explore the attitudes of staff to the current arrangement and the perception of a need for change. A 'Night Time Safety Brief' was developed by creating a proforma of key topics to be discussed and an agenda for a nightly meeting that was designed to take no more than five minutes and targeted to key information sharing. The location and timing of the briefing was designed to be convenient by liaising with key stakeholders in the meeting. The tool was then implemented with all medical critical care staff and the nurse in charge from each unit meeting to undertake the safety brief following the independent medical handover of each of the units. A follow up survey was undertaken to assess the impact of the safety brief and staff opinions on the introduction of the brief. Results: Every member of staff surveyed felt that the introduction of the brief was beneficial. 76% of staff surveyed felt that they were more comfortable working the shift simply by having met the medical and nursing staff from across the floor to better understand the skill mix and points of contact. 90% of staff surveyed felt that the brief would positively impact on patient safety. Conclusions: Briefings in intensive care are tools that increase the awareness of safety issues among front line staff and foster a culture of safety, making it part of the routine in a clinical area. A simple and effective brief has been developed and used in this tertiary hospital with the aim of improving patient safety. In this hospital with critical care split across two clinical areas, this has shown to improve communication and team working in a busy tertiary teaching hospital.

LIVING WELL WITH AN ADVANCED LUNG CONDITION

Background Whilst our established support for people living with breathlessness was long-standing, it was not multidisciplinary or fully evidence-based. We wanted to address this for the benefit of patients and the wider health system. The Cambridge Breathlessness Intervention Service (CBIS) model is an evidence-based approach to support people living with advanced lung conditions to manage their breathlessness (Higginson, Bausewein, Reilly, et al., 2014). Consultation with service users suggested that patients wanted support to: manage breathlessness, improve mental wellbeing, mobility and symptom management as well as help with planning ahead and reducing isolation. Aims To implement and evaluate a breathlessness intervention using a multidisciplinary skill mix and trained community volunteers. Methods Using the CBIS model as a framework, we reshaped, redeployed and trained our team to deliver this intervention at home. We supplemented this with a layer of social support provided by experienced compassionate neighbour volunteers. We evaluated the impact of the intervention through: before and after breathlessness self-rating scales, interviews with patients and case studies documenting the use of different parts of the service (e.g. physiotherapist, nurse, occupational therapist, rehabilitation assistant, complementary therapy). Results This project has been delivered during the COVID-19 pandemic, so there were practical issues around seeing patients face-to-face, and we were unable to support as many as expected. To date, 28 patients have been referred to the service. Of these, 18 received input. We will report on changes in self-rating scores and feedback from interviews with patients and families. To date, only a few participants opted to have a compassionate neighbour. Conclusions Initial findings suggest that although delivery of this project was hampered by the pandemic, patients valued the service and benefitted from practical input from the MDT. Limitations on being able to provide face-to-face support may have influenced uptake of compassionate neighbours and reduced the number of patients seen.

A quality-improvement project aiming to rationalise sedation use in a tertiary centre intensive care unit using the Wake Up and Breathe Protocol and goal-directed sedation

This mixed-methods quality-improvement (QI) project had the dual aims of improving goal-directed sedation to avoid accidental over-sedation, and improving adherence to the Trust's Wake Up and Breathe Protocol with particular focus on spontaneous awakening trials (SAT). Methods A QI team of two doctors and one pharmacist from the Critical Care Department was established. Baseline data were collected once weekly through March 2021, including all sedated patients across the Trust's two intensive care units (ICUs;housing 46 beds in total). Data included sedative agents and infusion rates, appropriateness for and implementation of SAT, documentation of a sedation plan, and recorded Richmond Agitation and Sedation Scale (RASS) score. Freetext answers from bedside staff helped identify barriers to change such as diluted skill mix, staffing pressures, lack of confidence and fear of adverse events. Baseline data were presented at a departmental QI meeting;feedback was gathered and thereafter data collection was streamlined to 10 patients per week across both ICUs, performed for 16 further weeks. Plan-do-study-act (PDSA) cycles were implemented based on data collected and barriers identified, including questionnaires to the medical team, departmental presentations and teaching, posters, altering pre-printed prescription charts, discussions with the Nurse Education team, and engaging in the department's Rehabilitation Month initiative. Results Baseline data revealed that half of protocol-defined suitable patients received SATs, and the most frequent RASS score was -4 in patients without neuromuscular blockade. These data were presented at a departmental QI meeting and awareness of the project was raised. Subsequent data showed that our practice, supported by interventions, improved over the 16 weeks. The average percentage of suitable patients receiving SATs rose from 54% to 86%. Documentation of sedation plans increased from 65% to 95%, and mean RASS scores showed improvement from -3.7 to -3.3. There was a significant reduction in the use of double-strength morphine and midazolam among non-COVID-19 patients, and weight-adjusted infusion rates of propofol and alfentanil also decreased. Discussion By focusing on broad, multidisciplinary stakeholder engagement, the QI team were able to identify and target multiple barriers to improved practice. Sequential interventions across multiple areas facilitated safe improvement in our sedation practice and adherence to local and national guidelines, with no adverse events reported.

The Association between Nursing Skill Mix and Mortality for Adult Medical and Surgical Patients: Protocol for a Systematic Review.

Skill mix refers to the number and educational experience of nurses working in clinical settings. Authors have used several measures to determine the skill mix, which includes nurse-to-patient ratio and the proportion of baccalaureate-prepared nurses. Observational studies have tested the association between nursing skill mix and patient outcomes (mortality). To date, this body of research has not been subject to systematic review or meta-analysis. The aim of this study is to systematically review and meta-analyse observational and experimental research that tests the association between nursing skill mix and patient mortality in medical and surgical settings. We will search four key electronic databases-MEDLINE [OVID], EMBASE [OVID], CINAHL [EBSCOhost], and ProQuest Central (five databases)-from inception. Title, abstract, and full-text screening will be undertaken independently by at least two researchers using COVIDENCE review management software. We will include studies where the authors report an association between nursing skill mix and outcomes in adult medical and surgical inpatients. Extracted data from included studies will consist measures of nursing skill mix and inpatient mortality outcomes. A meta-analysis will be undertaken if there are at least two studies with similar designs, exposures, and outcomes. The findings will inform future research and workforce planning in health systems internationally.

Health workforce response to Covid-19: What pandemic preparedness planning and action at the federal and state levels in Germany?: Germany's health workforce responses to Covid-19.

INTRODUCTION: The Covid-19 pandemic has required countries to prepare their health workforce for a rapid increase of patients. This research aims to analyse the planning and health workforce policies in Germany, a country with a largely decentralised workforce governance mechanism. METHODS: Systematic search between 18 and 31 May 2020 at federal and 16 states on health workforce action and planning (websites of ministries of health, public health authorities), including pandemic preparedness plans and policies. The search followed World Health Organisation (WHO) Europe's health workforce guidance on Covid-19. Content analysis was performed, informed by the themes of WHO. RESULTS: The pandemic preparedness plans consisted of no or limited information on how to expand and prepare the health workforce during pandemics. The 16 states varied considerably regarding implementing strategies to expand health workforce capacities. Only one state adopted a policy on task-shifting despite a federal law on task-shifting during pandemics. CONCLUSIONS: Planning on the health workforce, its capacity and skill-mix during pandemics was limited in the pandemic response plans. Actions during the peak of the pandemic varied considerably across states, were implemented ad hoc and with limited planning. Future action should focus on integrated planning and evaluation of workforce policies.