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

ABSTRACT

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.